How did La Sécurité Sociale come about?

The underlying principle of the French welfare system was originally instituted by the Conseil National de la Résistance or CNR. The CNR, which represented both the communist and the gaullist resistance was the coordinating organ of the French Resistance during the war, and played a major role in shaping post-war institutions and promoting social justice.

La Sécurité sociale was not created by one single piece of legislation. It was a very protracted process. Initially it concerned only employees in the private sector (1945)), civil servants (1947), agricultural workers (1961), other workers (1966). It became universal only in 1999 (until then part of the population and notably the homeless were not covered). There was a gradual shift as initially, the aim was to protect 'workers and their families', whereas today healthcare is considered as a human right rather than a worker's right.

How is it organized and managed

La Sécurité Sociale is what you people call a single-payer system. It covers 4 'branches' namely - Health Insurance (l'Assurance Maladie - we always seem to favor the pessimistic point of view) - Insurance against work accidents and illnesses - Pensions - Subsidies for families with >= 2 children

[Insurance for workers who lose their jobs belongs with a separate but similar entity called ASSEDIC].

La Sécurité Social is not government-run.

It has its own budget and is managed jointly (on a 50-50 basis) by trade unions and employer's organizations. In fact the employers are united and the trade unions are divided so that for all practical purposes the employers prevail, but they can't do exactly what they would like to do. [This is a personal appreciation based on facts].

How is it paid for?

It's not free! It is not paid for by taxes (or should not be) !

So how does it work? Let me give first my personal example. Each month I get about 4200 euros on my bank account from my employer. But my employer

pays 9500 for my salary. The difference, that is 5300, goes almost entirely to la Sécu (that's the social contribution). About half of that serves for Health insurance.

On the 4200 I get, I still have to pay the tax on the revenue (about 450 in my case) and local taxes (about 450 as well - I live in a city where local taxes are very high).

I think I have convinced you that it's not for free.

The algorithm for computing social contributions is complicated but roughly speaking, half of what an employer pays goes to the employee and the other half is the social contribution. That is, the social contribution is hardly progressive (meaning the ratio contribution/salary is roughly constant, unlike the ratio revenue tax/revenue).

Are there problems?

The system works well in the sense that if you are seriously ill you do not have to worry too much about money; essentially all is paid for.

Still everything is not paid for (especially in the case of everyday ailments) and there are more and more exceptions, more and more cases when you have to pay something - or even everything. But, if this trend is alarming to many people, right now we pay on average a tiny proportion of the costs.

It has drawbacks. The social contributions are public money (in a sense) which goes essentially to private pockets: most physicians, pharmacists and other medical professionals work in the private system, some hospitals are private, others are public. The fees are in principle negociated with La Sécurite Sociale but very often physicians ask for much more than what will be refunded to their patients. And of course the Pharma industry profits vastly. La Sécurité Sociale is not in a strong position to negociate as it is basically run by employers and governments are submitted to constant lobbying from the industry and physicians' organizations.

Moreover employers complain that the cotisations sociales are too much of a burden for them and since around 1970 all governements have granted them rebates (recall that basically employers also manage la Sécu). In principle those rebates are complensated by government money (that is taxes!) but in fact the government owes a huge amount to la Sécu. What with that and the increase in costs, la Sécu has a big deficit [in fact it's not that clear - according to some it is made up] which is constantly invoked to reduce payments.

Also, part of the population say that La Sécu is ill-managed, that many people cheat etc. In my opinion this is only marginally true and is mostly used as a political weapon against La Sécu.

How is it perceived?

All in all the French are deeply attached to their healthcare system. Some politicians and a small part of the population advocate a private insurance system like in the US. But I believe (hope?) that so far public opinion would absolutely oppose that.

My personal point of view is that in a sense the French system is crazy since public money goes to the private sector. I am often pissed off when I see industrial interests prevailing or when physicians get an huge increase in their fees when salaries are frozen.

But it works, in that people are effectively protected, and there is a strong consensus around it. That, in my opinion, is a good reason for keeping it going and protecting it. In fact all people involved have an interest in keeping the system as it is. I suspect that if we had an entirely public system, it would be much easier to attack it, less people would defend it, and ultimately it would be privatized which would be a disaster.

What do I think about the situation in the US?

Before WWII, there were private insurances in France (some non-profit, others profit oriented). After WWII France was in shambles, and in a near-revolutionary context, the Conseil National de la Résistance, using its quasi-divine prestige, initiated the French Welfare State. It took nonetheless more than 50 years to arrive at universal health care.

The situation in the US is less favourable so it would not be realistic to hope to achieve everything at one single stroke.

The French system is robust because it blends public and private interests into a notion of public service.

I think that, considering what US culture is, and where you are coming from, aiming at a 100% public system is not reasonable (even if I understand that such a system is preferable; but it seems the British system is having difficulties too).

You see, it would be all right to have a system which satisfies perfectly liberals: but, apart from the fact that I'm not sure all liberals can be perfectly satisfied at once, such a system would not live long. In order for the system to be long lasting it has to be accepted by the most part of the population.

In the current debate on Daily Kos, I note that 'bill-killers' denounce mostly what the bill does not do. There is also a lot of distraction about who did what with whom. In this diary I'm not interested in that; I

try to assess what the bill does, and what further evolutions it makes possible.

The French experience convinces me that a single bill cannot do everyting at once. This is a multi dimensional problem, or a war on several battlefields. The present bill has many flaws; most of these flaws can be corrected by subsequent bills; but it has also, in my opinion, the following merits (I'll make it short - 4 items only):

It establishes healthcare as a universal right - and that means, also, a universal duty! Healthcare has a cost, and everybody must pay for it othewise it doesn't work. This means a complete change of perspective. Once people have accepted that, the landscape will be completely different.

I think this is the key point and even liberals find it hard to swallow. Many oppose mandates because they are pissed off by such and such flaw in the bill (notably the fact that their money will be going to private insurance). I understand that but if you believe in universal healthcare

you must accept that you will be forced to pay even when you're in good health and your money will be going to private interests, notably the pharma industry and you will be pissed off. This happens in all the countries which have good health care (at least, it happens in France) but we have health care and that is what matters foremost. It's up to us to try and fight the lobbies when necessary and to elect politicians who will protect health care against private interests. There is no miracle here.

In the short term it makes healthcare more affordable and it will save many people from horrible situations. Sounds trite but there is no denying that. You can't imagine how these stories about people going bankrupt because of health problems sound barbaric. This is a humanitarian crisis, not a political game.

Even if it doesn't create a public option (not to mention single payer), the bill creates a new paradigm where private insurances provide a public service. By which I mean that they become accountable to the people (being providers of something which is no longer a marchandize but a right) and to the government which subsidizes.

That may seem a bit theoretical and far-fetched but I really think it makes thinks completely different. It applies a new sort of pressure on the insurance industry. They are the instruments of law; they can be taken ot task if they do not implement the rights of people. The insured are no longer just customers, they are human beings who have a right to healthcare. And, since the government subsidizes, it has a strong interest in people being happy about the system and in getting its money's worth.

Tis bill is by essence a step which will be followed by other steps. It creates a dynamic situation. As I see things, private insurance won the ability to survive. If their profits had been limited to 10%, that would have killed them ultimately. At 15% they can survive but with the pressure and the new obligations they will be facing, life will be harder for them and there will be room for non profit insurance. A public option will become possible. Legislation will follow.

Of course you people know the situation in the US much better that I do, still I've been following these discussions for quite some time and I think I understand what it is all about, to a certain extent. As I said previously, I've been an obamaniac from the start. During the 'primary wars' there was only one point on which I thought Hillary was right and Barack wrong: mandates. I think that mandates are a very positive part of this bill.

I expect many critics, but I would require only one thing: that in comments, you should discuss what the bill does, its pros and cons, what may come to pass. I beg you not to discuss individual people's actions or strategies. That is not what is at stake now and it only obscures this very important question. And there are many diaries on the rec list for that. Thank you for your attention!

Update [2009-12-26 13:57:16 by French Imp]: Wow! Thank you very much for the rec' list and especially for your positive reactions. Thank you also for granting me my wish and discussing the issues and avoiding the various distractions.

My primary aim was to provide some perspective. The French system is often considered as one of the best; however it is not perfect and I think that dreaming about the ideal system is good but it is also useful to have actual working examples in mind.

The second part of my diary is of less interest, as you know better than me what is good for you! As to my ignorance of the US situation, many thanks to those of you who were kind enough to deny it, and to those who agreed with me that it is considerable (and who turn out to be also those who disagree on my conclusions). However I would like to insist that, while I think this bill should pass, I also agree that it has many flaws. Killing this bill would be a huge mistake, but if it can still be improved even marginally that's fine. And once it is passed, it must be followed by better legislation until you reach a reasonable form of universal health care.

I will try to answer your questions as soon as possible.