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Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Health Care Insurance in France : Its impact on income distribution between age and social groups N Fourcade J Duval, R Lardellier, R Legal Drees, Ministry of Health and Social Affairs October 26th 2012 First Annual Symposium ITMO Public health 1 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Context : Two health insurance systems – Public Health Insurance (PHI) - compulsory : “Each pays according to their abilities and receives according to their needs” solidarity between people in good health and people in ill health make health care accessible to all (but co-payments intended to increase user responsibility with regards to health care consumption) long-term insurance against the risk of illness • benefits depend on health expenditures (level and type) and status (long term illness regime = ALD, pregnancy, occupational accidents), not (directly) on age or income • taxes depend mostly on income and are progressive October 26th 2012 First Annual Symposium ITMO Public health 2 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Context : Two health insurance systems - the Supplemental Health Insurance (SHI) : optional • benefits depend on health expenditures, and on the quality of the insurance • premiums depend mostly on the quality of the insurance, and in part on age (proxy for the risk) – the Supplemental Universal Health Insurance Coverage (CMU-C Couverture Maladie Universelle Complémentaire) : a free supplemental insurance system that guarantees full coverage for the most disadvantaged population group – the Aide à la Complémentaire Santé (ACS) scheme provides financial assistance for the acquisition of supplementary insurance Covers 94% of the population (ESPS - Irdes), of which 6% granted by the CMU-C Coverage depends on income level : households without SHI often have low income levels, and the SHI quality depends on purchasing power October 26th 2012 First Annual Symposium ITMO Public health 3 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Questions • Potentially huge transfers, between age and social groups : – Health care expenditures amounted to 11.6% of GDP in 2011 – The PHI provides 76.8% of these and the SHI, 13.7%. Out-of-pocket payments : 9.6% • How large are the redistributive effects of PHI and SHI ? – Direct effects : financing (income level, and age for SHI) – Indirect effects, due to the correlation between income level, age, morbidity, health expenditures and SHI coverage • How are the resulting out-of-pocket payments distributed among households ? October 26th 2012 First Annual Symposium ITMO Public health 4 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Method • No individual database on : – PHI and SHI benefits – health care insurance benefits and contributions • Database and microsimulation models : – Ines (Insee-Drees) : income and PHI financing. Data from l’Enquête revenus fiscaux = labour force survey (enquête emploi) + administrative data on income (DGFIP) and social benefits (CNAF) – Omar (Drees) : health expenditures and benefits from PHI (survey SPSIrdes and PHI administrative data : Sniiram), SHI benefits and premiums (Drees survey on SHI) – The two models have been merged : Ines-Omar • Method : microsimulation by imputation - year 2008 • Methodological paper to be published in Economie et Statistique in November (DREES working paper already available) October 26th 2012 First Annual Symposium ITMO Public health 5 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social 1. The impact of health care insurance on income distribution between social groups From « La redistribution verticale opérée par l ’assurance maladie », in Comptes de la santé 2011, DREES October 26th 2012 First Annual Symposium ITMO Public health 6 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Euros per household, in a year PHI financing strongly depends on income levels 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 Deciles of standard of living PHI financing SHI financing Source: Ines-Omar 2008 October 26th 2012 First Annual Symposium ITMO Public health 7 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Health benefits are higher for households with lowest income Average health expenditures PHI average benefits SHI average benefits of the 60% households with lowest income of the 40% households with highest income 5 600 € (2 500 € / pers.) 4 700 € (2 000 € / pers.) 4 600 € (2 100 € / pers.) 3 500 € (1 500 € / pers.) 700 € (300 € / pers.) 800 € (350 € / pers.) Source: Ines-Omar 2008 October 26th 2012 First Annual Symposium ITMO Public health 8 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Out-of-pocket payment 1,6% 800 € 1,8% 1,5% 700 € 1,6% 1,2% 1,2% 600 € 1,4% 1,1% 1,1% 0,9% 0,9% 500 € 1,2% 0,8% 362 € 331 € 336 € 292 € 275 € 243 € 100 € 178 € 200 € 266 € 300 € 378 € 400 € 0,7% 1,0% 0,8% 0,6% 576 € 900 € 0€ 0,4% 0,2% 0,0% D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 Deciles of standard of living Out-of-pocket payment Share of Out-of-pocket in income Source: Ines-Omar 2008 October 26th 2012 First Annual Symposium ITMO Public health 9 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social 2. The impact of health care insurance on income distribution between age groups From « La redistribution opérée par l ’assurance maladie obligatoire et par les assurances complémentaires selon l ’âge », in Comptes de la santé 2010, DREES October 26th 2012 First Annual Symposium ITMO Public health 10 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Age, health expenditures and insurance benefits Euros per individual, in a year 7000 280 590 6000 5000 280 490 4000 3000 2000 1000 5740 250 30 200 140 90 240 170 300 360 50 160 720 1310 1630 910 50 200 710 1460 <6 6-15 16-25 26-35 36-45 46-55 430 4030 2010 0 56-65 66-75 > 75 Age PHI benefits SHI benefits Out-of-pocket payment Source: Ines-Omar 2008 October 26th 2012 First Annual Symposium ITMO Public health 11 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social PHI financing and benefits 6 000 € 5 000 € <5 6 -15 16 - 25 Source: Ines-Omar 2008 October 26th 2012 26 -35 46 - 55 56 -65 66 - 75 First Annual Symposium ITMO Public health Financing 800 € Financing 1 020 € 4 030 € Benefits 2 690 € Financing 2 010 € Financing 1 460 € Benefits Financing 36 - 45 Benefits 3 660 € 1 630 € Benefits 2 760 € Financing Benefits Financing 510 € Benefits 720 € Financing0 € Benefits 710 € Financing0 € Benefits 910 € 0€ 1 310 € 2 000 € 1 000 € 4 040 € 3 000 € Benefits 5 740 € 4 000 € > 75 12 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social SHI financing and benefits 800 € 700 € 600 € 500 € 400 € 300 € 200 € 100 € <5 6 -15 16 - 25 26 -35 36 - 45 46 - 55 56 -65 66 - 75 Financing Benefits Financing Benefits Financing Benefits Financing Benefits Financing Benefits Financing Benefits Financing Benefits Financing Benefits Financing Benefits 0€ > 75 Source: Ines-Omar 2008 October 26th 2012 First Annual Symposium ITMO Public health 13 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Conclusion • PHI has important redistributive effects, that results from : – – its financing (redistribution between social groups) the increase of PHI benefits as age increases • This redistribution reduces out-of-pocket payments for households with low income levels • Heterogeneity among age and social groups : in each of them some people benefit from health care benefits superior to their contribution. Yet out-ofpocket payments are higher than average for these sick people October 26th 2012 First Annual Symposium ITMO Public health 14 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Limits • Care foregoing, which depends on income levels, has to be taken into account to assess the access to care • The life cycle redistribution cannot be assessed with this model • Need for individual administrative data on PHI and SHI financing and benefits • Work in progress : What is the share of health care insurance in the global redistribution ? October 26th 2012 First Annual Symposium ITMO Public health 15 Ministère de l'Economie et des Finances Ministère des Affaires sociales et de la Santé Ministère du Travail, de l'Emploi, de la Formation professionnelle et du Dialogue social Thank you October 26th 2012 First Annual Symposium ITMO Public health 16
