The French Social Protection System
THE FRENCH SOCIAL
THE FRENCH SOCIAL
THE FRENCH SOCIAL
THE FRENCH SOCIAL
PROTECTION SYSTEM
PROTECTION SYSTEM
PROTECTION SYSTEM
PROTECTION SYSTEM
The French Social Protection System Copyright © ADECRI, 2008
The French Social Protection System The ADECRI was created in 1995 by all of the French Social Security National Organizations, i.e. the National funds of all the basic regimes (employees of industry and commerce, farmers, minors, artisans and retailers), as well as the Groups of national funds and the EN3S (École Nationale Supérieur de Sécurité Sociale). The aim was to provide support, to those countries who wished it, in their development or reform of their own social protection system.
This common initiative brings forth answers to questions that could not be addressed or adequately dealt with without a collective approach. Inter-regimes and inter-branch, the ADECRI is the privileged contact for foreign institutions seeking to benefit from the expertise of the French system as a whole. Responsible for revitalizing the resource potential of the 600 national, regional and local organizations composing the French social security system, the ADECRI thus has approximately 80 experts, mainly working in the French social security institutions, participating every year in the development and reform of foreign social security systems.
Offering services of a real consulting firm, the ADECRI has positioned itself as a French player in terms of social protection on the world stage and is recognized as such by international institutions, in particular by the European Union and the World Bank.
Since 2002, at the request of its foreign partners, the ADECRI has published a booklet that presents the French social protection system as a whole. Updated every 3 years, this booklet, initially translated into English, Russian and Chinese, now exists in Arabic and Spanish in order to be of use to all of the institutions and countries with which the Agency undertakes co-operative activities. This booklet is also downloadable from the Agency’s website: www.adecri.org.
The French Social Protection System TABLE OF CONTENTS TABLE OF CONTENTS TABLE OF CONTENTS TABLE OF CONTENTS
Introduction: The French System of Social Prote Introduction: The French System of Social Prote Introduction: The French System of Social Prote
Introduction: The French System of Social Protection ction ction ction 8888
History 8
The French System Today 10
Part 1: Health Care and Health Insurance Systems Part 1: Health Care and Health Insurance Systems Part 1: Health Care and Health Insurance Systems
Part 1: Health Care and Health Insurance Systems 12121212
Introduction 12 I. Medical Services I. Medical Services I. Medical Services I. Medical Services 12121212
II. Health Insurance Schemes II. Health Insurance Schemes II. Health Insurance Schemes
II. Health Insurance Schemes 14141414
A. Basic Schemes 18
1. Benefits-in-Kind 19
1.1 General Scheme 19
1.2 Agricultural Workers’ Fund 19
1.3 Fund for the Self-Employed 20
2. Cash Benefits 20
2.1 General Scheme 20
2.1.1 Maternity Benefits 20
2.1.2 Sickness Benefits 20
2.1.3 Occupational Injury/Illness Benefits 21
2.1.4 Disability Pensions 22
2.2 Other Schemes 23
B. Supplementary Schemes 23
C. Universal Medical Coverage (CMU) 24
III. Organisational Aspects III. Organisational Aspects III. Organisational Aspects
III. Organisational Aspects 24242424 Part II: Retirement Pensions
Part II: Retirement Pensions Part II: Retirement Pensions
Part II: Retirement Pensions 27272727
I. Private Sector Employees I. Private Sector Employees I. Private Sector Employees
I. Private Sector Employees 28282828
A. Basic Pension 28
1. Pension 28
2. Indirect Benefits 31
B. Mandatory Supplementary Schemes 31
1. Direct Benefits 31
2. Indirect Benefits 32
C. Non-Mandatory Additional Pensions 32
D. Principles of the Agricultural Sector Employees’ Pension
The French Social Protection System
E. Management 32
II. Private Sector, Other Schemes II. Private Sector, Other Schemes II. Private Sector, Other Schemes
II. Private Sector, Other Schemes 34343434
A. Basic Pension Schemes 35
1. Entrepreneurs and Trades People 35
2. Professionals 35
B. Supplementary Pension Schemes 36
1. Entrepreneurs and Trades People 36
2. Self-Employed Professionals 36
III. Special Schemes: Civil Servants and the Publi III. Special Schemes: Civil Servants and the Publi III. Special Schemes: Civil Servants and the Publi
III. Special Schemes: Civil Servants and the Public Sector c Sector c Sector c Sector Corporations CorporationsCorporations Corporations 36363636 A. Pensions 37 B. Indirect Benefits 37 C. Supplementary Pensions 37
Part III: Family Support Programmes Part III: Family Support Programmes Part III: Family Support Programmes
Part III: Family Support Programmes 38383838
Introduction 38
I. I. I.
I. Different Types of Benefits Different Types of Benefits Different Types of Benefits Different Types of Benefits 39393939
A. Family Income Support Benefits 39
1. Assistance for Infants 39
2. Family Allowances that Evolve with Number of Children 41
2.1 General Family Allowance 41
2.2 Family Supplement 41
2.3 Old Age Insurance for Stay at Home Parents 41
3. Assistance to Single-Parent Families 41
3.1 Family Support Allowance 42
3.2 Assistance in Collection of Child Support Payments 42
3.3 Single Parents’ Benefits 42
4. Other Benefits 42
4.1 Specific Situations 42
4.1.1 The Handicapped Child: The Special Education Allowance 43 4.1.2 The Sick Child: The Parents Assistance Allowance 43
4.2 Schooling Expenses Allowance 43
B. Personal Housing Subsidies 44
C. Social Services 45
1. Disabled Adult’s Allowance 45
The French Social Protection System
II. The Role of the Family Branch’s Directorate II. The Role of the Family Branch’s Directorate II. The Role of the Family Branch’s Directorate
II. The Role of the Family Branch’s Directorate 47474747
Part IV: Social Assistance Part IV: Social Assistance Part IV: Social Assistance
Part IV: Social Assistance and Supplementary Social Actionand Supplementary Social Actionand Supplementary Social Actionand Supplementary Social Action 48484848
I. Social Assistance Programmes 48
II. The Minimum Income Policy 49
III. Supplementary Social Action 50
Part V: Unemployment Benefits Part V: Unemployment Benefits Part V: Unemployment Benefits
Part V: Unemployment Benefits 52525252
Introduction 52
I. I. I.
I. The Unemployment BenefitsThe Unemployment BenefitsThe Unemployment BenefitsThe Unemployment Benefits 53535353 A. The Unemployment Benefit Based on Previous Salary 53 B. The Assistance and Personalized Support Services for
Employment Seeking 53
C. The “Solidarity” Scheme (Society’s Responsibility) 53
II. Organisational Aspects II. Organisational Aspects II. Organisational Aspects
II. Organisational Aspects 54545454
Part VI: Financing the Different Benefits Part VI: Financing the Different Benefits Part VI: Financing the Different Benefits
Part VI: Financing the Different Benefits 56565656
Introduction 56
I. I. I.
I. Financing the Mandatory BenefitsFinancing the Mandatory BenefitsFinancing the Mandatory BenefitsFinancing the Mandatory Benefits 58585858
A. Principles 58
B. Decision-Making Process 59
C. The Role of the Collection Branch 60
II. Financing the Agricultural Sector Regime II. Financing the Agricultural Sector Regime II. Financing the Agricultural Sector Regime
II. Financing the Agricultural Sector Regime 60606060 III. Financing Non
III. Financing Non III. Financing Non
III. Financing Non----Mandatory BenefitsMandatory BenefitsMandatory BenefitsMandatory Benefits 61616161 Appendix
Appendix Appendix
The French Social Protection System INTRODUCTION: THE FRENCH SYSTEM OF SOCIAL PROTECTION
INTRODUCTION: THE FRENCH SYSTEM OF SOCIAL PROTECTION INTRODUCTION: THE FRENCH SYSTEM OF SOCIAL PROTECTION INTRODUCTION: THE FRENCH SYSTEM OF SOCIAL PROTECTION
It is not easy to provide an understandable yet accurate description of the French Social Security System.
For more than 100 years, numerous social, economic and political factors have had an impact on the development of the French Social Security System. The development of social security protection in neighbouring countries, particularly Germany and the United Kingdom, has also had an effect. Today, the French Social Security System consists of a complex network of schemes, covering virtually the entire population of France and providing a wide variety of benefits.
History History History History
As was the case for other European countries, the Industrial Revolution during the 19th century had a profound impact on the development of French society.
During a few decades, a growing working class appeared, totally dependent on regular wages for its livelihood. Occupational risks, associated with the development of modern industries, increased. At the same time a growing number of people were displaced, cut off from traditional forms of community support (religious, family or guild associations). They were, therefore, particularly vulnerable – at risk of becoming destitute as a result of old age, sickness, occupational injury or unemployment. Traditional tort liability law, when applicable, was ill adapted to helping them. Even when applicable, its implementation was inefficient, and it was poorly adapted to situations where power relations were clearly out of balance.
Over the century, mutual aid societies arose, taking the place of the old guilds, which had been abolished in 1791, during the French Revolution1. Toward the
end of the 19th century and the beginning of the 20th, a social assistance
system was developed. But this system, useful as it was, benefited only a fraction of the population. Based on voluntary contributions from working people, and conceived of as a last resort for people who were destitute as a result of old age, sickness, occupational injury or unemployment, it did not provide adequate protection for the population at large against the economic and social distress caused by the loss of income, for a person who could not work.
New institutions that provided more adequate protection slowly evolved. A law passed in 1898 established the principle of an industrial employer’s absolute liability in the event of an occupational injury.
1 Mutual aid societies ("sociétés de secours mutuel") were legally recognised in 1835. The right to
The French Social Protection System A number of schemes covered certain types of workers (seamen, civil servants, miners, railwaymen), but the first attempt at organising a mandatory old-age pension scheme benefiting all employees proved to be a failure: the first law, passed in 1910, had little, if any, impact.
After World War I, the region of Alsace-Lorraine that had been annexed by Germany was reunited with France. Social security programmes developed in Germany under Chancellor Bismarck had been implemented there, and this accelerated their adoption in France. After lengthy debates, an insurance scheme was introduced by law in 1930, protecting employees in commerce and industry against the financial consequences of sickness, maternity, disability, old-age and death. Funding the scheme depended on equal contributions from both the employee and the employer.
Family allowances were originally created by certain employers as a way to attract and retain workers, thus increasing employee retention. They were extended to all private sector employees in 1932. The effort to assist families was further extended by the Vichy regime. The family allowances of 1932 were extended first to agricultural workers (1936), then to agricultural employers (1938), then to all employees (1939).
After World War II, development of a comprehensive social security system was begun. The new scheme was influenced by the Beveridge Report; it promoted a universal system, with a unified scheme that expressed society’s responsibility toward all its members. In 1945, the General Scheme ("Régime général") was created, with the mission of rapidly covering the entire population2.
But after a short-lived period of national unity, differences arose, based on competing interests. Contributors benefiting from special schemes were unwilling to lose the advantages they enjoyed by participating in a single scheme. Their schemes were "temporarily" maintained. Independent workers, tradesmen and artisans did not want to be classed together with wage earners and were wary of the potential cost of a comprehensive system. They were granted the right to create their own schemes based on lower levels of coverage.
In 1947, a supplementary pension plan was introduced for managerial and professional employees ("cadres") by a national inter-professional collective agreement between trade unions and employees' associations. In 1962 a majority of private-sector employees were covered by a supplementary pension plan, in addition to their basic social security pension plan.
During post-war reconstruction, unemployment seemed to be less of a threat than it had been before. For this reason, unemployment insurance was not part
2 Although the General Social Security Scheme (“Régime général”) was implemented, a number of
The French Social Protection System of the 1945-1946 social security plan, but was created much later in 1958, by way of an inter-professional collective agreement3.
As supplements to the social security schemes were being developed and special independent schemes were being maintained or created, the status of the General Scheme (Régime général), as the main provider of social security benefits, was being strengthened. In addition to covering private sector employees, the scheme was extended over the years to cover other categories of the population (for example, students, war widows and orphans, and disabled persons). Successive reforms also allowed people who would otherwise have ceased to be eligible for benefits to remain covered, by applying increasingly liberal requirements for personal contributions.
In 1978, the entire population of France became eligible for family benefits, with no condition of employment. Today, the General Scheme’s national fund for family support programs (CNAF) provides family benefits to every eligible person legally residing in France.
Health Insurance has been constantly extended over the years to new categories of people, with the often repeated goal of attaining total coverage. The Universal Medical Coverage (Couverture médicale universelle: CMU) implemented in 2000 is the final step in this direction.
Contribution to a pension plan was made mandatory in 1972, for all working people, and a guaranteed old-age minimum income (“minimum vieillesse”) was established for people who had made little or no contributions.
The French System Today The French System Today The French System Today The French System Today
Over the years, the French social protection system has evolved into a complex mosaic of benefits, contributory as well as non-contributory, covering various social hazards. Although they were originally very different in terms of management, contributions and coverage, the various schemes have come to be very similar to the General Scheme (Régime général). This trend is noticeable among the different private sector schemes, especially for the health-care benefits.
The General Scheme (Régime général), is the main scheme. Itgenerates more than half of the total social security expenditure4 in France. Its basic pension
3 From the time they were created to today, French supplementary pension plans and the Unemployment Insurance fund have featured a management model with strong involvement on the part of the social partners both for their overall direction and their key decisions. Social Security institutions, on the other hand, despite affirming the principle of democratic management (with boards composed originally of a majority of trade union representatives) have always been under close State supervision.
The French Social Protection System plan5 covers private sector employees. Its health insurance scheme6 covers
about 80% of the population. Its family support programs are accessible to all eligible claimants, without requiring employment or personal contributions. Other professional or sector-based schemes, whether basic or supplementary, are also part of the first social protection pillar, which is usually called “Social Security”7. The most important of the professional or sector-based schemes are
the agricultural scheme, the different civil servants' schemes, and a series of more or less co-ordinated schemes covering self-employed workers8. The
agricultural workers’ fund (MSA) and the funds connected with it, play the same role as the General Scheme. They are responsible for collecting the withholdings of their members (agricultural employees and employers, rural trade groups and financial organisations) into special funds. They reimburse certain expenses (illness, maternity, disability, occupational injury, family expenses, old-age pensions, etc.), and are also responsible for promoting health and social welfare activity and preventing occupational accidents. On July 1st 2006, the Independents Social Scheme (RSI) was implemented as a
result of the fusion of the Independents Health Care Insurance Scheme (AMPI), the Artisans Old Age Insurance Scheme (AVA) and the Retailers’ Old Age Insurance Scheme (ORGANIC)9.
The institutions offering voluntary supplementary coverage comprise the second pillar.
Unemployment Insurance is separate from Social Security for historical reasons. The social assistance programs deliver subsidies and offer services to identified categories of the population.
All these components are part of what in France is called the “Social Protection System”. Its main features will be described in the different parts of this document. As a whole, the Social Protection System delivers benefits amounting to € 505.5 billion, or 29.6% of the GDP10.
5 Administered by the Caisse nationale d'assurance vieillesse des travailleurs salariés (CNAVTS). 6 Administered by the Caisse nationale d'assurance maladie des travailleurs salariés (CNAMTS). 7 In France, the term "Sécurité sociale" is often used to refer to the mandatory Health Insurance
scheme, which can be misleading.
8 See Appendix 2 for an overview of the different mandatory schemes. 9See: http://www.le-rsi.fr/.
10 See Julien BECHTEL et Michel DUÉE, « Les prestations de protection sociale en 2005 », DREES,
The French Social Protection System PART I: HEALTH CARE AND HEALTH INSURANCE SYSTEMS
PART I: HEALTH CARE AND HEALTH INSURANCE SYSTEMS PART I: HEALTH CARE AND HEALTH INSURANCE SYSTEMS PART I: HEALTH CARE AND HEALTH INSURANCE SYSTEMS
Introduction Introduction Introduction Introduction
Health care expenditures amount to 11.1% of GDP in France for 200611. That
same year, France allocated € 198.3 billion to its health system, or € 3,138 per inhabitant12. Health care and medical goods account for 12.1% of household
consumption. The French system can be described as expensive, but the population strongly supports it13. In a report released in 2000 that analysed the
performance of the health systems of its 191 members, the World Health Organisation (WHO), ranked the French system first in providing the best overall health care14.
I. I. I.
I. Medical ServicesMedical ServicesMedical ServicesMedical Services
Medical services in France are provided by public institutions (hospitals), private institutions (private hospitals: cliniques) and by private providers (doctors and other medical and paramedical professionals). Medical density is relatively high15 compared with other European countries, although distribution
across the nation is uneven. The growth of the number of practitioners in the different medical and paramedical professions is monitored by a numerus
clausus mechanism (system of quotas), which restricts the number of students
allowed to enter the different disciplines. Public hospitals account for about three-quarters of the overall number of hospital beds16, providing 81% of the
general medicine beds and 63% of the gynaecology-obstetrics beds. Surgery beds are about evenly divided between private and public hospitals (44% for clinics and 10% for private not for profit hospitals)17. On the one hand, the
number of short-stay hospital beds has decreased over the last 18 years, reflecting the general decrease in the length of stay and the development of alternatives to regular hospitalisation. On the other hand, beds in long-term
11 In 2006, France was ranked third in the Organization for Economic Cooperation Development
(OECD) countries. See http://www.sante.gouv.fr/.
12 See Annie FENNINA and Yves GEFFROY, “Les comptes nationaux de la santé en 2006,” DREES, n°
593, septembre 2007.
13 Two-thirds of the population are fairly satisfied with the system, which is relatively high compared
with public opinion in other European countries: Eurobarometer 1997, cited in “The changing Health System in France” OECD, 2000.
14 See World Health Report 2000 on http://www.who.int/.
15 See OECD, Health Data 2003: in 2003, France had 3.4 doctors per 1000 inhabitants (51% of them
specialists) and 465 494 hospital beds of which 38% for acute care. In 2003, a total of 201,400 doctors were practising in mainland France and 4,307 in the overseas departments .There were 423,400 nurses in 2003, 73% of whom were employed by a public or private hospital. See DREES “Données sur la situation sanitaire et sociale en France en 2005”, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour 2005.
16 See DREES “Données sur la situation sanitaire et sociale en France en 2005”, Annexe A au Projet
de la loi de financement de la Sécurité Sociale pour 2005.
17 See DREES “Données sur la situation sanitaire et sociale en France en 2005”, Annexe A au Projet
The French Social Protection System care institutions have increased in recent years, in response to the needs of a growing number of dependant elderly people18.
Public hospitals are funded through budgets set annually by local hospitalisation agencies (Agence régionale de l’hospitalisation - ARH). These are responsible for distributing the regional budget among the different institutions. Private hospitals are paid on a fee-for-service basis. A schedule of fees is contracted annually between the ARH and each private hospital. The different ARH are also responsible for monitoring the activity of the medical institutions operating in their region. They do this by setting objectives in the contract signed with each hospital. They also authorise the creation or expansion of medical departments and the acquisition of major pieces of equipment.
The prices of reimbursable drugs and other medical goods are set by the government following consultation with experts and providers. The prices of non-reimbursable drugs are set by the pharmaceutical companies.
Medical practitioners and allied medical workers are paid on a fee-for-service basis. Fees are part of periodic agreements (conventions) signed by professional associations and the three national health insurance funds (CNAM, MSA and RSI (Health Care Branch)), under the supervision of the State. Official schedules of reimbursement are set according to these agreements, but some of the doctors are allowed to charge more than the official schedules. At the present time, no additional doctors are being granted this privilege and the number of doctors benefiting from it is slowly decreasing19.
Hospital expenses accounts for 47.9% (€ 69.9 billion in 2006) of the total health care consumption, 27.3% (€ 42.8 billion in 2006) of these expenses are generated by health professionals and 20.4% by prescription drugs.20 Health
expenditures accounted for 11.1% of GDP in 2006 (€ 198.3 billion). France ranks third in the world behind the United States (15.3%) and Switzerland (11.6%)21, in terms of health expenditures as a percentage of GDP.
18 According to the memo DHOC/O/n. 44 of February 4th 2004 on home-hospitalization, in terms of
handling capacity, the closure of 70,000 hospital beds over the past 10 years was accompanied by the creation of 48,000 part-time beds, to which we can add 4,200 spaces for home care. Beds for long term care represented, in 2002, 17.5% of total beds, compared to 10% in 1987. See DREES “Données sur la situation sanitaire et sociale en France en 2005”, Annexe A au Projet de la loi de financement de la Sécurité Sociale pour 2005.
19 The “Secteur II” was created at the beginning of the 1980's. Since 1990 it has been closed to
further access. About 25% of doctors belong to “Secteur II”, but the percentage is higher for specialists than for general practitioners. The portion of the fee that exceeds the official schedule is not reimbursed by the basic Health Insurance scheme or by most of the supplementary schemes.
20 See Annie FENNINA et Yves GEFFROY, « Les comptes nationaux de la santé en 2006 », DREES,
Études et Résultats n° 593, septembre 2007.
The French Social Protection System Since the mid-1970’s, various reforms have been implemented in an attempt to slow the growth of health-care expenditure and reduce the deficit. Earlier plans attempted without success to balance Health Insurance accounts. They increased funds while raising the cost of health care for patients, in order to promote more economic behaviour and to counter the inherent tendency of spending, in a system that gives both patients and professionals a great deal of freedom to spend.
Faced with a severe financial crisis in the Social Security system in the 1990s, the authorities promoted a series of reforms in order to ensure the solvency of the system and to allow it to adapt to changing conditions. In 1996, the French constitution was revised, and a series of ordinances were established to allow Parliament to pass a law each year financing the Social Security system. This law contains a National Health Care Spending Objective (ONDAM), detailed in different sections (private hospitals, public hospitals, benefits-in-kind, ambulatory care, etc). This objective is based on revenue estimates and on health priorities defined by a National Health Conference. The ONDAM is not mandatory – benefits are paid even if the target is eventually exceeded (as has been the case so far), – but resources allocated to the different institutions and agreements contracted with professionals must be consistent with its provisions.
It is still early to judge the effectiveness of regulations which, in some cases, have not yet been fully implemented, but a trend towards a reduction in the rate of growth seems to be discernible, with health spending as a percentage of GDP falling slightly between 1995 and 1998. Health expenditure remains, nonetheless, a concern for public authorities.
II. II. II.
II. Health Insurance SchemesHealth Insurance SchemesHealth Insurance SchemesHealth Insurance Schemes
The French system of Health Insurance is composed of two tiers. The first tier provides basic coverage through different mandatory schemes, which cover about 75% of household medical expenses. The second tier consists of an optional supplementary coverage provided by mutual (not-for-profit) or private insurers. Health insurance schemes provide benefits in kind, as well as cash benefits, to compensate for the loss of income in certain kinds of situations (illness, disability, maternity, occupational injury/disease).
Since 2000, the legislation on the Universal Medical Coverage (CMU) is in place, thus ensuring that any legal resident in France who is not covered by another mandatory health care insurance scheme has access to the health care insurance to cover all medical costs: the basic CMU. 22
22 5.3 million low income persons also have access to 100% coverage under a supplementary CMU
The French Social Protection System After three weeks of debate at the National Assembly and another in the Senate, the legislation reforming healthcare was adopted on July 30th 2004
and promulgated on August 13th 2004 (Legislation n. 2004-810).
Key points of the legislative reform for the claimants Key points of the legislative reform for the claimants Key points of the legislative reform for the claimants Key points of the legislative reform for the claimants
The 2004 reform has led to many modifications to the services offered to the claimant23.
The Personal Medical File The Personal Medical File The Personal Medical File The Personal Medical File
No later than July 1st 2007, each claimant will be the holder of a personal medical file composed of health information obtained during medical visits. This will allow the tracing of health care acts and services.
Access to the medical file will be limited to medical acts (for Occupational Health Physicians or for contractual purposes).
The level of coverage for the expenses incurred by the claimant will be subordinate to the authorization to access the medical file that he or she will grant the health care professional. The variation of the level of coverage will be defined by the National Union of Health Care Organizations - UNCAM (Union nationale des caisses d’assurance maladie) within the limits imposed by a Conseil d’Etat decree (s. 3).
The Health The Health The Health
The Health----Care Protocol for LongCare Protocol for LongCare Protocol for LongCare Protocol for Long----Term Care (ALD)Term Care (ALD)Term Care (ALD)Term Care (ALD)
In order to benefit from the partial or total co-payment exoneration, the long term care patient must (except in case of emergency) present the consulting physician with the medical protocol, that he will have signed, as established by the attending physician and the medical expert of the fund (s. 6).
Furthermore, the health-care protocol must mention the obligations imposed to the beneficiaries of the ALD, including:
To follow the treatments as prescribed jointly by the attending physician and the medical expert;
To attend the medical visits and controls as organized by the fund; To abstain from all non-authorized activity and to do the prescribed exercises for re-education or professional reclassification purposes.
Treatments Possibly Leading to Improper Use Treatments Possibly Leading to Improper Use Treatments Possibly Leading to Improper Use Treatments Possibly Leading to Improper Use
The Health Care system will cover expenses and treatments that might lead to improper use (such as Subitex®) under certain specific conditions. For every
23 For further information on this reform, see “ Comprendre la reformer de l’Assurance Maladie“:
The French Social Protection System prescription renewal, the patient must provide the physician with the name of the pharmacist responsible for the delivery of the medication.
The physician must include the name of the pharmacist on the prescription – which must then only be delivered by him in order to ensure coverage (s. 17). The Attending Physician
The Attending Physician The Attending Physician The Attending Physician
Any claimant or beneficiary of at least 16 years of age must choose a primary physician (generalist or specialist) in order to benefit from the co-payment plan. If the claimant has not made this choice or has directly contacted a specialist in certain areas, the co-payment portion could be increased. This increase will not be applied in cases where a health care protocol is established (for long term care) and in cases of emergency (s. 7).
Furthermore, specialized physicians who are directly contacted by patients “are authorized” “to charge increased fees for all consultations” (s. 8). However, there are certain specialists, not identified as of the date of publication, who will still fall into the direct-access category (ex.: pediatricians, ophthalmologists, etc.).
Increased fees will continue to be the responsibility of the beneficiary of the supplementary CMU who would consult a specialist directly (s. 10).
Co Co Co
Co----paymentpaymentpayment payment
In order to render claimants responsible, they are required to financially participate for every act or for each appointment with a physician that is covered by health care insurance (whether in a private practice, a health institution or centre). Also, participation will be required for all biological medical acts.
This payment is applicable to claimants that are ill as well as those for workers victims of occupational injury or disease. However, all payments by these claimants will have a ceiling, established by decree, to a “maximum number of payment contributions”.
Furthermore, persons hospitalised (except in cases of emergency hospital care and external consultations), claimants under the age of 16, beneficiaries of the CMU and women covered by maternity benefits will not have to pay this supplement (s. 20).
The amount of this participation is to be established by decree and currently stands at € 1.
To discourage supplementary health care organizations from taking on the financial responsibility for this payment, the benefits related to the non payment of social costs on bonuses or contribution and non payment of taxes
The French Social Protection System on insurance agreements will be limited to those contracts that establish both a minimal level of coverage and exclusions to coverage (such as the one related to this payment). This schedule of conditions will be implemented for all applicable contracts as of January 1st 2006 (s. 57).
Assistance for acquiring supplementary health care coverage Assistance for acquiring supplementary health care coverage Assistance for acquiring supplementary health care coverage Assistance for acquiring supplementary health care coverage
As of January 1st 2005, assistance for acquiring supplementary health care
coverage is in place for those who, due to their low income, cannot otherwise benefit from it.
A tax credit will be available for supplementary individual health care insurance contracts signed with supplementary coverage organizations by those claimants whose resources are within the applicable ceiling for supplementary CMU and the same ceiling increased by 15%.
The amount of the tax credit will vary based on the number and the age (the age being evaluated on January 1st of that year) of the persons in the
household.
The management of this tax credit is the responsibility of the financial management fund of the supplementary CMU. The funds expenses will be financed by a global take on the health care system.
The Health Care Card The Health Care Card The Health Care Card
The Health Care Card –––– Carte VitaleCarte VitaleCarte VitaleCarte Vitale
The information contained in the health care card (medical acts, delivery of products and services provided) are now accessible to the physician. A picture will be added to the new version of the card (Vitale 2). Also, the legislation has included a provision whereby medical institutions can ask a claimant for proof of identity (s. 21).
Sick Leave and Payments of Daily Indemnities Sick Leave and Payments of Daily Indemnities Sick Leave and Payments of Daily Indemnities Sick Leave and Payments of Daily Indemnities
The payment of daily indemnities will be suspended when the claimant does not submit himself or herself to the controls established by the Medical Control Service (s. 27). The fund will inform the employer of this suspension. The employer will then have the possibility to suspend supplementary compensation.
Furthermore, the daily indemnities beneficiaries’ obligations (to follow physicians orders, to submit himself or herself to the controls, to respect the hours allocated to leaving the home and to abstain from all non authorized activity) are no longer included in the operational regulations of the CPAM – they have now been included in the legislation in order to have more clout. Should these responsibilities and obligations not be respected, the daily indemnities can be withheld, either partially or totally. A legal control, within the purview of the Social Security, can occur in case of recourse, “on the amount of the sanction announced and its appropriateness as it relates to the
The French Social Protection System infraction by the claimant”. The portion of the cash payment to be withheld will be obtained in one or more payments “depending on the social situation of the household” (s. 29).
Also, the renewal of the work stoppage or sick leave will now exist within a framework. The compensation will be conditional on the extension of the work stoppage order by the same physician who initially signed off on it (s. 28). Finally, new assistance possibilities are offered to the claimant to favour his or her return to work (s. 24).
A. A. A.
A. Basic SchemesBasic SchemesBasic SchemesBasic Schemes
There are not as many basic Health Insurance schemes as there are pension plans, but the principle of employment-based coverage still exists.
The General Scheme (Régime général) delivers 86.6%24 of the benefits, and
covers private sector employees, public servants (benefits-in-kind), as well as different categories of people who were not originally covered by a scheme (for example, students, war veterans, persons benefiting from certain guaranteed minimum incomes such as certain family allowances). The General Scheme (Régime général) has thus been used over the years as a “catch-all” scheme, to provide access to medical coverage for the entire population.
A variety of small special schemes cover different categories of workers (for example, railway employees, employees of the Paris public transportation system, seamen, and employees at the Banque de France25). Cash benefits for
public servants are funded by the State through the general budget.
Two other schemes cover other categories of workers: one protects those working in the agricultural sector (MSA26), and the other protects artisans, entrepreneurs, tradesmen and retailers, as well as professional people and lawyers (RSI27).
24 See Eco-Santé France, 2007 (January 2008 version), http://www.irdes.fr/. 25 See chart in appendix, “Other Special Schemes”.
26 See http://www.msa.fr.
27 A national fund (the Social Scheme for Independent Workers - RSI) is responsible for co-ordinating
the system. Benefits are paid by an approved insurer, chosen by the insured person from an approved list. Contributions are no longer paid directly to the chosen insurer as of January 1st 2008, except for
The French Social Protection System 1.
1. 1.
1. BenefitsBenefitsBenefitsBenefits----inininin----KindKindKindKind
Coverage provided by mandatory basic schemes varies according to the nature of the expenses. Hospitalisation-related expenses are covered at a rate of 80%. Outpatient care and medical equipment are covered at about 65% and 58% of their cost28, respectively. As a whole, Social Security schemes cover about 80%
of household health expenses.
For outpatient care, the patients pay the provider directly, and are subsequently reimbursed. Reimbursement by the Social Security is usually partial; the patient is responsible for a copayment (ticket modérateur), which in some cases is reimbursed by supplementary insurance. Direct payment to doctors from the Health Insurance fund is growing (and already exists in certain types of situations, such as occupational injuries). Local agreements between health insurance funds and pharmacists’ organisations have also led to an increasing percentage of medical prescriptions being paid directly.
1.1 1.1 1.1
1.1 General Scheme General Scheme General Scheme General Scheme (Régime général)(Régime général)(Régime général)(Régime général)
Benefits-in-Kind account for 93.7% (about € 112.9 billion in 2006) of the expenses of the health insurance scheme29.
Conditions of entitlement: employees must meet certain minimum requirements in terms of paid employment in order for them and their families to be covered30.
The reimbursement rates vary according to the services or medical goods provided31. Rates are set by the official schedules. Coverage can be 100% in
certain types of situations32.
28 See Eco-Santé France 2004, CREDES-DREES.
29 In 2006, total expenditure (sickness, maternity, disability, occupational injury/diseases, and death)
was € 112.2 billion, of which: € 112.9 billion was for benefits-in-kind, and € 7.3 billion was for cash benefits. 87% of the total was allocated to sickness benefits (both in-kind and cash). See “Chiffres et repères de l’assurance Maladie 2004”, http://www.ameli.fr/.
30 Conditions have become less and less stringent over the years. A contribution to the scheme from
employment income amounting to 60 times the minimum hourly wage is enough to cover the contributor and his/her dependants for a period of 4 years. If need be, special rules apply to maintain the coverage beyond that.
31 Examples: prescribed drugs: 35%, 65% or 100%. Physicians: 70% (for both specialists and general
practitioners (same rate applies to dentists). Allied medical workers: 60%. Optic lenses: 65%. See http://www.ameli.fr/ for other rates.
32 For example, persons suffering from a recognised long-term illness, disability or occupational injury,
pensioners, pregnant women (from the fourth month of pregnancy), and persons benefiting from the CMU. See http://www.canam.fr/ for more details.
The French Social Protection System 1.2
1.2 1.2
1.2 Agricultural Workers’ Fund Agricultural Workers’ Fund Agricultural Workers’ Fund Agricultural Workers’ Fund (MSA)(MSA)(MSA)(MSA)
The same reimbursement rates and conditions apply for the agricultural sector. The agricultural workers and their dependants covered have the same benefits in terms of sickness coverage as employees covered by the General Scheme.
1.3 1.3 1.3
1.3 Fund for the SelfFund for the SelfFund for the SelfFund for the Self----Employed Employed Employed Employed (RSI)(RSI)(RSI)(RSI)
Self-employed workers originally chose to remain outside the General Scheme (Régime général) and to set up their own scheme, with lower contribution rates and less benefits. Although the contribution rates remain inferior, the benefits-in-kind have been progressively adjusted and today are equivalent to those offered to employees33. Since January 1st 2001, the reimbursement rates are
aligned to those of the employees’ General Scheme (Régime général). This scheme covers entrepreneurs, tradesmen, artisans and independent professionals. Since January 1st 2006, the CANAM is an integral part of the RSI
(see note 27). 2.
2. 2.
2. Cash BenefitsCash BenefitsCash BenefitsCash Benefits
2.1 2.1 2.1
2.1 General Scheme General Scheme General Scheme General Scheme (Régime général)(Régime général)(Régime général)(Régime général)
Cash benefits amount to 7.3% of the total value of all benefits, and compensate the loss of professional income in a certain number of situations. Direct contributors (as opposed to covered family members) compelled to stop working are entitled to cash benefits. The surviving spouse of a deceased contributor is entitled to a death grant in certain circumstances34.
2.1.1 Maternity Bene 2.1.1 Maternity Bene 2.1.1 Maternity Bene 2.1.1 Maternity Benefitsfitsfitsfits
Conditions for entitlement Conditions for entitlement Conditions for entitlement
Conditions for entitlement: a pregnant woman has to meet certain requirements (in particular a minimum amount of paid employment prior to the leave) in order to be entitled to maternity leave35.
The length of the maternity leave The length of the maternity leave The length of the maternity leave
The length of the maternity leave varies based on the number of children expected and the number of children already born. The typical leave (mother of
33 See http://www.canam.fr/ for more details.
34 “Capital décès”: equal to the last3 months’ salary of the deceased contributor. The minimum
amount of the death grant is € 332.76 (as of January 1st 2008). The maximum amount of the death
grant is € 8,319.00 (as of January 1st 2008). See http://www.ameli.fr/ “Décès” for more details on the
conditions. On the Social Security ceiling mechanism, see Appendix 4.
35 A pregnant woman must have worked at least 200 hours in the three months prior to the beginning
of the pregnancy, or prior to the prenatal leave. She must moreover have been contributing for at least ten months to the scheme at the estimated date of the delivery. See http://www.ameli.fr/ for more details.
The French Social Protection System two or less children expecting a single child) is 16 weeks, 6 before and 10 after the birth36.
The amount of the maternity benefit The amount of the maternity benefit The amount of the maternity benefit
The amount of the maternity benefit depends on the wages. The daily allowance amounts to the average daily wage received in the 12 months prior to the maternity leave with a maximum amount of € 74.24 per diem in Alsace-Moselle and € 72.72 per diem in other French departments (as of January 1st
2008)37. Collective bargaining contracts often top up the social security benefit
in order to maintain the expectant mother’s income during the leave. 2.1.2
2.1.2 2.1.2
2.1.2 Sickness BenefitSickness BenefitSickness Benefit Sickness Benefit
Conditions for entitlement: Conditions for entitlement: Conditions for entitlement:
Conditions for entitlement: A minimum length of paid employment prior to the leave is required. The amount required varies according to the length of the leave (more or less than 6 months)38.
Sickness benefits Sickness benefits Sickness benefits
Sickness benefits are paid from the fourth day of leave in cases of hospitalisation, and on the eighth day in cases of illness or accident39. The
amount of the benefit is 50% of the average daily wage received in the 3 months prior to the leave, with a maximum of about € 46.22 per diem as of January 1st 200840. Collective bargaining agreements may top up the rest.
2.1.3 Occupational Injury/Illness Benefits 2.1.3 Occupational Injury/Illness Benefits 2.1.3 Occupational Injury/Illness Benefits 2.1.3 Occupational Injury/Illness Benefits
Occupational injuries have historically been the first risk covered by collective insurance mechanisms. Today, occupational injury and illness benefits are still organised under a specific body of rules, and constitute their own sub-scheme within the General Scheme’s (Régime Général) Health Insurance scheme. Funding comes from employer-only contributions; the following rates are applied:
0,6% of revenues within the annual limit of the Social Security ceiling (€ 30,123.00 for 2005)
36 Expecting mothers of twin babies are entitled to take 12 weeks prior and 22 weeks after the birth.
Expectant mothers having already had more than two children are entitled to take 8 weeks before and 18 weeks after the birth. In any case, it is mandatory to take a minimum of 8 weeks of maternity leave. See http://www.ameli.fr/ for further details.
37 See http://www.ameli.fr/ for further details.
38 Condition of entitlement: professional activity of at least 200 hours during the 3 months prior to the
leave or have contributed on a salary at least equal to 1,015 time the amount of the hourly minimum wage (SMIC) over the 6 months prior to the sick leave (less than 6 months), or (more than 6 months) 800 hours during the 12 months prior to the leave (with 200 hours during the 3 first of the 12 months) or have contributed on a salary at least equal to 2,030 times the hourly minimum wage (SMIC) over the 12 months prior to the sick leave, of which at les 1,015 times the amount of the hourly minimum wage (SMIC) over the first 6 months. See http://www.ameli.fr/.
39 See http://www.ameli.fr/. 40 See http://www.securite-sociale.fr/.
The French Social Protection System + 5.9% of revenues within the limit of 5 times the annual limit of Social Security ceiling (€ 150,960.00 for 2005)41.
Conditions for entitlement: Conditions for entitlement: Conditions for entitlement:
Conditions for entitlement: All employees42 are protected, without condition of
a minimum paid employment prior to the injury. Employment injuries are broadly defined by the law43. Traffic accidents, if they are work-related, receive
the same protection. Occupational illnesses are those itemised on a special list, and are contracted under the conditions described in the list.
Benefits: Benefits: Benefits:
Benefits: Two types of benefits can be paid. An allowance is paid if the incapacity to work is only temporary. In case of permanent disability, a pension is paid according to the level of disability.
Amount Amount Amount
Amount: Daily allowances are paid starting the day after the accident (the employee is responsible for the daily wage on the day of the accident). The daily amount is equal to 60% of the daily average wage of the last month for the first 28 days (with a maximum amount of € 151.08 per day as of January 1st 2005), and 80% from the 29th day (with a maximum amount of € 201.44
per day as of January 1st 2005). The maximum daily allowance is higher than
the allowance paid for regular sick leave44.
Pensions are based on the average wage of the last 12 months and consist of a percentage of this average depending on the recognised percentage of disability. Pensioners needing constant assistance from a third person receive an additional 40%.
Occupational injury and professional illnesses coverage is mandatory for agricultural workers as well as farmers, family helpers and spouses who participate in the work. It guarantees benefits in kind and cash benefits. The Agricultural Workers’ Fund (MSA) now manages the workers’ benefits: other categories have the freedom to select the insurer.
2.1.4 Disability Pensions 2.1.4 Disability Pensions 2.1.4 Disability Pensions 2.1.4 Disability Pensions
Conditions for entitlement: Conditions for entitlement: Conditions for entitlement:
Conditions for entitlement: To be eligible, a claimant must have suffered a reduction of 2/3 of his capacity to work, be under the age of 60, establish that he has been insured for at least 12 months and show that he has had a minimum amount of paid employment45.
41 For daily indemnities, artisans and trades people pay an extra due of 0.5% of revenues (within the
limit of 5 times the annual ceiling of the Social Security). See http://www.canam.fr/.
42 Other different categories of people are also protected. See L412-2 and L412-8 Code de la sécurité
sociale.
43 See section L411-1 Code de la sécurité sociale. 44 See http://www.ameli.fr/.
45 Evidence must be provided that least 800 hours of work have been performed in the last 12 months
The French Social Protection System Amount of the pension
Amount of the pension Amount of the pension
Amount of the pension: The amount is based on the salary history and depends on the level of disability.
Contributors able to undertake paid work are entitled to 30% of their average annual wage46. Maximum monthly pension is about € 754.80 (as of January 1st
2005)47. Contributors unable to undertake any paid work are entitled to 50%,
with a maximum of about €1,258 per month (as of January 1st 2005)48. The
pension is increased if the daily assistance of a third person is necessary49.
2.2 2.2 2.2
2.2 Other SchemesOther SchemesOther SchemesOther Schemes
Benefits available to employees in the agricultural sector are equivalent to those provided by the General Scheme (Régime Général): however, farmers do not benefit from a per diem rate for illness through the health care system. Civil servants are entitled to the benefits-in-kind provided by the General Scheme (Régime Général). Cash benefits are special50 and are financed
through the general budget. Cash benefits paid by the Fund for the Self-Employed (RSI) have been modified in 2002 and are becoming closer to those provided to private-sector employees51.
B. B. B.
B. Supplementary SchemesSupplementary SchemesSupplementary SchemesSupplementary Schemes
An estimated 91% of persons living in France have supplementary Health Insurance52. Slightly fewer than half the persons covered by a supplementary
plan have individual contracts. In more than 50% of the cases, supplementary coverage is a job-related benefit subscribed to on a group basis53. Three kinds
of institutions provide supplementary coverage: mutual insurers (not-for-profit: mutuelles) which cover 7.4%54 of the total health expenditure; private insurers
(3.2%) and Provident Institutions (institutions de prévoyance: 2.4%)55.
Supplementary schemes may provide both cash and in-kind benefits.
46 Average annual wage of their 10 “best” years. 47 See http://www.ameli.fr/.
48 See http://www.ameli.fr/. 49 See http://www.ameli.fr/.
50 Sickness leave: 12 months maximum of which 3 with full wage. Employment injury: full wage if the
injury can be linked to the position occupied. The family of a deceased civil servant is entitled to a lump sum equivalent to a year of wage (1/3 for the survivor spouse, 2/3 for children under 21 years of age). See http://www.fonction-publique.gouv.fr “le statut du fonctionnaire” for additional information.
51 See http://www.canam.fr for more details.
52 But only about 78% of the unemployed are covered. See CREDES, “Santé soins et protection sociale
en 2002”.
53 See above.
54 See DREES “Les comptes nationaux de la santé en 2006”, Etudes et résultats, n°593, septembre
2007.
55 47% of people are covered by a mutual insurer, 20% by a private insurer and 15% by a “Provident
The French Social Protection System C.
C. C.
C. Universal Medical Coverage Universal Medical Coverage Universal Medical Coverage Universal Medical Coverage ---- Couverture médicCouverture médicale universelleCouverture médicCouverture médicale universelleale universelleale universelle (CMU)(CMU)(CMU) (CMU) Universal Medical Coverage, which replaces the health care assistance provided by local authorities (départements), has been available since January 2000. It covers all people legally residing in France who would not otherwise have medical coverage, or who experience administrative difficulties in accessing basic coverage due to their particularly precarious situation.
As of December 31st 2005, 1.7 million persons were covered under this
scheme based on residential criteria, of which 300,000 in overseas departments (DOM). With 17% of the population, the basic rate of coverage of the CMU is still higher in overseas departments (by 2%). At the same time, the supplementary CMU covered 4.1 million beneficiaries in mainland France and approximately 600,000 people in the overseas departments56. In 2003, € 0.97
billion were allocated to the supplementary coverage.
Persons benefiting from the CMU are exempt from the co-payment (ticket modérateur), and do not have to pay fees up front (health professionals and institutions are directly paid by the health insurance funds57). They can freely
choose their provider for the supplementary coverage. III.
III. III.
III. Organisational AspectsOrganisational AspectsOrganisational AspectsOrganisational Aspects
The organisation of both the health care and the Heath Insurance system is complex. There is a basic mandatory public pillar with, in most cases, supplementary coverage. The system features a mix of public care (public hospitals58) and private care (cliniques, office-based doctors, allied medical
staff). The French health system delivers high-quality care. It gives patients the ability to choose freely among medical professionals, for both general practitioners and specialists. Treatment is usually provided without the patient having to be placed on a waiting list. Health professionals enjoy a large amount of freedom in prescribing therapies.
Control Control Control Control
Pursuant to the 2004 legislative reform, new rules have been implemented for health care professionals as they must now follow more stringent rules as established by the Executive Health Authority (Haute autorité de santé) or by another method established by decree. Those who do not respect this regulation risk sanctions (s. 14).
56 See http://www.sante.gouv.fr/. See also: DRESS Études et résultats « Les bénéficiaires de la CMU au
31 décembre 2005 » published in August 2006. The annual ceiling of resources allowed to benefit from the supplementary CMU is on January 1st 2007 in the amount of € 7,272 for a single person, €
10,908 for two people, € 13,090 for three people, € 15,271for four people and € 2,908 for each additional person. Amount increased by 10.8% exist for persons living in overseas departments (Martinique, Guadeloupe, Guyanne and Réunion). See http:// www.ameli.fr/.
57 Within the limit of the official fee schedules.
The French Social Protection System These sanctions are already established by the Social Security Code (code de la Santé publique). It will be possible to force a physician to submit to a prior control by the CPAM should he or she wish to prescribe sanitary transport or illness-related work stoppage for a period of 6 months or more (unless it is a confirmed emergency situation) (s. 25).
Reforms undertaken to better control the cost of the system have focused on the necessity of improving its management and allocating responsibilities more effectively between the system’s two major participants, the State and the Health Insurance system. Recent reforms to the French constitution have also given Parliament a role in defining objectives and financial targets, through annual legislation covering financing the Social Security system. Governance
Governance Governance Governance
The 2000 law regarding financing the Social Security system sought to implement a more rational and clear division of roles between the State and the Health Insurance authorities of the General Scheme (Régime Général) and of the two other main basic schemes59. The State is responsible for the hospital
sector, both public and private, and the pharmaceutical sector. Health Insurance authorities supervise the office-based sector. Their contracts with physicians and paramedical professionals specify the conditions of their activity and their fee schedules, within the financial limits set by Parliament under the supervision of the State.
Reforms implemented in the last few years emphasise the central role of the State in the management of the system. This is consistent with the fact that the Health Insurance system is becoming more and more universal and increasingly funded through public resources60. A greater role has been given
to elected representatives, and the responsibilities of the government and the health care funds are being clarified.
Social partners have a share in the management, through boards of directors of the Health Insurance funds, but public authorities make the key decisions. The 2004 legislative reform has led to the creation of 4 new organizations for governance purposes:
UNCAM and UNOAMC (s. 55 UNCAM and UNOAMC (s. 55 UNCAM and UNOAMC (s. 55 UNCAM and UNOAMC (s. 55))))
Creation of UNCAM (Union nationale des caisses d’assurance maladie) and UNOAMC (Union nationale des organismes d’assurance maladie complémentaire). The UNCAM will coordinate the actions of the CNAM, RSI (Health Care Branch) and the CCMSA, define the conditions for reimbursement of medical acts and prescription medication, and establish the applicable tariffs.
59 Régime général (CNAMTS), MSA and CANAM. 60 See Part VI, below.
The French Social Protection System The UNCAM will consult with the UNOAMC on all its decisions relating to registration for reimbursement for medical acts and services as well as the setting of claimants’ financial participation.
Furthermore, a more developed partnership has been instituted between the mandatory scheme and the supplementary ones, namely in the scope of negotiations with health care professionals and institutions, as well as defining common strategies for risk management.
Executive Health Authority ( Executive Health Authority ( Executive Health Authority (
Executive Health Authority (Haute autoritHaute autoritHaute autoritHaute autorité de santde santde santde santé))))
Creation of the Executive Health Authority that is responsible for evaluating “products, and health care acts or services”. This research will contribute to the decision making process for reimbursement.
The Executive Health Authority took over the responsibilities of the ANAES on January 1st 2005 (as the organisation was dismantled) (s. 35-36).
A Hospitalisation Council and Institute for Hea A Hospitalisation Council and Institute for Hea A Hospitalisation Council and Institute for Hea
A Hospitalisation Council and Institute for Health Care Informationlth Care Informationlth Care Information lth Care Information
Creation of the Hospitalisation Council: The Council will contribute to the elaboration of a financial policy, to the achievement of objectives pertaining to hospitalisation related health care costs (s. 45).
Prior to any governmental policy decision on the financial management of public health care institutions, the Council will have to be consulted (s. 64). The Institute for Health Care Information has been created to watch over the quality of the information systems used for illness related risk management as well as the privacy respecting sharing of information.
An Alert Committee on the Evolution of Health Care Costs An Alert Committee on the Evolution of Health Care Costs An Alert Committee on the Evolution of Health Care Costs An Alert Committee on the Evolution of Health Care Costs
This Committee was created in order to warn Parliament, the government and the Health Care funds of any evolution of health care costs that is incompatible with what was voted on by Parliament (s. 40).
The French Social Protection System PART II: RETIREMENT PENSIONS
PART II: RETIREMENT PENSIONS PART II: RETIREMENT PENSIONS PART II: RETIREMENT PENSIONS
Pensions in France are provided through a great variety of schemes organised on a professional or sector-related basis. Basic pensions are complemented by mandatory supplementary pensions covering a large part of the work force (private-sector employees in particular). Civil servants' pensions are organised differently (see below).
Reflecting this, the General Social Security Scheme that provides family benefits to the entire population and health care benefits to about 80%, is in charge of only 11.7million of the pensions annually distributed in France.61
The following principles govern the pension system: participation in a pension scheme is compulsory for individuals whose work is within its jurisdiction; Schemes are mainly funded through earnings-related contributions, and the pensions are provided on a pay-as-you-go basis; A means-tested minimum income, the Old-Age Solidarity Benefit (ASPA) is guaranteed to individuals over 65 years of age (between 60 and 65 years of age in case of inability to work);62
The retirement supplement and the Old-Age Solidarity Benefit replace the previous benefits that constituted the “minimum for the elderly” since January 1st 2006.
The old benefits already in payment by that date are grandfathered. Pension schemes can be divided into several categories:
The first category encompasses employees in the private sector and features two different mandatory pillars. A first-level pension is provided through the General Scheme (employees working in the agricultural sector belong to a different set of pension funds63). Mandatory supplementary pensions are
provided by a variety of funds, co-ordinated by two lead institutions: AGIRC and ARRCO.
The second category consists of the different schemes covering people who are not employees.
61As of July 1st 2007, the number of retirees of the General scheme is almost 11.7 million for almost
17 million contributors, i.e. a demographic ratio of 1.45 active persons for one retiree. This ratio was superior to 4 in the 1960s. The arrival to retirement age of the baby boomers brings with it an important demographic choc. The flux of persons reaching 60 years of age in the whole of the French population increases from approximately 500 000 for the generations born during the Second World War to 800 000 for the generations born after 1946. See “Les comptes de la sécurité sociale 2007”.
62 The old-age minimum is in the amount of € 7,537 per year for a single person and € 13,521.27 per
year for a household as of January 1st 2008.
63 For historical reasons, employees working in a certain number of other sectors, for example the
