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Mariona Vivar Mompel Rédactrice en Chef Adjointe News Assurances Pro

Plan séquence - Grande Sécu, grosse fièvre

vendredi 8 octobre 2021

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Alors que les pouvoirs publics envisagent de mettre en place une Grande Sécu, les organismes complémentaires, fébriles, peaufinent leurs arguments contre un projet qui remet en question leur existence. Et préparent leurs propositions pour réformer la complémentaire santé.

La grande Sécu : une vieille idée, un nouveau contexte

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L’idée de créer une grande Sécurité sociale qui gère seule les prestations santé des Français n’est pas nouvelle. Lors l’élection présidentielle de 2017, la Grande Sécu faisait partie du programme électoral de Jean-Luc Mélenchon. Cette idée était défendue par des intellectuels comme Didier Tabuteau, responsable de la chaire santé de l’Institut d’études politiques de Paris, Frédéric Bizard, économiste de la santé ou Martin Hirsch, directeur de l’AP-HP. Cependant, l’idée de supprimer les organismes complémentaires restait minoritaire et uniquement promue par l’aile gauche de l’échiquier politique.

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Par Mariona Vivar

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Un ministre engagé

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L’idée d’une Grande Sécu est sortie de la marginalité avec l’arrivée d’Olivier Véran au ministère des Solidarités et de la Santé. Le neurologue s’est souvent montré critique envers les organismes complémentaires, leurs frais de gestion et leurs hausses tarifaires.

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Devoir de neutralité pour le HCAAM

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Le Haut Conseil pour l’avenir de l’assurance maladie (HCAAM) choisit d’étudier des pistes pour réformer l’articulation entre régime obligatoire et complémentaire. Un rapport avec les études d’impact de plusieurs scénarios de réforme sera publié en novembre 2021. Olivier Véran, ministre des Solidarités et de la santé écrit un courrier au HCAAM pour lui demander d’étudier précisément le scénario d’une Grande Sécu.

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La Cour des Comptes enfonce le clou

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La Cour des Comptes publie en juillet 2021 un rapport dans lequel elle propose trois alternatives au système actuel : le bouclier sanitaire et donc un système de franchise au-delà de laquelle l’État prendrait en charge les dépenses de santé ; une nouvelle répartition des champs d’interventions entre l’assurance maladie obligatoire et complémentaire ; et enfin un encadrement renforcé des complémentaires santé (garanties, frais et tarifs).

Le périmètre des complémentaires se réduit

L’idée d’une Grande Sécu paraît aujourd’hui plus réaliste car plusieurs réformes sont venues réduire le périmètre d’intervention des organismes complémentaires ces dernières années. Par exemple, la fin du régime étudiant d’assurance maladie et du régime social des indépendants et leur transfert à l’assurance maladie.

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La mise en place de la complémentaire santé solidaire a également été l’occasion de placer l’Assurance Maladie comme assureur complémentaire des personnes à revenus modestes. Certes, ils peuvent toujours souscrire le contrat auprès de certains organismes privés qui ont choisi de distribuer la C2S, mais ces organismes ne gèrent plus le risque.

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La crise sanitaire a également été une occasion de tester l’idée d’une Sécurité sociale élargie. Pendant le confinement, l’Assurance maladie a pris en charge tous les soins essentiels pour combattre l’épidémie : les téléconsultations, les tests de dépistage et les vaccins.

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Certains voient également l’initiative de Valérie Pécresse de créer une mutuelle régionale en Île-de-France comme un signe avant-coureur d’une mutuelle nationale.

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Les limites du système Français

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Pourquoi faut-il revoir le système ? Nous sommes à un tournant en assurance santé. Ces dernières années, les pouvoirs publics ont soumis les organismes complémentaires à une injonction contradictoire entre une régulation accrue (contrat responsable, 100% santé, taxe Covid) et un marché de plus en plus concurrentiel (fin des clauses de désignation, résiliation infra-annuelle). Cela a conduit à une situation insatisfaisante pour tout le monde. Les assureurs ne trouvent plus de marges de manoeuvre pour innover et les pouvoirs publics n’ont pas le sentiment de voir les bénéfices d’un marché concurrentiel, à savoir une baisse des prix et des frais de gestion.

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Le Haut Conseil pour l’avenir de l’assurance maladie et la Cour des Comptes se sont penchés sur les défauts du système actuel de protection sociale.

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Pour chaque prestation de santé, il y a deux actes de gestion, l’un par l’assurance maladie obligatoire et l’autre par la complémentaire santé. Ce doublon des frais de gestion est jugé cher par le HCAAM. Les charges de gestion s’élèvent à 6,9Mds pour l’AMO et à 7,6Mds d’euros pour l’AMC. La France est donc le deuxième pays après les États-Unis où les frais de gestion du système de santé sont les plus élevés.

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La couverture complémentaire est jugée protectrice et accessible pour les salariés mais chère et de moins bonne qualité pour les retraités, chômeurs, étudiants et indépendants. Les assurés les plus modestes pour qui le taux d’effort est trop important risquent de résilier leur contrat. Le marché est segmenté et la tarification en fonction du risque peut rendre insoutenable le financement de la mutuelle pour une partie de la population.

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Les restes à charge après remboursement de l’assurance maladie obligatoire et complémentaire sur certaines dépenses hospitalières sont trop importants.

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Le HCAAM juge ce système à deux étages peu lisible pour les assurés. La complémentaire intervient après le remboursement de l’assurance maladie et il est difficile de savoir quel sera le montant du remboursement avant l’acte médical, tellement la nomenclature est riche et détaillée.

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Tous en ALD, la Grande Sécu vue par le HCAAM

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Le HCAAM doit rendre son avis sur l’articulation entre l’assurance maladie obligatoire et complémentaire en novembre prochain. Une première version non définitive circule d’ores et déjà et s’attarde sur le scénario de Grande Sécu. Étendre le champ d’intervention de la sécurité sociale consisterait, selon le HCAAM, à généraliser le dispositif des affections de longue durée (ALD) à l’ensemble des patients et prises en charge. Cela permettrait de simplifier les règles de remboursement, de diminuer la charge administrative des assurés et des offreurs de soins et à confier à l’Assurance maladie un champ plus large des dépenses.

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Le Haut Conseil considère que dans un scénario de Grande Sécu, « la régulation devrait être renforcée dans l’objectif de maîtrise des dépenses de santé et d’accès financier aux soins ». Cela devrait permettre de « faciliter les réformes des modes de rémunération des professionnels et des établissements vers des formes mixtes ainsi que la généralisation du tiers payant ».

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Concrètement, le HCAAM envisage la suppression de tous les tickets modérateurs qui seraient pris en charge par la sécurité sociale. Cela faciliterait la mise en place des paiements forfaitaires ou à la performance.

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A l’hôpital, la Sécu prendrait en charge le forfait de 24 euros, le forfait journalier hospitalier et le futur forfait de passage aux urgences de 18 euros. En revanche, la chambre particulière pourrait toujours être remboursée par les complémentaires santé. Pour les autres participations financières à l’hôpital, le HCAAM évoque la création d’une « franchise annuelle forfaitaire », ce qui permettrait aux assurés d’éviter des restes à charge élevés.

Concernant l’optique, le dentaire et les audioprothèses, la Sécurité sociale ne prendrait en charge que les actes du panier 100% santé, de façon intégrale, ainsi que le panier maîtrisé pour le dentaire.

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A propos des dispositifs médicaux, la Sécurité sociale définirait une liste des produits et prestations pour lesquels les prix limites de vente est égal au tarif de responsabilité et les prendrait en charge à 100%.

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L’assurance maladie jouerait un rôle renforcé dans la régulation des prix des tarifs conventionnels, des tarifs de la LPP mais aussi des tarifs libres afin de garantir l’accès financier aux soins et la maîtrise des dépenses.

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Concernant l’épineuse question des dépassements d’honoraires. « Il faudrait aligner les remboursements de la Sécurité sociale sur le tarif de responsabilité et remettre à plat les rémunérations des professionnels libéraux », écrit le haut conseil. Les dépassements d’honoraires pourraient toujours être remboursés par les complémentaires santé lors d’une phase transitoire, mais les pénalités fiscales associées à des niveaux élevés de remboursement des dépassements par les complémentaires seraient maintenues.

Quid des organismes complémentaires ? Leur champ d’intervention serait réduit aux exigences particulières des patients (chambre particulière, dépassements, ostéopathie et une partie des médicaments).

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La réglementation des ocam pourrait être « largement allégée ». Le HCAAM parle même de supprimer « l’obligation de souscription des employeurs, les mécanismes spécifiques pour la fonction publique et les travailleurs indépendants, les exonérations socio-fiscales des contrats collectifs. En revanche, les contrats aux garanties inflationnistes ou recourant au questionaire médical resteraient pénalisés financièrement via un taux majoré de TSA ».

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Cette réforme serait délétère pour beaucoup d’organismes complémentaires. La Grande Sécu menace par exemple l’emploi des 36.600 collaborateurs qui travaillent pour des mutuelles sur des activités d’assurance. Le HCAAM aborde l’impact sur les salariés des organismes complémentaires. Il évoque comme solution de reclassement des salariés en interne sur d’autres branches comme l’assurance dommages, la reprise des salariés par les organismes de sécurité sociale ou la reconversion professionnelle.

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Comment financer la grande Sécu ? Pour financer l’augmentation des dépenses prises en charge par l’AMO, il conviendrait d’augmenter les prélèvements obligatoires, en s’appuyant sur plusieurs sources comme les cotisations patronales, la CSG, la TVA et les ITAF.

Les complémentaires santé défendent leur modèle

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Dans ce contexte de remise en question du modèle, les représentants des organismes complémentaires, FFA, CTIP et FNMF, affinent leurs argumentaires. Ils soutiennent que le système français est loin d’être le plus parfait des modèles mais qu’il est le moins inégalitaire, avec le reste à charge le plus faible des pays de l’OCDE.

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La Mutualité Française a mis en place un groupe de travail piloté par Patrick Sagon, le président de La Mutuelle Générale. La fédération mutualiste a créé un « corpus argumentaire sur chacun des scénarios ». « Nous ne serons pas favorables à tout scénario qui portera un coup majeur à notre système hybride mais il faut qu’on trouve une solution pour cette partie de la population qui peine à financer une couverture complémentaire. Nous souhaitons traiter les postes de dépense qui créent des restes à charge excessifs et travailler avec l’assurance maladie obligatoire pour essayer de soulager l’effort de certaines populations », avance Séverine Salgado.

Hors sujet

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Le sujet de l’articulation entre AMO et AMC est devenu un problème pour l’administration, pas pour les Français. Les services de la rue de Ségur estiment que sans les complémentaires, ce serait plus simple d’appliquer le tiers payant, de mettre en place des modes de tarification innovants à l’épisode de soins, par exemple.

Or, « quand on regarde ce qui préoccupe les Français, ils s’inquiètent des déserts médicaux, de l’hôpital, de la prise en charge des parents dépendants ou des enfants handicapés », avance Séverine Salgado, directrice générale de la Mutualité Française.

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L’Association pour le développement de l’assurance française (Adaf), association qui regroupe les 12 plus grands assureurs santé qui représentent 70% des parts de marché, active son lobbying et peaufine ses arguments.

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Attention au trou de la Sécu

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« Un scénario de monopole de l’assurance santé présenterait des risques de dérive des dépenses beaucoup plus importants », souligne un assureur. « Nous sommes un contre-pouvoir de la Sécurité sociale, nous sommes là pour surveiller que la Sécu ne fasse pas assumer aux Français des déficits de plus en plus gigantesques », avance un autre dirigeant mutualiste.

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Attention à la liberté de choix

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Contre la nationalisation du système de santé, les assureurs mettent en avant la liberté individuelle, un sujet en vogue en cette période de crise sanitaire. Pour le patient, liberté de choisir son parcours de soins ; pour le professionnel de santé, liberté de choisir son mode d’exercice et d’appliquer des dépassements d’honoraires ; et pour les entreprises et les assurés, liberté de choisir la couverture santé la mieux adaptée.

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La médecine à deux vitesses

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« Nous pouvons craindre un déremboursement de certains actes, et donc, un reste à payer plus important pour les patients. Cela créerait une médecine à deux vitesses, avec une couverture universelle forcément pas très élevée et ensuite des assurances privées facultatives », indique Thomas Saunier, directeur général de Malakoff Humanis.

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Comment améliorer le système ?

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La Mutualité Française admet que le système est « perfectible » et compte faire des propositions pour corriger ses inconvénients dans les prochaines semaines. « On ne sera pas favorable à tout scénario qui portera un coup majeur à notre système hybride mais il faut qu’on trouve une solution pour cette partie de la population qui est mal couverte.

Nous souhaitons traiter les postes de dépense qui créent des restes à charge excessifs et travailler avec l’assurance maladie obligatoire et complémentaire pour essayer de soulager l’effort de certaines populations », a déclaré Séverine Salgado le 22 septembre face aux dirigeants mutualistes de l’Adom.

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« Nous pensons que c’est aux pouvoirs publics de mettre en place des mécanismes fiscaux pour rendre la couverture plus accessible auprès de certains publics. Par exemple, grâce au crédit d’impôt ou bien en appliquant un niveau de taxation réduit pour certains publics », suggère un dirigeant de l’Adaf.

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La FFA, de son côté, milite pour revoir le partage des champs d’intervention de la complémentaire santé et de l’assurance maladie. Les assureurs voudraient :

gérer seuls les remboursements en optique, dentaire et audioprothèse,
pouvoir avoir accès aux données de santé pour améliorer la gestion du risque grâce la lutte contre la fraude ou des actions de prévention ciblées
pouvoir contractualiser directement avec les professionnels de santé.

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En parallèle des travaux du HCAAM, le Ministère de l’Économie, des Finances et de la Relance, de son côté, a créé un groupe de travail, piloté par le Trésor, afin de proposer des pistes pour réformer l’assurance santé. « L’idée est d’expertiser le sujet, voir quel est l’apport des complémentaires santé et identifier des pistes de réforme qui vraisemblablement ne vont pas ressembler à la Grande Sécu », explique un membre de ce groupe de travail.

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« Il y a beaucoup de solutions à l’étude car les organismes complémentaires ne sont pas uniquement des extensions de la Sécurité sociale. Supprimer les complémentaires provoquerait d’autres problèmes. On doit se poser la question du partage entre ce qui relève de la solidarité nationale et ce qui relève des complémentaires. Elles pourraient demain gérer certaines dépenses en délégation de service public, avoir plus de responsabilité sur d’autres postes, afin de leur redonner des marges de manœuvre pour encourager l’innovation », imagine un autre membre de ce groupe.

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Toutes ces pistes de réflexion devraient nourrir les débats électoraux des mois à venir car la réforme de la complémentaire santé sera vraisemblablement un chantier important de la prochaine mandature.

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