The management of dependency must evolve. The associations plead in favor of collective financing of disabilities, regardless of age. This solution could involve the creation of a fifth social security risk.
This is a subject that brings together patients, their families and professionals in the sector. We are not talking about dependence, but about loss of autonomy. The chorus is not new, but it takes on new meaning on the eve of the presidential election. At a time of aging French society, the rise of chronic diseases and disability, associations agree on one point: the current system no longer holds. It must therefore evolve.
For Pascal Champvert, president of the AD-PA (Association of Directors in the Service of the Elderly), there is no doubt: the term dependency is the reflection of a society that discriminates against the elderly. “No one wants to be dependent,” he says. If we want to understand France’s backwardness, we must integrate the fact that society is ageist. Indeed, only one difference separates disabled and dependent people: age.
A common fund
A single example can summarize the magnitude of the problem. Before 60 years of age, several aids are available to disabled people. After this anniversary, some disappear without being systematically replaced. The personalized autonomy allowance (APA) is emerging. An exchange from which the patient does not necessarily win. The 60 candles blown out, “we are considered a burden, and not a chance,” laments Danielle Rollat, national vice-president of Ensemble et solidaires – UNRPA.
To evolve, dependency should therefore bring together all forms of disability; this would be Social Security’s fifth risk. According to a Senate report, carried out in 2007, such a system would require a budget of 18.5 billion euros – including 8 billion dedicated to the elderly.
Several arguments plead in favor of this solution, starting with the missions of the National Solidarity Fund for Autonomy (CNSA). Created after the deadly heatwave of 2003, it is most often associated with supporting the elderly. However, it is also responsible for coordinating actions in favor of disabled people. Since 2005, for example, it has managed departmental houses dedicated to this public (MDPH) and a specific service (PCH) open to citizens aged 20 to 59.
Redundant devices
The Court of Auditors itself underlines this in a 2016 report : Supporting devices may be redundant. Three coexist and aim to coordinate the different sectors of dependency care. But strong territorial inequalities are noted. In Essonne, for example, several gerontological networks are in place, several MAIA (1) and one PAERPA (2) “even though other areas remain poorly covered, if at all”. Not to mention that the budgetary constraints at the departmental level of health insurance “lead to setting the remuneration rates for services as accurately as possible”. The situation is just as complex in terms of disability.
Bringing together the mechanisms and sources of funding therefore makes sense. “Active solidarity must develop for people losing their autonomy,” insists Danielle Rollat. And I also include people with disabilities who need help all their lives. It is even an old tune: from 2007 to 2009, the State advanced its pawns towards the creation of the fifth risk of Social Security, dedicated exclusively to the loss of autonomy. The idea presented in 2009 is clear. It is a question of universalizing aid regardless of age, while improving home support and developing public / private partnerships. “It’s a fight that we have been waging for a long time,” underlines Joël Jaouen, president of the France Alzheimer association.
Evolution is inevitable
According to a study conducted by the DREES, the French are in favor of such a system. 6 out of 10 argue for the increased involvement of the State and the public authorities in dependency, and 85% are in favor of greater solidarity towards people with disabilities. Danielle Rollat goes further. She judges that all the elements are there. It remains to re-organize them. “Funding is already taken care of by the departments, via children’s aid for example,” she explains. Concerning the elderly, the management of the APA has been entrusted to the departments with commitment from the State. “
Pascal Champvert, president of the AD-PA: ” The French regularly say that they are ready for more solidarity, because everyone has had a family member at home or in an establishment. They know there is not enough time. “
Despite this collective enthusiasm, in 2011, the fifth risk was dropped during the national debate on addiction. However, such a development seems inevitable in the eyes of Joël Jaouen. A change that should not be rushed, however. All disabilities are not the same, he recalls: “There are different drawers. For example, Alzheimer’s disease is in the field of neurodegenerative diseases. We have things in common, but a lot of things also separate us. The balance between bringing together and taking into account differences promises to be delicate.
The variable involvement of the State
With its multiple allocations at different scales, France is located halfway between its neighbors in northern and southern Europe, estimates the Court of Auditors in a report dedicated to dependency. The distribution of expenses is shared between families and public authorities, which is not the case everywhere.
Germany has taken the step of the “5e risk ”from 1995 with the creation of compulsory long-term care insurance. With success since at the end of 2013, this system covered 2.5 million people, ie almost the entire target population. A choice that Japan has also made, with a few nuances. The Land of the Rising Sun offers universal insurance after 65 years, the State playing the role of organizer and the municipalities that of insurer.
The states of southern Europe are more cautious about their investments. Traditionally, the family is considered responsible for its elders. The smallest public resources are also taken into account. In Italy, for example, interventions in the dependency sector pass through framework laws but the regions and municipalities are responsible for implementing them.
(1) MAIA: Houses for the autonomy and integration of Alzheimer’s patients
(2) PAERPA: Elderly People at Risk of Loss of Autonomy
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