France

Health systems in transition France xxi
Financing
Health care expenditure in France has grown more rapidly than the economy as
a whole for many years (with the exception of the period 1997–2000), and faster
than in neighbouring countries (with the exception of the United Kingdom);
it rose from 10.4% of gross domestic product (GDP; produit intérieur brut)
in 1995 to 11.6% in 2013. This is well above the EU average of 9.5%, and in
Europe, second only to the Netherlands. From 1996, SHI annual expenditure
has been capped by the national ceiling for health insurance expenditure
(Objectif National des Dépenses d’Assurance Maladie; ONDAM). However,
this ceiling was exceeded nearly every year until 2010; since then, the ceiling
has been underspent as cost-containment measures have intensified. In 1996, a
specific agency for managing social security debt was established, funded by
a dedicated tax (amounting to 0.5% of income).
Just over three-quarters of total health care expenditure is publicly funded
(77%; just above the EU average of 76%), principally through SHI. The
proportion of costs covered by SHI varies across goods and services: from
15% for drugs with low medical benefit (service medical rendu; SMR) to 80%
for inpatient care. However, there are several conditions for which patients
are exempted from paying a part of the costs, such as chronic conditions or
pregnancy after the fifth month. Additional co-payments that are not allowed
to be covered by voluntary health insurance (VHI; assurance complémentaire)
have been created with the aim of reducing demand and thus SHI expenditure.
SHI resources mainly come from income-based contributions from
employers and employees (including retirees). Since 1998, as a result of
attempts to broaden the social security system’s financial base, employees’
payroll contributions have been almost fully replaced by a dedicated tax called
the “general social contribution” (contribution sociale généralisée; CSG) based
on total income rather than only on earned income, as was previously the case.
Additional revenue comes from specific taxes such as taxes on potentially
harmful consumption (tobacco, alcohol) and taxes on pharmaceutical companies.
VHI provides complementary insurance, such as for co-payments and better
coverage for medical goods and services that are poorly covered by SHI. It
finances 13.8% of total health expenditure and covers more than 90% of the
population. Over recent decades, VHI has gained a significant role in ensuring
equity in access and financing health care. Since 2000, publicly financed