Economie de la Santé

Organisateurs : Agnès Gramain (Université Paris 1) et Stéphane Gauthier (Université Paris-1 et PSE).

Le séminaire se tiendra le jeudi, en principe tous les quinze jours, de 9h30 à 11h00, à la Maison des Sciences Economiques.

Cet atelier réunit chercheurs et doctorants en économie de la santé pour analyser et discuter des travaux de recherche autour d’un grand thème de politique économique actuel, défini annuellement. Son objectif général est de cerner les grandes questions relatives à ce thème et les problèmes restants ouverts. Il est ouvert à toute personne intéressée.

Le thème de l’année 2012-2013 est celui des contours du financement collectif des dépenses de soins. Le groupe s’intéresse en particulier à l’efficience de l’articulation entre dispositifs publics et privés, aussi bien dans une cadre bismarkien (articulation des couvertures assurantielles) que dans un cadre beveridgien (production publique et production privée de soins).

Il est organisé en trois parties:

  • Partie 1 : Production de soins – secteur public et secteur privé
  • Partie 2 : Eligibilité et non recours
  • Partie 3 : Rationnement et files d’attente


Partie 1 : production de soins – secteur public et secteur privé

  • 11 octobre 2012 salle B21, Agnès Gramain

Glied S. &Stabile M. (2001), « Avoiding health insurance crowd-out: evidence from the Medicare as secondary payer legislation« , J Health Econ. Vol 20(2), pages 239-60.

Abstract – The cost of expanding health insurance coverage increases when people who would otherwise purchase insurance obtain public coverage. This paper investigates the effects of one of the first efforts to target insurance benefits to the most needy, the 1982 medicare as secondary payer (MSP) provisions. We find strong evidence of low compliance with the MSP both in terms of medical bill payments (payment compliance) and employer-sponsored insurance coverage (coverage compliance). We estimate payer compliance at approximately 33%. Coverage compliance is lower, at under 25%. We find weak evidence that the MSP caused older workers to shift toward MSP-exempt jobs.

  • 25 octobre 2012 salle B21, Mathilde Peron

Blomqvist, A. & Johansson, P-O., 1997. « Economic efficiency and mixed public/private insurance« , Journal of Public Economics, Elsevier, vol. 66(3), pages 505-516, December.

Abstract – In this paper we discuss the efficiency properties of insurance markets where supple- mentary private insurance is allowed to exist together with a compulsory government insurance plan. Our main conclusion, which is contrary to both those of Besley (1989) and Selden (1993), is that in a simple model focusing on the moral hazard problem alone, a mixed system will generally be strictly less efficient than a purely private (competitive) system. We also show that Selden’s (1993) main proposition is valid only in very special circumstances, which reduces the significance of his result on the welfare properties of systems of mixed government/private insurance.

  • 8 novembre 2012 salle B21

D. Fabbri & C. Monfardini (2011), « Opt Out Or Top Up? Voluntary Healthcare Insurance And The Public Vs. Private Substitution« , Quaderni – Working Paper DSE N° 780

Abstract – We investigate whether people enrolled into voluntary health insurance (VHI) substitute public consumption with private (opt out) or just enlarge their private consumption, without reducing reliance upon public provisions (top up). We study the case of Italy, where a mixed insurance system is in place. To this purpose, we specify a joint model for public and private specialist visits counts, and allow for different degrees of endogenous supplementary insurance coverage, looking at the insurance coverage as driven by a trinomial choice process. We disentangle the effect of income and wealth by going through two channels: the direct impact on the demand for healthcare and that due to selection into VHI. We find evidence of opting out: richer and wealthier individuals consume more private services and concomitantly reduce those services publicly provided through selection into for-profit VHI. These results imply that the market for VHI eases the redistribution from high income (doubly insured) individuals to low income (not doubly insured) ones operated by the Italian National Health Service (NHS). Accounting for VHI endogeneity in the joint model of the two counts is crucial to this conclusion.


Partie 2 : Eligibilité et non recours

  • 29 novembre 2012 salle B21, Jérôme Wittwer

Hoel Michael & Iversen Tor (2002), « Genetic testing when there is a mix of compulsory and voluntary health insurance« , Journal of Health Economics, vol. 21, pages 253–270.

Abstract – When the insurer has access to information about test status, genetic insurance can handle the negative effects of genetic testing on insurance coverage and income distribution. Hence, efficient testing is promoted. When information about prevention and test status is private, two types of social inefficiencies may occur; genetic testing may not be done when it is socially efficient and genetic testing may be done although it is socially inefficient. The first type of inefficiency is shown to be likely for consumers with compulsory insurance only, while the second type of inefficiency is more likely for those who have supplemented the compulsory insurance with substantial voluntary insurance. This second type of inefficiency is more important the less effective prevention is. It is therefore a puzzle that many countries have imposed strict regulation on the genetic information insurers have access to. A reason may be that genetic insurance is not yet a political issue, and the advantage of shared genetic information is therefore not transparent. © 2002 Elsevier Science B.V. All rights reserved.

  • 13 décembre 2012 salle 116, Angela Luci

Kreider B (1998) « Workers’ Applications to Social Insurance Programs when Earnings and Eligibility are Uncertain”, Journal of Labor Economics, October 1998, 848-877.31 janvier

Abstract – A worker’s decision whether to apply for public transfers may depend not only on his expected level of foregone labor earnings but also on his degree of uncertainty about such earnings. This paper provides theory and evidence about the effects of earnings and eligibility uncertainty on participation decisions. The application rate to the Social Security Disability Insurance program is estimated to be about 15 percent higher than it would be in the absence of earnings risk. As an application to tax policy, optimal marginal wage tax rates may be higher than indicated in previous analyses involving wage uncertainty.

  • 10 janvier 2013 salle 19, Jingyue Xing

Parsons, Donald O, 1991. « Self-Screening in Targeted Public Transfer Programs« , Journal of Political Economy, University of Chicago Press, vol. 99(4), pages 859-76, August.

Abstract – The self-screening properties of initial eligibility determination, a mechanism often under the control of the administrators of targeted transfer programs, are derived and the use of this mechanism in the social security disability insurance system is explored empirically. An increase in the rigor of initial eligibility screening may discourage potential applicants because they are unaware of appeal prospects and because the eligibility decision delay is lengthened, as denied applicants are forced to appeal their claims. In the disability program, a 10 percent increase in the initial denial rate induces a 4 percent decrease in applications. Self-selection is non perverse.

  • 31 janvier 2013 salle S/18, Stéphane Gauthier

Henrik Jacobsen Kleven, Wojciech Kopczuk (2008) « Transfer program complexity and the take up of social benefits« , NBER WORKING PAPER SERIES, Working Paper 14301

Abstract – This paper models complexity in social programs as a byproduct of efforts to screen between deserving and undeserving applicants. While a more rigorous screening technology may have desirable effects on targeting efficiency, the associated complexity introduces transaction costs into the application process and may induce incomplete take up. The paper integrates the study of take up with the study of classification errors of type I and type II, and argue that incomplete take up can be seen as a form of type I error. We consider a government interested in ensuring a minimum income level for as many deserving individuals as possible, and characterize optimal programs when policy makers can choose the rigor of screening (and associated complexity) along with a benefit level and an eligibility criterion. It is shown that optimal program parameters reflect a trade-off at the margin between type I errors (including non-take up) and type II errors. Optimal programs that are not universal always feature a high degree of complexity. Although it is generally possible to eliminate take up by the undeserving (type II errors), policies usually involve eligibility criteria that make them eligible and rely on complexity to restrict their participation. Even though the government is interested only in ensuring a minimum benefit level, the optimal policy may feature benefits that are higher than this target minimum. This is because benefits generically screen better than either eligibility criteria or complexity. We present numerical simulations on comparative statics with respect to budget size, ability distribution, complexity costs, and stigma. Our results are discussed in light of empirical findings for public programs in the United States.


Partie 3 : rationnement et files d’attente

  • 7 février 2013 salle 19, Marlène Guillon

Grassi Simona & Ma Ching-to Albert (2011), « Optimal public rationing and price response« , Journal of Health Economics, sous presse.

Abstract – We study optimal public health care rationing and private sector price responses. Consumers differ in their wealth and illness severity (defined as treatment cost). Due to a limited budget, some consumers must be rationed. Rationed consumers may purchase from a monopolistic private market. We consider two information regimes. In the first, the public supplier rations consumers according to their wealth information (means testing). In equilibrium, the public supplier must ration both rich and poor consumers. Rationing some poor consumers implements price reduction in the private market. In the second information regime, the public supplier rations consumers according to consumers’ wealth and cost information. In equilibrium, consumers are allocated the good if and only if their costs are below a threshold (cost effectiveness). Rationing based on cost results in higher equilibrium consumer surplus than rationing based on wealth.

  • 28 février 2013 salle 19

Finkelstein Amy (2004) « The interaction of partial public insurance programs and residual private insurance markets: evidence from the US Medicare program« , Journal of Health Economics vol. 23(1), pages 1-24.

Abstract – A ubiquitous form of government intervention in insurance markets is to provide compulsory, but partial, public insurance coverage and to allow voluntary purchases of supplementary insurance on the private market. Yet we know little about the effects of such programs on total insurance coverage and on welfare. A primary concern is that the compulsory public insurance program – designed to counter the effects of adverse selection in the private insurance market – may in fact exacerbate adverse selection pressures in the residual private insurance market. Theoretically, however, these programs may either improve or impair the functioning of the residual private insurance market. To examine this question empirically, I investigate the effect of the U.S. Medicare program – which provides partial public health insurance to individuals aged 65 and over – on the private insurance market for prescription drugs, a benefit not provided by the public program. The results suggest that Medicare does not have substantial spillover effects on residual private insurance markets. In particular, there is no evidence that Medicare is associated with increased adverse selection problems in the residual private health insurance market.

  • 28 mars 2013 salle 19

Tor Iversen (1997), « The effect of a private sector on the waiting time in a national health service« , Journal of health economics, vol. 16, pages 381-396

Abstract – This article examines the effect of a private sector on the waiting time associated with treatment in a public hospital. Without rationing of waiting-list admissions, a private sector is shown to result in a longer waiting time if the demand for a public treatment is sufficiently elastic with respect to the waiting time. When waiting-list admissions are rationed, the waiting time is shown to increase if the public sector consultants are permitted to work in the private sector in their spare time.

  • 11 avril 2013 salle 19

Hoel Michael & Magnus Sæther Erik (2003), « Public health care with waiting time: the role of supplementary private health care« , Journal of Health Economics, Vol. 22(4), pages 599-616.

Abstract – In any system of health insurance, a decision must be made about what treatments the insurance should cover. One way to make this decision is to rank treatments by their ratios of health benefits to treatment costs. If treatments that are not offered by the health insurance can be purchased out of pocket, the socially optimal ranking of treatments to be included in the health insurance is different from this standard cost-effectiveness rule. It is no longer necessarily true that treatments should be ranked higher the lower are treatment costs (for given health benefits). Moreover, the larger are the costs per treatment for a given benefit–cost ratio, the higher priority should the treatment be given. If the health budget in a public health system does not exceed the socially optimal size, treatments with sufficiently low costs should not be performed by the public health system if treatment may be purchased privately out of pocket.

  • 25 avril 2013 salle 19

Gravelle Hugh & Siciliani Luigi (2007), « Ramsey Waits: Allocating Public Health Service in Two-Sector Models of Endogenous Growth Resources when there is Rationing by Waiting« , Discussion paper in Economics, University of York, No. 2007/15.

Abstract – The optimal allocation of a public health care budget across treatments must take account of the way in which care is rationed within treatments since this will affect their marginal value. We investigate the optimal allocation rules for health care systems where user charges are Öxed and care is rationed by waiting. The optimal waiting time is higher for treatments with demands more elastic to waiting time, higher costs, lower charges, smaller marginal welfare loss from waiting by treated patients, and smaller marginal welfare losses from under- consumption of care. The results hold for a wide range of welfarist and non-welfarist objective functions and for systems in which there is also a private health care sector. They imply that allocation rules based purely on cost effectiveness ratios are suboptimal because they assume that there is no rationing within treatments.