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France's new system of Universal Health Insurance (CMU) came into effect in January 2000. This system provides totally free healthcare to those with incomes of not more than FRF 3,500 a month. Over and above the 6 million people directly affected by the new scheme, the CMU will have an impact on the way the whole French health system operates. Industrial relations implications include a new obligation on employers with a workforce of over 50 to negotiate on top-up health insurance cover with their employees.
The law establishing a system of Universal Health Insurance (Couverture Maladie Universelle, CMU) was adopted on 27 July 1999 and came into force in January 2000 (FR9902153F). The new scheme provides totally free healthcare to those with incomes of not more than FRF 3,500 a month for single people, FRF 5,250 for a couple, FRF 6,300 for a household of three, and increasing thresholds for larger households. The only eligibility requirement is that the individual have a fixed address.
The CMU provides basic health insurance for 150,000 individuals not covered by existing schemes, either because they are not eligible or more often because they are unable to assert their eligibility. Furthermore, the main consequence, in a country where basic coverage is only 75% of an individual's medical expenses, will be to provide the 6 million most disadvantaged members of society with free top-up, supplementary health insurance. Those qualifying for the CMU will enjoy completely free treatment dispensed by health professionals, who are required to accept payment under the direct settlement system (see below) and apply either the fees set by negotiations between health insurance funds and health professionals, or if none have been negotiated, then those set by the government. Funding is to be provided by channeling funds used by the départementsand some social protection agencies to pay for various types of medical assistance to the new scheme. Funding will also be raised through a 1.75% tax levied on the turnover of top-up insurance agencies. Those agencies which now accept responsibility for providing top-up insurance for recipients of the new CMU will pay out FRF 1,500 less per person in insurance.
Other changes
The CMU, above and beyond providing healthcare for those previously excluded, will bring about the following four major changes.
- The role of local sickness insurance agencies. Local sickness insurance funds, (Caisses primaires d'assurance maladie, CPAM), of which there is one in each département, had until now been benefit "clearing houses". In the future, they will be responsible for addressing the needs of and advising a large sector of the population (6 million individuals) facing the greatest hardship. The people covered by CMU will constantly fluctuate, with tens of thousands of individuals leaving this system and others replacing them each year. The CPAMs are now responsible for the initial processing of CMU cases and will have to manage this flow of people. Despite the fact that the CNAMs have hired an additional 1,400 employees, they are quite naturally overwhelmed by the implementation phase of the new system. However, it is not merely a new system but also a new profession that is being created. This shake-up has come at a time of major upheaval in the work of sickness insurance officers caused by new information technology.
- The definition of the care covered under the new system, and the fees involved. The CMU system creates a double threshold. First, those people with incomes just over the FRF 3,500 threshold are not eligible. The preliminary versions of the new system provided for the creation of an "individually-tailored health allowance" (Allocation personnalisée santé), which would have operated on a sliding scale depending on the individual's income. This provision was dropped because it posed formidable management headaches. A two-fold approach was adopted. Welfare agencies and départementswill be required to use the "welfare funds" still available to them to offset the threshold effect. A parliamentary amendment requires all companies with a workforce of over 50 to start negotiations on top-up health insurance for their employees. Second, the threshold effect leads to an unacceptable situation whereby people covered by top-up health insurance they pay for themselves are less well protected than those falling under the free CMU system. The care covered by CMU, the level of fees in as far as it determines the amount borne by the patient, and possibly payment methods (see below), will become a type of benchmark, setting the minimum level of top-up cover. December 1999 government decrees relating to sensitive items such as dental and eye care, which are currently poorly covered, set coverage levels for CMU recipients which are significantly higher than those provided for by existing top-up insurance schemes. It will be interesting to see just how quickly this "standard" is implemented across the whole healthcare system.
- The role of supplementary, top-up systems. Currently in France, more than half of all top-up health insurance is provided by mutual insurance societies. The remainder is almost equally divided between insurance companies and jointly-managed social protection funds. CMU recipients will be able to choose their own top-up insurance organisation. In addition to the CMU system, companies with a workforce of over 50 will, as mentioned above, be required to negotiate over top-up insurance for their employees. These two factors might alter the respective roles of the three major categories of insurance organisation. The issue is not merely one of the dividing up of the market but, at a more fundamental level, of the very role of top-up insurance itself. All the top-up agencies viewed the FRF 1,500 allowed for each CMU recipient's top-up insurance as unrealistic. They succeeded in securing agreement from the Minister on the capping of spending for any one individual CMU recipient (a cap that was not provided for in the Act). The Minister also committed himself to the principle of reviewing the level of the cap according to the future financial assessment of the new system. These successful demands by the top-up agencies have demonstrated their ability to influence fees as well as the types of care covered. Even before the adoption of the new law, the top-up insurance agencies had already negotiated a memorandum of understanding with the National Health Insurance Fund for Employees (Caisse nationale d?assurance maladie des travailleurs salariés, CNAMTS). This recognised the right of the top-up agencies to participate in both the defining of the services to be covered as well as in the collective bargaining process with health professionals. Finally, insurance companies, on the basis of their participation in the CMU system, have demanded an overhaul of healthcare tax regulations, which currently favour mutual insurance societies. The introduction of the CMU will alter the top-up insurance environment. Trade unions are currently involved in jointly-managed social protection funds and have a complex relationship with the mutual insurance societies (many senior figures in mutual societies are members, and sometimes officials, of unions), but are excluded from the running of commercial insurance companies. Thus, the unions themselves have a stake in the future make-up of the top-up insurance sector.
- Payment methods for health professionals. The new law stipulates that all health professionals dispensing treatment under the CMU system are required to work under the system of "direct settlement" (by the CMU) and of fixed fees. In the absence of agreements between health insurance funds and health professionals, the Ministry has set fee rates. The direct settlement rule formally applies only to the 6 million people covered by the CMU system, but there will be a lot of pressure to extend it to other areas of the healthcare system. However, the French medical profession has traditionally been very hostile to the direct settlement formula, since it views this practice as the first step towards a salary-based medical system. The fact remains that while recipients of RMI minimum income benefit already have the direct-settlement system, a mere 20% of specialists in a city like Paris are willing to take on this type of patient. Clearly, health professionals are not paid the same rate or in the same way for a CMU patient as for an "ordinary" patient. There is a worry that the fee rates applied in the CMU system may be extended to the rest of the health system and therefore imposed on health professionals. In the event that this does not occur, and if a significant gap between CMU fee rates and those for the rest of the healthcare sector were to develop, there could be a danger of creating a healthcare system specifically for the poorest sections of society. This would go against the very aims of the new law.
Commentary
The aim of the CMU was to set up a funding system that would not affect the position of public finances and would avoid higher compulsory contributions or taxes. All parties concerned now agree that the actual cost of the CMU, especially at the start-up stage, will largely depend on how beneficiaries use it. To what extent will those sections of the population, which previously deprived themselves of medical care for financial reasons, attempt to use the new free system to "make up for lost time"? (Pierre Volovitch, IRES)