Progressive segmented health insurance: Colombian health reform and access to health services

Equal access for poor populations to health services is a comprehensive objective for any health reform. The Colombian health reform addressed this issue through a segmented progressive social health insurance approach. The strategy was to assure universal coverage expanding the population covered through payroll linked insurance, and implementing a subsidized insurance program for the poorest populations, those not affiliated through formal employment. A prospective study was performed to follow-up health service utilization and out-of-pocket expenses using a cohort design. It was representative of four Colombian cities (Cendex Health Services Use and Expenditure Study, 2001). A four part econometric model was applied. The model related medical service utilization and medication with different socioeconomic, geographic, and risk associated variables. Results showed that subsidized health insurance improves health service utilization and reduces the financial burden for the poorest, as compared to those non-insured. Other social health insurance schemes preserved high utilization with variable out-of-pocket expenditures. Family and age conditions have significant effect on medical service utilization. Geographic variables play a significant role in hospital inpatient service utilization. Both, geographic and income variables also have significant impact on out-of-pocket expenses. Projected utilization rates and a simulation favor a dual policy for two-stage income segmented insurance to progress towards the universal insurance goal.     

Low rural health insurance take‐up in a universal coverage system: perceptions of health insurance among the uninsured in La Guajira,Colombia

Despite enacting a universal healthcare system in 1993, many Colombians do not participate. Understanding perceptions of the system could help the government market certain features or adjust benefits in order to increase enrollment. Using La Guajira, Colombia, as a case study, we surveyed uninsured rural households regarding insurance preferences, values and beliefs, and perceptions of available services. Four hundred heads of households responded in La Guajira, Colombia. Respondents reported high levels of long‐term uninsurance. Overall, the quality of services in the government‐run system is perceived as better than being uninsured, but there appear to be constraints on enrollment. Rural Colombians value more family coverage and better choice of physicians, but offering better benefits may not be enough. Many cited access barriers, so reducing these barriers may also increase enrollment. Further surveys in other parts of Colombia should be undertaken to confirm results. Copyright © 2013 John Wiley & Sons, Ltd.     

The likely effects of employer-mandated complementary health insurance on health coverage in France

In France, access to health care greatly depends on having a complementary health insurance coverage (CHI). Thus, the generalisation of CHI became a core factor in the national health strategy created by the government in 2013. The first measure has been to compulsorily extend employer-sponsored CHI to all private sector employees on January 1st, 2016 and improve its portability coverage for unemployed former employees for up to 12 months. Based on data from the 2012 Health, Health Care and Insurance survey, this article provides a simulation of the likely effects of this mandate on CHI coverage and related inequalities in the general population by age, health status, socio-economic characteristics and time and risk preferences. We show that the non-coverage rate that was estimated to be 5% in 2012 will drop to 4% following the generalisation of employer-sponsored CHI and to 3.7% after accounting for portability coverage. The most vulnerable populations are expected to remain more often without CHI whereas non coverage will significantly decrease among the less risk averse and the more present oriented. With its focus on private sector employees, the policy is thus likely to do little for populations that would benefit most from additional insurance coverage while expanding coverage for other populations that appear to place little value on CHI.     

Effects of health insurance coverage on risky behaviors

Prior to implementation of the Patient Protection and Affordable Care Act, dependent health insurance coverage was typically available only for young adults under the age of 19. As of September 2010, the Affordable Care Act extended dependent health insurance coverage to include young adults up to the age of 26. I use the National Health Interview Survey for the sample period from 2011 to 2013 to analyze the causal relationship between the expansion of dependent coverage and risky behaviors including smoking and drinking as well as preventive care. I employ a regression discontinuity design to estimate the causal effect of health insurance coverage and overcome the endogeneity problem between insurance status and risky behaviors. When young adults become 26 years old, they are 7 to 10 percentage points more likely to lose health insurance than young adults under the age of 26. Although young adults over the age of 26 are generally aged out of insurance coverage, presence or absence of health insurance does not affect their smoking and drinking behaviors and their access to preventive care.     

Effectiveness of tax credits for health insurance premium: Evidence from the health insurance tax credit

With the push to repeal the Affordable Care Act, there is renewed interest in using tax credits to increase health insurance coverage. Another tax credit‐driven policy, the Health Insurance Tax Credit (HITC), was implemented during 1991–1993. To date, only one paper has analyzed the effectiveness of the HITC on coverage rates. In this paper, I reexamine the effectiveness of the HITC by using the Survey of Income Program Participation and provide the first estimates of its effects on utilization and self‐reported health status. Despite using the different data set, I find a similar result regarding coverage as the previous paper—the effect of the HITC was about 5.8 percentage points. I also find that self‐reported health was significantly improved because of the HITC. I conclude by discussing the implications of these findings on the larger debate regarding current health care reform.     

Family structure, socioeconomic status, and access to health care for children

OBJECTIVE: To test the hypothesis that among children of lower socioeconomic status (SES), children of single mothers would have relatively worse access to care than children in two-parent families, but there would be no access difference by family structure among children in higher SES families. DATA SOURCES: The National Health Interview Surveys of 1993-95, including 63,054 children. STUDY DESIGN: Logistic regression was used to examine the relationship between the child's family structure (single-mother or two-parent family) and three measures of health care access and utilization: having no physician visits in the past year, having no usual source of health care, and having unmet health care needs. To examine how these relationships varied at different levels of SES, the models were stratified on maternal education level as the SES variable. The stratified models adjusted for maternal employment, child's health status, race and ethnicity, and child's age. Models were fit to examine the additional effects of health insurance coverage on the relationships between family structure, access to care, and SES. PRINCIPAL FINDINGS: Children of single mothers, compared with children living with two parents, were as likely to have had no physician visit in the past year; were slightly more likely to have no usual source of health care; and were more likely to have an unmet health care need. These relationships differed by mother's education. As expected, children of single mothers had similar access to care as children in two-parent families at high levels of maternal education, for the access measures of no physician visits in the past year and no usual source of care. However, at low levels of maternal education, children of single mothers appeared to have better access to care than children in two-parent families. Once health insurance was added to adjusted models, there was no significant socioeconomic variation in the relationships between family structure and physician visits or usual source of care, and there were no significant disparities by family structure at the highest levels of maternal education. There were no family structure differences in unmet needs at low maternal education, whereas children of single mothers had more unmet needs at high levels of maternal education, even after adjustment for insurance coverage. CONCLUSIONS: At high levels of maternal education, family structure did not influence physician visits or having a usual source of care, as expected. However, at low levels of maternal education, single mothers appeared to be better at accessing care for their children. Health insurance coverage explained some of the access differences by family structure. Medicaid is important for children of single mothers, but children in two-parent families whose mothers are less educated do not always have access to that resource. Public health insurance coverage is critical to ensure adequate health care access and utilization among children of less educated mothers, regardless of family structure.     

Insurance coverage and access: implications for health policy.

Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.     

Health insurance and opioid deaths: Evidence from the Affordable Care Act young adult provision

The concurrence of health insurance expansion under the Affordable Care Act (ACA) and increasing opioid‐related mortality has led to debate whether insurance increases or decreases opioid deaths. I use the introduction of the ACA young adult (YA) provision as a quasi‐experiment and utilize the resulting policy‐induced variation across states over time in YA access to insurance to study the effect of coverage on opioid‐related mortality. I rely on the share of state populations which stood to gain insurance before the ACA to perform a dose–response analysis, and find that the YA provision reduced opioid‐related mortality. The analysis suggests that 1 percentage point more coverage reduced opioid mortality among YA by 2.5/100,000 or 19.8%.     

Understanding consumer preferences in the context of managed competition

Background

In many countries, health insurance coverage is the primary way for individuals to access care. Governments can support access through social insurance programmes; however, after a certain period, governments struggle to achieve universal coverage. Evidence suggests that complex individual behaviour may play a role.

Objectives

Using a choice experiment, this research explored consumer preferences for health insurance in Colombia. We also evaluated whether preferences differed across consumers with differing demographic and health status factors.

Methods

A household field experiment was conducted in Bogotá in 2010. The sample consisted of 109 uninsured and 133 low-income insured individuals. Each individual evaluated 12 pair-wise comparisons of hypothetical health plans. We focused on six characteristics of health insurance: premium, out-of-pocket expenditure, chronic condition coverage, quality of care, family coverage and sick leave. A main effects orthogonal design was used to derive the 72 scenarios used in the choice experiment. Parameters were estimated using conditional logit models. Since price data were included, we estimated respondents?? willingness to pay for characteristics.

Results

Consumers valued health benefits and family coverage more than other attributes. Additionally, differences in preferences can be exploited to increase coverage. The willingness to pay for benefits may partially cover the average cost of providing them.

Conclusion

Policy makers might be able to encourage those insured via the subsidized system to enrol in the next level of the social health insurance scheme through expanding benefits to family members and expanding the level of chronic condition coverage.     

The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California

OBJECTIVE: To compare the extent with which child-only and family coverage (child and parent insured) ensure health care access and use for low income children in California and discuss the policy implications of extending the State Children's Health Insurance Program (California's Healthy Families) to uninsured parents of child enrollees. DATA SOURCES/SETTING: We used secondary data from the 2001 California Health Interview Survey (CHIS), a representative telephone survey. STUDY DESIGN: We conducted a cross-sectional study of 5,521 public health insurance-eligible children and adolescents and their parents to examine the effects of insurance (family coverage, child-only coverage, and no coverage) on measures of health care access and utilization including emergency room visits and hospitalizations. DATA COLLECTION: We linked the CHIS adult, child, and adolescent datasets, including the adolescent insurance supplement. FINDINGS: Among the sampled children, 13 percent were uninsured as were 22 percent of their parents. Children without insurance coverage were more likely than children with child-only coverage to lack a usual source of care and to have decreased use of health care. Children with child-only coverage fared worse than those with family coverage on almost every access indicator, but service utilization was comparable. CONCLUSIONS: While extending public benefits to parents of children eligible for Healthy Families may not improve child health care utilization beyond the gains that would be obtained by exclusively insuring the children, family coverage would likely improve access to a regular source of care and private sector providers, and reduce perceived discrimination and breaks in coverage. These advantages should be considered by states that are weighing the benefits of expanding health insurance to parents.     

Trends in Health Care Financial Burdens, 2001 to 2009

Context: Over the past decade, health care spending increased faster than GDP and income, and decreasing affordability is cited as contributing to personal bankruptcies and as a reason that some of the nonelderly population is uninsured. We examined the trends in health care affordability over the past decade, measuring the financial burdens associated with health insurance premiums and out-of-pocket costs and highlighting implications of the Affordable Care Act for the future financial burdens of particular populations.Methods: We used cross sections of the Medical Expenditure Panel Survey Household Component (MEPS-HC) from 2001 to 2009. We defined financial burden at the health insurance unit (HIU) level and calculated it as the ratio of expenditures on health care—employer-sponsored insurance coverage (ESI) and private nongroup premiums and out-of-pocket payments—to modified adjusted gross income.Findings: The median health care financial burden grew on average by 2.7% annually and by 21.9% over the period. Using a range of definitions, the fraction of households facing high financial burdens increased significantly. For example, the share of HIUs with health care expenses exceeding 10% of income increased from 35.9% to 44.8%, a 24.8% relative increase. The share of the population in HIUs with health care financial burdens between 2% and 10% fell, and the share with burdens between 10% and 44% rose.Conclusions: We found a clear trend over the past decade toward an increasing share of household income devoted to health care. The ACA will affect health care spending for subgroups of the population differently. Several groups’ burdens will likely decrease, including those becoming eligible for Medicaid or subsidized private insurance and those with expensive medical conditions. Those newly obtaining coverage might increase their health spending relative to income, but they will gain access to care and the ability to spread their expenditures over time, both of which have demonstrable economic value.     

The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999–2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.     

Choice of health insurance by families of the mentally ill

This paper investigates whether choice of health insurance is influenced by the perceived mental and physical health of family members among a sample of policy-holders with private health insurance. A multinomial probit model of the choice among major medical coverage only, traditional full coverage, and coverage through a health maintenance organization is estimated. Results indicate that the presence of at least one family member who rates his or her general health as poor does not affect the policy-holder's choice of health insurance. However, the presence of at least one family member considered at risk of mental illness does in some instances affect the policy-holder's choice of health insurance: We observe significant effects for policy-holders who are female, black, have some college education, work for a large firm, and live in an urban area. These findings suggest that adverse selection may arise when individuals are able to choose between health insurance policies with different degrees of coverage for mental health care and that such effects are far more pronounced for those people who consider themselves at risk for mental illness than physical illness.     

The impact of the tax system on health insurance coverage

A central question in health economics is the extent to which this tax subsidization matters for the health insurance coverage of the U.S. population. I assess the impact of taxes on health insurance by using the considerable existing variation in tax subsidies, both at a point in time and across time. I do so by putting together data from more than a decade of Current Population Survey (CPS) data sets, and matching to workers in those data sets their tax subsidies to health insurance coverage. I find that the elasticity of insurance eligibility of workers is at least –0.6, and that the elasticity of own insurance coverage is roughly similar; the results imply that most of the impact of taxes on insurance coverage arise through firm offering and eligibility decisions. I also find that higher tax rates induce more private coverage through other sources, but less public coverage, so that overall there is a reduction in the rate of uninsurance that is comparable to the change in own employer-provided insurance coverage.     

Social health insurance in Nepal: A health system departure toward the universal health coverage

The World Health Organization has identified universal health coverage (UHC) as a key approach in reducing equity gaps in a country, and the social health insurance (SHI) has been recommended as an important strategy toward it. This article aims to analyze the design, expected benefits and challenges of realizing the goals of UHC through the recently launched SHI in Nepal. On top of the earlier free health‐care policy and several other vertical schemes, the SHI scheme was implemented in 2016 and has reached population coverage of 5% in the implemented districts in just within a year of implementation. However, to achieve UHC in Nepal, in addition to operationalizing the scheme, several other requirements must be dealt simultaneously such as efficient health‐care delivery system, adequate human resources for health, a strong information system, improved transparency and accountability, and a balanced mix of the preventive, health promotion, curative, and rehabilitative services including actions to address the social determinants of health. The article notes that strong political commitment and persistent efforts are the key lessons learnt from countries achieving progressive UHC through SHI.     

The aftermath of health sector reform in the Republic of Georgia: effects on people's health

After the collapse of the Former Soviet Union a health reform process was undertaken in Georgia beginning in 1994. This process was intended to encompass all aspects of the health-care sector and to transform the Soviet-style health system into one that was directed towards quality of care, improved access, efficiency, and a strengthened focus on Primary Health Care (PHC). Health sector reform fundamentally changed the ways health care is financed in Georgia. There has been a transition to program-based financing, and payroll-tax-based social insurance schemes have been introduced. Despite these measures, the performance of the health system is still disappointing. All health programs are severely under-funded, and when the majority of the population is unemployed or self-employed, collection of taxes seems impossible. Overall, Georgian consumers are uninformed about the basic principles of health reforms and their entitlements and therefore do not support them. The analysis introduced in this paper of the current situation in Georgia establishes that the rush to insurance-based medicine was more a rush from the previous system than a well-thought-out policy direction. After 70 years of a Soviet rule, the country had no institutional capacity to provide insurance-based health care. To achieve universal coverage, or at least ensure that the majority of the population has access to basic health services, government intervention is essential. In addition, educating the public on reforms would allow the reform initiators to fundamentally change the nature of the reform process from a top-down centralized process to one that is demand-driven and collaborative.     

Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage

South Korea introduced mandatory social health insurance forindustrial workers in large corporations in 1977, and extendedit incrementally to the self-employed until it covered the entirepopulation in 1989. Thirty years of national health insurancein Korea can provide valuable lessons on key issues in healthcare financing policy which now face many low- and middle-incomecountries aiming to achieve universal health care coverage,such as: tax versus social health insurance; population andbenefit coverage; single scheme versus multiple schemes; purchasingand provider payment method; and the role of politics and politicalcommitment. National health insurance in Korea has been successfulin mobilizing resources for health care, rapidly extending populationcoverage, effectively pooling public and private resources topurchase health care for the entire population, and containinghealth care expenditure. However, there are also challengesposed by the dominance of private providers paid by fee-for-service,the rapid aging of the population, and the public-private mixrelated to private health insurance.     

Healthcare financing in Syria: satisfaction with the current system and the role of national health insurance--a qualitative study of householders' views

This study aims to identify the satisfaction with the current public health system and health benefit schemes, examine willingness to participate in national health insurance and review expectations and preferences of national health insurance. To this end, qualitative semi-structured interviews were carried out with 19 Syrian householders. Our results show that a need for health reform exists and that Syrian people are willing to support a national health insurance scheme if some key issues are properly addressed. Funding of the scheme is a major concern and should take into account the ability to pay and help the poor. In addition, waiting times should be shortened and sufficient coverage guaranteed. On the whole, the people would support a national health insurance with national pooling and purchasing under a public set-up, but important concerns of such a system regarding corruption and inefficiency were voiced too. Installing a quasi non-governmental organisation as manager of the insurance system under the stewardship of the Ministry of Health could provide a compromise acceptable to the people.     

Subsidies and the demand for individual health insurance in California

OBJECTIVE: To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population. DATA SOURCE: Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001. STUDY DESIGN: A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage. PRINCIPAL FINDINGS: The elasticity of demand for individual insurance by those without access to group insurance is about -.2 to -.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage. CONCLUSIONS: Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system.     

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.