Urban health insurance reform and coverage in China using data from National Health Services Surveys in 1998 and 2003

Background  

In 1997 there was a major reform of the government run urban health insurance system in China. The principal aims of the reform were to widen coverage of health insurance for the urban employed and contain medical costs. Following this reform there has been a transition from the dual system of the Government Insurance Scheme (GIS) and Labour Insurance Scheme (LIS) to the new Urban Employee Basic Health Insurance Scheme (BHIS).     

Out of the reach of children? Young people’s health-seeking practices and agency in Africa’s newly-emerging therapeutic landscapes

Despite a dominant view within Western biomedicine that children and medicines should be kept apart, a growing literature suggests that children and adolescents often take active roles in health-seeking. Here, we consider young people's health-seeking practices in Ghana: a country with a rapidly-changing therapeutic landscape, characterised by the recent introduction of a National Health Insurance Scheme, mass advertising of medicines, and increased use of mobile phones. Qualitative and quantitative data are presented from eight field-sites in urban and rural Ghana, including 131 individual interviews, focus groups, plus a questionnaire survey of 1005 8-to-18-year-olds. The data show that many young people in Ghana play a major role in seeking healthcare for themselves and others. Young people's ability to secure effective healthcare is often constrained by their limited access to social, economic and cultural resources and information; however, many interviewees actively generated, developed and consolidated such resources in their quest for healthcare. Health insurance and the growth of telecommunications and advertising present new opportunities and challenges for young people's health-seeking practices. We argue that policy should take young people's medical realities as a starting point for interventions to facilitate safe and effective health-seeking.     

全球最有效率的医疗卫生体系如何应对挑战?——香港特别行政区的医疗管理体制、医疗改革举措及对内地的启示

我国医药卫生体制改革取得了有目共睹的成绩,在深化医改的过程中,可以更多参考借鉴其他华人社会的成功经验并汲取其教训。香港特别行政区的医疗卫生体系蜚声国际,高居"全球最有效率卫生体系"之冠。本文主要评析香港特区的医疗管理体制,遇到的挑战,以及近年来的重要医改举措,并总结其对内地医改的启示。香港的医疗卫生治理结构充分实现了"管办分开",解决了"九龙治水"问题,医管局管理体制具有较高的效率和专业性。但是香港特区医疗系统也面临诸多挑战,特区政府近年来推行了自愿医保、公私营协作计划、长者医疗券等若干医改政策,其中许多改革理念和政策工具可供内地医改借鉴。     

建国60年我国医疗保障体系的回顾与展望

本文回顾了建国60年来我国医疗保障体系的发展历程,重点回顾了近三十年来,中国医保体系的巨大变革。上世纪50年代建立的以机关事业单位公费医疗、企业劳保医疗和农村合作医疗为主体的医疗保险制度不适应社会主义市场经济发展的要求,弊端逐步暴露,医疗保险制度改革的必要性日益突出。在这样的背景下,经过初步探索（1978--1992）、构筑框架（1993--2002）和全面推进（2003-）三个阶段,理论体系逐渐明晰,权利义务逐步理顺,运行机制日臻成熟,覆盖范围日渐扩大,初步构建了符合社会主义市场经济体制要求的医疗保险体系。     

The challenges of healthcare reforms in China

China is in the process of a new round of healthcare reforms. The Chinese Government has launched ambitious healthcare reforms aiming to achieve equitable access to basic health services; and to build a safe, effective, convenient and inexpensive healthcare system for both urban and rural residents. This paper will provide a brief overview of China's healthcare reforms, and describe the challenges and opportunities facing these reforms.     

我国贫困地区县域内健康扶贫工作进展与政策建议

通过健康扶贫政策梳理、定量分析卫生健康统计数据和典型案例分析,研究我国县域内健康扶贫工作的进展、成效及问题,提出后脱贫期县域内医疗卫生服务改革与发展的建议。整体上看,我国健康扶贫工作成效显著:医疗卫生机构"三个一"和医疗服务能力"三条线"目标基本实现;卫生技术人员配置基本达到"三个一"要求;贫困县床位和设备配置达到或接近全国平均水平;通过新建临床专科、开展新技术和新项目等,贫困县专科服务能力得到提升;此外,部分贫困地区积极探索县域内医疗卫生综合改革。今后,新脱贫地区面临的主要挑战是县域内卫生服务体系建设仍需加强,基层卫生人才队伍差距和财政投入与卫生改革协同不足三大主要问题。建议中央财政继续支持县域内卫生服务体系建设;以人才建设为抓手,提升县域内医疗服务能力;强化保障措施,推进县域内医疗卫生综合改革。     

供方支付方式研究及政策建议

1978年改革后的我国实行的是按服务项目付费为主、政府预算为辅的支付方式."总量控制、结构调整"起到了一定的控制医疗费用上涨的作用.公费、劳保医疗受到按服务项目付费方式的冲击.城镇职工医疗保险制度和农村的合作医疗制度都对供方支付方式进行了一些有益的探讨.结合国内外经验,混合支付系统是供方支付方式在未来的发展趋势.     

Utilizing an Intranet in Disease Management

Disease Management (DM) organizations are facing incredible challenges from outside and inside the industry. A focus on costs can help both managed care organizations and self-insured employers to be more open to the potential of DM in the US.The steep increase in spending for covered medical services has been the most disturbing development over the past 2 years. This trend is largely reflected by the average premium growth. Provider revenues per privately insured person (a proxy for spending on services) increased 6.6% in 1999, compared with 5.1% in 1998, and 3.3% in 1997. At the same time, consumer demand for quality service, easy access, and reasonable deductibles and co-payments has risen nationally. There is demand for greater accountability from the medical and administrative areas. Common challenges for DM entities mandate demonstrated quality, cost of care, outcomes and access to capital markets. Public debate over healthcare models and services has increased consumer awareness of issues that were previously internal matters. Government leaders are responding to consumer pressure with an increasing focus on healthcare issues, as evidenced by the Health Insurance Portability and Accountability Act enacted in 1996 by the US. The end result of all these changes has been an extremely competitive marketplace which requires increasingly sophisticated methods for sharing and tracking of information on patients, members, services, costs and quality.Today, DM executives increasingly view information technology as an essential tool for addressing these challenges and ensuring the survival of the DM industry. Disease managers have always understood the need for sophisticated systems to collect and track disease specific data, but the cost was a hindrance. As DM organizations evolve, there is a critical need for new technologies capable of cost effectively linking all the various providers, and ultimately the patient. Recent technological advancements include the Intranet, an Internet-related technology that has the potential to dramatically improve a DM organization’s ability to meet the needs of the marketplace. This technology and its implications for DM are discussed in this article.     

Unequable spatial accessibility to hospitals in developing megacities: New evidence from Beijing

The increasing inequality in spatial accessibility to hospitals in developing countries has been attracting attention from researchers and politicians. The situation seems to be worse in growing megacities where more than 10 million people live and rapid urban sprawl has caused serious problems with the supply of health and public transport services. The recent global COVID-19 pandemic calls for particular attention to be afforded to the matter of equal access to basic medical facilities and services for people across different neighborhoods. Although some studies have already been undertaken into the subject of health-focused inequality in the cities of developing countries, the spatial inequity in hospital accessibility has rarely been discussed to date. In this paper, I aim to provide new evidence by considering Beijing as a case study. With the results of my analysis, I show that low-income neighborhoods have experienced lower levels of accessibility not only to high-tier hospitals (secondary and tertiary hospitals) but also to primary healthcare services (primary hospital and neighborhood clinics). The rate at which high-income neighborhoods access secondary and tertiary hospitals is approximately 4 times and 1.5 times as high as that of low-income neighborhoods. Low-income face nearly twice the travel time of those from high-income neighborhoods to reach the nearest primary hospital or neighborhood clinics. Suburban neighborhoods have less access to medical services than neighborhoods that are located in the central urban areas. It seems that the rapid urban sprawl has been worsening spatial inequality in the context of access to medical services in the growing megacity of Beijing. Equal access to healthcare services should be prioritized in future policy discussions, especially in relation to the urban growth management of megacities in developing countries in order to ensure that fair and inclusive urbanization processes are undertaken. Equal access to healthcare services would also be widely beneficial in the context of managing the COVID-19 pandemic.     

Healthcare rationing: a guide to policy directions in Sri Lanka

Sri Lanka's tax-financed public health system has played a significant role in achieving high levels of health status for its people. The 21st century brings new challenges in terms of rapidly aging population and increasing prevalence of NCDs. These challenges are expected to place a heavier burden on the government health financing and provision. However, the government expenditure as a proportion of GDP has declined to 1.1-1.2%, the lowest level, since the country's independence in 1948. Available funding is channeled out of the preventive services and primary healthcare to the complex hospitals, contributed by inadequacy of prioritization in resource allocation. Already, there are evidences of high level of under-funding and implicit rationing with higher impacts on the rural poor and the estate poor. Analysis of the government subsidization of healthcare shows shifting of benefits to the urban better-off from the poor. In light of the findings, the paper focuses attention on policy directions the government health sector in Sri Lanka should follow.     

The impact of increased cost sharing on Medicaid enrollees

Many state Medicaid programs are implementing cost-saving mechanisms, but little is known about the impact of those strategies on low-income people. Recent increases in cost sharing for Oregon Health Plan (OHP, Oregon's Medicaid program) members have created a natural experiment that is ideal for examining such impacts. Early results from an ongoing cohort study suggest that cost-sharing increases led to a large reduction in OHP membership. Those who left OHP because of the cost-sharing increase reported inferior access to needed care, used primary care less often, and used hospital emergency rooms more often than those who left OHP for other reasons.     

我国城乡居民基本医疗保险制度衔接的现状、问题与建议

医疗保障作为城乡居民生存和发展的基本需求,是"城乡统筹发展"的重要保证。现行的城乡基本医疗保险制度建设取得了明显的成效,提高了城乡居民抵御疾病风险的能力,缓解了居民"看病难、看病贵"的压力。但城乡分治的医疗保险制度在推进过程中也存在着一些问题,如法律保障欠缺、卫生资源分配不均、制度衔接困难、统筹层次低等。因而,必须加强城乡医保制度尤其是城镇居民医保和新型农村合作医疗之间的制度衔接,逐步建立城乡一体化的医疗保障制度,推进城乡社会经济协调发展。     

Chronic non-communicable diseases and the challenge of universal health coverage: insights from community-based cardiovascular disease research in urban poor communities in Accra,Ghana

Background

The rising burden of chronic non-communicable diseases in low and middle income countries has major implications on the ability of these countries to achieve universal health coverage. In this paper we discuss the impact of cardiovascular diseases (CVD) on primary healthcare services in urban poor communities in Accra, Ghana.

Methods

We review the evidence on the evolution of universal health coverage in Ghana and the central role of the community-based health planning services (CHPS) programme and the National Health Insurance Scheme in primary health care. We present preliminary findings from a study on community CVD knowledge, experiences, responses and access to services.

Results

The rising burden of NCDs in Ghana will affect the achievement of universal health coverage, particularly in urban areas. There is a significant unmet need for CVD care in the study communities. The provision of primary healthcare services for CVD is not accessible, equitable or responsive to the needs of target communities.

Conclusions

We consider these findings in the context of the primary healthcare system and discuss the challenges and opportunities for strengthening health systems in low and middle-income countries.

     

State variation in health insurance coverage for U.S. citizen children of immigrants

In this paper we compare health insurance coverage for U.S. citizen children in all-citizen and mixed families in the fifteen states with the largest share of children in mixed families. Insurance coverage is lower and state variation in coverage is higher for children in mixed families vis-à-vis children in all-citizen families. The main challenges for states are tackling uninsurance among all low-income children and addressing the very low rates of employer-sponsored insurance for all low-income children and for children in all mixed families, regardless of income. We discuss state policy options to address the needs of children in mixed families.     

Knowledge-based changes to health systems: the Thai experience in policy development

Over the past two decades the government in Thailand has adopted an incremental approach to extending health-care coverage to the population. It first offered coverage to government employees and their dependents, and then introduced a scheme under which low-income people were exempt from charges for health care. This scheme was later extended to include elderly people, children younger than 12 years of age and disabled people. A voluntary public insurance scheme was implemented to cover those who could afford to pay for their own care. Private sector employees were covered by the Social Health Insurance scheme, which was implemented in 1991. Despite these efforts, 30% of the population remained uninsured in 2001. In October of that year, the new government decided to embark on a programme to provide universal health-care coverage. This paper describes how research into health systems and health policy contributed to the move towards universal coverage. Data on health systems financing and functioning had been gathered before and after the founding of the Health Systems Research Institute in early 1990. In 1991, a contract capitation model had been used to launch the Social Health Insurance scheme. The advantages of using a capitation model are that it contains costs and provides an acceptable quality of service as opposed to the cost escalation and inefficiency that occur under fee-for-service reimbursement models, such as the one used to provide medical benefits to civil servants. An analysis of the implementation of universal coverage found that politics moved universal coverage onto the policy agenda during the general election campaign in January 2001. The capacity for research on health systems and policy to generate evidence guided the development of the policy and the design of the system at a later stage. Because the reformists who sought to bring about universal coverage (who were mostly civil servants in the Ministry of Public Health and members of nongovernmental organizations) were able to bridge the gap between researchers and politicians, an evidence-based political decision was made. Additionally, the media played a part in shaping the societal consensus on universal coverage.     

贵州省毕节地区新型农村合作医疗和居民医保统筹管理的比较与思考

医疗保障管理体制是我国医保领域理论研究和实践探索的热点问题。贵州省毕节地区在新型农村合作医疗和城镇居民基本医疗保险由卫生部门统筹管理方面做出了积极探索,积累了一定经验,也面临着一些困难和挑战,有待各地参考借鉴。     

Cost-sharing and the utilization of clinical preventive services.

BACKGROUND: Little is known about the effect of different forms of patient cost-sharing on the utilization of clinical preventive services or if the effect varies by type of health plan. OBJECTIVES: To assess empirically the relationships between the utilization of recommended preventive services and different forms of patient cost-sharing and how the effect is mediated by type of preventive service (counseling, blood pressure, Pap smear, mammogram), type of cost-sharing (deductibles/coinsurance, copayments), and type of health plan (HMO, PPO/indemnity plan). RESEARCH DESIGN: Sixteen logit models were estimated to assess variation in receiving recommended preventive care as a function of cost-sharing within plan type. SUBJECTS: A sample of 10,872 employees, aged 18 to 64 years, of seven large companies served by 52 health plans with diverse cost-sharing arrangements who responded to the Pacific Business Group on Health, Health Plan Value Check Survey (response rate, 50.3%). MEASURES: Receipt of recommended preventive care was based on the U.S. Preventive Services Task Force Guidelines. The effect of cost-sharing was measured as the percentage change in the probability of receiving recommended preventive care in the cost-sharing group compared to the non cost-sharing group. RESULTS: The negative effect of patient cost-sharing was greatest on preventive counseling in PPO/indemnity plans (-15%) and on mammograms in all health plan types (-9%-10%). The effect on Pap smears was negative (-8%-10%) for deductibles/coinsurance in PPO/indemnity plans and copayments in HMOs. The effect of cost-sharing on blood pressure was mixed. Deductibles/coinsurance had a greater negative effect than copayments. CONCLUSIONS: Eliminating patient cost-sharing for selected preventive services may be a relatively easy and effective means of increasing utilization of recommended clinical preventive care.     

Indicators of health system coverage and activity in Ireland during the economic crisis 2008–2014 – From ‘more with less’ to ‘less with less’

A new Irish government came to power in March 2011 with the most radical proposals for health system reform in the history of the state, including improving access to healthcare, free GP care for all by 2015 and the introduction of Universal Health Insurance after 2016. All this was to be achieved amidst the most severe economic crisis experienced by Ireland since the 1930s.