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78 Health systems in transition <strong>France</strong> (e.g. unemployment and sick leave allowances) (3.95 percentage points for SHI). The rate decreases to 3.8% of earned income for individuals with low incomes who were otherwise exempt from income taxation, which represent nearly half of French households. Moreover, because the revenue base of SHI has been broadened and partly disconnected from earnings, it is less vulnerable to wage and employment fluctuations. A share of CSG contributions is generally deductible from income tax. In 2012, 70% of the revenues from the CSG went to the SHI schemes, accounting for 35% of their financing. The pharmaceutical industry is also required to contribute through a 1.6% tax on their turnover, a tax on advertising, a tax on drug retailing and an additional tax if their turnover exceeds a limit set in the Social Security Finance Act. In 2012, these taxes raised €1.04 billion for SHI. Additional revenue for SHI is levied on the profits of companies with turnover of more than €760 000. This 0.13% tax is estimated to have levied €55 million in 2013. Other taxes are levied on polluting activities of companies. In 2012, employers’ contributions, employee’s contributions and CSG revenue accounted for 82.3% of total SHI revenue. The remainder was provided mainly through state subsidies and additional earmarked taxes (e.g. on tobacco and alcohol consumption). Main body responsible for collecting SHI funds The Union for the Recovery of Social Security Contributions and Family Allowances (Union de Recouvrement des cotisations de Sécurité Sociale et d’Allocations Familiales) is in charge of collecting contributions and CSG at the local level. The money levied flows into a single national pool managed by the Central Social Security Agency (Agence centrale des organismes de sécurité sociale) and is distributed among the different national branches (SHI, retirement fund, family allowance, etc.) on the basis of contribution rates defined by law. Main body responsible for solving the social security debt Since 1996, the contribution for solving social security debt, the social debt repayment contribution (contribution pour le remboursement de la dette sociale) was implemented to address the increasing deficit of the social security system. The contribution is 0.5% of revenue regardless of the source (earned income, benefits, capital, sale of assets, etc.). At the same time, a special fund was created to manage the social security debt, the Agency for Funding Social Security Debt (Caisse d’amortissement de la dette sociale). To ensure that the social security debt is not continuously transferred to the next generation, the
Health systems in transition <strong>France</strong> 79 parliament requires any new debt transferred to the Agency to be accompanied by an increase in the Agency’s income, ensuring that the time frame required to eliminate the debt is not extended. Financing CMU-C and ACS Revenues for the CMU Fund, which finances CMU-C for low-income individuals as well as subsidies to purchase VHI for those with revenues up to 135% of the CMU-C ceiling (ACS) (see sections 3.5.1 and 3.5.4), mostly come from an earmarked premium tax on VHI contracts (€2 billion in 2012). The 2013 Social Security Finance Act added a fraction of the revenues from tobacco taxes (3.15%) to the CMU Fund. 3.3.3 Pooling of funds SHI retrospectively reimburses care and, consequently, there is no formal resource allocation mechanism, although the creation of ONDAM (described below) acts as a soft tool to control and allocate health care expenditure. Because SHI schemes vary in their resources and population characteristics, health insurance schemes are subject to a financial adjustment mechanism that takes into account their demographic profiles. ONDAM Since 1996, the parliament has set a maximum national ceiling for SHI expenditure (ONDAM) for the following year, including spending limits for specific health care sectors (ONDAM subtargets), as part of the annual Social Security Finance Act. In order to set the ONDAM for the coming year (n + 1), the government proposes an annual maximum growth rate for SHI expenditure. This rate is applied to the current year’s (n) actual expenditure. However, often the current year’s expenditure is a provisional estimate that is calculated in September, since voting on the ONDAM takes place before the end of the year. When genuine expenditure is known for year n, the change in expenditure in year n amounts to a ratification of overspending and to the integration of this overspending into the baseline used for defining the ceiling for the following year (n + 1). Once the overall ceiling has been set, it is divided into five target groups: • care provided in private practice; • hospital care paid on a DRG basis (including outpatient visits in the public sector);
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Health Systems in Transition Vol. 1
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Health Systems in Transition Karine
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Contents Contents Preface
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Preface Preface The Health Systems
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Acknowledgements Acknowledgements T
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List of tables, figures and boxes L
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Abstract Abstract This analysis of
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1. Introduction 1. Introduction The
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6. Principal health care reforms 6.
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7. Assessment of the health system
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8. Conclusions 8. Conclusions In Fr
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