The current page is not translated to the selected language.
Download article in original language : FR0405104FFR.DOC
In May 2004, the French government has still not announced the content of a long awaited and several times postponed reform of the jointly-managed sickness insurance scheme. The only area in which any details have yet emerged is a new system of governance for the scheme. The social partners have taken varying positions on the reform.
In 2002, the government announced that a reform of the public sickness insurance (assurance maladie) system, which is jointly managed by employers' organisations and trade unions, was scheduled for autumn 2003 (FR0306106F). The government has since postponed publication of its reform plans, first until the end of the first quarter of 2004, then until May, and finally until June. Beyond these questions of timing, the actual substance of the initiative itself remains vague. The Government has skirted around questions on how the reform package is to be funded and progress on an overhaul of the organisation of the healthcare system advocated in a recent report (FR0402107F) by the High Council for the Future of Sickness Insurance (Haut Conseil pour l’avenir de l’assurance maladie) (FR0311104F) remains stalled.
The governance of the sickness insurance system is the only area where the government has so far made announcements of any substance. Under the proposed new system, the following three bodies would be created :
These three organisations would be responsible for managing the sickness insurance system. The Union of Sickness Insurance Funds and Supplementary Insurance Union would negotiate agreements linking healthcare professionals to health insurance with the Healthcare Professionals’ Organisation. How each of these three bodies is to work in terms of internal organisation has not been specified. This raises sensitive issues. Thus, while the Movement of French Enterprises (Mouvement des entreprises de France, MEDEF) employers' confederation has demanded that the Union of Sickness Insurance Funds be run by a strong, government-appointed executive body, with the social partners relegated to a supervisory board, the trade unions are demanding seats on a beefed-up executive board, with more authority than the existing health insurance fund boards.
Trade unions are unanimous in demanding that talks be held on all aspects of sickness insurance reform - funding, organisation and governance - and not solely restricted to this last issue. They are also critical of the proposed timetable, which is too tight, in their view, for genuine negotiations.
On the issue of funding, the General Confederation of Labour (Confédération générale du travail, CGT) has come out against any increase in the universal social contribution (Contribution sociale généralisée, CSG), paid as a percentage of income - pay, pensions and 'unearned' income (eg from investments etc) (FR9710170F). However, it is advocating a hike in employers' contributions, in particular by including value added in the calculation of contributions. It is also demanding that there be a requirement for national negotiations to be held over social security contributions. The General Confederation of Labour-Force Ouvrière (Confédération générale du travail-Force Ouvrière, CGT-FO) is demanding an increase in employers' sickness insurance contributions and increased funding from the state, possibly by raising the CSG on unearned income to meet solidarity-related spending needs. The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) is in favour of funding healthcare through the CSG, provided that the overall tax system is reformed at the same time. The French Confederation of Professional and Managerial Staff-General Confederation of Professional and Managerial Staff (Confédération française de l'encadrement-Confédération générale des cadres, CFE-CGC) is calling for the creation of a general social security contribution levied on consumption.
As far as the role supplementary health insurance is to play, CFDT favours an approach whereby compulsory sickness insurance would work in tandem with mutual top-up insurers, particularly in the area of relations with healthcare professionals. Cooperation of this type between compulsory and supplementary insurance should be accompanied by a drive to open supplementary insurance to all. While CGT is not hostile to partnerships between the social security and mutual supplementary bodies, it is against any type of formal joint management. CGT-FO firmly rejects a single management system for both compulsory and supplementary funds. It views any move in this direction, particularly given the presence of commercial insurance companies in the supplementary insurance sector, as a first step in privatising the health insurance system. CFE-CGC is quite willing to discuss cooperation with supplementary bodies but rejects any jointly-run system. The French Confederation of Christian Workers (Confédération française des travailleurs chrétiens, CFTC), has floated the idea that supplementary insurance should become compulsory, based on a model that already exists for pensions. This would significantly alter the status of supplementary insurance.
These differences in opinion are reflected in the positions of the various union confederations on the definition of the care and services covered by the social security system. In the view of CFDT, expenses to be covered must be defined by both compulsory and supplementary schemes together. However, for CGT, what is covered should be defined only by the state. In the opinion of CGT-FO, it is the responsibility of parliament to set the range and level of coverage. Nevertheless, the it remains critical of this way of defining coverage for fear that the state might focus solely on restricting coverage. CFTC is urging that experts in this area should play only an advisory and not a decision-making role.
There is also a wide range of positions on the issue of governance. At one end of the scale is CGT, which is calling for a return to a system of elected members of social security fund boards, in line with the goals laid down for such 'social democracy' in 1945, while at the other end is CFE-CGC, which considers that the system of joint employer-union management of social security funds has outlived its time.
These various positions have logically led to different forms of action by unions. CGT called various demonstrations to defend the sickness insurance system on 6 June 2004. CGT-FO, which contends that workers cannot be expected to take action without knowing what they are taking action over, has stated that it is prepared to issue a strike call if the government’s initiative proves to be unacceptable. CFE-CGC, the National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA), and CFTC say that it is still too early to decide on a definitive position. CFDT has clearly indicated that greater consensus will be required on sickness insurance than was recently the case for pension reform (FR0309103F).
The vagueness of the sickness insurance initiative is all the more significant in light of the fact that major changes are planned for a number of closely-connected areas of the social security system without any clear stipulation of how the various reforms are to interconnect. As a case in point, parliament is currently voting on legislation dealing with coverage for people with disabilities and elderly dependents (FR0403106F). The challenge is to ascertain whether health expenses for the elderly that are currently managed by the sickness insurance funds are to be transferred to local authorities. The trade unions have made it clear at the outset that they reject any transfer of this type, but the structure of the body that will now be responsible for managing these funds has yet to be clearly defined.
Is the continual vagueness of the government’s health insurance initiatives the result of a deliberate attempt to delay unpopular announcements for as long as possible or does it reflect the inability of the government to make sensitive policy decisions? A likely conclusion, which is bad news for the sickness insurance system, is that the latter probably has a lot to do with it. (Pierre Volovitch, IRES)