Is Public-Private Mix in French Health System Sustainable?#

Three major values –solidarity, liberalism, and pluralism– underpins the French Health System. Despite low out-of-pocket payments,its joint reimbursement of the same health service by both private and public insurance raises equity, efficiency, and sustainability challenges.

Paper: Is Public-Private Mix in French Health System Sustainable?, PIERRE A. ET OR Z., 2023, Document de travail Irdes

Three major values –solidarity, liberalism, and pluralism– underpins the French Health System.

Differ from other private-public mix by joint reimbursement of the same health service.

The basis of solidarity: access to care depending on need, not income (horizontal equity) and solidarity between high- and low-income classes (vertical equity).


The comprehensive health service package covered by the Statutory Health Insurance (SHI) covers about 80% of the total cost of health care in 2021: 93% for hospital care, 8% for ambulatory treatments, and 44% for drugs and medical goods. These quantity are (slowly) increasing.

Private complementary insurances are crucial to cover 13% on average of health care expenditure: medical goods (38%), outpatient cares (22%), drugs (11%).

These companies are heavy regulated: loi Evin assuring lifetime guarantee for anyone insured. Tax incitation for responsible contracts that do not adjust on health status.

Concerns for equity contravening to the horizontal equity principle are: private insurance premiums contract conditioned on age (strong proxy of risk),higher part of the income spent on private health insurance for lower income classes, unequal access to some practitioners because of the insurance status (although illegal).

Efficiency concerns come from the multiplicity of payers for the same basket of care, inflationary incitations from generous CHI coverage, high administrative costs (14 billions, 50% linked to private insurance).

Health providers#

With 3.2 physicians, 10.5 nurses per 1,000 population in 2019, France is close to OECD average. However high heterogeneity. Outpatient care is given by 47% of doctors and 65% of GP that are self-employed in 2016. Secteur 1 respecting fee-for-services negotiated annually and secteur 2 with about 52% higher fees, but practitioners must purchase their own pension and insurance coverage. Secteur 2 is regulated since 1990 because more physicians than predicted entered it in 1980.

Highest hospitalization rate in the OECD despite decreased number of beds (50% of spending). 45% of public hospitals, 25% of private for-profit: not positioned on the same care segments (eg. market share of up to 65% for knee replacement, 80% for cataract or endoscopies).

The Tarification à l’activité introduced in 2005 has been initially welcomed by all actors. However, it created extra-fees mostly in for-profit organizations. Successful regulation by the public insurance managed to contain it to about 45% in 2016 compared to 80% in 2005. But this payment model had bad consequences on care quality and allocation efficiency.

Concerns about the sustainability of freedom of installation are increasing in a context of unequal repartition of the population. Some specialties display increasing waiting time (with high variance). Tentative to improve care pathways through mandatory GP remained unsuccessful because no incentive exist for collaboration and care coordination.

Concerns about extra-fees in ambulatory cares are persistent, especially for specialist and for the sickest patients. In 2007, the General Inspectorate of Social Affairs revealed that the average amount of extra-billing between 1995 and 2004 increased 3 times faster than average incomes in France. By allowing some practitioner to modulate their level of activity or productivity, it accentuates geographical disparities.

France had historically a regulation focused on health care costs. However, it fails to control the growth of total care expenditures because of volume compensation by the providers. The system encourages more hospital utilization, medical tests and medications with high risk of duplication of services and inefficient care process.

The ONDAM mechanism focused on aggregated targets with lower prices if volume augments too quickly, leading to the prices becoming (progressively) unrelated to hospitals’ costs.

Regulating volume rather than quality has been done through price regulation for fast growing activities with high variation between regions and potentially harmful consequences for patients. There has been a backward trend in collecting quality data such as 30-day readmission rates, mortality, adverse events or patient experiences in primary care.

Successful innovation incentive collaborations such as article 51 experimentation, bundled payments GHT and CPTS. But France needs to refine and diffuse indicators for benchmarking the quality of care across settings (readmissions, complications rates, inappropriate prescriptions, etc.). There is also a need for more public information on prices.

The authors also are in favor of dramatically reducing the market share of the private insurance.