A healthy re­la­tion­ship

As the Brexit process now of­fi­cially be­gins, Robin Gauldie ex­am­ines how health­care cover for Bri­tish ex­pats in France might be af­fected and the op­tions avail­able to them

Living France - - Contents -

How Brexit could af­fect your ac­cess to the French health­care sys­tem

Ex­pat Bri­tons will, af­ter Brexit, have to bud­get for a pol­icy that cov­ers their med­i­cal costs in full

If you al­ready live in France or are plan­ning to join the ranks of An­glo­phone ex­pats, it’s never been more im­por­tant, now that Ar­ti­cle 50 has fi­nally been trig­gered and the UK’s with­drawal from the EU be­gins, to make sure you have the right health in­sur­ance pol­icy.

Un­til now, ex­pats who have made France their per­ma­nent res­i­dence for five years, or who have reached re­tire­ment age, have been able to join France’s health­care sys­tem, which is rated among the world’s best – bet­ter, some claim, than Bri­tain’s be­lea­guered NHS.

Food critic, author and pro­gram­memaker Jonathan Meades, who has lived in France since 2006 (first near Bordeaux, now in Mar­seille) was rushed into a French hospi­tal for car­diac surgery last year.

“If I had been in Eng­land, with Jeremy Hunt’s cur­rent blood lust, I’ve no doubt I’d be dead,” he says in a re­cent in­ter­view in The Ob­server.

De­spite cost-sav­ing mea­sures in­tro­duced by suc­ces­sive French gov­ern­ments in the last decade, ac­cess to France’s Cou­ver­ture Mal­adie Uni­verselle (CMU) sys­tem, gen­er­ally rated the best op­tion for ex­pats, has un­til now been rel­a­tively easy.

“There are no med­i­cal ques­tions, no ex­clu­sion of pre-ex­ist­ing con­di­tions, no age lim­its, no claims de­ductible and no de­lay for ur­gent nec­es­sary treat­ment,” notes Ex­clu­sive Health­care, which spe­cialises in health in­sur­ance for An­glo­phone res­i­dents in France, on its web­site.

It also notes that: “In many coun­tries pri­vate full cover in­sur­ance is re­garded as bet­ter than the lo­cal NHS and many peo­ple con­sider it is nec­es­sary. In France this is def­i­nitely not the case; in com­par­i­son pri­vate full cover med­i­cal in­sur­ance hardly ex­ists.”

IN­SUR­ANCE COSTS

That is about to change, at least as far as Bri­tish res­i­dents are con­cerned. Cur­rently, pa­tients are ex­pected to con­trib­ute around 30% of the cost of their treat­ment, so most peo­ple buy a top-up health pol­icy to cover the gap be­tween med­i­cal bills and the French national health ser­vice’s re­im­burse­ment to health­care providers.

How­ever ex­pat Bri­tons will, af­ter Brexit, have to bud­get for a pol­icy that cov­ers their med­i­cal costs in full. That will be ex­pen­sive, and for those with pre-ex­ist­ing con­di­tions, it may be dif­fi­cult or even im­pos­si­ble. A typ­i­cal top-up pol­icy can cur­rently be bought for around €800-€1,000.

“Stan­dard pre­mi­ums for a 62-year-old buy­ing a fully un­der­writ­ten health pol­icy will range from €2,290 to €4,977, but the max­i­mum limit and the guar­an­tees are quite low,” says one France­based in­sur­ance ex­pert. “For a higher limit and bet­ter guar­an­tees the pre­mium would be from €6,702 to €8,412.”

Since 2007, new ar­rivals plan­ning to live per­ma­nently in France but not yet el­i­gi­ble for the French sys­tem have been re­quired to prove that they have per­sonal med­i­cal in­sur­ance or are cov­ered by Bri­tish National In­sur­ance con­tri­bu­tions, so that the French health­care sys­tem can re­coup from the UK the costs of treat­ing them.

PUMA (Protection Uni­verselle Mal­adie – uni­ver­sal ill­ness protection), in­tro­duced in 2016, equalised the rights of EU and non-EU cit­i­zens to ap­ply for France’s health in­sur­ance card, the carte vi­tale. That made life eas­ier for Bri­tish and other EU res­i­dents, who pre­vi­ously had to be res­i­dent for a pe­riod of five years be­fore they were el­i­gi­ble.

As with ev­ery other as­pect of Brexit, it’s too early to know ex­actly what the fu­ture may hold for Bri­tish res­i­dents in France. In par­tic­u­lar, it is un­clear whether they will still be el­i­gi­ble to join the French sys­tem, or to have their med­i­cal costs in France paid by the UK.

How­ever, main­te­nance of the re­cip­ro­cal sta­tus quo, un­der which the French health sys­tem (like that of other EU coun­tries) re­claims its share of the cost of treat­ing Bri­tish res­i­dents from Bri­tain, looks to be very un­likely.

POL­ICY OP­TIONS

“The health is­sue has been mis­han­dled by politi­cians who just for­got about it,” says Charles Wilson, pres­i­dent and managing di­rec­tor of Ex­clu­sive Health­care and pres­i­dent of the man­age­ment board of the In­sti­tut Hospi­tal­ier Franco-Bri­tan­nique.

Younger clients and those with a clean bill of health are un­likely to have prob­lems find­ing an in­sur­ance pol­icy to cover med­i­cal ex­penses cur­rently pro­vided un­der the French national sys­tem, says Wilson, who has him­self been res­i­dent in France for many years. How­ever, for many, the days of quick, no-ques­tions-asked ac­cep­tance by an in­surer are num­bered.

“For those over 65, an in­surer will have you, af­ter a med­i­cal ex­am­i­na­tion, at a price per ex­ist­ing con­di­tion. That price is de­pen­dent on your ag­gre­gated level of health.”

A record of treat­ment such as hip re­place­ment surgery is un­likely to be an is­sue for an in­surer, but Wilson warns that any­one who has had any form of can­cer will pay an extra load­ing, adding greatly to the cost of their pol­icy, or may even be re­fused cover. From the in­surer’s point of view, this is un­der­stand­able.

“Hos­pi­tal­i­sa­tion can be dis­as­trously ex­pen­sive. If you have a se­ri­ous bout of can­cer you can run up bills of €150,000 or more,” Wilson points out.

That said, the cost of a visit to a French doc­tor av­er­ages only €23. Com­mon pre­scrip­tion reme­dies are usu­ally rel­a­tively af­ford­able, and Bri­tons may find it makes sense to buy a cheaper pol­icy that ex­cludes mi­nor treat­ment but pro­vides cover for hos­pi­tal­i­sa­tion and more ma­jor surgery. Such poli­cies al­ready ex­ist.

“We have de­signed a pol­icy for peo­ple who just need cover for pos­si­ble hospi­tal bills,” Wilson says.

WILL THE EHIC STAY OR GO?

While full-time res­i­dents should al­ready be con­sid­er­ing their health­care op­tions, sec­ond-home own­ers who for now en­joy ac­cess to the French sys­tem while in France us­ing the Euro­pean Health In­sur­ance Card (EHIC) will also need to make sure they have pri­vate med­i­cal cover post-Brexit. With the end of re­cip­ro­cal health­care, in­sur­ers will no longer be able to move Bri­tish pa­tients into French state hos­pi­tals at no cost to them­selves, but will have to pay for hos­pi­tal­i­sa­tion and treat­ment. Inevitably, that will mean higher pre­mi­ums and higher pol­icy ex­cesses, say in­sur­ers.

Kate Huet, managing di­rec­tor of In­ter­na­tional Travel and Health­care, a Bri­tish in­sur­ance provider, spec­u­lates that some EU coun­tries could opt to hon­our cards with longer va­lid­ity un­til their ex­piry date. In that case, she warns, “there could be a rush to ac­quire a card” in the months be­fore Bri­tain’s fi­nal de­par­ture from the EU in 2019 – so re­new­ing your five-year EHIC next year could be a smart move.

“With­out the EHIC, I’m wor­ried that some peo­ple could have large med­i­cal bills they’ll strug­gle to pay, un­less the UK makes an­other pro­vi­sion,” says Philip Wright, managing di­rec­tor of the Euro­pean di­vi­sion of In­ter­na­tional Med­i­cal Group, a world­wide pri­vate health­care in­surer.

So far, there’s no in­di­ca­tion that the UK govern­ment is likely to do that, or has even be­gun to think about it.

In March, days be­fore the de­par­ture process was trig­gered, Brexit min­is­ter David Davis breezily ad­mit­ted that he hadn’t thought about the prob­lem. Ques­tioned by the House of Com­mons Brexit Se­lect Com­mit­tee, Davis said it was “prob­a­bly right” that Bri­tons would no longer be able to use the EHIC af­ter with­drawal from the EU.

Some UK sources say there is no need for Bri­tons to lose the EHIC. Alan War­dle, public af­fairs di­rec­tor of the travel as­so­ci­a­tion, Abta, says: “Abta dis­agrees with David Davis that UK cit­i­zens will have to lose the EHIC health treat­ment card. Brexit shouldn’t have to mean that we lose re­cip­ro­cal med­i­cal care rights with other Euro­pean coun­tries: the EHIC card is cur­rently valid in Switzer­land, which is not a mem­ber of the EU.”

But Davis’s com­ments show that pre­serv­ing the EHIC will not be a pri­or­ity as Brexit ne­go­ti­a­tions get un­der way. At best, some­thing sim­i­lar might be re­vived by a bi­lat­eral agree­ment be­tween Bri­tain and France at some fu­ture date.

While around 12.1 mil­lion Bri­tons visit France each year, only around 4.61 mil­lion French tourists head the other way, so ar­guably we need the EHIC more than they do, weak­en­ing Bri­tain’s ne­go­ti­at­ing po­si­tion on re­cip­ro­cal health­care ar­range­ments for visi­tors.

Charles Wilson, per­haps tongue-incheek, sug­gests that, in ex­tremis, Brits liv­ing in France could still make a dash to the UK for emer­gency treat­ment un­der the National Health Ser­vice and worry about pay­ing later.

“If you walk into a hospi­tal any­where in Bri­tain they are not go­ing to turn you away or de­mand cash pay­ment be­fore an op­er­a­tion,” he says, some­what op­ti­misti­cally.

That would make them, in ef­fect, ‘health tourists’ in their for­mer home­land. And in Jan­uary, the Home Of­fice launched a pilot scheme to re­strict free treat­ment of pa­tients who can­not prove they are res­i­dent in Bri­tain. Ac­cord­ing to a spokesper­son for the NHS im­prove­ment scheme, spe­cial­ist ‘cost re­cov­ery sup­port teams’ will ad­vise on iden­ti­fy­ing and re­cov­er­ing costs from non-el­i­gi­ble pa­tients, who would pre­sum­ably in­clude full-time Bri­tish ex­pats.

Two years ago, the UK De­part­ment of Health warned that Bri­tish ex­pats liv­ing out­side the EEA (which in­cludes the EU) who re­turned to the UK to be treated by the NHS would be clob­bered with bills of 150% of the cost of treat­ment un­less they had ad­e­quate med­i­cal in­sur­ance.

Robin Gauldie is a free­lance travel and busi­ness jour­nal­ist and a reg­u­lar con­trib­u­tor to In­ter­na­tional Travel & Health In­sur­ance Jour­nal and In­ter­na­tional Hos­pi­tals & Med­i­cal Tourism. When not trav­el­ling, he di­vides his time be­tween a vil­lage house in Aude in Oc­c­i­tanie and a home in Ed­in­burgh.

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