1Christophe Capuano’s book retracing the history of French social protections for older people no longer able to carry out fundamental daily activities without assistance arrives just as the question of how to deal with the problem of dependency in old age moves centre stage. The book actually covers public policy on both disability and old age, as French policymakers throughout the period remained undecided about which principles should shape policies targeting dependent older people.
2The first part examines the period 1880 to 1945, presenting the development of the “invalidité ordinaire” assistance system (that is, for disabilities not caused by work accidents) and the creation of a social benefit designed specifically to meet home care needs. During the second period, 1945 to the late 1960s, two distinct policies were developed, one targeting people with major disabilities and the other, the elderly. Capuano is careful to show that disabled older people could benefit from both policies, though they were not the priority target of either. In the third and last section, covering the period from the early 1970s to the present, he emphasizes the sector-specific approach characteristic of the period: disability, old age, and employment policies were strictly distinguished from each other, meaning that responses to disabled older people were not coordinated. He also discusses the radical change of 1997, when dependent persons were differentiated by age, causing older people to lose disability policy benefits. And he works to explain the various failed attempts to reform how the national insurance system handles dependency, referring here to France’s current debate on the “fifth risk” (the other four areas – health, family, work accidents, and pensions – are already covered by that system).
3The history of public policies targeting the needs of dependent older persons appears at first sight like a chaotic, relatively incoherent one marked by policymaker hesitation about the right direction to take. But by bringing into the picture the ideological and political issues of the periods as well as the perceptions of the various institutional and individual actors, Capuano manages to produce an extremely useful reading of how the French social protection system evolved and what its current characteristics are.
4Across all periods, French public administrations were constantly concerned to limit social welfare spending. Budget concerns come through as an extremely strong structuring principle of public policy and a strong determinant of its underlying principles. And at the turn of the century, budget concerns led public policymakers to interpret compensation for “invalidité ordinaire” as a matter of social assistance rather than risk insurance.
5Likewise, it has been the concern about spending that has led public decisionmakers past and present to favour the policy of “home care”. As early as 1930, the disabled received cash benefits to pay for home assistance from an outside (non-family) caregiver. The aim was clear: to keep such people, particularly those over 70, out of hospices and other institutions, which local governments considered too expensive. Throughout the twentieth century, reforms and revaluations of benefits never went far enough to support an effective home care policy, one that actually would reduce admissions to institutions.
6It was once again the authorities’ concern to contain social spending that led them to decide that age should be taken into account in policies targeting dependent persons. Initially, the answer was no: “infirm” persons and older persons with the same level of “infirmity” were to receive the same benefits. For many years, the authorities chose to consider “dependent” older people as “disabled” persons. The author points out that the refusal to differentiate was based primarily on economic concerns; once again, the aim was to keep dependent older people at home, a less costly solution than institutional care. But it was economic arguments – arrangements perceived as too comfortable for older disabled persons and the fear that finances would spin out of control given the phenomenon of population ageing – that led finally, in 1997, to legally distinguishing between older persons with disabilities and “disabled persons” by way of the Specific Dependence Benefit (Prestation spécifique dépendence, PSD). The PSD marked a turning point because it established a legal distinction between disabled people based on age, thereby breaking with traditional French policies for dependent persons in two ways, both of which can once again be linked to the concern to contain social spending. Whereas earlier policies distributed cash and did not at all monitor how it was spent, 90% of the PSD was earmarked as wages for home caregivers. The other radical break: Whereas decisions on who would receive the earlier non-family home help allowance, for which all older persons were eligible, had been made by the Technical Commission for Occupational Orientation and Re-categorization (COTOREP), attached to the Ministry of Labour, the benefit was now allocated by the payer (in this case, the governing body of the recipient’s département).
7The book’s second focus is the fit between public and family solidarity. Capuano shows that throughout the period studied, the authorities were concerned that public solidarity would reduce family solidarity. In the early twentieth century, public suspicion that families would use public assistance to shirk their obligations led to closely monitoring distribution of the “legal food obligation” benefit and to numerous benefit reductions and recipient disqualifications. The related increases in social aid recipient numbers and social spending were frequently imputed to recipients’ families, suspected of having the community pay for their disabled relatives. Starting in 1945, a discourse on demographic ageing developed that emphasized its potentially disastrous economic and social consequences, together with discourses and representations of the decline of family solidarity toward aged ascendants. Sociological studies of the time cited not only sociodemographic developments that were affecting family structures but also a decline in family solidarity, which they linked to the development of the welfare state and the understanding that older persons were losing their “status” due to the supposed regression of family values. Empirical studies on levels of intra-family support gradually diffused the paradigm of older people being abandoned by their relatives. The author discusses this at length in the last part of the book. The “rediscovery” of family solidarity later on appears as a boon to the public authorities, ever concerned to reduce public spending. At the turn of the twenty-first century, discourse emphasizing local governments’ uncertainty about the number of potential family caregivers, their availability, and their real ability to help has worked to shift the focus of public policy to support for family caregivers.
8We can only be struck by the similarities between current observations, issues, and debates, and those the book retraces over more than a century. These include the ideal of ageing at home, the financial difficulties of medical-social services and institutions; how to measure the harshness of working conditions, hiring difficulties and instability, regional disparities in service supply, adjusting wages for home caregivers, age limitations, need assessment, whether to apply benefit eligibility criteria, how to remunerate family caregivers, and the discourse on diminishing public aid to families.
9France’s Ministry of Solidarity and Health has just announced a plan for a national debate that will collect the opinions of all implicated actors and citizens and produce proposals for dealing with the situation by early 2019. In this context, Capuano’s book offers an extremely precious long-range historical perspective. Two points might have been discussed in greater detail: the history of social assistance to older persons through institutional care, and public funding of shelter and accommodation structures.
