Economic analysis of mixed health insurance systems.

Summary In France, in 2014, healthcare expenses amounted to 190 billion euros. This amount, which grows year after year, is financed for 76.6% by a social insurance, compulsory and proportional to income, taking care of all residents - the Health Insurance . 13.5% is financed by supplementary insurance and 8.5% directly by households in the form of out-of-pocket expenses. The relationship between public and private insurance is characteristic of mixed systems, in which insurance can complement each other, but can also lead to inefficient interactions. In the first part, we study theoretically a system where public insurance can be complemented by supplementary and/or additional insurance. While there was confusion between these two types of insurance in the literature (Petretto, 1999), we find sometimes opposite effects between complementary and supplementary insurance. Since the marginal utility of the poorest is higher than that of the richest, we find that by simply using the sum of individual utilities as the social welfare utility function, the optimal public insurance rate is positively related to the redistributive character of the insurance.In this first section, we note that the split between what is in the domain of supplementary and supplementary insurance is a function of the definition of the public goods basket. The second chapter studies the optimal composition of this public basket. At the heart of the choice of criteria to be used to select socially reimbursed goods is the possibility of comparing preferences, which has been debated at length in welfare theory and formalized by Arrow's incompatibility theorem. The income-equivalence principle of Fleurbaey et al (2013) proposes to overcome this limitation. This ordinal criterion, defined as income in full health equivalent to income in poor health, allows for interpersonal comparisons. Adapting a theoretical model studying the definition of a social optimal basket (Hoel, 2007) and using the income-equivalent principle, we find that the presence of private insurance changes the ranking of goods that need to be socially covered and reduces the optimal social budget. While the second part of the paper revealed which treatments should not be reimbursed as a priority by the health insurance system in the context of a limited budget, the last chapter studies a market characterized by a very low participation of the social insurance system. The optical market is characterized by information asymmetries and product differentiation. Beyond financing health care expenditures, we wonder whether private insurance is able to reduce these market failures and control health care expenditures. In the context of the literature on managed-care and competition for the right to serve, the last part studies the impact of networks set up by private insurers in the optical market to reduce expenditure. Using a proprietary database assembled by the author on a network of contracted opticians set up by the National Education Mutual Insurance Company (MGEN), the effect of the network on the number of sales and the prices charged is tested empirically. The effect of network and market competition on prices for single vision and bifocal lenses is estimated in 450 groups of French municipalities. Empirically, we find that in-network competition significantly reduces in-network prices, while in-market competition affects out-of-network prices.