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In summer 2003, France's Minister of Health announced that a reform of the sickness insurance system is to be presented in the autumn. While an increasing deficit posted by the sickness insurance funds has made this overhaul necessary, industrial relations tensions in the healthcare sector suggest that implementation may be problematic. The details of the reform are as yet unknown, but the major thrust appears to be a reduction in compulsory sickness insurance cover and the creation of specific measures for lower-income people.
The Minister of Health announced in summer 2003 that an overhaul of the sickness insurance system is to be tabled in the autumn. The reform package will deal with: funding; the extent of national sickness insurance coverage; the 'governance' and 'regionalisation' of the sickness insurance funds; 'quality of care'; and value-for-money spending. It is to be implemented in two phases; funding and quality of care are to be tackled in autumn 2003 and governance and other issues in December 2003.
Given that the government has recently adopted a public health bill, which is to be considered by parliament at the beginning of the autumn session, it is clear that the Minister intends to undertake a comprehensive reform of the French healthcare system.
Worsening financial situation and tense industrial relations
The drive to reform the system has undoubtedly been strengthened by the worsening financial position of the sickness insurance funds (which are jointly managed by the social partners). The general scheme, which covers all employees and three-quarters of sickness insurance spending, is in the red. In 2002, healthcare spending rose by 7.2%, whereas the target increase approved by parliament was only 3.8% (FR0112153F). The sickness insurance fund deficit for 2002 stood at EUR 6.1 billion. At a recent meeting, the Social Security Accounts Commission (Commission des comptes de la sécurité sociale) forecast a 5.9% rise in healthcare spending for 2003, while the target increase endorsed by parliament was 5.3% (FR0302112F). The forecast deficit for the sickness insurance scheme in 2003 is EUR 9.7 billion. The worsening situation is due to a slowdown in revenue growth on account of a drop in pay-roll growth - the basis on which social security contributions are calculated - from 3.3% in 2002 to a forecast 2.7% in 2003. It is also the result of spending increases, particularly due to doctors' fee increases implemented in the spring of 2002.
In January 2003, a draft agreement struck by the sickness insurance funds and almost all trade unions representing general practitioners was hailed as evidence of an improving relationship between the funds and healthcare professionals (FR0302110F). However, disagreement over fee-related issues between the funds and healthcare professionals subsequently led to a breakdown in talks. Even more serious still was the fact that département-level doctors' action committees, which are demanding 'free pricing', have urged, with some success, specialists to pull out of agreements - ie to cut all ties with the sickness insurance funds, thus making it impossible for patients to recover their healthcare costs. The general practitioner sector is not the only area experiencing tension. In hospitals, a shortage of staff (both doctors and nurses) needed to implement the 35-hour working week and pressures in emergency services have fuelled persistent industrial relations unrest (FR0302106N).
Possible directions for reform
While the exact shape of the reform package is not yet known, the official reports that have already been published and the stated position of supplementary insurers provide a clue to the main thrust. In particular, the government-commissioned 'Chadelat report' on the 'respective roles of compulsory and supplementary sickness insurance in healthcare expenditure' (Rapport sur la répartition des interventions entre les assurances maladies obligatoires et complémentaires en matière de dépenses de santé), published in April 2003, advocates a three-tier structure. According to this model, the government would identify a 'basket of [healthcare] goods and services' covered by compulsory sickness insurance (level one) and by supplementary insurance (level two). Individuals and families would be able to take out totally optional insurance for those goods and services not covered (level three).
The Chadelat report leaves many questions unanswered, such as whether parliament or the government would be responsible for choosing the basket of healthcare goods and services covered. Similarly, would the various insurance providers divide the cost of items in the basket between them by type of care, or would they reach an agreement on how to share covering the expense on all items? Private insurers have made it known that they prefer the first option. Under the proposals, compulsory sickness insurance would withdraw completely from dental, eye and other types of non-hospital care. Care of this type would be covered by supplementary insurance funds with the compulsory fund focusing on major treatments. This demarcation of tasks would benefit private insurers by enabling them to break further into the healthcare market without incurring the greatest financial risks.
In the view of advocates of this structure, the three-tier approach enables spending still borne by the compulsory insurance fund to be controlled and, at the same time, avoids restricting increases in general healthcare spending, which technological progress and an ageing population seem to make unavoidable.
Access to healthcare for people on lower incomes
The new structure proposed in the Chadelat report raises the issue of access to healthcare for lower-income individuals. The solution proposed is to set up a system to assist people in this situation to purchase supplementary insurance. What would be the rate and terms and conditions of this assistance? The mutual insurance movement is demanding a tax-credit system. The Chadelat report advocates a 'health voucher' system. Other unresolved questions include: Should supplementary insurers be free to set prices for 'basket' care cover? If so, how effective would assistance be? Or should rates be controlled? Yet, if that were the case, why have supplementary insurance at all?
The lowest-income groups currently receive free supplementary cover under the Universal Healthcare Insurance (Couverture Maladie Universelle, CMU) scheme (FR0001135F). A scheme to assist people in purchasing supplementary sickness insurance would have to target a broader audience than just those benefiting from CMU cover. Should such an assistance plan be implemented without reviewing the CMU scheme or should the opportunity be taken to overhaul that scheme too?
Commentary
There is broad agreement that the overhaul of sickness insurance must go beyond financial issues and that the very structure of the system requires reform. However, in undertaking a reform of this type, the government and the sickness insurance funds lack willing partners representing healthcare professionals (doctors, nurses, pharmacists, physiotherapists etc). Addressing this issue is complicated by the fact that the fragmentation and weakness of the representation of healthcare professional is, in large part, the result of the policies of the government and insurance funds, which have used minority trade unions to 'sideline' more representative and rebellious unions.
As for the purely financial side of the coming reform package, one major unknown variable remains. The Minister has, on several occasions, focused on the ageing population as a factor in the 'rising cost' of healthcare and stated that this phenomenon should be factored into funding. However, he has never actually identified any tangible measures. Today, retirees play a less significant role than the working population in funding the sickness insurance system. Is the Minister planning to increase the contribution made by pensioners? Or is he hoping to obtain funding from local authorities? (Pierre Volovitch, IRES)