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In the late Summer
of 2007, Exclusive Healthcare, a provider of complementary health insurance to the
expatriate community of France, had sight of a letter sent by a CPAM office to presumably
one of their clients. The letter stated that their health cover would be withdrawn
and that their "cartes vitales" should be returned. Contents of this letter
was subsequently landed in the hands of the press and the following article appeared
in the The Times on 2 September:
http://www.timesonline.co.uk/tol/news/uk/health/article2368553.ece
The article clearly
implied that many early retirees would have their health cover withdrawn. The article
had added pungency because during the French presidential election campaign Sarko
had said; "if you think 53 makes you old enough to retire, then fine go ahead
and retire. but don't expect the state to pay for it". But this could only
have been directed at French nationals because expatriates do not have the vote
in national elections. Expathealthdirect telephoned Exclusive Healthcare on 5th
September to ascertain whether they had been misquoted or quoted out of context.
It was clear that this was not so and Exclusive Healthcare had been the source of
the Times article.
Those affiliated
via E Forms (E121, E106 etc would not be affected. It was only those (mainly early
retirees) affiliated under "Couverture Maladie Universelle" (CMU) legislation
who were affected.
The article has
caused anger, distress, speculation and most of all non-thinking. Law 2006 - 911
of 24 July 2006 on the subject of Immigration and Integration stated that EU nationals
taking up residence in France should not be a burden on the social security and
"assurance maladie".
The article in
the Times implied many expatriates (mainly early retirees) were receiving free healthcare.
But most expatriates do not receive free healthcare. They pay 8% of their taxable
income. In addition other sources of income such as investment/interest income is
subject to "Contirbution Sociale Généralisé (CSG). CSG
is the single largest source of funding for the CPAM.
Additionally, by
affiliating to the CPAM by this means they were simply obeying a law, which obliged
them to do so. Taking out private insurance for cover that would otherwise be provided
by the state is an offence under pain of fines and/or imprisonment! Law DDOS of
4 February 1995 Article 43 refers. Expathealthdirect fed all this background information
through the British Consul in Marseille who in turn undertook to relay it to the
British Embassy in Paris to assist them with any negotiations with the French authorities.
Understandable
concern developed into panic and desperation as posters on internet forums suggested
such as methods as adopting French nationality, starting a business etc
By 7 September
it was becoming more and more evident ,what the Times referred to as a "brutal"
letter, was certainly exceptional, perhaps unique. The text of a letter, with a
translation, was subsequently published in The Connexion newspaper. In view of the
obvious close ties between Exclusive Healthcare and this newspaper it is reasonable
to assume it was the same letter that was quoted in the Times article. CPAM were
sending out routine letters requiring proof of residence and income in order to
calculate "cotisations" for the coming year. The letter also included
a threat of suspension of cover if such proof was not forthcoming. But that is not
the same as unilateral withdrawal of cover. Not one Expathealthdirect client, and
they are spread quite widely, reported receipt of such a "brutal" letter.
It is a great pity that the letter was leaked to the press in view of the distress
it has caused. There is a well established appeals procedure if one has a grievance
about a CPAM decision. Use of this means could have led to an amicable settlement.
High level discussions
took place between the French authorities and the British Embassy in Paris and after
a meeting at the health ministry on 11 September it was officially announced that
those who were already affiliated under residence criteria/"Couverture Maladie
Universelle" legislation would not have their health cover withdrawn.
But a few days
later the health ministry changed their mind again and said that affiliation would
be withdrawn but existing affiliates would have their cover extended until 31 March
2008 to give time to find alternative private insurance. On the 21st September a
press release from the health ministry confirmed this. However affiliation would
still be available to French nationals. There are around 5 million affiliated under
CMU legislation and, without knowing the precise figures, most of them must be French.
Furthermore the Directive, by definition, only applies to EU nationals. So what
would be the position of Americans for example? Expathealthdirect contacted the
"Centre des Liaisons Eurppéenne et Internationale de Sécurité
Sociale" (CLEISS). CLEISS confirmed that Americans could continue to affiliate
under CMU rules after proving 90 days of stable residence in France. Another anomaly.
The press release also stated that the health ministry would shortly be issuing
a circular to CPAM offices.
And what about
those with pre-existing conditions? Private health insurers are not going to pick
up the tab for those undergoing treatment . Are the French authorities; really going
to either withdraw treatment for say cancer patient with effect 1 April 2008 or
make the patient pay for everything? Surely not. This is France - not Burma, And
what about those who are of state pension age but do not receive a pension from
another EU state (and therefore do not qualify for E121) because their working lives
were spent outside the EU? On age alone a private insurer is unlikely to cover them.
At this point it
is worth establishing what the motives for these measures are. In the opinion of
Expathealthdirect it was not the sudden desire of the French authorities to comply
with EU Directive 2004/38. In any case this Directive does provide for member states
to grant a more favorable health regime to its residents if it so inclined. And
why were British expatriates in particular being targeted? Part of the answer was
a reaction to the scandal in the Dordogne in 2006 concerning social security abuse
by expatriates of different nationalities but particularly the British.. This was
reported by Internet French Property Limited (http://www.french-property.com). Both
via newletters and contributions to its Forum, the Editor of french-property.com
continues to bring thoughtful contributions to this whole subject. The anger of
the French authorities at this abuse was also confirmed by Mike Meade , Editor of
the Riviera Reporter (http://www.riviera-reporter.com). And of course underpinning
all this is the continuing health budget deficit forecast to be around 6 billion
Euros in 2007. So even though most expatriates are paying their way the illusion
of them not paying anything persists.
On 22 September
another twist in the tale appeared when the contents of the press release was published
on the British Embassy website with the additional statement that affiliation would
continue for those who could prove 5 years residency in France. This is reasonable
in that you are deemed to be a permanent resident according to the "Code de
l'Entree du Séjour des Etrangeres".
By this time lobbying
by the expatriate community was gathering momentum particularly via a MEP: Mary
Honeyball. Whilst no stone should be left unturned to achieve justice in this matter
Expathealthdirect took the view that EU pressure was unlikely to be fruitful because
the French authorities were quoting a EU Directive: and, in the final analysis,
it was unlikely that Brussels would criticize a member state for compliance. There
was not much point in lobbying British politicians either. Expathealthdirect continued
to probe and question via various channels but within France.
By the end of October
the circular, mentioned in the press release of 21 September, had still not been
issued. Nevertheless the Expathealthdirect mailbox was receiving a steady flow of
mails from people, who had already decided that the withdrawal of cover on 31 March
2008 was a done thing. This was far from being the case. The health ministry was
having legal difficulties in the drafting of the circular. No surprise. Possible
discrimination, retrospective aspect of measures and the sheer inhumanity of withdrawing
life saving treatment were formidable obstacles to overcome.
During the first
week of November Internet French Property Limited reported, with cautious optimism,
those already affiliated via CMU as at 30 September 2007 would be able to continue.
This is certainly a more just way forward and hopefully this will be confirmed by
the all important circular
There is still
a doubt about those presently affiliated via E106 and there will be many who have
this form expiring in the first week of January 2008. They are after all "in
the system" and have been allocated social security numbers. It is also tacit
acceptance by the CPAM they are legal, stable residents of France. And there will
be those with pre-existing conditions which will not be covered by private insurance.
The Circular dated
23 November finally appeared in the public domain on 14 December. Its main provisions
were:
Those affiliated
via CMU as at 23 November 2007 would have their rights continued.
Those affiliated
via E106 would, on expiry of this form, have to seek private insurance. Those with
a a pre-existing condition which would be excluded by an insurance provider could
appeal.
Those who can prove
5 years residence in France can affiliate via CMU.
There could be
a legal challenge to these provisions particularly on the subject of not allowing
existing E106 holders in good health not being allowed to affiliate via CMU. Expathealthdirect
will continue to monitor developments and update clients accordingly.
HEALTHCARE IN FRANCE
- A GUIDE FOR THE EXPATRIATE
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