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178 Health systems in transition France In 2011, OOP expenditure in France as a share of household consumption was the lowest of OECD countries after the Netherlands, and well below the OECD average (OECD, 2013) (Fig. 7.1). OOP spending is mostly for gaps in depth of coverage, including poorly covered goods and services (optical, dental, devices); extra-billing, particularly by specialists; and flat-rate deductibles designed to moderate consumer behaviour (capped at €50/year) (see section 3.3.1). Reductions in the scope of coverage, as a result of de-reimbursement of certain drugs and decisions by some VHI firms to no longer cover certain drugs with low SHI reimbursement contribute to OOP expenditure. OOP spending on drugs increased 4.2 percentage points between 2005 and 2008, growing from 13% to 17.2% of personal health expenditure and reaching 18.3% in 2012 (DREES, 2013a). However, in 2013, OOP spending decreased for the second year as a result of reductions in drug expenditure, most notably a decrease in non-covered drugs for the first time, as well as a decrease in the cost of optical devices, and a slowdown in the rise of extra-billing fees (DREES, 2014). Fig. 7.1 International comparison of public financing and OOP spending (2012 current health expenditures) 40 % 35 Korea Portugal Private household OOP spending 30 25 20 15 10 Hungary Switzerland Greece Poland Slovak Republic Spain a Belgium Australia a Finland Sweden Canada Austria Japan Germany Czech Rep. Norway Denmark 5 France Netherlands 0 50 55 60 65 70 75 80 85 90 Public financing (%) Source: DREES, 2014. Note: a 2011 data.
Health systems in transition France 179 7.2.2 Equity in financing Overall, the financing of the health system results in a redistribution of resources both horizontally from the well to the sick and vertically from people with higher incomes to those with lower incomes, through taxes on revenues (HCAAM, 2013b). SHI has facilitated a 19% reduction of inequalities in standards of living (four-fifths from the method of financing and one-fifth from services) (Duval & Lardellier, 2012). The financing of SHI is considered progressive because of the tax relief provided to individuals with low salaries as well as the different CSG contribution rates depending on the type of revenue (HCAAM, 2013). However, private expenditure through VHI and OOP is regressive, and the transfer of expenditure not covered by SHI towards VHI, for which the functioning and financing principles are not solidarity based as they are for SHI, has exacerbated inequalities in the financial access to care (HCAAM, 2013b). Moreover, people with lower incomes spend a greater share of their disposable income on private health care expenditure than the wealthier (Duval & Lardellier, 2012). Under the Kakwani index, which measures vertical equity, OOP financing would be considered progressive if the annual share borne by the lowest revenue deciles is lower than their share of total revenues. In France, the poorest 20% account for 7.1% of total revenues but for 14.7% of OOP spending, resulting in a Kakwani index of 0.25, demonstrating that OOP expenditure is vertically inequitable and regressive (Geoffard & de Lagasnerie, 2012). Patients with the highest levels of OOP spending are on average older (60 years or more), with one or more chronic diseases covered by the ALD programme (see section 3.3.1) and are three times more likely to have been hospitalized than the general population (HCAAM, 2013c). While patients who benefit from the ALD programme are covered 100% for care related to their chronic condition, they still may face high OOP expenditure for other health care, as well as for hospitalization (the daily hospital catering fee is not covered by ALD, even for hospitalization related to the covered disease) and extrabilling in excess of official tariffs that is not covered by SHI. Individuals do not pay for private VHI contracts according to their incomes but rather based on an estimate of their needs determined by age in the case of mutual firms or often by health questionnaires for commercial insurers or potentially in optional group contracts offered by provident institutions (see section 3.5.2). Moreover, group VHI contracts generally provide better coverage than individual contracts. Indeed, employees covered by group VHI contracts have a double financial advantage over those with individual
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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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Abstract Abstract This analysis of
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1. Introduction 1. Introduction The
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3. Financing 3. Financing Health ca
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