[fre] Assurance maladie : un bilan par génération Handicapée par une croissance économique ralentie, l'assurance maladie fait aujourd'hui l'objet d'interrogations. Réaliser pour chaque génération un bilan des bénéfices et des contributions auxquels donne lieu le système de protection sociale peut apporter au débat engagé autour du mécanisme de répartition quelques éléments de reflexion supplémentaires. Une telle mise en perspective sur l'ensemble du cycle de vie des transferts monétaires liés à l'assurance maladie est une entreprise hasardeuse et délicate à interpréter. Elle a été effectuée pour les générations nées de 1 930 à 1 970, et les projections qu'elle nécessite croisent les trois scénarios économiques du livre blanc sur les retraites avec trois variantes concernant les dépenses de santé (rigueur, dérive, scénario central). Elle conduit à rapporter le montant actualisé des prestations dont bénéficient l'ensemble des personnes d'une même génération, à celui des cotisations qu'elles ont acquittées. Le rendement de l'assurance maladie par génération est pour l'essentiel fonction des performances en matière de croissance sur le long terme. Au regard de ce rendement, les générations les plus anciennes (nées entre 1930 et 1945) sont les plus avantagées, car elles ont pu bénéficier de prestations sans avoir versé auparavant de cotisations. Cet avantage purement mécanique est caractéristique de la montée en charge d'un système géré en répartition. Il tend à s'atténuer pour les générations suivantes et disparaît totalement au-delà de la génération 1960. Le ralentissement de la croissance des dépenses de santé depuis les années quatre-vingt tend cependant à tempérer la dégradation du rendement pour les générations récentes : cette dégradation tient en effet au déport sur les plus jeunes des dépenses de fin de vie, qui vont s'accroissant en raison de l'allongement de la durée de la vie et du progrès technique. [eng] Health Insurance: A Study by Generation . Handicapped by slowed economic growth, health insurance has been thrown into question. A generation-by-generation study of the social security system's benefits and contributions can inject some new food for thought into the debate concerning the distribution mechanism. Yet an analysis of all health-insurance-related monetary transfers over an entire life cycle is complicated and hard to interpret. Such an analysis is made for the generations born from 1 930 to 1 970. The projections it entails cross the three economic scenarios in the White Paper on Pensions with three health spending variants (restraint, growth and central scenario). This enables a comparison of the current value sum of benefits received by all the members of one generation with the contributions that they have paid. The return on health insurance per generation is chiefly dependent on long-run growth performance. The oldest generations (born from 1930 to 1945) have obtained the highest return, since they were entitled to benefits without having to pay contributions beforehand. This purely mech...
[eng] Although general to every developed country, growth of health spendings has been particularly important in France. However, this movement has not led to a relatively better state of health. In the past, some factors have played an important role but are not so strong anylonger: elimination of supply shortage; extension of the social coverage. Other factors are still very strong: ageing of the population; growth of income; technological innovation. But these factors can explain only a part of the increase in health spendings. Further explanations are to be looked for in the health system organization and regulation. A balance between market and state regulations must be found. Public intervention can be justified by the need of larger efficiency. The health system is characterized by the presence of many imperfections: asymmetric information, medical uncertainty, specific nature of health as a public good, uncompetitive market structures which lead to collective inefficiencies. Public intervention is also necessary to greater equity in the access to health. However, complete public and centralized health systems also lead to collective inefficiencies. As experiments in several countries demonstrate it, state regulation can be associated with market mechanisms: prospective payments based for example on Diagnosis Related Groups; competition on the health production market and/or the insurance market. In France former regulation policies did not prove to be very efficient. Price control encouraged increase in health consumption. Hospital planning did not succeed in restructuring supply and copayments failed to moderate demand. Moreover, a clear configuration of roles between health providers, public and private insurers and the state has not been defined. Furthermore, regulation lacks a complete and consistent information system on health. Following the german and Canadian reforms' examples, a new policy, based on global budgeting or growth targets has been implemented in the '80s and the early 90s'. After the recent announcement of a large reform by the Prime Minister, lots of questions stay yet unanswered. How will the Parlement define health objectives associated with spendings limitation targets? How is it possible to improve incentives on demand? How to improve regulation mechanisms (enforcement of spendings targets, distribution of resources between different sectors and areas, evaluation and control of medical practices, development of incentives, more ambitious reforms based on greater competition between health providers and further responsibility of health insurance)? [fre] Caractéristique commune à tous les systèmes de santé développés, la croissance des dépenses apparaît particulièrement accentuée en France. Cette évolution ne se traduit pas par un état de santé globalement supérieur en France. Certains facteurs ont joué un rôle important sur la croissance des dépenses dans le passé, mais ne jouent aujourd'hui qu'un rôle faible: accès à une offre de soins autrefois rationnée ou encore amélioration d...
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