France: #28 in the 2020 World Index of Healthcare Innovation

Introduction

France’s mostly government-run health care system ranked 28th in the World Index of Healthcare Innovation with an overall score of 40.08. France ranked third-to-last in Fiscal Sustainability (#29, 30.03), ahead of only Japan (#31) and the United States (#30). Both the scale and growth of government health care spending in France has proven difficult for policymakers to address, without sparking a large public backlash.

France’s baseline single-payer system severely restricts insurance choices, and also access to innovative medicines. On a relative basis, France performed best in Science & Technology (#14, 39.17), thanks to its advances in health care digitization and scientific discoveries.

Background

In 1930, France established a system of mandatory, subsidized health insurance for workers below an income threshold. Private health coverage through mutual benefit associations was widespread; by 1939, two-thirds of French residents had health insurance. After World War II, France began gradually moving away from the German-style model of private insurers and more toward a government-centered system.

In 2016, France enacted a major overhaul of its health care system, consolidating its various occupation-based government-run insurers into a single system, the Protection Universelle Maladie (PUMA). More than 90% of the French population purchases supplemental private insurance, which provides benefits not covered by the government-run system and/or cost-sharing assistance, akin to “Medigap” Medicare supplemental insurance in the U.S.

France is home to one of the world’s largest innovative pharmaceutical companies, Sanofi, which is the product of mergers of several longstanding French and German concerns. Other large French companies include Ipsen, Servier, and Pierre Fabre. Drug prices are negotiated by a government agency, the Economic Committee for Health Products (Comité Économique des Produits de Santé, or CEPS); however, generic medicines have fairly low market share in France, which allows pharmaceutical companies to generate considerable revenues from drugs whose patents have expired.

Quality

Despite its reputation of longevity and wellness, France ranks #18 in Quality. France’s health care infrastructure (#10) is solid, but has room to improve on providing patient-centered customer service (#20). Finally, despite France scoring well on measures such as preventable hospitalizations and cardiovascular and cancer survival rates, the country still ranks #20 in measures of preventable disease, weighed down by poor performance in handling COVID-19.

Choice

France ranks #24 overall for Choice. On the plus side, France ranks high in affordability of health insurance (#9). However, it’s overall Choice ranking is weighed down by a low score in freedom to choose health care services (#26), in part because France’s two-tiered health insurance system — which helps eliminate out-of-pocket costs through supplemental insurance — weakens patient choice by making consumers less sensitive to the price of health care. In addition, there is virtually no choice in insurance carrier or plan design, with a single basic insurance choice determined by profession.

Science & Technology

France ranks #12 in Science and Technology, it’s highest ranking among the four dimensions in the Index. France continues a tradition as a leader in scientific discoveries (#8) with the fourth highest scoring for Nobel laureates as well as a significant body of cited research. However, France lags behind in health digitization (#24).

Fiscal Sustainability

France’s Fiscal Sustainability ranking comes in at #29, better only than the United States and Japan. In particular, its public health spending per capita is over 9% (#30), having grown almost a full percentage point in the last 10 years. Without further cost containment measures, the increasing public health spending threatens France’s national solvency — which already ranks #22 among countries in the Index.