How Does Expanded Public Health Insurance Coverage Impact Health Care Use of Students? Evidence from a Natural Experiment in France
We control for the endogeneity issue of the health insurance variable by using two specific features of the public health insurance system in France. (1) A ‘local’ public health insurance system exists in two local authorities (regions) that were under German occupation between 1870 and 1918. This local system called 'Alsace-Moselle regime” is a health insurance plan that offers employees in Alsace and Moselle regions a lower copayment than the ‘national’ public health insurance scheme in the rest of France, in return to increased employees’ contributions. (2) Under the age of 20, students are covered by the same health insurance policy as their parents. Over 20, all students are covered by the national health insurance policy. Students whose parents are covered by the Alsace-Moselle regime benefit from this local plan until the age of 20 and are covered by the national scheme afterwards.
We then use the loss of the local insurance benefit that occurs by law for students over the age of 20 and constitutes a quasi-experiment or natural experiment framework to identify the causal effect of the more generous plan on health care utilization.
The analysis is based on data from a health insurance provider in Eastern France that provides compulsory and complementary health insurance coverage to students. This provider has the originality of covering enrolled students in the local Alsace-Moselle regime (Alsace and Lorraine regions) and students enrolled in the national scheme (Champagne-Ardenne region). Our sample consists of 5,600 students who celebrated their 20th birthday during the 2009-2010 academic year and is divided into two different groups. The first one consists of students benefiting from the local plan until the age of 20. Over 20, they are covered by the national scheme (students living in Alsace and Moselle regions). The second group consists of students covered by the national scheme before and after their 20th birthday (students living in Marne and Meurthe et Moselle regions).
The average effect of the local policy is estimated by difference-in-differences between the two groups of students on their health care use one year before and one year after their 20th birthday. We evaluate the impact of the more generous plan on GP and specialist visits as well as prescription drug, optical and dental expenses.
The results will shed light on the impact of generalizing expanded public health insurance coverage on health care utilization and will provide useful information on health care access of students that remains unclear in France.