Risk pooling and universal health coverage – Prof. Monika Steffen EUHEALTH

Summary

Ce script aborde les systèmes de santé en Allemagne, en France et dans d'autres pays européens. Il explique comment l'Allemagne a résolu le problème de solidarité en créant un fonds national pour la compensation des risques. La France a réformé son système en intégrant l'assurance maladie universelle pour les pauvres dans l'assurance maladie sociale. Les Pays-Bas ont opté pour une approche mixte en privatisant leurs assurances maladie tout en mettant en place un fonds national pour la redistribution des risques. La Suisse a adopté une approche similaire. L'essentiel pour garantir un accès universel à la santé est une assurance maladie obligatoire pour tous les résidents, avec une mutualisation des risques entre les organismes d'assurance.

Takeaways

• 🇩🇪 L'Allemagne possède un système d'assurance maladie privée historique, principalement utilisé par les fonctionnaires et les très riches, qui représente environ 11% de la population.
• 🏥 En Allemagne, les assureurs privés paient en fonction de l'âge, de l'état de santé et du nombre de personnes à charge, offrant des tarifs avantageux aux jeunes professionnels sans famille.
• 🔄 Ceux qui rejoignent l'assurance privée en Allemagne et dont le revenu diminue ne peuvent plus revenir à l'assurance publique, ce qui peut entraîner des coûts élevés avec l'âge et les problèmes de santé.
• 🏛️ L'Allemagne a créé un fonds national pour la compensation des risques, permettant une répartition plus équitable des contributions entre les différents régimes d'assurance maladie.
• 🇫🇷 En France, l'assurance maladie est devenue individuelle en 2016 avec la réforme de la Protection Universelle Maladie (PUMA), éliminant ainsi les co-assurés familiaux.
• 🆓 En France, les personnes ayant un faible revenu sont affiliées gratuitement à l'assurance maladie et bénéficient également d'une couverture privée complémentaire.
• 🤝 La France a fusionné l'assurance maladie complémentaire avec l'assurance maladie sociale, offrant ainsi des droits et des prestations identiques à tous les affiliés.
• 👩‍⚕️ Les soins de santé en France ne sont pas soumis à des limitations d'âge ou de ressources pour les personnes âgées ou gravement malades, contrairement à d'autres systèmes de santé.
• 💊 Les co-paiements dans les systèmes de santé européens sont généralement faibles ou inexistants pour les personnes aux revenus les plus faibles et pour les maladies chroniques.
• 🌐 L'accès universel à la santé est garanti par une assurance maladie obligatoire pour tous les résidents, avec une mutualisation des risques entre les organismes d'assurance, ce qui est essentiel pour assurer un financement équitable.

Q & A

德国的私人健康保险是如何形成的？

德国的私人健康保险最初是由公务员之间形成的私人组织，这发生在俾斯麦创建社会健康保险之前。因此，即使在公共健康保险制度建立后，这部分人仍然保留了他们的私人保险。

在德国，什么情况下可以选择退出公共健康保险系统加入私人健康保险？

在德国，如果个人月收入超过一定数额（例如5000欧元），可以选择退出公共健康保险系统，加入私人健康保险。

德国私人健康保险的费用是如何决定的？

德国私人健康保险的费用取决于多个因素，包括加入者的年龄、健康状况以及是否有家庭成员共同参保。年轻人、健康状况良好且没有家庭负担的人可能会获得较低的费率。

德国的健康保险改革包括哪些重要措施？

德国的健康保险改革包括创建了一个国家风险补偿基金（Australis Fund），所有健康保险基金必须加入这个基金，通过风险评级系统来重新分配资金，以消除不同保险之间的不平衡。

法国的健康保险系统有哪些特点？

法国的健康保险系统通过CMU（全民医疗保障）为低收入人群提供免费或补贴的健康保险。此外，2016年的PUMA改革将CMU纳入法定健康保险体系，实现了个体化参保，取消了家庭成员共同保险的做法。

在法国，如何确保所有人都能获得必要的医疗服务？

法国通过CMU（全民医疗保障）确保低收入人群能够获得免费的医疗服务。此外，对于在法国境内居住三个月以上的移民，也可以免费加入健康保险。

荷兰的健康保险系统是如何运作的？

荷兰的健康保险系统通过将所有健康保险公司私有化，并要求所有居民都必须参保。保险费用分为社区评级部分和国家风险池部分，后者根据风险指数重新分配资金。政府对保险公司的活动进行严格监管，确保所有人都能获得医疗服务。

瑞士的健康保险系统有哪些特点？

瑞士的健康保险系统虽然以私人健康保险为主，但也引入了公共元素，通过风险池化和强制性保险来确保所有人都能获得医疗服务。

在欧洲，如何避免健康保险中的“风险选择”问题？

在欧洲，为了避免健康保险中的“风险选择”问题，许多国家引入了风险池化机制，确保不同保险公司之间可以共享风险，从而避免年轻健康人群被特定保险公司吸引，导致保险系统的不平衡。

为什么说强制性健康保险对于实现全民健康覆盖至关重要？

强制性健康保险确保了所有居民都必须参保，这样可以在健康人群中分散风险，为生病的人提供足够的资金支持。如果没有强制性保险，可能会导致部分人群无法获得必要的医疗服务，或者形成贫富差距明显的双层医疗体系。

Outlines

00:00

🇩🇪 Assurance maladie privée en Allemagne

Le premier paragraphe explique l'existence d'un système d'assurance maladie privée en Allemagne, principalement utilisé par les fonctionnaires et les très riches. Il est basé sur des critères tels que le revenu et l'âge des affiliés. Les jeunes professionnels et les personnes sans famille peuvent bénéficier de tarifs avantageux. Cependant, une fois que l'on a choisi l'assurance privée et que le revenu diminue, il est impossible de revenir au système public. L'Allemagne a créé un fonds national pour la compensation des risques afin de répartir les contributions de manière équilibrée entre les différentes caisses d'assurance maladie.

05:04

🏥 Réforme de l'assurance maladie en France

Le deuxième paragraphe décrit la réforme de l'assurance maladie en France, qui a créé le CMU (Couverture Maladie Universelle) pour les personnes aux revenus modestes. Ce système garantit un accès universel à l'assurance maladie, y compris pour les complémentaires. La réforme a également introduit la couverture individuelle, mettant fin au système de co-assurance familiale, et a élargi les droits aux soins pour les femmes et aux enfants majeurs.

10:05

🌍 Accès aux soins pour les migrants en Europe

Le troisième paragraphe traite de l'accès aux soins de santé pour les migrants en Europe. Il explique que la plupart des pays européens offrent un certain niveau de couverture médicale aux migrants, même s'ils ne sont pas titulaires de papiers. En France, par exemple, les migrants qui peuvent prouver qu'ils se trouvent sur le territoire français pendant trois mois sont affiliés gratuitement à l'assurance maladie. Il y a également une aide médicale d'urgence pour les personnes sans papiers.

15:05

🏘️ Réforme de l'assurance maladie aux Pays-Bas

Le quatrième paragraphe explique comment les Pays-Bas ont réformé leur système d'assurance maladie en le privatisant, tout en imposant une loi qui exige que tous les citoyens soient affiliés à une assurance maladie. Les contributions sont divisées entre les caisses d'assurance privées et un fonds national de partage des risques. Cette réforme a permis de maintenir l'accès universel aux soins et de subventionner les personnes aux revenus faibles.

20:06

💊 Frais de participation et soins de santé en Europe

Le cinquième paragraphe discute des frais de participation dans les systèmes de santé européens, en soulignant que les pays européens ont généralement peu ou pas de frais de participation pour les personnes aux revenus modestes et pour les maladies chroniques. Les frais de participation sont généralement limités et ne concernent pas les soins essentiels. La France a récemment introduit des soins dentaires, des lunettes et des prothèses auditives gratuites pour tous, même si la qualité est standardisée.

25:08

🌐 L'accès universel à l'assurance maladie

Le sixième paragraphe conclut que l'accès universel à la santé ne peut être garanti que par une assurance maladie obligatoire pour tous les résidents, avec une mutualisation des risques entre les organismes d'assurance. Il souligne que les systèmes d'assurance maladie sont plus efficaces pour assurer la couverture universelle que les systèmes de service de santé national, car ils permettent une meilleure répartition des risques et des ressources.

Keywords

💡Assurance maladie privée

L'assurance maladie privée est mentionnée comme étant une option en Allemagne pour les individus gagnant plus de 5000 euros par mois. Elle est définie comme un type d'assurance qui ne repose pas sur le système public d'assurance maladie, mais est plutôt gérée par des entités privées. Dans le script, cela est lié au thème de la solidarité et de l'égalité d'accès aux soins de santé, soulignant les défis de la couverture privée qui peut mener à des inégalités en matière de soins.

💡Solidarité

La solidarité est un concept clé dans le script, abordant l'idée que les systèmes d'assurance maladie devraient couvrir tous les membres d'une société, indépendamment de leur statut financier ou de leur situation de santé. C'est un élément important des systèmes d'assurance maladie universels et est mentionné comme un objectif à atteindre pour garantir l'accès universel aux soins de santé.

💡Assurance maladie sociale

L'assurance maladie sociale est décrite comme un système où les contributions sont partagées parmi tous les membres d'une société pour couvrir les coûts des soins de santé. Elle est présentée comme un moyen d'assurer l'égalité d'accès aux soins et de promouvoir la solidarité. Dans le script, l'Allemagne et la France sont citées comme des exemples de pays ayant des systèmes d'assurance maladie sociaux avec des réformes pour améliorer la couverture et la solidarité.

💡Répartition des risques

La répartition des risques est un mécanisme par lequel les risques financiers liés aux coûts de santé sont partagés entre les différents assurés ou les fonds d'assurance. Cela est mentionné comme une solution pour éviter que les assurances privées ne se concentrent sur les jeunes et les personnes en bonne santé, laissant les autres de côté. En Allemagne, par exemple, un fonds national est utilisé pour redistribuer les contributions en fonction de l'indice de risque.

💡Assurance complémentaire

L'assurance complémentaire est une couverture qui s'ajoute à l'assurance maladie de base pour couvrir des soins ou des traitements qui ne sont pas pris en charge par l'assurance principale. Dans le script, cela est mentionné comme une pratique courante en France, où même les personnes inscrites dans les programmes d'assurance maladie gratuits ou subventionnés ont accès à une assurance complémentaire.

💡Tarif

Un tarif est le coût ou le prix d'un service, comme l'assurance maladie. Dans le contexte du script, les tarifs sont discutés en relation avec la manière dont ils peuvent varier en fonction de facteurs tels que l'âge, la santé et le statut familial des assurés. Les tarifs plus bas sont mentionnés comme un avantage pour les jeunes professionnels en bonne santé qui choisissent l'assurance maladie privée.

💡Couverture universelle

La couverture universelle est l'idée que tous les membres d'une société doivent avoir accès aux soins de santé, indépendamment de leurs ressources financières. C'est un objectif central des systèmes d'assurance maladie et est abordé dans le script comme un moyen d'assurer l'égalité d'accès et de promouvoir la santé publique.

💡Co-paiement

Le co-paiement fait référence à la pratique où les patients doivent contribuer financièrement aux coûts des soins qu'ils reçoivent, en plus des contributions de l'assurance maladie. Dans le script, il est mentionné que dans de nombreux pays européens, les co-paiements sont limités ou inexistants pour les personnes ayant un faible revenu, soulignant l'importance de protéger les plus vulnérables financierement.

💡Assurance maladie nationale

L'assurance maladie nationale est un type de système où le gouvernement fournit directement les soins de santé à la population, souvent avec un financement par les impôts. Le script mentionne le Royaume-Uni et la France comme des exemples de pays avec des systèmes d'assurance maladie nationales, où le gouvernement a un contrôle direct sur la fourniture et le financement des soins.

💡Migrants

Le script aborde la question de la couverture des soins de santé pour les migrants, notant que dans de nombreux pays européens, les migrants ont le droit de bénéficier des mêmes services de santé que les citoyens. Cela met en évidence les défis et les responsabilités des systèmes de santé publique face à des populations mobiles et la nécessité de garantir l'accès aux soins pour tous.

Highlights

In Germany, there is a unique private health insurance system primarily used by public servants due to historical reasons.

Individuals in Germany earning over 5000 euros a month can opt for private health insurance.

Private health insurance in Germany is based on age and health status, with higher premiums for older or less healthy individuals.

About 11% of the German population is on private health insurance, including functionaries and high-income earners.

Once individuals switch to private health insurance in Germany, they cannot revert to the public system.

Germany has a national fund for risk compensation to balance the financial burden across different health insurance funds.

France introduced the CMU (Universal Medical Coverage) to provide free health insurance to low-income individuals.

In France, health insurance membership is now individual, ending the concept of co-insured family members.

The French health system, post-PUMA reform, ensures universal health protection without institutional differences between payers.

Migrants in France are entitled to free health insurance if they can prove a three-month stay in the country.

The Netherlands transitioned from social to private health insurances while maintaining universal access and risk sharing.

Switzerland, known for its liberal policies, adopted a system similar to the Netherlands with mandatory health insurance and risk pooling.

National Health Service systems can control costs more directly than health insurance systems.

Co-payments in European health systems are generally low or nonexistent for the underprivileged and those with chronic conditions.

France recently introduced free spectacles, hearing aids, and dental implants for all citizens, regardless of income.

Compulsory health insurance with risk mutualization is essential for achieving universal health coverage.

Transcripts

and there's a second problem in germany

which most people don't know what's

interesting for historical reasons there

is a

completely private health insurance in

germany most of the affiliated people

are

public servants from the government the

reason is they had this health insurance

between them as a private organization

long before bismarck created his social

health insurances so they were there

first and they wanted to

to remain they didn't want to die so

they were maintained and today you can

enter in germany you can leave the

public system of the social health

insurance

and join private health insurance

completely private

uh if you earn more than 5000 euros a

month it's not exactly the figure but i

made it a round figure 5 000.

uh

these people once you earn more than 5

000 you can opt out of the public system

and join a private one or don't drown

anything just keep without

if you think you're rich enough to pay a

big bill one day

um

it concerns about 11 of the population

it's functionaries because of historical

reasons and it's a state who pays a

contribution so it's not really them

and very rich people and

what else

what artists so people like this with a

quite high income

so eleven percent of the population

and their contribution to this private

health insurance which takes all your

service it's not complementary it's it's

a supplementary one who replaces the

other social health insurance

they pay on age the age you have when

you enter the more you are aged the more

you repay and then your health status

they will examine you from ted to to to

bottom to see whether you're in good or

bad health and every little illness you

have you have to pay more

and the number of co-insured family

members so if you have three children or

ten children or you're just just alone

you report more or less so this private

health insurance is very interesting for

young professionals who are not yet

married to earn a lot of money more than

5 000 euros and have no family under

good heads they will get a very good

tariff they will pay much less than in

the public health insurance

the problem is

if they change jobs

and they earn less than five thousand

they will have normally the choice to go

back to the public

one or stay in the

in the in the

in this private one

and eventually if they earn just a

little bit less

the public one will be more expensive

than the private one and from the

private one they get more benefits

as they are still young um and not

charged with family they will probably

want to stay in the private one but

there's a problem afterwards once you

opted for the private one and your

salary drops again and you should go

back to the public one and you don't

from that moment on you will have to

stay all your life in the private health

insurance you can never ever go back to

the public one and when you are 80 years

old

and very ill you will pay a lot of money

for this private health insurance so

there is a stop the government joined in

so to make the people think if really

they want to stay in a private health

insurance

anyway this is the traditional problem

germany had a breach

of solidarity between of the social

health insurances

tradition

because they were constructed like this

so they could reform this and they did

and this inheritance of the past with

this 11 of the population that private

health insurance nobody would do that

today such an insurance but they can't

stop it because these insurances their

own buildings their own hospitals

there's a legal problem you cannot

abolish it it's very difficult otherwise

i would do it so what was done in

germany i put it in red because this is

important

all this

the government made to reform that all

these social health insurances

they have to join a national fund for

risk compensation

and it's very easy that is the german

word australis fund there is a national

fund which collects now all the

contributions for all these 250 funds so

you don't send your money anymore to

this fund to your own health insurance

you send it to this national fund

and the national fund

they collect all this money

and they have risk

risk how would you call this risk

rating so they look into each of these

funds what are the affiliates what is

their age

the average age what is the health

status on about 40 or 60 illnesses

they know it because they have the

reimbursement figures so they know what

the illness of the people is so what is

the average chronic illnesses and and

accident rates and and heart attack

rates in the people from the people who

are insured in fund x egreg and said

and then they put it all together on a

computer program and what comes out is a

risk ratio

redistribution so the fund collected all

this money

the informatics system work and then

gives back the money to each of these

funds for each of its uh member to get

all the money back for me who is insured

in one of these funds it's not really

true but that's an example but it will

be more money for me or less according

to what is the risk rating for my fund

i hope this is clear

so they have a sort of risk rating for

all these different funds and then they

upgrade or under grade the money they

give back to this fund that all the

funds have the same

sort of contribution for each of the

members according to the risk of of

expenditure they have

so this eliminates completely the

inequal

um imbalance between these different

insurances and the result is this reform

was done

so what i said here you know creation of

this fund and then the fund

redistributes the collected

contributions

to the individual individual funds

corrected by risk index that's the right

word the risk index the national risk

index which is constantly renewed also

they always rework on it every year

so the result 20 years later is

if you have public opinion polls now

about people being able to afford care

or not germany reports today after this

reform with risk equilibrium

europe's lowest level of unmet health

needs

people don't say anymore i can't go and

see the doctor because i like the money

or the doctor is too far away or

whatever

almost none

declares unmet health needs for

financial reasons or other reasons

neither in the lowest income clinton

this is really an achievement because if

you do the same inquiries in france

about 20 of the people who say they have

unmet unmet health risks they can't pay

for the doctors

despite very high health expenditure in

floods and the very big

solidarity in the system so this seems

to have been a very very intelligent

technical solution

risk equilibrium between the different

health insurances

well this is between the public ones but

you can also include the private ones if

you want

it depends on the law so france has a

system for um we had the same problem in

france because we had a social health

insurance system with different branches

and people dropped out of the system

because too long unemployed or because

divorced and

not working anymore and the husband used

to

co-ensure the ladies and now it's it's

finished

so france had a very old law on medical

assistance a law that dated from 1800

and something

and it was abolished it was more than

100 years old the local law

local mayor had to pay for the medical

expenditure for the for the poor people

this functions of course very very badly

because it was very old and not adopted

so in 2000 that they abolished this law

replaced it by what they called the

universal medical coverage cmu

and made it a legal right for everybody

who earns less than a certain sum or so

three short income three short if you

have less income per month and according

to your family members of course it's

all counted you are entitled to get

this cmu

right which means

you can you will be affiliated with the

health insurance for free you don't pay

contributions anymore you are just free

affiliated and you have the same rights

than any other person who pays the same

rights and i have who pay

and so the same benefits like the paying

affiliates

but there's an income tree short it is

relatively low it is a little bit lower

than the three sort for getting social

assistance

so in addition as france has

social health insurance who never

completely reimburse the expenditure

only sort of 70 percent everybody has a

complimentary private health insurance

in france so we all insured twice

once in the mainstream public health

insurance the social one

and one complementary private health

insurance

so

these poor people who are under the tree

short they are affiliated without paying

also to the complementary private health

insurance

so there is a law about this the

government organized it all and the

private health insurance has to accept

the people who want to join because

there are several no

they're not entitled to look how

expensive you will be how ill you are

they have to accept you when they say

when you say i want to go to your your

insurance

so if they are just a little bit above

the tree sold you know 30 percent above

they get to voucher

uh some money from the government to

help them buy themselves such a

complimentary private health insurance

so the poor

people with poor income they get free

affiliation or a supple subject uh how

do you say a subsidized subsidized

subscription this is a basic format in

in france so um

and in 2016

this

uh

all this what was created in 2000

was murdered in another reform with the

main health insurance so all these

things about same uh doesn't don't exist

anymore we merged it into the normal

health insurance a big one

so there's no difference now anymore

institutionally between the people who

are free and short or those who pay you

all have the same health insurance the

difference i pay and other people don't

and we get the same service and go to

the same hospitals

so we call this the puma reform puma is

for universal health protection

there was another interesting the cmu

for the poor people was merged into the

statute statutory more the legal social

health insurance and another very

interesting point in this reform

concerns mainly women not only

membership is now individual you are in

the french health insurance

we don't know since 2016 any co-insured

family members anymore doesn't exist

anymore

so let's say you have the same couple mr

egreg and his wife

mrs egreg

and only mr egreg works and she looks

after the house and the children

so what will happen to her

by nothing

formally she was co-insured with him and

when they got divorced or separated or

when he would die she was without

insurance and she had to run around

many offices to get the right papers to

be reinsured as a widower

now she will be insured on her own name

and as she doesn't have any income she

will be free and short without paying

and if she gets divorced or her husband

dies it doesn't change anything she will

still be insured in your own name

without paying any contributions and

today she finds work and she starts

working she will have to contribute

so this is just a sort of

simplification administratively but it's

a big help for women

it really is to protect women for months

and months without insurance for just

administrative reasons

and it also works for grown-up children

once they reach the age that they can't

be

reinsured with the parents anymore they

are individually insured and as

generally their students or they don't

earn money they will be free and short

so there are quite a lot of people now

who benefit from this reform just being

free free and

free and short so there's a long history

behind and it was solved in the way you

merge it with the normal health

insurance and you have three short

income

and individual membership

now you may be curious about migrants

but all the people who migrate around in

europe and come to france if they can

prove that they are in the territory of

france for three months

they will be free affiliated to this

puma

thing to the normal health insurance but

they have to prove that they are there

for three months if they are less than

three months

they can still go to the public hospital

there is a special service in each

public hospital for people who need

medical help who don't have papers who

don't want to give their name because

they are afraid of the police because

they're illegal migrants you can even go

there without giving your name and you

will get the care you need

there is a state medical emergency aid

scheme that's a

money fund

government gives some money in this fund

and this fund will then pay for these

people to the hospital

and you have of course humanitarian

medical associations who will help so

basically everybody is covered it's just

to give you an example of

different types of coverage

in germany this works more or less the

same way the european countries they

consult each other and they all have

plans for migrants they all have plans

for these

people who earn very little and they're

more or less sort of the same but they

have to fit into their institutional

makeup architecture of the system

concerning migrants of course in europe

many countries have different policies

poland for instance in hungary are not

very friendly to migrants and they will

probably not be

so

ready to give them medical care but then

they just need to go to another country

next door

and they will get to what they don't get

in hungary or because

free movement in europe so that's no

problem quite a lot of people in france

who come from other countries just

because they need medical care and they

can't get it in the other country

so

netherlands uh you had some reading

about it just to summarize netherlands

had um

traditionally social health insurances

just like germany

and for all sorts of reason um

money-wise and it was not very efficient

it was very bureaucratic cost control

and so on they decided to privatize all

them they made them just private

we just declared now you're a private

organization you can recruit the manager

you want you just have to watch your own

budget

your private now

and

then the government of course regulated

very strongly their activity

and especially that they would keep

universal access

and ensure all the people who don't have

money also so in fact they do this

private

by privatization they did the same thing

than others did by risk materialization

of the french by

free affiliation so they made a law at

the same time

the dutch saying all citizens all the

people who are in the dutch territory

must be affiliated to health insurance

and as they all privatize now it means

to a private health insurance and the

private health insurance must accept

those who apply to them

the contribution this is interesting

is divided into two parts

one part of the contribution to that

private health insurance is community

rated that means probably according to

age groups and professions and things

like this you have a little bit

different tariffs

and that money goes directly to that

health insurance

and part of the income goes to a

national pooling fund they call it

that redistributes the money according

to risk index to the different

insurances so it's the same thing than

the germans did but the germans did it

for all the insurances for all the

contributions on the national level and

the dutch did it for half of the

contributions

and the other half continues on the

basis of more or less private ideas so

the community rated contributions

it's not your individual health status

but your status may be by age or the

region you live for the profession you

have

so there is a little bit of risk

in it

and all poor people are free and sure

the government subsidizes their

affiliation so if people don't earn

money they can still join these health

insurances although they're private and

the government will subsidize i will

send

a fixed sum for each member to each of

these insurances that they get some

money back and switzerland who is such a

free neoliberal country they adopted

more or less the same system they used

to have only private health insurances

and they they nationalized them they

made them public and introduced more or

less the same

things in holland so you can see the

combination between public and private

is not really important anymore what's

which is important is that you have risk

pooling between your insurances that

everybody in the country must be insured

and that the very poor people are

insured free

these are the sort of basis for

uh universal access as we see it in

europe so we can

summarize a few points the national

health service systems are easier to

monitor and regulate than health

insurance systems because government has

direct control over all the three

functions you remember the nice temple

we saw regulation funding and

distribution

the government in these in this national

health care system health systems can

limit capacities well the battery the

bed the manpower and the equipment

so it has all the power and the result

is waiting list age limits for heavy

heavy uh care

and in france this doesn't exist

oh we have some waiting lists but

they're not really very long

and uh

to decide whether a very old person of

80 should have a new hip

or of of 90 it's a doctor decides it's

not the government it's not the health

insurance so

uh hospitals get money for the work they

do so they're always interested in doing

work so they will give you a new hip

even if you are 90. they will just look

whether it's reasonably on a medical

stage so that if they think you will be

better afterwards because there is a

principle in

in

medicine which is

important in france they keep to their

traditional principles prima non-nursery

so a doctor should never do something

which makes you

afterwards worse so if you have some

chance of being better with your new hip

even if you're 100 years old that will

give you a new hip and they won't bother

at all about the cost

but that would be a bit different in

britain

because there's more control over what

should be paid and not paid

social health insurances germany

netherlands and austria and so on they

invented new efficient tools to avoid

risk skimming by private health

insurances taking all the young people

and correcting the traditional

solidarity breach of the social health

insurance so that means they introduced

risk mutualization even if you have a

thousand different health insurances

half of them private you can mutualize

the risk

by the risk ratio factor which you

use for redistributing the contributions

i hope this was clear it may be a bit

difficult for indians to understand this

even americans would find it difficult

so a few words about co-payments uh we

have seen in our statistics that there

are quite a lot of co-payment in the

poorer eastern european health care

systems

but i lined up a little bit general

general statements

in general in the european countries

even the poorer ones you have no

co-payments or very little for people

under income three shorts and they're

very very little money and generally

they are freed from co-payments

out-of-pocket payments are generally

unrelated for chronic disease

let's say somebody has a chronic heart

disease or cancer

chronic which comes back and back they

won't pay you out of pocket it will be

undulated because they always need care

or for very long and expensive illness

in several countries also there are no

out-of-pocket payments for children

under 18 or under 16.

most countries

also limits the out-of-pocket payments

which you can sort of accumulate during

a year year and it should not

outpass a certain amount in a year so

people who need a lot of care they will

not be penalized for the fact that they

need all the time to see a doctor and

have a little co-payment for this

sorry

uh

it always runs away so in france the

limit is six euros a year once you have

co-paid

one euro here and six euros here and

three euros here when you have reached

the 60 euros the health insurance

doesn't take any co-payment anymore

out of pocket

so uh

countries did different rules about

co-payments generally the out-of-pocket

payments are concentrated on

non-essential medicines

and on things like spectacles hearing

aids and dental implants

more expensive things but which are not

vital

except france they introduced just

recently in 21 in september it's very

new you can get totally free without any

penny to pay whatever is your income

even a millionaire

free spectacles free hearing aids and

free dental implants

without any out of pocket for everybody

but you have to take a standard model

for a standard quality so the government

negotiated with this with a specialist

for instance with the eye the eye

doctors what type of spectacles needs

this and this and this in this case and

what in average would they cost and they

made a list of about i don't know you

have a choice maybe about 10 different

spectacles

and which are all good for you for your

for your eyes and the glasses are okay

but it will be sort of average quality

and average sort of aesthetics

it's okay it's fine

i must admit i tried for my last

spectacles i start i tried the standard

models but i could see much better with

a more expensive model so i paid it

myself

but it helps many people who just

couldn't pay it i mean you get

reasonable quality uh are tested by

specialists and you can have it all for

free so afterwards the choice you make

you want a new car or you want good

spectacles

okay

i will finish with this after having

said all i said there's only one way to

universal access in its full sense and

that is a compulsory health insurance

for all residents in one country

with health insurance bodies that are

share risk mutualization there's no

other way because otherwise you can't

finance it

health insurance is like any insurance

if you want to have a good insurance you

have to have lots of people who pay and

very little who take the money out so if

you ensure the entire population that

most people are healthy you will get

enough money to pay for all the people

who are ill but if you don't have

compulsory insurance or let part of the

people get away with private insurances

who don't share the risk

afterwards

then you can't ensure universal health

care

for all or you have a two class system

you will have this sheep or medicine for

the poor people free of charge

the good doctors won't work there they

will work in other private clinics so

you have to decide one day or the other

if you want a universal access for

everybody according to the rules of

dignity of every human being

and in that case the technical way to

get there is compulsory health insurance

for all residents without exception

paid according to income not according

to risk

and that all the bodies who ensure the

risk share risk mutualization to avoid

to have poor and rich health insurances

with different care baskets