France: one of the best universal healthcare system in the world

Published 2023-05-02 10:19:11
Ambulance driving in Paris - Credit: Mathias Reding in Pexels

Twenty years ago, France was ranked number one for the best healthcare system globally. Now it is often overtaken by Scandinavian sytems, with Denmark ranking often at the top place. Although the system has its faults and failures (especially revealed with the Covid crisis) many health status indicators generally point to high consumer satisfaction. How do this and other universal healthcare systems compare to each other? Which of them is getting it right and which is failing abysmally? Let’s delve into the French universal healthcare system to break it down.

Sometimes ranked number one, number seven or eight, France is still widely recognised as a country with some of the best healthcare in the world.

How does the French healthcare work?

Health insurance is mandatory for all residents.

France provides universal healthcare coverage to its residents through a system called the statutory health insurance (SHI) system that is financed by contributions made by payroll taxes paid by employers and employees, national income tax and various tax levies from different revenues, like certain industries and products. These funds are consolidated nationally and funds are distributed accordingly.

The SHI is mandatory, because the insured must necessarily join it and contribute, via their salary.There are two main schemes within the SHI that provide equal health coverage and benefits. One is specifically for the agricultural sector and the other is a more general scheme. The SHI system is administered largely by central government.

Residents are automatically registered with the insurance fund that is applicable to them depending on their occupation. Although there are various plans within the scheme depending on a person’s occupation, they all operate within the same legal structure (called Union nationale des caisses d’assurance maladie - UNCAM). This structure intervenes in the financing of the health system:

  • determining the benefits reimbursable by the SHI;
  • setting the rate of reimbursement.

For example, a consultation with the general practitioner is refundable, and charged €25. Generally, about 70% of total health costs are covered by the SHI with the remaining paid by private insurance and out-of-pocket (OOP) payments (you will therefore be refunded €16.50, as you must deduct also a €1 process fee).

The SHI provides for approximately 90% of hospital care costs and about 44% of outpatient expenses.

As the SHI rarely covers the insured person’s entire health costs (reste à charge), private organisations (mutual societies, provident societies, private health insurances etc.) are available to complete the reimbursement. About 95% have private healthcare while 10.5% have certain subsidies depending on their income and about 8% of the population have fully subsidised healthcare coverage. There are two types of private health coverage:

  • Company health insurance: Since the National Interprofessional Agreement (ANI) law of 2016, all private sector employers must offer a mandatory insurance company to their employees. The private insurance company participates in the health care system by ensuring the full or partial reimbursement of the rest of the costs borne by the insured.
  • The individual health insurance: If the insured person is not covered by a compulsory mutual in their company, they may take out an individual contract. They will have to choose guarantees and repayment levels.

France’s healthcare system has an expansive array of benefits and boasts very low OOP payments. Unlike many other universal healthcare systems around the world, dental and optical might also be (usualy partially) included in the private insurance policy.

A person can access a fee-for-service private practice for outpatient services and public hospitals for acute hospital care, and any payments they have made will be reimbursed by the national health insurance (NHI) under the same rule whatever they choose. They are free to choose whichever hospital or private practice they wish to use. There are no limitations that regulate which specialists and hospitals can be accessed but since 2006, patients are required to see a primary care physician before consulting a specialist.

There is a traditional indemnity (sometimes called fee-for-service) model in place where all the health insurance plans provide reimbursement for ambulatory care, like doctor consultations. For hospitalisations, there are budgetary allocations which include daily allowances, where applicable.

France has recently focused its efforts on preventative healthcare and empowering patients in an effort to decrease healthcare spending.

The Politics of French Healthcare

The modern-day French NHI was derived from an old tradition of mutual aid societies and a system that developed after World War 2.

The last thirty years have seen various changes made under the guise of healthcare reform. Depending on whether the government of the day was on the political left or right, cost-control policies were implemented without addressing the actual management and organisation of the national health insurance. This has resulted in strains between the health insurance system, healthcare professionals and the government.

By January 2000, France was able to successfully provide medical insurance for the 1% of the population that was uninsured previously (on 27 July 1999 was created the CMU, a Universal Medical Insurance). In 2016, the Universal Health Insurance changed its name to Protection Universelle Maladie - PUMa, to address any healthcare coverage gaps and eligibility became universally granted to all. This new law replaced the existing structure by including comprehensive healthcare coverage for all French residents. This included those covered by the previous Universal Health Coverage and immigrants who were on state-sponsored health insurance.

There is also an additional coverage called Complémentaire santé solidaire or CSS, able to support 8% of its residents that had an income below a certain threshold level (no more than €8 951 currently) with a 100% reimbursement (it was created in the same 1999 law and originally called CMU-C).

Healthcare policy is structured, organised, financed and implemented by the Ministry of Social Affairs, Health, and Women’s Rights. The central government is responsible for allocating budgets to the various healthcare sectors (like hospitals, disability services, mental health, etc) and also to the different regions through the Regional Health Agencies.

Despite the tensions within the system, the French national health insurance works well when compared with other national health insurances, like the United States.

Most of the costs are regulated under the French system

According to OECD data available from 2019, France spent 11.1% of its gross domestic product on health compared with the US which spent 16.8%.

The basic principles of universal healthcare are similar for both, like supplementing healthcare with private insurance, co-payments by patients, fee-for-service, and the combination of private and public healthcare coverage for individuals. But there are a few glaringly important differences between the two systems.  

In the US, patients are obliged to choose a mandated provider but in France, patients are free to choose their doctor.

The French healthcare system provides more choices and easier access for patients in terms of choosing healthcare providers. The French NHI increases healthcare coverage as individual costs increase, there are no deductibles and the pharmaceutical benefits are far more extensive in France than in the US.

Most doctors are under contract to follow the Social Security fee scale which establishes their charges. This means that fees charged by doctors in the same area for comparable services are similar. Professional competition is not based on price but rather on the quality of service.

The SHI does not automatically cover all medical fees but depending on the type of service will cover a percentage. It may cover only 50% of inexpensive medications but 100% of expensive life-saving ones. Although patients have a small co-payment for doctor consultations, it is capped at €50 per person ($75). If a patient requires hospitalisation, costs are fully covered but there is a co-payment of €6 ($24) “hospitality” charge per day, although in most cases this fee will be paid by the private insurance.

Prices for prescription medicines in France are controlled and often can be up to half the price as in the US. Under French law, there can be no healthcare advertising to the public and medicines can only be promoted to healthcare professionals.

Another difference between the two is in the structure of the financing. The French system has a non-profit national health insurance system with obligatory coverage for all residents living there for longer than three months. It is funded by a combination of mandatory contributions by workers and employers, which is dependent on income. Households that earn less than a certain threshold are exempt and students pay a flat rate.

And last but not least, medical schools in France are not so expensive that newly qualified doctors are saddled with enormous student debt and they have no immense financial pressure, unlike their counterparts in the US.  

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Author: KashGo
Expat Mum in the Desert and content writer for

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