Publications in peer-reviewed academic journals

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

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

What is the impact of publicly financing private competitors on the hospital market? Evidence from Denmark with Daniel Herrera-Araujo and Søren Rud Kristensen

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

This paper quantifies inequalities of opportunity in the utilization of healthcare services, and the share of illegitimate differences because they fall outside the scope of individual responsibility. Using data from the SHARE survey we include 21,889 individuals aged 50+ living in 14 European countries. Three binary outcomes of healthcare use over the last 12 months are considered: GP visits, specialist visits, and overnight hospitalization. In the first step, we decompose healthcare utilization according to (1) healthcare needs (2) legitimate sources of inequalities (3) illegitimate sources of inequalities, and (4) country-fixed effects. In the second step, we decompose the needs variable into the same four sets of variables. We show that care needs are the main determinants of explained inequalities in healthcare: their contribution varies between 49 and 87%, depending on the outcome. The country-specific effects account for 7 to 40% of differences in utilization. Effort- and circumstances-related variables only account for a marginal share of the explained differences (from 1.5 to 6.8% for circumstances and 0.6 to 2.8% for efforts). Further decomposing the need variable does not drastically change our results, since the contribution of efforts and circumstances to the variance of needs remains marginal compared to the contribution of unexplained sources. Decomposing the needs does not change the balance between efforts and circumstances either. Despite the existing evidence of the influence of risky behavior on health, our results underline the important role played by circumstances and luck as determinants of the use of healthcare services. Such a result should be considered when the temptation to hold individuals responsible for their risky behaviors’ comes.

Low-income adults and complementary health insurance: is subsidizing impacting the choice? (Revise & Resubmit 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 (Submitted at 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 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 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 a 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. 

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)