Health care services utilization and access inequalities in the Sao Paulo Metropolitan Region

This paper presents case study findings in five municipalities in the S?o Paulo Metropolitan Region. Inequalities in access to health care services and their utilization were described through advanced tabulation data from the 1998 SEADE Life Conditions Survey. The variables analyzed were: owning or not owning private health care insurance, income and age brackets. The health care service attributes studied were: health care services coverage by a health insurance plan, health services demands and average waiting time to receive health care. Compared with other studies, using the 1998 IBGE PNAD, the results allowed us to confirm interregional imbalances which can only be detected in shorter special scale studies: the municipalities. Despite showing the high private health insurances coverage the S?o Paulo Metropolitan Region has a great inner heterogeneity. The inequalities in private health care insurance, access, waiting time, and type of insurance coverage were observed through income quintiles and age classes analyses. Findings suggest that an expansion of the State's regulation capacity is necessary in order to empower the Brazilian Health Care System principles of universality and equity to be qualified to offer Brazilians the right to access health care services.     

Private medical insurance and saving: evidence from the British Household Panel Survey

This paper uses the British Household Panel Survey for the years 1996-2000 to investigate the relationship between saving and private medical insurance in the UK. Because the National Health Service (NHS) gives comprehensive health coverage and is generally free at source, one would not expect private medical insurance to crowd-out saving. However, the NHS being characterised by long waiting lists and generally poor quality, many people prefer to use private health services. In such circumstances, those individuals who are not covered by private medical insurance, and who are therefore more exposed to facing unexpected out-of-pocket private health care expenditures or income losses while waiting for public treatment might save more for precautionary reasons than those who are covered. According to our findings, which are based on a wide range of econometric specifications, there is a positive association between insurance coverage and saving, suggesting that private medical insurance does not generally crowd-out private saving. However, we found some evidence of crowding-out in those areas where the quality of medical facilities is perceived as poor, and in rural areas, characterised by fewer NHS providers.     

Unmet healthcare needs in Ireland: Analysis using the EU-SILC survey

The analysis used the 2013 Survey of Income and Living Conditions to examine the extent and causes of unmet need for healthcare services in Ireland. The analysis found that almost four per cent of participants reported an unmet need for medical care. Overall, lower income groups, those with poorer health status and those without free primary care and/or private insurance were more likely to report an unmet healthcare need. The impact of income on the likelihood of reporting an unmet need was particularly strong for those without free primary care and/or private insurance, suggesting a role for the health system in eradicating income based inequalities in unmet need. Factors associated with the healthcare system – cost and waiting lists – accounted for the majority of unmet needs. Those with largely free public healthcare entitlement were more likely than all other eligibility categories to report that their unmet need was due to waiting lists (rather than cost). While not possible to explicitly examine in this analysis, it is probable that unmet need due to cost is picking up on the relatively high out-of-pocket payments for primary care for those who must pay for GP visits; while unmet need due to waiting is identifying the relatively long waiting times within the acute hospital sector for those within the public system.     

Out-of-pocket health expenditure differences in Chile: Insurance performance or selection?

Chile has a mixed health system with public and private actors engaged in provision and insurance. This dual system generates important differences in health expenditure between private and public insurances. Selection is a preeminent feature of the Chilean insurance system. In order to explain the role of the insurance in out-of-pocket expenditures between households for different insurance schemes, decomposition methods are applied to disentangle the effect of household ‘composition and insurance’ degree of financial protection on health expenditures. Health expenditure patterns have not changed in the last 10 years with drugs, outpatient care, and dental health representing 60% of the health expenditure. Health expenditure/income is similar for different income groups in the public insurance, but decreases with income in households with private coverage, reflecting regressivity in health expenditure. On the other hand, health expenditure as share of expenditure increases with income for both groups.Per capita health expenditure in households with private coverage is four times the expenditure of households with public insurance; this gap is mostly explained by differences in households’ expenditure and demographics. Roughly 80% of the difference in expenditure is explained by the model, showing the role of selection in understanding the expenditure gap between insurance schemes.     

Waiting times for elective surgery and the decision to buy private health insurance

More than 45% of Australians buy health insurance for private treatment in hospital. This is despite having access to universal and free public hospital treatment. Anecdotal evidence suggests that avoidance of long waits for public treatment is one possible explanation for the high rate of insurance coverage. In this study, we investigate the effect of waiting on individual decisions to buy private health insurance. Individuals are assumed to form an expectation of their own waiting time as a function of their demographics and health status. We model waiting times using administrative data on the population hospitalised for elective procedures in public hospitals and use the parameter estimates to impute the expected waiting time and the probability of a long wait for a representative sample of the population. We find that expected waiting time does not increase the probability of buying insurance but a high probability of experiencing a long wait does. On average, waiting time has no significant impact on insurance. In addition, we find that favourable selection into private insurance, measured by self-assessed health, is no longer significant once waiting time variables are included. This result suggests that a source of favourable selection may be aversion to waiting among healthier people.     

Health insurance and health services utilization in Ireland

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.     

Inequities in mental health care after health care system reform in Chile

OBJECTIVES: We compared differences in mental health needs and provision of mental health services among residents of Santiago, Chile, with private and public health insurance coverage. METHODS: We conducted a cross-sectional survey of a random sample of adults. Presence of mental disorders and use of health care services were assessed via structured interviews. Individuals were classified as having public, private, or no health insurance coverage. RESULTS: Among individuals with mental disorders, only 20% (95% confidence interval [CI]=16%, 24%) had consulted a professional about these problems. A clear mismatch was found between need and provision of services. Participants with public insurance coverage exhibited the highest prevalence of mental disorders but the lowest rates of consultation; participants with private coverage exhibited exactly the opposite pattern. After adjustment for age, income, and severity of symptoms, private insurance coverage (odds ratio [OR]=2.72; 95% CI=1.6, 4.6) and higher disability level (OR=1.27, 95% CI=1.1, 1.5) were the only factors associated with increased frequency of mental health consultation. CONCLUSIONS: The health reforms that have encouraged the growth of the private health sector in Chile also have increased risk segmentation within the health system, accentuating inequalities in health care provision.     

Private expenditure and the role of private health insurance in Greece: status quo and future trends

The health care system in Greece is financed in almost equal proportions by public and private sources. Private expenditure, consists mostly of out-of-pocket and under-the-table payments. Such payments strongly suggest dissatisfaction with the public system, due to under financing during the last 25 years. This gap has been filled rapidly by the private sector. From this point of view, one might suggest that the flourishing development of private provision may lead in turn to a corresponding growth in private health insurance (PHI). This paper aims to examine the role of PHI in Greece, to identify the factors influencing its development, and to make some suggestions about future policies and trends. In the decade of 1985–1995 PHI show increasing activity, reflecting the intention of some citizens to seek health insurance solutions in the form of supplementary cover in order to ensure faster access, better quality of services, and increased consumer choice. The benefits include programs covering hospital expenses, cash benefits, outpatient care expenses, disability income insurance, as well as limited managed care programs. However, despite recent interest, PHI coverage remains low in Greece compared to other EU countries. Economic, social and cultural factors such as low average household income, high unemployment, obligatory and full coverage by social insurance, lead to reluctance to pay for second-tier insurance. Instead, there is a preference to pay a doctor or hospital directly even in the form of under-the-table payments (which are remarkably high in Greece), when the need arises. There are also factors endogenous to the PHI industry, related to market policies, low organisational capacity, cream skimming, and the absence of insurance products meeting consumer requirements, which explain the relatively low state of development of PHI in Greece.      

Elasticity estimates from a dynamic model of interrelated demands for private and public acute health care

This paper investigates the private/public mix in acute health care provision in the UK. It uses an interrelated shares model derived from a translog function combined with dynamic adjustment. Using prices for public care constructed from NHS waiting lists, the insurance cost of private care and the retain price index, impact, intermediate and long run elasticities of demand for private and public care are obtained. The role of hospital consultants and of an aging population are also considered.     

Public versus private health care in a national health service

This paper studies the interaction between public and private health care provision in a National Health Service (NHS), with free public care and costly private care. The health authority decides whether or not to allow private provision and sets the public sector remuneration. The physicians allocate their time (effort) in the public and (if allowed) in the private sector based on the public wage income and the private sector profits. We show that allowing physician dual practice 'crowds out' public provision, and results in lower overall health care provision. While the health authority can mitigate this effect by offering a higher wage, we find that a ban on dual practice is more efficient if private sector competition is weak and public and private care are sufficiently close substitutes. On the other hand, if private sector competition is sufficiently tough, a mixed system, with physician dual practice, is always preferable to a pure NHS system.     

The effect of private insurance access on the choice of GP/specialist and public/private provider in Spain

This paper sheds light into the investigation of differential patterns of utilisation of physician services by populations subgroups that is emerging in a number of studies. Using Spanish data from the National Health Survey of 1997 we try to explain the distinct role of the type of insurance on the choice between specialists and GPs and its intertwining with the choice between private and public providers. We estimate a two-stages probit to conclude that differences in insurance access is the main determinant of both, the choice of sector and the kind of physician contacted, giving rise to very different patterns of consumption of GP and specialist visits. People with only public insurance go 2.8 times to the GP per one time that they visit a specialist; individuals with duplicate coverage have a ratio of GP/specialist visits equal to 1.4 (the combination being public GP and private specialist) and people with only private insurance access actually have an 'inverted' pattern of visits: they contact specialists more often than GPs. Age, sex and health and public supply characteristics also have a distinct and interesting impact on these choices. Finally, equity concerns based on the implied assumption that specialists care is superior to general practitioner care are discussed.     

Time spent on waiting lists for medical care: an insurance approach

In this paper, we develop a simple model of the benefits and costs of being on a waiting list. The model shows that complex factors are in operation, implying that a shorter waiting time need not necessarily be preferred to a longer waiting time. We also present an empirical study, where a sample of Swedes are offered the possibility of purchasing private insurance, thus reducing waiting time for surgery beyond the three-month guarantee offered by the public sector health care system. Respondents could choose between two insurance contracts. A 'spike' model, where the probability of a zero WTP is strictly positive, was developed and estimated to obtain demand functions for private insurance.     

Minority Response to Health Insurance Coverage for Mental Health Services

BACKGROUND: To promote access to mental health services, policy makers have focused on expanding the availability of insurance and the generosity of mental health benefits. Ethnic minority populations are high priority targets for outreach. However, among persons with private insurance, minorities are less likely than whites to seek outpatient mental health treatment. Among those with Medicaid coverage, minorities continue to be less likely than whites to use services. AIMS OF THE STUDY: The present study sought to determine if public insurance is as effective in promoting outpatient mental healthtreatment as private coverage for ethnic minority groups. METHODS: The analysis uses data from the 1987 National Medical Expenditure Survey to model mental health expenditures as a function of minority status and private insurance coverage. An interaction term between the two highlights any differences in response to private and public insurance coverage. The analysis uses a two stage least squares method to account for endogeneity of insurance coverage in the model. RESULTS: Minorities are less responsive to private insurance than whites in two ways. First, minorities are less responsive to private insurance than to public insurance whereas whites do not show this difference. Second, minorities are less responsive to private insurance than whites are to private insurance. DISCUSSION: Results suggest that there is a difference in the effectiveness of public and private health insurance to encourage use of mental health services. Among minorities but not among whites, those with private coverage used fewer mental health services than those with public coverage. Minorities were not only less responsive to private insurance than public insurance, but among those who were privately insured, minorities used fewer mental health services than whites. These results imply that insurance may not be as effective a mechanism as hoped to encourage self-initiated treatment seeking particularly among minority and other low income populations. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest that increasing private insurance coverage to minority populations will not eliminate racial and ethnic gaps in professional help-seeking for outpatient mental health care. Although the total number of people receiving treatment might increase, these results suggest that whites would seek care in greater numbers than minorities and the size of the minority-white differential might grow. IMPLICATIONS FOR FURTHER RESEARCH: Areas for further research include the impacts of alternative definitions of mental health services, the dynamics of the substitution of inpatient for outpatient mental health care, elucidation of nonfinancial barriers to care for minorities, and determinants of timely help-seeking among minorities.     

Health care in China: the role of non-government providers

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.     

Insurance, income, and access to ambulatory care in King County, Washington.

OBJECTIVES. We studied simultaneous effects of income and insurance on access measures in an indigent population, focusing on Medicaid and the marginal effects of increasing income. METHODS. Surveys were distributed in waiting rooms of county clinics and welfare offices. Models examined insurance (private, Medicaid, or none), income (to twice the poverty level), single-parent status, age, gender, and presence of a regular source of care; first-order interactions were evaluated. RESULTS. In terms of ease of access, postponing care, and having a regular source of care, uninsured respondents fared worst and Medicaid recipients were at an intermediate level. However, relative to those with private insurance, Medicaid recipients had four times the odds, and uninsured respondents twice the odds of being denied care. Income had no consistent effect; however, older, poorer people may have greater problems. For preventive services, income was significant, while differences between Medicaid and private insurance were generally not significant. CONCLUSIONS. Except for denial of care, access for indigent people is improved by Medicaid but remains worse than the access of those with private insurance. Income had variable effects, but support for income criteria used for public insurance eligibility was not found.     

Evaluating the redistributive impact of public health expenditure using an insurance value approach

This article analyses the redistributive impact of public health expenditure in Spain using an insurance value approach to compute individual and household’s value of health services non-cash benefit. We model the intensity of use of different health care services using a count data framework on a nationally representative health care survey and then predict probabilities on the 2006 Spanish EU-SILC sample. This allows us to extend disposable income with the expected monetary value of public health services and to compare it with strictly cash income. Since non-cash income due to public health services is associated with health needs, we use needs-adjusted equivalence scales to perform distributional analysis and poverty/inequality comparisons. The results show that public health expenditure in Spain acts progressively on income distribution, and that health in-kind benefits, once considered as part of disposable income, can be extremely effective in reducing poverty and inequality.     

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey

OBJECTIVE: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. DESIGN: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. RESULTS: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. CONCLUSIONS: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.     

Do public clinic systems provide health care access for the urban poor? A cross-sectional survey

The purpose of this study was to describe the health care access provided to a low-income urban population by a system of county run public clinics. We conducted a cross-sectional interview survey of a random sample of subjects applying for or renewing eligibility to use the public system. The setting was a public system consisting of inner-city community health centers and hospital-based clinics delivering primary care. We interviewed 547 adult nonpregnant subjects; mean age was 41 years; 55% were women, 54% were Hispanic and 28% were non-Hispanic Blacks; 78% had household income below $15,000 per year, and 75% had no health insurance. Access to health care was measured in three ways: physician contact during year prior to survey; and answers to two separate questions concerning delaying needed medical care because it cost too much, and delaying care because it would take too long to be seen. Although 80% of subjects had seen a physician at least once, 46% had stayed away sometime during the year due to financial reasons and 24% had stayed away because of waiting time. Surprisingly, 35% reported private sector use. These rates varied significantly with insurance status. Hispanics had significantly less access by all three measures, even after multivariable adjustment for potential confounders such as sex, age, chronic disease and insurance status. We conclude that this study demonstrates financial barriers to access, while showing substantial private sector contact, even by low-income subjects already using the public sector.     

Generational Status,Health Insurance,and Public Benefit Participation Among Low-Income Latino Children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children’s Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33–3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14–0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25–0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.