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As France prepares to enforce on 1 January its latest non-reimbursable medical fee, opposition is building to what critics have called everything from unconstitutional to the only unpopular measure proposed by the president, Nicolas Sarkozy, since he came to power last May.
Furthermore, critics say that this and other such measures are moving France towards a healthcare system that is based upon payment according to means, which would leave many people either unable or unwilling to pay for medical treatment.
Introduced on 24 September among a series of measures to reduce a social security deficit predicted to reach €12.7bn (£9.1bn; $18.7bn) in 2008, the law was passed in parliament on 23 November. It calls for a non-reimbursable charge of €0.50 on every drug packet and every visit to paramedical staff, such as physiotherapists, and €2 on the cost of transport related to treatment, such as an ambulance ride (BMJ 2007;335:690 doi: 10.1136/bmj.39356.459688.34).
Although the charges will not be reimbursed by public or private health insurance, the government set an annual limit of what any one person would have to pay, of €50. Pregnant women, children, and people below the poverty line are exempt, and the money that is raised will go towards France’s Alzheimer’s and cancer treatment programmes.
But the measure has led to demonstrations from labour unions, special interest groups, and others, who complain that “the ill are paying for the ill.” On 28 November the opposition Socialist Party filed a complaint with the Constitutional Council saying that the law violated the “right of health to all and the principle of equality.”
In an annual opinion poll that measures satisfaction with public services published by La Tribune newspaper, the French health system received a 14 percentage point drop compared with a year earlier. Although 74% of those polled were satisfied with the speed of reimbursements, only 51% were satisfied with the amount that was being reimbursed (www.latribune.fr, 7 Dec 2007, “Les services publics sont-ils en danger?”).
An article in L’Express magazine called the non-reimbursable charge Mr Sarkozy’s only unpopular measure in his six months in power (Dec 2007, p 66)
Since 2004 patients have already been paying a €1 non-reimbursable charge for every visit to a doctor (BMJ 2004;328:1278 doi: 10.1136/bmj.328.7451.1278) but critics fear the trend will leave a portion of the population without full health coverage. The social security system reimburses roughly 80% of medical costs, and private insurance pays for the rest—but not everyone can afford such private plans.
Isabelle Durand-Zaleski, of the faculty of medicine at the University of Paris-Creteil, said that the non-reimbursable charges are only the tip of the iceberg. She pointed to a new programme that is set to come to force by 2010, which outlines how ceilings on annual health coverage will be set according to the income of each patient.
In this new system, although people below the poverty line will not be expected to pay anything, a rapidly rising scale based on income may require families of moderate means to pay as much as €1300 a year more than what the social security system reimburses. Although these means tested, out of pocket payments are expected to be covered by private insurance plans, many poor families may either not be able to afford the premiums or have to risk paying the extra charges themselves. The fee may also encourage people to refuse medical attention.
“For me it’s like my car insurance, where there is a minimum excess payment,” she said. “If you have a small accident then you may not repair the car because the minimum excess payment is higher than the cost of the repairs.”