reste à charge - médecin écrivant sur une feuille de soins devant un ordinateur

The public authorities want to get rid of co-payments! For almost 10 years, regulatory changes in the French public health insurance system have been constantly reducing the out-of-pocket share paid by people for their health care. The 100% healthcare reform, following on from the generalisation of supplementary health insurance and the desperate efforts to control excess fees via contractual arrangements (“Optam ” and “CAS “), has been fully operational since 1 January making dental care, hearing-aid and optical appliances almost free. Although the effects of this latest reform are not yet visible in studies, France is already one of the OECD countries with the lowest co-payment levels. Social progress that does not, however, hide a few shortcomings.

Co-payments below 7%, an historic low

In 2019, healthcare expenditure in France amounted to €3,102 per inhabitant. The portion ultimately paid out by patients, after basic health insurance and supplementary health insurance reimbursements, was limited to an average of €213, or 6.9% of the total bill. This is the lowest level of co-payments ever achieved. In 2016, the figure was still 7.7%.

The share of healthcare expenditure financed by supplementary health insurance organisations is now 13.4%. A slightly increased figure. The generalisation of supplementary health insurance and new insurance portability arrangements have had the effect of increasing the coverage rate among the most vulnerable people. The 100% healthcare reform, whose stated objective is to do away with people having to forgo dental, optical and hearing-aid care, should confirm the upward trend in supplementary insurance pay-outs. Indeed it is in 2020 and 2021 that the most significant measures on optical and dental care came into force. In 2019, dental care and optical expenses accounted for almost 30% of co-payment expenses for households. Although the current health crisis has considerably disrupted implementation of the reform, there is every reason to believe that co-payment expenses will continue to decline.

Chronic diseases and population ageing

Whilst supplementary insurance organisations have taken onboard part of the reduction in co-payments resulting from successive reforms, the public health insurance system has also had a lot to pay. Indeed, the volume of health expenditure for long-term conditions (ALDs ) covered 100% has continued to grow. According to the Health Ministry , health expenditure for people with illnesses classifed as ALD (diabetes, cancer, psychiatric conditions, cardiovascular diseases, etc.) amounts to an average of €8,900 per insured person, i.e. seven times more than for the rest of the population. In total, the 18% of insured persons with ALD conditions account for 60% of expenditure! As age increases, so does the proportion of the population with ALD. From the age of 75 onwards, more than half of insureds are ALD, compared with 5% of those under 45. Finally, the reduction in co-payments can also be explained by the increase in expenditure linked to serious conditions, which are also fully reimbursed. Population ageing may well contribute to increasing this trend over the coming years.

France, the ‘zero co-payment’ champion

How are insured persons in our neighbouring countries in Europe reimbursed for their health costs? Not as well as in France! After applying a different method of calculation – for international comparison purposes – whereby “long-term care” includes benefits linked to functional dependency, France leaves only 9.2% of health expenditure to be paid by households, compared with 15.5% for the EU-15 (i.e. the 15 most developed EU countries). In Italy, households pay 23.5% of their health costs, while Germans, Swedes and Danes pay between 12 and 14% of their health costs out of their own pockets, for an annual bill of almost €600. However, throughout Europe, the trend is for wider health insurance cover, particularly as a result of the growth of compulsory private insurance.

Blind spots in co-payment issues

For several years now, the public authorities have been focusing on the issue of healthcare co-payments. However, in France, there are some people who have been left out of co-payment reforms: people in a situation of functional dependency who receive long-term care (help getting up, toileting, assistance at home or in residential establishments). In this area, France is rather at the bottom of the European league. French households pay 25% of such expenditure, whereas the average co-payment in the EU-15 is barely more than 20%, and less than 10% in Sweden, the Netherlands and Denmark. This comparison with our neighbours is not very flattering for France. It reminds us of an all-too-necessary reform that has been on all political agendas for over fifteen years but seems impossible to achieve, i.e. the functional dependency reform. A complex project that was mooted in 2019, only to be pushed under the pile of Covid-19 priorities. It is undoubtedly a issue with greater priority than the projected all-embracing health insurance system .

Damien Vieillard-Baron

President of gerep