EXCLUSIVE – Health: the trail of a shield against “catastrophic out-of-pocket costs”

Posted on 10 Jan 2022 at 13: 02 Updated 10 Jan 2022 at 13: 20

This is perhaps the line of work that is most likely to be followed, among all those mentioned by the High Council for the Future of Health Insurance (HCAAM). In October, this independent body for reflection and foresight aroused strong reactions by disseminating to its members a draft report aimed at improving the link between compulsory and complementary health insurance which included beautiful to the revolutionary project of a “great Sécu” – as the had asked him the Minister of Health Olivier Véran .

The report submitted this week to the minister, which “Les Echos” could read, still evokes this scenario to 20 billion euros , which arouses the opposition of complementary , doctors and social partners, plus three other scenarios. But since the working session of 13 December, it also includes in annex a quantified assessment of the cost and impact of the establishment of a health shield, as exists in Germany, Belgium, Switzerland or the Netherlands.

Resolve the most glaring injustices

Since the Briet-Fragonard report by 2007, this avenue of reform often comes up in the public debate. But it does not pierce. The HCAAM shows however that without radically modifying the existing system, the measure would make it possible to resolve the most glaring injustices, these “catastrophic charges” which affect around 1 to 1.5 million French people, often elderly or chronically ill. It could be a fallback solution if the “great Security” did not see the light of day .

The Haut Conseil is developing two scenarios in particular. The first aims to cap hospital out-of-pocket expenses at 1. 100 euros per year, which would cost everything likewise 1 billion to public finances. The percentage of policyholders who would touch the ceiling and would therefore have nothing to pay beyond it would be very low: 1.2% of French people, or less than 1 million people. But this would particularly benefit retirees (4% of beneficiaries, against 0.5% of employees).

A purely hospital shield

At the scale of the entire population, this shield would not fundamentally change the current situation, in particular the fact that an elderly person has to spend out of his pocket a sum four times greater than a young working person. In this scenario, the ratio between the remainder dependent on the over 70 and 20 – 39 years, which is currently 4.1, would decrease a bit, to 3.8.

One clarification, however: in all of these simulations, only “opposable” expenses are covered. In other words, beyond the ceiling, there are no longer any deductibles, co-payments or daily lump sums to be paid for the insured, but the excess fees persist.

Lower additional contributions for seniors

We could also consider extending the shield to city care. This is the second scenario. With a city-hospital shield of 1. 400 euros per year, the bill would double, to 2 billion euros, but the senior / young active out-of-pocket ratio would drop to 3.5. This extension, which would protect 1.7 million French people (2.6% of the population) would benefit 8% of retirees and even 13, 5% of over 70 years compared to 1.4% of employees.

It would also benefit 6.1% of people with long-term ailments. These patients are in theory well covered, with coverage at 95% of everything that falls under their chronic pathology. In reality, they multiply the consultations for other reasons, due to a poor general state of health, which can cost them dearly.

A cost transferable to the insured

Establishing such a shield would reduce the risk taken by insurers when they sign contracts with seniors, underlines the HCAAM, and could therefore affect additional contributions, with lower prices. Those over 80 years would pay 150 euros less per year, and the septuagenarian 150 euros of less. In the hospital shield scenario, these reductions would be respectively 100 and 95 euros.

The High Council specifies that the cost of the health shield could be transferred to the insured, via a general increase in user fees, for example, or by modulating the ceiling according to the resources of the household or the insured.

Other scenarios that are much more costly for public finances are also touched on in this appendix. To bring the ratio of outstanding senior / young workers down to 3 frankly, a ceiling would be needed at 720 euros per year , city plus hospital, which would already cost 4.2 billion euros.

To pass the shield to 225 euros, the budget would be 7.2 billion euros. A large number of policyholders could then choose to bypass additional coverage. The entire health system would be changed.