Venue: The Fuqua School of Business, Duke University, 1 Towerview Drive, Durham, NC 27708-0120

 

Presentation

Inequalities among users' payments of the French Health Care System: microsimulation of several reforms and measure of equity and social acceptability

Authors: Anne-Line Couillerot (Haute Autorité de Santé (HAS)); Sandrine Chambaretaud (Haute Autorité de Santé (HAS)); Thierry Debrand (Institut de Recherche et Documentation en Economie de la Santé); Lise Rochaix (Haute Autorité de Santé (HAS))

Presenter: Anne-Line Couillerot (Haute Autorité de Santé (HAS))

Session: Poster Session

Room: Kirby Winter Garden

When: Monday 2:30 p.m. - 3:15 p.m.

In France, patients have to cope with growing inequalities in out-of-pocket expenditure. Those without supplementary health insurance (8% of the population) have to face these payments alone, and in most cases, these are households with low incomes.

The French Health Care System is based on multiple cost-sharing devices: co-payments, deductibles, sanctions and extra-billing, with no account of patients' incomes. Exemptions apply for most chronic diseases;

Two concepts are commonly used to measure equity: The first, horizontal equity, refers to the idea that equals are treated equally, and is often used to measure equity in access. The second, vertical equity implies that unequals should be treated differently, ie that the patients with different contributive capabilities should contribute differently to the financing of the health care system. We use vertical equity in our study of users payments.

In our microsimulation model, we offer both a measure of vertical equity and social acceptability of several reforms of users' payments. Since we focus on short term impacts, we use a static model with exogenous behavior.

Various scenarii were implemented, based on recent reform proposals. Among these, we analyze the implementation of various deductibles; the definition of a uniform out-of-pocket ceiling above which free care is granted to patients and finally a ceiling proportional to both household income and size. Each scenario is tested with or without exemptions (long-term ailments, work accidents and disability)

To compare these scenarii we use several criteria: vertical equity and social acceptability. Concerning equity, we use Kakwani indices to measure the progressivity (proportionality/ regressivity) of the reform. Social acceptability indices measure the proportion of patients who are 'evicted' from the Health Insurance reimbursement and the distribution among users of the average additional burden resulting from these measures.

These microsimulations shed light on a number of key points in the definition of a user payment policy:

Deductibles clearly increase the system regressivity. The uniform ceiling, because of the high level at which it has been defined, is also regressive, although less markedly. When proportional to income, and or proportional to household size, the ceiling is the least regressive of the three options. Finally, maintaining exemptions or not has very strong equity implications, due to the correlation between income and morbidity.