Debate: Is the "Grande Sécu" a myth or reality?
Last November, Health Minister Olivier Véran commissioned the High Council for the Future of Health Insurance—whose role includes exploring “possible changes to health insurance policies”—to produce a report on the relationship between mandatory health insurance and supplemental health insurance. This marked the launch of the idea of a “Grande Sécu,” which would eliminate the portion of healthcare reimbursement currently covered by mutual insurance companies in favor of the health insurance fund.
William Genieys, Sciences Po and Mohammad-Saïd Darviche, University of Montpellier
While private health insurers voiced their opposition, the national press took up the debate. Among the bill’s critics was former Health Minister Xavier Bertrand, who sharply attacked it in an op-ed titled “The ‘Grande Sécu’ Would Be Madness.” The specter of a two-tier healthcare system modeled on the British or American systems was then raised.
Published in early January 2022, the report commissioned by Olivier Véran outlines four scenarios for healthcare reimbursement. Despite its release online, the debate over the future of Social Security remains absent from the presidential election’s political agenda. The “Grande Sécurité sociale” initiative is nonetheless a reality that began to take shape forty years ago. We trace its history in a forthcoming essay, the main points of which are outlined below.
The Long Farewell to the 1945 Social Security Model: The Role of the Welfare Elite
The shift toward the “Great Social Security” system was initiated in the early 1980s by an elite group comprising several generations of senior civil servants. Since then, the 1945 social contract—which linked health coverage to employment—has been continually redefined.
To understand this, let’s go back a few decades. At the end of World War II, the October 1945 ordinance established the new social contract centered on Social Security. Inspired by the German model, Social Security took the form of a social democracy based on joint management: Social Security funds were co-managed by employers and labor unions. During the Trente Glorieuses, Pierre Laroque and the legal experts of the Council of State, guided by social philosophy, worked with the unions to implement the distribution of social benefits. But the oil crises of 1973 and 1979, which led to rising unemployment, plunged this system of health insurance governance into a structural crisis.
A long power struggle then began over the governance of Social Security. On one side stood the social partners, advocates of privatization, and state elites divided into three groups. The first consisted of the “heirs” of Pierre Laroque among the State Councilors, who favored the status quo. The second group, the “soldier monks” of Bercy, launched a campaign to rein in the spiraling social budget. The third, finally, which has been described as the Welfare Elite, comprises magistrates of the Court of Auditors who are promoting a plan to reform the administration of Social Security.
The career of Jean Marmot, a magistrate at the Court of Auditors, is emblematic of the struggle waged by the new elite. A graduate of the École nationale d’Administration’s “Botte” class (the top fifteen in his graduating class), this magistrate at the Court of Auditors dedicated himself to social affairs even though careers in that field were not highly valued. His goal: to work with his colleagues at the Court to initiate Social Security reform by establishing democratic oversight of the accounts, which had been nonexistent until then. His time at the Social Security Administration allowed him to advance this idea.
With the change in government in 1981, the issue of social security accounts fueled the political divide between the left and the right, two years before the shift toward fiscal austerity fractured the ruling left. Despite the French-style “spoils system” (the principle whereby a new government replaces incumbents with loyalists), the welfare elite increased its power within the Social Security administration. Some of them clashed with their supervising ministers—Nicole Questiaux and then Georgina Dufoix—over the issue of exercising control over social security accounts. The conflict ended in 1995 when President Jacques Chirac, following a campaign centered on the “social divide,” decided to undertake the reform of the Social Security administration.
The 1996 constitutional reform, which requires Parliament to exercise oversight over Social Security funding, followed a few years later by the introduction and subsequent expansion of universal health coverage (CMU 2000 and PUMa 2016), will form the foundation of the Comprehensive Social Security system.
Moving Toward a "Comprehensive" Social Security System: Universal Coverage and Government Oversight
The “Great Social Security” model envisioned by the welfare elite took shape through a series of reforms implemented by both right-wing and left-wing governments. The constitutional reform of February 22, 1996, first established the Social Security Financing Act. Universal Health Coverage (CMU) was established shortly thereafter by the Jospin administration in 2000.
Following the 2003 pension reform, the right-wing government launched a reform of the health insurance system (the 2004 Douste-Blazy Act), thereby stripping the social partners of their management authority and handing it over to the welfare elite. The creation of the National Union of Health Insurance Funds (UNCAM) allowed the position of Fund President—traditionally held by a union representative—to be subordinated to that of director, a role granted to a senior civil servant.
Under President Nicolas Sarkozy, the creation in 2009 of a Ministry of the Budget and Public Accounts—to which the powerful Social Security Directorate was attached—sparked a final conflict with the Bercy elite. Drawing on its ability to develop policies that balance medical and social issues with spending control, the welfare elite bolstered the momentum of the “Grande Sécurité sociale” initiative.
To consolidate the course they have set, the new generation of the welfare elite has monopolized government posts within an “iron triangle” comprising the Social Security Administration, the National Union of Health Insurance Funds, and the various high-level authorities and agencies in the health sector established since the late 1990s.
Gradually, the sociological profile of the welfare elite is changing. Judges from the Court of Auditors are stepping aside. The new senior officials come from the General Inspectorate of Social Affairs or have been trained within the Social Security Directorate itself. The career path of Dominique Libault, the first Director of Social Security to be trained internally (2000–2012), attests to this evolution. That of Thomas Fatôme, an Énarque and Inspector General of Social Affairs who served in ministerial offices under the Sarkozy and Macron presidencies and subsequently became Director of Social Security and of the UNCAM, confirms it.
Their strong professional identity and their detachment from politics make the members of this elite interchangeable. This is how they were able to make themselves indispensable under the presidencies of Sarkozy, Hollande, and Macron, ensuring control over health insurance spending while steering the system toward universal health coverage.
The French Social Security System Facing the Challenges of the 2008 and 2020 Crises
The development of the Comprehensive Social Security project was not without its challenges. The 2008 global financial crisis had a severe impact on public finances. The 2020 COVID-19 pandemic put the hospital system under strain. The challenge posed by the health insurance deficit served as a true litmus test for the future of the Comprehensive Social Security system.
On the financial front, the welfare elite worked during the Sarkozy and Hollande administrations to keep health insurance spending under control. Indeed, the Social Security deficit stood at 28 billion euros in 2010, immediately following the financial crisis; by 2015, it had fallen to 10.8 billion euros. In 2018, it was reduced to 1.2 billion euros before rebounding to around 5 billion euros in 2019 and 2020. With the pandemic in 2021, it reached 34.6 billion euros, with a forecast of 21.6 billion euros for 2022… Proven budgetary techniques, such as strict adherence to the National Health Insurance Expenditure Target (ONDAM), have allowed for relative control of deficits. Nevertheless, the zealous application of the fee-for-service system for medical procedures in hospitals, known as “T2A,” has been perceived as particularly restrictive.
In this regard, a group of 123 signatories—including medical professors, doctors, experts, and others—has spoken out against the harmful effects of this policy. These advocates for public hospitals condemn the implementation of a “managerial” ideology. However, for the welfare elite, the issue of controlling healthcare spending is inseparable from the strategy of universalizing health coverage.
Under Marisol Touraine’s tenure as minister, the Universal Health Coverage Act relaxed the residency requirements for access to health insurance. At the same time, the elite secured the creation of a fifth branch of Social Security dedicated to long-term care (2021). In late 2021, a proposal to eliminate private supplemental health insurance was introduced.
Today, the Social Security budget (470 billion) exceeds the federal budget (350 billion). It is intended to reflect a progressive approach consistent with the requirements of fiscal discipline. But the COVID-19 crisis has put this approach to the test.
Will the Ségur de la santé—the agreements signed between Jean Castex’s government and the social partners in July 2021—be enough to prevent another crisis? Only time will tell.
More broadly speaking, the implementation of the Grande Sécurité sociale highlights the positive role played by certain senior civil servants in defending the public interest. This is worth emphasizing at a time when anti-elitism is rife, and should lead us to take a more nuanced view of the reflexive rejection of state elites responsible for public affairs.
For more information:
- Genieys, William; Darviche, Mohammad-Saïd, *In Praise of an Elite: The Hussars of the “Great” Social Security System*, 2022 (forthcoming).
William Genieys, CNRS Research Director at the CEE, Sciences Po and Mohammad-Saïd Darviche, Associate Professor, University of Montpellier
This article is republished from The Conversation under a Creative Commons license. Readthe original article.