Long Term Care (LTC) as a 5th branch of the french social security system, how would that work?

Loss of autonomy associated with old age is not a recent discovery. It is in fact an issue that has been handed on over several recent presidential terms. But crises keep on appearing and are not necessarily alike. While previous crises had invariably led governments to postpone the LTC issue, the crisis due to Covid-19 has brought caregivers and elderly care homes to the front of the stage. The emotion aroused by the fragility of elderly people and the institutions that care for them begs for an answer. So, there is now an “LTC” momentum! The solution would be to create a 5th SS branch to be labelled “dépendance” (dependency). But, what would that really change?

Increasing life expectancy is a challenge for our social model

According to figures from the Ministry of Health, the number of ‘dependent’ elderly people stood at 1.265 million in 2015. This figure is expected to reach 2.235 million by 2050, i.e. almost double. Not surprisingly, the cost of long-term care (dependency) will follow the same curve. Today, the bill stands at 1.4% of GDP, or 30 billion Euros. In forty years time, LTC is expected to cost 2.78% of GDP. This development, due to increasing life expectancy and therefore population ageing, is inevitable. Even though the system is already under pressure, we must anticipate an increase in financing needs. Caregivers are complaining that there is a shortage of staff, remuneration is not attractive enough and homes are in a bad state. After the health crisis, this feeling is shared by the population at large. The OECD, in a recent study, confirms this. France has only 2.3 LTC professional caregivers per 100 persons over age 65 compared to an average of 5 in OECD countries.

How can a 5th SS branch be financed?

Given current circumstances, creating a 5th SS branch devoted to LTC, comes over as a strong gesture. It is the recognition of “dependency” as a fundamental social risk. It should make it possible to institute a coherent and standard old-age policy across the whole country, as called for in the Libault report. There are many avenues for improvement: relaxing  compartmentalisation of working conditions, avoiding disruptions in the “care itinerary”, strengthening prevention, encouraging home care, supporting the development of practitioners’ skills, upgrading professions, simplifying systems and improving their readability… Beautiful ambitions which could however be shattered, as often, on the wall of budgetary realities.

Even if creating a 5th branch could open up new rights for people in France, it still does not solve the major problem of finance. The Libault report estimated that additional costs related to demographic trends and the necessary improvement in cover for LTC would reach 9 billion by the year 2030. Where could all this extra funding come from? First possibility: redeployment of existing resources. This means having to establish priorities in terms of current social protection expenses and, as a result, find savings in certain benefits. This is tricky, to say the least. The easy solution would be to call on businesses once again by inventing a new compulsory contribution. This would be inconsistent with the efforts over recent years to bring down the cost of labour. Final option: play on symbolism and use a flurry of announcements to ask for an effort from people in France such as giving up a bank holiday or a small contribution from retired people. Not so easy….in the end, creating a 5th branch raises more questions than answers.

What should be the role of the private sector?

By officially becoming part of the Social Security system, the LTC risk finally turns its back on the insurance approach – as people in France have wanted. According to the statistical arm of the Health Ministry (DREES), two in three people want loss of autonomy to be covered by the public authorities and 7 in 10 want benefits to be reserved for modest income levels. Insurers and personal protection providers would appear to have little room for manoeuvre. It is just not possible to meet the expectations most often expressed by works councils, namely that insurance should cover not only LTC for employees themselves but also their parents. Recipients of benefits must be part of the company. As for the funded approach, this would mean offering mechanisms similar to those already in existence for retirement savings. An innovative approach could be to set up a modular system offering the possibility of a capital release in the form of a “dependency” annuity payable in addition to SS benefits. But before dreaming up ancillary products, private sector player are, for the moment, just waiting to hear what the new rules of the game are to be.