Fraser Forum

How France embraces the private sector to deliver universal health care

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Canadians keen on improving the state of our universal health-care system would do well to consider the case of France. Like Australia, Germany, the Netherlands, Sweden and Switzerland, the French health-care system is yet another example of a well-performing universal health-care system that delivers more timely, quality care,- for similar or lower costs than Canada. Unlike many Canadians, however, the French (and their counterparts in these other countries) do not appear to be frozen by a fear of profit-making in health care. Rather, they have embraced an expansive role for private for-profit hospitals as part of their approach to universality.

In this second installment of our multi-part blog series, we present a brief characterization of France’s universal health-care system, paying particular attention to the role of for-profit hospitals.

Part 2: Universal health care in France

France spent 11.3 per cent of its GDP on health care in 2012, slightly less than Canada (11.8 per cent) on an age-adjusted basis. For that level of spending, France had only slightly fewer practising nurses and diagnostic technology units, but a higher number of physicians and hospital beds, and lower wait times.

France’s universal-access health-care system is based on a statutory health insurance [SHI] model where individuals are required to purchase a health insurance policy (based on their employment) from a regulated insurance company. Strong state regulations and subsidies ensure universal access to that insurance (although the general population is subject to cost-sharing). Private insurance is available, but is generally of a complementary or supplementary nature. In 2007, 88 per cent of the French population had some form of private voluntary health insurance.

Apart from the required copayments, the essentially non-competitive nature of the insurance system in France may seem quite familiar to Canadians. However, in stark contrast to Canada, both public and private insurers purchase care from a common pool of public, private not-for-profit, and private for-profit hospitals.

In 2012, there were 1,041 for-profit hospitals in France representing 39.2 per cent of all hospitals in the country. These hospitals competed with 928 public and 688 private not-for-profit hospitals for patients under the universal scheme.

While acute medical, surgical, and obstetric care is provided by all three types of hospitals, their relative level of involvement varies.

For example, public hospitals are responsible for the majority (about three-fourths) of acute medical-care capacity and full-time episodes, and perform about a third of all surgical procedures (including more complex procedures). While private for-profit hospitals also deliver such services and perform more than half of all surgical procedures, they tend to focus on a smaller range of technical procedures (such as invasive diagnostic procedures) and specialize in routine procedures with short and predictable in-hospital stays. About 75 per cent of all surgeries performed in a day-care setting are provided by for-profit hospitals. About one-third of obstetric procedures (related to pregnancy and childbirth) are also performed in private for-profit hospitals. In addition, private for-profit hospitals can also carry out public service duties paid for through contracts with a regional health agency. Meanwhile, private not-for-profit hospitals provide a range of services including follow-up and rehabilitation, and cancer treatment (including prevention, screening, treatment, surgery, and research).

Canadian health policy discussions are often hobbled by the misunderstanding that universal health care means government health care. Reality, however, is rather different. Private insurers and hospitals form the basis of many of the world’s finest universal access health-care systems. Even in France, whose core universal health insurance system is essentially non-competitive, private for-profit hospitals play an expansive role in the delivery of universally accessible services.


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