“This risks having a very big impact on our society and on how we want our health system to function,” said OGBL head Nora Back. Photo: Paperjam

“This risks having a very big impact on our society and on how we want our health system to function,” said OGBL head Nora Back. Photo: Paperjam

Union leaders warned that the breakdown of the CNS convention could dismantle the country’s health insurance framework, speaking at a joint OGBL–LCGB press conference in Luxembourg on 28 April. They said tariff freedom and legal uncertainty risk shifting costs onto patients and undermining equal access to care, while doctors argue the deadlock stems from unresolved legal constraints.

Luxembourg’s main trade unions warned on Tuesday that the country’s health system could be fundamentally altered if the convention governing relations between doctors and the national health fund collapses, raising what they described as the prospect of higher out-of-pocket costs and unequal access to care.

At a joint press conference on what they described as the “dismantling of our health system”, the OGBL and LCGB said the dispute between the Caisse nationale de santé (CNS) and the doctors’ association AMMD risks ending the tariff-based framework that underpins reimbursements, opening the door to freer pricing.

Nora Back, president of the OGBL, said the unions were speaking on behalf of patients and warned that the issue extended beyond a technical dispute. “This risks having a very big impact on our society and on how we want our health system to function,” she said, describing the situation as a “bomb” that “risks changing everything”.

She also warned against a shift towards unequal access to care and called on the government to intervene. Her intervention set the political tone for the discussion that followed.

Christophe Knebeler, a member of the LCGB board, then set out the unions’ core argument, describing the convention as the central mechanism holding the system together. “The mandatory and automatic convention is the heart of our health insurance,” he said, warning that its collapse would have system-wide consequences.

Dispute over framework

Knebeler said the framework ensures uniform tariffs and consistent reimbursement conditions across the system, allowing the CNS to operate on the basis of predictable pricing and standardised procedures. “If the convention fails, the entire system will fall apart, with dire consequences for the insured and patients,” he said.

He said the convention structures the relationship between doctors and the CNS and ensures that patients are treated under consistent conditions. Without it, he said, both pricing and administrative coherence would be put at risk.

Knebeler said that, without an agreement, doctors would no longer be bound by official tariffs and could set their own prices. “Doctors would no longer have to adhere to the agreed tariffs and could bill whatever they want,” he said, adding that “the difference between the official rate and the free rate would be entirely borne by the insured”.

He said this could introduce uncertainty in both pricing and reimbursement for patients, particularly where billing practices diverge. In such cases, he said, patients could face higher out-of-pocket costs depending on the prices charged.

Access to care threatened

The unions argue that such a shift would change access to care. “This would inevitably lead to a systematic two-class system,” Knebeler said, pointing to the risk that patients’ access and costs could vary.

Patrick Dury, president of the LCGB, said the dispute represents a break with earlier reform debates. “The situation we are faced with today is completely different,” he said, arguing that the system no longer operates within its traditional framework.

“The system, as we know it, has been broken down and we no longer operate in a conventional framework,” he said, adding that the political context now touches the foundations of the system. He said the unions were responding to what they see as a shift affecting those foundations.

Doctors point to legal deadlock

The AMMD presents a different explanation for the impasse, arguing that the core issues go beyond the convention itself and relate to broader structural and policy questions that cannot be resolved within the current negotiation framework. In a newsletter sent to the press on 28 April, it says the social security code would need to be amended before a new convention can be concluded, and that key structural demands remain unresolved.

The current agreement remains in force until 31 October 2026, with negotiations between the CNS and AMMD ongoing but without a signed replacement to date. The government has said it is working on a fallback regulation to ensure continuity of reimbursements and avoid what it describes as a “two-tier” system if no agreement is reached.

The association says its position is aimed at modernising the system rather than restricting access to care. It argues that changes to governance and tariff-setting require legislative action and that the CNS cannot move beyond the limits set by existing law.

Knebeler said replacing the convention with regulation would be complex and potentially incomplete, as many operational aspects are not fully set out in law. He said there was no guarantee the system would function in its current form beyond late 2026 if no agreement is reached, and called on the government to ensure a new framework is secured.

The dispute reflects a broader disagreement over the future direction of Luxembourg’s health system, with unions warning of liberalisation and doctors pointing to legal constraints. Its outcome could determine whether the current model of uniform tariffs and broad access is preserved or replaced by a more fragmented system with greater variability in pricing and coverage.