Assistance for the elderly and disabled people under debate

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The issue of assistance for elderly people and people with disabilities has been topical in France in 2004. With a 'personalised independence allowance' scheme introduced in 2002 seen as inadequate, the government pushed through parliament a vote to create a National Independent-living Support Fund in June 2004. Neither the Fund's role nor the financing arrangements were specified at the time of the vote and concerns were raised among the social partners about losing control over some some funds they currently administer. Clarification on some of the ways the Fund is to function was provided in the autumn, but the decisions taken are far from being definitive.

Legislation creating a 'personalised independence allowance' (Allocation Personnalisée d'Autonomie, APA), which provides assistance for elderly people and people with disabilities came into force on 1 January 2002 (FR0303104N). The APA is a benefit that is jointly funded by the state and the general councils (Conseils généraux - the elected assemblies at département level). It varies according to the level of disability of the person concerned. It is paid to the facility providing assistance to the dependent person or to the people themselves if they are able to live in their own home. The benefit pays the wages of one or more carers assisting the disabled person with his or her daily life. Means-tested user fees are covered by beneficiaries. After an initial implementation period, more than 820,000 people were in receipt of the APA as of the first quarter of 2004. The allowance is available only to the very seriously dependent. Those with lesser degrees of dependency are covered by the social assistance programmes of the old-age insurance funds.

National Independent-Living Support Fund

The death of 15,000 elderly people during a heatwave in the summer of 2003 indicated that the needs of the elderly and people with disabilities were not being adequately met. The government’s reaction to this was to pass legislation creating the a National Independent-Living Support Fund (Caisse nationale de solidarité pour l’autonomie, CNSA) on 30 June 2004 (FR0403106F). However, issues of defining the role the Fund is to play and how it is to work have yet to be addressed, such as what money will pass through the Fund and who will be responsible for administering it.

The two following areas were clarified when the CNSA was created :

• proceeds from a 0.3% tax on earned income as well as a 0.3% tax on financial investment income and a 2% tax on income from property, the impact of which is offset for companies by the elimination of one day’s public holiday for employees, are to be allocated to the Fund; and

• the CNSA is designed to ensure a balance in funding between the various départements in order to ensure that major disparities do not get any worse.

However, details on other issues have been sketchy. A report on the role of the CNSA and the way it is to work compiled by two senior civil servants, Raoul Briet and Michel Jamet, was submitted to the government in autumn 2004. The report advocates the idea that policy on assistance for the elderly and the disabled should essentially be defined and administered by départements themselves. In the view of the authors, whereas the welfare system 'provides one-size-fits-all benefits, the required benefits have to be tailored to the specific needs of each individual'. Consequently, the départements, which are already running the APA, are the local bodies best able to administer resources channeled through the CNSA. Under the plan, old people’s homes would become the responsibility of départements, which would enter into framework agreements with them. To put the proposals into context, there have recently been two important developments in related areas. First, the running of the 'minimum integration income' (Revenu Minimum d’Insertion, RMI) benefit, now known as the 'minimum employment income' (Revenu Minimum d’Activité, RMA), has been devolved to départements (FR0401103N). Second, there are plans afoot to transfer the administration of the 'allowance for adults with disabilities' (Allocation pour Adultes Handicapés, AAH) to this level as well.

Reactions

The Briet-Jamet report’s proposal has hit two obstacles.

• In exchange for taking over responsibility for elderly and disabled people, départements, and thus local elected politicians, would gain control over money from health insurance funds intended to defray medical expenses covered by the benefit. In early 2003, a health insurance fund specifically for elderly people had been planned. The dramatic events resulting from the heatwave during the summer of 2003 derailed this initiative. Has the Briet-Jamet report put it back on track? The National Federation of Private Health and Social Organisations (Union nationale interfédérale des oeuvres et organismes privés sanitaires et sociaux, UNIOPSS), the largest umbrella group of associations providing assistance to the dependent elderly as well as people with disabilities, has expressed concern over the 'planned exclusion of the elderly and disabled resident in homes and social health centres from the orbit of the health insurance system'. The social partners, which administer the social security funds, have expressed their hostililty to any initiatives 'curbing their powers' in this area. During the parliamentary debate on the role and operation of the CNSA, amendments were tabled reasserting the unity of the health insurance system. The government had its majority vote down these amendments but the Minister of Health was careful to emphasise to the National Assembly that 'any idea of removing care for the elderly and disabled from the jurisdiction of the health insurance fund was out of the question'.

• The départements, the majority of which are believe that the devolution of jurisdictions proposed by the government has not been accompanied by an equivalent transfer of financial resources, have stated that they do not wish to take on the new responsibilities in the areas of health and social services.

Latest clarification

The rules that are to govern the CNSA were not passed as a specific piece of legislation but as part of a law relating to rights for people with disabilities.

It is now known that the CNSA will be a state-run entity under the auspices of the Ministry of Social Affairs. The regional health agencies set up by another piece of legislation on the overhaul of health insurance (FR0406105F) are to develop a multi-year, cross-départemental plan on assistance for the elderly and disabled, dealing more specifically with the distribution of assistance capacity. The CNSA, which is to be funded from the abovementioned 0.3% tax on earned income and part of the funding set aside for the APA, as well as general taxation revenue, will distribute the overall funding 'envelope' between the regions in such a way as to alleviate disparities between them. There will be two equal funding envelopes: one for the elderly and one for people with disabilities. By 2006, the CNSA should have available funding to the tune of EUR 850 million per annum for each of the two.

In order to implement this policy, the CNSA will enter into contractual arrangements with the state and social security bodies. The Fund board is to be made up of representatives from the state and the general Councils, representatives from disabled and elderly persons’ associations, social partner administrators of social security funds and other 'qualified persons'.

Commentary

The proposed structure of assistance for elderly people and people with disabilities is not a simple one. Critics of the new situation that it creates have pointed out that the government, which wants to give sole responsibility for social organisation and social health plans to the individual départemental general councils, plans to organise the distribution of CNSA resources on a cross-départmental- and therefore regional - programme basis. It might be thought that these partly improvised institutional arrangements will need to change fairly quickly, particularly since there is an agreement-in-principle to eliminate the age limit separating disability (younger than 60) and old-age dependency (older than 60) (FR0406106F). The problem is that assistance for these two groups is currently provided by a multitude of funding arrangements and bodies that will take a long time to harmonise. The disabled persons’ legislation that has recently been voted into law provides for the elimination of this age threshold by 2010. One fundamental issue remains outstanding. The attempt to transfer the administration of funds currently part of the welfare system, and therefore under the control of the social partners, to local authorities has foundered. However, the multitude of actors and funding arrangements involved in assisting people with disabilities is such that the issue is sure to resurface in the near future. (Pierre Volovitch, IRES)