health care in france health care in france the french health care system is one of universal health care largely financed by government national health insurance. in its 2000 assessment of world health care systems, the world health organization found that france provided the "best overall health care" in the world. in 2017, france spent 11.3% of gdp on health care, or us$5,370 per capita, a figure higher than the average spent by rich countries (oecd average is 8.8%, 2017), though similar to germany (10.6%) and canada (10%), but much less than in the us (17.1%, 2018). approximately 77% of health expenditures are covered by government funded agencies. most general physicians are in private practice but draw their income from the public insurance funds. these funds, unlike their german counterparts, have never gained self-management responsibility. instead, the government has taken responsibility for the financial and operational management of health insurance (by setting premium levels related to income and determining the prices of goods and services refunded). the french government generally refunds patients 70% of most health care costs, and 100% in case of costly or long-term ailments. supplemental coverage may be bought from private insurers, most of them nonprofit, mutual insurers. until 2000, coverage was restricted to those who contributed to social security (generally, workers or retirees), excluding some poor segments of the population. the government of lionel jospin put into place universal health coverage and extended the coverage to all those legally resident in france. only about 3.7% of hospital treatment costs are reimbursed through private insurance, but a much higher share of the cost of spectacles and prostheses (21.9%), drugs (18.6%) and dental care (35.9%) (figures from the year 2000). there are public hospitals, non-profit independent hospitals (which are linked to the public system), as well as private for-profit hospitals. history public health initiatives (1871–1914) the french third republic followed well behind bismarckian germany, as well as great britain, in developing the welfare state including public health. tuberculosis was the most dreaded disease of the day, especially striking young people in their 20s. germany set up vigorous measures of public hygiene and public sanatoria, but france let private physicians handle the problem, which left it with a much higher death rate. the french medical profession jealously guarded its prerogatives, and public health activists were not as well organized or as influential as in germany, britain or the united states. for example, there was a long battle over a public health law which began in the 1880s as a campaign to reorganize the nation's health services, to require the registration of infectious diseases, to mandate quarantines, and to improve the deficient health and housing legislation of 1850. however the reformers met opposition from bureaucrats, politicians, and physicians. because it was so threatening to so many interests, the proposal was debated and postponed for 20 years before becoming law in 1902. success finally came when the government realized that contagious diseases had a national security impact in weakening military recruits, and keeping the population growth rate well below germany's. since 1945 the reduction in infant mortality between 1960 and 2008 for france in comparison with ireland, switzerland, sweden, the united kingdom, and the united states. the current system has undergone several changes since its foundation in 1945, though the basis of the system remains state planned and operated. jean de kervasdoué, a health economist, believes that french medicine is of great quality and is "the only credible alternative to the americanization of world medicine." according to kervasdoué, france's surgeons, clinicians, psychiatrists, and its emergency care system (samu) are an example for the world. however, despite this, kervasdoué criticizes the fact that hospitals must comply with 43 bodies of regulation and the nit-picking bureaucracy that can be found in the system. kervasdoué believes that the state intervenes too much in regulating the daily functions of french hospitals. furthermore, japan, sweden, and the netherlands have health care systems with comparable performance to that of france's, yet spend no more than 8% of their gdp (against france's spending of more than 10% of its gdp). according to various experts, the battered state of the french social security system's finances is causing the growth of france's health care expenses. to control expenses, these experts recommend a reorganization of access to health care providers, revisions to pertinent laws, a repossession by cnamts (french acronym: caisse nationale d'assurance maladie des travailleurs salariés or french national health insurance fund for salaried workers) of the continued development of medicines, and the democratization of budgetary arbitration to counter pressure from the pharmaceutical industry. health care system total health spending per capita, in u.s. dollars ppp-adjusted, of france compared amongst various other first world nations. the entire population must pay compulsory health insurance. the insurers are non-profit agencies that annually participate in negotiations with the state regarding the overall funding of health care in france. there are three main funds, the largest of which covers 84% of the population and the other two a further 12%. a premium is deducted from all employees' pay automatically. the 2001 social security funding act, set the rates for health insurance covering the statutory health care plan at 5.25% on earned income, capital and winnings from gambling and at 3.95% on benefits (pensions and allowances). after paying the doctor's or dentist's fee, a proportion is reimbursed. this is usually 70%, but can be 100% (for certain long duration medical problems—such as a cancer, diabetes, cardiovascular disease). the balance is a co-payment paid by the patient but it can also be recovered if the patient subscribes to a complementary health insurance policy (more than 99% of the population as every worker is entitled, per law, to access to a company subsidized plan). most of them are managed by not-for-profit groups called mutuelles. under recent rules (the coordinated consultation procedure, in french: "parcours de soins coordonné"), general practitioners ("médecin généraliste" or "docteur") are expected to act as "gate keepers" who refer patients to a specialist or a hospital when necessary. there is a free choice of the reference doctor, which is not restricted to only general practitioner and may still be a specialist or a doctor in a public or private hospital. the goal is to limit the number of consultations for the same illness. the incentive is financial in that expenses are reimbursed at much lower rates for patients who go directly to another doctor (except for dentists, ophthalmologists, gynaecologists and psychiatrists); vital emergencies are exempt from requiring the advice from the reference doctor, who will be informed later. most health providers accept the "carte vitale", a smart card with information on the patient. when a patient pays a doctor or laboratory directly, the doctor/lab swipes the carte vitale to send the treatment and payment information to the social security system and the reimbursement usually arrives in the patient's bank account in five days. the information can also be forwarded by the provider to the complementary insurance company, which likewise reimburses its share. in pharmacies, the patient usually doesn't advance the payment; it is the pharmacy that is reimbursed by the national and complementary insurance. most hospital payments are not seen by patients either. there is a problem in that most specialists and some in-hospital physicians do not respect the official fee structure. patients pay the additional cost out of pocket, although some complementary policies will cover a limited excess charge. around 62% of hospital beds in france are provided by public hospitals, around 14% by private non-profit organizations, and 24% by for-profit companies. minister of health and solidarity is a cabinet position in the government of france. the healthcare portfolio oversees the public services and the health insurance part of social security. as ministerial departments are not fixed and depend on the prime minister's choice, the minister sometimes has other portfolios among work, pensions, family, the elderly, handicapped people and women's rights. in that case, they are assisted by junior ministers who focus on specific parts of the portfolio. the system is managed by the caisse nationale de l'assurance maladie. fees and reimbursements the global system (social security system) will cover 70% of the global cost unless the person has an "ald" (long duration medical problem) such as cancer or diabetes where all expenses are covered (100%). in the alsace-moselle region, due to its special history as having belonged to france and germany at one time or another, the social security system covers 90% of the global cost. people must subscribe to a "mutuelle" (non-profit insurance) or a private for-profit insurance for additional cover. all workers have access to a specific plan where their company has to pay at least 50% of the cost. prices range from €10/month (full basic coverage; i.e., the balance of the official fees and medicines) to €100/month (luxury coverage including single room while in hospital, babysitters for children if they have to remain at home, housemaids at home if needed...). in large cities, such as paris, physicians (especially specialists) charge significantly more for consultations (i.e. 70–80 eur as opposed to 25 eur) because they are not adhering to the fees imposed by the assurance maladie, patients are reimbursed 70% of the official fee, with the mutuelle covering the rest up to 100% of the official fee. for instance, for an ophthalmologist in paris, if the patient pays 80 eur, he will be reimbursed 15.9 eur by the assurance maladie and part of the remainder, up to a cap, by the mutuelle. act fee % reimbursed patient charge before co-insurance patient charge in us dollar (2016) before co-insurance generalist consultation €23 70% €6.60 $7.30 specialist consultation €25 70% €7.50 $8.20 psychiatrist consultation €37 70% €11.10 $12.16 cardiologist consultation €49 70% €14.17 $15.52 filling a cavity 19.28–€48.20 70% 5.78–€14.46 $6.33–15.84 root canal €93.99 70% €28.20 $30.89 teeth cleaning €28.92 * 70% €8.68 $9.51 prescription medicine variable 15–100%, usually 65% variable variable 30 ibuprofen 200 mg €1.34 65% €0.87 $0.96 dentists will get around this by scheduling or charging for two cleanings, upper and lower arch. patients are now charged a fee per package of medicine as a deductible. the fee varies according to the number of pills in the box (duration of treatment supply) and is not reimbursable by any insurance, but there is a maximum charge of €50 per year. there is also a recent fee for dispensing costs, which was accompanied by an offsetting decrease in the price of drugs. it is reimbursable by complementary insurance, as are new charges of about €0.50-€1.00 when prescriptions are for young children or the elderly, on the grounds the pharmacist must take time to give explanations for such patients. médecin généraliste, médecin traitant main article: general practitioner § france the médecin généraliste is the responsible doctor for a patient long-term care. this implies prevention, education, care of diseases and traumas that do not require a specialist. they also follow severe diseases day-to-day (between acute crises that may require a specialist). since 2006, every patient has to declare one generalist doctor as a "médecin traitant" (treating doctor) to the healthcare fund, who has to be consulted before being eventually referred to consult any specialist (gynecologists, psychiatrists, ophtamologists and dentists aside). this policy has been applied to unclog overconsultations of specialists for non-severe reasons. they survey epidemics, fulfil a legal role (consultation of traumas that can bring compensation, certificates for the practice of a sport, death certificates, certificates for hospitalization without consent in case of mental incapacity), and a role in emergency care (they can be called by the samu, the emergency medical service). they often go to a patient's home if the patient cannot come to the consulting room (especially in case of children or old people) and they must also perform night and week-end duty. health insurance because the model of finance in the french health care system is based on a social insurance model, contributions to the program are based on income. prior to reform of the system in 1998, contributions were 12.8% of gross earnings levied on the employer and 6.8% levied directly on the employee. the 1998 reforms extended the system so that the more wealthy with capital income (and not just those with income from employment) also had to contribute; since then the 6.8% figure has