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In June 2004, the French government announced that consultations with the social partners over proposals for a reform of the jointly-managed sickness insurance scheme had been completed. The proposals will now be submitted to parliament in July. The trade unions are all critical of the government's plans, believing that households will bear a disproportionate burden, and a protest demonstration was held on 5 June. However, unity among the unions has broken down, with differing views over the role of sickness insurance.
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 postponed publication of its reform plans on several occasions (FR0402107F), before meetings with the social partners on the issue began in mid-April 2004. The Minister of Health then outlined the thrust of the initiative on 17 May (FR0405104F). This announcement gave only part of the picture, with the Minister making a series of further announcements at later dates. He made it clear that the initiative was not yet cast in stone and that amendments could be made when parliament begins debate on the issue, due on 5 July.
On 7 June, the Minister of Health declared that the period of consultation with the social partners on the sickness insurance reform initiative was at an end. The process had been particularly swift and unsettled.
Government initiative
The announcements made by the government on 17 May dealt with three issues:
- on sickness insurance funding, a series of 13 initiatives are designed to restore budgetary balance by 2007. This is to be achieved by making EUR 10 billion in savings and generating EUR 5 billion in new revenue;
- on the organisation of the healthcare system, only one measure was announced - the creation of computerised medical records; and
- on governance of the system, the Minister confirmed that he intended to set up three national umbrella organisations to cover basic sickness insurance funds, supplementary insurance and healthcare professionals respectively (FR0405104F). Furthermore, the Minister confirmed the creation of a health statistics institute as well as a High Health Authority (Haute Autorité de Santé) with the principal task of assisting in the definition of the range of care to be covered by the sickness insurance system.
Successive announcements were made between 17 May and 7 June 2004 dealing with: the jurisdiction of the managing bodies of the proposed new National Union of Sickness Insurance Funds (Union nationale des caisses d’assurance maladie); the non decision-making, advisory role of the High Health Authority; hospital funding; the retention of local hospitals; multi-year budgets set by parliament; and the terms and conditions for the implementation of specific financial initiatives. The announcement on 7 June made official the Minister’s plans to assist low-income households to purchase supplementary sickness insurance cover.
Reaction and trade union positions
The initiatives announced on 17 May, particularly the financial aspects of them, were criticised by all trade unions. All the unions take the view that households are being asked to dig the deepest to pay for the reforms. This is happening in several ways:
- more revenue is to be generated through the creation of a EUR 1 non-reimbursable component in every medical consultation fee;
- people will be required to pay higher non-reimbursable costs for stays in hospital;
- the amount of 'universal social contribution' (Contribution sociale généralisée, CSG) (FR9710170F) paid by tax-paying pensioners is to be increased;
- the CSG will be levied on a wider range of employees' incomes; and
- savings are to be made by reducing coverage for long-term illness and by more closely monitoring people claiming sickness benefit.
The unions consider that companies are being asked to make only a symbolic contribution to the initiative. The unions have also strongly criticised the fact that the government is not asking healthcare professionals to shoulder any of the burden. Apart from these shared criticisms, the alternative funding proposals put forward by the various unions are very different (FR0405104F).
Even before the 17 May announcements, the General Confederation of Labour (Confédération générale du travail, CGT) had called a demonstration to be held on 5 June. In the wake of the 17 May announcements and in light of their criticisms of the initiative, the various trade unions all decided, at different points, to take part in the demonstration, but each with its own slogans.
The 5 June demonstration, although not a complete failure, only managed to rally a modest number of people. The Minister of Health took advantage of the relatively small turn-out to state that 'French people were not opposed to reforms if they were explained to them properly', and the fragile union alliance broke up.
CGT, which called for a further demonstration to be held on 15 June, clearly rejects the government's proposed initiative. It has spoken out against the government’s perceived 'purely management-reform approach' and sees the initiative to assist low-income households to purchase supplementary cover as a move to cut the coverage provided by the compulsory sickness insurance scheme. It was very critical of a statement by the Minister that fraud was the main cause of the rapid increase in sickness benefit claims. CGT considers that it is rather worsening working conditions that are to blame for this rise.
The General Confederation of Labour-Force Ouvrière (Confédération générale du travail-Force Ouvrière, CGT-FO) said that it did not rule out calling strike action in all sectors of industry. However, this union confederation is currently focusing on lobbying members of parliament. Apart from CGT-FO’s criticism of the proposed funding measures, it is making demands in two areas. It wants the government to specify the way that financial regulation is to work and clearly rules out the possibility of capped budgets leading to cuts in the coverage provided by basic schemes. While CGT-FO agrees that supplementary insurance may play an advisory role, it rejects the idea that these insurers should take part in negotiations between the basic health insurance funds and health are professionals.
In the view of the French Confederation of Managerial and Professional Staff-General Confederation of Managerial and Professional Staff (Confédération française de l’encadrement-Confédération générale des cadres, CFE-CGC), the reform initiative is 'totally inadequate' and fails to 'address the issues raised'.
In the opinion of the National Federation of Independent Unions (Union nationale des syndicats autonomes, UNSA), the reform package 'falls short'. It was disappointed that no announcement had been made on the clarification of the sickness insurance funds' accounts. However, it sees the proposed assistance to purchase supplementary insurance as a positive measure.
The French Democratic Confederation of Labour (Confédération française démocratique du travail, CFDT) wants to build on the government’s plans - as it stands, the initiative is too far from its own demands. The funding proposals are seen by CFDT as unfair, the response to the issue of universal access to supplementary insurance is insufficient and only partial responses have been provided to the matter of the organisation of care. However, the union confederation takes the position that the original initiative can be improved. Together with the National Federation of French Mutual Insurers (Fédération nationale de la mutualité française, FNMF), CFDT called for a day of action on 22 June.
The French Confederation of Christian Workers (Confédération française des travailleurs chrétiens, CFTC), says that it is placing considerable confidence in the parliamentary debate on the proposals, and is calling for universal access to supplementary insurance.
Commentary
The same fault lines that appeared among the trade unions over the controversial Juppé social security reform initiative in 1995 (FR9712184F) have resurfaced in the break-up of the trade union united front over the sickness insurance reform. One of the major points of difference is over the type of relationship that sickness insurance should have with healthcare professionals. At one end of the spectrum, CGT-FO is advocating no - or at the very most, little - involvement by the sickness insurance funds in the activities of healthcare professionals, while at the other end CFDT is calling for them to take a major role. The CGT-FO scenario would see talks between the funds and healthcare professionals dealing solely with fee levels while the situation advocated by the CFDR would see funds and healthcare professionals striking agreements whereby the latter would have to meet commitments in the area of care provision.
Initially, the government’s initiative was believed to be very favourable to general practitioners, who therefore welcomed it. However, if the government decides to ally itself with CFDT and FNMF, its relationship with doctors will become more complicated. (Pierre Volovitch, IRES)