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N°103-104 (octobre 2021)

English Abstracts

Special Issue Health Insurance: on the border of the public and private sectors

The construction of an “educated market” for health insurance: A reorientation of solidarity?

Philippe BATIFOULIER, Victor DUCHESNE and Anne-Sophie GINON

The development of top-up cover for medical costs in France is under-
going a major shift towards promoting goals and values traditionally associated with public services, throughout the top-up health insurance sector. We propose to apply the term “educated market” to this collection of legal frameworks which configure the health insurance market in such a way as to instil social values and “elevate” it to a more solidarity-oriented form of mutualisation. This article is based on a bi-disciplinary – legal and economic – analysis. It analyses the construction of this educated market and the renewal of public intervention in health cover. By drawing comparisons with the United States, we will show that the “educated market” amounts to a modern resolution of the conflict between prioritising the development of the market and attempting to preserve the social aims of medical cover.

Keywords: health insurance, educated market, social responsibility, solidarity, France.

Employee top-up health insurance through the lens of fiscal welfare… what’s going wrong in France?

Marion DEL SOL and Pascale TURQUET

This article simultaneously examines the rationality, legitimacy and equity of socio-fiscal expenditure aimed at implementing collective top-up health insurance schemes within businesses. This type of spending is fairly well-established, but changed fundamentally from the 1 January 2016, from which date businesses are required to finance at least 50% of supplementary health cover for their employees. The system of incentives which dominated previously has therefore given way to one of subsidisation of private insurance purchasing. Though numerous questions and criticisms have been raised in relation to the inconsistent and unequal nature of such subsidisation as well as the inefficient coexistence of “AMO” (assurance maladie obligatoire = compulsory health insurance) and “AMC” (assurance maladie complémentaire = supplementary or top-up health insurance), private insurance does nevertheless seem to be the inevitable destination of reforms to health insurance.

Keywords: health insurance, private health insurance, fiscal welfare, inequality, France.

Social health cover entrusted to private insurers: Medicare Advantage in the United States


Medicare is the only socialized health insurance in the United States and covers those aged sixty-five and over. Since Medicare cover allows for considerable excesses or “copayments”, insured individuals generally take out a private top-up policy. However, a new scheme may also be taken up by Medicare recipients: a contract known as “Medicare Advantage”, offered by a private insurer managing a care network. This type of contract is financed by Medicare and provides the same cover, except that it also offers supplementary cover. The proportion of Medicare users selecting Medicare Advantage – currently 40% – is rising each year. For users of social health cover, the networks restrict choice of care providers but also bring savings, in that users receive better cover than Medicare without paying more. However, competition between private insurers imposes contracts which have the effect of diminishing solidarity between the sick and the healthy.

Keywords: health insurance, Medicare, Medicare Advantage, private insurer, United States.

The American federal government at the bedside of health insurance


For many observers of US health policy, the fact that 28 million people remained deprived of health insurance in 2020, ten years after the passing of Obamacare, the health system reform emblematic of Barack Obama’s first term, is a demonstration of its failure and calls for a reform of the reform. The Affordable Care Act (ACA) gambled on it being possible, with the right legislative instruments and incentives, not only to support and reconstruct a health insurance market which seemed to be on the verge of collapse, but also to provide it with incentives to endorse goals of public service and the common good. However, ten years later, the limitations of the reform, both in terms of population coverage and in terms of managing healthcare spending, are subject to many criticisms. This article looks back at the strategy adopted by the ACA. It explains its key instruments, analyses the difficulties encountered in their implementation, and discusses the alternatives suggested today by both Democrats and Republicans.

Keywords: health policy, Affordable Care Act, health insurance, United States.

Cobble together a low-cost, municipal-level health scheme, or rebuild organised solidarity?
A look at the diversity of “municipal mutuals”

Clémentine COMER

Looking at the case of “municipal mutuals”, supplementary health insurance contracts through which local elected officials offer preferential pricing to their constituents, this article examines the low-cost broadening of municipal social interventions. As part of this, it looks at the improvisations and experiments of local authorities despite health insurance cover falling outside of their remit. Since it addresses a civic and social project of political significance, integrates with the local network of actors in the matter of insurance, and because it is up against a commercial market contested by regional mutual organisations, networks of brokers and large insurance companies, the deployment of municipal mutual organisations exhibits a variety of public action configurations, from the point of view both of the reach of the schemes’ solidarity and of their economic sustainability.

Keywords: supplementary health insurance, municipal mutuals, local authorities, insurer, France.

Private insurers acting in service of better access to certain health goods?

Renaud GAY

The healthcare networks set up by top-up health insurers consist of contractual arrangements with healthcare professionals aimed at regulating the prices of certain procedures and facilities poorly covered by public health insurance and to reduce out-of-pocket excess for patients. This article analyses their formation and development from the late 1990s onwards, looking at the system of relationships between organisations which allow them to exist. In this way, it highlights the heterogeneity of formats and practices associated with these arrangements, the disputes surrounding them, and their partial demonetisation in the late 2010s as a result of state interventions recodifying the trade rules for certain health goods. The article thereby highlights several modalities of investment by private insurance operators in pursuit of the civic goal of improving access to healthcare for individuals.

Keywords: top-up health insurance, healthcare network, managed care, privatisation, healthcare administration, France.

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