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September 2015
Cour des Comptes
hereby publishes its annual report on the implementation of the Social
Security Finance Acts.
Despite the persistence and amount of Social Security
’s abnormal
deficits, the latter receded
only slightly in 2014, as in 2013.
A marked slowdown in the speed of the deficits
’ reduction
is expected in 2015. The goal of
balancing social security accounts in 2017 is henceforth postponed for an indefinite period.
Cour des Comptes
identifies the new possible fields of reform which could help restore
Social Security’s financial balance.
A modest reduction of Social Security deficits in 2014
In 2014, the general Social Security, which includes the main health insurance, family benefits, workers
compensation and pension schemes for the private sector, was in deficit for the thirteenth year in a row.
The deficit registered in 2014 (-
bn.) was lower than that of 2013
by €2.2
bn. This limited reduction
was once again made possible only by increased levels of social contributions and taxes. Although
social expenses have been consistently less dynamic in 2014, they still increase faster than GDP or the
wage bill.
Return of social security accounts to balance postponed for several years
According to the most recent forecasts, sluggish growth combined with steady increase in expenditure
should result in a marked slowdown in deficit reduction for 2015. This course of events means that
return to balance is delayed, in the best case scenario, until after 2020.
In these circumstances, social security debt is continuing to grow, raising the prospect that an ever
larger proportion of the latter will be financed on a short-term basis on volatile financial markets. It is
paramount that this short-term debt be taken over by the Fund for amortisation of the social security
debt (Cades
Caisse d’amortissement de la dette sociale
Focussing on tighter control social expenses
Since 2012,
bn of additional revenues has been drawn upon for reduction of social security
deficits. Following this trend would be contrary to the current public policy that consists in encouraging
competitiveness and employment by means of a vast company tax credit (CICE /
Crédit d'impôt pour la
compétitivité et l'emploi
) and by further decreases of compulsory insurance contributions. The extension
of such discounts on social contributions is a sensitive issue. Balance of social security accounts can
only be achieved by more ambitious efforts with regard to control of expenditure, particularly within the
health insurance system, which in itself accounts for half of social security deficit.
The urgent need to curb health insurance expenditure through structural reform
While the health insurance deficit amounted to €5.9bn. in 2012, it is set to reach €7.2bn. in 2015.
Although the target of the annual national health insurance spending set by Parliament(ONDAM /
Objectif national annuel de dépenses d’assura
nce maladie
) has improved in its structure, and despite its
deceleration, effective spending has increased by +2.4% in 2014.
Tighter control of health insurance spending can by and large be achieved by two means: increased
efficiency in services providing healthcare and tighter control of particularly dynamic items of health
Enhancing the reorganisation of the health system
According to the
Cour des Comptes
assessment, the initiatives undertaken over the last twenty years
for reorganising the mapping of health structures have been disappointing. 37% of health expenditure is
still taken over by hospitals and clinics. The organisation of outpatient services/community healthcare
has changed little. Significant inequalities remain regarding access to health. Further reorganising of the
supply of health care is thus required.
The network of maternity wards, which has been thoroughly reorganised since the end of the 1990s, still
acknowledges vulnerable situations due to serious financial imbalances and shortages in hiring. The
future of the 18 cancer-treatment centres (
centres de lutte contre le cancer
), is called into question by
the financial weaknesses shown by some of them.
Firmer control of dynamic expenditure needs to go hand-in-hand with
improvement of the quality of treatment provided
Expenditure due to nurses and
masseurs/physiotherapists services
represented €10.7
bn. in 2014 and
has increased by 5.7% per year since 2000 (in constant euros). Population ageing notwithstanding, its
main factor is to be found in the vast increase in the number of professionals, are very unevenly
scattered on
territory. This situation calls for more effective provision of treatment.
The treatment of end-stage chronic renal failure, to take another example,
represents €3.8bn. and is
growing by 4.9% per year. However, prevention and provision of treatment modes that are most cost-
efficient and best adapted to
patients’ needs (
home-based haemodialysis and transplants) are
insufficiently developed, while the majority of dialysis treatments is provided by overly paid medical
Social solidarities require an overhaul
Coverage for medical expenses by basic compulsory medical insurance has deteriorated since the
1990s, patients suffering from
long-term illnesses (ALD /
affections de longue durée
) aside. The
proportion of healthcare expenditure reimbursed by the national health care insurance system was only
61.3% in 2012 and a mere 51% for community healthcare/outpatient services. However schemes
providing access to supplementary cover for low-income households show qualified results, albeit faced
with looming financial difficulties.
The vast diversity of rules regarding pensions for widows, which amount to
generates wide
discrepancies between pensioners. Their modernisation has become highly necessary.
Improved management needs to be part of deficit reduction goals
Strategic organization management of the healthcare system by the central administration should be
consolidated. The general social security network calls for continued reorganizing, while basic social
security offices should be pooled together. Q
uality of health institutions’ management processes
to be improved and thus contribute to tighter expenditure.
A comparison of pensions and health insurance systems in France and Germany
highlights greater collective involvement of German stakeholders
The French and German retirement pension and health insurance systems are based upon similar
principles, which show close parallels in terms of their organisation and financing.
However, their financial balances show uneven performances: while the German health insurance
system showed a surplus of €12
bn between 2000 and 2014, France was registering
a deficit of €105
in the meantime. Over the same period, the old age pension scheme for employees showed a surplus
of €16bn. in Germany as compared with a deficit of €65bn. in France.
Amongst the roots of such discrepancies, the
Cour des Comptes
sheds light on the explicit priority of
financial balance in Germany. Stakeholders (social insurance contributors and prescribers in particular)
are made well aware of the responsibilities placed upon them, which highlights one of the foundational
elements of the social security system in Germany.
Out of the 240 recommendations set out in the 2012, 2013 and 2014 reports on the social security
system, 59% were implemented, thoroughly or partially.
This year, the
Cour des Comptes
sets out 55 recommendations, some of which are reiterated, aimed in
particular at:
returning to a sustained financial balance for Social security and reducing its debt in the near
improving the structure of the
national health insurance spending target (ONDAM) and
consolidating its implementation;
reinforcing the consistency and clarity of social security contributions;
reorganising healthcare provision;
improving control of health insurance expenditure;
modernising social solidarity schemes;
managing more effectively social security organizations.
To read the full report click here
Ted Marx
Head of communication
+33 (0)1 42 98 55 62
Denis Gettliffe
Head of Press Relations
+33 (0)1 42 98 55 77