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Prepared by Ousmane Dore.
An extensive debate on the future of the health care system culminated in the Livre Blanc sur le système de santé et d’assurance-maladie (1994), which provides a complete analysis of the system.
The government exercises control over the health care system through the regulation of social security contribution rates, the control of global budgets for public hospitals and of wages and posts in public hospitals. It also supervises the negotiation of fees and prices for doctors and private hospitals and directly controls the prices paid by the statutory insurers for drugs and medical goods.
In mid-1993, the ticket modérateur for consultations with a doctor was 25 percent of the conventional fee, for necessary drugs it was 30 percent, and for comfort drugs, 60 percent.
There are also about 15 smaller funds, which cover for example farmers and the self-employed (including self-employed miners and transport workers).
The employees’ contribution has been lowered from 6 8 percent to 5.5 percent under the tax reform proposed by the government.
In general aggregate health outcomes are only weakly related to medical care spending. This weak association between health spending and available outcome indicators partly reflects well-established evidence that direct spending does not capture the full array of social, environmental and cultural factors which influence health status.
Using as a broad rule of thumb that persons aged over 65 consume on average roughly four times as much health care as those below 65.
For example. Hourriez (1992) found that in 1950 persons aged 70 saw generalists and specialists, respectively 1 5 and 0 8 times more than persons aged 40. by 1990, this had increased to 2 6 and 1 1 times.
Improved cataract operations, renal dialysis, organ transplants, coronary bypass, micro-surgery, and hip and knee replacements have increased the range of conditions which can be successfully treated Advances in anaesthetics have reduced the risks of operating on older patients New imaging and other technologies (echography, improved radiology, magnetic resonance scanners, endoscopy and biological tests) have improved diagnosis.
Compulsory health insurance dates back to the aftermath of World War I, when the provinces of Alsace and Lorraine, where the German health insurance (Bismarckian model) had been established, were returned to France. A 1920 law creating compulsory insurance did not become operative until 1930, due largely to the opposition of doctors to the capitation of pay.
There are numerous non-profit insurers (or mutuelles) and private insurers providing supplementary voluntary insurance in the system. They cover the ticket modérateur, some extra billing, and a few benefits not covered by the social security scheme.
In 1992, the Caisses Primaires d’Assurance Maladie were employing some 80.000 staff, not counting personnel collecting contributions See Pouilier (1992).
The typical household currently pays about 20 percent of gross compensation on health care, including voluntary contributions to mutuelles.
This delay may be attributed to the financing of social security through payroll taxes, which tend to reflect the lagged response of employment to output.
The experience with the 1994 law concerning a set of some 30 références médicales opposables (RMO), setting out “good practice” procedures and treatments for a range of illness and provides for sanctions in case of abuse has been quite successful, during the first eight months of 1994, physicians’ fees and pharmaceutical spending fell by around 4 percent compared with a year earlier (CNAMTS, 1994)