This is in a nutshell my own condensed analysis of the French universal health care system, combining universal coverage with a public-private mix of hospital and ambulatory care and a higher volume of service provisions than in the United States. It must be understood when
studying the French system that universal coverage can thus be achieved without excluding private insurers from the supplementary insurance market.
The French health care system was rated the best in the world by the World Health Organization in 2001 while the US health care system ranked 37th. In 2004, France spent 10.5% of its gross domestic product (GDP) and it increased to 11.5% of GDP on health care in 2017. By contrast, the US spent 18% of its GDP on health care in the same year. Payroll taxes in France provide 53% of funding, with employers paying 80% of the tax and employees paying the rest. In addition, a national earmarked income tax contributes 34% of funding, and State subsidies account for 1% of funding.
Universal coverage was achieved over seven decades by extending statutory health insurance (SHI) to all employees (in 1945), retirees (in 1945), the self-employed (in 1966), and the unemployed (in 2000). In 2000, the Couverture maladie universelle (Universal Health Coverage), or CMU, was created for residents not eligible for SHI, although the program required yearly renewals and entitlement changes whenever a beneficiary’s professional or family situation changed. After the implementation of CMU, fewer than 1% of residents were left without baseline coverage.
In January 2016, SHI eligibility was universally granted under the Protection universelle maladie (Universal Health Protection law), or PUM, to fill in the few remaining coverage gaps. The law also replaced and simplified the existing system by providing systematic coverage to all French residents. It merged coverage for persons previously covered by the Universal Health Coverage and immigrants covered by the state-sponsored health insurance.
Most voluntary health insurance (VHI) is complementary, covering mainly copayments and balance billing, as well as vision and dental care, which are minimally covered by SHI. In other words, the universal health care system in France is dominated by solo-based, fee-for-service private practice for ambulatory care, while public hospitals are open to all for acute institutional care, among which patients are free to navigate and be reimbursed under the national health insurance (NHI).
All residents are automatically enrolled with an insurance fund based on their occupational status. In addition, 90% of the population subscribes to supplementary health insurance to cover other benefits not covered under the NHI. French NHI evolved from a 19th-century tradition of mutual aid societies to a post–World War II system of local democratic management by “social partners” —trade unions and employer representatives— but it is increasingly controlled by the French state.
This combination of free enterprise (private practice) to complement state programs seems to be the solution to the deficiencies suffered by many countries that lean too far in one direction or the other. The fact is that the vast majority of French citizens claim to be satisfied with their healthcare system.