The Commission alone decides how many resources it makes available to the scheme, who are the managers, executors, doctors, etc., what the service orders are, and above all, what the JSIS covers and what it does not cover. It is true that it adopts the lowest level of regulation, the General Implementing Provisions, only after consultation with the unions and some joint bodies, but it is not obliged to follow their advice. And the higher levels of regulation, the Staff Regulations (Article 72) and the Common Regulations, are not subject to any negotiation.
It is true that there is a Management Committee for Health Insurance (CGAM), in which all the institutions and their staff are represented. But it is only consultative in nature. It has nothing to do with a real Management Committee, except in name.
On behalf of the staff of all the Institutions, bodies and agencies, and on behalf of the insured, Union Syndicale demands that the JSIS become truly co-managed, between employers and insured.
Let us continue with a problem of philosophy. The JSIS deliberately limits itself to curative medicine. It refuses a preventive approach, even when all the studies show that it has a beneficial financial effect, to the extent that almost all national schemes emphasise it. It is a question of promoting healthy lifestyles, of contributing to the costs of practising a sport, for example; of detecting diseases at an early stage; of setting up a system for monitoring the progress of children; or simply of taking full responsibility for vaccination.
Then there is this very negative attitude towards alternative medicine, or towards psychological disorders. The regulations in force, with all their holes and ambiguities, allow the medical officers (chosen exclusively by the employers) to refuse to cover treatments that would not be discussed by national insurance companies.
Serious illness is certainly also a problem for the JSIS. The general logic of the scheme is to always leave part of the medical cost to be borne by the patient, in order to make him/her responsible and thus limit recourse to medicine that is not always necessary. However, there are vital treatments that do not allow this logic to be applied. The scheme has established 4 (debatable) criteria according to which it is decided whether a patient suffers from a so-called serious disease – in this case, he/she gets 100% reimbursement. Except that many life-saving treatments do not meet these ultimately arbitrary criteria. For example, malaria does not meet these criteria – the patient has to pay part of the costs. It is absolutely absurd to apply the logic of the non-reimbursable part to treatments without which the patient dies. What overuse do we want to avoid?
So far, no viable solution has been found for the problems that arise for medical expenses incurred outside Belgium (and this is the majority). Reimbursement ceilings are defined in relation to the prices usually charged in Belgium – but elsewhere they can be different, very different. A complex system of thousands of correction coefficients has been put in place, but it is far from perfect. For example, members in Italy may only receive 10% of a dental treatment. In general, our policyholders are often overcharged by private doctors or dentists, hospitals or paramedical providers (whether in Belgium or elsewhere). However, case law has clearly established the illegality of these practices: as the JSIS is a public and compulsory scheme, our insured persons must have access to care at the public prices agreed in each Member State.
And let’s finish our overview with the ceilings applied for the different treatments. These ceilings are reviewed, if there is sufficient trade union pressure, every 15 or 20 years. But in the meantime, prices change. More and more of the costs are borne by the members. Today, we are far from the legal (statutory) obligation to cover 80-85% of the total medical costs.
A complete overhaul of the whole scheme is needed!