Chapter 2

CEIS Health Report 2006
tegies of interest groups, led to a large extension of coverage in the last years. The first
extension was related to the financing of co-payments. Co-payments may be substantial
for primary care: doctors’ visits are reimbursed only 70% in France (it once was 80%),
lab tests 65%, and the coverage of drugs may vary from 100% to 0. Co-payments on
hospital care exist but are lower in percentage of total charges. Insures can then subscribe
to complementary insurance schemes, to cover part or all of the co-payment, on
a voluntary basis. A large number of low-income insures could not afford such coverage,
and in 1999 the Jospin government passed a law, the Couverture Maladie Universelle
Law (CMU), to offer low-cost, subsidized complementary insurance to all. The number of
beneficiaries of the CMU rose from 880.000 in 2000 to 1,32 million in 2004, and continues
to rise. Although there is some debate as to whether this has induced some unjustified
increase in health care expenditures, most studies agree that at the least, this
induced beneficiaries to get even with the rest of the insures in terms of utilization.
A second extension of coverage is related to what is called in France the “Affections de
Longue Durée” (ALD): this scheme offers a 100% coverage rate (no co-payment) for
patients who suffer from severe chronic diseases. The list of eligible diseases is limited
to 30 (like cancer, terminal renal failure, severe hypertension, depression), but the admission
to the ALD status has been made easier in the past five years, and the number of
ALD patients has risen from 5 million insures in 2000 to almost 7 million in 2005. ALD
patients represent 12% of the insured population and 56% of all reimbursed expenditures!
They explain a large share of the increase of drug expenditures, since most new
drugs put on the market address chronic diseases and their management.
The third value is access to innovation. Although drugs companies complain that the
French reimbursement and pricing regulations are slow and prices low, there is quasi no
rationing of new innovative drugs, and this is an explicit public policy. In 2004, when a
prospective per DRG payment scheme was implemented for hospitals in France, a
restrictive list of around 80 expansive drugs were pulled out of the scheme and reimbursed
retrospectively, to avoid any rationing of innovative drugs for patients. As a result, the
level of expenditures for these drugs in public hospitals rose on average by 25% each
year.
Thus, public policy in France regarding health care is moving continuously between decisions
that will extend coverage and increase demand, on the basis of fundamental
values, and cost-containment measures, like the increase of premiums and taxes, and
the reduction of benefits through the increase of co-payments. As a result, the coverage
of health care expenditures through the Social Security system has remained relatively
stable through time, and has even slightly increased in the late years, as a result of more
protection for the sickest and the poorest patients.
2.1.3 Improving the efficiency of health care services
If deficit containment is the name of the game, under the preceding constraints and
values, what actions have governments taken to limit the gap between expenditures and
available resources? A basic permanent line of action has been to cut down the benefits
served by the sickness fund (while simultaneously organizing the extension of coverage)
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