Ten years ago, I launched the idea of “Private Social Security”. The expression caused a stir. In my mind, it was about opening up the management of compulsory health insurance to private or parapublic institutions and not, of course, about abolishing Social Security. The subject is still relevant but the situation has gotten worse! Social Security has gradually become a real public body directly governed by the State which is at the same time the initiator of the rules, the organizer of the provision of care, the financier of this offer and the insurer of demand.
Health insurance today
Social Security defines what is reimbursed and what is not. Access to health insurance is based on residence and no longer on the exercise of a professional activity. A large part of the financing is based on company payroll. In addition to the CSG that they pay directly, few employees are aware that their contribution to health insurance represents more than two months’ salary annually. They do not know what is the cost of their own risk and what is a solidarity contribution.
It is the National Health Insurance Fund which pays the doctors, the hospital and the medicines. We cannot say that it manages the disease risk. It is enough to observe the adventures of the Personal and Shared Medical File, the anarchic distribution of doctors across the territory, the impoverishment of our public hospitals and finally, what seems most serious, the total absence of a posteriori evaluation .
The disease risk of the French
We can divide the protected people into groups representing 5% of the population (20 groups in total), going from those who spend the least to those who spend the most.
In the first three groups (30% of the population), the expenditure is zero or insignificant. In the 10th group , it reaches 529 euros per person per year.
For 50% of the population, the average annual healthcare expenditure does not exceed 530 euros.
In the 17th group , the average expenditure is 1,717 euros. In the last group bringing together the last 5% of the population, it is 21,687 euros.
Only 1 to 2% of the population represents the “great risk” with average annual expenses of around 82,000 euros.
Health spending is increasing and will continue to grow faster than GDP (more than 11% of GDP today, 15% in the next ten years). This is inevitable and due to the increase in life expectancy, technical progress, and the fact that the French – and this is normal – want to take care of themselves to maintain good health.
Over the past few years, we have clearly seen, through the “reforms” put in place, the extent to which compulsory health insurance today escapes all control. The reforms essentially consisted of supporting the drift in costs by an increase in levies and a reduction in reimbursements without calling into question the structure of the system put in place. Our current system is clearly on its last legs. We can only respond to the challenges of the future by changing the paradigm.
The disease risk is well distributed (see box), it evolves slowly and regularly, and is never very high. It is therefore not difficult to insure.
The possible solutions have the starting postulate that these expenditures contribute to growth, that is to say the creation of wealth and jobs, and even that they will be an essential factor tomorrow. That they are the source of scientific and technological progress. That they are also a factor in improving the quality of life of our fellow citizens.
To have a chance of saving the principles to which the French are attached: health coverage for all, solidarity and high quality of care, the proposed measures must be politically acceptable, effective and pragmatic.
Redefining the role of the state
Its role is essential. He sets the rules and guarantees their application. If the State wishes, these functions could be those of the redefined Social Security.
Define reimbursable care
Few employees are aware that their contribution to health insurance represents more than two months’ salary annually.
It is up to the public authorities to decide what constitutes universal health insurance, that is to say listing the care and services which are fully covered for the entire defined population. This is what we call “the basket of care”.
We recommend linking care to the observation of therapeutic protocols precisely describing all the care necessary for the treatment of a pathology or medical situation, whatever they may be. The same procedure may or may not be reimbursed, depending on whether the therapeutic protocol is respected. It is obvious that common sense must guide this approach, which must include flexibilities and exemptions in order to allow the system to function properly and of course be scalable.