The figures are enormous, frightening. Without corrective measures, the Social Security deficit will reach 28.4 billion euros next year, after already 18.5 billion this year and 10.8 billion in 2023. A deficit largely fueled by the health branch, whose accounts should show a negative 14.7 billion in 2024 and 18.7 billion next year. This slippage on an unprecedented scale obviously calls for strong measures.
It also calls for a necessary explanation of its real causes. Explanations that we have struggled to hear in recent weeks. To find out more, nothing beats diving into the writings of the Social Security Accounts Commission. An austere, not to say forbidding, reading, his reports nevertheless prove to be enlightening. What do we learn there? Firstly, it is appropriate to “bring together the deficit in the health sector for the years 2023 and following years with the funding granted under the Ségur de la santé” – 13.2 billion in expenditure for 2023 alone. long-term projects which “have not been covered by the allocation of additional resources”, note the Commission’s experts.
These specialists also endeavored to distinguish the effect of recent crises – pandemic, inflationary shock, etc. – in the evolution of health spending. Their conclusions? Excluding “exceptional events”, between 2019 and 2023, expenditure in the field of ONDAM, the objective voted each year by Parliament, increased by 2.9% per year, “thus approaching previous developments crisis”.
High-stakes delistings
Clearly, the Health Insurance deficit is explained much more by the non-financing of the increases granted to hospital staff at the end of the pandemic than by a completely uncontrolled surge in expenditure. The consequences remain the same: faced with the urgency of replenishing the coffers and in a context of generalized tensions on public finances, the government has no other choice but to propose a plan, with dereimbursement measures and therefore an increase in the share of care remaining the responsibility of patients or their complementary health insurance if they have one.
A decision fraught with challenges – loss of purchasing power, increase in supplementary prices, strengthening of inequalities, potential undermining of the adherence of a part of the population to the principles of Social Security (why continue to contribute for coverage that is dwindling?)… A decision which, above all, forces us to question the future.
Unless we endanger the beautiful edifice of Social Security, to which the French are so attached, we must ask ourselves how to get out of this ham-fisted policy. Because beyond the current difficulties, heavy but occasional, linked to the legitimate and imperative choice to defend the attractiveness of the hospital, can we seriously envisage seeing expenses continue to increase at the “usual” rate of 2.9% per year on average – and probably even more in the future, due to the aging of the population and the increasing technicality of care?
Invest in prevention
A real control policy is required. We can doubt that the classic recipes used until now (fight against abuse and fraud, control of prescriptions, pressure on the prices of health products, etc.), however essential they may be, will be sufficient. Because with the aging of the population, the growth in spending will be increasingly fueled by the increase in chronic pathologies – diabetes, cancers, cardiovascular diseases, psychiatric illnesses.
Faced with this challenge, the answer is known: it involves prevention, in particular through two major levers (alongside the fight against cigarettes and alcohol): diet and physical activity. The observation is unanimous, taking action is proving much more difficult. Without even mentioning the difficulties in implementing behavioral tax-type measures, as we still see today with the sugar tax, taking action requires investment. The range of possibilities is immense: dedicated consultations, sports-health, cardiovascular check-ups around forty to give just a few examples.
But investing today to avoid spending several years from now proves impossible within the straitjacket of a budgetary text, the Social Security financing law, whose sole objective is to find short-term savings. To get out of this impasse, a multi-year approach to health spending, through a programming law, is necessary. Such a reform would in no way prevent short-term adjustments, but it would allow us to think about the medium term. In the field, most stakeholders (health professionals, patient representatives, establishments, laboratories, etc.) request it. Which politician will be able to hear them?