Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 77
APPENDIX 4: CROSS-NATIONAL COMPARISON
FRANCE
Introduction
The French health care system is based on a social insurance model in which
contributions are based on income. All citizens and legal foreign residents are covered.
In addition, 90% of the population subscribes to supplementary health insurance to
cover other benefits not covered under NHI.
Responsibilities are divided between the state (the parliament, the government and
various ministries), the statutory health insurance funds and, after the reforms of 1996,
regional and departmental authorities (DRASS [Regional health and social affairs
services] and DDASS [Health and social affairs services at the department level]). The
Social Security Funding Act of 2000 gave the state responsibility for the whole hospital
sector, including private for-profit hospitals that previously were regulated by the
insurance funds 75 . The Ministry of health, among other tasks, divides the budgets over
different health care sectors (and if hospitals are concerned over regions).
The health insurance schemes are under the supervision of the Social Security
Directorate of the Ministry of Social Security. It has the responsibility for the financial
and operational management of health insurance too.
The health system is dominated by solo-based, fee-for-service private practices for
ambulatory care and public hospitals for acute institutional care. Patients are free to
consult each level of care and be reimbursed under NHI 76 .
Insurance framework
Three main health insurance schemes provide a uniform package of benefits: the general
health insurance scheme (Régime Général), the agricultural scheme (Mutuelle Sociale
Agricole, MSA) and the national insurance fund for self-employed non-agricultural
workers (Régime Social des Indépendants, RSI). In addition, there remain several
insurance systems for some professional groups who already had insurance coverage in
1945, including civil servants, mariners, miners, railway-workers, and employees of the
national bank 75 .
In 2000 the Universal Health Coverage Act (Couverture Maladie Universelle, CMU) was
introduced, opening up the right to statutory health insurance coverage on the basis of
legal residence in France and for persons below a certain income level 75 .
Reimbursement is regulated through uniform rates. The financing is supported by
employers, employee contributions, and personal income taxes.
Major reforms were adopted in 2004: the Public Health Policy Act and the Health
Insurance Reform Act, followed in 2005 by new agreements between the national health
insurance funds and medical trade unions on rules governing private practice. The Public
Health Policy and Health Insurance Reform Act insist on the role of the state and
parliament in priority setting in the health sector. They give more power to local and/or
dedicated structures for implementation. The Health Insurance Reform Act also
renewed the governance of national health insurance by reinforcing still further the
position of the government in national insurance fund management. A new branch (the
fifth) of the social security system was created in 2005 to provide support to people
living with disabilities 75 .
The three main insurance funds (Régime Général, MSA and RSI) are federated in a
National Union of Health Insurance Funds (Union Nationale des Caisses d’Assurance
Maladie, UNCAM). This new federation has become the sole representative of the
insured in negotiations with the state and health care providers. In order to regulate
ambulatory health care expenditure, the director-general of UNCAM now has more
power than the health insurance funds had previously, to negotiate with the doctors’
unions and other professionals in private practice.