Expand Health Insurance Coverage Research Articles

Changes in initiation of adjuvant endocrine therapy for breast cancer after state health reform

BackgroundSocioeconomic differences in receipt of adjuvant treatment contribute to persistent disparities in breast cancer (BCA) outcomes, including survival. Adjuvant endocrine therapy (AET) substantially reduces recurrence risk and is recommended by clinical guidelines for nearly all women with hormone receptor-positive non-metastatic BCA. However, AET use among uninsured or underinsured populations has been understudied. The health reform implemented by the US state of Massachusetts in 2006 expanded health insurance coverage and increased the scope of benefits for many with coverage. This study examines changes in the initiation of AET among BCA patients in Massachusetts after the health reform.MethodsWe used Massachusetts Cancer Registry data from 2004 to 2013 for a sample of estrogen receptor (ER)-positive BCA surgical patients aged 20–64 years. We estimated multivariable regression models to assess differential changes in the likelihood initiating AET after Massachusetts health reform by area-level income, comparing women from lower- and higher-income ZIP codes in Massachusetts.ResultsThere was a 5-percentage point (p-value< 0.001) relative increase in the likelihood of initiating AET among BCA patients aged 20–64 years in low-income areas, compared to higher-income areas, after the reform. The increase was more pronounced among younger patients aged 20–49 years (7.1-percentage point increase).ConclusionsThe expansion of health insurance in Massachusetts was associated with a significant relative increase in the likelihood of AET initiation among women in low-income areas compared with those in high-income areas. Our results suggest that expansions of health insurance coverage and improved access to care can increase the number of eligible patients initiating AET and may ameliorate socioeconomic disparities in BCA outcomes.

Health Disparities among Lesbian, Gay, Bisexual, and Transgender (LGBT) Adults in Nashville, Tennessee.

Health disparities for lesbian, gay, bisexual, and transgender (LGBT) adults are well documented, but LGBT health data at the municipal and county levels are lacking, especially in the southern United States. The objective of this study was to compare access to care, health outcomes, and behavioral risk factors between LGBT and non-LGBT adults in Nashville and Davidson County, Tennessee. Data for this study came from a randomly selected, population-based sample of LGBT (n = 128) and non-LGBT (n = 1583) adults in Nashville. Multivariable logistic regression models were used to compare health outcomes between LGBT and non-LGBT Nashvillians while adjusting for demographic characteristics and socioeconomic status. LGBT Nashvillians were more likely to be uninsured (odds ratio [OR] 3.96, 95% confidence interval [CI] 1.72-9.10), report unmet medical care needs because of cost (OR 2.20, 95% CI 1.14-4.25), exhibit worse mental health outcomes (eg, frequent mental distress; OR 4.53, 95% CI 2.33-8.80), and report high-risk behaviors for human immunodeficiency virus (OR 9.47, 95% CI 3.96-22.62) compared with non-LGBT Nashvillians. To achieve health equity for LGBT individuals at the municipal level, Nashville and Tennessee should consider multifaceted approaches to expanding health insurance coverage and nondiscrimination protections and address mental health and human immunodeficiency virus risks among vulnerable populations.

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York. We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses. After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries. Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.

Sexually transmitted infections, their treatment and urban change in colonial Leopoldville, 1910–1960

AbstractDuring the colonial period sexually transmitted infections (STIs) came to be recognised as a major public health problem in African cities. Thus, STI control and urban modernisation became deeply entangled as authorities redrew spatial and social boundaries to manage populations and their cross-cultural interaction. Public health measures, urban planning and policing were part of a coordinated effort to neutralise the potential impact of rapidly growing African urban migration on the Belgian Congo’s ‘model’ capital Leopoldville. While STI control was facilitated by new drugs (arsenicals, sulfonamides and antibiotics) to treat syphilis, chancroid, gonorrhoea and chlamydia (bacterial STIs), the effects of the 1929 economic crisis and urban social change illustrated the limits of colonial authority. Redesigning urban spaces and repressive measures to curb polygyny and prostitution operated in a parallel fashion with the expansion of health coverage, new treatments and awareness campaigns. To gain a better understanding of the evolution of STI incidence among African urban populations during the colonial period between 1910 and 1960, extensive archival records and secondary literature were consulted to assess the interplay between improved screening, diagnostic and therapeutic methods with demographic and social change. They show that STI rates, probably peaked during the pre-1929 period and apart from a short period in the early 1930s associated with mass screening, declined until becoming residual in the 1950s. Reflecting upon sanitary interventions and their broader dimensions, the article analyses the evolution of treatment regimes and their impact in the changing urban organisation and environment of the colony’s capital.

Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa.

IntroductionIn the pursuit of achieving the Sustainable Development Goal targets of universal health coverage and reducing maternal mortality, many countries in sub-Saharan Africa have implemented health insurance policies over the last two decades. Given that there is a paucity of empirical literature at the sub-regional level, we examined the prevalence and factors associated with health insurance coverage among women in in sub-Saharan Africa.Materials and methodsWe analysed cross-sectional data of 307,611 reproductive-aged women from the most recent demographic and health surveys of 24 sub-Saharan African countries. Bivariable and multivariable analyses were performed using chi-square test of independence and multi-level logistic regression respectively. Results are presented as adjusted Odds Ratios (aOR) for the multilevel logistic regression analysis. Statistical significance was set at p<0.05.ResultsThe overall coverage of health insurance was 8.5%, with cross-country variations. The lowest coverage was recorded in Chad (0.9%) and the highest in Ghana (62.4%). Individual-level factors significantly associated with health insurance coverage included age, place of residence, level of formal education, frequency of reading newspaper/magazine and watching television. Wealth status and place of residence were the contextual factors significantly associated with health insurance coverage. Women with no formal education were 78% less likely to be covered by health insurance (aOR = 0.22, 95% CI = 0.21–0.24), compared with those who had higher education. Urban women, however, had higher odds of being covered by health insurance, compared with those in the rural areas [aOR = 1.20, 95%CI = 1.15–1.25].ConclusionWe found an overall relatively low prevalence of health insurance coverage among women of reproductive age in sub-Saharan Africa. As sub-Saharan African countries work toward achieving the Sustainable Development Goal targets of universal health coverage and lowering maternal mortality to less than 70 deaths per 100,000 live births, it is important that countries with low coverage of health insurance among women of reproductive age integrate measures such as free maternal healthcare into their respective development plans. Interventions aimed at expanding health insurance coverage should be directed at younger women of reproductive age, rural women, and women who do not read newspapers/magazines or watch television.

Health Care Reform Through the Tax and Budget Reconciliation Process

The tax and budget reconciliation process could be used to substantially expand health insurance coverage and improve health insurance outcomes. Potential health-related items, which could be included in a tax and reconciliation bill, include expansions in Medicaid eligibility and federal Medicaid funding, new tax credits for subsidies of state exchange insurance by small businesses for employees, tax credits for contributions to health savings accounts, and additional risk-adjustment subsidies for complex health care cases. These health-related tax and budget provisions would alleviate economic turmoil and hardships associated with the COVID pandemic. Moreover, these provisions are, if structured properly, likely to satisfy the constraints of the Byrd rule defining eligibility for inclusion in a reconciliation bill.

Age-Period-Cohort Analysis of Trends in Infectious Disease Mortality in South Korea from 1983 to 2017.

We aimed to describe the infectious disease (ID) mortality trends and evaluate age–period–cohort (APC) effects on ID mortality in Korea. Using cause-of-death and census population estimates data from 1983–2017, age-standardized ID mortality trends were investigated by joinpoint regression analysis. The APC effects on ID mortality were estimated using intrinsic estimator models. The age effect showed a J-shaped concave upward curve. Old age, especially ≥70 years, was a critical factor for ID deaths. Similar to the W-shaped period curve, ID mortality rapidly decreased due to economic development and the expansion of health coverage in the 1980s, decelerated with increasing inequality, surged due to the 1997 economic crisis, and has gradually increased since the mid-2000s. The cohort effect showed an inverted U-shape. The increasing cohort effect due to the deterioration of living standards led to a decreasing trend after the independence of Korea. Notwithstanding the slowdown during the 1950–1953 Korean War, educational expansion, economic growth, fertility reduction, and the improvement of ID-related policies might have led to a continued decline among the cohorts born since the 1960s. Diverse socioeconomic events may have influenced ID mortality trends in Korea via period and cohort effects. Policies to reduce the growing burden of ID deaths should be further improved.

Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes.

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.

Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria: a qualitative study among sub-national level actors, healthcare and insurance providers

BackgroundHealth insurance is an important mechanism to prevent financial hardship in the process of accessing health care. Since the launch of Nigeria’s National Health Insurance Scheme (NHIS) in 2005, only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure. Understanding the contextualized perspectives of stakeholders involved in NHIS is critical to advancing and implementing necessary reforms for expanding health insurance coverage at national and sub-national levels in Nigeria. This study explored the perspectives of sub-national level actors/stakeholders on the design and implementation challenges of Nigeria’s NHIS.MethodsA descriptive case study design was used in this research. Data were collected in Ibadan, Oyo State in 2016 from health insurance regulators, healthcare providers, and policymakers. Key informant interviews (KII) were conducted among purposively selected stakeholders to examine their perspectives on the design and implementation challenges of Nigeria’s National Health Insurance Scheme. Data were analysed using inductive and deductive thematic approaches with the aid of NVIVO software package version 11.ResultsImplementation challenges identified include abject poverty, low level of awareness, low interest (in the scheme), superstitious beliefs, inefficient mode of payment, drug stock-out, weak administrative and supervisory capacity. The scheme is believed to have provided more coverage for the formal sector, its voluntary nature and lack of legal framework at the subnational levels were seen as the overarching policy challenge. Only NHIS staff currently make required financial co-contribution into the scheme, as all other federal employees are been paid for by the (federal) government.ConclusionsSub-national governments should create legal frameworks establishing compulsory health insurance schemes at the subnational levels. Effective and efficient platforms to get the informal sector enrolled in the scheme is desirable. CBHI schemes and the currently approved state supported health insurance programmes may provide a more acceptable platform than NHIS especially among the rural informal sector. These other two should be promoted. Awareness and education should also be raised to enlighten citizens. Stakeholders need to address these gaps as well as poverty.

Does Health Insurance Reduce Catastrophic Health Expenditure in Sudan?

High out of pocket (OOP) health expenditure has negative effects on households' budgets, pushing a considerable portion of the population below the poverty line, and potentially creating a financial catastrophe for the majority of the population in poor countries. Therefore, health insurance has been regarded as an important mechanism to protect people from the financial consequences of poor health and financing healthcare. However, in the context of developing countries, empirical findings on the impact of health insurance on incidence of high health expenditure are inconclusive. This study investigates the causal effect of health insurance on catastrophic health expenditures in Sudan. The analysis relies mainly on 2009 and 2014/2015 national household budget surveys. To control for possible endogeneity that may arise due to omitted variable bias and/or reverse causality, the study uses government and Zakat subsidies to instrument for health insurance across different localities. For the purpose of comparison and robustness check, the empirical model is estimated using three instrumental variable procedures: bivariate probit, IV-probit; and the two-stage least square (2SLS) model. The results indicate that for the 2014/2015 survey, health insurance has negative and significant effect on the catastrophic health expenditures, while for the 2009 survey I found that health insurance has no significant impact on catastrophic health spending. These outcomes hold for different catastrophic threshold levels, indicating that the role of health insurance in protecting households from the financial risk associated with health spending is improving over time. These findings also imply that the ongoing efforts to expand health coverage through Zakat and charitable institutions have a significant effect in mitigating catastrophic health expenditure. The study concludes with important policy implications given the pervasive issue of high out of pocket health expenditure in Sudan. Thus, policy makers should prioritize legislation and interventions to expand health insurance coverage further to protect households from financial vulnerability, as well as to improve health overall. In particular, enrollment of employees of the informal sector in health insurance is an urgent need. Moreover, charitable bodies such as Zakat and NGOs should prioritize health insurance coverage in their work. Furthermore, government subsidies to health insurance scheme should continue until achieving universal health coverage.

Does health insurance contribute to improved utilization of health care services for the elderly in rural Tanzania? A cross-sectional study

ABSTRACT Background: Health care systems in developing countries such as Tanzania depend heavily on out-of-pocket payments. This mechanism contributes to inefficiency, inequity and cost, and is a barrier to patients seeking access to care. There are efforts to expand health insurance coverage to vulnerable groups, including older adults, in Sub-Saharan African countries. Objective: To analyse the association between health insurance and health service use in rural residents aged 60 and above in Tanzania. Methods: Data were obtained from a household survey conducted in the Nzega and Igunga districts. A standardised survey instrument from the World Health Organization Study on global AGEing and adult health was used. This comprised of questions regarding demographic and socio-economic characteristics, health and insurance status, health seeking behaviours, sickness history (three months and one year prior to the survey), and the receipt of health care. A multistage sampling method was used to select wards, villages and respondents in each district. Local ward and hamlet officers guided the researchers in identifying households with older people. Crude and adjusted logistic regression methods were used to explore associations between health insurance and outpatient and inpatient health care use. Results: The study sample comprised 1,899 people aged 60 and above of whom 44% reported having health insurance. A positive statistically significant association between health insurance and the utilisation of outpatient and inpatient care was observed in all models. The odds of using outpatient (adjusted OR = 2.20; 95% CI: 1.54, 3.14) and inpatient services (adjusted OR = 3.20; 95% CI: 2.46, 4.15) were higher among the insured. Conclusion: Health insurance is a predictor of outpatient and inpatient health services in people aged 60 and above in rural Tanzania. Further research is needed to understand the perceptions of both the insured and uninsured regarding the quality of care received.

Health financial hardship among ethnic minority populations in Vietnam

ABSTRACT This study was conducted to report the prevalence of financial hardship and identify associated factors among ethnic minority populations in Vietnam. In 2019, we conducted a cross-sectional study of 5,033 ethnic minority participants from 12 provinces located in four socioeconomic regions in Vietnam. Financial hardship was measured by asking the study respondents if they had to borrow money, sell household assets, or stop using health care services due to health care service fees. Among the health service users, 24.0% (95% CI: 22.3–25.8%) faced a health-related financial hardship. Participants with secondary education were more likely to experience financial hardship than illiterate participants. In contrast, those who were able to speak the Vietnamese language, had a religious affiliation, or had health insurance were likely to have lower financial hardship. Continuing to expand health insurance coverage and develop essential packages covered by health insurance is vital to reducing financial hardship.

Black Births Matter: Addressing the Injustices of African-American Mothers and Infants

African American women face a particularly difficult inequity surrounding their healthcare, especially when pregnant. For decades, the United States has used infant mortality rates to measure the health of each pregnant population. Efforts have been made to decrease these rates by expanding health coverage and implementing the national Healthy Start initiative. The Healthy Start Initiative was created with the intent of reducing infant mortality rates by 50% over a 5-year period through providing proper prenatal care, ensuring basic health needs are met, and reducing barriers to healthcare access (National Healthy Start Association, 2015). However, only minuscule changes in the death rate gaps between races have been seen since the program was enacted. (Kirby, 2017). While rates are dependent upon location, Michigan had a rate of about 15.1 black infant deaths for every 4.5 white infant death in 2018 (Michigan Department of Health &amp; Human Services, 2020). These rates have decreased within the past few decades, but black infants continue to die at a much higher rate than white infants. Eliminating the gap begins with addressing the root of the disparities head on, which is racism, and looking inward at one's own assumptions and stereotypes that are unconsciously made.

The Affordable Care Act : Against the Odds, It's Working.

This issue of the North Carolina Medical Journal focuses on the 10-year anniversary of the Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010. Since its inception, the ACA has been highly controversial. Yet, it has contributed to positive improvements in our health care system. The ACA expanded health insurance coverage to more of the uninsured, made investments in prevention and in improving quality of care, and started our journey toward value-based care. This issue brief touches on how the law has been implemented in North Carolina, along with an assessment of the successes and failures of the law. It is followed by more detailed commentaries on specific aspects of the law and its implementation in our state. While much has been accomplished in the last 10 years, more is needed to achieve our goals of an affordable, equitable, and accessible health care system-one that promotes positive health outcomes while reducing unnecessary costs.

Access to Care as a Barrier to Mammography for Black Women.

Racial disparities in breast cancer screening, morbidity, and mortality persist for Black women. This study examines Black women's mammography beliefs and experiences with specific focus on barriers to mammography access in an urban city in the South East, United States. This retrospective, qualitative study used Penchansky and Thomas' conceptualization of health care access as the framework for the data analysis. In-depth, semistructured interviews were conducted with 39 Black women. Structural and personal factors continue to create barriers to mammography among Black women. Barriers to mammography were identified for each of the Penchansky and Thomas five dimensions of access to care: accessibility, affordability, availability, accommodation, and acceptability. Clinical practice strategies to increase mammography screening in Black women must be multifactorial, patient-centered, and culturally congruent. Policy development must address the structural barriers to mammography screening through expansion of health insurance coverage and increased accessibility to health care.

Impact of health insurance on healthcare utilisation patterns in Vietnam: a survey-based analysis with propensity score matching method

ObjectivesThe study aims to evaluate the impact of the Revised Health Insurance Law 2014 on the utilisation of outpatient and inpatient care services, healthcare services utilisation at different levels of...

Indonesian Health System Performance Assessment: The Association between Health Insurance Expansion with Health Status and Health Care Access

This paper analyzes health outcomes and inequality in Indonesia, and the links to intermediate factors and inputs. Between 1997-2015, the country's health performance indicators had improved and became more equal. This achievement could potentially be correlated with improvement in health care access, which might be a result of the Indonesian government's policy to expand health insurance coverage, mainly to the most impoverished population. By 2020, the Indonesian government operates national social health insurance, the Jaminan Kesehatan Nasional (JKN), which covers about 83% of the country's population, including the poor and vulnerable. This paper uses the Control Knob Framework and focuses on the health insurance expansion as the financing knob adjustment conducted by the government. The analysis starts with the improvement of health status indicators and tracks back its association with health care access and health insurance coverage expansion. This paper finds that health status improvement in Indonesia between 1997-2015 was correlated with health care access increase. The decline in the infant mortality rate (IMR) and the under-five mortality rate (U5MR) between 1997-2015 were associated with an increase in health care utilization, including the use of trained birth attendants and diphtheria-pertussis-tetanus (DPT) immunization. This paper then observes a strong correlation between the expansion of health care access and health insurance coverage. In terms of equality, the article sees a weaker, but evident, correlation between health insurance equalization across different population groups with more equitable health care access and health outcomes. The findings of this paper justify the effectiveness of the financing knob (expanding and equalizing health insurance coverage) in increasing access to care (outpatient and inpatient care, trained birth attendants, immunization) and improving health status (IMR and U5MR). This study is among the firsts to utilize Control Knob Framework as an analytical tool for health insurance assessment. The study recommends the government to combine health insurance expansion with other progressive policy, such as financial support to poor patients to cover the non-medical expenses of attending health care, to optimize the effectiveness of the interventions.

Health Insurance Deepening and Its Impact on Maternal Healthcare Demand in Private Hospitals in Kenya

Promotion of maternal healthcare services through the expansion of health insurance coverage has been a core strategy that has been adopted in the reduction of maternal and child mortalities in Kenya. In this study, we seek to establish how health insurance coverage and benefits influence the demand for maternal health utilization in private hospitals in Kenya. The study utilized the latest Kenya Demographic Household Survey 2014 data to estimate the relationship. The binary probit regression model was employed in estimation. From the findings, only 15 percent of mothers were enrolled in a health insurance plan, whereas 14 percent of the women reported to have attended antenatal clinics in private health facilities, and 13 percent benefited from skilled delivery in private healthcare facilities. Results further revealed that health insurance ownership led to a significant increase in the likelihood of utilizing maternal health care services in private hospitals in Kenya. Similarly, age of the mother, marital status, birth order, higher education level, all wealth index categories, and employment status were cofactors associated significantly with use of healthcare services. It was concluded that the advent and increase of health insurance coverage is associated with a significant rise in demand of maternal healthcare services in private hospitals. This study argues that the current health subsidies would be more effective if they were channeled through health insurance with wider coverage of private hospitals. The study recommends reforms in policies and guidelines governing insurance coverage, which we argue would significantly bring down the cost of insurance coverage, thus become more accessible to more Kenyans.

THE EFFECTS OF ILL-HEALTH AND DISABILITIES ON LABOUR FORCE PARTICIPATION AMONG NIGERIAN HOUSEHOLDS

Nigeria has demeaning health statistics together with declining labour supply despite the large population size. This paper investigated the effect of illness, disability and other socio-demographic factors on labour force participation among Nigerian households. This study is cross-sectional in which secondary data from the General Household Survey (2015/2016) was used for the analysis. A representative sample of 4,200 household heads was used for the analyses. Both predictive and descriptive analyses were undertaken. Binary logistic regression was used to investigate predictors of labour force participation among the household heads. The data revealed that 52.1% of respondents were engaged in labour force. Controlling for other variables, the various forms of disabilities, ill-health, body injury, gender and educational attainment were significant determinants of labour force participation. The result provokes the need for policymakers to articulate policies that improve access to healthcare through the expansion of health insurance coverage. The study concluded that self-assessed health and education attainment influence labour force participation. Policies should be used to expand educational opportunities and improve access to healthcare services in Nigeria. To improve access to healthcare, the Nigeria government should increase the ownership of health insurance policy by broadening the coverage of the formal health insurance and encouraging community-based health insurance in the informal and rural sectors.

The impact of the policy of expanding coverage for 4 major diseases on out-of-pocket payments

Abstract In South Korea, Cancers, cardiac disease, cerebrovascular diseases and rare incurable disease cause high medical expenses which are putting a heavy burden on the household economy. They are called '4 Major Severe Diseases'. The government has established the plan of Expanding Coverage for Four Major Severe Diseases. The Policy of Expanding Coverage for the 4 Major Severe Diseases is to apply the necessary medical services including coverage for uncovered services to national health insurance payments in stages. This study aims to evaluate the effects of the policy implemented from 2013 to 2015 by comparing the changes in the out-of-pocket payments before and after the policy. Using the data from the Korea Health Panel(2012, 2016), the policy effect was evaluated by the Difference-In-Difference analysis. A total of 4,686 patients (2,343 in 2012 and 2,343 in 2016) were included, who are enrolled in National Health Insurance, and have at least one chronic disease. People who are under 20 years old were excluded. In addition, severity of disease was adjusted by CCI(Charson's comorbidity index). Compared to before the policy was implemented, the Out-of-pocket payments significantly decreased. In addition, there were significant differences in gender, types of health care system, disabled, economic activity, income level, and CCI. According to previous studies, the policy of Expanding health insurance coverage since 2005 has been criticized for its low effectiveness. However, It is revealed that the Policy of Expanding Coverage for 4 Major Severe Diseases has an effect in this study. Given that the policy needs time to work, this study showed the effect of the policy more comprehensively compared to previous studies evaluating the effectiveness for just one year. Key messages Due to the Policy of Expanding Coverage for 4 Major Severe Diseases, the out-of-pocket health expenditure were reduced in the policy group. Given that the policy needs time to work, this study has shown more comprehensive results than previous studies that evaluated the effect of policy carried out over a short period.