Faced with an imminent structural deficit, the government and social partners are at odds over the measures to be taken to balance the books. These starkly contrasting positions were highlighted following the health quadripartite talks held on 6 May, whilst the CNS’s accounts are in the red.
As for the Union of Luxembourg Businesses (UEL), there is no question of increasing contributions. For the trade unions, the red line is the full retention of benefits. A red line that was highlighted in the speeches on 1 May. However, leaders of both unions believe that a reduction in reimbursements, which would lead to a two-tier healthcare system, would trigger a general strike. Caught in the middle, doctors feel held hostage and fear that an agreement will be reached at their expense. This dialogue of the deaf highlights a deep-seated conflict between the need for rigorous management and the desire to safeguard a healthcare system based on solidarity.
A “purely accounting-based” approach
For Christophe Knebeler, a member of the LCGB’s executive committee responsible for social policy, priority must be given to efficiency and solidarity rather than budget cuts. “Balancing the books must not be at the expense of the quality of care or the level of reimbursements.” How can these accounts be balanced? “By strictly separating the budgets.” This means incorporating into the budget expenditure that should not be borne by the health insurance system, but by the state. Such as expenditure related to maternity care, family leave or the 20% of movable and immovable assets of public hospitals, currently covered by the CNS. “The CNS [must] focus exclusively on healthcare services.”
The aim is to eliminate waste without reducing services.
Faced with a “purely accounting-based” approach, Christophe Knebeler sees the solution in striving for greater efficiency. “The aim is to eliminate waste without reducing services.” He advocates the creation of medical guidelines that would allow needs to be precisely defined for each condition (such as Alzheimer’s disease) in order to avoid duplication whilst ensuring care is provided. He also calls for better regulation of prescriptions “to avoid shortages and unjustified expenditure”. He cites the example of Ozempic, a drug intended to treat type 2 diabetes but often used—and prescribed—for weight loss. This is a convenience prescription that the trade unionist wants to see phased out.
Increasing contributions is the best solution for the LCGB
Whilst the LCGB rejects any reduction in benefits, it says it is in favour of an increase in contributions. This is an issue which, in its view, must be addressed in the autumn if it is found necessary to maintain the statutory reserve level—which, according to calculations by the General Inspectorate of Social Security (IGSS), is set to be breached in 2027. “There is already a costed proposal for a 0.25% increase, shared equally between insured persons and employers, i.e. 0.125% for each.”
Christophe Knebeler sees the increase in contributions as a means of fostering solidarity. “Everyone contributes according to their means, but everyone receives the same level of benefits. Unlike a reduction in reimbursements, which would place a heavy burden on those on low incomes, an increase in contributions has a minimal net impact compared to the loss an insured person would suffer if benefits were cut.” Such a reduction remains a red line that the trade unions will not cross. Moreover, this support for higher contributions is strictly conditional on benefits being maintained in full.
Daniel Marques, a trade union representative at the OGBL, takes the same view. In his opinion, the need to cut costs—which he acknowledges—must never be allowed to compromise the quality of care for insured persons. He firmly rejects the idea of a “two-tier healthcare system”, where the quality of treatment would depend on the patient’s financial means. Maintaining the current level of reimbursement is considered essential to guaranteeing this fairness. He does not see an increase in social security contributions as a miracle solution, but rather as the last possible option.
This involves reviewing prescribing practices more carefully, prioritising less expensive medicines that are equally effective, and engaging in discussions with pharmaceutical companies.
The top priority is to review the system’s efficiency. This would involve three key areas. Firstly, the medicines aspect: “This involves reviewing prescribing practices, prioritising less expensive medicines that are equally effective, and holding discussions with pharmaceutical companies.” Next, the hospital aspect: “The focus must be on reducing average lengths of stay in hospital, offset by improvements in home care.” Finally, the fight against abuse and fraud: “Greater monitoring of prescriptions for inappropriate or unnecessarily expensive treatments or medicines is required.”
Steering and consistency for the UEL
For the UEL, an increase in contributions is unacceptable. “Any increase would be detrimental to the country’s competitiveness,” its representatives insist. Faced with the growing structural deficit in health and maternity insurance—a situation attributed to the “double-digit” growth in cash benefits—sickness benefits, the increase in the volume of medical procedures and high hospital expenditure, the employers’ organisation criticises the inadequacy of the proposed budget savings.
It advocates far-reaching structural reforms, including better management of healthcare provision and control over expenditure on cash benefits. To get the system back on track, the UEL wants a package of costed measures centred on three key areas: national management of healthcare provision to prevent the risks of overcapacity, shortages or regional inequalities; control of wage spillover effects—meaning limiting the impact of pay rises in the public sector; and improved governance. “The implementation of reforms must be accompanied by explicit political commitments and regular monitoring of results to stay on course in the long term.”
Employers have drawn a line in the sand: no increase in contributions. Raising them would amount to “running away from the problem”. Such a measure would merely shift the problem elsewhere whilst eroding purchasing power and business competitiveness. The organisation believes it is essential to tackle the root causes of costs before considering increasing the burden on labour.
Pending a comprehensive agreement, the UEL proposes a precautionary approach, notably through a moratorium on any decision likely to automatically increase the deficit.
No one made any serious effort to resolve this deficit sooner. […] They’re trying to make savings at our expense.
Doctors feel held hostage
For Dr Chris Roller, president of the Association of Doctors and Dentists of Luxembourg (AMMD), the CNS deficit comes as no surprise. “It is a structural problem that politicians have been aware of since at least 2019,” he says, criticising the lack of foresight. “No one looked for serious ways to resolve this deficit earlier, and we are now waiting until the last minute to make service providers foot the bill. “They are trying to make savings at our expense,” Chris Roller claims. He gives an example: whilst €24m had been budgeted for an increase in medical fees in 2025, doctors ultimately received no increase. In other words, “we have already made a saving of €24m at our expense,” according to the president of the AMMD.
He condemns a climate of “intellectual dishonesty” in the discussions. On the part of politicians, first and foremost. “It is illusory and unfair to promise patients the best possible medical care whilst claiming that costs will not rise. Healthcare, like any other sector, inevitably becomes more expensive. To claim otherwise would be to deny the economic reality of the current system of care.” He considers the current contractual framework, which defines the relationship between the CNS and doctors, to be completely unsuitable.
In his view, beyond the agreement itself, it is the entire legal framework — “which dates back to the 1990s and no longer reflects the realities of modern medicine or the expectations of today’s society”—that needs to be reviewed. He laments that the negotiations have turned into a sort of “unilateral diktat” on the part of the CNS. Stalled discussions. As things stand, the AMMD will not sign the agreement. This will have no impact on policyholders, its president points out.
Intellectual dishonesty—even deafness—on the part of the unions as well. Chris Roller believes that the unions are misusing the concept of solidarity to put pressure on doctors. In his view, the unions’ message is: “If you don’t do as we want, you’re not showing solidarity.” He firmly rejects this view, pointing out that doctors are on call 24 hours a day and bear the full responsibility for patient care.
