Council issues report on future of sickness insurance

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In January 2004, a High Council set up by the Prime Minister submitted a report on the future of France's jointly-managed sickness insurance scheme . The report focuses, beyond issues relating to balancing the scheme's budget, on the need to reorganise the healthcare system. Trade unions reacted cautiously to the substance of the report. Commentators believe that the consensus expressed in the report may break down when the exact shape of the government's forthcoming sickness insurance reforms become known.

The Prime Minister set up a High Council for the Future of Sickness Insurance (Haut Conseil pour l’avenir de l’assurance maladie) (FR0311104F) on 13 October 2003 to examine the future perspectives of the public sickness insurance (assurance maladie) system, which is jointly managed by employers' organisations and trade unions. The Council was given a mandate to consider the necessary dividing line between 'the responsibilities of the private citizen and the duties that the principles of the French Republic impose on the state'. It issued a unanimous report on 23 January 2004, which in the view of some commentators failed to fulfil this mandate.

Focus on reform of the healthcare system

The summary of the report opens with the following statement: 'sickness insurance is one of our greatest success stories as a nation. In providing very broad access to care, it has, in addition to its purely health-related function, played a major role in fostering social cohesion. Today, it is one of our most precious national assets.' The report stresses two main lines of action. First, it states that 'the way the system operates and the coordination of the various players needs to be improved … Sickness insurance can no longer restrict itself merely to financing healthcare while leaving provision to look after itself'. Second, it insists on the need to 'make choices'.

The report is divided into three sections. The first deals with the overall balance of the healthcare system and deals mainly with finance. The second, and longest section, looks at improving the healthcare system. The third and least specific section deals with the issue of sickness insurance governance.

• The section on the overall balance of the system identifies three areas for improvement. There should be methodical and determined action targeted, first, on the quality and effectiveness of care and, second, on adjustments to coverage, in the shape of new ways of determining the costs to be met by patients out of their own pockets. Last, action is contemplated in the area of revenue.

• The section in the report dealing with improving the healthcare system puts forward the following seven goals: 'active and critical management' of the range of goods and services covered by the sickness insurance fund; an 'incentive-based' refund system; more effective use of fee-setting procedures; a healthcare system guided by 'principles of efficiency'; more evenly spread healthcare provision throughout the country; more effective coordination between healthcare professionals so as to provide better patient service (in particular by breaking down the division separating hospital and non-hospital care); and the improvement of information provided to patients, who remain 'the poor relation' in the healthcare system.

• The section dealing with sickness insurance governance mainly focuses on the 'tangle of jurisdictions' that the High Council sees as one of the reasons for the system’s finances having drifted out of control.

Reaction from social partners

In the opinion of the French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT), the High Council’s diagnosis of the situation 'avoids two possible danger areas, ie putting funds in competition with private insurance and putting the sickness insurance fund under state control'. CFDT 'rejects any increase in the universal social contribution (contribution sociale généralisée, CSG) [FR9710170F] until it is satisfied with the reorganisation of the healthcare system'. It added that 'the current joint management system is now outdated and it is time to broaden it to include other stakeholders from civil society'.

Refusing to join what it refers to as the 'so-called consensus' on this issue, the General Confederation of Labour-Force Ouvrière (Confédération générale du travail-Force Ouvrière, CGT-FO), asserted that it 'intends to stick to its own positions and continue to exercise the freedom to defend them … and rejects the consensus-based diagnosis [which could be used] to justify a decision presented as inevitable'. A few days later, the new general secretary of CGT-FO reasserted this position, stating that 'the High Council’s report is merely a description of the facts and not a shared diagnosis of the situation'. He went on to say that his union confederation 'does not feel bound by these finding … Any attempt by the government at partial privatisation of sickness insurance, whether by reducing the role of the compulsory scheme or further increasing the number of medicines no longer covered by it would be unacceptable. It would in fact it would be the opposite of a reform, and we would fight it tooth and nail.'

In the view of the General Confederation of Labour (Confédération générale du travail, CGT), the report, while not perfect, 'seems well balanced'. CGT believes that 'it will be very difficult for the government to go off at a tangent and focus solely on massive cuts in coverage, for example, or pass over the funding problem in silence'. CGT is critical of the report's deficit analysis and states that 'welfare funding is not principally a technical issue but rather one that is related to the way society chooses to organise and to the responsibilities incumbent on the various stakeholders, especially the corporate sector'. The union confederation also claims that the High Council report 'fails to make a real break with the logic of the current hospital reforms' and 'skirts around the issue of the conditions required to create genuine democracy in social matters'.

The French Christian Workers’ Confederation (Confédération française des travailleurs chrétiens, CFTC), is more up-beat, pointing out the High Council’s assertion that health spending will continue to increase. This union is looking forward to 'genuine negotiations, in sharp contrast to the procedure for pension reform' (FR0309103F).

The General Confederation of Professional and Managerial Staff-French Confederation of Professional and Managerial Staff (Confédération française de l'encadrement-Confédération générale des cadres, CFE-CGC), focussed on 'the need to preserve the structure of the coverage system, without introducing variable refunds according to income'.

In the opinion of the National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA), 'the report can provide a valuable starting point for debate on this crucial issue'. UNSA states that 'it will not be satisfied if only budgetary reform is undertaken and will work to ensure that a reorganisation of care provision is an integral part of the overhaul initiative'.

The Movement of French Enterprises (Mouvement des entreprises de France, MEDEF), having maintained that it could 'not agree to any action on revenue', publicly declared that it would not reconsider its earlier decision to pull out of the administration of the sickness insurance fund (FR0107167N). It appears that the main employers' organisation is prepared only to sit on a sort of 'supervisory board'. For MEDEF, reform of sickness insurance must cover at least the following three areas. First, 'continuity between hospital and non-hospital care must be ensured'. Second, overall spending must be brought under control, with MEDEF advocating immediate savings of 'between EUR 10 billion and EUR 15 billion'. Lastly, MEDEF wants to see an initiative designed to make 'patients more responsible' by making them liable for a share, however small, of their healthcare costs.

Commentary

The High Council's report, designed as a non-partisan fact-finding exercise, is not binding on the government. The latter's proposed schedule follows the recently completed fact-finding phase with a period of consultation. In early April 2004, after the government has tabled a 'policy document', a period of negotiations will be launched. They are to conclude in June 2004 with the tabling of a bill.

That the High Council was able to agree on its findings within the short time allowed was not always a foregone conclusion. Most observers have pointed to the relatively unexpected nature of this outcome. In fact, the members adopted the report without a vote. Quite plainly, the report is a product of compromise and the wording of several sections in it is sufficiently vague to allow any number of interpretations. However, the fact remains that the report finds the answer to the funding issue it was mainly commissioned to tackle in the reorganisation of the healthcare system, so making this reorganisation a precondition of any discussion on balancing the sickness fund's finances. (Pierre Volovitch, IRES)