Publications in peer-reviewed academic journals

Réduire les barrières financières à l'accès aux soins with Florence Jusot and Jérôme Wittwer

Abstract: In France, the horizontal equity principle is a founding principle of social security. It is stated by the maxim “From each according to his ability to pay, to each according to his need”. However, the French health insurance system lets copayments for all health expenses, to contain health expenditures and give incentives to patients. However, such copayments are financial barriers to healthcare access and sources of inequalities in the utilization of health services. To improve equity in financial access to health services, policies have been implemented in the last decades. This paper proposes an overview of the findings of these policies and provides new results on inequalities in access to health care in France. Most policy packages consist of setting free access to certain types of care or reducing health insurance premiums. Free care and free insurance have been demonstrated to be effective in reducing healthcare use inequalities, although such actions can diminish the perceived quality of the service and lead to discrimination when physician fees are caped. By contrast, the literature has also shown the ineffectiveness of health insurance premium subsidies. More recent reforms of the health system, not assessed yet, are aiming at containing prices and types of care which are poorly covered by public health insurance. Despite those policies, we demonstrate that controlling for need, inequalities in healthcare use subsist, particularly in specialist, dental, optical, and preventive care. This suggests that the reduction in the financial barriers to healthcare access is a necessary condition but far from being sufficient for achieving equity in health.

Revue Française d'Économie 2019, https://doi.org/10.3917/rfe.191.0133

Work in progress

Inequalities of opportunity in the utilization of healthcare services among 50+ in Europe with Louis Arnault and Florence Jusot

Low-income adults and complementary health insurance: is subsidizing impacting the choice? (Under review at Health Economics)

Subsidizing health insurance is a common policy to help low-income populations access health insurance and has an impact on the generosity of plans purchased by recipients. I study the impact of increasing the level of subsidies for low-income individuals on their choice of complementary health insurance plan in France. Plans differ in coverage for optical materials, hearing aids, and dental prostheses. Using administrative data and exogenous variation in the subsidy level, related to the month of birth, I estimate the subsidy increase effect on the probability of choosing the most generous plan. Results show a positive and significant effect of increasing the subsidy on the demand for the most generous plan level. It provides new evidence of health insurance subsidization on plan choice when insurance is complementary, voluntary, and covers specific types of care. Interpretation of these results is twofold, a premium sensitivity of the demand for complementary health insurance or an affordability effect as the subsidy relaxes the budget constraint. 

Are low-income willing to pay more to remain insured? Evidence from subsidized complementary health insurance in France with Cécile Gayet (Under review at Journal of Health Economics)

This paper investigates the impact of benefit regulation policies on the take-up of complementary health insurance (CHI). Recent theoretical results indicate a negative expected effect of mandating health insurance benefits on the insurance take-up rate, but empirical evidence is scarce. Using a benefit regulation reform of a French means-tested subsidized CHI program as a quasi-experiment, we examine this question on a population of low-income French retirees. Our analysis shows that healthier individuals have a lower probability of staying in the program after the reform when they face a higher post-reform premium. In contrast, sicker individuals stay in the program whether their premium increases or not. These results provide evidence of the existence of adverse selection in this CHI market.

Making health care accessible, do prices matter? Evidence from a means-tested complementary health insurance program in France with Florence Jusot and Jérôme Wittwer 

In France, state-financed complementary health insurance (CHI) provides free care at the point of use to the poor, at no cost. This program offers the opportunity to study the effect of exempting low-income from co-payments on a wide range of healthcare goods and services, in a system where the alternative option is not to go uninsured but a universal primary health insurance.  Using claims data we estimate the program enrollment impact on healthcare utilization. Selection in the program is controlled for, using coverage variations that are endogenous at the household level but exogenous at the individual level. Using a difference in difference methodology, we find that exempting from even modest co-payments has a strong and significant impact on the probability of using healthcare services and on conditional expenditures. We also show that the free CHI has long-lasting impact over the two years of coverage. Finally, we show that program take-up also impacts adults who were previously privately covered by a CHI and adults who benefit from payment exemption because of chronic health conditions. 

The effect of aid for the acquisition of complementary health insurance (ACS) on the utilization of healthcare with Mounir Hayab, Yann Videau and Dorian Verboux

 The "Aide à la complémentaire santé" (ACS) is a means-tested benefit that subsidizes access to supplementary health insurance. Based on administrative claims data over the period July 2015 - December 2018, we estimate the causal effect of benefiting from the ACS on the use of care and the level of expenditure for individuals previously covered by private complementary health insurance using a difference-in-differences approach. We find that the ACS has a positive and significant influence on the probability of seeking care compared to the average probability of seeking care at baseline and on the level of conditional expenditure. The ACS, therefore, appears to improve the use of care by its beneficiaries, particularly those covered by the health insurance system, which also translates into an increase in the average level of care expenditure, with the most affected items being ambulatory care, drugs, and dental care.

Other publications 

Le recours aux soins des populations pauvres en France with Florence Jusot, Antoine Marsaudon and Jérôme Wittwer

Actualité et dossier en santé publique n° 113 (2021)

Évolution de la dépense en part de complémentaire santé des bénéficiaires de la CMU-C: analyse et prévision with Marc Perronnin

Rapport Irdes n°169 (2018)