Stages in the universalization of health coverage
1800-1945 | The beginnings of health coverage
In the 19th century and the first decades of the 20th century, private health insurance schemes were set up: mutual aid societies, insurance systems specific to a company or sector of activity, particularly in sectors where work was particularly arduous (mining, railways, navy, etc.); some of these schemes were retained after 1945, in the form of mutual insurance companies (professional or local) managing supplementary cover, or special schemes.
1945/46 | Foundation of Social Security, and creation of the General Scheme including health insurance
The general health insurance scheme then compulsorily covers only employees (active and retired) in the private sector and part of the public sector, as well as employees (active and retired) in the three civil services (State, local authorities, hospitals). Employees of state-owned companies running public services are still covered by special health schemes that existed before 1945. Created in 1930, the Mutualité sociale agricole was confirmed in 1947 as the manager of the compulsory health insurance schemes specific to the agricultural professions, for farmers and employees. Self-employed workers (craftsmen, shopkeepers, self-employed professionals) refuse to join the general scheme, and must turn to the private sector (insurance or mutual insurance) if they wish to be covered.
Health insurance provides benefits in kind (coverage or reimbursement of treatment, drugs and medical devices) and cash benefits (daily allowances). Initially, in-kind benefits focused on hospital care (the heaviest and most costly), but they have diversified considerably over time.
This reform took place in the particular context of the end of the world war. In May 1944, the Conseil National de la Résistance (National Council of the Resistance) included the creation of a new social security system as a key element in the program of reforms to be carried out after the liberation of France.
The political will of those who prepared this reform in 1944-45 was to set up a single compulsory social security scheme covering the entire working and non-working population. It was thwarted by the double refusal of the self-employed professions to join such a single, compulsory scheme, and of employees covered by special schemes to join a single scheme. This failure needs to be put into perspective, as the great economic growth of the 1950s favored strong growth in salaried employment rather than self-employment.
However, this reform involves two fundamental choices:
- to make social security the fundamental instrument of national solidarity, despite the limitations of its 1945 organization;
- the emergence of social democracy alongside political democracy. As a result, the new social security system is organized separately from the State: it is based on three sets of local funds (health insurance, family insurance and pension funds) with private-law status, whose administrators are elected by the insured and whose staff have private-law employee status.
1966 | Creation of compulsory health insurance for the self-employed
The plant was actually set up in 1970, after the intervention of a2nd By law, it is organized separately from the general health insurance scheme (i.e. its own scheme and network of national and regional funds, and contracted organizations dedicated to part of its management), and only provides benefits in kind, at rates lower than those of the general health insurance scheme for outpatient care.
25 years after the refounding of Social Security and the failure to set up a single, compulsory scheme, the independent professions (shopkeepers, craftsmen and the self-employed) are making a double choice: that of compulsory health cover and that of organized solidarity between the independent professions alone. Nevertheless, this represents an important step towards the universalization of health insurance, in a socio-professional logic.
1967 | Voluntary opening of the general health insurance scheme to everyone
The health insurance branch of the general scheme is now open to people residing in France who are not covered by a compulsory health insurance scheme, either personally or as a beneficiary.
This 1967 measure was a step towards the universalization of health insurance. Since 1945, the possibility of voluntarily joining the general health insurance scheme has been reserved for a small number of people, those who have had close links with the scheme in the recent past.
Enrolment in the scheme is automatic, unless the person concerned declines, for people covered by a compulsory scheme who cease to meet the conditions required for entitlement to their benefits because they are no longer in employment (end of contract, redundancy, etc.) and are unable to liquidate their pension rights.
1967 | Tougher conditions for access to the General Regime's health insurance scheme
Since 1945, the only requirement has been 60 hours of salaried employment in the quarter preceding the occurrence of the risk; now, 120 hours of salaried employment in the month are required.
The road to universal health insurance has not been a linear one.
This restrictive measure soon appeared to be excessive and a source of insecurity: in 1969, the possibility was introduced of acquiring rights on the basis of 200 hours worked per quarter.
1978 | Substitution of personal insurance for voluntary insurance
A law on the generalization of social security, on the one hand, assimilates the cohabitant to the spouse for the right to health insurance benefits in kind, and, on the other hand, maintains benefits for 3 months instead of 1 when the conditions for opening this right no longer exist. It substitutes personal insurance for voluntary insurance as a means of accessing health insurance under the General Scheme, as well as health insurance under the schemes for farmers and agricultural workers.
As with the previous scheme dating back to 1967, membership is voluntary and open to people not compulsorily covered by another health insurance scheme. But the logic is reversed: members are affiliated by default, and can only opt out if they can prove that they are covered by a compulsory scheme.
The creation of personal insurance, a modest reform in the movement to standardize health insurance, was part of a wider reform movement: that same year, 1978, saw the creation of a scheme for ministers of religion, providing health cover identical to that of the Régime général in terms of benefits in kind. It should also be noted that artists-authors, who had benefited from a pension scheme since 1964 designed as a subset of the Régime général, have been entitled to the same sickness benefits since 1975.
As part of the drive to universalize social security, 1978 also saw the generalization of entitlement to family benefits: these are now available only on condition of regular residence in France, and are no longer linked to professional activity.
1980 | Relaxation of the conditions of access to the health branch of the General Regime
The conditions of access to the sickness branch of the General Scheme have been relaxed, with the introduction of a minimum amount of remuneration as an alternative to the conditions relating to the number of hours worked.
This measure confirms the progressive generalization of health insurance, using the parameters of affiliation to the General Regime’s health branch.
1995-2000 | Creation of daily sickness benefits for craftsmen and tradesmen
The creation of the scheme was primarily the decision of the Board of Directors of the Caisse Nationale du Régime Maladie des Professions Indépendants, which set the parameters for the benefit and the contribution to finance it, which were subsequently adopted by law and decree.
Another component of the self-employed, the liberal professions, did not wish to benefit from this reform.
1999 |Creation of Universal Health Coverage (CMU) and Complementary Universal Health Coverage (CMU-C)
Personal health insurance under the general health insurance scheme disappears. The CMU entitles any French or foreign person not covered by a compulsory health insurance scheme, who has been residing in France for three months on a stable and regular basis, to health insurance benefits under the Régime général. Compulsory health insurance schemes and their membership criteria therefore remain in force and have priority application.
The CMU entitles you to all care reimbursed by the health insurance scheme, under the same conditions as other insured persons.
What’s more, in view of their low income, some people can benefit from free supplementary cover under the CMU-C scheme.
The creation of the CMU represents a major new step towards the universalization of health insurance.
It is the first result of the realization that the universalization of Social Security is only truly accessible when based on a membership criterion based on regular residence in the country, as has been successfully demonstrated since 1978 by the method of access to family benefits, another branch of the General Regime.
However, it does not draw all the consequences from this by continuing to give precedence to the criterion of having a professional activity for working people or a former professional activity for retired people.
By facilitating financial access to healthcare, the creation of CMU-C demonstrates our determination to strengthen national solidarity in favor of the most disadvantaged members of the population.
This move towards universalization has also been accompanied by a diversification of funding (creation of the Contribution Sociale Généralisée (CSG), allocation of revenue other than contributions, etc.) and by changes in governance methods (creation of the Social Security Financing Acts (LFSS), the National Health Insurance Expenditure Target (ONDAM), the Objectives and Management Agreements (COG), etc.).
1999 | Creation of Aide Médicale d'Etat (AME) and the Urgent and Vital Care Scheme
As part of the Social Action scheme, which falls within the remit of the State or the départements and not the Social Security system, the Aide Médicale de l’Etat (AME) (State Medical Aid) and the Dispositif de Soins Urgent et Vitaux (Urgent and Vital Care Scheme) were created.
The AME guarantees free medical care for illegal residents who have been living in France for more than three months without interruption, and whose income is below a certain ceiling.
The more restricted “Dispositif de Soins Urgent et Vitaux” (Urgent and Vital Care Scheme) concerns illegal foreign nationals who do not qualify for the AME, but whose serious state of health justifies it.
These two schemes are managed by the health insurance authorities on behalf of the state, which finances them.
2004 Creation of complementary health insurance (ACS)
Aide à la complémentaire santé (ACS) is a residence and means-tested benefit. It enables you to receive financial assistance to reduce the cost of acquiring supplementary health cover (taken out with mutual insurance companies, insurance companies or provident institutions). This scheme is distinct from CMU-C.
By facilitating access to healthcare, the creation of the ACS is a further demonstration of our determination to strengthen national solidarity in favor of the less well-off sections of the population.
2006 | Creation of the Social Regime for the Self-Employed (RSI)
The Régime Social des Indépendants (RSI) covers health insurance for the self-employed and old-age insurance for craftsmen and tradesmen (old-age insurance for the self-employed is still covered by special schemes).
The creation of the RSI reflected the desire of the independent professions to consolidate the specific organization of their social security schemes. It could not, however, hide the fact that the health insurance benefits in kind provided by the scheme’s funds were the same as those of the Régime Général (as were the rules applied by its pension branch).
2013 | Decision to introduce compulsory supplementary health cover for private-sector companies from 2016 onwards
A national interprofessional agreement, now enshrined in law, will make supplementary health cover compulsory for all private-sector companies from 2016.
This agreement was signed by the nationally-representative social partners – employee unions and employer organizations. The law simply gave it full legal force by extending it to the entire private sector. It demonstrates the company’s interest in ensuring that all employees benefit from high-quality supplementary health cover. Employers and employees shared half the funding.
2016 | Introduction of universal health protection (PUMA) in place of CMU
Health insurance is now available on condition of regular residence in France. Young people over the age of 16 are affiliated to health insurance funds and are issued with a health insurance card (carte Vitale). The creation of PUMA completes the process of universalizing health coverage.
70 years after the refounding of Social Security in 1945, the goal of universal health coverage can be considered to have been achieved.
Formally, there is no single health insurance scheme, since several health schemes remain alongside the Régime général, but :
- the funds of these schemes provide the same benefits in kind as those of the general scheme, supplemented by more or less significant benefits of their own (benefits which, for members of the general scheme, come under the heading of supplementary cover);
- these schemes are financially fully integrated into the General Scheme for benefits in kind identical to those provided by the General Scheme.
Two of these health schemes – including the largest, the self-employed workers’ scheme (RSI) – will disappear in 2020.
2019 | Creation of Complémentaire santé solidaire (C2S) to replace CMU-C and ACS
Complémentaire santé solidaire (C2S) is either free (with no financial contribution from the person concerned) or subject to a charge (with a financial contribution from the person concerned), depending on the resources of the insured.
This reform simplifies the system and improves policyholder access to supplementary health cover.
2019 | 100% health package
The 100% health scheme offers all policyholders with supplementary responsible health insurance or C2S (couverture santé solidaire) cover for a wide range of audiology, optical and dental treatments and equipment, which are reimbursed at 100%.
The aim of this scheme, which is being rolled out progressively until the beginning of 2021, is twofold: to facilitate access to care and quality care, and to strengthen prevention.
Responsible supplementary health insurance contracts were introduced in 2004.
2020 | Abolition of the RSI
Basic health insurance cover for the self-employed is now provided by the Régime général.
The quality of management of the social security scheme for the self-employed (which covered the risks of sickness, maternity, disability, death and retirement), and whose contributions were collected in conjunction with the specialized bodies of the General Regime (URSSAF), had been the subject of recurring criticism for some years.
It has been decided to abolish this scheme for all the risks covered, while ensuring that the self-employed are treated with the same care and attention as the general scheme, taking into account their specific characteristics.
2021 | Creation of daily sickness benefits for the liberal professions
This completes a process of generalizing coverage for sick leave, either through the payment of daily sickness benefits (private-sector employees and self-employed professionals), or through the maintenance of salary (public-sector employees) or wages (civil servants).
2021 | First stage of compulsory supplementary health cover for all three civil services
Following on from the 2013 Accord national interprofessionnel concerning the generalization of compulsory supplementary health cover by private sector companies, a process has now begun leading to the generalization of this cover to all working people.