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The French socialsecurity system providesmedicalcoverage through astatutory health insurance scheme forthe entire population (66 million inhabitants).Thisscheme comprisesthree distinctregimes:the Régime Général for salaried workers, the Régime des Indépendants for self-employed workers and professionals,and the MutualitéSocialeAgricoleforfarmersand agriculturalworkers.In addition to these employment-based systems,two specificregimesexistforpeople outside the labormarket,and who are not co-insured asfamily members.Universalaccessto healthcare isorganized through the combination offive distinctive levels:
1．Compulsory health insurance (AssuranceMaladie,hereafterreferred to asAM).The founding principlesare those ofaBismarckian socialhealth insurance,based on professionalstatusand wor
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ⅰAbstract:In France,alaw passed in 1999 modernized and unified the variousformsofmedical assistance forthe poor.Thislaw providesfree affiliation to the statutory health insurance scheme aswell asfree orsubsidized affiliation to acomplementary health insurance scheme.People with little orno income thushave accessto free medicalcare.The new scheme bindstogetherwhatthe theoretical literature on healthcare systemsconsidersto be contrasting components:universalism,choice,and income thresholds.The particularFrench arrangementresultsfrom acompromise between two general policy streams:poverty relief,and controlofpublicspending.The resultisaunified publicsafety netfor healthcare,financed by the private complementary health insurance funds,viaaspecifictax.Thisarticle firstmapsoutthe institutionalcontextand related theoreticaldebates.The second partthen analysesthe policy making process,and presentsthe organization ofthe universalmedicalbenefitssystem (CMU -CouvertureMaladieUniverselle).The third partfocuseson the beneficiaries,the financing and the expenditure. The fourth and final part assesses the outcomes in terms of success and failure: a substantialimprovementofthe medicalsafety net,albeitwith ratherlow thresholds;broad political consensus supporting the legislation, though ongoing controversy over the benefits granted to undocumented migrants;and institutionalnormalization thatpromotessocialassistance to the statusofa legalright.
Keywords : health safety net,universalhealth coverage,Couverture Maladie Universelle (CMU), undocumented migrants,France
related income.The AM isco-financed by apayroll-based contribution from employers,and,since 1996,by an earmarked tax on the members’entire income1.
2．Voluntary complementary health insurance (AssuranceMaladieComplémentaire,hereafter referred to as AMC), operated by private organizations,which covers a large percentage of members’health expensesthatare notreimbursed by the statutory health insurance:approximately 25%. Nearly the entire population (96%2) is affiliated to this type of AMC scheme. The high prevalence ofAMC hasapositive solidarity effect:itspreadsthe remaining costsoverthe entire population ofAMC affiliates,which avoidsthe concentration ofout-of-pocketpaymentson individual patients.Two-thirdsofthe AMC marketisheld by not-for-profitorganizations.Many ofthem still operate with the traditionalincome-based premiums,although they are now adjusting forage and numberofco-insured family members,asfor-profitcomplementary health insurersdo.Only such limited risk selection ispermitted in France.
3．The listofserious and long-term illnesses (Affection deLongueDurée:ALD)definesthirty-three categoriesofpathology,comprising more than 400 illnesses,forwhich the AM reimbursement amountsto 100%.Accessto thisregime dependsmainly on amedicaldecision,and doctorshave often used the ALD arrangementto obtain fullreimbursementfortheirpatients3.The rapid growth in the numberofALD beneficiariesreflectsofcourse the growing impactofchronicdisease,butit also indicatesaneed forastrongermedialsafety net4.
4．Universalmedicalcoverage (CouvertureMédicaleUniverselle:CMU5)hasbeen in operation since 2000.Itwasinstituted by law in orderto provide aunified safety netforthose who are notcovered by the AM and/ordo nothave the meansto afford an AMC.The scheme comprisesthree layers,all subjectto meanstesting:first,the “basic”CMU (hereafterreferred to asthe CMU-B),which providesaccessto the AM forpeople residing in France,who cannotbe affiliated otherwise.Iftheir income isbelow athreshold,they are affiliated free ofcharge.Second,the “Complementary”CMU (hereafterreferred to asthe CMU-C),which providesfree affiliation to an AMC.Third,acash benefit, the ACS (Aideau paiementd’uneComplémentaireSanté),which isfinancialassistance foraccessto complementary health insurance.A “health voucher”isgiven to people whose income islow but exceedsthe CMU threshold,in orderto help them pay fortheirown complementary health insurance. 5．State medicalassistance (AideMédicaled’État:AME).Since undocumented migrantscannot benefitfrom the CMU,which isbased on officialresidence in France,thisspecificregime was added to the CMU legislation.Itservesanyone with administrative difficultiesand needing medical care.The care basketisthe same asforCMU patients.
One more regime should be mentioned here:humanitarian medicalassistance.Thispurely private and very militantassistance focuseson particulargroupsto which the officialinstitutionscannotreach out,ordo so only with difficulty and poorresults.The humanitarian organizationscan receive publicsubsidies6oract asservice providers,negotiating theirprogramswith localorcentralgovernment,including the AM.They actas“fire fighters”in extremely marginalized populationsorsituationswith publichealth risks(the homeless,isolated mentally illindividuals,people living underground,such asheavy drug addicts,migrants fearing expulsion,Romacommunities,etc).Theirwork consistsmainly in community organizing,and in offering the firstpointofcontactforindividualsin need.They provide translation and counseling,resolve administrative problemsand guide patientsto join the CMU and AME.Theiraction constitutesanecessary complementto the statutory regimes,forinformation and counseling,and thusactsasaform of“delegation ofpublicservices”(Maury,2013).
Thisarticle willfocuson the CMU regime and itsby-product,the State medicalassistance (AME)7.It willexamine how and to whatextentthese arrangementsfulfiltheirmission ofproviding an effective medicalsafety netto the populationsin need.
The CMU legislation waspassed in 1999 with abroad politicalconsensusamong allmajorpolitical parties,from the Leftto the Right.Intellectualshoweverengaged in controversy underpinned by theoretical debatesaboutthe legitimate foundationsofthe new CMU arrangement,aswellasitsarticulation with the principlesofsocialsecurity and the “normal”health insurance system.
The linksbetween asocialhealth insurance based on entitlement,on the one hand,and safety-net arrangementswith income thresholds,on the other,do indeed constitute achallenging theoreticalissue, because ofthe nationaldifferencesin institutionalframeworksand the politicalmeaningsthey convey.The interesting question here is:to whatextentare the conceptsand theoriesofgeneralsignificance,orlimited to nationaland historicalboundaries?
French intellectualdebatesin thisrespectcan be summarized underthree headings8.The firstpoint concernsthe linksbetween socialsecurityand socialassistance(Borgetto,Chauvière etFrotiée 2004; Chauchard etMarié,2001;Desprès2010;Lafore 2010):are they contradictory orcomplementary?Several authorssee the CMU asawatershed in the history ofthe French socialsecurity system,areform that “seversthe relationship between citizenship and professionalactivity”(Frotiée,2006:12).However,asmany have pointed out,thisevolution wasalready initiated before the CMU,in 1988,when allbeneficiariesofthe minimum income supportscheme were affiliated to the AM,automatically and free ofcharge.Othersargue thatthe CMU issimply anotherstep in the generalization ofsocialsecurity and AM coverage (Chauchard et Romain 2001).Lafore and Borgetto (2000)discussthe role ofsocialassistance in the “Républiquesociale”,in particularin connection with democracy,law and the reciprocity ofduties.In thisarticle itwillbe argued thatthe CMU safety netisapragmaticadaptation to new socioeconomicrealities:an incrementalprocessof modernization aimed atupdating previously existing arrangements.
The second pointoftheoreticaldiscussion concernsthe conceptofuniversalism,in relation to equity, equalchances,and the fightagainstpoverty (Borgetto,2000).In French,the term universalism commonly conveyscontradictory meanings:on the one hand,itisunderstood asequaltreatment,rejecting targeted schemesand policies;on the other,itrefersto “accessforall”,agoalwhich often callsfortargeted actions in orderto reach outto those in specialneed.In thiscontext,analystsofthe CMU often pointoutthatthe French health insurance doesnotreimburse the fullexpenditure,which obviously constitutesahandicap for achieving universalism,and furthermore thatuniversalism can only be based on residency,noton a Bismarckian-type ofsocialhealth insurance.These argumentswould suggestthatthe French healthcare system could notachieve universalcoverage,because ofthe Bismarckian structure linked to employment, aswellasthe importantrole ofprivate providersand doctorswho overcharge,on the one hand,and the refusalin publicopinion aswellasin the policy networksto adoptaBritish-type ofNationalHealth Service, on the otherhand.However,in empiricaltermsand by internationalcomparison9,medicalcoverage in France standsoutforitshigh level.Asthe statisticsbelow show,the CMU hascontributed to further improving access.
The third pointofthe controversy theorizesalongstanding politicaldebate opposing the socialsecurity institutions,conceived forand financed by the working population,on the one hand,to the tasksof “nationalsolidarity”considered asbeing the responsibility ofthe nationalgovernment,on the other.From the latter point of view, healthcare for targeted populations such as CMU beneficiaries should rely exclusively on “nationalsolidarity”and be financed from generaltaxes.Thisperspective would however demand new organizationalframeworksand could lead to aseparate “public”distribution ofmedicalcare for the poor,e.g.a“two-tiered”healthcare system – an option thatisnotsupported in France by politiciansor publicopinion.In empiricaltermsthe question relatesto organizationalproblems:which institution should be in charge ofthe managementofthe healthcare safety netand who should pay forit?
These debatesneed to be linked to the particularitiesofthe French healthcare system,which doesnot easily fitthe common categoriesused in internationalcomparison.The French system hasbeen described in variousand contradictory terms:ashalfway between the Bismarckian and the Beveridgian models (Hassenteufel2001),asmainly a“public-private mix”(Godt1991);asa“neo-Bismarckian regulatory healthcare state”(Hassenteufeland Palier,2007);and asasystem underdirectgovernmentcontrol(Rochaix and Wildford),with few veto points(Immergut,1992).
To understand the articulation between the statutory AM and the medicalassistance regime,one needs to focuson the relationship between the state,localauthorities,and the socialhealth insurance.In this perspective,the French healthcare system resemblesa“StatistmodelofSocialHealth Insurance”(Matsuda and Steffen,2013;Steffen 2010b).Furthermore,one needsto considerthe importantrole thatthe private sectorplaysin the system.Itsunique combination ofuniversalaccess,free choice forthe patients,private doctorsand complementary health insurances,hasbeen conceptualized as“LiberalUniversalism”(Steffen 2010a).Given thiscontext,three key questionsneed to be answered:
― How isthe residence-based safety netcombined with the socialhealth insurance? ― How isthe safety netarticulated with private providersofcare and insurance? ― How iscare and administration organized fornon-registered residents?
In otherwords:Who paysforthe care forthe non-contributing population?Whatisthe care basketfor them?Who decideson these mattersand how?
Table 1:Healthcare financing,2013
Origin offunding Share in %
Expenditure forMedicalConsumption
Compulsory contribution 76.0
Socialhealth insurance
“Public”(in principle) 1.4
State (forCMU and AME)
Private premium,to not-for-profit organizations
7.3 Complementary mutualhealth insurance
Idem,forprofit 3.9
Complementary commercialhealth insurance
Idem,partly not-for-profit 2.6
Complementary health insurance within contingency funds
Private individuals 8.8
Outofpocket
€2,843 percapita/annum 100%
187 billion Euros (8.8% ofGDP)10
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The law instituting the CMU and the AME,passed on 27 July 1999 and applied on 1 January 2000,did notstartfrom scratch.Itreplaced the previousmedicalsafety netoperated underalaw dating allthe way back to 189311,which obliged localpublicauthorities(municipalities,Départements)to provide medicalcare forthe “poor”oftheirterritory.The system wasessentially discretionary,withoutany nationalrulesor guidelinesbeing defined.Once arequestformedicalassistance had been approved by the localmayoror commission,the administration issued adocumentthatthe patientwould give to the doctor,who would be paid directly by the localauthority according to locally setrates.The system suffered from the medical profession’sreluctance to cooperate and from differentconditionsforaccessand benefitsacrossthe country. There was need for reform and unified rights, especially as the labor market was changing and unemploymentgrowing.The 1999 law transferred the responsibility forincome testing12from local politiciansand socialservicesto the localfundsofthe statutory AM.Itsetup standardized nationalincome thresholds,varying only according to the size ofthe household,and fixed the listofbenefitsvalid throughoutthe country.Free care thusbecame aright,and no longerassistance depending on the good willoflocalpoliticians.
The CMU replaced notonly the formerlocalmedicalassistance scheme,butalso “personalaffiliation” to the health insurance scheme.The lattertype ofaffiliation had been created in the early 1980sforpeople who did not qualify for compulsory affiliation to the AM through employment. But as the personal premiumswere very high,people tried to escape from thisaffiliation,which became asource ofcheating. Former“personal”affiliateswhose income isbelow the CMU threshold are now entitled to free affiliation. Furthermore,the CMU legislation constituted apoliticalalternative to amore generalreform planned in 1995 by formerPrime MinisterAlain Juppé (from the rightwing),fora“universalhealth insurance”,whose projectwasfiercely and successfully foughtby the (socialist)opposition and the trade unions.
The 1999 CMU law included aprovision forundocumented residentsand immigrants,who were excluded from the residence-based CMU scheme.Since the localmedicalassistance scheme had been abolished,undocumented migrantswould be deprived ofany accessto medicalcare.The law therefore included aspecificsafety net,the AideMédicaled’État(AME),mainly forillegalforeigners,butitservesfor any otherperson with administrative difficulties.
The CMU legislation wassuccessfully adopted and implemented,because itwaspartofamore general policy stream aimed atpoverty alleviation.Itenjoyed broad supportfrom publicopinion,in sharp contrastto the rejected Juppé plan.The CMU legislation also had an importantforerunner:the automaticaffiliation to the AM,free ofcharge,forallbeneficiariesofthe “Minimum Income support”instituted in 1988 by the (socialist)Prime MinisterMichelRocard.In 1998,when the socialistsreturned to power,afurtherlaw was adopted to improve “accessto allfundamentalrights”forpeople with low incomes.The barriersto accessto medicalcare are wellknown and regularly mentioned in reports:incomplete reimbursementand the necessity to pay foraAMC,the reimbursementsystem thatobligespatientsto firstadvance costs,and the possibility for many doctors to overcharge. Policy-making for the safety net was fuelled by strong mobilization by humanitarian organizationsworking atthe frontline ofpublichealth issuesin marginalized populations.Welltrained in mobilization,politicallobbying and fund raising,these organizationsargued that
amedicalsafety nethad become a“socialurgency”.They were listened to in the senioradministration of the health ministry,and actually participated in drafting the bill(Frotiée 2004).
The failure ofthe Juppé plan forauniversalhealth insurance scheme,and the successofthe CMU and itsparticularorganizationalarrangementswhich willbe analyzed below,illustrate the difficulty ofcarrying outstructuralreformsin the healthcare sector,and the importance ofincrementalchange building on existing institutionsand inherited ideasand beliefs.The successofthe new legislation wasachieved through three practical measures: effective response to identified needs, clear common rules, and administrative simplification through asingle reception desk.
The CMU-B providesfree affiliation to the AM forsmallincome earners.In addition to this,the CMU-C offersfree affiliation to an AMC.Both these partsofthe CMU operate on the basisofofficialresidence in the country and income testing13.Healthcare forbeneficiariesispaid directly to the providers,withoutthe patienthaving to advance money orto pay the out-of-pocketlump sumsusually required.In addition to this advantage,medically prescribed itemsthatare normally notreimbursed oronly atasymbolicrate (e.g. spectacles,dentalprostheses,hearing devicesand otherequipment),are provided free ofcharge to CMU patients,within price limitsallowing foraverage quality standards.CMU and AME beneficiariesthushave a more extended coverformostmedicalneedsthan the contributing affiliatesto the AM.
Residentswhose income isslightly above the CMU threshold receive a“health voucher”(known as Aidepourl’acquisition d’uneComplémentaireSanté,ACS)to help them to subscribe to aprivate AMC.
Applicationsforthe differentlayersofthe safety net– CMU,AME,and ACS – are allto be submitted to and treated by the same localoffice ofthe AM.Thissingle reception desk checksthe documents, especially the applicant’sincome,organizesthe paymentofthe ACS-health voucher,and issuesthe CMU or AME electronichealth cards.These proceduresneed to be renewed annually.Family membersare affiliated according to the same rulesasthose governing the statutory AM.
Forthe CMU and ACS,the only documentsrequired are proofofidentity,residence (such aselectricity bills or rent payments) and income (tax notification, social allowances, etc.14). For the AME, the requirementisproofofforeign nationality and ofpresence in the country foratleastthree monthsbutfor lessthan ayear15(hotelbills,witnesstestimonials).
Two typesofcontroversy accompanied the implementation ofthe CMU safety net.
The firstconcerned the income thresholds,criticized asbeing too low.Criticspointed in particularto the factthatpeople with income justabove the thresholdswould be excluded from the benefitsofthe CMU although theirincome would notbe sufficientto pay foran AMC.The decision makersin the ministry responded in the following way:thresholdsneeded to be fixed with regard to othersocialminimaand thresholds(minimum income,old-age socialassistance,etc.),and to remain below them forreasons pertaining to publicspending.Thiswasseen asbeing socially acceptable since notbenefitting from afree AMC waslessdramaticthan losing the monetary allocation foreveryday living costs.Illnesswasnot considered to be apermanentrisk (CMU Fonds2001:3).
Adjustmentshave howeverbeen introduced.Article 23 ofthe CMU law already obligesthe AMC to keep any formerCMU-C beneficiary atthe same premium foratleastanotheryearafterthey have ceased to be eligible forthe CMU scheme.During the year2000,the governmentallocated aspecialpublicgrantof €400,000 to the statutory health insurance in orderto “help people atthe CMU borderlines”(CMU-Fonds, Report2001:3).LocalAM fundstook variousmeasuresto soften the borderlines.Itbecame generalpractice in the AM fundsto acceptcandidateswith income up to 10% above the threshold.The ministry then centralized these variousinitiatives,and added corresponding paragraphsto the law.In 2000,the principle wasthuslegalized thatup to 10% above the threshold,people could stillbenefitfrom the third-party-payer system,e.g.withouthaving to advance money forcare.The provision waslaterextended to one more year ofmembership ofthe CMU system afterexceeding the income threshold (unlessthe person entered employmentand could be insured underthe regularcompulsory system).
The mostimportantadjustmentwasmade by alaw enacted on 13 August2004,which introduced the ACS (health voucher)arrangement,applicable from 1 January 2005.Thissubsidy isgiven to allpeople with income above the CMU threshold,fixed initially at20% above16,then extended to 35% in 201317,in orderto help them pay fortheirown AMC.The levelofthe ACS-subsidy varieswith the age ofthe individual household members:for2014,peryearand person,itamounted to €100 forhousehold membersunderthe age of 16, €200 for 16-49 year-olds, and €550 for those over 60. This public subsidy may favor the commercialAMC market,with risk-adapted premiums,butmostofthe beneficiaries(84.7%)optforthe statutory health insurance astheircomplementary AM (CMU Fonds,2013b:36-37).CMU beneficiariesare the onlypersonsforwhom the publicAM actsalso asAMC.Thisparticularprovision may prefigure afuture evolution ofthe French health insurance towardsacatalogue ofoptionsin the health coverage,similarto those in the Netherlandsand Germany.
The thresholdsforthe ACS “health voucher”benefithave been fixed at60% ofthe netmedian income, which correspondsto the poverty line.The latterissituated at€977 permonth forasingle person (CMU Fonds,2013b:18).Alltogether,the CMU and ACS thresholdsremain low,which keepsthe numberof beneficiarieswithin limits.Thresholdshad notbeen updated foryears,when PresidentFrançoisHollande (socialist)decided on ageneralupgrading of8.3% from 1 July 2013.A furtherincrease isplanned butmay notbe implemented,given the high levelofpublicdebt.
Table 2:Income Thresholds in 2013 (Mainland France) ACS (“Health Voucher”)
in Euros CMU and AME
in Euros Household members Permonth Peryear Permonth PerYear 977 11,670 720 8,645 1 1,459 17,505 1,081 12,967 2 1,751 21,006 1,297 15,560 3 2,042 24,507 1,513 18,153 4 2,431 29,175 1,801 21,611 5 +389 + 4,668 + 288 + 3,457
Additionalperson
The second controversy concerned the articulation ofstatutory and complementary health insurance. To understand thisparticularFrench problem we need to bearin mind the following:
― The CMU-C arrangementisanecessary complementsince the statutory AM reimbursesonly approximately 75% ofmedicalcosts,which appliesalso to the CMU-B.
― MostCMU beneficiarieschoose the statutory AM astheirpointofaffiliation fortheirCMU-C, despite the existence ofthe private AMCs.
An importantideologicalelementin the French healthcare system is“free choice”.When the CMU law wasin preparation,the humanitarian non-profitassociationsinsisted strongly on the principle offuture beneficiarieshaving “free choice”concerning the organization to which they would like to be affiliated for theirCMU-C coverage.The aim wasto “preventstigmatization”thatcould arise from specificpubliccare pathwaysforCMU patients.Seniorgovernmentofficialsin charge ofdrafting the legislation were sensitive to this “normalization” argument. Consequently, at the time of admission to the CMU-C scheme, beneficiarieshave to choose whetherthey wantto use the statutory AM astheirAMC,orbe affiliated to a private AMC and,ifso,to indicate which one.
The issue became atricky financialproblem once the system wasoperating,because the publicfunding allocated by the governmentto the institutionsaffiliating the beneficiariesfollowsthe beneficiary’schoice. Initially,the publicAM fundswere reimbursed fortheirCMU expenditure atthe realcost,whilstprivate AMCsreceived afixed percapitasum,and had to supportthe financialrisk themselves.Seniorofficialsin the socialsecurity departmentofthe ministry in charge ofhealth promoted thisoption with atwofold argument:on the one hand thatasafety netwasa“nationalsolidarity”mission and therefore to be financed by publicauthority and generaltaxes,buton the otherhand that,asthe beneficiarieswould also be “clients”forthe private AMCs,the governmentneeded to pay only forthe “affiliation”,notforthe actual medicalchargesthe affiliated CMU beneficiarieswould incur.Opinionsevolved when the 2004 law was drafted,to reform the health insurance in amore managerialsense.Itwasthen decided thatthe state could “delegate”itsmission ofnationalsolidarity to the statutory AM,and henceforth pay only alump sum for each affiliated CMU beneficiary,instead ofthe fullexpenditure (Frotiée,2008:14).The statutory AM was thusaligned with the private AMC.Willthisprecedentopen new windowsforfuture AM reformsin France? The indirectcostofthe new legislation wasconsiderable in termsofwork force,job training,and creative institutional renewal. The local AM funds had to learn how to handle income testing and coordination with othersocialadministrations,in particulartax offices,laborofficesand the many AMCs. According to the firstEvaluation Reportofthe CMU Fund setup specifically forthispurpose,the AM administration created 1,930 new stable positions(life employment)and in addition concluded 973 work contractsforlimited periods(CMU Fonds,2001:3).With new rulesand high publicexpectations,litigation also multiplied,especially during the firstyear.In 2000,the commissionsforarbitration processed 38,000 CMU-related cases,nearly allofwhich contested the levelofincome18.Whilstmostofthe complaintswere dismissed,atlocalornationallevel,the huge work ofinquiry setacase precedent,especially forincome testing thatconstituted amajorinnovation in the French socialsecurity system.The governmentprovided only generalguidelinesto the executivesofthe new system:remain flexible to avoid publicanger,butkeep thresholdsmodestto avoid exploding publicbudgets(CMU Fonds,2001:4-5).
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To organize,steerand manage the CMU system,the 1999 Law setup anew publicagency,the CMU Fund (FondsdeFinancementdela Protection Complémentairedela CouvertureUniverselledu Risque Maladie).The Fund organized the implementation ofthe law,and since then hashad the task ofmonitoring the situation,writing detailed annualevaluation reports19,and making policy recommendationsto the governmentand the socialsecurity institutions.Itsmain mission isto organize the financing ofthe CMU system.Itcollectsthe resourcesattributed to the system and allocatesmoney to the institutionsaccording to theirnumberofaffiliated CMU beneficiaries.
Up to 2012,the Fund allocated to the affiliating bodiesan annualpercapitalump sum of€370.Thisdid notcoverthe realcosts,which averaged €440 perbeneficiary in 2013 (forCMU-C beneficiariesaffiliated with the statutory AM;the only figuresknown).The 2013 law forfinancing the socialsecurity system fixed the annuallump sum at€400,butchanged the rulesto promote costcontainment:the relevantinstitutions, both AM and AMC,are now reimbursed up to theirrealannualexpenditure,butonly within the limitof €408 (figure for2014).
The source offinancing hasevolved considerably.Initially the governmentprovided the funds,together with a limited voluntary participation of all AMCs. Following an agreement negotiated between the governmentand the nationalfederation ofthe AMCs,the latterparticipated with a“solidarity contribution” then fixed at1.75% oftheirgeneralturnover.The rate wasraised twice:to 2.5% in 2006,and to 5.9% in 2009. A majorchange occurred in 2011 when the annuallaw forthe financing ofthe socialsecurity transformed the contribution into a“tax”,labeled “Tax forAdditionalSolidarity”(Taxedesolidarityadditionnelle).The rate wassetat6.27% ofthe insurer’sturnover,payable by allAMCs,including those who did nothave CMU-C affiliatesordid notparticipate in the scheme.Thischanged the rulesofthe game,since atax isnot negotiable butcompulsory.The tax hasto be paid to the office thatcollectsbusinesstaxes,which transmits itto the CMU Fund.The AMCsprotested,especially the mutualistAMCs,arguing thatthey had aprivate and only voluntary membership,butthe governmentstood firm.
Asaresult,the CMU safety netisnotfinanced by generaltaxes,assuch residency-based publicsafety netsusually are,butalmostexclusively by the private AMCs.The latterintegrate the costincrease into the price oftheirpremiums,thustransferring the charge ofa“nationalsolidarity task”to theirprivately paying affiliates.The publicinputislimited to the recently decided attribution ofasmallpart(3.15%)ofthe tobacco tax.
Although itisdifficultto know the precise expenditure forthe safety net20,the totalexpenditure can be estimated ataround three billion Eurosperannum.In addition to the financialtransfersoperated by the CMU Fund (2,097 million Euros),the AME forundocumented residentsrepresents€712 million,and public subsidiesto medicalhumanitarian non-profitassociationsanother€100 million.Furthermore,an unknown but non-negligible part of the 100% reimbursement within the ALD scheme (serious and long-term illnesses)21should be added because the ALD issometimesused asaway to free patientsfrom out-of -pocketcharges,asasocialarrangementbetween the care providersand theirpatients.
Table 3:Financialbalance ofthe NationalCMU Fund,2013 Receipts: in million € Expenditure: in million €
2,066 Solidarity Tax paid by the private complementary health insurance funds 1,581
Paymentsto the statutory AM for CMU-beneficiaries＊
352 Partofthe Tobacco Tax transferred by the government
264 Paymentsto the private AMC for CMU-beneficiaries＊＊
16 Unused service provisions
234 Paymentsto AMC to compensate for “ACS”＊＊＊ 17 Service provisions 1 Administration 2,434 Totalreceipts 2,097 Totalexpenditure
Surplus,forreserves + 337 Finalresult:
Sources:Zaidman etal.(2014:95),CMU Fund statisticsfor2013
＊ Transfersto the publicAM:up to €440 maximum perCMU-C beneficiary. ＊＊ Transfersto the private AMCs:up to €370 perbeneficiary.
＊＊＊Transfersto the private AMCsto compensate fortheirACS expenditure on beneficiaries.
Table 4:Estimation ofthe totalcostofthe safety netforhealth,2013 Financed by:
In million € Destination ofexpenditure
Totalchargesofthe CMU Fund (tax on private AMC)
2,097 Basicand Complementary CMU,and ACS
(Health voucher)
State (centralgovernment) 712
AME
Totalforthe compulsory schemes: 2,809
Humanitarian organizations(centraland localgovernment)
100 Publicsubsidiesto private action
2,909 Totalexpenditure
Source:Author’sown calculation,on the basesofthe figuresofofficialreportson the CMU (CMU Fonds,2013b)and Zaidman etal.(2014:90-95).
Figure 1:Numberofbeneficiaries ofCMU-B,2007―2013
Figure 1 showsthe sudden growth in the numberofbeneficiaries,since 2008 and 2009.Thiscan be interpreted as a direct effect of the financial crises and the economic slow-down causing more unemployment.Since the beginning ofthe CMU scheme,the numberofbeneficiariesreflectsexactly the evolution ofunemployment,including geographicaldistribution (CMU Fonds2013b:35).
Table 5:Beneficiaries ofCMU-B
Total OverseasTerritories Metropolitan France France % ofpop＊ Number % ofpop＊ Number % ofpop＊ Number 2.2 1,407,823 14.3 261,075 1.8 1,146,748 2007 2.2 1,461,592 14.4 266,051 1.9 1,195,541 2008 2.8 1,856,915 16.2 302,094 2.4 1,554,821 2009 3.3 2,159,253 16.6 310,699 2.9 1,848,554 2010 3.3 2,191,858 16.7 314,515 2.9 1,877,343 2011 3.3 2,221,931 18.2 343,657 2.9 1,878,274 2012 3.4 2,242,482 18.2 344,152 2.9 1,898,330 2013
Source:Statisticsofthe CMU Fund
＊Percentage ofthe totalpopulation
Table 6:Beneficiaries ofCMU-C
Total Overseas Metropolitan France % ofpop＊ Number % ofpop＊ Number % ofpop＊ Number 6.8 4,398,063 32.2 589,415 6.0 3,808,644 2007 6.4 4,206,894 31.0 574,488 5.7 3,632,406 2008 6.3 4,154,665 31.0 577,244 5.6 3,577,406 2009 6.4 4,203,711 30.3 566,477 5.7 3,637,234 2010 6.5 4,315,590 29.7 560,703 5.8 3,754,887 2011 6.7 4,416,648 29.6 559,192 6.0 3,857,456 2012 7.0 4,623,369 30.0 566,173 6.3 4,057,196 2013 7.7 5,125,000 2014 firstestimation
Source:Statisticsofthe CMU Fund
＊Percentage ofthe totalpopulation
Table 7:Beneficiaries ofthe “Health Voucher” % oftotalpopulation Totalnumber
Overthe last12 months
0.90 597,892 On 1 January 2010 0.96 634,620 Idem 2011 1.19 784,575 Idem 2012 1.54 1,014,209 Idem 2013 1.76 1,160,863 Idem 2014 1.78 1,173,339 1 June 2014,latestavailable
The numberofbeneficiariesevolvesdifferently,depending on the scheme.Ittendsto reflectthe economicsituation aswellasthe threshold effectsresulting from policy decisions.Whilstthe population covered by the CMU-B hasgrown slowly butsteadily,the numberofbeneficiariesofthe CMU-C remained atnearly the same levelbetween 2007 and 2012,and even declined in 2008 and 2009,reflecting unchanged thresholds.Itconsequently increased immediately when the socialistsreturned to powerand raised the thresholds.Thiseffectiseven strongerforthe ACS beneficiaries,which exceeded the symboliclevelofone million beneficiariesin 2013.The numberofbeneficiariesofthe CMU-linked schemes,including AME,is estimated atmore than 8 million people,i.e.approximately 12.5% ofthe population22.
Detailed analysisshowsthatthe CMU arrangementsbenefitmainly young people,who are mostheavily hitby unemploymentin France.The majority are women.The geographicaldistribution showsastrong concentration in the French OverseaTerritories,where CMU and AME beneficiariesaccountforup to 30% ofthe population,followed by underprivileged suburban areassurrounding big cities,especially Paris(13%), and the mostde-industrialized regions(Nord and Mediterranean coast,where the rate is10 to 12 %).The geographicdistribution ofthe medicalsafety netissimilarto thatofthe minimum income,which suggests thatthe medicalsafety netspreadswhere itiseconomically mostneeded.
The AME beneficiariesconstitute the main subjectofpubliccontroversy around the medicalsafety net. Theirevolution in numbersreflectspolitics,in which immigration isone ofthe main subjectsofelectoral debate.Thisexplainsthe restrictionsintroduced in 2011,and theirimmediate abolition afterthe 2012 presidentialelection,when powerpassed from the Rightto the Left:
― an annualflatrate of€30 to be paid peradultbeneficiary,
― the priorauthorization ofthe AM forany hospitalinpatienttreatment,
― the restriction ofentitled family membersto only (one)spouse and own children,excluding ascendantsand siblings.
The AME hasthe same thresholdsasthe CMU,and allowsaccessto allnecessary care without payment.Furthermore,itincludesseveralitemsofself-medication,butexcludesthermalcuresand artificial insemination.
The numberofAME beneficiarieswas284,000 in 2013.Afterasteady growth rate of5.4% peryear during the period from 2007 to 2010,the numbersuddenly declined by 8.4% in 2011,apre-electoralyear underPresidentSarkozy (rightwing).With the arrivalofthe socialistPresidentHollande,the number jumped up immediately,by 20% in 2012,and by another12% in 2013 (Zaidman etal.,2014:90).
Two problemsregularly triggercontroversy and aquestforbettermeansofcontrol– generally without any noteworthy success.First,itisvery difficultto identify the realincome ofillegalimmigrants,and equally difficultto identify the exactfamily relationships,especially with migrantsfrom countrieswith weak administrative systems,acommon situation in Africafrom which many migrantsto France come.Second, the 2007 reportofthe SocialAffairsInspection Board on the AME regime found majorabuse,and regretted thatprosecution forfraud wasrare,even when itwasclearly identified (IGF/IGAS,2007).Collaboration between the Police and the AM started,forthe firsttime,afterthisreport.
A tricky everyday problem isthatofasylum candidates,whose residency in the country islegalaslong asno negative decision hasbeen made.They thusqualify forthe CMU scheme immediately on arrival.The AM administration howeverhasdifficultiesdistinguishing asylum candidatesfrom illegalmigrantsand tries to orientthem,often wrongly,towardsthe AME scheme.A new and growing problem isto identify care seekerswho use the asylum window to benefitfrom legally provided free medicalcare forsevere illnessand urgency,before afinalnegative decision istaken on theirasylum demand,which may take severalmonths orayear.These casesillustrate the many practicaldifficultiesin managing acoherentsafety netthat includesallresidents,legaland illegalalike.
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Despite intellectualcriticism and practicalshortcomings,the CMU isunquestionably asuccessstory.It hasorganized aunified nationaland legitimate safety netthatismore comprehensive and efficientthan the previouslocalones.Asitisintegrated into the common health insurance regime,itentitlesbeneficiariesto use the same care institutions and care baskets as the average contribution-paying patient. This normalization limitsstigmatization,and transformsmedicalassistance into alegalrightforfullAM coverage. Italso guaranteesthe quality ofcare delivered to the economically more underprivileged population. The comprehensive assessmentofpolicy outcomes,including contradictory results,isadelicate task.In thisempiricalcase,the framework developed by Bovens,’tHartand Petersforanalyzing “successand failure in publicgovernance”(2001),and the conceptof“institutionalfit”borrowed from EU studies (Guiliani,2003)provide usefultools.These theoreticaltoolsallow precise assessmentby distinguishing three closely interwoven levels:programmatic,institutionaland political.
Programmatic success and failure
In France the majorobstacle to equalaccessto care isthe incomplete reimbursementby the statutory AM,which makesitnecessary to subscribe to an AMC.Therefore,an effective safety netmustnecessarily respond to thisparticularproblem,asreportsregularly pointout(Jusot2014).The CMU scheme focuses directly on thisproblem.According to the IRDES study (2010),only 4% ofthe generalpopulation stillhasno complementary health insurance.Among these people thatare notcovered by an AMC and noteligible for the CMU scheme,lessthen 43% claim thatthey cannotafford an AMC,which representslessthan 1.7% of the country’spopulation.The othersstate thatthey do notneed one because they are already fully covered, eitherby the ALD scheme orasafamily member,ordo notwish to have one,orlack information.Given the comparatively young average age ofthispopulation withoutAMC coverage (29 yearsold,compared to an overallaverage age of41),one may suppose they enjoy rathersatisfactory health conditionsand consequently have relatively little need formedicaltreatment.The main question then iswhetherthe CMU reachesitsspecifictargetpopulation,the poorestpartofthe population,when medicalcare isneeded.The scheme isclosely monitored,buttwo comprehensive indicatorssuffice to answerthe question.One indicatoristhe socioeconomicdistribution ofthe CMU-C.Itshowstwo categoriesthattogethercompose more than three quartersofallbeneficiaries:“having neverworked”,and “unqualified workers”.The CMU thusmeetsitstargetpopulation.The second indicatoristhe comparative percentage ofpeople who say that, forfinancialreasons,they have notsoughthealthcare atleastonce during the pastyear.Thisdoesnotdiffer much between CMU-C beneficiariesand the generalpopulation with aprivate AMC:only 6% lessforCMU-C
beneficiaries(Desprèsetal.2011:2).Thissuggeststhatthe reasonsfornotseeing adoctorare not specifically linked to CMU shortcomings.
Resultsconcerning the ‘health voucher’(ACS)show amore complex picture.In 2011,78% ofthe potentially entitled ACS beneficiariesdid notbotherto apply forit(CMU Fonds2013a;Guthmulleretal 2013).The high levelofnon-take-up suggestsfailure ofthe scheme to meetitsgoals.In orderto identify the reasons,in-depth studieswere conducted in Northern France overseveralyears,including practical experimentation offering ahighersubsidy,and improving information by inviting potentialbeneficiaries personally to briefing sessions(Guthmulleretal.2014,2011,2010).The firsttestsshowed thatthe higher sum ofmoney offered improved the leveloftake-up only slightly;abetterresult,although stillmodest,was obtained with amore effective strategy ofinformation and communication.
The studiesrevealed thatmany potentialbeneficiariesconsiderthe administrative procedure astoo complex to dealwith,and too heavy compared to the expected advantage.Difficultiesto understand administrative and practicalproblems,such asopening hoursortransportation,have been identified asmain reason fornotapplying forthe ACS.One may conclude from thisthatthe ACS scheme isnotadapted to the mostdisadvantaged partofitstargetpopulation,orinversely thatthe healthcare sectoralone cannotcorrect the cumulated effectsofgeneralsocialinequality and weak inclusion.
Meanwhile,the amountofthe subsidy hasbeen increased.Information gapsand administrative problemshave been identified and are currently being addressed.A precise gap hasbeen identified since 2009,when the minimum income scheme wasreformed.Before the reform,affiliation to the CMU used to be automaticforbeneficiariesofthe originalminimum income allowance,withoutthem having to follow any procedure.By contrast,the reformed version (Revenu deSolidaritéActive),which entitlesbeneficiariesto the publicallocation in addition to alimited amountofwork income,now obligespotentialbeneficiariesto declare theirincome to the AM,and thusto take apositive action to initiate theiraffiliation to the CMU or ACS.In its2013 report,the CMU Fund recommendscloserinstitutionalcollaboration between the AM and the employmentagencies,in orderto close thisgap (CMU Fonds2013b).Itproposesan obligation forthe localemploymentagenciesto systematically inform theirclientsaboutthe change in the procedure,and furthermore an automaticelectronictransmission ofthe relevantdata.Such dataconnection between institutionshashoweverencountered significantpublicand politicalopposition in France.
Despite these ongoing problems,the CMU seemsto reach itsprogrammatictargets,within the limitsof the healthcare sector,withoutbeing able to solve allgeneralproblemssuch asweak administrative coordination,illiteracy,socialexclusion,orculturallimitsto the connection ofdatasystems.
Institutionalcoherence
The question here ishow the CMU scheme fitsin with otherinstitutionalstructuresand principles. CMU thresholdsremain very low,beneath the othersocialminima.This,the main shortcoming ofthe scheme,isan explicitpolicy choice linked to publiccostcontainment.The AM hasbeen cumulating deficits fortwo decades.Today ithasbecome the main driverofthe socialsecurity deficit,ahead ofretirement pensions23.One may considerthatlow thresholdsare afailure,butequally thatthe CMU standsoutasa successin acontextwhere the nationalpublicdebtexceedsthe agreed European Union levels.
The CMU fitsthe institutionalorganization and powerstructuresofthe French healthcare system.This hasmade the scheme workable,butalso explainsitslimits.Asdoctorsare notallowed to overcharge CMU and AME patients,many try to keep them away from theirpractice.Contractsheld by ACS beneficiariesare generally ofthe cheapestcategory,and exclude the reimbursementofovercharged medicalfees.The promised free choice ofdoctorsisin reality limited forCMU beneficiaries.The CMU cannotremove the privilegesofprivate medicalpractice,such asfee-for-service and overcharging,butitdoespromote the thir d-party-payersystemsforCMU and AME beneficiaries.Studiesshow thathalfofthe reimbursementspaid out by private complementary health insurance companies,thatis,forcontribution-paying members,concern ambulatory care ofprivate doctorsand dentists,followed by non-vitalmedicines(Le GarrecetBouvet 2013:194).Thispattern contrastswith the predominantuse ofthe emergency departmentofpublichospitals by safety-netbeneficiaries.
The key institutionalfitofthe CMU isitsprovision ofcomplementary health insurance.Thistakesaway the need foramajorreform,which would be necessary iffullreimbursementwasto be granted by the statutory AM.Instead the CMU shiftsthe additionalexpenditure forthe safety netto the contributing affiliatesofthe private AMC.The residency-based safety netdoesnotinvalidate the employment-based statutory AM.Residency asacriterion foraffiliation isonly subsidiary in France,thatis,limited to the CMU.Furthermore,the publicCMU doesnotcontradictthe dualarchitecture ofthe care offer,composed ofapublichospitalservice and médecinelibérale.
Politicalsuccess and failure
Publicopinion and allthe French politicalpartiessupportthe CMU system.Itisonly now,with the effective reduction ofpublicspending,thatcriticism isarising around the ideathatCMU beneficiaries“get more”than those who work and pay contributionsto the AM.The key pointofcontroversy howeveris limited to amarginalbuthighly symbolicpartofthe system and the costs:the inclusion ofillegalmigrants, thatis,the AME scheme,and the related difficulty to controlbenefitsand preventabuse.The subject continuesto fuelelectoraldebate.Thisisharmfulboth to the beneficiariesand to the developmentofthe CMU/AME system.The controversy willgrow howeverwith the massive arrivalofmigrantsand refugeesin Europe.
To sum itup,there issufficientevidence to supportthe argumentofsuccess.On the programmatic level,the safety netisreaching those forwhom itwasdesigned.On the politicallevel,publicopinion and officialreportscontinue to approve the scheme.On the institutionallevel,the CMU followed acomplex public-private mix,in line with the architecture ofthe French healthcare and health insurance systems.The factthatgeneralfeaturesofthe healthcare sectorand aratherhigh levelofsocialinequality,in general, limitequalaccessto healthcare,and thatelectoraldebate spreadsinto the health sector,doesnotmean a failure forthe CMU.The CMU hasbeen relatively successfulin problem-identification,policy-making and implementation.The failuresare spilloversfrom generalnationalpolitics.The CMU respondsto asocial need,and restson amore generalpolicy ofsecuring basicrightsforpoorpeople.
Three lessonscan be learned from the French CMU case.
socialassistance program (Lafore 2008).The case indicatesthatthe boundary between social assistance and socialsecurity can become blurred,despite currentinternationaltrendstowardsa deepening separation.
― Second,the CMU showshow reform-resistanthealthcare systems,such asthe French one,can adaptto new needsand conditions.The processofchange isincremental,bottom-up and pragmatic in termsofpublicexpenditure.
― Third,the CMU may be more than justamedicalsafety net.Itispartofa“new generation ofsocial rights”(Gazier,PalieretPérivier2014),responding to asocioeconomicevolution characterized by more unstable jobs,working poor,and youth unemployment.In thiscontext,itprovidesan example ofhow asocialhealth insurance system and centralized state regulation can interactto secure universalaccessto health insurance and care.
Acknowledgements
Iacknowledge the supportoffered by the College ofSocialSciences,Ritsumeikan University,during my visiting professorship from September2014 to February 2015.Thispaperwaswritten forthe 50th Anniversary of the College ofSocialSciences,and Iexpressmy deep thanksto the discussantsand colleages,especially to ProfessorRyozo Matsudafortheirvaluable suggestionsand comments.
Notes
1 This“generalsocialcontribution”(CSG – Contribution socialegénéralisée)wasfirstintroduced in the mid-80s asasmallcomplementary contribution on allnon-work-related income,and wasthen gradually extended.A 1996 reform replaced the work-related contribution fully by a“general”socialcontribution on allincome, including socialbenefits,interestfrom capital,rentfrom assets,etc.
2 Figure for2010,the latestavailable:http://www.irdes.fr/EspaceEnseignement/ChiffresGraphiques/Couverture Complementaire/DonneesGnles.html(consulted 10.02.2015)
3 Although to alesserdegree today,this“socialdiversion”ofamedicalregime hasconstituted atop priority for costcontrolsince the 2000s.The attribution ofthe ALD benefitisnow closely controlled by the NationalFund ofthe AM,and by the High Health Authority (HAS – HauteAutoritédeSanté).
4 The numberofADL beneficiariesgrew from 3.7 million in 1994 to 9.2 million in 2011,which representsnearly one seventh ofthe population.
5 Forthe sake oflegibility,the French term and itsacronym “CMU”willbe translated throughoutthisarticle as “UniversalMedicalCoverage”,although itisan arrangementthatguaranteesaccessto comprehensive health insurancecoverage.
6 The biggesthumanitarian organization,specialized in medicalassistance and militancy,Medécinsdu Monde, hasan annualbudgetofapproximately 65 million Euros,ofwhich 40% ispublicfinance (subsidies,service contracts)and 60% private fund raising (streetcollection,campaigning fordonations),(Maury,2013:252). 7 Given the difficulty oftranslating the namesofinstitutions,Ihave opted here to use the originalFrench
abbreviationsCMU and AME.The abbreviation CMU refersto the regime asawhole,comprising:the “basic” CMU (CMU-B)orthe “complementary CMU”(CMU-C).
8 Whilstinternationalliterature on the CMU israre,French literature on the subjectisabundant.In addition to the publicationsquoted in thisparagraph,cf.Frotiée 2004,2006,2008;Borgetto,2000;Lafore,2008;Kerleau, 2012.
9 In 2000 the World Health Organization (WHO) rated the French system as offering “the best overall healthcare”,asregardswaiting listsand universalequalaccess(WHO,2000).
10 The French totalhealth expenditure ismuch higher:250 billion Euros,nearly 12% ofthe GDP (2013). “MedicalConsumption”(BiensetServicesMédicaux)isthe smalleststatisticalcategory used in French health statistics:itcountsthe expenditure formedicalcare and prevention devoted to the individualpatient,excluding pay forsicknessleave,long-term care,administration,research,training,and investment.Furthermore,the way to calculate the GDP wasrevised in 2010:with the formercalculation,the medicalconsumption would be +0.3% higher,amounting to 9.1% ofGDP in 2013 (instead ofthe 8.8% mentioned above).
11 Thisisthe famous1893 Law creating the “AideMédicaleGratuite”for“indigents”.Fordetailssee:Renard 1995. 12 The term “income testing”isused in thisarticle,since only income isconsidered forthe admission to the
CMU,notassets.
13 The information used here and in the following pagesistaken from the originalFrench officialdocuments:the legal texts, the reports and statistics of the health ministry, the IRDES (Institut de Recherche et de Documentation en Economiedela Santé),the CourdesComptes,the inspection board forsocialaffairsIGASS (Inspection GénéraledesAffairesSociales),the CNAM (CaisseNationaledel’AssuranceMaladie)which isthe AM nationalfund,and the CMU Fund,especially itsAnnualEvaluation Reports(available viathe Fund’s website:www.cmu.fr).
14 Allincome istaken into account,ofallthe membersofthe household:income from work and capital,social benefits,pensions,and furthermore rent-free housing and any otherfree commodity.
15 The “three-month”delay aimsatpreventing abuse through “care-immigration”.The limitwasfixed in accordance with the limitsofvisaregulations(especially concerning family visits).Militantassociations continue to fiercely criticize thisdelay,on groundsofmedicalurgency.In practice,in casesofemergency the necessary care willstillbe delivered,authorized on acase by case basis.
16 The initial2004 projectofthe (rightwing)governmentwasto increase the CMU-threshold by 10%.The first draftofthe 2004 billspecified +16%,and the finalversion voted by Parliamentwas+20%.Thisillustratesthe low levelofthe threshold,and the stillhigh publicsensitivity formore solidarity when illnessisconcerned (Guthmulleretal.,2010:5).
17 An electoralpromise ofPresidentHolland,implemented immediately afterhiselection.The government’splan to extend thisto 44.5% hasso farnotbeen implemented because ofthe high levelofpublicdebt.
18 Ofthese 38,000 complaints,in 12,000 casesthe decision wasrevised by the localcommissions,and 260 were judged afterappealatthe nationallevel,ofwhich 60 received arevised decision in favorofthe plaintiff(CMU Fonds,Evaluation Report2001:4-5).
19 The Fund’sreportsprovided mostvaluable information forthisarticle (reportsavailable atwww.cum.fr). 20 Itisimpossible to isolate the realcostsformedicalcare ofCMU beneficiarieswithin the accountancy system
ofthe private AMC (CMU Fonds,2013b)
21 In 2009,the ALD concerned 15% ofthe affiliated membersofthe statutory AM:8.6 million people,consuming nearly 60% of the expenditure of the AM (Dourgnon, Or, et Sorasit 2013: 1-2). The number of ALD beneficiarieshad grown to 9.2 million in 2011.
22 The NationalFund ofthe AM (CNAM)indicates(website:www.ameli.fr)thatdouble counting ispossible, between the CMU-B and -C,forprobably 1.5 million beneficiaries.Itestimatesthe corrected numberofboth at 5.8 million beneficiaries.Thatistogetherwith ACS and AME beneficiaries11.9% ofpopulation.
23 The deficitofthe statutory HIamounted to 6.8 billion Eurosin 2013,compared to the deficitof3.1 billion for the statutory pension fund.The deficitofthe HIisexpected to grow fast:to 7.3 billion in 2014 and 10.5 billion in 2015, against an improvement of the deficit of the pension fund (-1.6 and -1.4 billion respectively) (Commission desComptesde laSécurité sociale,2014:12,17-19)
References
Borgetto,M.,M.Chauvière etB.Frotiée (2004).“Lesdébatssurl’accèsaux droitssociaux entre lutte contre les exclusionsetmodernisation administrative.”Dossiersd’étudesn° 60,Paris:CNAF (Caisse Nationale des AllocationsFamiliales).
Borgetto,M.(2000).“Equité,égalité deschancesetpolitiquesde lutte contre lesexclusions.”Guglielmi,G.and G. Koubi,L’Egalitédeschances,Paris:LaDécouverte.
Bovens,M.,P.t’Hart,and G.Peters(2001).Successand Failurein PublicGovernance.A ComparativeAnalysis. Cheltenham (UK)and Northampton MA (USA):Edward Elgar.
Chauchard,J.etR.Marié,(2001).“Lacouverture maladie universelle:Résurgence de l’aide sociale ou mutation de lasécurité sociale ?”,Revuefrançaisedesaffairessocialesn° 4:137-156.
CMU (Couverture Maladie Universelle)-Fondsde Financementde laprotection complémentaire de lacouverture universelle du risque maladie.Reports,Paris:FondsCMU
― 2001:Premièreévaluation del’application dela loidu 27 juillet1999 ― 2013a:Rapportd’activitédu FondsCMU,2012
― 2013b:SixèmeRapportd’évaluation dela loidu 27 juillet1999.
Commission descomptesde laSécurité sociale (CCSS)(2014).Lescomptesdela Sécuritésociale.Résultats2013, Prévisions2014 et2015 (septembre2014),Paris:Direction de laSécurité Sociale.
Desprès,C.(2010).“LaCouverture maladie universelle,une légitimité contestée:Analyse desattitudesde médecinsetdentistesàl’égard de sesbénéficiaires.”,Pratiquesetorganisation dessoins41(1):33-43.
Desprès,C.,P.Dourgnon,R.Fantin,etF.Jusot(2011).“Le renoncementaux soinspourraisonsfinancières:Une approche économétrique.”Questionsd’économiedela santé,n°170 – novembre.
Dourgnon,P.,Z.Or,etC.Sorasit(2013).“L’impactdu dispositifdesaffectionsde longue durée (ALD)surles inégalitésde recoursaux soinsambulatoiresentre 1998 et2008.”Questionsd’économiedela santé,n°183 (janvier).
Frotiée,B.(2004).La fabriquedu social,l’exempledela CMU,Rapportau FondsCMU,Paris:Fondspourla Couverture Médicale Universelle (Collection Documentsdu Fonds).
Frotiée,B.(2006).“Laréforme française de laCouverture maladie universelle,entre risquessociaux etassurance maladie”,Lien socialetpolitiques,5:33-44.
Frotiée,B.(2008).“Lalégitimité despolitiquessocialesen question.”Paperpresented atthe Colloquium ofthe Network Réseau RT6,Grenoble (CNRS/Pacte),17-18 January.
Le Garrec,M.etM.Bouvet(2013).Comptesnationauxdela Santé-2012,DocumentdeTravail,SérieStatistiquen° 185,Paris:DREES (Direction de Recherche,Etudes,Evaluation and Statistiques).
Gazier,B.,B.Palier,etH.Périvier(2014).Refonderlesystèmedeprotection sociale.Pourunenouvellegénération de droitssociaux,Paris:Pressesde Sciences-Po.
Godt,P.(1991).“Liberalism in the dirigistestate:A changing public-private mix in French medicalcare.”C. Altenstetterand S.C.Hayward,eds.ComparativeHealth Policyand theNew Right.From RhetorictoReality, Basingstoke:Macmillan:23-47.
Guiliani,M.(2003).“Europeanization in comparative perspective:institutionalfitand adaptation.”K.Featherstone and C.M.Radaelli,eds.,ThePoliticsofEuropeanization.Oxford:Oxford University Press:134-155.
Guthmuller,S.,F.Jusot,T.Renaud,etJ.Wittwer(2014).“Commentexpliquerle non-recoursàl’Aide àl’acquisition d’une complémentaire santé?Lesrésultatsd’une enquête auprèsde bénéficiairespotentielsàLille en 2009.” Questionsd’économiedela santén°195 (février).
Guthmuller,S.,F.Jusot,T.Renaud,etJ.Wittwer(2013).“Le non recoursàl’Aide Complémentaire Santé:Les enseignementsd’une enquête auprèsd’une population éligible de laCPAM de Lille.”RapportpourleFonds CMU,Paris:Université Paris-Dauphine.
Guthmuller,S.,F.Jusot,and J.Wittwer,in coll.with DesprèsC.(2011).“Take-up ofasubsidising scheme for acquiring acomplementary health insurance in France:key findingsfrom asocialexperimentin Lille.” Questionsd’économiedela santé,n°162 (February).
Guthmuller,S.,F.Jusot,T.Renaud,J.WittweretC.Desprès(2010).Lerecoursà l’Aidecomplémentairesanté:les enseignementsd’uneexpérimentation socialeà Lille,Paris:IDRES (Documentde travail,36,Decembre 2010). Hassenteufel,P.(2001).“Liberalisation through the state:Why isthe French health system becoming so British?”
PublicPolicyand Administration,16(4):84-95.
Hassenteufel,P.and B.Palier(2007).“Towardsneo-Bismarckian health care states?Comparing health insurance reformsin Bismarckian welfare systems.”SocialPolicyand Administration,41(6):574-96.
IGF / IGAS (Inspection Générale desFinances/ Inspection Générale desAffairesSociales)(2007),Mission d’audit demodernisation.Rapportsurla gestion del’aidemédicaled’État,Paris:IGF/IGAS.
Immergut,E.(1992).“The rulesofthe game.The logicofhealth policy-making in France,Switzerland,and Sweden.”S.Steinmo and K.Thelen eds.,StructuringPolitics.HistoricalInstitutionalism in Comparative Analysis,Cambridge:Cambridge University Press.
IRDES (2010).EnquêteSantéetProtection Sociale(ESPS)2010,Section:“Lacouverture complémentaire santé.” http://www.irdes.fr/EspaceEnseignement/ChiffresGraphiques/CouvertureComplementaire/DonneesGnles.html. Jusot,F.(2014).“Lacomplémentaire santé:Une source d’inégalitésface àlasanté?”LesTribunesdela santé
2014/2 n° 43:69-78.
Kerleau, M. (2012). “De la couverture maladie universelle aux politiques d’accès à l’assurance-maladie complémentaire:diversité desmodèlesetdesprotections.”Revuefrançaisedesocio-économie2012/1 n° 9: 171-189.
Lafore,R.(2010).“L’État-providence,queléquilibre entre assurance etassistance ?”Cahiersfrançaisn° 358:32-40. Lafore,R.(2008).“Droitetpauvreté:Lesmétamorphosesdu modèle assistancielfrançais.”Revuededroitsanitaire
etsocialn° 1:111-126.
Lafore,R.etM.Borgetto (2000).La Républiquesociale.Contribution à l’étudedela question démocratiqueen France, Paris:PUF.
Matsuda,R.and M.Steffen (2013).“Variationsin institutionsand politics:The case ofsocialhealth insurance in France and Japan.”Paperpresented atthe FirstInternationalConferenceon PublicPolicy,Grenoble.Accessible viaHAL:https://halshs.archives-ouvertes.fr/WP-IEPG/halshs-00936082v1.
Maury,C.(2013).L’humanitairemédicalen France.Rôledel’action associativedansla priseen chargesanitairedes populationsprécaires.LecasdeMédecinsdu Monde,Thèse de Doctorat(PhD thesis),University Grenoble-Alpes. Renard,D.(1995).“Assistance etassurance danslaconstitution du système de protection sociale français.”Genèses
n° 18:30-46.
Rochaix,L.and D.Wilford (2005).“State autonomy,policy paralysis:Paradoxesofinstitutionsand culture in the French health care system.”JournalofHealth Politics,Policyand Law 30(1-2):97-119.
Steffen,M.(2010a).“The French healthcare system:Liberaluniversalism.”JournalofHealth Policy,Politicsand Law 35(3):335-365.
Steffen,M.(2010b).“Socialhealth insurance systems:Whatmakesthe difference?The Bismarckian case in France and Germany.”JournalofComparativePolicyAnalysis12(1-2):141-161.
World Health Organization (2000).TheWorld Health Report2000 – Health Systems:ImprovingPerformance,Geneva: WHO.
Zaidman,C.,R.Roussel,M.Le Garrec,M.Bouvet,J.Solard etM.Mikou (2014).Comptesnationauxdela santé -2013,Collection ÉtudesetStatistiques,Paris:DREES.
１９９９年の法改正によりフランスでは，貧困者に対するさまざまな医療扶助が刷新され統合された。この法 により法定健康保険制度に無料で加入が行われるようになるとともに，無料あるいは補助金を受け取って補 完健康保険制度に加入することが可能となった。つまり，無所得ないし低所得の人々は無料の医療アクセス を手に入れたのである。新しい制度は，医療機構についての理論的検討では対立する要素と考えられている もの，つまり普遍主義，選択，所得制限，を組み合わせたものである。このフランス独特のやり方は，貧困か らの救済と公費支出の管理という二つの政策の潮流の妥協によって生まれている。結果として，特定の税を 介し，私的な補完保険の資金によって賄われる統一された公的セイフティ・ネットとなった。本論文は，ま ず制度的な文脈と関連する理論上の論争を概観する。次に政策形成の過程を分析し，普遍的な医療給付の編 制（CMU-Couverture Maladie Universelle）を記述する。３つめの部分では，受給者，財政，支出に焦点をあ てる。４つめの最後の部分では，改革結果の成否を検討する。そこでは，緩やかな所得制限があるとはいえ 医療セイフティ・ネットが実質的に改善したこと，滞在資格を持たない移民については今もなお議論がある ものの，この法制を支持する広範な政治的コンセンサスが生じたこと，そして社会扶助を法的権利とする制 度上の通常化が生じたこと，が述べられる１）。 キーワード：医療セイフティ・ネット，普遍医療給付，普遍医療給付制度（CMU），滞在資格を持たない移民，フラ ンス １）本抄録の翻訳は松田亮三（立命館大学・産業社会学部）が行った。なるべく読みやすい日本語となるよう一 部意訳してあることをお断りしておく。
