Good morning,
Thank you for your invitation,
Elisabeth has invited to speak about the French experience, but when you hear my English, it will be, for you, also, a French experience.
A) THE FRENCH SYSTEM
The main feature of the French system is its complexity. Indeed, it is not a uniform system.
Private and public sectors are combined both in the offer and also in the financing.
The core principle is that of compulsory health Insurance. However, this is not the only component. This principle is widely completed by voluntary Insurance that is to say mainly Mutual Insurances but also private insurances.
Therefore, I will talk to you about the historical description of the system. I will then describe the “Crisis” of the last ten years and the reform implemented today by the French conservative government. We will then see with the various alternatives and the green perspectives.
During the industrial Revolution, at the end of the 19 th century, two kinds of structures were born:
- Free medical aid (15/07/1893)
- Child welfare (27/06/1904)
- Old age and disabled benefit (14/07/1905)
These structures are still relevant today and our French system is based upon the two of them.
However, in the beginning of the 20 th, Mutual Benefit being on a voluntary basis and State Welfare being focused on specific aid had an impact limited to a small number of people.
Therefore, until WWII, a series of laws favors compulsory insurance such as Employers liability Insurance (09/04/1898), Elderly Insurance (05/04/1910), Sickness and Maternity Insurance (30/04/1930).
This created a system covering all aspects of society but not as a whole and, indeed, the system was weak.
In 1945, a general system of welfare is established concerning gradually everybody: The various local or State insurances become coordinated into one single body: the well-known “Sécurité Sociable”, an expression that cannot really be translated.
The over whole system is theorically finally completed with the instauration of the Universal Medical insurance (28/07/1999).
The “Sécurité Sociale“ today
It is a wide body covering 4 sectors:
This is not an individual saving system, but a system based on solidarity: the amount put aside by those who work is distributed to the retired. There is also solidarity between branches (for example, between teachers insurance and farmers insurance)
Employers Liability insurance includes accident at work, but also on the journey to work and professional diseases.
This health welfare covers a large field including reimbursement of :
Furthermore, and beyond that, this national welfare covers:
This system not only covers the affiliated member but also his family (wife or husband, children, etc….)
Two conditions are necessary for drawing the health benefits :
Firstly, you have to go and see an authorized professional (that is to say who has an official diploma and is registered) and of course, the hospital or the clinic you go to should also be registered.
Secondly, the benefit only covers a list of authorized medicine (no whisky, for example.) and this within a frame of medical and paramedical acts or drugs taken into consideration (you cannot have a new nose, unless you had an accident !)
The basic fares are fixed by contract between doctors, pharmaceutical companies, or private clinics and the “Healthcare Insurance”. When there is no agreement, they are imposed by the State.
The frame of the offer of care is very large.
French people can choose freely amongst a large wide scope of medical services, primary or secondary. In France you can choose the doctor you want to visit, or the hospital or clinic you want to go to .
There is no limit to the liberty of choice.
Most of the hospitals are public and they are free.
Yet, there are two kinds of private hospitals which have contract with the
“Sécurité Sociale”
Private hospitals, providing they comply with the public frame, if and their aim is not to make profit. The Red Cross is a good example : It has its own clinics; doctors and nurses are not civil servants but are paid directly by the Red Cross. This means their functioning is private but they are partly financed by the State on a global basis similar to the cost of the public hospital.
The “Sécurité Sociale” will pay you back on the base of the set price for those acts .The difference is paid out of your own pocket or by complementary insurances
Outside hospitals, medicine is practiced by private generalists or specialist doctors, nurses or paramedical professionals.
You pay each medical or paramedical act.
If the price of the visit exceeds the fixed price, you pay the difference .Generally, complementary insurances cover this exceeding amount.
You can also consult a doctor within the hospital or health centers (mainly municipal or mutuality) where you do not have to pay.
The rate of reimbursement of drugs by the “Sécurité Sociale” is fixed by decree and it varies from 35% to 100%. Again, the difference is paid by yourself or complementary insurances.
For “Over the counter” medicine (such as vitamins, some ointment etc.), there is no rule and you pay out of your own pocket.
The financing of the system
Health Care Insurance covers about 74% of general health cost. 7% are covered by Mutual Insurances and 5% by Private Insurances.
Around 15% of the health costs are not covered (but it is including OTC products and alternative medicines, which are not reimbursed)
65% of the income of the Health Insurance itself (one of the sector of the “Sécurité Sociale”) comes from private and public companies on the base of the total salaries. Money is directly deducted from your gross salary and paid by your employer who also has to contribute (on a 50/50 base).
3% comes directly from the State in the form of subsidy and 20% from different taxes.
In theory, delegates from Trade Unions, State and employers officially manage Health Care.
The insurance cover is almost total in France.
The sector of hospital and of doctors outside the hospital offers a very wide choice and patients are free to choose.
The system appears efficient and fulfills the expectations, both of the population, who feels it is all free, and of private doctors and pharmaceutical industry, which have guaranteed incomes.
And WHO ranks France Number One in health field.
All seems perfect …
And yet today, we are undergoing a crisis …
What is going on?
The Health Care System is undergoing a double crisis:
As I have little time, I will deal here only with the problem of health in a strict sense, despite the fact that other factors such as social or environnemental policies have consequences on health, and despite the fact that the financial crisis of the “Sécurité Sociale” has the same consequences on pension benefits or family allowances.
The financial crisis is due both to the increase of spending and reduction of income :
. Expenses are increased because :
. On the other side, income is going down because of an economy based on a liberal system. The source of financing of healthcare being mainly based on wages, it goes down when :
2) The crisis of the medical model
The over medical conception of the system is also responsible of the crisis.
The focus on technical performance limits the role of the individual to that of a passive consumer of care. Because research is only based on technical and medical performances, it increases the weight of pharmaceutical industry, of private doctors and biomedical engineering, which use the health Insurance as an endless source of finance.
Beyond the financial aspect, there are other elements to the crisis :
Sociale” big differences, geographical and social still exist in terms of life expectancy or illness. Major sanitary Crisis such asbestos or the last heat wave is recurrent.
These are linked to the industrial and collective behaviors and environnemental degradation.
C) THE DIFFERENT ANSWERS
There are, of course, several ways of dealing with this crisis.
1) The liberal answer
WTO, through GATTS, clearly aims at transforming health into an ordinary trade product, under the pretext of control spending and fight against waste.
This is exactly the same purpose for the EU directive ”Bolkenstein”. This is the privatization way.
In a classic privatization, the State or the consumers pay collectively for the costs and non-profitable activities. The other wide profits are privatized as well as the more profitable activities.
It is difficult to apply this doctrine in France, as it already works like this :
Indeed, what is there left to privatize?
In public hospitals what brings profit (such as small surgery, deliverance, specialist consultations, etc…) is already privatized . The other activities are not really profitable, or only after a big increase of reimbursing costs or increase of private insurances.
Therefore, the only remaining ”liberal” solution is to privatize part of the financing by developing private insurances.
When Conservatives become in charge of this already very profitable system, they have no intention of killing the excuse of the financial crisis to try to reduce, not really the spending of the State, but within the income, the share of private firms, and the rate of reimbursement.
The excuse that will be given to reduce the share of private firms, is, in this difficult economic context, that in order to employ people, firms need more money, and therefore their taxes on wages need to be reduced.
The decrease of income will be balanced by a reduction of “Sécurité Sociale” spending (to be politically correct, this will be called : “control of spending”), and this is done by decreasing rates of reimbursement …
The difference will, of course, be paid by consumers either directly or indirectly via Mutual Insurances and also above all, via the increase of private insurances. The circle is closed.
Yet, the French population being attached to its system, the government will proceed in a “soft way”.
First, there will be a massive communication on the financial crisis of the healthcare and the need of strong measures. A debate is launched.
Then the proposed measures will appear as “small measures” sparing the system and people will feel relieved.
Yet, facts speak for themselves :
Of course, no deep reform being implemented, French people take slowly the way to have a small complementary private insurance.
Same causes leading to the same effects, the next crisis, followed by the next health insurance reform, will lead to more private insurances at the expense of health and solidarity.
2) The “socialist” answer
The opposite way of dealing with the crisis as suggested by the traditional Left (and communists) could be worded as follows:
“ We want an efficient Health Care System free for all”
Who could be against that ?
Yet, this approach does not question a system based on scientist and productivist ideology focusing on hospitals.
The answer of the traditional Left is increasing hospital spending, increasing care offer, increasing prevention.
The increase of spending and the deficit would be paid by an increase of incomes.
What kind of income ?
Where to find money ?
The radical Left has a simple message : “employers can pay”.
At the other end, social democrats plan to settle the deficit by increasing taxes and partly limiting spending.
The radical Left answer would also add nationalization of all private hospitals and pharmaceutical industry.
3) The Green perspective
Are there other solutions than that put forward by the liberal, the social democrat or the radical left ?
For the Greens, the approach is a global one. Public health cannot be dealt with only by focusing on the issue of care.
French Greens have a 20 pages program and I only have a few minutes to summarize it.
Prevention is a key word to deal with Public Health.
The Greens believe it is essential to :
I will only quote some of the numerous proposals :
- Greens propose a deep reform of the hospital, which must be
Refocused on its essential aim like real emergencies, heavy
Care and surgery, research
- Develop health networking, links between hospitals and outside doctors, between doctors and all medical professionals
Reform of the financing System
The greens propose a reform towards more solidarity, that is to say :
As a conclusion, these reforms can only be carried out by a democratic and transparent system … but this could be a debate in itself and time is running out!
Thank you for your attention
Dr Didier Claude ROD