Debate: The "Grande Sécu" (social security system), myth or reality?
Last November, Olivier Véran, Minister of Health, commissioned the High Council for the Future of Health Insurance, whose role is to consider "possible developments in health insurance policies," to produce a report on the relationship between compulsory health insurance and supplementary health insurance. This launched the idea of a "Grande Sécu" (Great Social Security) system that would eliminate the portion of healthcare reimbursement 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 project's detractors was former Health Minister Xavier Bertrand, who sharply criticized it in an op-ed entitled "The 'Grande Sécu' would be madness." The specter of a two-tier healthcare system based on the British or American model was then raised.
Published in early January 2022, the report commissioned by Olivier Véran considers four scenarios for healthcare reimbursement. Despite being published online, the debate on the future of social security remains absent from the presidential election agenda. The Grande Sécurité sociale project is nonetheless a reality that began to take shape forty years ago. We trace its history in an essay to be published soon, the main points of which are outlined below.
The long farewell to the 1945 social security model: the actions of the welfare elite
The shift towards "comprehensive social security" was initiated in the early 1980s by an elite group comprising several generations of senior civil servants. Since then, the 1945 social contract linking health coverage to employment has been continuously redefined.
To understand this, let's go back a few decades. At the end of World War II, the October 1945 ordinance established a new social contract based on social security. Inspired by the German model, this took the form of a social democracy based on joint management: social security funds were jointly managed by employers and employee unions. During the Trente Glorieuses, Pierre Laroque and the lawyers of the Council of State, imbued with social philosophy, worked with the unions to organize 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 ensued for control of the Social Security system. Opposing sides included the social partners, supporters of privatization, and state elites divided into three groups. The first group consisted of the "heirs" of Pierre Laroque, who were in favor of maintaining the status quo. The second group, the "monk soldiers" of Bercy, launched a campaign to control the drift of the social budget. The third group, finally, was described as the welfare elite, brought together magistrates from the Court of Auditors who were promoting a plan to reform the government of Social Security.
The career of Jean Marmot, magistrate at the Court of Auditors, is emblematic of the struggle waged by the new elite. A graduate of the École nationale d'Administration (the top fifteen in his class), this magistrate at the Court of Auditors became involved in social affairs at a time when careers in this field were not highly valued. His goal was to work with his colleagues at the Court to initiate social security reform by introducing democratic control of accounts, which had been non-existent until then. His time at the Social Security Directorate enabled him to advance this idea.
With the change of government in 1981, the issue of social accounts fueled the political divide between the left and the right, two years before the shift to fiscal austerity fractured the left-wing government. Despite the French "spoils system" (the principle whereby a new government replaces those in power with loyalists), the welfare elite increased its power in the Social Security government. Some of them confronted their minister – Nicole Questiaux and then Georgina Dufoix – on the issue of control over social accounts. The conflict ended in 1995 when President Jacques Chirac, after a campaign focused on the "social divide," decided to undertake the reform of the Social Security government.
The constitutional reform of 1996, which requires Parliament to exercise control over the financing of Social Security, followed a few years later by the introduction and then the expansion of universal health coverage (CMU 2000 and PUMa 2016), will form the basis of the Grande Sécurité sociale (Great Social Security).
Towards a "Great" social security system: universalization and state control
The model of comprehensive social security envisioned by the welfare elite took shape through a series of reforms carried out 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 government in 2000.
Following the 2003 pension reform, the right wing embarked on health insurance reform (the Douste-Blazy Act of 2004), thereby completing the process of stripping the social partners of their management powers in favor of the welfare elite. The creation of the National Union of Health Insurance Funds (UNCAM) made it possible to subordinate the position of Fund President, traditionally held by an elected union representative, to that of Director, granted to a senior civil servant.
Under Nicolas Sarkozy's presidency, the creation in 2009 of a Ministry of Budget and Public Accounts, to which the powerful Social Security Directorate is attached, provided an opportunity for a final clash with the elites at Bercy. With its ability to develop policies that combine medical and social issues with cost control, the welfare elite reinforced the momentum of the Grande Sécurité sociale.
To consolidate the path thus taken, the new generation of the welfare elite monopolizes government positions within an "iron triangle" composed of the Social Security Directorate, the National Union of Health Insurance Funds, and the various high authorities and agencies in the health sector created since the late 1990s.
Gradually, the sociological profile of the welfare elite is changing. Magistrates from the Court of Auditors are stepping down. 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 internally trained director of Social Security (2000-2012), attests to this evolution. That of Thomas Fatôme, an Énarque and Inspector General of Social Affairs, who worked in ministerial offices under the Sarkozy and Macron presidencies and successively as director of Social Security and the UNCAM, confirms it.
Their strong professional identity and depoliticization 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 and ensure control of health insurance spending while moving the system toward universal health coverage.
Social Security facing the challenges of the 2008 and 2020 crises
The development of the Greater 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 of the health insurance deficit was a real crash test for the future of Greater Social Security.
On the financial front, the welfare elite worked under the Sarkozy and Hollande presidencies to keep health insurance spending under control. Indeed, the social security deficit stood at €28 billion in 2010, just after the financial crisis, and €10.8 billion in 2015. In 2018, it was reduced to €1.2 billion before rebounding to around €5 billion in 2019 and 2020. With the pandemic in 2021, it rose to €34.6 billion, with a forecast of €21.6 billion in 2022. Proven budgetary techniques such as strict compliance with the National Health Insurance Expenditure Target (ONDAM) have enabled relative control of deficits. Nevertheless, the zealous application of the pricing of medical procedures in hospitals, known as "T2A," has been experienced as particularly restrictive.
As such, a group of 123 signatories, including medical professors, doctors, experts, etc., has spoken out against the harmful effects of this policy. These defenders of public hospitals denounce 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 ministry, the Universal Health Protection 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 covering long-term care (2021). At the end of 2021, a bill to abolish private supplementary health insurance was presented.
Today, the Social Security budget ($470 billion) exceeds that of the State ($350 billion). It aims to reflect a progressive doctrine in line with budgetary control requirements. But the Covid-19 crisis has put this perspective to the test.
Will the Ségur healthcare agreement, signed by Jean Castex's government and social partners in July 2021, be enough to prevent another crisis? Only time will tell.
More generally, the creation 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 our reflexive rejection of the state elites responsible for running the country.
To go further:
- 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 CEE, Sciences Po and Mohammad-Saïd Darviche, Senior Lecturer, University of Montpellier
This article is republished from The Conversation under a Creative Commons license. Readthe original article.