Candidate Macron’s flagship health measure in 2017 was zero out-of-pocket costs. The French no longer had to pay for their glasses, dentures and hearing aids. The government has just published a decree on February 17, 2024 which plans to double the amount of deductibles for medicines, medical transport and the financial contribution to medical consultations, justifying this measure by a principle of citizen responsibility.
The French no longer have to pay anything for their glasses but must help finance their medical care, to realize that health has a cost! The cup is therefore full in terms of political incoherence and technical complexity of the financing system.
Too bad, because readability for the insured is an essential condition for the effectiveness of the system and its fairness. Also knowing that it is the insured person who finances 100% of the care.
A bureaucratic gas factory
Like any meaningless measure, the recovery of medical deductibles is a bureaucratic gas factory. Each citizen can see that their health expenses are mainly through third-party payment, that is to say without direct financing. To recover medical deductibles, Health Insurance has only two options: either deduct them from the reimbursement of a procedure for which the insured pays directly – a physiotherapy procedure for example – or ask the insured to pay him by transfer the amounts due, in other words the overpayment.
Health financing in France today includes reimbursement by social security, reimbursement by mutual insurance companies, a non-refundable financial contribution and deductible, a refundable co-payment, a remainder payable on certain acts… In twenty years, those responsible Politicians have constantly tinkered with the machine, to the point of making it illegible and administratively costly, therefore ineffective in its “empowering effect”.
Bercy’s diktat in the face of Ségur’s impotence
This measure is part of a context of unprecedented drift – excluding a major crisis – in the financial trajectory of social security between now and 2027. After a deficit of 9 billion euros in 2023, entirely driven by health, the deficit cumulative from 2024 to 2027 is expected to reach 60 billion euros, two-thirds of which is due to health.
Faced with the inability of the Ministry of Health to propose structural reforms, Bercy takes control and uses the tools in place, regardless of their coherence for the system, that is not its subject.
Remember that financial contributions – 1 euro on the consultation – and medical deductibles – 50 cents on the medicine and 2 euros on medical transport – were introduced in 2005 and 2008 respectively. The decree of February 17, 2024 provides for the doubling of these sums, for an expected annual gain of 800 million euros.
The French clearly understood that the cocktail of degraded public finances and political incapacity to reform health condemned them to seeing these amounts increase with increased recurrence in the coming years. How long will they agree to endure?
Twenty years of political incoherence
This political inconsistency is profound since it amounts to imposing an additional charge on heavy care and not on routine care: a real economic counter-model.
This political inconsistency is persistent since it dates back to the 2000s, with the establishment of third-party payment, the mutual insurance contract which has become the benchmark – requiring the reimbursement of user fees -, then the obligation of collective contracts for active workers.
This deep and persistent political inconsistency comes at a high price for policyholders and caregivers alike.
For the former, it increased the cost of access to care, due to the exorbitant management fees of private insurers, while reducing the quality of the latter, as shown by the multiplication of dental centers that emerged following the zero remains to be paid.
For the latter, by encouraging overconsumption of care, it has encouraged public authorities to keep prices as low as possible at a level below inflation, and leads to the impoverishment of caregivers.
A burden on middle-class retirees
A significant point is to know whether these medical deductibles are fair, in short whether they represent a painful budgetary drain, or not, for the insured.
The effort rests on the middle class – the most modest are exempt – and in particular retirees in this category, who consume the most care. Even with an annual franchise ceiling of 50 euros, the increase primarily concerns them.
This sum is added to the 4 billion euros increase in the prices of supplementary health insurance in 2024 (+ 10%), the main victims of which are also… middle-class retirees.
A salty addition
All things being equal, the addition of the additional cost of access to care will therefore be steep in 2024, of the order of 5 billion euros, or 100 euros per adult on average, but with a very unequal distribution. of this additional cost. For retirees, the bill will run into several hundred euros.
This measure is a sign of the abandonment, for this five-year term, of any desire for structural reforms in health matters, which are the only ones capable of restoring a healthy and virtuous financial perspective.
A structural reform of health financing which would change the system from two financiers – social security and mutual insurance – to a single financier – social security or mutual insurance, depending on the benefits – would save 20 billion euros, including 50% for public finances, every year.
Bercy would obtain the 10 billion euros in savings sought, while improving the readability, equity, and effectiveness of health financing in France.
“ In a changing world, it is better to think about change than to change the dressing » said Francis Blanche, rightly.
*Frédéric Bizard is professor of economics at ESCP and founding president of the Institut Santé.
.