Debate: The "Grande Sécu", myth or reality?
Last November, Olivier Véran, the French Minister of Health, commissioned a report from the Haut Conseil pour l'avenir de l'Assurance Maladie (High Council for the Future of Health Insurance), whose role is to reflect on "possible developments in health insurance policies", on the relationship between compulsory and complementary health insurance. The report launched the idea of a "Grande Sécu", which would eliminate the portion of healthcare reimbursements covered by mutual insurance companies, in favor of the health insurance fund.
While private health insurers voiced their opposition, the national press covered the debate. Among the project's detractors was former health minister Xavier Bertrand, who attacked it in a column entitled "La 'Grande Sécu' serait une folie" ("The 'Grande Sécu' would be madness"). The scarecrow of a two-tier medical 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 its publication online, the debate on the future of Social Security remains absent from the political agenda of the presidential election. The Grande Sécurité sociale project is nonetheless a reality that began to take shape forty years ago. We retrace its history in a forthcoming essay.
The long farewell to the 1945 social security model: the actions of the Welfare elite
The turning point of the "Great Social Security" was initiated in the early 1980s, by an elite made up of several generations of senior civil servants). Since then, the 1945 social contract associating health coverage with the practice of a profession has been constantly redefined.
To understand this, let's go back a few decades. At the end of the Second World War, the Ordinance of October 1945 founded the new social contract around Social Security.) Inspired by the German model, the latter took the form of a social democracy based on paritarianism: the Social Security funds were co-managed by employers and employees' unions. During the Trente Glorieuses, Pierre Laroque and the jurists at the Conseil d'État, imbued with social philosophy, worked with the unions to set the rules for the distribution of social benefits. But the oil shocks of 1973 and 1979, which led to rising unemployment, plunged this system of health insurance government into a structural crisis.
A long war of power began for the government of Social Security. Face to face: social partners, privatization advocates and State elites divided into three groups. The first was the group of State Councillors "heirs" to Pierre Laroque, in favor of the status quo. The second, the "soldier monks" of Bercy, are campaigning to control the drift of the social budget. Finally, the third group, known as the Welfare eliteis a group of magistrates from the Cour des Comptes (French Court of Auditors) who are proposing a reform of the Social Security government.
The career of Jean Marmot, a magistrate at the Cour des Comptes, is emblematic of the struggle waged by the new elite. A graduate of the École Nationale d'Administration (the first fifteen in a class), this magistrate at the Cour des Comptes committed himself to social affairs, despite the fact that careers in this field were not highly valued. His goal: to work with his colleagues at the Cour des Comptes to reform the Social Security system by introducing democratic control of the accounts, which had previously been non-existent. His time at the Social Security Department enabled him to push this idea forward.
With the 1981 changeover, the issue of social accounts fueled the political divide between left and right, two years before the turn to budgetary austerity fractured the governing left. Despite the French "spoils system" (the principle whereby a new government substitutes loyalists for those already in power), the Welfare elite increased its power in the government of Social Security. Some of them clashed with their supervising minister - Nicole Questiaux, then Georgina Dufoix - over the issue of exercising control over social accounts. The conflict came to an end in 1995, when President Jacques Chirac, after campaigning on the "social divide", decided to reform the Social Security government.
The constitutional reform of 1996, requiring Parliament to exercise control over the financing of Social Security, followed a few years later by the introduction and extension of universal health protection (CMU 2000 and PUMa 2016), will be the foundation of the Great Social Security.
On the road to a "Great" social security system: universalization and State control
The Great Social Security model envisioned by the Welfare elite was to take shape in a series of reforms carried out by governments of both right and left. The constitutional reform of February 22, 1996 introduced the Social Security Financing Act. In 2000, the Jospin government introduced universal health coverage (CMU).
Following the pension reform of 2003, the right-wing initiated the reform of health insurance (Douste-Blazy law of 2004), thus completing the process of dispossessing the social partners of their management powers in favor of the Welfare elite. With the creation of the Union Nationale des Caisses d'Assurance Maladie(UNCAM), the position of Caisse President, traditionally held by an elected trade union official, became subordinate to that of Director, granted to a senior civil servant.
Under the presidency of Nicolas Sarkozy, the creation in 2009 of a Ministry of Budget and Public Accounts, to which the powerful Social Security Department is attached, is the occasion of a final conflict with the Bercy elites. The Welfare elite's ability to develop policies that combine medico-social issues with cost containment strengthened the momentum of the Great Social Security.
To consolidate the path thus taken, the new generation of the Welfare elite monopolizes government positions within an "iron triangle" made up of the Social Security Department, 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 changed. Magistrates from the Cour des Comptes gave way. The new senior civil servants come from the Inspectorate General of Social Affairs, or are trained within the Social Security Department itself. The career of Dominique Libault, the first internally-trained director of the Social Security Department (2000-2012), bears witness to this evolution. The career of Thomas Fatôme, enarque and Inspecteur général des affaires sociales, who served in the ministerial cabinets under the Sarkozy and Macron presidencies, and successively as Director of Social Security and UNCAM, confirms it.
Their strong professional identity and depoliticization make the members of this elite interchangeable. This is how they made themselves indispensable under the Sarkozy, Hollande and Macron presidencies, controlling health insurance expenditure while moving the system towards universal health protection.
The Great Social Security facing the challenge of the 2008 and 2020 crises
The development of the Great Social Security project was not without its pitfalls. The global financial crisis of 2008 had a severe impact on public finances. The Covid-19 pandemic of 2020 put a strain on the hospital system. The challenge of the health insurance deficit was a real crash test for the future of the Great Social Security.
On the financial side, the Welfare elite worked under the Sarkozy and Hollande presidencies to keep health insurance spending under control. Indeed, just after the financial crisis, in 2010, the Social Security deficit was 28 billion euros; in 2015, 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 rises to 34.6 billion euros, with a forecast of 21.6 billion euros in 2022... Tried-and-tested budgeting techniques, such as strict adherence to the National Health Insurance Expenditure Target (ONDAM), have enabled deficits to be kept relatively under control. Nevertheless, the zealous application of the "T2A" pricing system for medical acts in hospitals has been particularly restrictive.
A group of 123 signatories, including professors of medicine, doctors, experts, etc., have spoken out against the deleterious effects of this policy). These defenders of the public hospital 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 the ministry of Marisol Touraine, the Universal Health Protection Act has relaxed the residence criterion for access to health insurance. At the same time, the elite will secure the creation of a fifth branch of Social Security to cover dependency care (2021). At the end of 2021, a plan to abolish private supplementary health insurance is presented.
Today, the Social Security budget (470 billion) exceeds that of the State (350 billion). It is intended to reflect a progressive doctrine in line with the requirements of budgetary control. But the Covid-19 crisis has put this perspective to the test.
Will the Segur healthcare agreement signed between Jean Castex's government and the social partners in July 2021 be enough to avert another crisis? Only time will tell.
More generally, the creation of the Great Social Security highlights the positive role played by certain senior civil servants in defending the general interest. This is particularly noteworthy at a time when anti-elitism is the order of the day, and should help to qualify the reflex of rejection of state elites in charge of public affairs.
To find out more :
- Genieys William, Darviche Mohammad-Saïd, Éloge d'une élite. Les hussards de la "Grande" Sécurité sociale, 2022 (forthcoming).