The Impact of Medical Consultations on Health Care Use Among Unemployed Youth in France
- Youth
- Employment
- Mental health
- Information
- Insurance
- Preventive health
Poor physical and mental health can prevent youth from becoming financially independent, as people with health problems or disabilities are less likely to find work. In France, universal health insurance coverage is available, but unemployed youth may not enroll in it for a variety of reasons. Researchers tested whether health counseling targeted at youth increased insurance coverage and health care use, leading to better employment outcomes. Adding a physician roughly doubled the share of youth who consulted a psychologist, though neither program affected employment.
Policy issue
Poor physical and mental health can prevent youth from becoming financially independent, as people with health problems or disabilities are less likely to find work.1 At the same time, it is not fully understood how unemployed youth make decisions about their healthcare.
There are multiple barriers that could prevent disadvantaged youth from accessing and using health care. One possible barrier is financial, because many may not be able to afford the cost of services. A recent study by J-PAL affiliated professors showed that providing free health insurance for low-income adults increased demand for health care.2 Other possible barriers to health care use include a lack of understanding of the health system, distrust of the medical profession and institutions, and underestimation of health risks. Can increased information about affordable health care options and encouragement to use health services help low-income youth overcome these obstacles and improve health insurance coverage, health care use, and ultimately, employment prospects?
Context of the evaluation
In France, all individuals have access to health insurance, either through social security (available to all households with at least one member employed or receiving unemployment benefits), or through a health insurance program called Universal Medical Coverage (CMU), which is offered to low-income households for free. Both kinds of public insurance reimburse a portion of the costs of medical consultations and prescribed medications, and remaining expenses are borne by the patient. However, low-income households can also sign-up for a complementary insurance, Universal Complementary Medical Coverage (CMUC), which covers all out-of-pocket expenditures.
Although universal health insurance coverage is available, a recent survey showed that unemployed youth were unlikely to use primary health care and had a higher prevalence of physical and mental health conditions than employed youth.3
To try to address this problem, the French Ministry of Employment and the Ministry of Health encourages job centers—government-funded non-profits running local job-placement programs for disadvantaged youth—to provide information on health insurance and rights, advice on preventive health practices, and medical counseling to detect and treat health problems. As a result, some job centers offer consultations with medical staff, partner with local health centers, or operate information campaigns on the importance of health support. These job centers, located across France, target youth aged 16-25 years who are unemployed and have low levels of education. Among youth attending job centers involved in this evaluation, 49.6 percent did not have a high school diploma and 29.2 percent faced difficulties covering their expenses. Seven percent of youth had no health insurance coverage, and 20.9 percent had partial coverage.
Details of the intervention
Researchers conducted a randomized evaluation to test the impact of health counseling on insurance coverage, health care use, and employment among unemployed youth. To do so, researchers partnered with five job centers across France (in Clichy-sous-Bois, Sénart, Reims, Poitiers, and Toulouse) that had hired social and medical staff to provide health services to registered youth.
Eligible youth had recently enrolled in the job centers and had visited the center at least twice. The 1,528 youth in the sample were randomly assigned to one of three groups:
- Social worker only (501 youth): Youth were encouraged to meet with a social worker at the job center. The social worker provided information on health insurance and rights, checked whether youth had full health insurance, and explained how to navigate the system. If participants had no health insurance, the social worker advised them how to get coverage.
- Social worker plus physician (532 youth): Youth were encouraged to meet with a social worker, and in addition, to visit a physician working at the job center. The physician was in charge of detecting possible health problems, referring youth to relevant specialists when needed, and providing advice on health best practices.
- Comparison (495 youth): Youth did not receive any encouragement to meet with a social worker or physician, but they could access standard services at the job center (generally personalized job counseling).
Social workers and physicians were free to arrange follow-up meetings with youth over a one-year period, although 63 percent of youth met with a social worker only once. Researchers collected information on insurance coverage, perceived health, health care use, health behavior, and employment status at the beginning of the study and after twelve months.
Results and policy lessons
The physician intervention almost doubled the number of youths that consulted a psychologist. Both interventions increased enrollment in the public universal health insurance, but neither affected youth’s understanding of the insurance reimbursement procedures. The physician intervention increased the number of youths participating in vocational training programs, but it did not affect employment rates.
Health Care Use: The physician intervention almost doubled the number of youths that consulted a psychologist, to 17 percent from 9 percent in the comparison group. The researchers tie this to the correction of mistaken beliefs. In this case, many youths underestimated their own health needs: among those the physician referred to a psychologist, about a third rated their mental health as good or very good. The rise in consultations appeared to be largest for the young people whose self-assessment was furthest from the physician's diagnosis. This suggests the program worked by giving youth accurate, personalized information about problems they had not recognized in themselves. Neither intervention changed how often youth met other specialists. The physician intervention showed signs of encouraging healthier habits, with youth more likely to have a regular doctor and to use contraception.
Neither intervention changed how youth rated their general health, although youth encouraged to meet a social worker rated their mental health as slightly worse. The researchers suggest this could have happened because meeting with the social worker increased the salience of health insurance, which increased stress.
Health Insurance Coverage: Respondents encouraged to meet with at least a social worker were more likely to sign up for CMU-C (35.2 percent among respondents encouraged to meet with social workers and 30.6 percent among those encouraged to meet with social workers and physicians, from a baseline of 19.3 percent in the comparison group). This change reflects people switching from private insurance to the free CMU-C, as well as people without any complementary insurance signing up for CMU-C. The social worker intervention led to more switching from private to public insurance, while the physician intervention caused more initially uninsured people to sign up for CMU-C. Neither intervention affected understanding of insurance reimbursement procedures.
Employment Outcomes: The physician intervention increased the proportion of youth participating in employment training courses (from 42 to 50 percent reported in the comparison group). However, neither intervention had an effect on employment rates.
Social outcomes: The physician intervention increased the likelihood of youth having more than 10 friends from 4 to 8.2 percent in the comparison group and increased involvement in associations by 5.1 percentage points (from a base of 15.8 percent in comparison).
Compliance: Most participants met with the social workers or physicians they were encouraged to visit: 82 percent of youth assigned to the social worker intervention met with the social worker and 63 percent of youth assigned to the physician intervention met with the physician and the social worker.
Cost-analysis: The social worker intervention cost €14 per job seeker per year, and the physician intervention cost 47. These figures assume social workers and physicians are paid €192 and €442 per day, and that they work with youth two days per week.
https://www.oecd.org/en/publications/2010/11/sickness-disability-and-work-breaking-the-barriers_g1g10adb.html, p. 50
http://www.povertyactionlab.org/evaluation/oregon-health-insurance-experiment-united-states