France, like the rest of the European countries, searches solutions in order to slow down sanity expenses. The French Government has given themselves six months to reform the Illness Insurance and renew sanitary protection.
Not meaning to review France’s history in sanitary protection, I think it can be useful; to have a better comprehension of today’s actual situation, to specify certain stages representing the strong points of an important social evolution. If we go back in time, we can see that in the 17th century, coal miners and Colbert Royal Marine’s sailors already counted with a protection against possible illness.
Despite some experiences in the late years of the 19th century, were we had the collaboration of some Free Care Centres located in the Town Councils, we had to wait until 1930 to see how Social Securities offering protection against possible illness, disability, decease, the same way as a maternity compensation and a retirement right, were created. These Social Securities, at the end of World War two, only counted with 7 million members. The medical expenses covered up to an 80% and in case of sick leave a daily compensation, covering approximately a 50% of the salary, was paid. The first institution working for a collective social protection had, without doubts, positive effects in the enlargement of the life expectancy. But this protectionist system was limited and incomplete because of:
· Insufficient benefits.
· Too restrictive conditions to achieve the right’s enlargement, related to age and the seriousness of the illness.
· Refund of the medicines within a limited time.
After the 1944’s worldwide conflict, the Resistance and the Provisional Government’s National Committee pronounced in favour of the creation of a complete Social Security System. Two models were the bases for reflection. The system adopted in 1889 by the German Chancellor, Bismarck and the system proposed to Churchill in 1942 by Lord Beveridge. These two systems were based in three basic principles:
1. Universality: the fact of being a citizen guarantees the Nation’s solidarity.
2. Uniqueness: with only one contribution a contribution can be obtained.
3. Equality: the contributions are the same for everybody.
The French system would be inspired in these two examples, but would also make an effort to overcome them. The order enacted by General de Gaulle on the 4rth of October 1942, constitutes the base of the French’s Social Security, an organization destined to cover the workers and their families against any risk capable of reducing or eliminate their incomes, the same way as the sanitary costs that these problems can cause.
This order predicts an administration of the Social Security by the employed staff and the salaried workers, in the context involving volunteering and an Autonomy management. This clause is important because it permits us understand better the actual situation, because this Autonomy management of the social partners was rapidly attacked and alienated by a more defined State’s guardianship.
In 1967 we saw an important change affecting the actual situation. Before the life expectancy’s enlargement, the medical advances and the improvement in pensions, the Social Security must face their first economic crisis. To put and end to it the creation of three protection areas is decided: old age, family and health. Each area must be independent and responsible for their economic balance. This decision constitutes an important stage in France’s Sanitary Protection.
During the nineties, our system for social health protection has suffered more important crisis:
· A solvency crisis because of the financing descent due to a growth decrease, to the fact some companies had to close down and to the unemployment’s increase.
· An efficiency crisis due to the growth of inequalities.
· A legitimacy crisis because of the individualism’s increase.
In 1995 and before an enworsening situation in the health branch, the Government wanted to control this situation adducing that the sanitary protection represents more than 20% of the GDP. Then they reduced the economic aids and introduce the Parliament’s responsibility in the yearly financial balances, specifically, in what has to do with the expenses. What is more, in 1996, the JUPPE plan carries out an effort in order to control the medical and sanitary expenses. From this point of view, the expenses are opposed to the private system, and mean a possible recuperation in health advancements. It is the first time the system conveys financial sanctions.
As we can see, we are far from the base principles of the Autonomy management that came into force with General de Gaulle’s 1945 Order.
This short historical reference is necessary to understand and delimit the actual situation because we are approaching an important reform of France’s Sanitary Protection.
In fact, the continuous small reforms haven’t been able to channel deficit. The growth of sanitary’s expenses are alarming. The accumulated deficit will reach this year 10.000 million Euros; if everything stayed as it is now and supposing the maintenance of sanitary’s expenses in 1.5 points in the GDP’s evolution, the yearly deficit would reach 30.000 millions in 2010 and 66.000 million Euros in 2020, an unbearable level for the French’s Sanitary System to cope with.
Excepting some concrete cases where the sanitary expenses are covered 100%; the Illness Insurance leaves for the patients to pay a part of the prescription. The Benefit Societies and the Private Insurances offer the possibility of a complementary complete cover of the sanitary expenses. With the CMU’s recent incorporation (Universal Illness Cover) we can say that, in France, everybody can have a medical insurance.
The Sanitary System is facing the most serious crisis ever, where the financial situation is only the top part of the iceberg.
All the French feel they are directly affected by the Illness Insurance to come. The Government has just started “the great Social Security’s reform” by creating the High Council for the Illness Insurance to come (Haut Conseil), formed by all the affected parties: health workers, employer’s organizations, trade unions, insurance companies…
The High Council has given out a first report indicating some important issues:
· During several decades the Illness Insurance has contributed to development of an equal opportunity to have a to medical assistance. But 5% of the people covered by the Illness Insurance rise 60% of the reimbursement.
· France is one of the developed countries using more money towards sanitary expenses, but is going though the worst crisis ever known.
· This crisis is not only financial, it also affects the quality and the sanitary’s assistance coherence and the Illness Insurance’s management. More worrying are the System’s absence of structural organization and the representation crisis involving all the participants in the Sanitary System because they are causing an enormous waste of money. And they don’t only alter the sanitary care’s quality and coherence, but also they stop the possibility of a decrease referring to the inequalities existing in the health system.
This report given out by the High Council has been adopted by all the participants, but what will happen with this Council when the moment to ask the Government to save the Illness Insurance comes?
What solutions will the Government take to face the danger, politically speaking?
We are afraid the Government will take advantage of this reform in order to start an expenses transfer movement between the Public system (Illness Insurance Protection Areas) and the Private System (Benefit Societies, Insurances), fact that would take us to an imbalance in the complementary sanitary benefit societies. In 2003 the Government decided to remove the reimbursement of 650 medicines and the 35%’s reimbursement instead of the 65% of other 617 medicines. These decisions caused approximately a 1000 million Euros expense transfer, and obliged companies to make their quotes a 10% higher in 2004.
The collective’s break-up because of the worsening, and also the fact these transfers are being carried out, could lead us to create an uneven sanitary `protection. A situation like this would be damaging for those with less purchasing power, but though we don’t think so, and in spite of the CMU (Universal Illness Cover), 7% of the French people don’t have a complementary sanity cover, and the most inferior group’s situation is the worse, for example: 20% of the unemployed don’t have a complementary cover and have to pay the whole prize of the prescriptions.
Our country spent in Sanity 165.000 million Euros in 2003, but still 11% of the French population has said having refused, at least once a year, to medical care because of financial reasons. The actual French Health System’s organization doesn’t cover all the needs, nor reduces social inequalities in case of illness. The High Council Members and the experts agree when they consider this situation as an structural and an organizational phenomenon, knowing that today they can’t elude quality and utility when referring to sanitary attention nor ban those who decide to solve the Treasury’s difficulties by means of reducing the reimbursements and the quotes.
The pensioners of France’s Saving Banks have access to the companies’ mutual benefit association: THE SAVING BANKS’ NATIONAL MUTUAL BENEFIT ASSOCIATION.
This association joins the FRENCH MUTUAL BENEFIT ASSOCIATION that represents 36 millions of affiliated persons.
The FRENCH MUTUAL BENEFIT ASSOCIATION (MF) sent the Republic President a document with proposals aiming the renovation of our health system. These proposals turn around 3 concepts, which have been developed in 25 measures:
Ø Coherence: Nowadays there is no health politic based on priorities worked on in an explicit and coordinate way with the health insurance. The MF proposes:
q to create a higher Health authority in charge of defining the health’s national priorities.
q to enlarge the field of the obligatory and curative health insurance to the obligatory prevention and that takes into account the disability.
q to establish a credit of taxes for all of us which allows everybody to reach a complementary health covering.
ØResponsibility: nowadays the obligatory health insurance, the mutual benefit associations and the health professionals act in a disperse way inducing a loss of efficiency and a squandering of the resources. The MF proposes:
q to create the representative application of all the health professionals and a national public centre which allows to centralize the public health’s data in order to avoid the regional inequality and the recurrences in the health matter.
ØQuality: nowadays the division and lack of coordination of the insured risks, the insufficiency of its global position are expressed in a service that offers the insured persons a lower quality that they may expect. The MF proposes:
q to organize the access to a medical attendance closer to their home by means of a better distribution and a better coordination of the participants.
qthat each health professional avail themselves of a shared access to a single dossier applied to computers and of the health results, in order to avoid the multiplication of the medical acts.
Together with the French Confederation of Pensioners, which groups 2 millions pensioners, we consider that it must start working to preserve the good health conditions of the population and the equality of access to the health care, without discrimination or difference moreover about the age. It seems obvious that the current situation is not only a result of the population’s old age. It is then unthinkable for them to be based on arguments linked to age or illness to introduce specific measures against the elders.
Even if it is true that the structural reform will not make up for the deficit by itself and that it will be necessary to turn up taxes, we do uphold the rise of incomes on the gross tax base in order to take into account all the incomes, no matter its origin, without distinguishing between family situation, health or age.
As we have already pointed in the pensioners’ reform, the problems added to the social protection are faced at the same time in the European Union countries.
Currently, Europe is looking for remedies to reduce the medicines’ costs. In order to fight against the drift of the public health services, the governments increase the economic measures and they try to modify the consumption habits, running the risk of upsetting and prejudicing the most vulnerable population.
Nowadays, the public health accounts are in the red in nearly all Europe. The different approaches to lead these accounts to acceptable parameters are draconian; they are often turned down and always unpopular. The political leaders tend to cose as first measure of restructuring, a restriction in the refund of medicines, which had been, in the past, generously prescribed and distributed.
The “pill” is getting more and more bitter for the European governments. It seems difficult for them to set about structural reforms because they will have to take into account economic and political parameters. One single aim seems to be obvious to them: to decrease the medicines’ costs and consumption, to reduce the medicine’s expenses in a radical way
Let’s give an example of some significant figures: the expense of medicines per person rised 17% in Germany and 28% in Italy between 1990-2000. In France, the expenses increased 63%. In general, the European Union sets 15% of the total expenses public health for medicines expenses; in France 21% and in Italy 23,5%.
Something must be done about it but what? In the European Union, the tendency reversal will be difficult and more complicated: It is a delicate matter to reduce the costs of the public budget which has direct effects on the life of millions of persons and it may make the State Providence, on which Europe was built, stumble.
Some countries have already taken measures to stop the constant degradation. In Greece a new way of participation in the cost of the products of 25%, which can be covered by a private insurance company, has been established. In Italy, a distinction has been made between the medicine the citizen must pay and the ones paid by the Servizio sanitario nazionale, which is directly reimbursed at the chemist’s. The order to the regions for them to find additional economies is also added. This solution has led the regional governments to establish new prescriptions. In Spain, the consumption habits have been modified to avoid squandering. Since now, some medicines such as antibiotics and analgesics are sold by units, with the danger of seeing packets with one single dose which may lead the patient not to complete his treatment. The United Kingdom also tries to introduce the Single Medicine Market, through the adjustment of the new prescription (10 cents more per prescription) which Hill become real in April.
The strategy of reduction of the costs will also go trough the diffusion of the so named “generic” medicines. On that score, Europe shines because of its disparity. In Spain the generic medicines market covers 6% of the medicine expenses while in Italy and France it has got difficulties to reach 6%. In Germany and the United Kingdom, it is situated at 50 and 40% respectively.
With regard to us, we are afraid of seeing the proposed reform articulate around the costs without studying the structural dysfunctions we have already tried to describe briefly.
The same as we did with the pensioners’ reform, it seemed important to us to debate this problem of social protection in the bosom of the European Group. It is the European Group’s role and mission. We are linked to this role and to this mission because we are convinced that the health’s social protection is and will be, in the future, a subject which will concern the European requests.
To be persuaded by that we only have to know Karin Jöns’ report which has been presented and adopted by the European Parliament about health care and elders care. This report confirms the validity of the triple focus the commission of Brussels preserves: access, quality and trustworthy. These three elements must act as basis of national strategies of modernization of the health protection.
The report considers that it is convenient to strengthen and structure in a better way the cooperation between the Associated status: interchange of information and experiences, identification of the best national practices.
In conclusion, in France and in other places, pensioners must mobilize in order for the health protection to lean on basic and unifying ideas:
●The national solidarity, between persons and generations.
●The universality, to ensure uniformity of rights and duties in the whole territory.
●The equality in the access to the health care, in order for the right to a high level of health social protection for everybody to become true.
●The contributive equity, in order not to weigh down the inequality of incomes.
Let’s prove our governors and ourselves
That health is not a luxury
That health is no a load for the society
That health is not a cost but has got no price
That health is an essential factor of progress in the European social space.
JC Chrétien
