Opinion of the Economic and Social Committee on 'Supplementary health insurance'
Date: 2000-05-24
Institutions: European Economic and Social Committee
Subjects: additional benefit, equal treatment, health care, health insurance, social security

18.7.2000

EN

Official Journal of the European Communities

C 204/51

Opinion of the Economic and Social Committee on ‘Supplementary health insurance’

(2000/C 204/11)

On 11 April 2000 the European Parliament decided to consult the Economic and Social Committee,
under the fourth paragraph of Article 262 of the Treaty establishing the European Community, on
‘Supplementary health insurance’.

The Section for Employment, Social Affairs and Citizenship, which was responsible for preparing the
Committee’s work on the subject, adopted its opinion on 5 May 2000. The rapporteur was Mr Bloch-
Lainé.

At its 373rd plenary session of 24 and 25 May 2000 (meeting of 24 May 2000), the Economic and Social
Committee adopted the following opinion by 113 votes to two with two abstentions.

1.

INTRODUCTION

I. Analysis of the Working Document

1.1.
A working document of the European Parliament’s
Committee on Employment and Social Affairs, on supplemen-
tary health insurance (PE.286.193 — DT/402.876), was
referred to the Economic and Social Committee. The Com-
mittee warmly welcomed this referral
for two series of
interlinked reasons: firstly, the importance and seriousness of
the subject in question; and secondly, the role the Committee
believes it can and should usefully play in the future in the on-
going preparation of the basic building blocks of a European
social model.

1.2.
In its preamble to the present opinion, the Committee
highlighted how the document in question forms part of a
series of discussions and documents aimed at a clearer
definition and establishment of the Union’s social mission.
The initiative taken by the EP’s Committee on Employment
and Social Affairs bears witness to the growing attention
which has focused since the early 1990s on the question of
social protection, of which health cover is a major factor in
combating social exclusion. Following the recommendation of
27 July 1992 on the convergence of social protection objec-
tives and policies(1), recognition of this aspect has been
expressed in three Commissions communications in 1995,
1997 and 1999 (2). On 1 March 2000, the Committee issued
an opinion on the Communication from the Commission on
a concerted strategy for modernising social protection (3).

The working document on which the Committee is

1.3.
now being consulted marks a new stage in this process.

Three elements can be identified for the purposes of analysing
this text: a judicious reminder of certain basic rules laid down
by the Union Treaties, governing how the question should be
approached and handled (A); recognition of a worrying
situation (B); and proposals (C).

A. The constraints of the institutional context

1.
The document recalls that responsibility for organising
and funding national social protection systems lies with the
Member States.

2.
It emphasises that social protection is implemented
according to models, and shaped by social and historical
factors, unique to each Member State.

3.
It highlights the fact that by virtue of the direct appli-
cation of the principle of subsidiarity, the Member States must
retain their own responsibilities in this field.

4.
It points out that free competition, which is one of the
basic principles of the European Union, will of course continue
to govern the insurance industry.

5.
It indicates that in this field as in others, in accordance
with the approach laid down in the Treaties, the Union should
take action ‘by establishing minimum standards’ with the aim
of creating a ‘safety-net’.

The document states that so-called ‘comfort’ treatment

6.
lies beyond its scope.

(1) OJ L 245, 26.8.1992, pp. 49-52.
(2) COM(95) 466 final — COM(97) 102 final — COM(1999) 347

final.

(3) CES 238/2000 — OJ C 117, 26.4.2000, p. 33.

The Committee has highlighted these points from the docu-
ment in order to illustrate the clear concern of its authors not
to underestimate any of the constraints to be observed, and
difficulties to be overcome, in responding adequately to the
challenges raised by this issue.

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B. An alarming picture

To sum up: in spite of the diversity of national circumstances,
emerging or worsening discrimination in terms of prompt
access to high-quality care can be seen in all the Member
States. This inequality — which there is no reason to suppose
will disappear spontaneously — is a particularly damaging and
unacceptable form of social exclusion and can only tarnish the
image and future of the European venture.

1. R e a s o n s

Although the Parliament document sets out to define the scope
of supplementary health insurance, the direction and scale of
problems in this area cannot be clearly grasped without an
understanding of the background. This may be summarised as
follows:

— regardless of their specific features, all European health
protection schemes are confronted with a number of
powerful trends, i.e.:

— a history of 25 years of sluggish growth, generating
unemployment
contributory
and restricting
capacity — tax or social security contributions — of
households and businesses;

the

— an ageing population;

— the appearance of new diseases and, as a result of
progress in research and treatment, increasingly costly
care.

The combination of these factors has, with very few exceptions,
inevitably led to a decline in the proportion of total health
spending — which is everywhere rising as a percentage of
GDP — covered by public funds. At the same time, and in
several parts of Europe, it has been seen that access to prompt,
high-quality care for the most disadvantaged individuals has
become more difficult, or even that the quality of care available
to them has deteriorated. In other words, statutory solidarity-
based health systems have, to varying degrees, reached their
limits.

As overall cover funded by compulsory contributed has
contracted, cover by supplementary insurance has expanded.
Private sector social protection systems — whether profit-
based or otherwise — have grown, at varying rates and in
different ways.

Use of supplementary health insurance, together with any
improvements broadening its availability, can and should be
hailed as fundamentally beneficial. To do so is simply to
recognise the facts. Recognising the facts, however, entails not

idealising supplementary cover, but rather striving as far as
possible to eliminate any ambiguity. To this end, and at this
stage of its opinion, the Committee would emphasise the
following points:

a) For quite understandable reasons, which it would be facile
to condemn, political discourse often tends to obscure the
reality of existing constraints and, with regard to public
opinion, to perpetuate the illusion that states can and will
continue to be able to satisfy aspirations, regardless of
their contributory base. It is to be hoped that courageous
steps can be made in the direction of plain speaking to
public opinion.

b) Whether we like it or not, supplementary insurance
mechanisms respond, in varying ways, to essentially differ-
ent operating principles to statutory schemes, from two
interlinked points of view:

— their costs depend on the nature of the risks. The cover
they provide depends on the financial capacity of
clients or members. These costs can act as a deterrent.
A selective approach,
is
therefore in play.

in one form or another,

— all these schemes, whatever their motivations, cultures
or strategies, operate in a competitive environment.
Membership or contracts are voluntary. This cannot be
changed without running counter to their nature and
destroying their own basis, and without the state
abandoning to them its fundamental mission of soli-
darity. From this point of view, as well as others, the
Parliament document is perfectly clear. This does not,
however, imply that we should simply sit back and
watch an unfolding situation leading to financial
and/or health-determined exclusion, on the grounds of
not interfering with competition.

Whether they say so openly or not, the Member States are all
aware of the implications of the choices they must make:

— to increase the burden of compulsory contributions (taxes

and/or social security);

— to allow the quality and rapidity of care to be reduced;

— to optimise the growing role of supplementary cover

systems; or

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— to make statutory schemes work more effectively.

The question raised in the document submitted to the Com-
mittee concerns the steps to be taken in this third direction.

§ 2-3.
The purpose of the right to health care is to guarantee
prompt access to medical care which is judged necessary under
medical criteria deemed to be objective. This can only involve
medically-recognised needs.

2.

I d e n t i f y i n g o b s t a c l e s

§ 3-5.
care are covered by statutory schemes, and to what level.

It should be ascertained whether optical and dental

It should be pointed out that here, we are touching upon
difficult and delicate matters, on account of the diversity of
circumstances, traditions and approaches of the EU Member
States:

— taxes in one place; contributions in another; elsewhere,

both, to varying degrees;

— legislation in one place; negotiation and contracts in

another;

— differentiated procedures in one place; uniform ones in

another, etc.

II. Specific comments

N.B.: This part of
paragraph by paragraph order of Parts II and III of
Parliament document.

the Committee’s opinion follows the
the

Preamble — Part II

The Committee welcomes and endorses the restatement of the
purposes of social protection for which the European Union is
responsible, both in recognising specific characteristics and in
acknowledging the common objective of solidarity.

Part III of the document

§ 3.
This paragraph states that ‘the laws of the market
would tend to introduce selection on the basis of risk’. The
Committee notes that all the market players are seeking clients.
Some offer the lowest premiums. They select ‘good risks’:
young, healthy people. Others pool risks, preventing the most
economically disadvantaged, the most sick and the oldest from
being excluded. In a crude interpretation of the law of the
market, systematic risk selection can only lead to the eviction
of the weakest from the market.

The document advocates minimum rules in order to prevent
withdrawal of social cover. If this refers to absence of the
minimal care which would be covered by the statutory
schemes, then the quality of care and time limits for provision
of care should be specified.

A pool system should be organised for ‘major risks’, setting
up, for example, guarantee funds, to be financed by insurance
operators, shouldering the cost of additional premiums.

§ 5.

The Committee fully endorses the remark.

§ 1-2.
The Committee believes that the figures quoted
would be clearer if they indicated the portion of expenditure
which is reimbursed.

III. Opinion on the proposed measures

§ 1-3.
The Committee considers that to make the point
more effectively, European-level data — if available — should
be provided. This would help to clarify which types of care,
treatment or products have to be paid for in part or full by the
patient. In an attempt to control spending, while maintaining
a basic minimum level, some Member States have introduced
new arrangements to determine selection priorities. Infor-
mation on this point would be welcome.

The Committee believes that solidarity, as a principle,
§ 1-5.
firstly concerns statutory schemes. The question of possible
sharing solidarity with supplementary schemes should be
subject to open debate. This point cannot be left hanging.

A. Charter of fundamental rights

The Committee feels that the charter should lay down strong
principles: it should be based on the Council of Europe’s social
charter and the charter of workers’ fundamental rights.

B. Follow-up instruments

The Committee believes that the Union should set up effective
means for European-level monitoring of this important subject:

Figures on the number of people covered by sup-

§ 2.
plementary health insurance should be made available.

— either by means of an some existing agency;

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— by allocating the necessary logistic and budgetary resources
to the social protection committee, which it has recently
been agreed to set up;

— or, if such resources are not allocated, by setting up an

observatory.

C. Framework of basic rules

1.
The Committee advocates retaining a shared concept of
universal service with regard to access to high-quality, prompt
care.

State. This would prevention the exclusion which over-zealous
use of a risk-selection approach might cause.

The Committee favours a recommendation to this end, under
the provisions of Treaty Article 152.

3.

The Committee is in favour of the idea of life-long cover.

In the Committee’s view, every effort should be made to

4.
mobilise supplementary insurers in prevention activities.

The Committee opposes the use of genetic data for

5.
discriminatory insurance purposes.

2.
It considers that the aim should be to lay down guidelines
rather than to legislate in an area whose complexity has
been clearly shown. The objective would be to ensure that
contractual specifications, serving as codes of good conduct,
would be negotiated with private insurers in each Member

6.
The Committee would like to see an ombudsman
established in each Member State to help assessment and
resolution of disputes between insurance companies and
policy-holders on the basis of the ethical codes advocated in
point 2 above.

Brussels, 24 May 2000.

The President

of the Economic and Social Committee

Beatrice RANGONI MACHIAVELLI