France

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Health systems in transition
France
2013
• Under a provision of the National Interprofessional Agreement enacted as part of the
Employment Protection Law (loi sur la sécurisation de l’emploi), all employers must
provide group VHI coverage for their employees (effective 1 January 2016).
• The 2013 Social Security Finance Act created the CASA, a 0.3% tax on retirement and
disability pensions, for the purpose of financing a planned Aging and Dependency Law
(see section 6.2). Consideration of the proposed law was postponed until late 2015 and
will not be implemented until 2016.
• The revenue ceilings for access to CMU-C and financial assistance to purchase a private
VHI contract (ACS) (section 3.5.1) were exceptionally increased by 7%, pursuant to the
recommendation of an interministerial committee to combat exclusion. While the ceilings
are adjusted annually for inflation, this additional increase was undertaken to improve
financial access to care by expanding VHI coverage for the less well-off population.
2014
• The 2014 Social Security Finance Act included a programme of regional pilot projects
aimed at improving care coordination for frail elderly people and finding alternatives to
the existing fragmented care organization.
6.1.1 Improving health system governance and transparency
The institutional complexity of the French health care system and the conflicts
of power and legitimacy associated with it are major issues, particularly with
respect to the relationship between the state and SHI. Reforms, therefore, tend to
search for institutional equilibrium. Since the late 1980s, health care governance
has been substantially reorganized, with a process of decentralization at the
regional level, an increase in the role of parliament and an attempt to clarify
the respective roles of the state and SHI.
In the French context, decentralization was mainly a form of deconcentration,
where policies and frameworks are defined at the central level and implemented
at the local level, adapted to local situations. The Ministry in charge of Health
and the government remain the main decision-makers in health care in France.
The last major step forward in decentralization was made through the 2009
HPST Act, which created the ARSs (see section 2.4). However, while creation
of the ARSs, which are autonomous bodies, can be seen as a step towards
devolution, the Ministry in charge of Health retains the power to nominate each
ARS director. Moreover, the planned 2015 health reform will likely increase
state control of ARS governance (see section 6.2). Indeed, power at the national
level remains significant even when compared with other countries such as
England, which is considered to be highly centralized (Ettelt et al., 2010) (for
more details, see section 7.1.2 in Chevreul et al., 2010).