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Chapter 3 | The impact of the crisis on the health system and health in France
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and have a major role in articulating the ambulatory, hospital, and health and
social care sectors. 3
Moreover, the financial sustainability of the health system was relatively fragile
at the onset of the crisis. Since the 1980s, the need to control SHI expenditure
had led to several measures attempting to contain demand, to increase SHI
resources or to decrease SHI expenses, eventually leading to an increase in
patient OOP payments. In acknowledgement that such measures may have
negative effects on equity in access, counterbalancing measures were introduced.
These included the creation of safety nets for given populations, such as free
public complementary universal health coverage (couverture maladie universelle
complémentaire; CMU-C) for people with low income and financial aid for
purchasing voluntary health insurance (VHI) contracts for households with an
income just above the ceiling for free complementary health insurance. 4
Despite these measures, socioeconomic disparities in access to health care
were increasing and, as a consequence, disparities in health status remained
significant. These social health inequalities result not only from risk factors,
such as alcohol and tobacco consumption, but also from differences in access to
health care that seem to increase over time. In 2008, 16.5% of the population
aged 18–64 years reported having forgone health care in the last 12 months
for financial reasons, compared with 14% in 2006. This inequity in access was
concentrated in a limited number of goods and services for which patients'
OOP expenditure is the highest. Dental care was of greatest concern (10.7%
of the population aged 18–64 years had forgone dental care in the previous
12 months), followed by spectacles (4%). Forgoing health care increases
inversely with the level of income: people in the poorest quintile forgo three
times more care than people in the richest quintile. Several public policies have
been implemented since the late 1990s to tackle this issue, mainly focused
on improving access to health care, although they have not shown significant
results (Chevreul et al., 2010).
To tackle the debt accumulated by the SHI (estimated at around €135 billion in
2009), France implemented a budget cap for SHI expenditure by creating the
national ceiling for SHI expenditure (objectif national des dépenses d'assurance
maladie) in 1996. One difficulty with this measure is that statutory tariffs
for self-employed professionals, medical devices and drugs are negotiated on
3 From 1 April 2010, and with the aim of achieving better governance of the system at the regional level, better response
to needs and greater efficiency, the regional health care agencies were created by merging seven regional institutions: the
Regional Hospital Agency, the Regional Union of Health Insurance Funds, the Regional Health Insurance Fund, the
Regional Directorate of Health and Social Affairs, the departmental Directorate of Health and Social Affairs (which was
the subsidiary of the Ministry of Health at the departmental level), the Regional Public Health Group and the Regional
Health Mission. For additional information on the role of the regional health care agencies, see Chevreul et al. (2010).
4 In 2013, the revenue ceilings for access to free public complementary health insurance and financial assistance to
purchase a private VHI contract were exceptionally increased by 7%. While the ceilings are adjusted annually for
inflation, this additional increase was undertaken to improve financial access to care by expanding VHI coverage of the
less healthy well-off population.