Strategic plan for sickness insurance
In March 1999, the joint employer-trade union administrative board of France's National Sickness Insurance Fund (CNAM) approved a "strategic plan" whose aim is to cut sickness insurance spending by FRF 62 billion per year from 2003 onwards. The implementation of this strategic plan, which will soon be the subject of wide-ranging consultation, is supposed to have two consequences: a fundamental reorganisation of the way the health system works; and, more generally, the redefinition of the roles of the state and the social partners in the management of social security in France. Beyond the health system, the future of the French model of jointly managed funds is thus also partially at stake.
On 30 March 1999, a "strategic plan" was presented to the administrative board of the National Sickness Insurance Fund (Caisse Nationale d'Assurance Maladie, CNAM) by its director, Gilles Johanet. CNAM is one of the three national fundholding organisations for France's general social insurance schemes, along with CNAV (old-age pensions) and CNAF (child benefits). This plan was approved by the majority of the CNAM board's members - representing the MEDEF and CGPME employers' organisations, the CFDT, CFTC, CFE-CGC trade union confederations and the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française, FNMF) - despite the opposition of the CGT and CGT-FO union confederations. The plan will now be discussed in consultation with the authorities, associations representing health service professionals, the other sickness insurance funds (for farmers and the professions) and all the protagonists concerned. In late May or early June, the plan, which may have been altered by then, will again be submitted to the board. Its objective is to enable FRF 9 billion worth of savings to be made from the year 2000 and, thanks to an acceleration in the rate of savings, to save FRF 62 billion per year from 2003 onwards. With an annual FRF 600 billion currently being spent, this is an ambitious objective. To achieve it, the plan seeks simultaneously to:
- change the sickness insurance's status from a "reckless spender" to a "wise purchaser capable of making choices over its spending priorities"; and
- "clarify the responsibilities" of the state, the sickness insurance funds (obligatory and complementary), health service professionals and the people insured under the system, so that power can be shared out on a more "rational" basis.
From reckless spender to wise purchaser
The plan revolves around 22 measures.
- The first six measures concern health service professionals. The principal idea is to review the practice whereby the sickness insurance funds automatically grant contracts to doctors. The CNAM estimates that there are in the region of 20,000 too many self-employed practitioners in the system. The granting of contracts would in future be linked to the quality of the services provided. Doctors should renew their medical certification every seven years, and granting of a contract would be accompanied by financial incentives for those practices complying with the quality objectives set out by the sickness insurance funds. Contracts would be granted in such a way that healthcare professionals would be more evenly spread over the country than is currently the case. The application of all these measures concerned with health service professionals will eventually lead to savings of around FRF 20 billion.
- The next four measures concern the patients. The proportion of costs covered by insurance would rise for those following set healthcare procedures.
- Three other important measures are contained in the third part of the plan: total reorganisation of the dental care system (making it completely free for young people, increasing prices for repairs, and revising the prices of false teeth); basing the amount of costs reimbursed to the patient on the prices of generic medicines (savings of FRF 8.5 billion); and FRF 30 billion saved thanks to the introduction of parity in the ways in which public hospitals and private clinics are funded, on the basis of variable pricing according to the condition treated.
The reactions of health service professionals to the announcement of the plan have been very negative. The Union of French Doctors (Confédération Syndicale des Médecins de France, CSMF), the majority union among self-employed doctors, which has been opposed to the various attempts to reform the system since 1995, deemed the plan "inadmissible". Médecine Générale France (MG France), a union for general practitioners, which was the only medical union to have signed a convention with the sickness insurance fund, labelled it "unacceptable". Finally, the French Hospital Federation (Fédération Hospitalière de France) declared that a FRF 30 billion saving on hospital spending would mean the loss of between 100,000 and 150,000 jobs.
A more rational distribution of power
In the healthcare field, the theoretical distribution of power between the state and the sickness insurance funds is complex. The reality is even more complicated as some of the protagonists (most often the state) frequently encroach on the prerogatives of others. For some time, employers have been raising the issue of the usefulness of their presence on the administrative boards of funds, whose decisions have very little influence on the real development of costs. By contrast, CFDT, which has chaired the CNAM board since 1995 with the goal of demonstrating the capacity of the social partners effectively and efficiently to manage the various aspects of social insurance cover, is seeking to continue for the foreseeable future with the system of "majority management" of the fund, in which it is involved with MEDEF and others. The strategic plan thus also functions as a way of strengthening the role of the social partners in the management of the health system, and so provides arguments for those within MEDEF who are pleading for employers to retain a voice on the boards of the sickness insurance funds.
- More than three-quarters of spending on health goes into the income of healthcare professionals. The objective of making cuts of FRF 60 billion out of an overall figure of FRF 600 billion will reduce the income of these workers by 10% in four years. The scale of this goal and the proximity of its deadlines can only cause industrial tensions to run high.
- On many points, such as the selection of doctors to be granted contracts and the restructuring of hospitals, the plan has adopted positions not shared by the Ministry responsible for healthcare. During the talks that preceded the drafting of the bill on the implementation of "universal health insurance" (Couverture Maladie Universelle, CMU) in early 1999 (FR9902153F), a conflict between the Ministry and complementary insurers had already developed, in the front line of which were the private insurance companies. At that time, the CNAM board took a stance in favour of the complementary insurers, signing a protocol agreement, which appears as an appendix to the strategic plan.
- The increasing strength within MEDEF structures of private insurance companies, which have an interest in the future of the health insurance market, has strengthened the hand of supporters of a withdrawal from the board of CNAM. In employers' circles, it is being said that if the plan is not implemented, MEDEF could well withdraw from the board of the CNAM. This move would weaken the whole edifice of French jointly-managed social insurance funds. (Pierre Volovitch, IRES).