Universal Health Insurance system to be created

Source: Health insurance accounting records.

It is in this context, and as part of its overall battle against social exclusion, that the government has tabled legislation which should pave the way for the setting up of a Universal Health Insurance (Couverture Maladie Universelle, CMU) by 1 January 2000. The aim is to provide basic health cover to people who currently have none and to make complementary health cover available to the entire population.

The Boulard report

In June 1998, the Prime Minister, Lionel Jospin, asked a parliamentary colleague, Jean-Claude Boulard to report on the issue of health insurance coverage. The Boulard report, submitted at the end of August 1998, proposed that basic cover, under the general health insurance scheme, be immediately and automatically made available to those who require it, providing they are resident in France. It would be the responsibility of the general scheme to check whether the person was covered by another scheme. The report put forward three possible models - which could possibly be combined - for the provision of complementary top-up cover:

1. "decentralised cover", which would make general councils - local authorities that handle social issues - in each départementresponsible for the implementation of the CMU (France is divided into 99 départements). However, this is a non-starter, since départementaladministrations do not want health insurance within their jurisdiction;

2. "centralised cover," whereby the general scheme would also provide complementary cover. This would have the advantage of creating a "one-stop shop" basic and supplementary health cover service. However, it would have the disadvantage of possibly leading to the creation of a complementary scheme specifically for very poor people; or

3. "a partnership model," under which all complementary health insurers (mutual funds, welfare funds and private insurers) would fund a new "personalised health assistance" (Aide Personnalisée Santé, APS) scheme, proportionally to their share of the insurance market. APS would ensure that sufficient funds were available to provide top-up insurance and those qualifying for it would be able to choose either a mutual fund, insurance company or welfare fund. APS recipients would pay a reduced contribution of FRF 30 per month. The insurers providing complementary coverage would pay contributions into an "equalisation" fund from which would be deducted FRF 1,500 per APS recipient covered.

The amount of money people spent on healthcare rose rapidly in France in 1998. Some mutual insurers were concerned that this increase would lead to an uncontrollable rise in the proportion of medical costs borne by them. In addition to this hesitation on the part of mutual insurers, associations that provide assistance to very poor people were also sceptical. They rejected the idea of a contribution of FRF 30 and called for a one-stop, high-quality cover approach.

Draft legislation

In early January 1999, the Minister for Employment and Solidarity, Martine Aubry, submitted proposals for legislation:

• those eligible for the CMU will be those with earnings below the level of the minimum old-age pension of FRF 3,500 per month (for a person living alone, rising to FRF 5,250 for two people, FRF 6,300 for a couple with a child and FRF 7,700 for a couple with two children);

• the scheme will be based on a combination of the "centralised" and "partnership" models. Recipients will deal with the general scheme, which will act as a one-stop service by either providing complementary cover or by guiding recipients towards the complementary insurer of their choice. As a result, complementary insurers will not be the sole cover providers for those who come under the CMU scheme. Contributions made to the scheme by complementary insurers have been set at 1.75% of their turnover; and

• CMU recipients will not make contributions. All costs including dental and eye care will be borne fully by the CMU scheme. Those eligible for the scheme will not be required to pay cash advances on medical fees.

Those organisations which form the "managing majority" on the board of the jointly-run National Health Insurance Fund (Caisse nationale d'assurance maladie, CNAM/general scheme), the CFDT trade union confederation, the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française- FNMF) and the MEDEF employers' confederation (formerly CNPF) reacted negatively to the Minister's decisions. They are concerned that the setting up of a complementary cover scheme by the general scheme's local funds will blur the dividing line between basic and complementary cover. They have therefore asked the government to review the wording of the legislation so as to make it clear that CMU recipients are covered by the complementary insurers and that general scheme local funds will intervene only in the case of a shortfall among these complementary insurers. Two other trade union confederations, CGT and CGT-FO, although not totally satisfied with the government's proposals, support greater participation by general scheme funds.

The legislation will be debated in parliament, starting in April 1999.

Commentary

An unchecked rise in spending on healthcare has resulted in a deterioration in the relationship between the government and health professionals. This had a direct effect on discussions on the CMU and accounts for the absence of health professionals from a discussion which greatly affected them, in particular because it would alter the way the medical bills of 6 million people are met.

A more fundamental question is whether a move towards "universalisation" of benefits without improving basic cover can really be envisaged. Can "universality" be achieved using complementary health insurance, which historically has been specific, employment-based and even individual?

The reaction by the "managing majority" in CNAM to the government's proposals is part of a long-running debate between the social partners, health insurance managers and the government. Should the government or the social partners run health insurance? (Pierre Volovitch, IRES)