Social partners adopt sickness insurance funding plan

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In July 1999, the joint employer-trade union administrative board of France's National Sickness Insurance Fund (CNAM) approved, by a large majority, a strategic reform plan. This package of measures is designed to reduce spending and improve the quality of healthcare. CNAM hopes that the government will give legislative effect to the plan.

In March 1999, the joint administrative board of the National Sickness Insurance Fund (Caisse nationale d'assurance maladie, CNAM) approved a draft strategic plan, aimed at cutting sickness insurance spending, and initiated wide-ranging consultations on the proposals (FR9904171F). The strategic plan should fundamentally reorganise the way the French health system works and, more generally, redefine the roles of the state and the social partners in the management of social security in France.

On 5 July 1999, the CNAM chair, Jean-Marie Spaeth of the CFDT trade union confederation, and deputy chair, Georges Jollès of the MEDEF employers' organisation, presented the results of the reflection on the strategic plan. Mr Spaeth announced that while the plan had initially focused solely on employees and their dependants, it had now been altered to include all those individuals covered by social security. He added that "in light of the fact that all the heads of the various sickness insurance schemes had been consulted, they could safely claim to be the legitimate representatives of all social security users". The revised plan is designed, like the original version, to deliver savings of FRF 62 billion per year in the long term. The health insurance fund is set to remain in deficit this year to the tune of FRF 12.3 billion.

The CNAM administrative board approved the strategic plan by a large majority on 12 July 1999.

Changes to the plan

The new version of the plan, drawn up following discussions conducted by CNAM officials, does not focus solely on figures and potential savings. It also aims to lay the groundwork for "comprehensive re-engineering of the healthcare system," focusing on both family medicine and hospitals. Mr Spaeth explained that the limitations of the 40-year-old sickness insurance scheme had become apparent, and that "renewed emphasis must be placed on the user." In all, the three-month consultation process resulted in 15 new measures designed to lay the groundwork for "a quality-oriented approach, in addition to the 22 initial proposals." Some of these new proposals further develop existing ideas. However, some are brand new, in particular:

  • a shift towards covering the cost of "genuinely useful medical treatments";
  • "making users more responsible" by adapting the reimbursement of drugs and treatment expenditure to reward more "careful" behaviour;
  • setting up regular skills testing for doctors (licences would be renewed every seven years);
  • drawing up agreements with doctors (ie authorising them to dispense care and drugs covered by social security) on the basis of regional and local community requirements; and
  • saving FRF 32 billion on hospital budgets (out of the total potential savings of FRF 62 billion).

Reactions

The final measure on the above list has raised hackles, even within CNAM's "managing majority", made up of the CFDT, CFE-CGC and CFTC trade union confederations, the MEDEF employers' organisations and the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française, FNMF). CFTC has made plain its misgivings on this matter.

The CGT-FO union confederation voted "against the plan as a whole" but "it would have undoubtedly signed up to part of it, if the CNAM management had agreed to a vote on a measure-by-measure basis." CGT-FO is "in favour of using regular doctor skill testing as a means of upgrading the quality of care ... and of distributing doctors more effectively on a needs-oriented basis".

CGT also came out against the plan. However, it did say that "certain measures proposed were in line with ideas it had put forward, in particular, in terms of outpatient treatment and the quality of healthcare."

CGT and CGT-FO also condemned the public hospital system shake-up. The general secretary of CGT-FO, Marc Blondel, predicted "relatively hostile reaction" from hospital staff in autumn 1999.

Social and political issues

Senior CNAM officials requested a meeting with the Prime Minister, Lionel Jospin and the Minister for Employment and Solidarity, Martine Aubry so as to "jointly present" the proposals and translate them into concrete measures, to be implemented within the framework of the social security finance bill for 2000. It will be possible to implement the plan only if the government decides to introduce new legislation. In light of the hostile reaction, in particular towards the proposed shake-up of public hospital user fees, this would be a political gamble. Nevertheless, very similar hospital reforms are among proposals drafted by the Socialist group in the National Assembly and published simultaneously with the definitive version of the CNAM strategic plan. The Socialist plan also proposes to tie in drug expenditure reimbursement with the medical service provided. This is in line with CNAM proposals.

Commentary

The CNAM strategic plan has not been approved by the Ministry for Employment and Solidarity, which favours a different approach both on the issue of selective agreements with doctors and hospital reform.

In drawing up its plan, the CNAM managing majority has aimed both to resolve the issue of the funding of healthcare and to assert the independence of its management within the jointly run system which oversees a healthcare budget of more than FRF 600 billion. Since the "Juppé reform" in 1995, it is the National Assembly that has taken the major decisions concerning social security. In the light of the fact that an ever-increasing number of decision-making powers formerly allocated to the social partners have been taken over by the government, MEDEF has long been voicing concern about the appropriateness of the joint management system. MEDEF regularly threatens to pull out of such decision-making bodies, the rationale of which it believes has become questionable. This is exacerbated by the fact that within the organisation itself, advocates of private insurance are interested in the healthcare cover market. The CNAM strategic plan therefore represents an opportunity for CFDT to consolidate the managing majority that it has built up around the precept that the social partners can play a greater role.

The ball is now in the government's court. It will have to make some tough decisions, including those on the management of the healthcare system and the future of the joint management system. MEDEF has declared that its continued participation in jointly-managed decision-making bodies is contingent upon the government, and ultimately the National Assembly, accepting the plan. (Alexandre Bilous, Ires)

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