By Jules Morel. Originally published on 2013/01/20

Mutuals (les mutuelles santé)

What was the government’s incentive in raising such hostility towards the French liberal doctors? Why such reform? The answer is fairly simple: money, and drawing the public’s attention away from where the socialists get their funding.

In the 1980s, while the Raymond Barre reform froze the prices of medical acts and enabled the practice of top-up fees, a market niche opened to all forms of medical insurance willing to take on the redemption of the dépassements d’honoraires. A very special type of business emerged: the complementary health insurance, called “mutuals”. Here is how it works.

By means of subscription fees, members in a mutual healthcare fund put together a pool of capital that will be allotted to needing subscribers. Although they don’t like being qualified as business  – because they are officially non-profit social entities – mutuals still raise considerable amount of money. In fact, thanks to a very particular legal structure, they do not contract any sort of corporate taxes and thus benefit from huge tax shields advantages (annually estimated amount: 8 billion euros). Such a fiscal advantage should be an invaluable asset for the subscribers, however the mutuals tend to cover less and less medical acts.

Where does the money go then?

Well, this is another thing about mutuals: they are not bound to make any financial statement public, making their finances quite opaque. Former IMF president Dominique Strauss-Kahn in his days as Minister of the Industry is believed to have obtained 600,000 francs (around 100,000 euros) from the National French Students Mutual (MNEF) in obscure conditions. To avoid other scandals of this type, Nicolas Sarkozy had proposed to render the mutuals’ financial statements public as of 2013. As another way to cut from the previous government, Marisol Touraine postponed that bill.

Upon confirmation of amendment 8, the French medicine structure will utterly evolve. One of the bill’s main implications is that healthcare will be priced as a “package” rather than the accumulation of different medical acts. For instance, the fees for changing a knee prosthesis will be charged as one raw price encompassing everything from surgery to stiches, including the nursing and post-surgery follow up instead of charging every component of the care chain. Therefore, it will enable mutuals to provide bundles of treatments that will be more or less reimbursed. Doctors will be thus affiliated to mutuals on the contracts the insurer provides. Instead of being able to pick their own doctors, French patients will be oriented towards the doctor that is best redeemed by the mutual insurance fund, clearly leaving some doctors out of the game.

Complying doctors would thus be subordinated to the mutual healthcare fund, having to charge the price grid dictated by the association. Although we might not see it yet, Holland’s amendment could definitely lead to a complete privatization of the French healthcare system although aiming at the opposite.

Medical vacuums (les deserts médicaux)

Another issue the French medicine faces is commonly referred to as “medical vacuums”. In the 1980s, healthcare offer was drastically diminished by a measure known as “numerus clausus”, limiting the number of spots available in med school (less than 10% admissions at the end of year 1 exam!). The incentive was to reduce the demand in order to cut spending. This meant a clear decline of the number of French medical practitioners. The structure of med school studies also facilitates the phenomenon. In fact, upon achieving their diploma, med school graduates can chose where to establish their activity. Consequently, some rural areas in France (especially the North-East: Franche-Comté and Bas-Rhin) have become … doctors deprived.

Evidently the numerus clausus went against natural demographic needs, and it made vital the inflow of foreign doctors into France. The working conditions being eased by European Union agreements, French hospitals have gradually filled with Eastern-Europe doctors coming into to France to benefit from higher wages. For example, a Romanian doctor usually earns 600 euros per month in his home country, while he can make 2400 euros in France. However with uneven quality of studies, there is uneven quality of treatment. On average, one every three French patients comes across a foreign doctor in the course of his medical cares. In light of these statistics, the fact that the numerus clausus is still applicable is puzzling.


Decreasing number of spots in med school, increasing tax burdens, less an less government support but clearer hostility from the healthcare ministry … all that gives the French doctors very little incentive to work as liberal practitioner (average age of establishment: 39 years old).

Obviously the French Government does not bother giving such details. Rather, it scapegoats the dépassements d’honoraires instead of revealing the Securité Sociale’s flaws, and exhibits a worrying skilfulness in stigmatizing the whole medical milieu. In fact these past years, the French mentalities have grown utterly unhappy with their neighbour’s success. Although French doctors’ revenues are not even close to their American counterparts, the profession still remains highly profitable – a fair compensation if you think about the duration of the studies –surely resulting in great levels of animosity. While Nicolas Sarkozy’s “work more to earn more” seemed like a fair creed, it has been rapidly and completely discredited by François Hollande’s government. “Pour vivre heureux, vivons cachés” might well become the doctors’ main principle.

Although the Hollande’s government has not initiated the move against the liberal field itself, it might have just accelerated it. The French medicine is ill. However it seems the government will opt for euthanasia rather than spending more to save it.

Dis­claimer: This art­icle was ori­gin­ally pub­lished as ”French medicine: somebody please find a doctor (part 2/2)“ on December 12, 2012 on The Polit­ical Bouil­lon, EST cooper­a­tion partner.