on the application of the European Code of Social Security
(Period from 1 July 2004 to 30 June 2005)
(Adopted by the Committee of Ministers on 6 September 2006
at the 972nd meeting of the Ministers’ Deputies)
The Committee of Ministers,
In the exercise of the functions conferred upon it by Article 75 of the European Code of Social Security (hereinafter referred to as the “Code”), and with a view to supervising the application of this instrument by the Contracting Parties;
Whereas the Code, signed on 16 April 1964, entered into force on 17 March 1968 and since 18 February 1987 has been binding on France, which ratified it on 17 February 1986;
Whereas, when ratifying the Code, the Government of France stated that it accepted, in addition to the parts which must be applied by every Contracting Party (Parts I, XI, XII, XIII and XIV), the following parts of the Code:
– Part II on “medical care”,
– Part IV on “unemployment benefit”,
– Part V on “old-age benefit”,
– Part VI on “employment injury benefit”,
– Part VII on “family benefit”,
– Part VIII on “maternity benefit”,
– Part IX on “invalidity benefit”;
Whereas, in pursuance of paragraph 1 of Article 74 of the Code, the Government of France submitted, on 22 July 2004, its 18th annual report and the additional information on the application of the Code, for the period from 1 July 2004 to 30 June 2005;
Whereas, in accordance with paragraph 4 of Article 74, that report was examined by the ILO Committee of Experts on the Application of Conventions and Recommendations, at its 76th meeting in November and December 2005,
I. concerning the major social security reforms, that the government’s report describes important changes in France’s social security legislation which affect, in particular, Parts II, IV, V and VII of the Code:
1. concerning Part II (Medical care), that the report introduces the adoption of Act No. 2004-810 of 13 August 2004 on sickness insurance as a new step in the far-reaching reforms made necessary by a deterioration in the financial position of the sickness insurance system. With the aim of improving governance of the health system, the act introduces deep changes in the structure of sickness insurance, reforms its operation and improves its administration at both national and local levels. While the state retains responsibility for policy-setting and public health finances, parliament will monitor more closely the manner in which sickness insurance finances are conducted. The act improves co-ordination between the basic sickness insurance schemes and co-ordination between these and other bodies and players by establishing, respectively, the National Union of Sickness Insurance Funds (UNCAM), the Union of Supplementary Sickness Insurance Bodies and the National Union of Health Professionals. The act confirms and extends the UNCAM’s duties: contractual relations with health professionals, designation of refundable services and benefits and of the amount of the insured person’s share in costs. In the interests of improved medical care management, an independent public authority has been set up, the Haute autorité de santé (HAS), to assess more accurately the medical usefulness of refundable health services and products and to promote sound use of health care among health professionals and insured persons. The HAS is also responsible for drawing up and implementing procedures for the evaluation of professional practices, the accreditation of professionals and medical teams, and the certification of health establishments. The act extends the competence of the Economic Committee on Health Products, particularly as regards the pricing of drugs, and the participation of sickness insurance in the committee. To ensure the accountability of all players and contain the cost of sickness insurance, by 1 July 2007 every individual will have a computerised personal medical file so as to keep track of outpatient and hospital medical care and services. The amount of the medical care or service payable to the individual will depend on the file being presented to the practitioner. A lower share in costs will be an incentive for people to opt for a “care path” co-ordinated by a general practitioner, freely chosen as from 1 July 2005. Exemption from cost sharing for patients suffering from long-term diseases (approximately 12% of the population) will henceforth be subject to observance of a “care protocol” drawn up jointly by the patient’s own doctor and the fund’s advisory doctor, and signed by the patient. In addition to the patient’s own contribution, there is a flat-rate charge of €1 for every item of medical and biological care, up to an annual ceiling, except for children, women more than six months pregnant and beneficiaries of supplementary universal sickness coverage (persons with the lowest income, approximately 7% of the population). The act also steps up medical control by the insurance funds and the penalising of abusive practices by health professionals that involve extra costs unnecessarily.
According to the report, the various measures introduced by the 2004 reform to streamline and improve the health-care supply should allow savings of some €10 billion, in addition to the €1 billion from patients’ contributions. The 2004 act also establishes a new revenue of approximately €4 billion. The rate of the overall social contribution (la contribution sociale généralisée) is increased from 6.2% to 6.6% of the replacement wage, from 7.5% to 8.2% of income from assets and investments and from 7.5% to 9.5% of proceeds from gambling; the income tax assessment base has also been increased slightly (from 95% to 97% of gross income). The same is true for assessment of the “tax for reimbursement of the social debt”. The “corporate social solidarity tax”, based on a rate of 0.13%, has been increased by 0.03% for companies with an annual turnover of more than €760 000. The tax on promotional spending for medical equipment and drugs and the pharmaceutical laboratories’ turnover tax have also been increased.
The Committee of Ministers notes the government’s statement that the measures undertaken to reform sickness insurance, and in particular to redress its finances, appear not to have affected application of Part II of the Code, but that more specific information will be provided in the detailed report for 2006.
With regard to patients’ cost sharing, the Committee of Ministers notes that the government shares the objective of keeping the patient’s contribution low enough not to place too heavy a burden on beneficiaries who are hospitalised or who use the services of hospital specialists. According to the government, the reform of hospital charge setting does not affect the rates of specialists or arrangements for patient participation, and aims first and foremost to improve transparency in the activities of medical establishments and the associated costs and to further improve resource allocation. The 2004 reform introduces no changes to the arrangements for providing full coverage for the most needy. People with the lowest incomes are given, in addition to universal sickness cover (CMU), a “supplementary CMU”, which aims to avoid any financial participation by the beneficiaries: it includes more advantageous payment rates for certain types of care (optical care, dental care, etc.), and, under the tiers payant (direct payment by the insurer) system, provides exemption from advance payment of the contributions and various fixed charges. Approximately 7% of the population benefit from this arrangement. The 2004 reform does, however, supplement this arrangement by providing financial assistance to facilitate the acquisition of supplementary insurance by persons whose income is slightly over the ceiling set for supplementary CMU (approximately 2% of the population). The government indicates that the various measures introduced by the 2004 reform in order to rationalise health-care provision should amount to some €10 billions in savings, to which must be added €1 billion in patients’ contributions;
2. concerning Part IV (Unemployment benefit) that Act No. 2005-35 of 18 January 2005 on the planning of social cohesion modernises and adapts the organisation of the services market to jobseekers in order to improve its overall efficiency: end of the National Employment Agency’s monopoly and opening up to private operators (with supervision) of placement activities, definition of “public employment service”, co-ordination and guidance of the activities of all those involved at national and subnational level. It also provides for the establishment of employment centres, the main purpose of which is to co-ordinate the public employment service’s local activities and to conduct activities to anticipate human resource needs at local level. According to the report, the act reforms the system of jobseekers’ obligations and the administrative sanctions that may be applied to make the obligations more effective, setting them in order of importance and introducing the principle of adversarial proceedings (implementation measures in preparation). It contains specific and clear provisions on the organisation and supervision of jobseeking to be applied by certain officials of the Ministry of Employment, the National Employment Agency and unemployment insurance bodies.
The Committee of Ministers takes note of this general information, which gives an account of radical change in the organisation of the employment services and in the jobseekers’ obligations;
3. concerning Part V (Old-age benefit), that further to its previous conclusions, detailed information on how Act No. 2003-775 of 21 August 2003 reforming pensions is affecting the application of each Article of Part V of the Code will be sent in the detailed report for 2006. The government also states that in its calculations pursuant to Part V of the Code, it is not planning to count the benefits provided under occupational or personal pension schemes in addition to the benefits provided by the general old-age insurance. It furthermore indicates that the retirement pension (basic and supplementary) of a standard beneficiary with an insurance and employment career of 30 years at the minimum wage will have a replacement rate of 62.5% in 2008;
4. concerning Part VII (Family benefit), that further to its previous conclusions, the government undertakes to provide in its detailed report for 2006, the updated statistics required by the report form under Article 44 of the Code, concerning the total amount of family benefit;
Finds that law and practice in France continue to give full effect to the parts of the Code which have been accepted;
Decides to invite the Government of France, concerning the major social security reforms, in order to be able to assess the impact of the changes on the application of the provisions of the respective parts of the Code, to provide additional information on the points mentioned hereunder:
1. concerning Part II (Medical care):
a. to include in the detailed report for 2006 information and statistics showing that the measures taken have been effective in terms not only of restoring equilibrium in the branch by 2007, but also of the principal criterion set by the Parliamentary Assembly of the Council of Europe (Recommendation 1626 (2003) on the reform of health-care systems in Europe: reconciling equity, quality and efficiency) for judging the success of health system reforms, namely effective access to health services for all and improvement of the general standard of health and welfare of the entire population;
b. to state the main indicators used to monitor the general standard of health and welfare of the French population and trends in this standard in the last few years;
c. to provide information on the measures taken or envisaged to ensure the sustainability of the sickness insurance system in the long term;
d. with regards to patients’ cost sharing, in view of the sizeable transfer of sickness insurance charges to users, to explain which categories of patients will be the most affected and what kind of effort will be asked of them in order to recover the various amounts, and in particular the practical arrangements, and the consequences for ordinary (non-preferential) beneficiaries, of a flat-rate contribution (€1) for every medical and biological item of care up to an annual ceiling;
2. concerning Part IV (Unemployment benefit) to include information in its detailed report for 2006 on how the changes are affecting the application of Part IV of the Code, particularly as regards the notions of availability for work and suitable employment used in Article 20 of the Code, read in conjunction with Article 68.h.