Is the gap in the social security budget a myth?

French social security has been suffering for nearly thirty years from lack of funding. Because of unemployment and an aging population, revenues go down and spending goes up. The result: the French people have to pay more for their health care. Some are even talking of the birth of a two-speed medical service.

Social security was born in the aftermath of the Second World War. Founded on the principles of equality and universality, it’s financed by contributions from salaried employees. This complex system is organised into four branches that manage health spending, but retirement pensions as well and some expenses linked to the family, for example an allowance at the beginning of the school year. The problem is that for some thirty years now, all the branches of the social security system are in deficit, creating a global hole of 12 billion euros in 2007, of which health spending alone accounts for 6 billion. There are several reasons for this collapse: on the one hand an increase in unemployment that’s led to a reduction in contributions, on the other an ageing of the population that’s caused an increase in health spending. In face of this lack of resources, public hospitals are on the front line, notably the emergency services. Indeed para-medics launched a token strike at the end of December calling for more recognition as well as payment for overtime. Jacques-Yves Phélipot, a doctor specialising in accident and emergency from Haguenau in Alsace testifies:

-We’ve lived through several strikes since I’ve been in the emergency services, but this time I think the action was strongly supported, because in fact in Alsace we had between 80% and 100% striking on several emergency sites in Alsace. Above all it is about recognising the hardship involved in the work, because in fact we’ve never really known the 35 hour week. All of us work at least 48 hours per week. There are also presidential promises that have been made, notably about overtime working. Well, for the moment, paramedics, well doctors, are excluded. Secondly, it’s about working conditions more than anything, so the difficulty of finding hospital beds; funds are being re-evaluated downwards rather than upwards, while at the same time the population is getting older. Life expectation regularly goes up by several months. Old people need more care, are more often in hospital, and so, well, you have to recognise that health has a cost and now, in years to come of course, it is going to cost more, therefore. That’s the problem. Well actually we can make efforts to reorganise some things. That is what we are being asked to do at the moment, to do better with the same means, or less.

In a morose economic climate, governments are therefore churning out reforms in an attempt to limit health spending. Some medicines that are judged to be of little benefit are no longer on subscription, and there are more and more advertising campaigns about reducing waste. For example this television commercial which aims to reduce ineffective prescriptions for antibiotics.

– Mum, it’s me. Could you look after the little one tomorrow? He has a soar throat. Ah, hang on.
He asks his wife.
– Has the doctor given him antibiotics?
– No,they won’t do any good. He has diagnosed it: it is a virus.
– No. No antibiotics. There you are! They are not automatic. Fine.
To his wife.
– She says that with antibiotics, maybe we wouldn’t need her tomorrow maybe.
– Has she become a doctor, your mother? For a virus, antibiotics do no good. Antibiotics, they are not automatic.
– When are you coming tomorrow?

At the same time, health service managers are trying to raise awareness among general practitioners, as Doctor Erdogan Kaya, a country doctor in Alsace, explains:

– There is a representative from social security who comes twice a year to show us a so-called personal record card. So, on this card there are all the medical interventions we’ve been able to do over the previous six months, the sick notes which we have been able to give. When he comes to see us the representative says “You see, by comparison with your colleagues in the region or even at the national level, you’re giving, for example, too many sick notes or you are prescribing too many medical tests or you are prescribing too much of this or that medicine etc.” So he draws our attention to that. But if all the same we judge that something is necessary, what’s absolutely certain is that no-one’s going to tell us not to prescribe this or that medicine. That’s not the question. The question is more about the quantity of tests prescribed. When you know – and it is flagrant, it is striking – that after a television program that talks about this or that illness, you can be absolutely certain that in the following days, you are going to be full of people who are coming with these symptoms… It is not by chance. And so these people have heard in this program that, well, for such-and-such illness we do this and that test. Well they will come saying “Doctor, I want this and that test”; and, once again, you can’t reason with them. And to reason with them takes time anyway; meanwhile the waiting room is full and you see time marching on and you say to yourself “Bother, if I now have to start spending 5 or 10 minutes with every person who demands that type of test, I’ll never manage!”. All the more so because you can haggle all you want, whatever happens, most of the time they’ll end up getting what they want. If it is not me, it’ll be one of my fellow practioners who will prescribe it. There you are, it’s like that. For two or three decades, since social security has provided for people like that, people think they have a right to – moreover they’re right – they think they have a right to health care completely free of charge. We, on our side, it is sure that we are trying, we are trying to make people aware of the problem, but people see their case only in isolation. It’s sure that as an individual, it bothers me, but on the other hand, it is not my responsibility to play the role of policeman for the social security.

With doctors wary of taking on the role of policeman, it’s necessary too to make patients more responsible. Already, every patient has to pay a euro from their pocket for each medical appointment. Since the first of January 2008, every health service user must also pay 50 centimes for each box of medicine bought. In the waiting rooms, this action has some patients gnashing their teeth.

-It is true when you’re admitted to hospital, it goes without saying that it is fairly expensive and then if you don’t have the means to pay for the treatment; it’s hard for us.

-In the end, if you read the press, there are countries much worse off than us, but what I’ve noticed, in the last few years, is that things have gone backwards in human terms view. Personally I think that it is a step backwards. I do not understand how 50 years ago, I am 81, I do not understand how 50 years ago, we had it all free of charge, we did not even pay the doctor and today you must pay money and I find that a step backwards. I don’t understand it at all.

True, for the least well off, there has been the CMU since January 2000: the universal sickness cover which enables all people resident in France and whose income is below 599 euros per month to take have full health cover without having to pay. This affects five million people. But for all the others, the cost of health care goes up and it’s estimated that today someone covered by the system has to pay on average 25% of the price of treatment.

Beyond the numbers, some are asking for a more profound rethink on the question of financing and casting doubt on the principle of social security contributions being based almost exclusively on salaries. The association ATTAC for example is calling for financial revenues of companies and institutions to face the same deductions as salaries. That would bring in, according to them, 20 billion euros per year. Frédéric Henry, activist of the association ATTAC:

-It has to be said that everything concerning funding of social protection, and that includes retirement pensions etc, comes from salaries. If we take into account that at the moment there are around three and a half million people unemployed, a million in unstable employment etc., that’s all social security contributions that aren’t going into the funds for social protection. So already there, there is a kind of cheating: that of saying we have problems funding health care, social security, whereas first and foremost we have above all a problem of unemployment and a problem of earnings for salaried employees. The second point is that in the space of twenty years in total, there has been, how can I put it, a shift in the distribution of wealth from work towards capital. Roughly 10 per cent, which represents around 140 billion euros in the space of twenty years. So there is a kind of cheating in the way of thinking about health care which transfers all the responsibility of this defecit onto the ill. When we see income from capital is generally higher than the income from work and much less taxed, much less taxed than the income from work, we see that there, there’s an ideological dimension and I believe to a certain extent we are at a turning point.

You will have gathered that medical insurance is a subject that’s both political and economic. And it is not the only headache for the social security system. There is also the funding of retirement pensions which is posing a problem. In 2000, 10 active people were financing 4 in retirement; in 2050, it’s estimated that 10 active people will finance 7 in retirement.

$Id: 2008_03_soc.htm 35 2021-02-12 12:17:35Z alistair $

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