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November 29, 2015

By SUSAN CALLAHAN, Associate Editor and Featured Columnist




You’ve made your way to France. Congratulations, you are now standing in the most sought-after holiday destination in the world. Many a starry-eyed tourist to Paris has left smitten, vowing to return one day to make a life in the City of Lights or to frolic among the purple fields of Lavender in Provence or in any one of the many hundreds of idyllic  villages of France.

So, now, naturally you want to enjoy all the best that France has to offer -- Paris, the inimitable City of Lights and the world’s brightest beacon of architecture and culture, the lavender fields of Provence, the Gothic churches, the monuments, cafe’s, and oh yes, the healthcare.

The health care system of France is rated as the best in the world by the World Health Organization.  By the way, on that same list, Germany is Number 25, Canada is Number 30, Australia is Number 32, the United States is Number 37 and China is Number 144. Ouch!

Here is a snapshot of the Top 20 on the list:









1 France

2 Italy

3 San Marino

4 Andorra

5 Malta

6 Singapore

7 Spain

8 Oman

9 Austria

10 Japan

11 Norway

12 Portugal

13 Monaco

14 Greece

15 Iceland

16 Luxembourg

17 Netherlands

18 United Kingdom

19 Ireland

20 Switzerland

What makes France’s healthcare system tops?  From a personal perspective, I can say that it is the ability to live without fear of being uncovered. France does not screen out people based on “pre-existing conditions” or age. In the United States, prior to the introduction of the Affordable Care Act, even those lucky enough to have health care insurance feared being dropped by their carrier. People are often blacklisted after being diagnosed with cancer, heart disease or another “uninsurable” disease on some list in the back office of an insurance company.

Another reason I love the French healthcare system is ease of use and reimbursement. Once you have joined the system, you receive the "Carte Vitale".  The Carte Vitale is swiped at the doctor’s office and you are reimbursed with 72 hours by deposit directly into your bank account.  Contrast that with the system that prevails throughout much of the world, in which you have to submit a written claim after you pay the money out-of-pocket and then pray that eventually you will get reimbursed.

But that’s just my subjective point of view. More objectively, the World Health Organization ranks France ahead of the world in terms of 5 factors:

-overall level of population health; health inequalities (or disparities) within the population;

-overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts);

-distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system); and

-the distribution of the health system's financial burden within the population (who pays the costs).

How in the World Does France Pay for This?

Little wonder that France, with such a sterling health care system, feels the financial burden of keeping the system afloat. How does it do it?

First of all, most people who think of coming to France are surprised to learn that healthcare here is not free.  People who are covered by the health care system pay a premium based on their income. Roughly, you pay 8% of your income, after deducting 9534 euros. So, if you make 70,000, you would pay 8% of the difference between 70,000 euros minus 9534 euros, which is 8% of 60,466 euros. Your annual premium would be 4837 euros, or  403 euros per month.  Not expensive but not free either.

For that premium, you would get reimbursed for 80% of your hospitalization costs and 70% of your out-of-hospital medical costs.

The biggest part of the funding for the French healthcare system comes from employers --who pay 13% of your salary- and the government itself. That 8% of your income that gets paid in is reduced to 7.5% if you work for a company, so the total paid by employer and employee is 20.5%.  Not cheap.

One of the biggest surprises I have had in living in France is not that everyone is covered but that the total costs of the system itself is reasonable compared with that of other countries.

Other countries spend a lot more than France on healthcare, for example. France spends 11.7% of its GDP on healthcare, according to the latest statistics available from the World Bank. That’s about the same amount as Germany, which is ranked 25th. The US spends 17.1% of its massive GDP, yet its healthcare system is only ranked 37th.

In other words, France does way more with what it spends than other countries. Why? Part of the reason is that the money spent is allocated differently than it is in other countries. You may think that the answer is the oft-repeated mantra that US doctors make 4 times what France’s doctors.  

But the truth is that France’s doctors are fairly well compensated. A report from the French Inspector General for Social Affairs found that, in 2007, a hospital-based radiologists earned 686,913 euros, surgeons earned 198,766 euros and internists earned 111,705 euros.

By comparison, in the US, a radiologist in 2014 earns $216,577 according to the Bureau of Labor Statistics. A surgeon, on average earns $240,440 and an internists earns $190,530.

Of course, we’re comparing apples to oranges somewhat because hospital-based professionals generally earn more than private office doctors but, as you can see, the differences are not huge.

Perhaps the real reason that France is able to do more with less is because, a health system that is accessible to all helps to keep everyone healthier which means they don’t “burden” the system with catastrophic costs --massive heart surgery statistics, for example.

In the US, double, triple and quadruple bypass surgeries are pretty common. In France, where body weight is lower and lifestyles include walking and riding bicycles, bypass surgery is much rarer. The US Centers for Disease Control keeps a tally of the number of surgical procedures performed in the US. In 2014, there were 51 million surgical operations performed, with a significant share of those related to heart procedures or diseases either caused by or complicated by obesity (knee replacements and so on).

So, again, maybe the French people, with their health-supportive lifestyles are the secret sauce that makes the French health system work.

Who Gets In and Who Is Kept Out?

To access the French health access system, you must either be an employee working in France for a French company which is paying into the system, start your own business which will then pay into the system for you or live in France legally.  

To live in France legally if you come from a country outside the EU, you have to prove that you have sufficient financial resources to obtain a visa to stay a year. To get this long-stay visa, you need to apply at the French embassy or consulate in your country of origin.

One of the key hurdles to obtaining that long-stay visa is to have private health insurance.

Where you apply to affiliate to the French healthcare system depends on your situation. If you work for a company, your employer will enroll you. If you have started a company, you will need to apply to a caisse, one of the trade associations that covers your type of company. If neither of these situations applies to you because you are retired/independently wealthy, you will  need to go to a CPAM (“caisse primaire d'assurance maladie”) office in your town.

You will then have to demonstrate residency and resources

For EU nationals, you will need to be resident for 5 years. France put in this requirement to avoid being overwhelmed by “inactive” EU nationals who, because of the Schengen Treaty, are entitled to live in France. For non-EU citizens, you will need to prove your financial resources and that you have legally resided in France for at least 3 months ( at least this is the current state of this rapidly changing  law as of 2015).

Unless you are independently wealthy, you will need to create an income or come with a job waiting for you. You won’t be able to get a job in France without a work permit which generally requires, again, that you have 5 years residency. After 5 years, you become eligible for permanent residency which includes the right to work.

How do you prove your financial resources? Most CPAMs (the name of the offices which handle affiliations to the French healthcare system) ask you  to produce tax documents for 12 months and sometimes, these need to be certified by your government. You may also be asked for certified and translated birth certificates for yourself and any family members who live with you in France, proof that you live in France and an up-to-date residency permits (carte de sejour).

You will also need to state up to date on changes in French laws.  You could be covered today but not tomorrow. This was the unhappy turn of events which confronted British retirees in 2007 who had previously been covered by the French health system before they were dumped out of the system by France and required to obtain private health coverage. Despite intense pressure from the EU, France would not change its position --- only those EU citizens who had lived in France for 5 years would continue to be covered under the French system.




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