Debate on reform of sickness insurance

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In May 2001, several trade unions and doctors' organisations presented a proposal for the reform of France's jointly-run sickness insurance scheme, which runs contrary to the priorities followed by both the CNAMTS sickness insurance fund and successive governments since 1995. This proposal has restarted the arguments over the principles and priorities of the French social security system.

On 4 May 2001, a group of four trade union confederations - CFE-CGC, CFTC, CGT and CGT-FO- and three medical practitioners' associations, calling themselves "G7", presented an "ambitious proposal for reforming the sickness insurance scheme". Under this proposal, the current annual parliamentary vote on a "national sickness insurance spending target" (Objectif national des dépenses d'assurance maladie, ONDAM) would be replaced by a "flexible mult-year target reflecting the populations' health requirements" (Objectif pluriannuel révisable en fonction des besoins sanitaires de la population). If spending targets were exceeded, this would not be accompanied by punitive measures or obligations on doctors and other health professionals to repay some of the excess fees they had received to the social security system.

Contrary to the publicly-expressed willingness of the National Salaried Employee Sickness Insurance Fund (Caisse nationale d'assurance-maladie des travailleurs salariés, CNAMTS), the social partner-run body which administers the sickness insurance scheme, to sign separate agreements with general practitioners and specialists (FR9904171F), the G7 proposal provides for a single agreement for all doctors, the progressive winding down of the "unrestricted fees sector" (in which doctors charge much higher rates that are mainly borne by the patients), and the establishment of a policy for reducing inequalities between patients in different regions of France. However, the proposal also raises the idea of increasing the price of consultations with general practitioners, from EUR 17.53 to around EUR 30.50. The G7 plan also suggests that patients' costs should be refunded at a higher rate by the insurance scheme (up from 70% to 90%).

Criticisms of the proposal

Criticisms of this proposal have referred to several issues. First, it seems to some to be very incomplete: a number of important issues such as medication, private hospitalisation and other health sector professions are not dealt with. The authors responded to this point in advance, by indicating that, on all these subjects, discussions with the parties involved must be started. Second, any implementation of the plan could not be anything other than slow, as it is proposed that it will apply only to doctors entering the profession in the future. Lastly, there is no assessment of the extra costs involved (although the CNAMTS has estimated them to be around EUR 4.5 billion).

The G7 organisations have reacted in three ways to these criticisms. They argue that their proposal is first and foremost an attempt at designing a general policy orientation for sickness insurance, rather than a finished document putting forward all the relevant financial data. It is not so much a question of extra expenses, but of investment, the organisations state. Thus not only the immediate expenditure but also the positive long-term impact should be assessed. Part of the costs should be compensated for in the long term by a reduction in the number of medical consultations, prescriptions and surgical operations.

Difficult context

The policy of containing health expenditure, established in autumn 1995 by the "Juppé plan" on social security (named after the Prime Minister of the time) and since pursued by successive governments (FR9712184F), has revealed its limits. Since 1998, no target set by parliament has been kept to. Over the 1997/2000 period, while the rise in costs should have been 7.6%, it was actually 11.6% (FR0011104F).

Additionally, the "policy of negotiated agreements" between doctors and sickness funds is experiencing serious problems. The French Federation of General Practitioners (Fédération Française des Médecins Généralistes, MG-France) trade union, representing general practitioners, was the sole signatory to the most recent such medical agreement, which was later invalidated by the courts. In 1994, MG-France received 55% of general practitioners' votes in elections of doctors' representatives, but at the most recent elections in 2000, this support fell to 31% (FR0007180F). By contrast, the doctors' unions that signed the May 2001 G7 proposal are all against current CNAMTS policy and represent more than two-thirds of all general practitioners and over 90% of specialists.

Currently, serious tensions are evident in the relationship between the CNAMTS and the government. The former Minister of Employment, Martine Aubry, had reduced the CNAMTS' field of jurisdiction to managing a "delegated envelope of expenditure" (covering fees and prescriptions excluding medication), accounting for only 20% of total sickness insurance expenditure. After a year of experience with this system, the CNAMTS feels that it does not have the power to manage this budget, and turned down the idea of a "delegated envelope" for 2001 when asked by the government for its opinion about it.

The MEDEF employers' confederation had planned, as part of its current "industrial relations overhaul" project (FR0002143F), to discuss a revision of the sickness insurance scheme with the trade unions. Given the state's particularly powerful role in this field in France (in terms of forming public health policy and managing staff in public hospitals), MEDEF had not called for "negotiations" on sickness insurance, but for "contributions to future thinking". However, the opening of discussion on this issue, originally planned for March 2001, has been "postponed" (FR0102134F).

The final element in the current context that may explain the complex strategies of the protagonists is that there must be elections and new appointments to the administrative boards of the various social security funds jointly run by the social partners before the end of summer 2001. Thereafter, a "managing majority" will have to emerge within each fund in order for a management policy to be implemented.

Strategies

Trade unions that have taken very different positions in the negotiations under the MEDEF "industrial relations overhaul" project have come together in G7. CFE-CGC and CFTC signed the December 2000 intersectoral agreement on occupational health (FR0101116N), CFTC signed the agreements on unemployment insurance (FR0101114F) and supplementary pensions (FR0103136N), while CGT and CGT-FO signed none of these accords. As regards sickness insurance, CFE-CGC and CFTC are still members of the "managing majority" running the CNAMTS - this "managing majority" includes the largest mutual health insurance body, the the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française, FNMF), alongside employers' associations and CFDT, CFE-CGC, and CFTC. Finally, alongside the unions, G7 includes self-employed doctors associations, some of which have occasionally been very critical of the social security system, challenging in particular the increased state involvement in the health sector, of which the social security system is said to have been an accomplice. The agreement creating "G7" is thus an unprecedented move.

The CNAMTS (chaired by CFDT) has not been silent, and has made its own proposals, including: linking the parliamentary vote on expenditure targets to explicit public health goals set with a long-term perspective; the establishment of consistent monitoring tools for local practitioners and hospitals; the redefinition of the roles of the state and the CNAMTS, affording a wider degree of autonomy to the latter to negotiate with health sector professionals; and the conclusion of a "basic" agreement between the CNAMTS and all health-sector professionals (including doctors), around which the agreements specific to each profession would be articulated. Furthermore, CFDT, the National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA) , FNMF and MG France, have, with some other professional associations, formed a "group of 14" to design a "healthcare system with shared responsibilities".

Commentary

In this debate, the contradictions within the various "groups" or coalitions are such that the pacts made between them may change very quickly. When it rallied behind the "Juppé plan" on social security reform in 1995, MEDEF made it clear to self-employed doctors that the lowering of social security contributions was its priority. Those doctors then found themselves relatively marginalised, and they looked for a means of counter-attack. Certain doctors' organisations, some of which are now members of G7, then indicated their interest in plans for private sickness insurance schemes mooted by private insurance companies. They have now reached an agreement with several trade unions in which they appear to have traded a rise in expenditure (hence the reference in the proposal to "needs", and an increase in doctors' charges) for a greater degree of collective cost-sharing, thus leading to a rise in expenditure financed out of the state's budget in the field of healthcare. Is the split between employers and self-employed doctors now irrevocable? (Pierre Volovitch, IRES)