French social security is going through turbulent times. One reform after another has failed to satisfy the insured population nor guarantee balancing the health system’s finances over the long term. And the challenge of population ageing remains to be met. And so, some people are suggesting a new approach known as the “Grand Social Security project” (“La Grande Sécu”[1])… Centralisation and state control would then be the keys to solving all the problems. Germany, so often held up as a model, has not gone down that route. Quite the contrary! This has been revealed in a recent study sponsored by Gerep, devoted to the German health insurance system, past and present. [1] “La Grande Sécu”, a project to reform first layer Public Health Insurance and second layer Complementary Health Insurance.
The German system ensures free choice and solidarity
Hérité d’une longue tradition (une histoire mouvementée détaillée dans l’étude) qui prend sa source au Moyen-Âge, le système d’assurance maladie allemand a évolué vers une organisation fondée sur la décentralisation de la gestion, la solidarité nationale et la liberté de choix des assurés. Oui, c’est possible ! Aujourd’hui, les allemands peuvent choisir entre plus de 100 « caisses légales » historiquement liées à une entreprise, une région ou un métier, et qui ont pu ouvrir leur offre à tous. Ces caisses assurent le remboursement des soins et collectent les cotisations sur les salaires bruts à un taux unique défini par l’Etat. Les contributions de l’ensemble des caisses légales sont placées dans un « Fonds santé » sur lequel sont également prélevés les remboursements des affiliés. Un mécanisme de compensation des risques existe et l’Etat peut être amené à combler les déficits ou prendre en charge certains frais comme l’assurance maladie des enfants ou les allocations familiales. Dans ce système, la multiplicité des acteurs n’a qu’une vertu : assurer la qualité des services et la maîtrise des coûts grâce à la concurrence !
Room for private insurance
In Germany, health insurance is compulsory. However, it is possible to opt for private insurance from the first Euro, i.e. be fully covered by private health insurance. This choice is open to civil servants, the liberal professions and employees earning more than 62,000 Euros a year. Surprisingly varied categories of people, once again inherited from the past! 8.7 million German insureds have chosen from around fifty private funds. These offer differentiated rates and personalised rules, as well as a few privileges. These funds are not increasing in number, as the range of care and cover offered by the statutory funds is considered satisfactory. However, 26 million insured persons have chosen to supplement their basic coverage with complementary private insurance, which allows them, for example, to obtain a single room when in hospital or 100% reimbursement of dental care, compared to 80% maximum in the statutory funds.
Enviable performance and ‘inspiring’ solutions
Healthcare expenditure is roughly equivalent in France and Germany: around 12.5% of GDP in 2020. In terms of copay, French policyholders are better off than Germans: according to the OECD, they are left to pay 9% of their healthcare costs compared to 13% in Germany. Yet, the level of satisfaction with the healthcare system is much higher in Germany. With hospital beds having become a subject of debate in our country, one figure can illustrate this difference: Germany has 34 beds per 100,000 inhabitants compared with only 16 in France.
Something that characterises the German system above all is its capacity to evolve smoothly, to adapt and to balance its budget. On the French side, social security is an issue that is much more fraught, often sparking national political quarrels, probably because the system is so centralised. In neighbouring Germany, insured persons’ free choice and competition between funds does not detract from the feeling that health and social protection are a common good: healthcare is satisfactory, solidarity is ensured and the social contract is respected. This undoubtedly stems from a decentralised pragmatic approach, which seeks concrete solutions to problems rather than spectacular reforms. For example, the premium rates charged by complementary insurers to pensioners in France (who no longer benefit from an employer’s contribution) is seen as justification for the “Grande Sécu” upheaval. In Germany, expenditure is kept stable, in most funds, by a mechanism involving contributions from pension funds. Quite simply… At a time, here in France, when major reforms are being prepared based on reports and studies, it may be enlightening and inspiring to take a look at the systems that work rather well and peacefully for our European neighbours.
Damien Vieillard-Baron
President of Gerep