This thesis deals with two questions relative to efficiency and fairness in mixed health insurance systems with partial mandatory coverage and voluntary supplementary health insurance (SHI): (i) the inflationary effect of SHI on medical prices; (ii) the fairness of SHI premiums. We set the analysis in the French context and perform empirical analyses on original individual-level data, collected from the administrative claims of a French insurer (MGEN). The sample is made of 99,878 individuals observed from 2010 to 2012. In Chapter 1, we estimate the causal impact of a generous SHI on patients' decisions to consult physicians who balance bill their patients. We find evidence that better coverage contributes to the rise in medical prices. In Chapter 2, we specify individual heterogeneity in moral hazard and consider its possible correlation with coverage choices. We find evidence of selection on moral hazard: individuals who are more likely to ask for coverage exhibit stronger moral hazard. In Chapter 3, results show that when SHI is voluntary, age-based premiums maximize transfers between low and high healthcare users but do not guarantee vertical equity.

This dissertation is composed of three essays that consider the determinants and persistence of health care spending and how policies that control increasing health care costs affect the distribution of health care spending in the U.S. In the first essay, I study the association between education and health care spending for a set of health conditions amenable to self-management. Empirical findings from estimated health expenditure models reveal strong inverse relationships between education and health care spending among elderly adults with hypertension and/or asthma. Additionally, I find that greater educational attainment is associated with a reduced likelihood of being in the top 5% of health care spenders for elderly adults with hypertension and nonelderly adults with diabetes, and also with less severe conditions. The second essay assesses how the distribution of family out-of-pocket health care spending has been affected by changes in recent cost-sharing to understand the effectiveness of the risk protection function of private health insurance against high medical care expenses. The results suggest that families who rely more on health care because of one or more their member's existing health conditions are most affected by changes in cost sharing during the period 2001-2005 and the increased exposure to out-of-pocket spending occurrs primarily for families at higher percentiles of the out-of-pocket spending distribution, thus reducing the "return" to risk protection from holding private health insurance. The final essay examines the dynamics of out-of-pocket health care spending by looking at the persistence of such spending among Medicare beneficiaries. The findings suggest that having a certain chronic condition or a health shock clearly increases the probability of out-of-pocket health care spending persistence. Additionally, having an existing health insurance that supplements Medicare coverage or the acquisition of a new supplementary health insurance has a significant impact on the probability of persistence.

The third essay investigates the switching behavior of non-elderly enrollees in U.S. managed care plans. Treatment effect analysis is used to examine the disaggregated expenditures of plan switchers and plan stayers prior to their decision to switch or stay. Propensity score matching methods are used to estimate the average treatment effects on the treated. The results, which are based on a national representative data set from the Medical Expenditure Panel Survey, indicate that switchers (from HMO to non-HMO) spend more on hospitalization. The other type of switchers (from non-HMO to HMO) spends less on prescribed medicine and office-based physician visits. The findings suggest that the non-HMO private managed care plans provide better coverage on hospitalization, office-based physician visits and prescribed medicine than the HMO plans.

Many Americans believe that people who lack health insurance somehow get the care they really need. Care Without Coverage examines the real consequences for adults who lack health insurance. The study presents findings in the areas of prevention and screening, cancer, chronic illness, hospital-based care, and general health status. The committee looked at the consequences of being uninsured for people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. It focused on the roughly 30 million-one in seven-working-age Americans without health insurance. This group does not include the population over 65 that is covered by Medicare or the nearly 10 million children who are uninsured in this country. The main findings of the report are that working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash.

This dissertation explores the functioning of the non-group health insurance market under various regulatory regimes. The first chapter estimates the relationship between health status and product choice in this market prior to the Affordable Care Act (ACA). I use insurers' decisions of whether to approve or reject applications for health insurance to identify this relationship. These decisions are based upon a comprehensive health history that the consumer must disclose to the insurer upon applying. I assume that the insurer uses this health history, as well as the financial characteristics of the product that was applied for, to estimate the expected cost of insuring the consumer, approving whenever this cost exceeds the product's premium. This assumption allows me to estimate how insurers' forecasts of applicants' costs differ depending on the type of product chosen in a discrete choice framework. I estimate that demanders of high deductible coverage are much costlier to insure than others. Additional analysis reveals that these consumers are likely to be impoverished, suggesting that cash constraints and/or price sensitivity may explain their preference for minimal coverage. The second chapter is co-authored with Pietro Tebaldi, and estimates the impact of age-based pricing restrictions in the post-reform market. The ACA fixes the ratio between health insurance premiums charged to consumers of different ages, which generates a relationship between the fraction of relatively old consumers in a geographic market and the prices faced by young consumers in that market. We show that this relationship is present in the prices faced by consumers on the ACA exchanges, but was not present in the pre-ACA market. We take this as evidence that the relationship between price and population age observed in the ACA data is indeed attributable to this regulation. We then use this variation, combined with a model of insurer price-setting, to back out the age-specific prices that would prevail if the regulation of interest were eliminated. We estimate that this regulation substantially raises premiums for younger buyers while reducing them for older buyers, and therefore alters the allocation of coverage to consumers of different ages. Because the value of the subsidies that the federal government provides is directly tied to premiums, this regulation has also had a substantial impact on the federal budget, decreasing subsidy outlays by approximately $2.3 billion. The final chapter is co-authored with Michael Dickstein, Mark Duggan, and Pieto Tebaldi, and explores another aspect of the ACA's pricing restrictions. Individual states have discretion in how they define coverage regions, within which insurers must charge the same premium to buyers of the same age, family structure, and smoking status. We exploit variation in these definitions to investigate whether the size of the coverage region affects outcomes in the ACA marketplaces. We find large consequences for small and rural markets. When states combine small counties with neighboring urban areas into a single region, the included rural markets see .6 to .8 more active insurers, on average, and savings in annual premiums of between $200 and $300.

This book concentrates on public health insurance scope and impacts of various insurance regimes on accidents in Canada. It is shown that it may be optimal to provide full coverage for some, but no coverage at all for other conditions. An important implication of the result on the impact of horizontal equity on health-care coverage is that primary health care policies which deliver services, such as homecare, to sick people are likely to be highly efficient, particularly as compared to providing additional health care services to these individuals. On investigating how various insurance compensation systems can influence driving behaviors, the results indicate that no-fault rules have led to an increase in fatal accident compared to provinces with tort rules in place but with significant provincial differentiation. On the severity impacts, the results of the Ordered Probit Model on Saskatchewan drivers involved in accidents show that no-fault regime has been associated with shift in injuries from minor to more serious injuries and fatal accidents. However, the result on choice system does not provide any significant sign of decreasing the level of severity of accidents.