A “Jacobin” vision of an all-embracing state seems to be calling into question the role of complementary health insurance[2] in favour of “Comprehensive Social Security[3]”, contrary to the expectations of people in France, as several recent studies have shown. So why turn everything upside down? With the presidential elections coming up, who wants to see the death of complementary health insurance?

Much has been written about healthcare in recent months, and not only because of Covid. Complementary health insurance, in particular – or rather strangely – has found itself pushed to the forefront after a series of little stabs in the back, firstly a report by the High Council for the Future of Health Insurance (HCAAM)[4] on transformation of the French health system, and a targeted report by the Court of Auditors[5] in which various rather irrelevant grievances were set out. As a result or by coincidence, the Minister of Health has commissioned the HCAAM to think about “Comprehensive Social Security” to the detriment of the other players.

Damn it, of course! All the difficulties of the French health system stem from complementary insurance schemes! Let’s go for the jugular…

We find this analysis very disappointing and so, in this article, we have explored several suppositions in an effort to understand why on earth it was so urgent to bring complementary insurances to heel, to the pillory or to a standstill.

Because policyholders – who are also citizens – have a grudge against their complementary health insurance?

Wrong. 78% of people insured feel that the health system, as it is currently structured, works well. A survey by the firm Elabe for Malakoff Médéric[6] also indicates that 61% of them attribute this good functioning to the complementarity between state health insurance[7] and complementary health insurance.

It is important to remember that the highly competitive complementary health insurance sector guarantees policyholders diversified contracts with a balanced quality/price ratio, and numerous innovations such as access to care networks, cover for preventive healthcare services, support for carers, cover for wellness care, routine use of direct payment, etc. But also new services, such as telehealth, second medical opinions or cover for psychotherapy, partly covered by Social Security.

Private health insurers have succeeded in achieving progress on all of these issues. Policyholders’ favourable opinion is undoubtedly the end result.

Because the “Comprehensive Social Security” project would be less unfair and unequal than the current system?

Wrong again. France has one of the lowest “copay” levels in the OECD (6.9% of medical care consumption in 2019) and the 100% Healthcare reform has not yet had its full effect. Furthermore, according to the Elabe study, 75% of those surveyed believe that complementary health insurance schemes play their role well. This data just does not justify the risky and counter-productive “Comprehensive Social Security” project. On the contrary, policyholders (78%) fear that a “comprehensive social security system” would reinforce a two-tier health system. Why? Because only a few people would be able to afford extra insurance to top-up an enlarged social security system. And unless we twist consultants’ arms or turn GPs into civil servants, it is likely that such top-up insurance will give access to care and treatment more quickly and under better conditions than the basic system.

Because companies no longer want to get involved in employees’ social insurances?

Wrong yet again. An overwhelming majority of employers – 93%[8] – are satisfied with the health system in its current form.  Half of them consider that offering private health insurance is a lever of attractiveness in recruiting and retaining employees. Better still, 56% of managers believe that health cover is a good opportunity to build positive industrial relations dialogue.

A freely agreed and negotiated employee benefit, adapted to the needs and means of each individual, would be transformed by a “Comprehensive Social Security” project into a new compulsory national insurance contribution. One more senseless tax that would be swallowed up in the public finance deficit. Companies have understood the interest of financing part of their employees’ healthcare expenses. Will they be just as keen to finance health insurance through higher social security contributions? We know the answer to this question, given the already excessive social security contributions, including for employees.

Because centralisation is a guarantee of efficiency?

Since when? The “Comprehensive Social Security” project simply consists of recentralising, or even nationalising, healthcare. The Jacobin reflex has struck again! Obsessed with the operating expenses of private health insurers, the great centralising minds imagined that there might be a way of rationalising the health system by eliminating a player and its operating expenses. Neither policyholders (of which 86% believe the involvement of two players is essential for the proper functioning of the system[9]), nor companies seem to share this view: 76% of managers believe that a “Comprehensive Social Security” scenario would lead to a sharp increase in employer contributions.  While 70% of them believe that the health system is well managed by complementary scheme insurers, only 43% feel the same way about state health insurance.

Perhaps over 30 years of deficits and more than 230 billion in accumulated deficits of first tier health Insurance (not counting the impact of COVID in 2020 and 2021!) inspire little confidence?  It must also be said that, every year, complementary scheme insurers strive to balance healthcare expenditure accounts and to encourage policyholders to act responsibly in claiming on their health insurance contracts, particularly by offering preventive healthcare

So no, complementary scheme insurers cannot be replaced by a centralised administration! They are essential players in controlling expenditure and play a positive role in supporting and empowering the insured and helping them cover costs.

But why then?

“Comprehensive Social Security” is not in any government bill. It’s too late for the 2021 Social Security finance bill (PLFSS[10])! This is just a campaign topic tossed into the wind. The nationalisation of healthcare would therefore be the first “innovative” idea before demagogic one-upmanship leads, why not, to the nationalisation of the car industry! Bringing Renault and Stellantis under state control would look great. This would reduce the unnecessary accumulation of management expenses by the two companies!  

But beware. Even though the “Comprehensive Social Security” idea does not hold water, we must denounce it because it could become an election campaign commitment. For ten years, the world of health insurance has been able to cope with a series of profound upheavals without batting an eyelid – or very little -: the generalisation of complementary health insurance, the so-called “responsible contract”, the 100% Healthcare reform, etc.  The sector has proved its flexibility and adaptability, and plays a major role in the overall performance of the system (and in financing it through more than EUR 5 billion in direct annual taxes (TSA – additional solidarity tax – and a variable patient tax)[11] not to mention their own indirect costs. And it would be tempting for some to design a major reform on the back of this? In the meantime, other urgent, crucial, explosive and thorny issues are kept waiting.

So why reform a system that works?

Because it’s easy to do so? But it would be an aggression against the insuring public, against the hundreds of thousands of local jobs in the different types of insurance providers (mutual insurance companies, provident institutions and insurance companies), and against the liberal medical professions who could be forced to apply the tariffs imposed by “Comprehensive Social Security”!

Damien Vieillard-Baron

President of GEREP

[1] “Grande sécu”

[2] Private health insurance

[3] All – Inclusive state health insurance project

[4] Haut Conseil pour l’avenir de l’Assurance maladie (HCAAM)

[5] Cour des Comptes

[6] A survey conducted in June 2021 among a sample of 3,004 people representative of the French population.

[7] Social Security

[8] A study by Elabe for Malakoff Humanis in July 2021 among a sample of 259 company executives

[9] An Elabe June 2021 survey for Malakoff Humanis based on a sample of 3004 representative people

[10] Projet de loi de financement de la Sécurité sociale

[11] Source: Court of Auditors report on complementary healthcare – June 2021