Their role has gradually consolidated, up to the point that insurance is compulsory for all employees, making complementary health insurers essentially partners of the state social security health provision. Interaction between the two components could nonetheless be considerably smoother.
The French healthcare system is based on two main components, the basic state health insurance and complementary health insurance, a judicious blend of public and private services. Over time, complementary health insurers have gained increasing ground. In 2014, they accounted for 13.5% of all spending, versus 12.8% in 2006. According to the French Directorate for Research, Studies, Assessment, and Statistics (DREES), in comparison with other European countries, France has the highest level of financing of healthcare spending.
“However, in reality, if we exclude insured persons with long-term medical conditions (who are 100% covered by the Social Security system for a chronic illness), the number of which is constantly increasing, hitting 11 million people in 2016, the proportion taken by complementary healthcare in reimbursements is much higher. For the population not covered by long-term conditions, across our portfolio of insured persons, public Social Security health insurance reimburses 46% of healthcare expenses and private complementary insurers 45%,” comments Jean-Marc Esvant, Head of Social Protection at Verlingue.
Transfers. We have reached this point simply because the public health insurance scheme, to call a halt to the relentless increase in healthcare spending and balance its books, operated a shift to private mutual insurance providers, by reducing reimbursements for certain aspects of healthcare, including medicinal products. This did not particularly improve its figures, mainly because of the increase in the number of people with long-term medical conditions, a result of the ageing population, and the expansion in chronic illness, but this was how the role of complementary health insurance was consolidated.
At the same time, taking out complementary insurance policies was encouraged, by means of financial support, particularly tax and social security breaks, applying to policies contracted by companies for the benefit of employees, at a cost to the public purse estimated by France’s national audit office at €3.6 billion in 2016. In a second stage, complementary healthcare cover was made compulsory in all French companies with effect from 1 January 2016.
Poor coordination. However, coordination between the mandatory state health insurance component and complementary private insurance providers has not been clarified, and key questions remain unanswered as regards organisation and efficiency of the healthcare system. The first body to pay proper attention was the French national audit office, the Cour des Comptes. In its report on the future of the state health insurance scheme in November 2017, it again criticised the poor coordination between the various components of health cover. It did not mince its words. “These developments now make the terms & conditions for reimbursement of healthcare costs particularly complex and difficult to understand for those insured. They moreover hamper risk management policies and lead to poor sharing of responsibility,” the office wrote.
This entanglement means those covered by the mandatory state health insurance scheme struggle to understand how reimbursement operates. On this point, Macron announced during his presidential campaign that he would force insurers to make their policies easier to understand, in particular by asking them to set up three standard policies, covering different ranges, but to be identical from one insurer to another, so that French consumers could compare them and make an informed choice. Since his election, his emphasis has been more on zero OOP and not so much about these three standard policies, blighting complementary insurers before they even start. Questioned on this point during the breakfast organised by the AJIS (association of social news journalists) at the end of the November 2017, the French Minister for Health, Agnès Buzyn, reiterated that the presidential pledge still held good and she would ensure it came to pass.
In addition, there is poor circulation of information between the basic state insurance and the mutual providers. France’s national association of complementary health insurance providers, UNOCAM – which has members from the three categories of insurers, insurance companies, mutuals and provident institutions – designed to be a fully-fledged partner of the state health insurance scheme, satisfies no-one. Providers rarely manage to reach agreement and the state health insurance scheme only begrudgingly invites them to its discussions with healthcare professionals. “Obliged to find consensus, or at least no objections, on all subjects, between the three categories of insurer that often have divergent interests, it struggles to commit to anything,” the Cour des Comptes observed. As for data held by the state health insurance fund, CNAM, mutual insurers still have no access, preventing the emergence of a common assessment and action tool to act on health spending, reported the audit office. Lastly, the state scheme and complementary insurers each deduct management costs to manage exactly the same risks, which is sub-optimal.
Absorption. The radical solution, advocated by Martin Hirsch, chief executive of the public hospital system in Paris (AP-HP) and Didier Tabuteau, head of the Health Chair at the Paris Institute of Political Studies, and indeed by Jean-Luc Mélenchon and Marine Le Pen on the political left and right, whereby the state social security system absorbs complementary providers, is a utopia, if only financially speaking. How could the state health insurance fund, already on its last legs, absorb the share of costs borne by the complementary health insurers, more than €26 billion in 2015? Even with savings in management costs, this would require an increase in social security contributions, which is not really on the agenda.
The Cour des Comptes, meanwhile, proposes rationalising the existing system, either by making the complementary component truly universal (the retired and long-term unemployed in particular are still excluded), or by restricting the basket of healthcare covered by the state scheme but in exchange improving the payments, in particular in cases of hospitalisation. The third proposal – close to that proposed back in the day by François Fillon – consists of dividing up risk between the state and the mutual insurers, each bearing a given cost in full, generating savings in management efficiency. The last possible avenue is to create a healthcare shield, capping out-of-pocket costs for patients which would automatically reduce the usefulness of complementary insurance.
The fact remains that for the moment, the government is being kept very busy with negotiations on zero out-of-pocket payments. Besides this huge task, Agnès Buzyn’s priorities are firstly “access to complementary health cover for pensioners and the low take-up of financial help for complementary health insurance”, according to comments made at AJIS at the end of November. But for all that, there is little prospect of immediate change.
Mireille Weinberg – L’Opinion