Minimum wage and employer‐sponsored supplementary health insurance: Evidence from Canada

The effects of supplemental health insurance on health-care consumption crucially depend on specific institutional features of the health-care system. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. Within this institutional background, we find only weak evidence of adverse selection in the coverage of supplemental health insurance. We find much stronger effects of socio-economic background. We estimate a bivariate probit model and cannot reject the assumption of exogeneity of insurance availability for the explanation of health-care use. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights per spell. We comment on the implications of our findings for equality of access to health care in Belgium.

Dear Editor- in- Chief Voluntary health insurance schemes help those who are not included in social health insurance (1). These are divided into supplementary and self-employed insurance. Generally, the supplementary health insurance provides health facilities in nongovernmental sectors for the insured, fills the gap in services and commitments of basic health insurance, (2) makes the room for innovation, diversity and competition in the field of health insurance activities (2). In addition, self-employed health insurance is awarded to persons who work with an employer or alone (self-funding) based on work permits issued by the competent authorities or under the recognition of Social Security Organization (3). This study emphasizes on measuring main determinants of demand for supplementary health insurance. Data are extracted from website of Statistical Center of Iran in 2012. We select a sample of 4055 urban households and 1594 rural ones. Due to binary nature of dependent variable (y), we use a Logistic regression model to estimate supplementary health insurance demand (4). Pr⁡[y=1]=exp⁡(βx)1+exp⁡(βx) y indicates demand for supplementary health insurance and takes 1, if one buys supplementary health insurance policy, or 0 otherwise. Xs consist of both quantitative variables (head of household’s age, income and household size) and qualitative variables (head of household’s gender, and head of household’s education level). Occupation was classified into government employee, non-government employee and the retiree; head of household’s marital status was classified into single (base group), married and divorced or deceased. House ownership status was classified into the leased (base group), owner-occupied and mortgaged houses. The results of Logistic regression model estimation are reported in Table (1), in which likelihood ratio (LR) and Hosmer-Lemeshow test imply goodness of fit of the model. The odds ratios (OR) in Table 1 are of probabilistic interpretations. For example, for each year increase in age, the probability of demand for supplementary health insurance in both urban and rural households increases by 1.03 and 1.09 times, respectively. The similar interpretations are applicable for the remaining odds ratios. Table 1: The regression results of logistic model for supplementary health insurance demand The demand for supplementary health insurance is not related to gender of household’s head and household size in urban areas. However, in rural areas, as the size of household increases, the higher expenses for housing, clothing, food and transportation reduce demand for supplementary health insurance (5). The household head’s age is of positive impact on demand for supplementary health insurance; possible reasons are high motivation to improve faster and greater likelihood of developing a disease with aging. According to Table 1, the higher the income level, the more the ability of household to pay and the probability to demand for voluntary health insurance. A positive significant relationship between education level of household head and demand for supplementary health insurance shows that low-educated people are high risk-taker but high-educated people are risk-averse. Demand for supplementary health insurance in urban households is positively linked to occupation due to regulatory mechanisms, which provide more facilities to the retired and employed people. Lack of similar relationship in rural households originates mainly from self-employment of villagers in agriculture or animal husbandry activities. There is no significant relationship between demand for supplementary health insurance and marital status in both urban and rural households. In urban households demand for supplementary health insurance in house owner group is higher than tenant group, because rent costs impose additional burden on household income and as a result reduce household ability to pay [for insurance] (6). In rural households, demand for supplementary health insurance has no significant relationship with house ownership, since villagers as house owners or living together households have no extra rent expenses.

It has been suggested that the unequal coverage of different socio-economic groups by supplemental insurance could be a partial explanation for the inequality in access to health care in many countries. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. We find that this institutional background is crucial for the explanation of the effects of supplemental insurance. We find no evidence of adverse selection in the coverage of supplemental health insurance, but strong effects of socio-economic background. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights. This is in line with patterns of socio-economic stratification that have been well documented for Belgium. It is also in line with the regulation on extra-billing protecting patients in common rooms. For ambulatory care, we find a positive effect of supplemental insurance on visits to a dentist and on number of spells at a day centre but no effect on visits to a GP, on drugs consumption and on visits to a specialist.

In Israel, the whole population is covered by comprehensive universal health insurance. Despite that, most of the population purchases supplementary health insurance (SHI). It has been shown that individuals purchase more health insurance and preventive medicine when they are uncertain of their state of health, while a majority may not fully understand basic concepts in their health insurance coverage. The purpose of this study was to examine the role of fear of catastrophic health expenditures and unrealistic expectations in purchasing SHI, which does not cover expenses for life-threatening illnesses. A cross-sectional survey was conducted among random samples of 814 Jews and 800 Arabs in Israel. A structured questionnaire was administered by telephone using random digit dialling. Log-linear regression was used to identify factors associated with reasons for purchasing SHI and expectations from SHI. The most common reason for purchasing SHI was fear of catastrophic health-related expenditures (41%). The most important service expected from SHI was 'cancer medications' (mean 4.68 [standard deviation 0.87]). Differences in the reasons for purchasing SHI and in expectations from SHI were found according to population group, age, gender and education. Consumers' misconceptions and fear of catastrophic health expenditures are major factors leading to the purchase of SHI, despite universal health coverage. Improved and accessible information should help consumers make informed decisions as to whether or not to purchase SHI.

Like many other countries, the Netherlands has a health insurance system that combines mandatory basic insurance with voluntary supplementary insurance. Both types of insurance are founded on different principles. Since basic and supplementary insurance are sold by the same health insurers, both markets may interact. This paper examines to what extent basic and supplementary insurance are linked to each other and whether these links generate spillover effects of supplementary on basic insurance. Our analysis is based on an investigation into supplementary health insurance contracts, underwriting procedures and annual surveys among 1,700–2,100 respondents over the period 2006–2009. We find that health insurers increasingly use a variety of strategies to enforce a joint purchase of basic and supplementary health insurance. Despite incentives for health insurers to use supplementary insurance as a tool for risk selection in basic insurance, we find limited evidence of supplementary insurance being used this way. Only a minority of health insurers uses health questionnaires when people apply for supplementary coverage. Nevertheless, we find that an increasing proportion of high-risk individuals believe that insurers would not be willing to offer them another supplementary insurance contract. We discuss several strategies to prevent or to counteract the observed negative spillover effects of supplementary insurance.

Why Employment During and After COVID-19 Is a Critical Women's Health Issue.

The influence of health insurance systems on the treatment of end-stage kidney disease (ESKD) patients ispoorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalitiesand patient outcomes. The influence of health insurance systems on the treatment of end-stage kidney disease (ESKD) patients is poorly understood. We investigated how supplemental private health insurance (PHI) coverage impacted ESKD treatment modalities and patient outcomes. All adult patients commencing ESKD treatment in New South Wales, Australia from 2000 to 2010 were identified using the Australia and New Zealand Dialysis and Transplant Registry. Data were linked to the state hospitalisation dataset to obtain insurance status, allowing the comparisons of mortality, ESKD treatment modality and health service utilisation between privately insured and public patients. The cohort of 5737 patients included 38% (n = 2152) with PHI. At 1 year after ESKD treatment initiation, PHI patients had lower mortality (hazard ratio 0.84, 95% confidence interval (CI) 0.74-0.95, P = 0.01), were more likely to be receiving home haemodialysis (HD) (odds ratio (OR) 1.38, 95% CI 1.01-1.89, P = 0.04), to have been transplanted (OR 1.75, 95% CI 1.25-2.46, P = 0.001) and used fewer hospital days (incidence rate ratio 0.85, 95% CI 0.74-0.96, P = 0.01). After adjustment, PHI patients were more likely to initiate ESKD treatment with facility-based HD (OR 1.22, 95% CI 1.01-1.46, P = 0.03) but were less likely to be started on peritoneal dialysis (OR 0.81, 95% CI 0.67-0.98, P = 0.03). Our findings suggest that supplemental PHI in Australia is associated with lower-risk ESKD treatment attributes and improved health outcomes. A greater understanding of the treatment pathways that deliver these outcomes may inform treatment for the broader ESKD treatment population.

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Effects of health insurance on racial disparity in osteoporosis medication adherence

The aim of the study was to analyse the effects of supplementary health insurance on the incidence of hospitalisations for musculoskeletal conditions in Switzerland. Cross sectional and small area analyses of surgical interventions for major musculoskeletal disorders in Switzerland were conducted. The regional distributions of populations with basic and basic plus supplementary insurance were estimated using census data for the period of 2002-2005. Effects of insurance class on the incidence of orthopaedic interventions were calculated with logistic regression using the complete discharge dataset of hospitalisations for orthopaedic conditions performed in the years 2002 to 2005. The data show significant differences in the age- and gender-adjusted incidence of surgery between populations with compulsory basic health insurance and those with basic plus supplementary cover. The study provides evidence that health insurance status accounts for variation in surgery for musculoskeletal problems in Switzerland. There are indications that supplementary health insurance - as a proxy for higher socioeconomic status - is related to lower need for surgery. There are signs that resources for spinal surgery and arthroscopy are diverted to the private sector at the expense of social health insurance. The results are only partially consistent with the hypothesis that volume of services increases with comprehensiveness of coverage.

Abstract. The longitudinal nature of the Master File of the Survey of Labour and Income Dynamics (SLID) for the period 1993–9, enables comparing transitions from employment to non‐employment for individuals affected by minimum wage changes with appropriate comparison groups not affected by minimum wages. This is based on the large number (24) of minimum wage changes that have occurred across the different provincial jurisdictions in Canada over the 1990s. The results indicate that the minimum wage increases have increased the transition from employment to non‐employment of employed low‐wage youths, who are at‐risk of being affected by a minimum wage increase, by around 6 percentage points (ranging from 4 to 8 percentage points). These disemployment effects in turn imply ‘minimum wage’ elasticities of about −0.4 (ranging from −0.3 to −0.5).

BackgroundKnowledge and understanding of what health insurance covers is an important public health issue. In Israel, whereas national health insurance covers all residents, optional supplemental health insurance (SHI) can be purchased from the healthcare providers, for additional, special services. The purpose of this study was to identify disparities between Jews and Arabs in their knowledge and understanding of SHI.MethodsNational, cross-sectional, telephone survey using a structured questionnaire, among random samples of 814 Jews and 800 Arabs. Knowledge and understanding of health insurance was assessed by a score based on correct answers to 8 questions. Log-linear regression was used to estimate association between health insurance knowledge and population group, after controlling for potential confounding independent variables.ResultsNinety one percent of Jews and 62% of Arabs reported owning SHI. Among both groups, knowledge levels were low on a 0–8 scale. However, the average score for Jews was statistically higher (Mean = 3.50, S.D = 1.69) as compared with Arabs (Mean = 2.78, S.D = 1.70) (p < 0.001). The adjusted health insurance knowledge score was significantly higher among Jews than Arabs (Prevalence ratio = 1.10; 95% CI = 1.06–1.13), indicating that differences remain even after controlling for socio-demographic characteristics and SHI ownership.ConclusionsThere is a large gap between the public’s understanding of what is covered by SHI and the services that it covers in practice. Low SHI knowledge and understanding may lead to frustration, and limit access to additional health care among populations that suffer from socio-economic inequalities. These findings emphasize the need to provide clearer and more culturally sensitive information on health insurance coverage.

Most developed nations provide generous coverage of care services, using either a tax financed healthcare system or social health insurance. Such systems pursue efficiency and equity in care provision. Efficiency means that expenditures are minimized for a given level of care services. Equity means that individuals with equal needs have equal access to the benefit package. In order to limit expenditures, social health insurance systems explicitly limit their benefit package. Moreover, most such systems have introduced cost sharing so that beneficiaries bear some cost when using care services. These limits on coverage create room for private insurance that complements or supplements social health insurance. Everywhere, social health insurance coexists along with voluntarily purchased supplementary private insurance. While the latter generally covers a small portion of health expenditures, it can interfere with the functioning of social health insurance. Supplementary health insurance can be detrimental to efficiency through several mechanisms. It limits competition in managed competition settings. It favors excessive care consumption through coverage of cost sharing and of services that are complementary to those included in social insurance benefits. It can also hinder achievement of the equity goals inherent to social insurance. Supplementary insurance creates inequality in access to services included in the social benefits package. Individuals with high incomes are more likely to buy supplementary insurance, and the additional care consumption resulting from better coverage creates additional costs that are borne by social health insurance. In addition, there are other anti-redistributive mechanisms from high to low risks. Social health insurance should be designed, not as an isolated institution, but with an awareness of the existence—and the possible expansion—of supplementary health insurance.

To determine the effect modification of supplemental insurance on the relationship between race and bone mineral density (BMD) in female Medicare beneficiaries. Retrospectively analyzing hospital administrative claim and clinical data of female Medicare beneficiaries (n = 1,398), we performed multivariate logistic regressions of BMD testing including data from all study participants and the subsets of health insurance. Significantly fewer Black than White female Medicare beneficiaries received the BMD testing in the overall sample (odds ratio, OR = 0.63; p = 0.02) and those without supplementary health insurance (n = 709; OR = 0.38; p = 0.004). By contrast, the magnitude of this racial disparity in the BMD testing was diminished among those with supplementary private health insurance (n = 689). We found a significant racial disparity in BMD testing for Black and White female Medicare beneficiaries. This disparity became more pronounced among those without supplementary private health insurance.

To counter the exceptionally high inefficiency and cost inflation in the U.S. health sector, some health economists advocate a consumer costconsciousness strategy to be implemented by patient cost-sharing under income-related major-risk (catastrophic) national health insurance (MR-NHI). These economists generally recognize that their strategy would fail if most households obtain complete supplementary private health insurance (SI), thereby eliminating patient cost-sharing. Nevertheless, the optimal treatment of SI under MR-NHI has begun to receive attention only recently. This paper develops a criterion for the optimal treatment of SI under MR-NHI, and uses it to derive the optimal treatment under an MR-NHI proposal that may be enacted. Virtually all observers agree that the U.S. health sector is plagued by exceptionally high inefficiency and cost inflation [1]. In response, several health economists have advocated a consumer cost-consciousness strategy, to be implemented by income-related major-risk (catastrophic) national health insurance (MR-NHI) [4, 10, 17]. These economists generally recognize that the treatment of supplementary private health insurance (SI), if MR-NHI is enacted, may well determine whether the strategy is successful. Although the treatment of SI has begun to receive attention [8, 13], further analysis is warranted. The purpose of this paper is to provide such analysis, and suggest an optimal treatment for SI under MR-NHI. Consumer Cost-Consciousness Strategy Advocates of the consumer cost-consciousness strategy believe that although a minority of households are inadequately insured against large medical expenses, the majority are over-insured for typical expenses. This widespread first dollar coverage makes most hospital care virtually free to the patient.' Free care encourages physicians to seek the most expenLaurence S. Seidman is Assistant Professor of Economics, University of Pennsylvania. The research for this paper was supported by the Leonard Davis Institute of Health Economics, University of Pennsylvania. ' Nearly 95 percent of all hospital revenues for patient care come from third parties -either private insurers, or the government [1]. Most private policies feature basic hospital insurance, with little or no patient cost-sharing for the average hospital stay. Many plans, however, have an upper limit on covered expenses, so that the patients with an exceptionally long stay often will exhaust their basic hospital coverage-just when