GRAMAIN Agnes

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This article provides an overview of the organization of the financing of assistance to dependent elderly people in France. It restores the principles that have governed, since 1996, the construction of national public solidarity for the financing of independent living assistance, based on the historical foundation of social assistance, and analyzes, beyond theoretical principles, the actual global consequences of their implementation through a tangle of more or less coherent systems. Finally, it puts forward some recommendations for improving the economic efficiency and equity of public action in the field of autonomy support. At a time when the Covid-19 epidemic has just focused the media spotlight on collective accommodation facilities for dependent elderly people (EHPAD), we feel it is particularly important to guide, without sentimentality or haste, the reflection on the investments that the community is ready to make for the care and safety of dependent elderly people.

Demographic aging raises questions about the sustainability of the pension system and support for the elderly. These issues have led to pension reforms and several developments in policies to support the elderly. This thesis aims to improve knowledge of the implications of these policies. The first part focuses on the impact of retirement on health. Chapter 1 summarizes the results of previous studies regarding the impact of retirement on health. Chapters 2 and 3 focus on the impact of delayed retirement on mortality and on health expenditures, respectively. They show that retiring later as a result of the 1993 reform in France has no impact on mortality and decreases health care expenditures for men. The second part of this thesis focuses on support policies for the elderly in France. Chapter 4 uses a microsimulation model to project the future needs for assistance to the elderly. The number of dependent elderly is estimated at 3.63 million people in 2060, with an expansion of morbidity. Chapter 5 looks at the impact of a change in formal assistance on the use of informal assistance. It shows that an increase in the amount of formal assistance decreases the probability of reporting receiving informal assistance.

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L'évident et l'invisible was born from the meeting of young researchers, economists and economic historians. Reflecting on the processes of construction of the data from which each works, the authors gathered here question, together, the status of the documents they use daily to propose texts from their own scientific experience. Such a reflection is at the heart of the historians' profession and is precisely, for them, a matter of course. On the other hand, the work of criticizing and elaborating the numerical sources from which they build their reasoning and establish calculations remains mostly invisible to economists. This is why the authors of this collection share a common approach: to explain the obvious and make visible what is not obvious at first glance. The result is a collection of essays, accompanied by short introductions that situate them on an epistemological level, which reveal all the richness of this disciplinary exchange between historians and economists, which is coupled with a fruitful dialogue between generations.

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A number of issues arise from the context of demographic ageing in Europe, the prevalence and generalisation of which on the European continent make it unprecedented. Thus, the increase in the number of elderly people, and more particularly, the number of elderly people in a situation of dependence, democratizes the question of their care and the role of each of the stakeholders. This thesis proposes to study the issues related to aging and the provision of informal care. The first chapter studies the relationship between mortality and income. The second chapter examines the motivations of children to become informal caregivers for their parents. The third and fourth chapters analyze, respectively, the impact of informal care on the health of the caregiver and that of his or her partner.

relating to the adaptation of society to aging (ASV law), which came into force on January 1, 2016, includes a reform of the personalized autonomy allowance (APA) for dependent persons living at home. This reform is primarily aimed at reducing the remaining out-of-pocket expenses borne by APA beneficiaries, particularly the most dependent and those belonging to the "middle classes." Three years after the adoption of the ASV law, however, its impact on the remaining costs of living at home has been poorly documented, due to the lack of individual data allowing for an ex post evaluation. Given the various changes that have been made to the APA scale, what impact can the reform have on the remaining costs borne by dependent elderly people at home? Which categories of beneficiaries, in terms of income and level of dependence, should benefit the most from this reform? This note proposes elements of evaluation of the APA reform based on data on the clientele of a home assistance and support service (SAAD). The simulation of the reform on this particular population makes it possible to illustrate the different channels through which a change in the APA benefit can affect the remaining expenses of beneficiaries.

The market for professional home help for dependent elderly people in France is regulated. The APA makes part of the demand for professional home help financially viable, while certain professional help structures are subject to fees and are obliged to respond to all the requests they receive. These regulation policies are decentralized at the level of the departmental councils and aim to reduce financial and geographical inequalities in access to professional help within each department. The goal of the thesis is to determine whether these policies of reducing intra-departmental inequalities lead to inter-departmental inequalities. The first chapter of the dissertation uses a survey of departmental councils to determine whether the decentralization of regulatory policies leads to significant policy heterogeneity across departments. The second chapter of the thesis analyzes the impact of the observed heterogeneity. This chapter proposes an estimation of the elasticity of the demand for home help of dependent elderly people, using a national survey. The third chapter of the thesis analyzes, within a department, the distribution of public financing according to income and its impact on consumption differentials. For this we use billing data from a home help service. Finally, the fourth chapter of the thesis proposes a theoretical model of a mixed market, studying the effects of the service obligation of a part of the market structures on the quality of the assistance offered.

This thesis focuses on the difficulties of access to dental care in the French semi-regulated market. The analysis focuses on the financial barrier to access to dental care and thus the role and mechanism of price setting. The first part allows us to contextualize the delivery of dental care in France and shows that the dental profession is particularly isolated in the French health field. The purpose of the second part is to identify the determinants of access to dental care. We show that the M'T'dents preventive program for children, which is entirely free of charge, was used only by the most affluent households and had little impact on the disadvantaged households that need it most. The importance of social support in access to care is also affirmed in our second empirical study. Primary access to adult dental care presents the main barrier to access. Once this difficulty is overcome, patients most often engage in the next necessary treatments, with expenditure levels that can be significant even for the less affluent. Following these results, we were specifically interested in the role of price. We showed that the higher the price of dental prostheses, the greater the renunciation of this care for financial reasons. According to our work, the intensity of competition has a negative impact on pricing, as opposed to the solvency of the demand. Prices between competitors are also strategic complements. These are all factors that could be regulated to combat the renunciation of dental care and the resulting social inequalities in health.

Based on the Handicap-Santé survey, Household component (INSEE-Drees, 2008), we study the configurations of family assistance around an elderly and dependent parent in France. A first descriptive step shows that the assistance provided by children is affected by the parent's marital status, the size of the siblings and the rank in the siblings. The analysis then focuses on two-child families and shows that the differences in mobilization observed according to rank stem from three sources: differences in individual characteristics between older and younger siblings, the different impact of these characteristics on the decision to help, and finally a difference in the adjustment of one to the behavior of the other (endogenous interactions). The impact of family characteristics appears to be relatively similar for older and younger people - in particular the strong assignment of women with a brother to the role of caregiver - but the behaviour of younger people also reveals a trade-off between the costs and benefits of assistance. With a definition of help focused on the tasks of daily living, only one major explanation for the differences remains: asymmetry in adjustment to the other child's behavior, given individual and family characteristics.

As the population ages, the question of caring for dependent older adults is becoming a major issue for society. The French government has introduced policies on the issue, but family and children provide much of the care themselves. When a person becomes dependent, does the number and gender distribution of their children have an impact on the care they receive? It is known that the majority of caregivers are women, but what happens with single-sex sibships? Do older and younger siblings behave differently? Taking data from the Handicap-Santé survey on disability and health, Quitterie Roquebert, Romeo Fontaine and Agnès Gramain highlight asymmetries of both gender and birth order in the care children give their parents, with differences according to the type of help provided.

The law on adapting society to aging (ASV law), passed on December 28, 2015, includes a reform of the personalized autonomy allowance (APA) for dependent people living at home. Through several measures, this reform aims to reduce, for the most dependent beneficiaries, their financial participation in home assistance expenses. One of these measures provides for an increase in the amount of the legal ceilings, i.e. the maximum amount of expenses that can be financed by the APA. The impact of this measure on the amount of home help subsidized by the APA is difficult to anticipate. It depends on the answer to two questions. To what extent did the assistance plans run up against the legal ceilings? How much of the home help was consumed beyond the assistance plans? Using data on the clients of a home care service (SAAD), this note puts into perspective the mechanism of action of the legal ceilings by analyzing the differences between the quantity of aid consumed by the clients of the service, the level of the aid plans prescribed to them and that of the ceilings set by the legislator.

Disability is multifactorial. All of its components are potential sources of barriers and disadvantages. The originality of this thesis is to take into account the complexity of the definition of disability in the analysis of the use of primary health care. The ultimate goal of primary health care is better health for all, through the reduction of exclusion and social inequalities in access to the health system. We understand disability in different ways until we integrate the three dimensions of "a disability situation" (functional dimension, environmental dimension, and social participation) in a single explanatory model. First, we analyze the functional dimension by considering disabled people as physically limited. Then, we investigate the environmental dimension through a study of adults living in institutions. Finally, we adopt a global vision of disability by simultaneously integrating all dimensions through the measurement of latent capabilities. The estimated model approaches an inter-individual comparability revealing, all other things being equal, the levels on which to act to mitigate inequalities. The analyses suggest that a favorable societal and/or socioeconomic environment could compensate for the negative effects of cognitive and physical limitations and restrictions. We conclude that there are several possible ways to improve the use of primary care: action on the environmental dimension and on social participation.

This article studies the determinants of the decisions of members of a sibling group with two children to provide assistance to an elderly, lonely and dependent parent. The application of a semi-structural methodology, already used on European data (SHARE survey), makes it possible to distinguish between structural determinants (individual and family) and interactions (influence of the decision of one member of the sibling on the decision of the other). The results obtained from the 2008 French Handicap-Santé survey confirm the importance of sibling rank in understanding assistance behavior. Indeed, two distinct behavioural logics appear, both in the structural determinants and in the interactions. On the one hand, if children's help is influenced by the characteristics of the parent, whatever their rank, the elders seem to react mainly to the composition of the siblings, while the younger ones adapt their behaviour to their personal constraints. On the other hand, the involvement of the other sibling increases the usefulness of being a caregiver for the elders, while it decreases it for the younger siblings. The elders' help is therefore understood as the acceptance of a social assignment, whereas the younger siblings' help is based on a logic of arbitration, based on the comparison of the costs and benefits associated with help.

The number of people over 60 in a situation of dependence varies from 1.24 million if we refer to the number of beneficiaries of the Allocation personnalisée d'autonomie (personalized autonomy allowance), to nearly 3.3 million according to an epidemiological measure. The cost of dependency for care, accommodation and informal assistance is between 41 and 45 billion euros per year, of which 23.5 billion, or a little more than one point of GDP, is public expenditure. The latter is expected to increase by 0.3 to 0.7 GDP points by 2040, taking into account demographic and epidemiological projections.

This article proposes a methodological reflection on the use of serialized data, based on a critical review of three research studies, conducted in history and economics, on judicial practices. These three studies differ in their disciplinary anchorage, but also in the period considered (from the Middle Ages to the present day) and in the jurisdiction studied (the royal court of Chatelet, the disciplinary councils of the advocate's office and the family court judges). However, they share the same motivation: to try to reveal, by the serialization of individual data, the norm of behavior of a judicial institution. This same research motivation makes it possible to compare the methodological choices made. It confronts the researcher, even for the contemporary period, with non-exhaustive information that he must construct himself from the archival material that he examines. The type of loss of information with which the researcher is confronted - which refers in part to the properties of the institutional context of the phenomenon studied - explains the methodological choices between the researches, independently of their disciplinary anchoring. Only the inferential use of the statistical method, i.e. the articulation between models and data, seems to reveal differences in methodological habit, without these differences covering disciplinary affiliations.

The purpose of this thesis is to carry out an economic analysis of the field of informal help for young adults living at home and suffering from severe neurological disease. The research question posed concerns the articulation between the organization of informal help and the kinetics of neurological pathology. The methodology is based on the construction of four neuro-pathological and economic models on the one hand, and on the constitution of four representative cohorts, each comprising a hundred "caregiver-helper" pairs on the other hand. Thus, the models of brutal pathology with stabilized residual disability, progressive pathology with increasing disability, pathology with rapid deficit kinetics, and hereditary degenerative pathology are respectively illustrated by head trauma, multiple sclerosis, brain tumor and Huntington's disease. Our work (1) highlights the economic characteristics of informal caregivers (young spouses) who are heavily involved in the production of care, (2) demonstrate the strong predetermination of the kinetics of neurological pathology on informal caregiving behaviors through different temporal indicators that must be taken into account for economic analysis (3) show the need to use a two-dimensional measure (subjective and objective) in the analysis of the burden of informal caregivers. Such a measure underlines on the one hand the insufficiency of recourse to public professional help and on the other hand the impact on caregivers of cognitive-behavioral disorders (invisible handicap) and of the neuro-palliative phase at home of a serious neurological pathology. These results open perspectives for the implementation of public action measures in France in the complex field of neurological disability.

In France, 75% of establishments specialized in the care of dependent persons are now EHPADs. Created with the aim of rationalizing the offer, this agent questions its capacity to be efficient. In this thesis, the behavior of EHPAD directors is analyzed in order to identify new levers for improving the performance of these institutions. The main hypothesis is that directors adopt alternative management practices, which can be explained by differences in their professional characteristics. An exploratory analysis confirmed the existence of a wide range of managerial behaviors. Statistical analyses conducted on the basis of an original survey matched to the EHPA survey made it possible to draw up a typology of managers' management methods and to highlight the importance of managers' training in explaining their management strategies in the field of human resources. These results open up new public policy perspectives for improving the efficiency of the sector.

This dissertation studies the aid policies for dependent elderly people at home in Japan, in order to draw lessons for France. We develop our study through three axes: i) the analysis of the differences between the Japanese and French systems in the organization of public aid and in the aid actually perceived by the persons in loss of autonomy, ii) the examination of the potential barriers to the access to public aid in Japan, iii) the study of the consequences of informal aid on the employment of senior women in Japan In this perspective, we conducted two qualitative studies comparing Japanese and French policies, followed by two micro-econometric studies of individual and family caregiving behavior in the Japanese context. This work thus highlights the specificities of the policies implemented in the two countries, and underlines the advantages and weaknesses of the Japanese model.

The Personalized Autonomy Allowance (APA), which came into effect in 2002, is a public assistance program for dependent elderly people (Articles 232 and following of the Social and Family Action Code). For people who live at home, this allowance finances part of the professional assistance devoted to the activities of daily living. Within the framework of the decentralization of social policies, the general councils are responsible for the implementation of the APA on their territory and ensure a large part of the financing of the allowance. The national legal framework defines a priori the modalities for calculating the APA: for each hour of assistance, the APA beneficiary assumes a financial participation that depends on his/her resources. But this legal framework leaves a grey area as to how to estimate the cost of the hour of assistance on which the beneficiary's contribution is calculated. How then do the general councils organize the calculation of the amount of the APA for the beneficiaries in their territory? Is the choice of a calculation method only technical or is it a public policy choice with consequences for the general council's expenditure, for the care of beneficiaries and for the regulation of assistance services? This study proposes to analyze the practices of the general councils in the implementation of the APA in their territory. It is based on the results of the Territory survey conducted in 2012, which describes, at the departmental level, the policies for the care of dependent elderly people living at home. The MODAPA team would like to thank the Territoire collective for making it possible to use the results for this note. Publisher.

Dependency of the elderly and the republican motto: what are the links? This thesis examines the professional support of dependency, a subject of public interest, with regard to the republican principles of liberty, equality, from which territorial equity derives, and fraternity, from which solidarity derives. The geographical approach, which is innovative in this field, analyzes the professional offer in metropolitan France in a cross-sectional manner, using quantitative and qualitative methods, and at several territorial levels. The aim is to study the territorialization of support for the elderly, i.e., its apprehension based on spatial realities and related processes. Three axes are retained. First, the major terms of the study, such as ageing or dependence, in addition to key national figures, are illuminated by historical realities and testimonies of actors, in national and local perspectives. An analysis of the current organization of the supply for dependent elderly people is carried out, including home helpers and social workers, home nursing services and private nurses, accommodation facilities for dependent elderly people, as well as coordination structures. The second part of the thesis focuses on the territorial anchoring of the professional offer. It is true that the services studied are local, as shown by their comparison with other types of facilities. However, their presence in the départements is not homogeneous; for example, private nurses are more present in the départements on the Mediterranean coast, while home helps and social workers are more present in the départements of northern France. Between complementarities and substitutions, this research studies the economic, social and political issues arising from a differentiated spatial distribution. In the last part of the thesis, two revealing themes are explored. First, the non-use of the Allocation personnalisée d'autonomie à domicile (personalized autonomy allowance for the home), a solidarity-based dependency compensation benefit granted by the Departmental Councils at the request of the individual, is studied. Next, the determinants of migration of people when they enter an EHPAD. The difficulty lies in the fact that the same behaviors, of non-use or migration, can reflect both the choices of individuals and the failure of the public authorities to provide an adapted and available offer in the territories. An analysis of individual determinants, based on detailed databases and on the testimonies of local actors, makes it possible to distinguish the limit between individual freedom and the responsibility of public authorities. This study produces territorial diagnoses, potential decision-making tools, for DREES, which is the funder, and the four partner departmental councils.

The departmental councils, which have been recognized as the leaders of social action since the law of August 13, 2004, are responsible for policies for the care of dependent elderly people in their territory. Their action is, however, constrained by the legal framework, particularly for the personalized autonomy allowance at home and the regulation of assistance services. At a time when both territorial reform and reform of the dependency care system are being considered, it is useful to take stock of this complex organization: what is the real room for maneuver that departmental councils have today in terms of dependency policy? After a brief presentation of the legal framework for solving the demand and regulating the supply of aid, we will focus on the practices of the departmental councils, which reveal the public policy instruments actually available to them and the priorities they pursue.

Entrusted to the departmental councils in 2002, the procedure for allocating the personalized autonomy allowance (APA) provides that elderly people who apply for the APA receive a visit at their home from a departmental council medical-social team. The purpose of this visit is to assess the degree of loss of autonomy of the person based on a legal grid (AGGIR grid) and to develop a personalized assistance plan financed in part by the APA. The law sets out the overall composition of the medico-social teams: they must include at least one doctor and one social worker. However, it does not specify the type of professional training required for the other members of the team who are also responsible for home visits. In practice, although they occupy similar positions, the members of the medical-social teams may have undergone different initial professional training, which is mainly either paramedical (nursing diploma) or social work (social service assistant, family social economy counsellor or educator diploma). Does this difference in initial training have any effect on their professional practices in terms of assessing the degree of loss of autonomy and drawing up assistance plans? This note presents the main elements of an answer to this question obtained following a sociological research study conducted in four departments.

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Local situations in terms of dependency care differ from one territory to another, for example in terms of the organization of the offer or the level of public expenditure. This variety may reflect both the diversity of the territory's characteristics and the diversity of departmental policies. Indeed, social action for the elderly is largely decentralized to the general councils. The Code de l'action sociale et des familles (CASF) entrusts them in particular with the regulation of home help and support services (SAAD): it is the general council that issues the administrative authorization to operate and sets the rates charged by "authorized" SAADs (which are distinguished from "approved" services). How do the general councils exercise this role of regulating the home help sector? Are authorization and pricing practices an opportunity to define specific departmental policies for the care of dependency at home? This study aims to describe the practices of authorisation and pricing of ADAS by the general councils. It is based on the results of the Territoire survey, carried out in 2012 by a multidisciplinary team to which some of the MODAPA members belong. This survey analyzes the policies for the care of dependent elderly people at the departmental level.

Women are more involved in caring for the elderly than men, both in jobs providing services to the elderly and in caring for dependent relatives. This is due in part to gender norms, which push women to become involved in caregiving activities. However, there are various configurations around these norms, which allow for differences in involvement. In addition, demographic changes and changing norms are likely to push men to become more involved in these activities.

The Personalized Autonomy Allowance (APA), which came into effect in 2002, is a public aid dedicated to dependent elderly people, which aims to reduce the cost of taking care of their difficulties in the activities of daily living (cleaning, dressing, etc.). For people living at home, this assistance is partial in two ways: for each hour of assistance, the APA generally covers only a portion of the cost and the allowance is only granted for a limited number of hours per month. Beneficiaries must therefore pay a remaining amount for each hour of assistance used. Does the existence of this remaining cost and its amount have an impact on the amount of professional assistance actually used by APA recipients? What is the weight of the other determinants of the demand for professional help at home (degree of dependence, age, gender, income, municipality of residence, etc.)? This paper aims to answer these questions by presenting the results of an econometric study based on administrative files of APA beneficiaries in a metropolitan department.

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In France, since 2001, home care for disabled elderly can be partially subsidized by a public allowance (allocation personnalisée d'autonomie - APA). For eligible elderly people, the amount to be paid for one hour of formal home care depends on their income, according to a national rule, but also on the rate charged by the chosen provider, and the type of provider, according to parameters fixed by local authorities. This specific institutional frame allows us to estimate the price- and income elasticity of the demand for formal home care by disabled elderly, using administrative data, collected in a local district in October 2010, on 11 040 APA beneficiaries and 13 providers. Our estimation results show that, in this district and for regulated long-term care providers, the price-elasticity of demand is slightly negative. An increase of the price charged by the provider by 10% induces a reduction of the number of care hours by 5.5%.

In the face of an aging population, the expected increase in the demand for long-term care raises the question of the role that our societies wish to entrust to families in the care of dependent elderly people. In this research, we conduct three micro-econometric analyses of individual and family caregiving behaviors. Three major results emerge. First, the evidence of an interdependence of caregiving behaviours within the family leads us to question the idea of a programmed decrease in informal care. Secondly, the reduction in the supply of work beyond a certain volume of assistance points to the limits of a public policy aimed at both increasing the activity of older people and keeping the oldest populations at home. Finally, the use of public assistance for caregiving has a relatively modest effect of crowding out family assistance.

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