Why People Forgo Healthcare in France: A National Survey of 164 092 Individuals to Inform Healthcare Policy-Makers

Document Type : Original Article

Authors

1 HP2 laboratory, INSERM U1300, University Grenoble Alpes, Grenoble, France

2 AGIR à Dom, Homecare charity, Grenoble, France

3 EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France

4 Research Division, Grenoble Alpes University Hospital, Grenoble, France

5 Social Sciences Research – PACTE Laboratory, CNRS UMR 5194, University Grenoble Alpes, Grenoble, France

Abstract

Background 
Even in countries having nearly universal healthcare provision some individuals forgo or postpone healthcare to which they are entitled. Socioeconomic and geographic inequalities can make access to healthcare difficult for some people, such that they fail to seek it, particularly if they deem the type of care as non-essential. The need to pay at the point of care, the complexity and cost of top-up health insurance, and delays or only partial reimbursement can discourage take-up of care. This can affect the general health of the population.

Methods 
To estimate the rate of forgoing healthcare in the general French population, between 2015 and 2018 we conducted a nationwide cross-sectional survey of individuals visiting French primary healthcare insurance agencies (Caisse Primaire d’Assurance Maladie, CPAM). We asked whether the person had foregone or postponed healthcare in the last 12 months, if so the types of healthcare forgone or put-off, and reasons. Individuals were stratified by the type of complementary (top-up) health insurance they had.

Results 
Out of 164 092 individuals who responded, 158 032 were included in the analysis. Respondents had either private complementary (top-up) insurance (60%), top-up insurance subsidized by the state (29%), or no top-up health insurance (11%). Forgoers (n=40 115; 25.4%) most often lived alone (with or without children), were unemployed, and/ or female. Dental care (54%) and consultations with ophthalmologists, gynaecologists and dermatologists (41%) were most commonly forgone. The reasons were: inability to advance payment and/or to pay the uninsured part (69%), time constraints and difficulty in obtaining appointments (26%).

Conclusion 
We present a snapshot of forgoing healthcare in a developed country, highlighting the need for continuing review by policy-makers of payment regimens, insurance cover, availability and accessibility. While initiatives have already emerged from the results, further reforms are needed to address the problem of people forgoing preventative or perceived non-urgent healthcare, particularly for disadvantaged subgroups.

Keywords


  1. Gostin LO. Five ethical values to guide health system reform. JAMA. 2017;318(22):2171-2172. doi:1001/jama.2017.18804
  2. Forouzanfar MH, Alexander L, Anderson HR, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(10010):2287-2323. doi:1016/s0140-6736(15)00128-2
  3. Jusot F. [Inequalities in access to care and their evolution: a review]. Rev Epidemiol Sante Publique. 2013;61 Suppl 3:S163-169. doi:1016/j.respe.2013.05.011
  4. Fjær EL, Stornes P, Borisova LV, McNamara CL, Eikemo TA. Subjective perceptions of unmet need for health care in Europe among social groups: findings from the European social survey (2014) special module on the social determinants of health. Eur J Public Health. 2017;27(Suppl_1):82-89. doi:1093/eurpub/ckw219
  5. Fiorillo D. Reasons for unmet needs for health care: the role of social capital and social support in some western EU countries. Int J Health Econ Manag. 2020;20(1):79-98. doi:1007/s10754-019-09271-0
  6. Jusot F, Wittwer J. [Financial access to healthcare in France: assessment and perspective]. Regards croisés sur l'économie. 2009;1(5):102-109. doi:3917/rce.005.0102
  7. Pegon-Machat E, Jourdan D, Tubert-Jeannin S. [Oral health inequalities: determinants of access to prevention and care in France]. Sante Publique. 2018;30(2):243-251. doi:3917/spub.182.0243
  8. Baggio S, Iglesias K, Fernex A. Healthcare renunciation among young adults in French higher education: a population-based study. Prev Med. 2017;99:37-42. doi:1016/j.ypmed.2017.02.002
  9. Bazin F, Parizot I, Chauvin P. [Psychosocial determinants of cessation of care for financial reasons in five sensitive urban areas of the Paris region in 2001]. Sci Soc Sante. 2006;24(3):11-31. doi:3917/sss.243.0011
  10. Chaupain-Guillot S, Guillot O. Health system characteristics and unmet care needs in Europe: an analysis based on EU-SILC data. Eur J Health Econ. 2015;16(7):781-796. doi:1007/s10198-014-0629-x
  11. Pascual M, Cantarero D, Lanza P. Health polarization and inequalities across Europe: an empirical approach. Eur J Health Econ. 2018;19(8):1039-1051. doi:1007/s10198-018-0997-8
  12. Osborn R, Squires D, Doty MM, Sarnak DO, Schneider EC. In new survey of eleven countries, US adults still struggle with access to and affordability of health care. Health Aff (Millwood). 2016;35(12):2327-2336. doi:1377/hlthaff.2016.1088
  13. Unmet health care needs statistics - Statistics Explained. https://ec.europa.eu/eurostat/statisticsexplained/index.php/Unmet_health_care_needs_statistics#Unmet_needs_for_health_care. Accessed February 14, 2020.
  14. Zins M, Goldberg M. The French CONSTANCES population-based cohort: design, inclusion and follow-up. Eur J Epidemiol. 2015;30(12):1317-1328. doi:1007/s10654-015-0096-4
  15. Feral-Pierssens AL, Rives-Lange C, Matta J, et al. Forgoing health care under universal health insurance: the case of France. Int J Public Health. 2020;65(5):617-625. doi:1007/s00038-020-01395-2
  16. Chaupain S, Guillot O, Jankeliowitch-Laval E. [Forgoing medical and dental care: an analysis based on data from the SRCV survey]. Econ Stat. 2014;469:169-197. doi:3406/estat.2014.10426
  17. Desprès C. [Complementary universal health coverage, the legitimacy in question: analysis of the attitudes of doctors and dentists towards its beneficiaries]. Prat Organ Soins. 2010;41:33-43. doi:3917/pos.411.0033
  18. Naing NN. Easy way to learn standardization: direct and indirect methods. Malays J Med Sci. 2000;7(1):10-15.
  19. Bivand R, Lewin-Koh N, Pebesma E, et al. Maptools: Tools for Handling Spatial Objects. 2019. https://CRAN.R-project.org/package=maptools. Accessed February 28, 2019.
  20. R Development Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2019. https://www.R-project.org.
  21. Tambor M, Pavlova M, Rechel B, Golinowska S, Sowada C, Groot W. The inability to pay for health services in Central and Eastern Europe: evidence from six countries. Eur J Public Health. 2014;24(3):378-385. doi:1093/eurpub/ckt118
  22. Health at a Glance 2017: OECD Indicators. https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017_health_glance-2017-en. Accessed October 23, 2021.
  23. L’accessibilité potentielle localisée (APL): une nouvelle mesure de l’accessibilité aux médecins généralistes libéraux - Ministère des Solidarités et de la Santé [Localized potential accessibility (PLA): a new measure of accessibility to private sector general practitioners - Ministry of Solidarity and Health]. https://drees.solidarites-sante.gouv.fr/etudes-et-statistiques/publications/etudes-etresultats/article/l-accessibilite-potentielle-localisee-apl-une-nouvelle-mesure-de-l. Accessed February 13, 2019.
  24. Tyrrell J, Poulet C, Pe Pin JL, Veale D. A preliminary study of psychological factors affecting patients' acceptance of CPAP therapy for sleep apnoea syndrome. Sleep Med. 2006;7(4):375-379. doi:1016/j.sleep.2005.10.005
  25. Protection Universelle Maladie. https://www.ameli.fr/assure/droitsdemarches/principes/protection-universelle-maladie. Accessed October 9, 2019.
  26. Revil H. [Identification of the factors explaining the renunciation of care to understand the different dimensions of health accessibility]. Regards. 2018;1(53):29-41. doi:3917/regar.053.0029
  27. Andermann A. Screening for social determinants of health in clinical care: moving from the margins to the mainstream. Public Health Rev. 2018;39:19. doi:1186/s40985-018-0094-7
  28. Bodenmann P, Wolff H, Bischoff T, et al. [Patients forgoing health care for economic reasons: how to identify this in a primary care setting?]. Rev Med Suisse. 2014;10(452):2258-2260.
  29. Davidson KW, McGinn T. Screening for social determinants of health: the known and unknown. JAMA. 2019;322(11):1037-1038. doi:1001/jama.2019.10915
  30. Greenwood-Ericksen MB, Kocher K. Trends in emergency department use by rural and urban populations in the United States. JAMA Netw Open. 2019;2(4):e191919. doi:1001/jamanetworkopen.2019.1919
  31. Peters AL. The changing definition of a primary care provider. Ann Intern Med. 2018;169(12):875-876. doi:7326/m18-2941
  32. Anderson AM, Matsumoto M, Saul MI, Secrest AM, Ferris LK. Accuracy of skin cancer diagnosis by physician assistants compared with dermatologists in a large health care system. JAMA Dermatol. 2018;154(5):569-573. doi:1001/jamadermatol.2018.0212
  33. Jackson GL, Smith VA, Edelman D, Hendrix CC, Morgan PA. Intermediate diabetes outcomes in patients managed by physicians, nurse practitioners, or physician assistants. Ann Intern Med. 2019;171(2):145. doi:7326/l19-0200
  34. Warin P. Waiting for common-law solutions for the most vulnerable populations' healthcare access. Rev Epidemiol Sante Publique. 2019;67 Suppl 1:S33-S40. doi:1016/j.respe.2018.12.063
  35. Friedman J, Kim D, Schneberk T, et al. Assessment of racial/ethnic and income disparities in the prescription of opioids and other controlled medications in California. JAMA Intern Med. 2019;179(4):469-476. doi:1001/jamainternmed.2018.6721
  36. Polite BN, Gluck AR, Brawley OW. Ensuring equity and justice in the care and outcomes of patients with cancer. JAMA. 2019;321(17):1663-1664. doi:1001/jama.2019.4266
  37. Ver Hoef JM, Peterson EE, Hooten MB, Hanks EM, Fortin MJ. Spatial autoregressive models for statistical inference from ecological data. Ecol Monogr. 2018;88(1):36-59. doi:1002/ecm.1283
  38. Feng Y, Wang X, Du W, Liu J. Effects of air pollution control on urban development quality in Chinese cities based on spatial Durbin model. Int J Environ Res Public Health. 2018;15(12):2822. doi:3390/ijerph15122822
Volume 11, Issue 12
December 2022
Pages 2972-2981
  • Receive Date: 04 May 2021
  • Revise Date: 24 April 2022
  • Accept Date: 30 April 2022
  • First Publish Date: 01 May 2022