dropped to 0.75% of earned income. in its place a wider levy based on total income has been introduced, gambling taxes are now redirected towards health care and recipients of social benefits also must contribute. because the insurance is compulsory, the system is effectively financed by general taxation rather than traditional insurance (as typified by auto or home insurance, where risk levels determine premiums). the founders of the french social security system were largely inspired by the beveridge report in the united kingdom and aimed to create a single system guaranteeing uniform rights for all. however, there was much opposition from certain socio-professional groups who already benefited from the previous insurance coverage that had more favourable terms. these people were allowed to keep their own systems. today, 95% of the population is covered by 3 main schemes, one for commerce and industry workers and their families, another for agricultural workers, and lastly the national insurance fund for self-employed non-agricultural workers. all working people are required to pay a portion of their income into a health insurance fund, which mutualizes the risk of illness and which reimburses medical expenses at varying rates. children and spouses of insured individuals are eligible for benefits, as well. each fund is free to manage its own budget and reimburse medical expenses at the rate it saw fit. the government has two responsibilities in this system: the first is a government responsibility that fixes the rate at which medical expenses should be negotiated and it does this in two ways. the ministry of health directly negotiates prices of medicine with the manufacturers, based on the average price of sale observed in neighbouring countries. a board of doctors and experts decides if the medicine provides a valuable enough medical benefit to be reimbursed (note that most medicine is reimbursed, including homeopathy). in parallel, the government fixes the reimbursement rate for medical services. doctors choose to be in sector 1 and adhere to the negotiated fees, to sector 2 and be allowed to charge higher fees within reason ("tact and mesure") or sector 3 and have no fee limits (a very small percentage of physicians, and their patients have reduced reimbursements). the social security system will only reimburse at the pre-set rate. these tariffs are set annually through negotiation with doctors' representative organisations. the second government responsibility is oversight of health-insurance funds, to ensure that they are correctly managing the sums they receive, and to ensure oversight of the public hospital network. today, this system is more or less intact. all citizens and legal foreign residents of france are covered by one of these mandatory programs, which continue to be funded by worker participation. however, since 1945, a number of major changes have been introduced. firstly, the different health care funds (there are five: general, independent, agricultural, student, public servants) now all reimburse at the same rate. secondly, since 2000, the government now provides health care to those who are not covered by a mandatory regime (those who have never worked and who are not students, meaning the very rich or the very poor). this regime, unlike the worker-financed ones, is financed via general taxation and reimburses at a higher rate than the profession-based system for those who cannot afford to make up the difference. finally, to counter the rise in health care costs, the government has installed two plans (in 2004 and 2006), which require most people to declare a referring doctor in order to be fully reimbursed for specialist visits, and which installed a mandatory co-payment of €1 (about us$1.35) for a doctor visit (limited to €50 annually), €0.50 (about us$0.77) for each prescribed medicine (also limited to €50 annually) and a fee of €16–18 ($20–25) per day for hospital stays (considered to be the "hotel" part of the hospital stay; that is, an amount people would pay anyway for food, etc.) and for expensive procedures. such declaration is not required for children below 16 years old (because they already benefit from another protection program), for foreigners without residence in france (who will get benefits depending on existing international agreements between their own national health care program and the french social security), or those benefiting from a health care system of french overseas territories, and for those people that benefit from the minimum medical assistance. an important element of the french insurance system is solidarity: the more ill a person becomes, the less they pay. this means that for people with serious or chronic illnesses (with vital risks, such as cancers, aids, or severe mental illness, where the person becomes very dependent of his medical assistance and protection) the insurance system reimburses them 100% of expenses and waives their co-payment charges. finally, for fees that the mandatory system does not cover, there is a large range of private complementary insurance plans available. the market for these programs is very competitive. such insurance is often subsidised by the employer, which means that premiums are usually modest. 85% of french people benefit from complementary private health insurance. quality a government body, anaes, agence nationale d'accréditation et d'evaluation en santé (the national agency for accreditation and health care evaluation) was responsible for issuing recommendations and practice guidelines. there are recommendations on clinical practice (rpc), relating to the diagnosis, treatment and supervision of certain conditions, and in some cases, to the evaluation of reimbursement arrangements. anaes also published practice guidelines which are recommendations on good practice that doctors are required to follow according to the terms of agreements signed between their professional representatives and the health insurance funds. there are also recommendations regarding drug prescriptions, and to a lesser extent, the prescription or provision of medical examination. by law, doctors must maintain their professional knowledge with ongoing professional education. anaes was combined with other commissions in the high authority of health on 13 august 2004. emergency medicine private ambulance in pontarlier main article: emergency medicine in france ambulatory care includes care by general practitioners who are largely self-employed and mostly work alone, although about a third of all gps work in a group practice. gps do not exercise gatekeeper functions in the french medical system and people can see any registered medical practitioner of choice including specialists. thus ambulatory care can take place in many settings. spending total health spending as a percentage of gdp for france compared amongst various other first world nations from 2005 to 2008 healthcare spending vs life expectancy for some countries in 2007 the french healthcare system was named by the world health organization in 2008 as the best performing system in the world in terms of availability and organization of health care providers . it is a universal health care system. it features a mix of public and private services, relatively high expenditure, high patient success rates and low mortality rates, and high consumer satisfaction. its aims are to combine low cost with flexibility of patient choice as well as doctors' autonomy. while 99.9% of the french population is covered, the rising cost of the system has been a source of concern, as has the lack of emergency service in some areas. in 2004, the system underwent a number of reforms, including introduction of the carte vitale smart card system, improved treatment of patients with rare diseases, and efforts aimed at reducing medical fraud. while private medical care exists in france, the 75% of doctors who are in the national program provide care free to the patient, with costs being reimbursed from government funds. like most countries, france faces problems of rising costs of prescription medication, increasing unemployment, and a large aging population. expenses related to the healthcare system in france represented 10.5% of the country's gdp and 15.4% of its public expenditures. in 2004, 78.4% of these expenses were paid for by the state. by 2015 the cost had risen to 11.5% of gdp – the third highest in europe. in a sample of 13 developed countries france was first in its population weighted usage of medication in 14 classes in both 2009 and 2013. the drugs studied were selected on the basis that the conditions treated had high incidence, prevalence and/or mortality, caused significant long-term morbidity and incurred high levels of expenditure and significant developments in prevention or treatment had been made in the last 10 years. the study noted considerable difficulties in cross border comparison of medication use. hospitals about 62 percent of french hospital capacity is met by publicly owned and managed hospitals. the remaining capacity is split evenly (18% each) between non-profit sector hospitals (which are linked to the public sector and which tend to be owned by foundations, religious organizations or mutual-insurance associations) and by for-profit institutions. doctors while french doctors only earn about 60% of what american doctors make, their expenses are reduced because they pay no tuition for medical school (cost for a year range from €200 to 500 but students get paid during their internships in hospitals) and malpractice insurance is less costly compared with the united states (as all doctors subscribe to the same fund). low medical malpractice insurance may also be the byproduct of past litigations often favoring the medical practitioners. this started to change due to the implementation of the patients' rights law of 2002. the french national insurance system also pays for a part of social security taxes owed by doctors that agree to charge the government-approved fees. the number of french doctors has recently declined. reasons for this may be because they prefer to specialize and get jobs at hospitals rather than setting up general practices. the workload for general practice doctors requires more hours and responsibility than workplace and supply doctors. waiting times and access siciliani and hurst did a major comparison of countries reporting long waits for health care and countries that did not. in a comparison of health care funding, institutions and level of resources between countries, prevention of long waiting lists in france was attributed to a high number of doctors and hospital beds, combined with fee-for-service funding of doctors and private hospitals. in france, many specialists treat patients outside hospitals; these ambulatory specialists are paid fee-for-service. private hospitals were also paid by diem daily rates and fee-for-service in 2003, and provided much of total surgery. fee-for-service rather than limited budgets, with access for patients with public health insurance helped prevent long waits for surgery (siciliani and hurst, 2003, pp. 69–70). now, public, private nonprofit hospitals and for-profit hospitals are all paid by a drg system. however, assertions that france does not have waiting lists at all are not true. long waits apparently remain unusual. however, some moderate waits have developed. french patients were relatively unlikely to report forgoing care because of waits (eurostat, 2012). however, there are wait times for some procedures such as mri scans, perhaps relating to low numbers of scanners, and in certain areas for certain specialties like ophthalmology, partly relating to unequal distributions of doctors (chevreul et al., 2015, p. 182). the commonwealth fund 2010 health policy survey in 11 countries reported found that a relatively high percentage of french patients reported waiting more than four weeks to see their most recent specialist appointment in france (higher than new zealand, the u.k and australia). this percentage held relatively constant over time, showing that waiting lists in france for appointments and elective surgery are not a new phenomenon. fifty three percent of specialist appointments took less than 1 month (relatively low), and 28% more than two months. however, while moderate waits for elective surgery were common (only 46% said they had waited less than one month) the percentage reporting four-month-plus waits was only 7%, low and similar to the u.s., switzerland, and the netherlands. so, it appears that extremely long waits (like those in the u.k.'s nhs in the 1990s) are still rare. this study has limitations. the number of people surveyed may not have been perfectly representative, although the figures held similar over time. the study also did not state the percentage of total appointments taking this long (whether a patient's appointments after the initial appointment were more timely or not), although the most recent appointment would presumably reflect both initial and subsequent appointments), or the total number of appointments available. the waits were self-reported, rather than collected from