医疗保险设计如何影响卫生服务的成本和可及性——根据11个国家不同收入人群的调查

2010年的调查研究了澳大利亚、加拿大、法国、德国、荷兰、新西兰、挪威、瑞典、瑞士、美国和英国成人的医保相关经历。这些国家的医保有不同的覆盖范围,体现在既有公共的又有公私合营的保险体系,并且具有不同的费用报销比例。总的来说,本次研究发现医疗保险设计导致不同保险的可及性、成本分担和问题等方面存在显著差异。即使在有保险的情况下,美国的成年人承担的医疗费用最高,需要花费大量时间填写保险书面材料和处理争议并且有可能被拒绝支付。德国人和美国人在填写书面材料上花费的时间差不多,但是不需要自付费用;瑞士人的自付费用虽然很高,但是在获得医保或者费用支付上没有任何障碍。对于美国成年人,全面的医疗改革可以在很多方面改进,包括减少本次研究中发现的因收入不同而产生的差别。     

Basic patterns in national health expenditure

Analysed in this paper are national health accounts estimates for 191 WHO Member States for 1997, using simple comparisons and linear regressions to describe spending on health and how it is financed. The data cover all sources - out-of-pocket spending, social insurance contributions, financing from government general revenues and voluntary and employment-related private insurance - classified according to their completeness and reliability. Total health spending rises from around 2-3% of gross domestic product (GDP) at low incomes (< 1000 US dollars per capita) to typically 8-9% at high incomes (> 7000 US dollars). Surprisingly, there is as much relative variation in the share for poor countries as for rich ones, and even more relative variation in amounts in US dollars. Poor countries and poor people that most need protection from financial catastrophe are the least protected by any form of prepayment or risk-sharing. At low incomes, out-of-pocket spending is high on average and varies from 20-80% of the total; at high incomes that share drops sharply and the variation narrows. Absolute out-of-pocket expenditure nonetheless increases with income. Public financing increases faster, and as a share of GDP, and converges at high incomes. Health takes an increasing share of total public expenditure as income rises, from 5-6% to around 10%. This is arguably the opposite of the relation between total health needs and need for public spending, for any given combination of services. Within public spending, there is no convergence in the type of finance - general revenue versus social insurance. Private insurance is usually insignificant except in some rich countries.     

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.     

Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address.     

Individual insurance benefits to be available under health reform would have cut out-of-pocket spending in 2001-08

Under the Affordable Care Act, individual health insurance will probably become more generous and more like employment-related insurance. Currently, individual insurance typically has less generous benefits than employment-related insurance. This study compared out-of-pocket spending on health care between individual and employment-related insurance, controlling for numerous characteristics such as health status. Then it simulated the impact of full implementation of provisions of the Affordable Care Act on adults who currently have individual insurance, including important subgroups-adults with chronic conditions, the near-elderly (ages 55-64), and low-income populations. If adults who had individual insurance during 2001-08 had instead had benefits similar to those under the Affordable Care Act, their average annual out-of-pocket spending on medical care and drugs might have been $280 less. The near-elderly and people with low incomes might have saved $589 and $535, respectively. An important improvement would have been the reduced probability of incurring very high out-of-pocket spending. The likelihood of having out-of-pocket expenditures on care exceeding $6,000 would have been reduced for all adults with individual insurance, and the likelihood of having expenditures exceeding $4,000 would have been reduced for many.     

Employer-sponsored health insurance for early retirees: impacts on retirement,health, and health care

The proportion of large employers offering retiree health insurance in the US has declined by half in the past 20 years. This paper examines the potential implications of this change by estimating the effects of a retiree health insurance (RHI) offer on a comprehensive set of labor, health and health care use outcomes in the near-elderly population. An RHI offer increases the probability of early retirement by 37% for both men and women. While the results suggest that an RHI offer has little, if any, effect on health, there is strong evidence that RHI provides significant protection from high out-of-pocket medical costs. In the top 40% of the out-of-pocket spending distribution, those with an offer of retiree coverage spend 22% less on average. Estimates of the value of RHI of over $4,000 per year suggest that increasing opportunities for the near-elderly to purchase coverage at actuarially-fair prices through the individual market or public programs could significantly increase insurance coverage and reduce financial risk for this age group.     

Trends in out-of-pocket spending by insured American workers, 1990-1997

This paper examines trends in out-of-pocket spending for insured workers from 1990 to 1997. Data are from the Consumer Expenditure Survey conducted by the U.S. Bureau of Labor Statistics. The survey collects detailed quarterly data on all consumer spending from logs kept each year by more than 10,000 households with job-based health insurance. During the study period, total out-of-pocket spending in constant dollars remained unchanged. Spending for medical expenses, drugs, and supplies declined by 23 percent, but this decline was offset by rising employee contributions for health insurance premiums. The shift to managed care, whose benefit structure requires less cost sharing, may have played a role in reducing out-of-pocket spending.     

Measuring financial protection in health in the United States

One rationale for health insurance coverage is to provide financial protection against catastrophic health expenditures. This article defines a lack of financial protection as household spending on health care when: (1) out-of-pocket (OOP) health expenditures exceed 10% of family income; (2) out-of-pocket expenditures exceed an absolute level of 2000 US dollars per family member on an annual basis; and (3) combined out-of-pocket and prepaid health expenditures exceed 40% of family income. The article explores how the likelihood of households in the United States surpassing these thresholds varies by income level, extent of insurance coverage, and the number of chronic conditions. The results show clearly that there is a lack of financial protection for health services for a wide segment of the US population-particularly so for poor families and those with multiple chronic conditions. The results are placed in an international context. Similar studies in other countries would allow for more in-depth comparisons of financial protection than are currently possible.     

Privatization of health services in less developed countries: an empirical response to the proposals of the World Bank and Wharton School.

Academics and World Bank officials argue that, by reducing out-of-pocket expenditures, expanded private insurance may improve access to needed health services in less developed countries. In this empirical response, the authors examine this recommendation through observations from their research on privatization of health services in the United States, Argentina, Chile, and Mexico. Privatization, either through conversion of public sector to private sector insurance or by expansion of private insurance through enhanced participation by corporate entrepreneurs, generally has not succeeded in improving access to health services for vulnerable groups. Although the impact of privatization has differed among the Latin American countries studied, expansion of private insurance often has generated additional co-payments, which have increased rather than decreased out-of-pocket expenditures, thereby worsening access to needed services. Privatization usually has improved conditions for private corporations and has led to higher administrative costs. To address the devastating problems of access to services worldwide, we must find ways to enhance the delivery of public sector services and must move beyond conventional wisdom about market-based policies such as privatization.     

Does the financial protection of health insurance vary across providers? Vietnam’s experience

Using household panel data from Vietnam, this paper compares out-of-pocket health expenditures on outpatient care at a health facility between insured and uninsured patients as well as across various providers. In the random effects model, the estimated coefficient of the insurance status variable suggests that insurance reduces out-of-pocket spending by 24% for those with the compulsory and voluntary coverage and by about 15% for those with the health insurance for the poor coverage. However, the modest financial protection of the compulsory and voluntary schemes disappears once we control for time-invariant unobserved individual effects using the fixed effects model. Additional analysis of the interaction terms involving the type of insurance and health facility suggests that the overall insignificant reduction in out-of-pocket expenditures as a result of the insurance schemes masks wide variations in the reduction in out-of-pocket sending across various providers. Insurance reduces out-of-pocket expenditures more for those enrollees using district and higher level public health facilities than those using commune health centers. Compared to the uninsured patients using district hospitals, compulsory and voluntary insurance schemes reduce out-of-pocket expenditures by 40 and 32%, respectively. However, for contacts at the commune health centers, both the compulsory health scheme and the voluntary health insurance scheme schemes have little influence on out-of-pocket spending while the health insurance scheme for the poor reduces out-of-pocket spending by about 15%.     

The effect of social health insurance on prenatal care: the case of Ghana

Many developing countries have introduced social health insurance programs to help address two of the United Nations’ millennium development goals—reducing infant mortality and improving maternal health outcomes. By making modern health care more accessible and affordable, policymakers hope that more women will seek prenatal care and thereby improve health outcomes. This paper studies how Ghana’s social health insurance program affects prenatal care use and out-of-pocket expenditures, using the two-part model to model prenatal care expenditures. We test whether Ghana’s social health insurance improved prenatal care use, reduced out-of-pocket expenditures, and increased the number of prenatal care visits. District-level differences in the timing of implementation provide exogenous variation in access to health insurance, and therefore strong identification. Those with access to social health insurance have a higher probability of receiving care, a higher number of prenatal care visits, and lower out-of-pocket expenditures conditional on spending on care.     

The impact of benefits coverage expansion of social health insurance: Evidence from Korea

Despite mandatory social health insurance in Korea, the fraction of total healthcare spending paid out-of-pocket has been considerably high. In 2013, the Korean government expanded benefits coverage of social insurance for patients diagnosed with the costliest disease groups (cardiovascular and cerebrovascular diseases, cancer, and intractable diseases). We analyze individual longitudinal information from the 2010 to 2016 Korea Health Panel to estimate the impact of the policy change on healthcare spending, utilization, and enrollment in private supplemental health insurance. Impacts on other health-related and financial measures are additionally assessed to evaluate the effects in multiple dimensions. Our difference-in-differences approach with entropy balancing weights shows that the expansion of benefits coverage of public health insurance reduced out-of-pocket spending on health by 30% without accompanying increases in healthcare utilization. The impact was smaller for the individuals with high socioeconomic characteristics, who are more likely to use other costly services that remained unaffected by the policy. We do not find evidence that expanding social insurance benefits coverage changed the demand for supplemental private health insurance.     

Health insurance coverage among foreign-born US residents: the impact of race, ethnicity, and length of residence.

OBJECTIVES: This study examined the health insurance status of the US foreign-born population and the influence of race, ethnicity, and length of residence on health insurance status. METHODS: Data were obtained from the 1989 and 1990 National Health Interview Surveys, including the Insurance and Family Resource Supplements. RESULTS: In 1989 and 1990, the foreign-born population was twice as likely as the US-born population to be uninsured (26.2% vs 13.0%). The highest rate of uninsured status, 40.8%, was found among foreign-born Hispanics. Persons who had lived in the United States for less than 15 years were 1.5 to 4.7 times more likely to be uninsured than were US-born Whites. CONCLUSIONS: Foreign-born US residents-especially Hispanics and persons residing in the United States for less than 15 years-are vulnerable to not having health insurance, which may limit their access to medical services. The administrative criteria for public programs may explain the high rates of uninsured status among recent immigrants. Recently enacted federal legislation could substantially increase the number of uninsured among the US foreign-born population, with profound public health implications.     

National health expenditures, 1995

This article presents data on health care spending for the United States, covering expenditures for various types of medical services and products and their sources of funding from 1960 to 1995. In 1995, $988.5 billion was spent to purchase health care in the United States, up 5.5 percent from 1994. Growth in spending between 1993 and 1995 was the slowest in more than three decades, primarily because of slow growth in private health insurance and out-of-pocket spending. As a result, the share of health spending funded by private sources fell, reflecting the influence of increased enrollment in managed care plans.     

Public health care funding modifies the effect of out-of-pocket spending on maternal,infant, and child mortality

Increased out-of-pocket (OOP) health care spending has been associated with increased maternal, infant, and child mortality, but the effect of public health care spending on mortality has not been studied. I identified a statistically significant interaction between public health care expenditure and OOP health care spending for maternal, infant, and child mortality. Generally, increases in public expenditure coincide with decreased rates of mortality, regardless of OOP spending levels. Specifically, higher levels of public expenditure with moderate levels of OOP spending may result in the lowest mortality rates. Increased public health care spending may improve health outcomes better than efforts to reduce OOP expenditure alone.     

Formalizing under-the-table payments to control out-of-pocket hospital expenditures in Cambodia

Growing evidence has demonstrated that informal fees for health services comprise a large proportion of total health spending in some countries. In 1999, individual out-of-pocket payments for health in Cambodia were estimated at 27 US dollars per person, with a proportion paid as under-the-table fees at public facilities. By formalizing such payments and implementing resource management systems within a comprehensive health financing scheme, Takeo Referral Hospital controlled out-of-pocket patient expenditures, ensured patients of fixed prices, protected patients from the unpredictability of hospital fees and promoted financial sustainability. Utilization levels increased by more than 50% for inpatient and surgical services, and cost recovery from user fees averaged 33%. Furthermore, the hospital phased out external donor support gradually over 4 years and achieved financial sustainability.     

Financing mental health services in low- and middle-income countries

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.     

Where Would You Rather Live If You Were Insured? Assessing Community Uninsurance Spillover Effects on the Insured

This study sought to understand the cost, quality of, and access to health care for the insured population in the context of spillover effects resulting from community-level uninsurance. We examined the health care access, quality, and cost experienced by insured Latina mothers in two communities, Minneapolis, Minnesota and McAllen, Texas. These communities differ substantially by the size of the local population without health insurance coverage. Four focus groups were conducted with insured Latina mothers who were caring for at least one child in their household. Eleven and thirteen mothers participated in each community, respectively. The experiences of the insured population in McAllen were substantially different from the experiences of the insured population in Minneapolis. The perceptions of health care quality and access by insured Latina mothers were substantially lower in McAllen while out-of-pocket costs were perceived to be higher in Minneapolis. Our study provides key insights about the US health care system and the role that the relative size of the local uninsured population may have in impacting the health care experiences of the insured. Health insurance coverage rates are expected to increase substantially across US communities within the next few years but local health care system challenges related to cost, quality, and access will remain for both the insured and the uninsured.