PLFSS 2009 ou la bataille des amendements

Véritables lois financières avec de véritables « soldes » financiers, les lois de financement de la Sécurité sociale offrent, depuis la loi organique du 2 août 2005, une grande lisibilité des comptes sociaux au Parlement qui est en mesure de comprendre l’évolution et l’usage de l’Objectif national des dépenses d’assurance maladie (ONDAM). Il n’est pas aisé de fixer les dépenses d’assurance maladie dès lors que, si ces dernières présentent en partie un caractère obligatoire (les assurés sociaux ont droit à une protection), elles sont également marquées par l’aléa, incertitudes liées à des événements extérieurs (croissance faible, pandémie grippale, etc.) ou à des comportements collectifs (abus de prescriptions, évasions fiscales, etc.).

En acquérant une portée indirectement normative, l’ONDAM est devenu l’instrument de la réduction de l’offre de soins.

Pour mémoire, l’ONDAM se calcule sur la base des évolutions de dépenses de l’année précédente et en considération aussi bien des besoins de la population que de la croissance de la richesse nationale. Le but est bien sûr d’éviter que les dépenses ne croissent plus vite que les ressources qui les financent, sans remettre en cause la liberté d’accès aux soins reconnus aux assurés sociaux.

Le calcul de l’ONDAM 2009 n’avait pas initialement prévu la grave crise financière qui est apparue il y a maintenant un peu plus d’un mois et qui est un événement par nature aléatoire et imprévisible.

Or, l’article 47-1 de la Constitution fixe le délai d’examen du PLFSS à 50 jours, ce qui est extrêmement bref. Déposé le 13 octobre dernier, examiné par les députés dès le 28 octobre suivant et voté solennellement par l’Assemblée nationale le 4 novembre dernier (voir ici), le PLFSS 2009 a été rapidement expédié vers les sénateurs.

C’est ainsi que les différentes fédérations de l’hospitalisation, en amont de cet examen, ont –  c’est désormais un rituel – aiguisé leur argumentaire et ont prévu leurs propres amendements.

Dans son argumentaire, la FHF considère que l’hôpital public est le garant de la qualité des soins en France, auquel les Français sont très attachés. Loin d’être un monolithe incapable de se réformer et d’innover, cette structure publique sait s’adapter pour une meilleure efficience (contraction des termes efficacité et science ?). Or, le service public de la santé est aujourd’hui menacé par l’asphyxie budgétaire, par la fragilisation de l’égalité d’accès aux soins et la convergence des tarifs public/privé sans tenir compte des activités propres au secteur public telles que la prise en charge de la précarité, insusceptible d’être mesurée actuellement par la tarification à l’activité.

Parce que les hôpitaux ont vocation à soigner tout le monde sans distinction. Parce que leurs missions d’intérêt général sont insuffisamment financées. Parce que les hôpitaux publics engagent des dépenses dont les cliniques peuvent se dispenser. Parce que les hôpitaux publics gèrent du personnel au statut très protecteur et sur lequel ils n’ont pas de prise. Pour toutes ces raisons, la FHF souhaite plus de moyens à disposition des hôpitaux pour défendre leur image d’excellence et assurer l’égalité d’accès aux soins de tous les citoyens.

A cette fin, elle a préparé un panel d’amendements.

Dans son argumentaire, la FHP dresse le constat de ce que l’hospitalisation privée prend en charge et soigne 7 millions de personnes par an, détenant ainsi une place essentielle dans l’offre de soins. Les cliniques emploient les deniers publics à bon escient, qualité attestée, selon la FHP par l’Inspection Générale des Affaires Sociales, par l’Assurance maladie, et par l’Agence Technique d’Information sur l’Hospitalisation, cependant que les hôpitaux publics sont empêtrés dans une culture du déficit et gèrent des charges de personnel écrasantes pour un absentéisme chronique.

La qualité des soins dispensés dans les établissements privés lucratifs est reconnue par l’ancienne Agence Nationale d’Accréditation des Etablissements de Santé (ANAES), devenue Haute Autorité de Santé (HAS).

La FHP explique enfin que la convergence tarifaire est un impératif vital et possible, en ce qu’elle est inscrite dans la loi, parce qu’il s’agit d’une question d’équité et d’un impératif économique pour l’Assurance maladie.

Proposition audacieuse, ce syndicat propose, à titre expérimental, de confier par contrat la gestion d’établissements publics en situation de déficit chronique, à des opérateurs privés.

Ses propositions d’amendements peuvent être consultées ici.

En l’absence d’argumentaire, la FEHAP, de son côté, a focalisé ses propositions d’amendements sur des points précis, tels que la fixation des tarifs plafonds pour les unités de soins de longue durée, la valorisation de l’activité de consultations externes des praticiens salariés, le reversement par les établissements d’hébergement des personnes âgées dépendantes des sommes indues dans le cadre des forfaits de soins, etc.

Il reste peu de temps maintenant pour que ces différents syndicats pèsent de tout leur poids dans les discussions devant le Sénat afin de faire valoir leurs arguments où se mêlent à la fois études sérieuses et fiables, mauvaise foi et tactique politique. C’est le jeu de la démocratie.

Omar YAHIA

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