The sustainability of one of the keystones of the French health system is under threat. While people currently suffering from a chronic illness are particularly well covered by Social Security for their healthcare costs, the “budgetary sustainability” of this system is “not assured”, warns an administration report published this week. It calls for a “structural reform”, even if the savings envisaged on this sensitive subject are not colossal.
Nearly 20% of the French population currently benefits from the reinforced coverage system provided by Health Insurance for people suffering from one or more “long-term conditions” (ALD), notes the report written by the Finance and Social Affairs Inspectorates (IGF and Igas). In concrete terms, these victims of diabetes, respiratory failure, tumors or even psychiatric illness do not have to pay the share of care that normally remains the responsibility of the insured (the excess fee generally reimbursed by mutual insurance companies).
A search for savings criticized
Given the franchise systems, hospital packages, the care of chronically ill people is not 100% covered by Social Security but their bill is considerably reduced. If this system dating back to the birth of “Sécu” is considered “effective”, the Igas and the IGF are worried. Because with the aging of the population and the development of chronic diseases, the number of patients with ALD is increasing regularly (+2.7% per year between 2010 and 2022). The bill for public finances is swelling with it. Already in 2021, the specific coverage of ALD (the exemption from the co-payment) weighed more than 12 billion euros (for 83 billion of expenses related to ALD).
As public accounts sink into the red, the previous executive had asked the administration to identify savings to be made on the item of expenditure related to ALD, ideally for 2025. The “inspections” have therefore come up with several ways to ease public finances, for example by proposing to remove payment exemptions, particularly for the supply of paracetamol. However, they are temporizing by emphasizing that the savings to be made are “limited unless the system is distorted” and risk increasing the charges for policyholders, particularly via an increase in the premiums requested by mutual insurance companies.
Even before the dissolution, the quest for savings on ALD coverage had sparked strong criticism from the opposition and patient associations. Despite the ever-deepening “hole” in the Social Security accounts, it seems unlikely that Michel Barnier’s government, in a precarious situation with no majority in the Assembly, will seek to make savings by tackling such an explosive issue head-on.
Two levels of coverage
The Igas and the IGF believe, however, that a thorough reform is “necessary”. In addition to the increasing cost of the system, the inspections suggest that its “social acceptability could decrease” and that it does not place enough emphasis on health prevention. Hence one of their proposals, suggesting providing two levels of ALD support rather than one, established according to the patient profile.
Less severely affected patients, who do not need very expensive care – for example diabetics without complications or injectable treatment – should generally pay a co-payment (a priori covered by their mutual insurance) like other insured persons. These patients with “level 1” ALD would not benefit from maximum coverage for their medical transport.
On the other hand, they would be exempt from co-payments for a certain number of “preventive acts”. The higher level of coverage “level 2” would focus on the most severe forms of pathologies and “particularly intensive and costly” treatments.
The Igas and the IGF urge caution in assessing the cost of the proposed reform. If their recommendations were followed and the reform applied to all patients currently on long-term illness, more than 4 million insured persons could no longer benefit from the maximum level of coverage and would have to turn to their mutual insurance company to cover care currently covered by the Social Security.
The fact remains that specific care coverage for less severe chronic illnesses would also have a cost. So much so that the net gain could be in the order of 265 million euros per year. Not enough to fill the hole in Social Security. Even if the new system aims to strengthen prevention and thus avoid new expenses.
