Universal Health Insurance (CMU) in France

1. Universal Health Insurance (CMU) in France Martine M. BELLANGERmartine.bellanger@ensp.fr ENSP RENNES

2. Contents • Background & implementation of CMU • Some characteristics of the beneficiaries • Impact on access to health services

3. Background • Q Universalism:1998 Act related to tackling exclusion” • “access for all to all fundamental rights, such as employment, housing, education & health • Under the “health umbrella” of 1998 ACT: two provisions • R Creating a Universal health insurance • R Implementing regional programmes for prevention and access to health care for people suffering from deprivation (PRAPS)

4. CMU • Introduction of a Universal health insurance (CMU): 1st January 2000. • CMU allows the neediest members of the society residing lawfully in France to be covered by the national health insurance coverage - ‘General Scheme’, irrespective of their employment status

5. ‘CMU basic package’ • A basic package of good and services was defined ‘ a priori by law’ for the CMU beneficiaries. This package includes services such as: • In patient and ambulatory services • Optical and dental care, • Implants (e.g. earrings)

6. ‘Complementary CMU: CCMU’ • In addition to the CMU basic package • A free complementary coverage is provided on a third party payer basis • for people below an income threshold (€587: £ 391 per month for a single person, in 2006) • who are exempting from making the initial direct payment, from hospital flat rate fee (€16: £10.7) and from out-of-pocket payments for spectacles and dental care

7. Beneficiaries: some data • 1.7 Millions people for the ‘basic CMU’, i.e. 2.8% of the whole population, 1st January 2006): • 4.7 Millions for the CCMU, i.e. 7.6% of the whole population • 44 % of the beneficiaries of the CMUC are less than 20, and 4% more than 60

8. Beneficiaries: some data • Large regional disparities for both CMU & CCMU, between France & oversea departments • CMU: 2.3% in metropolitan France, versus 16.8% in overseas departments • CCMU: 6.8% in France versus 33.5% in overseas departments • Large regional disparities within France • From 3.3% in Haute Savoy to 12.7% in Seine-Saint Denis (Paris Suburb) • Higher level coverage rates in a crescent South-South East and in North of France (see map: following slide)

10. Beneficiaries: some data • CMUC Beneficiaries and Activity Minimum Revenue (RMA) Beneficiaries: • Strong relationship between these two variables: • Correlation coefficient r = 0.95 in 2005 (0.82 in 2000)

11. Impact of CMU on access • Breakdown of CMUC spending (in 2006) • 50% ambulatory care and drugs • 25% hospital services • 15% dental care • 20% (others such as spectacles, implants) • Improvement in access to specialized health services (e.g. dental care, prosthesis, optical care) • Increase of specialist consultation in outpatient settings (instead of hospital setting after A&E)

12. Improvement of health state • Perceived health state lower for the CMU beneficiaries than for the rest of population (12% declared being in ‘bad health’, versus 4%, in 2003) (Same finding in the National health survey 2004) • But some improvements: • 30% declared suffering from a chronic disease, versus 37% the year before • Oral health conditions improved for those beneficiaries, in comparison with previous results

13. For further discussion … • Still some room for improvement (e.g. equal access for equal needs) • This scheme was called ‘UNIVERSAL’ but a specific basic package was defined for the neediest of the society, with a risk of stigmatising these ‘peculiar citizens’ • It could be said that the CMU aims to give the maximum to the worst off, according to the MAXIMIN Rawls principle