Chasing fake work stoppages is good, but if we invented a bonus malus on health insurance, that would be better… right?

©Philippe HUGUEN / AFP

Bercy’s plan to chase convenient sick leave is provoking a debate that reflects the contradictions of French opinion in the face of reform. It’s even a caricature. Almost everyone agrees that health insurance is one of the cornerstones of our social model. The whole world, or almost, envies us Carte Vitale and all that goes with it. But everyone also recognizes that our health care coverage system is so generous that it gives rise to waste. The waste begins with the spread of fake health cards, continues with drug prescriptions that are sometimes very reassuring but useless, and also ends with an abuse of short-term sick leave, less than 8 days.

Not all sick leave is justified for medical reasons. Many are also there for reasons of personal convenience: fatigue, stress, family problems, psychological problems or disagreements with the employer, with the complicity of the general practitioner who sometimes diagnoses discomfort at work rather than a real pathology. A third of sick leave of less than 8 days would be false, to use a somewhat vulgar but common term. These sick leave apparently cost around 8 billion, and everyone agrees that as part of a policy of cleaning up public and social accounts, we could hunt waste.

Everyone knows it, but as soon as a minister, supported or not by the Court of Auditors, decides to bring a little order, he must face a bronca coming from all political horizons because public opinion cannot bear to be suspected of fraud in this way. The body politic defends its electoral base, medical or pharmaceutical lobbies defend their interests, and the minister finds himself alone. Unless he is suicidal, he will postpone the matter until later under the pretense that the political situation is not suitable… but it never is, and consequently we accumulate from year to year the social costs and deficits.

Which will not stop the same political leaders from continuing to not know how to run state affairs. Health insurance is a gap, and this is normal because the population is getting older and therefore needs care. Medicine is making huge scientific advances, but is becoming more and more expensive. But doing everything to extend a healthy life expectancy is rather progress. No one complains about it. Except that if health insurance is a loophole, the social security that ensures its funding is a “loophole.” To finance health insurance and its development, there are three solutions:

1. We reduce health care costs, but we deprive ourselves of the benefits of progress and we alienate public opinion.
2. We let spending follow the development of demand, and we increase taxes or social charges, but we alienate the taxpayers once again.
3. Tired, we try to cut back here and there, but in the end we accept the deficit.

When we hunt waste in work stoppages, we are right, but we are not sure that the health software can sort real work stoppages from fake ones.

The idea circulating in mutualist or insurance circles, an idea originally conceived by a few health economists, would be the equivalent of establishing a bonus/penalty on health insurance as it exists for car insurance..

First point: liberal economists (there are a few left) know that our society must only function with respect for the values ​​of freedom and individual responsibility. Currently, our society operates more on coercion than on membership. They are punishing. Establishing an incentive system would obviously be more effective than a series of restrictions. Our healthcare system operates on the fulfillment of a certain number of rights. Public opinion believes that we have a right to health and that it is up to the state to fulfill it. This is a mistake, we can believe that we have a right to health, provided we agree to respect an individual duty of prevention.

Second point: The health insurance system, which is guaranteed by the state, does not provide for individual prevention, because the insured does not immediately find an interest in it. Hence the idea of ​​creating a bonus/malus that applies to each insured person. Just like in car insurance: this insurance is mandatory, but if the insured drives well, without mistakes or deductibles, he gets a bonus on the premium, which can go up to 50%. If he misbehaves, he is punished with a punishment. So of course there are cheaters, there are some who drive without insurance and even without a driver’s license, but that is not the norm. In health, the bonus/malus will encourage the insured to protect their health with healthy behaviour: don’t smoke, don’t drink, do sports and have periodic checks to objectively calibrate the bonuses/malus. Monitor yourself responsibly to limit the risks you know about (cancer, cardiovascular disease, etc.). Currently, medicine is perfectly capable of telling us that there is an explosion of skin cancer (melanomas) attributable to excessive exposure to the sun, doctors know the harmful effects of tobacco, alcohol, obesity, etc. So life is very unfair, we all know seriously ill people who have led an exemplary and monastic life, but they are the exceptions of nature. The opposite is also true: we know of centenarians in good health who have not committed excesses in their lifestyle, but again these are exceptions.

The problem is that public opinion will find it difficult to accept that the smoker or alcoholic is penalized in relation to his insurance premium… and yet it is his responsibility. In the current system (too expensive), the insured who takes care of his health, who does not smoke and drinks in moderation, pays a premium which will also cover the risks taken by his neighbor who lives without protection. This is neither fair nor just.

Note that the arrival of complementary mutual insurance companies to relieve health insurance has begun to be part of this logic of individual responsibility. The mutual deals on two levels:

On the one hand, at the level of the insured, it adjusts the size of the premium to the risks incurred. It is a negotiation with the company and staff representatives, which corresponds to the awarding of bonuses/fines.

On the other hand, at the level of health care providers that the mutual recommends because it measures the relationship between quality and price and encourages competition. Today, membership of an add-on plan has been mandatory for more than ten years, and frankly, no one is complaining about it.