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Health insurance voucher plan: mid-term evaluation

Country: 
France
Partner Institute: 
Institut de Recherche et Documentation en Economie de la Sant (IRDES), Paris
Survey no: 
(7)2006
Author(s): 
Carine Franc, Marc Perronnin
Health Policy Issues: 
Role Private Sector, Funding / Pooling, Quality Improvement, Access
Reform formerly reported in: 
Health Insurance Vouchers Plan
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no
Featured in half-yearly report: Health Policy Developments 7/8

Abstract

Health insurance vouchers have been introduced since January 2005 in order to encourage the use of supplementary health insurance among low-income individuals not eligible for CMU (complete free health insurance for the poorest). The voucher is a grant based on a few household characteristics (income, age, etc.) which reduces the cost of a supplementary insurance contract. After a year of implementation, outcomes appear to be rather modest.

Purpose of health policy or idea

The main objective of the health insurance vouchers plan, also called tax credit plan, is to improve access to the voluntary health insurance for a larger population (see also survey 4(2004)). The complementary insurance generally covers the co-payment (30% on average, but could be much higher for some services like dental care) that patients must pay under the basic health insurance scheme.

The health insurance vouchers plan was introduced to complete another health insurance reform, the CMU, implemented in 2000 to provide free supplementary health insurance coverage to the poorest households. In 2002, about 9% of the French population did not have any supplementary health insurance. However, this rate reaches up to 30% for individuals with an income just above the upper income limit that gives right to the CMU. There were about 600 000 people in this population without any supplementary insurance. Another 1.5 million people are estimated to be under-insured.

The eligibility to these vouchers is defined by income: the household income should not be higher than 15% over the upper limit of eligibility for the free universal health insurance coverage (between 7000€ and 8100€ per year for an individual living alone). The limit depends on the number of individuals in a household (see below). Before the introduction of the health insurance voucher plan, individuals just above the CMU income threshold were disadvantaged as they were not poor enough to benefit from the free supplementary health insurance plan (CMUC) but they were generally too poor (and usually in unstable jobs to have access to employer-supported groups contracts) to afford supplementary insurance.  

Thus, the voucher system gave possibility to these households:

  • to access a supplementary health insurance contract
  • to opt for a higher level contract for those who already have a supplementary health insurance contract.

Main points

Main objectives

The ultimate objective of this reform was to reduce income-related inequalities in access to health care by:

  1. improving access to supplementary health insurance lowering the price of contracts for those who cannot afford it otherwise,
  2. improving the average service range covered by the health insurance contract bought by the low income population.

The second objective was to regulate the voluntary health insurance market by enforcing the supplementary health insurance providers to align their contracts with the objectives of the public insurance reform that aimed at rationalising health care consumption (a gatekeeper system is being implemented since January 2006). In particular, the private insurers (mutuels) are asked not to reimburse extra-fees for the consultations not prescribed by the GP gatekeeper.  

Type of incentives

The incentives are financial. The tax credit plan entitles individuals within a certain income bracket to a voucher of which the actual amount depends on the number of individuals within the household and their age:

in 2005:

  • From 16 to 24 : 75€
  • From 25 to 59: 150€
  • More than 60: 250€

 

Since 01/01/2006 :

  • From 16 to 24 : 100€
  • From 25 to 59: 200€
  • More than 60: 400€ 



The entitled individuals can ask their local public health insurance funds (Caisse primaire d'assurance maladie) to calculate the yearly amount of the grant and obtain for them the vouchers from a central fund. They then have six months to use their voucher to purchase a contract from a list of private health insurance providers.

Groups affected

Patients or consumers with low income, supplementary health insurers mainly not for profit ones (mutuelles), public local health insurance funds (Caisse de Sécurité Sociale)

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Characteristics of this policy

Degree of Innovation traditional rather traditional innovative
Degree of Controversy consensual consensual highly controversial
Structural or Systemic Impact marginal marginal fundamental
Public Visibility very low neutral very high
Transferability strongly system-dependent neutral system-neutral

Overall, we think that this plan would have a positive impact in reducing income-related inequalities in access to care.

Political and economic background

In France, compulsory public health insurances finance about 75% of health care expenditures leaving to the patients a co-payment which varies by type of care. Supplementary health insurance covers at least partially this co-payment which can be quite important The part for certain services like dental care or eye care, especially for low income individuals. Especially for the hospital care, the part left to the patients can be significant for low income individuals (at least 16€ per day). The implementation of the Universal Health Coverage (CMU) mechanism in 2000 recognizes the importance of voluntary health insurance in assuring access to care by acknowledging that compulsory health insurance has not been sufficient to guarantee fair access for all (particularly for dental prosthesis and eyewear glasses). This recognition that voluntary health insurance needs to be subsidized at least for those who cannot afford it gives a new legitimacy to voluntary insurers.

The health insurance vouchers plan is the outcome of a large debate on the organization and the regulation of the health system and insurance market. The upcoming idea was that insurance contracts, to be eligible for the voucher plan, have to be in line with the regulatory objectives of the public insurance scheme. An alternative solution considered by the government was to extend the population covered by the CMU plan by raising the limit by around 10% of annual income to be eligible. However, this solution was considered to be more costly both for public and private insurers (as beneficiaries for supplemental insurance would be fewer), and would not remove the threshold effect as it only shifts the threshold. (see HPM report 4(2004) for more details).

Change based on an overall national health policy statement

Loi n°2004-810 du 13 août 2004 relative à l'assurance maladie (health insurance reform law 2004-810 from August the 13, 2004)

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no no no yes no

Origins of health policy idea

According to the "Health care and insurance survey conducted in 2002", about 30% of the targeted population do not have a supplementary health insurance and the majority of the rest (about 1.5 million people) have a contract providing low coverage. Yearly household income to be eligible for health insurance vouchers depends on the number of individuals in a household as follows (lower and upper limits of income are given into brackets):  

  • 1 individual: [7 045€, 8 102€]
  • 2 individuals: [10 568€, 12 154€]
  • 3 individuals: [12 682€, 14 585€]
  • 4 individuals: [14 796€, 17 016€]
  • 5 individuals: [17 614€, 20 257€]
  • 6 individuals: [20 433€, 23 498€]



The idea of introducing health insurance vouchers for this population group is not new. Initially they were introduced to complete the CMU system by a Decree of public health insurance fund (in August 2002). However, only a few individuals actually benefited from these vouchers. As a matter of fact, in this first version, resources conditions were more restricting (between the CMU upper income limit and this limit plus 10%), the amounts of the voucher tended to be lower (115€ per year for one individual however aged he was) and no initiative was taken to actually diffuse this information. During the presidential campaign, Jacques Chirac promised to improve access to supplementary health insurance by developing this type of vouchers. However, his government hesitated for a while between introducing vouchers and extending the universal coverage (CMU) by raising the (maximum) income ceiling. This second solution was criticized by providers of voluntary insurance who feared to loose some of their clients. Finally, the vouchers plan was adopted.

Health insurers to inform their customers

The article 56 of social security law reformed in August 2004 compels local health insurance funds to broadcast the information and to deliver appropriate certificates of eligibility to concerned individuals. The plan was given a lot of media coverage mainly to counterbalance the reaction of the public on the other aspects of the reform: the reform of 2004 had introduced an uninsurable co-payment for almost all users of health system (except for children and for hospitalisation) and a gate-keeping system for regulating the access to ambulatory care.  The public coverage is reduced for those who see a specialist without a referral from their usual physician. All these measures tend to increase the financial risk for patients.  

Initiators of idea/main actors

  • Government
  • Parliament
  • Payers

Approach of idea

The approach of the idea is described as:
amended: As mentioned above, the health insurance voucher plan described and implemented by the law (article 56, August 2004) constitutes a strong reinforcement of a system initially offered through an administrative memorandum.

Stakeholder positions

see the previous policy report for more details

Actors and positions

Description of actors and their positions
Government
Governmentvery supportivesupportive strongly opposed
Parliament
Parliamentvery supportivevery supportive strongly opposed
Payers
Social security fundvery supportivesupportive strongly opposed
Mutuellesvery supportivesupportive strongly opposed

Influences in policy making and legislation

The voucher plan is the 56th article of the health insurance reform law 2004-810 which modified the Social security Code. This law has been voted by the parliament on August the 13rd 2004 and was implemented on January 2005. The law 2005-1579 relative to the financing of Social security, which was voted on December 2005, increases the amount of vouchers.

Legislative outcome

success

Actors and influence

Description of actors and their influence

Government
Governmentvery strongvery strong none
Parliament
Parliamentvery strongvery strong none
Payers
Social security fundvery strongvery strong none
Mutuellesvery strongstrong none
ParliamentMutuellesGovernment, Social security fund

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

see the previous policy report for more details

Monitoring and evaluation

According to the article L. 863-5 of Social security code the "CMU Fund" (the national fund in charge of managing the free universal coverage CMU) must annually evaluate this mechanism. The CMU fund investigates the dissemination (the use) of these vouchers as well as the characteristics of the different contracts offered: price and levels of coverage.  

This continuous evaluation is necessary to prevent voluntary health insurers to benefit from this subsidy to increase their prices.

There are two indicators to study the uptake of the insurance vouchers: the number of certificates of eligibility provided by the local public health insurance funds and the number of certificates actually used that is the number of beneficiaries declared by the voluntary health insurers.

Dimensions of evaluation

Outcome

Results of evaluation

According to the reports provided by voluntary health insurers, 220 000 certificates of eligibility (covering 402 000 persons) were provided and 178 335 were used to purchase a contract at the end of 2005. The number of certificates provided monthly has been regularly increasing over the last year and during the first two months of 2006 where around 70 000 more people obtained a certificate of eligibility. Since the validity of the certificate of eligibility is six months, there is a lag between the number of certificates distributed and the actual contracts bought.

Around 40 % of beneficiaries are under 25 years old (annual deduction 75 €), 45 % are between 25 and 59 years old (annual tax credit 150 €) and 14 % are older than 60 (annual tax credit 250 €). Thus, the average amount allocated per voucher in 2005 was 133 €.

Not-for-profit insurers (mutuelles) cover about 79% of the beneficiaries with for-profit insurers covering the remaining 21%.

Clearly, the introduction of the vouchers by law in 2004 appears to have a significant impact on their use. Already the number of beneficiaries is much higher than the outcomes reached after three years of implementation until 2004 (only 60 000 beneficiaries).

A first evaluation is currently being carried out on the profile of new beneficiaries but the results are not yet available (the results will be available by the end of June 2006 on the CMU website: www.cmu.fr). This evaluation will allow for example to compare the service ranges covered by the contracts subsidized by the vouchers with those of other (average) complementary insurance contracts.

Expected outcome

The health insurance vouchers encourage low income individuals to buy a supplementary health insurance contract or to improve their coverage for those who already got one. But they do not cover their entire cost. Providing a supplementary health insurance contract may not always solve the problem of access to care. Indeed, there are significant variations in terms of the numbers of services covered and their cost between contracts. Thus, future assessments will have to compare the coverage provided by contracts subscribed by vouchers beneficiaries with other contracts.  

While the use of vouchers is growing regularly, the uptake rate is still rather slow. Despite the large media coverage for this plan, after eleven months, only 20% of the targeted population actually benefit from a voucher. One reason for this might be the value of vouchers.

Given that the average cost of a supplementary insurance contract for an individual is about 430€, the initial value of vouchers (between 75 and 250€) might have been too low to be attractive for low income households. This is why the value of vouchers was increased at the beginning of the 2006. The rise is particularly significant for individuals who are over 60 years old which went up 60% (from 250€ to 400€), and 33% for all others individuals.

This should improve significantly the attractivity of these vouchers.

Nevertheless, there might also be some problems as to the communication and diffusion strategy for this plan. Even the official name of the plan, which is "credit d'impôt" it is to say tax credit (because the vouchers are granted to the household through a tax reduction for the complementary insurance companies), might be an obstacle for access since some of the individuals with low income, who are targeted by the law, believe that they can not have access to the plan as they do not pay any tax. It is also possible to simplify further the administrative procedures to obtain the vouchers.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable system more equitable system more equitable
Cost Efficiency very low very low very high

There is always a risk of a moral hazard both from patients and insurers point of view. Private insurers can profit from this system to increase their prices rather than improving the coverage or the quality of individual contracts. And some of the insured may profit from high coverage to consume services which are not forcibly useful. 

References

Sources of Information

Health insurance voucher plan ("credit d'impôt") : conditions of eligibility, amount, statistics: www.fonds-cmu.fr/site/index.php4

CMU plan ("Couverture maladie universelle complémentaire") : conditions of eligibility, statistics: www.fonds-cmu.fr/site/index.php4

Results from ESPS 2002 survey: Auvray, L, Doussin, A., Le Fur, P.  « Santé, soins et protection sociale en 2002. Enquête sur la santé et la protection sociale (ESPS) France 2002 ». Rapport n° 1509. Série résultats. Décembre 2003. 181 pages.

Reform formerly reported in

Health Insurance Vouchers Plan
Process Stages: Implementation

Author/s and/or contributors to this survey

Carine Franc, Marc Perronnin

Suggested citation for this online article

Carine Franc, Marc Perronnin. "Health insurance voucher plan: mid-term evaluation". Health Policy Monitor, April 2006. Available at http://www.hpm.org/survey/fr/a7/3