A Review on How to Apply Digital Technology to National Health Insurance from Five Countries

Context: Throughout Europe, the financial risks of health and long-term care are covered to varying degrees through models of national (health) insurance. Such insurance draws upon the principle of solidarity. Much is unknown on the solidarity-effects of reforms in national insurance schemes. Objective: To present an empirical analysis of the effects of recent reforms in national health insurance on solidarity in one country. Methods: We conducted a comparative analysis of the 2006 health care insurance reform and the 2015 long-term care insurance reform in the Netherlands. A multidimensional analytical framework of solidarity was developed to study the solidarity-effects of both reforms. Findings: Reforms of health care and long-term care insurance in the Netherlands had some solidarity effects, but they should not be overstated. We found evidence for increased and decreased solidarity. Health care insurance seems more ‘immune’ to reductions in solidarity than long-term care insurance. Limitations: The present case study involves reforms in the Netherlands. The solidarity framework is specifically designed for the study of solidarity-effects of reforms on national health and long-term care insurance. Effects on informal arrangements for care are beyond the scope of this study. More detailed and quantitative research is required to investigate how the reforms played out for specific groups, for instance the frail elderly, people with a disability and people with rare conditions. Similarly, long-term effects require further investigation. Implications: Given the limited scope of our analysis, more comparative research (including on an international scale) is required to develop systematic insight into the solidarity-effects of reforms in national health and long-term care insurance.

Lung Cancer in Vietnam

Our Health Care System at the Crossroads: Single Payer or Market Reform?

Do Canada and the United States Differ in Prevalence of Depression and Utilization of Services?

BackgroundDigital health technologies enable patients to make a personal contribution to the improvement of their health by enabling them to manage their health. In order to exploit the potential of digital health technologies, Internet-based networking between patients and health care providers is required. However, this networking and access to digital health technologies are less prevalent in sociodemographically deprived cohorts. The paper explores how the use of digital health technologies, which connect patients with health care providers and health insurers has changed during the COVID-19 pandemic.MethodsThe data from a German-based cross-sectional online study conducted between April 29 and May 8, 2020, were used for this purpose. A total of 1.570 participants were included in the study. Accordingly, the influence of sociodemographic determinants, subjective perceptions, and personal competencies will affect the use of online booking of medical appointments and medications, video consultations with providers, and the data transmission to health insurers via an app.ResultsThe highest level of education (OR 1.806) and the presence of a chronic illness (OR 1.706) particularly increased the likelihood of using online booking. With regard to data transmission via an app to a health insurance company, the strongest increase in the probability of use was shown by belonging to the highest subjective social status (OR 1.757) and generation Y (OR 2.303). Furthermore, the results show that the higher the subjectively perceived restriction of the subjects' life situation was due to the COVID-19 pandemic, the higher the relative probability of using online booking (OR 1.103) as well as data transmission via an app to a health insurance company (OR 1.113). In addition, higher digital literacy contributes to the use of online booking (OR 1.033) and data transmission via an app to the health insurer (OR 1.034).ConclusionsSocially determined differences can be identified for the likelihood of using digital technologies in health care, which persist even under restrictive conditions during the COVID-19 pandemic. Thus, the results indicate a digital divide with regard to the technologies investigated in this study.

Healthcare Reform: Obama vs McCain

The objectives of this international comparison are: a) to describe and analyze the current status of mental health financing and purchasing in Romania, the Czech Republic, Slovakia, Bulgaria; b) to identify common trends as well as national specifics in mental health financing and purchasing and find opportunities for transfer of knowledge and experience among the countries, c) to improve understanding of the attitudes towards mental health services in the countries. Methods: The country-specific information was obtained by a questionnaire that was developed by the research team in the project “Finance and Mental Health Services Training in Czech Republic/Central Europe”, sponsored by the U.S. National Institutes of Health John E. Fogarty International Center. The questionnaire includes both quantitative and qualitative information on the mental health policy, health services, financing and purchasing.Results: In all countries, the tax-financed system was transformed to public health insurance one, though the countries differ in the implementation. The Czech Republic and Slovakia have multiple health insurance funds; Romania has the national unique social health insurance fund administrated by the National Health Insurance House through its district houses and Bulgaria run one national health insurance fund. The compulsory social health insurance system secures that citizens have access to mental health services. The Czech Republic and Slovakia do not have any separate budget for mental health care; mental health care is financially integrated with other services. In Romania is the Mental Health National Program developed by the Health Ministry through the national unique social health insurance fund. Bulgaria is the only country in which inpatient care for the mentally ill is financed from the state budget and outpatient care is financed from health insurance.

BackgroundThe national health insurance scheme of Nigeria recently proposed a national premium for community based insurance scheme. This study determined the capacity of households in the rural and urban areas in Nigeria to pay for the premium and different hypothetical health insurance schemes namely national health insurance scheme, national urban health insurance scheme, national rural health insurance scheme and regional health insurance schemes. It determined the likely impact of different premiums on membership across socio-economic status quintiles, and then determined the threshold premium affordable to rural and urban households.ResultsThe results show that the mean capacity to pay for the households in different regions ranged from US$194 ± 100 to US$986 ± 907. The threshold premiums of the national health insurance scheme, urban national health insurance and rural health insurance schemes were US$66, US$154 and US$53 respectively.ConclusionsOverall, the threshold premium for rural national health insurance scheme and national health insurance schemes were affordable to the lowest socio economic group. Hence, it is recommended that threshold premium for rural national health insurance scheme be adopted as the maximum premium not to be exceeded in the proposed national health insurance scheme.

Digital health technologies and health-care privatisation

THE UNITED STATES IS THE ONLY INDUSTRIALIZED NATION THAT does not have national health insurance. It has, however, witnessed 5 attempts to achieve it. In the early 1900s, patients paid physicians directly for their services. Concerned that more than a quarter of the population could not afford basic care, the American Association for Labor Legislation (AALL) in 1915 proposed a national insurance system that would cover medical care, sick pay, maternity benefits, and funeral expenses for low-paid workers and their dependents. It would be financed by mandatory employer and employee contributions and additional state funds. Later expanded to cover large segments of the population, the AALL proposal was called a social insurance plan because it would cover only those who paid into it. Opposition from the American Medical Association (AMA), business, and labor, compounded by shifting attitudes and priorities as the United States entered World War I, defeated the proposal. The next movement toward national health insurance came in the 1940s, when senators Robert Wagner and James Murray and Rep John Dingell proposed a plan to expand Social Security, enacted in 1935, to cover physician and hospital care for workers and retirees. Employers and employees would pay into a federal trust fund that would in turn reimburse providers. The unemployed would rely on government assistance or charity care. At the time, 74% of the public favored national health insurance, and 68% liked the idea of Social Security coverage of medical fees. In 1945, President Truman embraced a similar proposal, making him the first president to support national health insurance. Public opinion on the Truman proposal was initially evenly split—38% for and 38% against—but its support by a wide range of legislators and organizations led analysts to predict that it would be passed. The AMA opposed the plan, however, and defeated it with a massive campaign. The first successful push toward national health insurance came in 1965 with the passage of Medicare and Medicaid under President Johnson. At that time, 85% of the elderly were uninsured, and political pressure to cover them was great. Medicare narrowed the Wagner-Murray-Dingle plan to cover only those over 65 with funding from Social Security payments, federal income taxes, and individual premiums. Although Medicare was initially opposed by the AMA, it was supported by 61% of the public. At the same time, Medicaid became the first public assistance program in the national health insurance movement. Public assistance programs are need-based and, unlike social insurance programs, do not require that recipients have paid into them. Medicare and Medicaid are not true national health insurance programs because, unlike similar programs covering the elderly and poor in other nations, they were never expanded to cover all Americans. The 1970s brought a wave of public debate and over a dozen health reform bills, most espousing national health insurance. Two competing proposals, each the first of its kind, stood out. In 1970, Sen Edward Kennedy and Rep Martha Griffiths proposed the first single, universal health insurance program to cover all Americans. The KennedyGriffiths Health Security Program would be funded by employer and employee contributions and federal income taxes. Medicare and Medicaid would be folded into the program. Organized labor supported the bill but the AMA, the insurance industry, and President Nixon opposed it. Like earlier proposals, the Kennedy-Griffiths bill would have replaced the private insurance industry with government-based health insurance. Nixon countered with the first national health insurance plan to maintain the private insurance industry and tie health insurance to employment. Nixon’s plan mandated that employers purchase private insurance policies for their employees. The government would contribute funds to cover the unemployed. With two thirds of the public in support and both Nixon and Kennedy willing to compromise, many thought the passage of national health insurance was imminent. However, congressional delays and the distraction of the Watergate scandal reduced political pressure for national health insurance, and no plan was passed. National health insurance entered public discourse again in the early 1990s, as the number of uninsured in the United States rose from 25 million to 40 million. Voters ranked health care among the top three issues of the 1992 presidential campaign, and two thirds of Americans favored tax-financed national health insurance. President Clinton’s proposal, like Nixon’s, combined mandated employer-based private insurance with governmentfunded public assistance. Clinton’s plan organized payers into a government-regulated system called “managed competition.” Groups of insured would be consolidated into large purchasing cooperatives that would buy insurance for their members, decreasing but not eliminating the number of private insurance companies. Clinton’s plan initially had 59% of the public’s support, but opposition campaigns cut support to 40% in 10 months and reduced momentum for reform. At about the same time, supporters of governmentfinanced national health insurance began calling their pro-

Nations fund healthcare in various ways. Both the individual and society play fundamental roles in financing health management. Healthcare expenditure often constitutes a substantial part of the national budget. Among the most important factors in health financing is health insurance. Health insurance remains the primary source of healthcare funding, and its accessibility is directly correlated to national health. Insurance, however, remains at odds with certain models of Universal Health Care (UHC) , and issues of affordability and financial protection have been central in attempts to secure UHC in Africa. Despite the numerous benefits, national health insurance in developing African countries faces several challenges and it is evident that health insurance does not cover large proportions of many populations and nations in Africa. This chapter starts with a review of the state of health financing in Africa and explains the role of health insurance, which often involves pooling risks with others in order to diffuse the cost of healthcare. This chapter discusses the types of health insurance in Africa (social, private for-profit, private-non-profit and community-based health insurance (CBHI)), and their unique benefits and drawbacks.

The aim of this paper is to identify the factors that determine the prevalence of private medical insurance (PMI) in England. Secondary data sources are the British Household Panel Survey (BHPS) 1997-2000, Laing's Healthcare Market Review 1999-2000, the United Kingdom (U.K.) Department of Health's National Health Service Waiting Times Team, and the Work Force Statistics Branch of the Department of Health. Logistic regression models for panel data were used to compare non-PMI subscribers with individual subscribers and those with employer-provided PMI. The BHPS data are collected by the Institute for Social and Economic Research at the University of Essex. Other data used were collected by Laing and Buisson and the U.K. Department of Health. Individual PMI is more prevalent among the well-educated and healthy. Income, age, sex, and political preference are key determinants of PMI prevalence for both individual and employer paid PMI. Individuals are also likely to reflect on information with regard to waiting times in deciding whether or not to purchase PMI cover. The withdrawal of the tax subsidy in 1997 to PMI subscribers over 60 years of age did not impact on their rate of withdrawal from PMI coverage relative to the rate among all PMI subscribers, but may have discouraged potential new subscribers. Current trends in the PMI market suggest that, over time, individually purchased PMI is likely to be partially displaced by PMI purchased as part of a company-based plan. However, having PMI is linked to economic factors in both groups, suggesting a similar segment of the population valuing the responsiveness that PMI provides. Geographic factors relating to waiting times and supply-side factors are associated with both individual and company-based PMI. The withdrawal of the tax subsidy to individual subscribers older than age of 60 resulted in a significant decline in the demand for PMI. In particular, the number of new subscribers in this group declined substantially.

To the Editor: At the 2008 SAMA conference ‘The Future of Health Care in South Africa – How Will It Be Provided and Funded?’, I addressed the history of South Africa’s health policy, in particular the views of the mass movements on health and access to health care, traced back to the Freedom Charter (1955). Their continued appeal for a state-run preventive health scheme, free medical and hospital care (with special attention to mothers and children) and better access to health care is highlighted in frameworks such as the Reconstruction and Development Plan (1994), the ANC’s National Health Plan for South Africa of 1994 (developed with the World Health Organization and UNICEF), the Constitution of the Republic of South Africa (1996), the White Paper for the Transformation of the Health System of South Africa (1997) and the National Health Act (2004). National Health Insurance (NHI) was an aspiration of the people as a human right; its development was therefore inevitable. Despite detractors, this vision came to fruition in the Policy on National Health Insurance (Green Paper), gazetted on 12 August 2011. This argues for the necessity for such a system and that the NHI will ensure that ‘everyone has access to appropriate, efficient and quality health services’. It meets our constitutional obligation (Section 27: ‘[e] veryone has the right to have access to health care services ...’) and our obligation to do what is socially and morally just. The NHI Green Paper refers to the previous government’s attempts at health care reform, e.g. the Commission on Old Age Pension and National Insurance (1928), the Committee of Enquiry into National Health Insurance (1935), Gluckman’s National Health Service Commission (1942 - 1944), and subsequent committees and task teams of the current government. The NHI principles and objectives cannot be contested, because it underpins respect for social justice. It recommends piloting to deal with the challenge of implementation. Health professionals committed to better health care are called on to support and to add constructive comments to the NHI proposal. It proposes strengthening the South African health system based on a re-engineered primary health care approach and system that focuses on outreach services and emphasises prevention of ill health and disease and promotion of good health and wellbeing. Special mention is made of a District Clinical Specialist Support Team of specialists in obstetrics and gynaecology, paediatrics, family medicine and anaesthetics, supported by appropriate professional nurses. Consideration should be given to include specialists familiar with planning, programme implementation, monitoring and evaluation of health and health services at a community level to support the District Specialist Team, i.e. public health medicine (‘community health’), community psychiatry, community dentistry, and occupational medicine. Public health medicine is already incorporated into the draft Human Resources for Health for South Africa Plan in the ‘leadership’ of public health units at district level to provide a strategic role in addressing health priorities. Extending this specialist support to the district specialist team is therefore logical. The role of the ‘community health’ nurse too should be revisited in this regard. Much increased and appropriate production of health professionals is required. Medical and dental schools and nursing colleges are called on to take up the challenge, with special emphasis on targeting recruitment from rural areas. Together with intersectoral efforts to reduce determinants of health such as poverty alleviation, improved access to good education, water and sanitation, adequate nutrition, shelter and an enhanced social welfare network, this will improve health outcomes, impact positively on the economy and make this country better for its citizens. Congratulations to the Minister and the

Preventive Medicine: A Ready Solution for a Health Care System in Crisis

While health reform in Australia has been marked by piecemeal, incremental changes, the overall trend to increasing Commonwealth involvement has not been accidental or driven by power-hungry centralists: it has been shaped by broader national and international developments including technological change and the maturing of our nation and its place internationally, and by a widespread desire for a national universal health insurance system. In many respects the Australianhealth system performs well, but the emerging challenges demand a more integrated, patient-oriented system. This is likely to require a further shift towards the Commonwealth in terms of financial responsibility, as the national insurer. But it also requires close cooperation with the States, who could play a firmer role in service delivery and in supporting regional planning and coordination. The likelihood of sharing overall responsibility for the health system also suggests thereis a need to involve the States more fully in processes for setting national policies.
 This article draws heavily on a lecture presented at the Australian National University in October 2015. It includes an overview of Australia’s evolving federal arrangements and the context within which the current Federalism Review is being conducted. It suggests Australia will not return to ‘coordinate federalism’ with clearly distinct responsibilities, and that greater priority should be given to improving how we manage shared responsibilities.
 There is a long history of Commonwealth involvement in health, and future reform should build on that rather than try to reverse direction. While critical of the proposals from the Commission of Audit and in the 2014 Budget, the lecture welcomed the more pragmatic approaches that seemed to be emerging from the Federalism Review discussion papers and contributions from some Premiers which could promote more sensible measures to improve both the effectiveness and the financial sustainability of Australia’s health and health insurance system.
 The Commonwealth’s new political leadership in 2015 seemed interested in such measures and in moving away from the Abbott Government’s approach. But the legacy of that approach severely damaged the Turnbull Government in the 2016 federal election as it gave traction to Labor’s ‘Mediscare’ campaign. In addition to resetting the federalism debate as it affects health, the Turnbull Government now needs to articulate the principles of Medicare and to clarify the role of the private sector, including private health insurance, in Australia’s universal health insurance system. Labor also needs to address more honestly the role of the private sector and develop a more coherent policy itself.
 Abbreviations: COAG – Council of Australian Governments; NHHRC – National Health and Hospitals Reform Commission; PHI – Private Health Insurance; VFI – Vertical Fiscal Imbalance.