Le Monde diplomatique
December 2003
‘SOCIETY SCORNS THE OLDEST, EXCLUDES THE YOUNGEST AND TAKES INDIVIDUALITY TO EXTREMES’
France: health as a commodity
French healthcare leads the world, but the government is about to change the financing of the system from public funding to private insurance. This threatens not only the future well-being of the French but the basis of the nation’s social contract.
By MARTINE BULARD
WILL the French social security system soon be just a memory? Using this year’s deficit forecasts, the government is tweaking its arguments to justify structural reform, which has been officially postponed until early 2005. But measures already taken have set the tone, including cuts in reimbursements, a rise in the daily hospital charge and hospital bed closures. This is a traditional package in most developed countries.
Public health systems are being challenged everywhere, whether they are based on employment-related resources and co-run by employers and employees (the Bismarck system in Germany and the Netherlands), state-run and funded by taxation (the Beveridge system in the United Kingdom, Italy and Sweden), or a mixed model (as in France). Inequalities are soaring but so are deficits, although health-benefit cuts were supposed to plug the financial gaps.
The social security deficit curve generally shadows the unemployment curve. In France, if contribution revenue had grown by 6% in 2002 as it did in 2001, there would be no gap. But slumping growth reduces contribution revenue and deepens deficits, prompting austerity programmes that cause falling consumption, stifling growth, thus reducing social security contributions and so on. The pit is bottomless.
This should prompt questions over remedial cuts, which are about as useful as bloodletting. But there is an ideological barrier here. True, there is no global conspiracy, no hidden mastermind imposing the same solution everywhere. However, there are very real pressure groups with a direct interest in the health-benefit bonanza – $3.5 trillion worldwide. Their lobbying targets are international organisations that claim to be neutral, such as the World Bank with its influential 1994 report that explained how social spending would become an unbearable burden for nations and cause lasting changes to security systems (1). The World Trade Organisation (WTO) provided the general agreement on trade in services, a byword for privatisation.
These ideas circulate freely because the experts involved easily change hats. An author of the World Bank report, Estelle James, joined President George Bush Jr’s team to handle privatising health benefits (2). In France the health minister, Jean-François Mattei, and the social affairs minister, François Fillon, asked two private-sector figures – François Chadelat, a senior executive with the insurer Axa, and Alain Coulomb, representing private hospitals – to propose ways to clarify the roles of public and private sectors. Transfers are two-way: Gilles Johanet, director of France’s national social security fund (CNAM), left to run the health and collective insurance division of giant AGF.
The solutions stay the same: cuts in collective spending and the promotion of personal initiative, deemed to yield better performance. In the name of this principle, accounting-driven regulation was introduced in the mid-1980s, promising that by cutting doctors, pharmacies and hospital beds, there would be fewer patients or, at least, lower spending. French governments have tried to achieve this for 25 years, capping the number of doctors and nursing staff. The operation has been more successful than expected. From 2010 more doctors will retire from medicine than will enter it, although public hospitals are already 3,500 doctors short, despite 9,000 foreign practitioners, underpaid and with insecure status.
Public hospitals have lost more beds – 35,352 in seven years- than private ones (18,475). Small local hospitals that could treat common conditions and distribute patients have closed. They would have been useful during this summer’s heatwave and could ease the strain on casualty departments in large towns. Patients must sometimes travel long distances to hospitals that, while superbly equipped, are unsuited to treating ordinary cases. Maternity hospitals have been shut down in the name of safety and women redirected to large complexes often too sophisticated to deal with routine pregnancies: yet there is astonishment at the rising proportion of reimbursements for transport costs.
Spending rises steeply with no reduction in inequalities.The lack of joint regulation in the assignment of doctors is leaving areas unserved: Picardie has only 110 specialists for 100,000 inhabitants compared to 220 in Provence-Alpes-Côte-d’Azur, 234 in Ile-de-France and an average 169 across the whole European Union.
France still ranks first in the world for healthcare, according to the World Health Organisation. Doctors do not yet have to keep patients waiting a year for hip or heart operations, as they do in Britain, or 208 days for a cataract operation, as in Finland, or 128 days as in Denmark (3).
But there are danger signs: in Ile-de-France 60% of patients wait at least two weeks for a magnetic resonance imaging appointment; the experts say that time limit should not be exceeded (4). “The quotas for medical equipment are ridiculous,” says Professor Bernard Debré. “France ranks last in the world for the number of MRIs performed, behind Turkey” (5). People in business, political and media circles have contacts and are unaffected by this.
The lack of preventive medicine, and the way that it is being sidelined where it had been developed in schools and businesses, deepens inequalities further. According to the French research centre for health economics Credes, 14.7% of French people have given up healthcare for financial reasons; 30% of this group are jobless. Despite the creation of Universal health insurance (known in France as CMU), between a quarter and a third of those entitled to it have not been
able to afford it. Working-class households spend half as much as managers’ families on specialist consultations, but twice as much in hospital costs. They seek care later, which costs more. The authors of Inégalités sociales de santé say that 10,000 premature deaths a year could be avoided if blue- and white-collar workers had the same mortality rate as senior managers (6).
The measures in the pipeline will, instead of tackling these injustices, steepen the slide. In 2001 the French business confederation Medef presented a full report on its version of social security: a US-style system with minimal, tax-funded care provision for the poorest and top-up insurance for the rest, as individual or group pol icies provided by mutual societies and insurers. Yet we know the economic outcome of this. The US, the land of optional insurance and always the example quoted, holds the record for health spending. In 2001 the proportion was 13.9% of wealth created, compared to 10.7% in Germany, 9.5% in France and 7.5% in Finland, where free care is the rule (7); anyway, 41 million Americans have no health cover and the problem is now affecting the middle classes. In 2001, according to the New York Times, 1.4 million people, 800,000 of whom earned more than $75,000, lost their health insurance (8). Rising unemployment was a factor but the main cause was insurance premiums, which have soared (9). Patients who want to be reimbursed cannot choose their doctors, who cannot practise as they would like. “Managed care has become the de facto national health policy of the US” (10), writes George Anders, citing paediatricians; insurance companies have forced them to shorten their consultations by some 10 minutes.
The French government, inspired by this model, is seeking to redefine the areas covered by the public and private sectors. Jacques Barrot, of the Union for the Presidential Majority coalition, explains: “We need to distinguish between small risks and heavy risks. The latter must be covered by compulsory insurance and the other risks by top-up or voluntary insurance from mutual societies or private insurers” (11). Such a distinction is medically absurd (a small risk can conceal a serious disease), socially unjust (only the rich would be able to look after themselves) and economically costly (the later care is sought, the more is spent). Chadelat’s report (12), the basis for the government’s work, is written in the same spirit. In proposing a major change in the health cover mechanism in France as it has existed since 1945, he calls for “a basket of care” (minimum care provision with no precise definition), which would be co-funded by the general social-security scheme (compulsory health insurance) and by top-up insurance, mainly from mutual societies. These sources would supply 80% of funds, with the rest covered by extra top-up insurance.
But top-up cover does not exist for some part-time employees and expires when workers lose their jobs or retire. Only 52% of over-65s have it. Moreover regulation of mutual societies is now similar to that of insurers and premiums are likely to grow. Alongside this new share-out, the contributions payable by employers and employees would be cut; this would cost the social security system an estimated ?2bn per full year, more than 2% of its resources.
Total health commoditisation would damage society. The social security system is about more than health and pensions: it shapes the contours of social organisation. It gives those without capital some independence in bad times. It allows people to do without charity or welfare and gain entry to a system of rights. Social security made a leap forward, gradually freeing social relations from the market. To revert to the uncertainty of the individual contract and the madness of the financial markets would be a leap backward. Many young people and women, insecure and with no top-up insurance, but too “wealthy” to qualify for CMU, would have to agree to live in permanent anxiety about the future, unable to make positive plans. The old would have no right to an untroubled retirement. The economist Alain Cotta, noting that 70% of healthcare costs are incurred in the last six months of life, proposed in all seriousness “self-regulation organised by society [which would create] a social function: putting people to death” (13) and a cut-off of healthcare for anyone over 90, which would codify social euthanasia.
A society that scorns the oldest, excludes the youngest and takes individuality to extremes is far from inevitable. Reforms are essential, but also a recognition that health spending will continue to grow. In all countries rising standards of living result in greater demand for care – and for culture and leisure. Technological progress increases the cost of treatment; people live longer and need greater medical supervision; the advent of serious diseases (Aids) or their growing incidence (cancer) demands extra funding. In France the birth rate is rising. In 2002 midwifery costs were one of the highest increases, 11.8%, in social security reimbursements.
In France and other developed countries the share of national wealth devoted to health will rise. This is no great drama or insurmountable hurdle, as long as the debate sticks to genuine issues and a new architecture is built based on new financial resources. Health spending underpins growth. It generates qualified jobs for care provision direct to consumers in hospitals and laboratories, research and industry. Promoting a real prevention policy, especially in schools and the workplace, would also create jobs. Throughout the developed world, generating qualified employment is the best way to increase jobs: in France 100,000 more jobs would mean an extra ?1bn in contributions.
That is why contributions must remain linked to business wealth creation and not be replaced, as some advocate, by the contribution sociale généralisée (CSG), the universal social security tax introduced in 1991 by the Socialist party. The CSG was initially justified as being a tax on capital revenue, not being deducted from salaries; in fact 93% of it is taken from salaries. The exemption of French businesses from contributions, with no positive requirements in return, is freeing masses of money, much of which flows into stock markets. Exemptions jumped from ?1.3bn in 1991 to ?8.8bn in 2001, more than that year’s social security deficit. Exemption cutbacks would allow proper funding reform: use VAT and not salaries as a funding source and adjust contributions to favour companies that created properly-paid and qualified jobs. This would add value to labour without intensifying it or abolishing national holidays.
Aspects of French healthcare need an overhaul, especially the introduction of a more preventive system. Prevention currently costs 2.3% of total spending. Improving it would cost slightly more initially but would soon generate savings. Oral-hygiene pilot schemes in schools in the Seine Saint-Denis département have reduced tooth decay and costly treatments. Mutual societies have conducted other positive experiments.
To make the healthcare system more efficient and economical, the role of drugs needs to be re-evaluated. France is not the world’s biggest consumer, ranking below Sweden, the US, Canada, Finland, Australia and Ireland, but above Germany and Italy (although the French do seem to take the most anti-depressants) (14). Pharmaceutical companies have too much power in the decision-making process and the government has enabled them to fix the price of new drugs. To escape this, transparent and independent commissions, with doctors and representatives of the social security system, mutual societies and patients, should set prices and favour generic products, at present only 10% of French prescriptions compared to 28% in Germany.
We need to redefine the doctor’s role. There is no question of reviewing patients’ freedom of choice and practitioners’ freedom to prescribe. But we must recognise the system’s failings: 14% of GPs prescribe 50% of reimbursed medicines; 40% of specialists and 50% of dentists charge more than the basic rate set by the social-security scheme. Doctors in rural and problem areas struggle to make ends meet at ?20 a consultation, but others do well – radiologists earn an
average of ?14,200 a month gross.
Continuing vocational training remains marginal. Philippe Houcarde, a health economics specialist, advocates more active control – stopping patients from specialist-hopping and limiting doctors’ prescriptions. But he primarily recommends encouraging new forms of practice and pay: different rates according to the scope of the diagnosis and the time spent on it, or flat fees according to the service provided; group practices and experimental clinics open evenings and weekends, run by a rota of doctors who provide minor treatment and refer patients to specialists as necessary, thus absorbing patients from hospital casualty departments.
The system cannot be re-energised to boost performance and save money without democracy. French deputies set annual spending standards with no idea of medical consequences. The genesis of disease and the evolution of pathologies are scarcely studied. The managers of the social security system – unions and employers – are accountable to no one; elections to choose them were suspended in 1983. Patients’ associations are excluded. The system combines state control and bureaucratisation.
Pierre Laroque, father of the French social security system, believed that the creation of universal insurance meant combining an economic policy geared to full employment, a health infrastructure and medical organisation policy that aimed for prevention first and treatment second, and a revenue distribution policy that tended to modify the blind distribution of economic mechanisms (15). His mighty ambition, soon forgotten, is more topical than ever: it is about building a different health system.
Rather than leave all this to the market, it would be better to reduce the insecurity of daily life and build on the solidarity – between young and old, healthy and sick, the single and families – that is at the heart of the social security system.
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(1) “Averting the old age crisis”, World Bank, Washington DC, 1994. Also La régulation du système de santé, Conseil d’analyse économique, La documentation française, Paris, 2000.
(2) Dean Baker, “The World Bank’s attacks on social security”, Centre for Economic and Policy Research, 7 August 2001, Washington.
(3) “Les systèmes de santé danois, suédois et finlandais”, Etudes et Résultats, n° 214, Direction de la recherche et des études de l’évaluation et des statistiques, January 2003, Paris.
(4) “Les trajectoires des patients en Ile de France”, Questions d’économie de la santé, n° 31, July 2000, Paris.
(5) “Comment soigner un tel malade”, France soir, 2 December 2002.
(6) Annette Leclerc, Didier Fassin, Hélène Grandjean, Monique Kaminski and Thierry Lang, dir, Inégalités sociales de santé, La Découverte/Inserm, Paris, 2000.
(7) “Health data 2003”, second edition, Organisation for Economic Cooperation and Development, July 2003.
(8) “Problem of lost health benefits is reaching into the middle class,” New York Times, 25 November 2002. Available on Commondreams.org.
(9) Milt Freudenheim, “Health benefit costs soar in US,” International Herald Tribune, Paris, 11 September 2003.
(10) “The medicine in our future,” New York Review of Books, 12 June 1997. NYROB’s archives are on subscription.
(11) La Tribune, Paris, 28 October 2002.
(12) “La répartition des interventions entre les assurances obligatoires et complémentaires”, Commission des comptes de la Sécurité sociale, Paris, July 2003.
(13) Journal du Dimanche, Paris, 7 September 2003.
(14) Health Data 2003, op cit.
(15) Henry C Galant, Histoire politique de la Sécurité
sociale française – 1945-1952, Librairie Armand Colin, 1955.
Translated by Paul Jones
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