1. The French Health care system: Liberal Universalism Monika STEFFEN CNRS/Pacte - Institute of Political Studies, Grenoble University / France Seminar: “Health and Social Protection Policies” Oswald Cruz Foundation, National School of Public Health “Sérgio Arouca”, Rio de Janeiro, 11-12 March 2009

2. Classifying and comparing healthcare systems Three theoretical models: –NHS, SHI, Private systems Main opposition : NHS / Private systems –Contrasting situation for regulation and choice In reality, most systems are mixed –Mix is growing with ongoing reforms Hybridization: learning, adapting to global constraints, creating sustainability

3. Models versus Hybridization? If all systems are mixed, what use for models? Are all systems « national » ? The French healthcare system: little known, complex. How to classify? An exception ? Comparative traditions: WFS / Healthcare systems – Universal / private; SHI / state run Models are analytical tools: helping to describe systems and reform trajectories.

4. Main arguments The « same » institution (SHI) is run by different actors, having a different history, different self-understanding and values. In the HC sector, professionals/doctors are crucial actors for reform implementation. The medical profession has to negotiate its place, role and power within the social security system in a different set of policy actors in each country.

5. PLAN of paper History of the main actors Reforms in access, financing, regulation of consumption Regulation in the ambulatory care sector: no progress, policy crises Regulation in the hospital sector: slow but real progress

6. A generous healthcare system

7. History and its lasting impact Medical profession: « liberal » identity, four principals (fees, site, prescription, secret) Mutual benefit funds: doctors’ ally. Lasting role as supplementary insurers. Health insurance: 1930,1945: late, weak. 1967: class struggle, state control. Political regulation: consensus for inflation (opinion, elections, doctors, employment). Finance ministry remains isolated.

8. Financing Public/private share unchanged 1995-2006 despite lower reimbursement for medicines. +78 % public, -9% out of pocket, 13 % complementary insurance, mainly non-for- profit. Very small market fringe for for-profit HI Slight growth of employer-sponsored supplementary HI (careful privatization).

9. Reforms for extending financing 1991: first introduction of « general social contribution », then several extensions. 1996: GSC replaces HI-contribution (but employer part remains on salaries). 1996: Reimbursement of Social Deficit: 0.5 % for 13 years, 2004 «indefinite time». 2004: further increase of GSC: 6.2 to 6.4 for work income, 7.5 to 8.2% capital income.

10. Reforms extending universal access 1883 «Medical assistance » at local level. 1988 Minimum Income with free HI affil. 2000 Unifying the schemes and free affiliation to a complementary HI (5 mill). 2004 Correcting threshold effects. 2007 Increasing the latter from 15 - 20 %. Medical assistance for illegal migrants.

11. Weak attempts to reduce choice 2001: modulate reimbursement for 850 medicines with little or no effect: 8 years. 2003: Chadelat report: restrict basket, only now attempts for «100% long term illness». 2004: Voluntary enrollment with GP for gate-keeping, penalty 20% less reimbursed. 2004: High Health Authority, for basket restriction, politically critical enterprise.

12. Weak regulation 1996: Parliament votes the annual growth rate ONDAM, overspending up to +100%. Main raisons: –100% long term illness regime, –private doctors do not respect medical guidelines. Policy deadlock since 1993, –Difficult redistribution of hospital capacities. Hospital management has improved, in line with international practice.

13. Characteristics of French system 1- Split in regulation between ambulatory care system (liberal doctors, SHI) and hospital sector (state managed via regional agencies). 2 - Weak regulation capacity: Bismarckian SHI without social partners to manage it, and central government limited by electoral risks.

14. 3 - A model combining universalism and liberalism: it is historically grounded, and growing with the reforms: 4 - … instead of cost containment, new finance is provided and deficits are put on future generations. 5 - Liberal universalism is a sustainable model for the future: 6 - …the public trust towards the mutual funds allows to absorb the growing cap between HI-income and expenditure. 7 - Muddling through will continue......

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