Cette thèse est consacrée aux systèmes d'assurance maladie mixtes où la couverture publique obligatoire peut être améliorée par une complémentaire santé. Les questions abordées portent sur l'effet inflationniste de la complémentaire sur le prix des soins et sur l'impact de la tarification à l'âge sur les solidarités entre malades et bien portants et entre catégories de revenu. Les analyses empiriques sont réalisées sur données françaises. Cette base de données originale regroupe les consommations de soins de 99,878 affiliés à la MGEN sur la période 2010-2012. Le chapitre 1 estime l'effet causal d'une meilleure couverture sur la consommation de dépassements d'honoraires et démontre l'effet inflationniste de la complémentaire sur le prix des soins. Le chapitre 2 considère l’hétérogénéité de l'impact d'une meilleure couverture sur les dépassements et sa corrélation avec la demande d'assurance. De fait, l’effet inflationniste de la complémentaire est accentué par des effets de sélection. Le chapitre 3 montre que la tarification à l'âge permet de maximiser les transferts entre malades et bien portants au détriment de la solidarité entre hauts et bas revenus. / 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.

Mayotte département d’outre-mer français depuis 2011, fait partie de l’archipel des Comores ; elle est séparée des îles de l’État de l’Union des Comores depuis 1975. L’instauration d’un visa en 1995 et l’ordonnance n° 2002-688 du 12 juillet 2004 entréeen vigueur le 1er avril 2005 relative à l’extension de la sécurité sociale à Mayotte exclut les malades étrangers du système de santé mahorais. Ceci entraine des processus d’évacuation sanitaire par la voie d’une immigration clandestine qui provoque des naufrages et des violations des droits du patient. L’attrait de Mayotte et de la France métropolitaine pour les populations défavorisées occasionne des situations de conflits et de concurrence pour l’accès à la protection sanitaire et sociale. Les populations défavorisées de Mayotte, qui se battent pour combler leur retard par rapport à la métropole, vivent mal cette concurrence ; tandis que les populations immigrées vivant dans la clandestinité et sous la menace d’une expulsion imminente, rencontrent des difficultés pour faire valoir leur droit aux soins et au bénéfice à l’assistance du système social. Les obstacles sont nombreux et souvent considérables, dus notamment à la discrimination, à une disparité de difficultés sociales et économiques et à leurs conditions de vie généralement très difficiles. La maîtrise des flux migratoires et la lutte contre l’immigration irrégulière demeurent des priorités de la politique du gouvernement français en matière d’immigration. Laspécificité de la situation du département de Mayotte ainsi que l’importance des flux migratoires qui y sont constatés ont conduit les autorités sanitaires à gérer les flux migratoires liés aux évacuations sanitaires par la voie illégale. La France mène une politique sanitaire en continuant de soutenir l’Union des Comores dans l’amélioration de l’accessibilité et de laqualité des soins, à travers les programmes d’appui au secteur de la santé. Ces programmes auront pour finalité l’amélioration de la santé des mères et des enfants, notamment la réduction des mortalités maternelle et néonatale. La France à travers son organisme Agence française de développement (AFD) entend appuyer le ministère de la Santé dans l’élaboration et la mise en oeuvre des politiques publiques et contribuer au renforcement du cadre institutionnel et juridique du secteur. Il s’agira notamment d’appuyer l’État comorien dans la mise en place de mécanismes de régulation du service privé dans le secteur public et de réformer la pharmacie nationale. Cette recherche pointe les enjeux liés au droit de la protection sociale et au droit de la santé des étrangers sur le territoire national, aussi bien en France métropolitaine qu’à Mayotte. La diversité des droits nationaux applicables à Mayotte constitue une entrave sérieuse face aux dispositifs locaux relatifs à l'accompagnement sanitaire et social. Il est donc indispensable de chercher des solutions juridiques relatives à l’uniformisation de ce droit sanitaire et social afin d’améliorer le système de santé. Les résultats de cette recherche ont montré que les dispositifs locaux tels que le « bon rose » et le « bon AGD » ne sont pas du tout équivalents aux dispositifs nationaux (l'AME et la CMUc). / Mayotte a French overseas department since 2011, is part of the comorian archipelago from which it was separated from the State of Union of the Comoros islands since 1975. The introduction of a visa in 1995 and the order n° 2002-688 delivered on 12 july 2004 and entered into force on April 1st 2005 with regard to the extension of social security in Mayotte exclude the foreign sick from Mayotte's health system. This leads to a process of medical evacuation following an illegal immigration way that causes shipwrecks and the violation of the patient's rights. The attraction of Mayotte and Mainland France for disadvantaged populations lead to conflict situations and competition in the access to health and social protection. Mayotte's disadvantaged populations, who are struggling to catch up with the mainland, do not get along with that competition. At the same time the illegal immigrants living clandestinely and with the threat of expulsion are facing difficulties to assert their right to health care and to benefit from social system assistance. Obstacles are numerous and most of the time considerable, mainly because of discrimination, because of their judicial status, of disparity in their social and economical difficulties and because of their generaly very hard living conditions. The control of migratory flow and the fight against illegal immigrant remain the top priorities of the French government policy as far as immigration is concerned. The singularity of the situation in the department of Mayotte and the huge migratory flows that have been observed led healthcare authorities to handle migratory movements related to illegal medical evacuations. France has a healthcare policy and continues to support the Union of Comoros in the effort to improve healthcare access and quality, through support programs to health sector. These programs aim at improving the health of mothers and children, mainly in reducing maternal mortality. Through its organisation AFD, France aims at supporting health ministry in elaborating and implementing public policies and helping comorian state to put in place regulatory mechanisms of a private service within public sector and to reform the national pharmacy. This work focus on the issues related to the right to social protection and the health law for foreigners on the national territory, in mainland France and in Mayotte as well. Diversity of national laws applicable in Mayotte is a significant barrier to local devices in terms of medical and social assistance. It is necessary to seek legal solutions related to standardization of this health and social law in order to better the healthcare system. During our field research we observed that local devices such as the "pink warrant" and the "good AGD" are not at all equivalent to the national devices (AME and CMUc).

Made available in DSpace on 2011-05-04T12:36:18Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / A presente pesquisa tem como objetivo analisar a utilização de serviços de saúde financiados pelo Sistema Único de Saúde por beneficiários de planos de saúde e pretende contribuir para o debate sobre o mix público-privado no sistema de saúde brasileiro. Trata-se de um estudo quantitativo baseado nos microdados de 1998 e 2003 da PNAD / IBGE e em dados secundários provenientes de bases de dados da Agência Nacional de Saúde Suplementar (ANS). Com base na tipologia de mix público-privado proposta pela OECD (2004) e no referencial teórico acerca do acesso e utilização dos serviços de saúde, buscou-se analisar aspectos relacionados à cobertura duplicada do segmento privado de saúde brasileiro e as desigualdades no uso dos serviços de saúde, a partir dos tipos de serviços mais utilizados, das diferenças regionais do uso do SUS por pessoas com cobertura de planos de saúde, do perfil dos usuários e das características dos planos de saúde cujos beneficiários mais fazem uso do sistema público no atendimento às demandas por serviços de saúde. Como resultado concluiu-se que, a despeito dos avanços alcançados com a regulamentação do setor suplementar, o SUS é responsável por uma parcela importante na assistência à saúde dos beneficiários de planos de saúde, tanto para as internações (10,7 por cento) como para os demais atendimentos (11,0 por cento), sendo a única fonte de financiamento que apresentou incremento da participação relativa entre 1998 e 2003 (+ 12,5 por cento nas internações e +29,6 por cento nos atendimentos), contribuindo para a existência de desigualdades no sistema de saúde brasileiro. / The present research aims at analyzing the use of health services funded by the National Health System (called SUS) for the population with health plans and to contribute to the debate on the public-private mix in the Brazilian health system. This is a quantitative study based on micro-data of the National Sample Household Survey (PNAD/IBGE), from 1998 and 2003, and secondary data from databases of the national regulatory agency for private health plans. (Agência Nacional de Saúde Suplementar - ANS). Based on the taxonomy of public-private mix proposed by the OECD (2004) and the theoretical framework on access and use of health services, sought to examine issues related to duplicated coverage of the private health insurance in the Brazilian Health System and inequalities in use of health services, from the types of services most used, regional differences in the use of SUS for people with health coverage plans, the profile of users and the characteristics of health plans whose customers make more use of the public to supply his needs for health care. As a result it was concluded that, despite the progress made with the regulations of the private health sector, the SUS is responsible for an important part in health care of population with health plans, both for hospital admissions (10,7%) as for the others health services (11,0%), being the only source of funding showed that increasing the relative share between 1998 and 2003 (+12.5% in hospital admissions and +29.6% in others health services), contributing to the existence of inequalities in the Brazilian health system.