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Reforms in Long-Term Care Policies in Europe pp 139–157Cite as

Steps Toward a Long-Term Care Policy in France: Specificities, Process, and Actors

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Abstract

This chapter presents the French policy framing process, which began in the 1980s and has led to the so-called “French compromise” combining elements of different types of care systems. This chapter begins by developing the process of defining this policy over time in order to identify the main phases of and drivers for reform and to understand the role of the main actors involved in the process. We then focus on the cost of this policy and its various dimensions, both public and private. France is characterized by the introduction of a new long-term care (LTC) program at the beginning of last decade (the APA, Allocation Personaliseè a l’Autonomie), which offers a combination of service and cash transfers to the dependent older population. We subsequently trace the development of the current debate on LTC, which lays the ground for a long-awaited and possible reform. This ongoing debate illuminates additional facets which may be useful in understanding the conditions of the reform in the French context as a combination of both political impulse and “retrenchment” as evidenced by continuous reports by diverse experts, senior civil servants and professional coalitions.

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Notes

  1. 1.

    “In-kind” means that the allowance (the cash) has to be used for the payment of services, mainly formal, in return of invoices.

  2. 2.

    The French social security system is based on four risks: illness, retirement, family, and accident at work.

  3. 3.

    This principle has important consequences in terms of family obligations. There is indeed in France a legal obligation—called “obligation alimentaire”—to intergenerational solidarity (upward and downward), which imposes to support one’s relatives. The application of such a principle can mean that public coverage is secondary to family support.

  4. 4.

    This Lion’s report inspired the first socialist Government after the election of François Mitterrand in May 1981. Concretely, it was the main orientation of the Secrétariat d’Etat aux personnes âgées set up by this Government. But this orientation disappeared after the “neoliberal turn” of the socialists in 1983.

  5. 5.

    There are 101 conseils généraux in France: one for each department.

  6. 6.

    Right-wing government “Balladur” (March 1993–May 1995): Prime minister: Edouard Balladur; minister of Social Affairs: Simone Weil.

  7. 7.

    Right-wing government “Juppé II” (November 1995–November 1997). Prime minister: Alain Juppé; minister of Work and Social Affairs: Jacques Barrot.

  8. 8.

    Left-wing government “Jospin” (June 1997–May 2002). Prime minister: Lionel Jospin; minister of Employment and Solidarity: Martine Aubry.

  9. 9.

    Political “cohabitation” means in that case that a right-wing President, Jacques Chirac, had to cohabit with a left-wing Prime minister, Lionel Jospin.

  10. 10.

    The first national inquiry (‘Handicap, incapacité, dépendance’) of the National institute of statistics (INSEE) estimated for the first time in 1999 that the number of dependent elderly people was almost a million people.

  11. 11.

    Right-wing government “Raffarin II” (June 2002–March 2004). Prime minister: Jean-Pierre Raffarin; minister of Health, Family and Handicapped People: Jean-François Mattei.

  12. 12.

    The media even considered that Jean-François Mattei paid the political price of this tragedy by losing the charge of the ministry of Health, Family and Handicapped People.

  13. 13.

    Right-wing government “Raffarin III” (March 2004–May 2006). Prime minister: Jean-Pierre Raffarin; minister of Health and Social Protection: Philippe Douste-Blazy.

  14. 14.

    A first Plan was implemented for the period 2004–2007 and a second one for the period 2008–2012.

  15. 15.

    Called “Contribution solidarité autonomie.”

  16. 16.

    Called “journée de solidarité.”

  17. 17.

    Concerning specifically the sector of elderly care, the prestataires services represented 46 % of the services used, 18% the mandataires, and 36 % the gré à gré (FNORS 2008, p. 54).

  18. 18.

    Until March 2002, the CAFAD (certificat d’aptitude aux fonctions d’aide à domicile) was the only diploma available to personal assistants and only a few of them had it (only 18 % of personal assistants had a qualification in social and health sector and 9 % the CAFAD). The training has since been improved with the DEAVS (Diplôme d’Etat d’auxiliaire de vie).

  19. 19.

    These statistics concern a larger sector than “personal assistants” who cares for frail elderly. The service to individuals includes care toward frail elderly, childcare, domestic tasks, and all support needed by individuals (such as gardening, computer help, odd jobs…). Care toward frail elderly represents 60 % of the global activity of services covered by “quality agreement” and domestic tasks 33 %.

  20. 20.

    A total of 12,000 if one includes private firms.

  21. 21.

    In February 2006, a specific plan for the development of such services (“plan de développement des services à la personne”) announced the creation of 1 to 2 million jobs by 2010 and created a specific Agency to organize this sector (Agence des services à la personne).

  22. 22.

    In the case of institutions, the benefit can either be allocated to individuals or globally to the institution itself, which uses it according to the dependency needs of the residents. The choice between the two options is made by the institution. In France, institutions for the elderly distinguish among three expenditure components: dependency costs (paid by the resident and the APA), accommodation costs (paid by the resident), and healthcare costs (paid by the health insurance).

  23. 23.

    The administrative control is organized by the local authorities and can vary according to the “départements.”

  24. 24.

    This success also had an impact on the political debate, both local and national, after the political change of April 2002 and the comeback of a conservative Government. The new government and right-wing local authorities criticized the increasing cost and the previous socialist government’s failure to plan the funding of their care system for frail elderly people. In April 2003, the decision was taken to reduce the threshold below which the recipient does not contribute at all to the funding of the care package, from 943 to 623 € per month. This reform has reinforced the copayment system by increasing the user’s contribution and has contained the costs.

  25. 25.

    Cour des Comptes (2005); CAS (2006); Gisserot and Grass (2007); Vasselle (2008); CAS (2010); Rosso-Debord 2010.

  26. 26.

    The first one on “society and aging” (President: A. Morel, 54 members); second on demographic and financial trends for dependency (President: J-M. Charpin, 40 members); third on “services for elderly people” (President: E. Ratte; 57 members), and fourth on “funding strategy of the dependency policy” (President: B. Fragonard; 52 members).

  27. 27.

    http://premier-ministre.gouv.fr/information/questions_reponses_484/est_cinquiemerisque.

  28. 28.

    The executive board is composed of representatives of the funding institutions—the State and local authorities—and representatives of the health branch of the social security system. A specific consultative board has also been set up (“conseil d’orientation et de surveillance”), which associates representatives of the private insurances, on one side and of nonprofit organizations providing services, on the other.

  29. 29.

    The two authors identify two types of approach. The first one refers to “care,” which is defined as “long-term” and is characteristic of the American (Long-Term Care) or German (Pflegeversicherung) systems. The second, the French approach, does not use the term “care” (soins) but “dependency” or “loss of autonomy.” These notions do not refer to the needs, but to the physical, mental, and social state of the old person, an approach which makes the assessment of the situation easier.

  30. 30.

    Recovery on inheritance was one of the criteria to obtain the first allowance created in 1997 (PSD) and at that time, many old people were reluctant to ask for the allowance. The reintroduction of such criteria will probably have similar consequences. Therefore, other solutions have to be proposed.

  31. 31.

    A total of 12.5 million people have such a life insurance contract, which represents 40 % of the households for a global amount of 1,100 € billion in 2007.

  32. 32.

    Reverse mortgage is a bank loan guaranteed on real estate and used to enable old people to finance long-term care, without having to sell their property. Some experts (Chen 2001) go even further and propose to develop reverse mortgage in order to finance life or dependency insurance. But there are many obstacles to the development of such a system: it is open only to house owners and even for them it is not an attractive solution, because it could mean the end of succession (Assier-Andrieu and Gotman 2009).

  33. 33.

    http://collectif-pour-un-vrai-5eme-risque.over-blog.com.

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Authors and Affiliations

  1. EHESP School of Public Health, Rennes, France

    Asst. Prof. Blanche Le Bihan Ph.D.

  2. EHESP School of Public Health, Avenue Professeur Léon Bernard, 35042, Rennes Cedex, France

    Prof. Claude Martin Ph.D.

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  1. Asst. Prof. Blanche Le Bihan Ph.D.
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  2. Prof. Claude Martin Ph.D.
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Correspondence to Blanche Le Bihan Ph.D. .

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Editors and Affiliations

  1. , Economic Sociology, Milan Polytechnic, VIA BONARDI 3, MILANO, 20133, Italy

    Costanzo Ranci

  2. , Economic Sociology, University of Macerata, Don Minzoni 2, Macerata, 62100, Italy

    Emmanuele Pavolini

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Bihan, B., Martin, C. (2013). Steps Toward a Long-Term Care Policy in France: Specificities, Process, and Actors. In: Ranci, C., Pavolini, E. (eds) Reforms in Long-Term Care Policies in Europe. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-4502-9_7

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