Understanding universal health care, Part 3: Cost-Sharing for Patients in France

The vast majority of universal health-care countries generally expect patients to share the cost of treatment through deductibles, coinsurance payments and copayments. This is unsurprising in light of economic evidence that suggests how such requirements can reduce the use of outpatient care without necessarily resulting in adverse consequences—so long as vulnerable populations are protected. Yet Canada remains among a small minority of universal health-care countries that eschew these mechanisms.

This series of blog posts documents how eight high-performing universal health-care systems employ cost-sharing mechanisms while simultaneously protecting the vulnerable. The last post described the Belgian health-care system and the different ways it expects patients to share the cost of their care, while this post focuses on France.

The French health-care system is based on a social health insurance model [SHI]. Universal coverage is provided through several non-competitive employment-based statutory schemes where enrollment is mandatory. The system is funded via contributions from both employers and employees, and the state and out-of-pocket payments.

The two main SHI schemes are 1) the general scheme, which covers most employees, the self-employed, students and others and 2) the agricultural scheme, which provides protection for farmers. Residents can also purchase private voluntary insurance of a complementary or supplementary nature.

Coverage under the universal scheme generally includes hospital care, outpatient care, diagnostic services, prescribed medications, maternity care and home care. However, French patients are generally are expected to share the cost of their care. This typically involves a mix of co-insurance payments (whereby patients pay a certain percentage of the cost) and a fixed co-payment. Both of these typically apply to GP visits, specialist consultations, inpatient care and outpatient prescriptions (see the table below). The amounts physicians can charge are regulated, however, some physicians can charge above the official service tariffs.

Outpatient care provided by GPs and specialists is covered at 70 per cent (requiring a co-insurance of 30 per cent) of the statutory tariff plus a €1 (C$1.59) co-payment. For patients receiving inpatient care, individuals could expect 80 per cent coverage (requiring a co-insurance of 20 per cent) in addition to a daily co-payment of €18/day (C$28.57). Most drugs are covered at a rate of 65 per cent—although coverage can range from 15 per cent to 100 per cent. Patients are also expected to pay a co-payment of €0.50 (C$0.79) per box of medication.

The French health-care system also uses several safety nets to protect vulnerable patients. First, as shown in the table above, there’s a €50 (C$79.35) per year cap on co-payment charges for GP visits, specialist consultations and outpatient medications. For inpatient care, coverage automatically increases from 80 per cent to 100 per cent (eliminating the 20 per cent co-insurance) after 31 days of care. Further, if the cost of received medical and surgical procedures exceeds €120 (C$190.44) a day, patients only pay a flat fee of €24 (CA$38.09) per hospital stay in addition to daily hospital accommodation fees.

In addition to spending caps, French patients who meet certain conditions (the chronically ill, disabled children, pensioners, etc.) can also qualify for different cost-sharing exemptions (e.g. co-insurance and hospital accommodations). Lastly, the French system also entitles low-income individuals to qualify for “free” or state-sponsored health insurance, dental and eye care. The income threshold to qualify for this insurance in 2020 was <€8,723 (C$13,843.25).

This third post has discussed the basic structure of the French health-care system, the cost-sharing expectations for patients, and the protections in place to help ensure vulnerable patients are not disparately impacted. The next post will discuss the health-care system in the Netherlands and its cost-sharing expectations.