National Healthcare Insurance Research Articles

DINAMIKA POLITIK HUKUM DALAM PEMENUHAN HAK ATAS KESEHATAN DI INDONESIA

The right to health is widely recognized as basic human rights and consequently it is the state’s duty to guarantee its fulfilment. The Indonesian government, in realization of this duty, develops and put in place a national health care (insurance) system, which successful working depend on citizens paying equal amount of the premium needed to sustain this public health care system. However, the same state, in the context of social justice and welfare, provide poor citizens with monetary aid. This article discusses, by using a juridical normative approach, supplemented by an inter-multi disciplinary approach, the political dynamics underpinnings influencing the social or health care system’s implementation.

DINAMIKA POLITIK HUKUM DALAM PEMENUHAN HAK ATAS KESEHATAN DI INDONESIA

The right to health is widely recognized as basic human rights and consequently it is the state’s duty to guarantee its fulfilment. The Indonesian government, in realization of this duty, develops and put in place a national health care (insurance) system, which successful working depend on citizens paying equal amount of the premium needed to sustain this public health care system. However, the same state, in the context of social justice and welfare, provide poor citizens with monetary aid. This article discusses, by using a juridical normative approach, supplemented by an inter-multi disciplinary approach, the political dynamics underpinnings influencing the social or health care system’s implementation.

Epidemiology of multiple myeloma in Taiwan, a population based study

BackgroundAlthough the incidence of multiple myeloma (MM) in Asia is lower than in Western countries, it is steadily increasing. However, limited data are available that describe the epidemiology of MM in Asia. MethodsWe conducted a retrospective cohort study using the Taiwan National Healthcare Insurance Research database to estimate the disease burden and clinical characteristics of patients with MM in Taiwan. All newly diagnosed confirmed MM patients during 2007–2012 were enrolled. Patients were followed up until death or end of the observation period (December 31, 2013), whichever occurred first. ResultsA total of 2723 newly diagnosed MM patients were included in the cohort analysis, of whom 58.0% (1578/2723) were men. The average age of MM patients was 67.6 years. At the time of diagnosis, the mean Charlson Comorbidity Index was 1.8, 35.3% of patients had anemia, 18.0% had bone fracture, 16.4% had renal disease and 17.3% had pneumonia. The crude annual incidence of newly diagnosed MM increased from 1.74 per 100 000 population in 2007 to 2.27 per 100 000 population in 2012 (p < 0.0001), and the age-adjusted incidence from 1.41 to 1.59 per 100 000 population (p = 0.01). The use of novel treatments expanded over the study period. The crude and age-adjusted annual MM mortality rate did not change significantly over time. Case fatality decreased from 25.5% in 2007 to 19.4% in 2012 (p < 0.0001). ConclusionThe age-adjusted incidence of MM in Taiwan increased by 13% between 2007 and 2012. Despite the introduction of new treatments, MM remains largely incurable with 19.4% mortality.

SYSTEM FOR DETECTION OF NATIONAL HEALTHCARE INSURANCE FRAUD BASED ON COMPUTER APPLICATION

Background: The national healthcare insurance (JKN) has been in deficit since 2014-2016; one of the causes is fraud inpatient hospital service. Objective: This study aimed to analyze the validity, reliability and effectiveness of detection system of national healthcare insurance fraud based on computer application in hospital.Methods: Cross-sectional method was used. Fraud data were collected at one episode in the inpatient JKN participant service.Results: Validity was assessed by Fischer exact test. The interpretation was done by hospital internal verification officer and BPJS Kesehatan verification officer. There were only 2 out of 1.106 services claims were different, resulted in p-value 0.01. Reliability was assessed using Human Organization Technology Benefit questionnaire filled by admission administrator officer, BPJS Kesehatan officer and hospital internal verification officer; and then analyzed using Stata® software resulting in Cronbach’s alpha value of 0.8. Effectiveness was assessed by reducing potential fraud, conducted by RSUP dr. Soeradji Tirtonegoro from May until July 2017, which on May 2018 there were 8 findings, June 1 finding, and on July 2018 had no finding.Conclusion: System for detection of national healthcare insurance fraud based on computer application is valid, reliable and effective to be implemented in inpatient service in hospital.

Information System for Prevention of National Healthcare Insurance Fraud Among Inpatients of Advanced Referral Health Services

Background: The National Health Insurance (JKN) was started from January 1st, 2014, however every year there was a deficit between the income of the Social Security Administrator Healthcare (BPJS Kesehatan) and the money paid to healthcare facilities. One of the causes was the potential for JKN fraud in inpatient services at advanced referral health facilities (FKRTL). As a response, the Ministry of Health, the Corruption Eradication Commission (KPK) and other JKN stakeholders currently are developing a JKN fraud prevention, early detection, investigation and action system.Objective: This research aimed to analyze the implementation of the new information system for potential JKN fraud prevention and detection in inpatient services for JKN participants in RSUP Dr. Soeradji Tirtonegoro as an example of FKRTL.Design: This study used cross-sectional methods in assessing JKN fraud in single episodes of patient care by using JKN fraud indicators in the information system. We identified potential JKN fraud during April-July 2017 from JKN claim data. Reliability of information system was assessed by HOT-Fit research questionnaire (Human Organization Technology and Benefit) and Stata® software.Results: The data shown there was a significant decrease in potential JKN fraud conducted by FKRTL between April-July 2017: in April 14 findings, May 8 findings, June 1 findings, and July there were no findings. Prevention and early detection of potential JKN fraud among hospitalized JKN participants were conducted effectively by using an information system that contains indicators of JKN fraud. Reliability analysis of information system on the patient administration officers (TURP), BPJS Kesehatan officers and hospital internal verification officers resulted in alpha Cronbach value of &gt; 0.8.Conclusions: The results show that the information system is reliable to prevent and early detect potential JKN fraud in inpatient services for JKN participants in FKRTL. Information system is effective and reliable for prevention and early detection potential National Health Insurance fraud in service of inpatient advanced referral health services.

Temporomandibular joint arthroplasty for osteoarthrosis: A series of 24 patients that received a uni- or bilateral inter-positional silicone sheet

PurposeTo evaluate mid-term results from using a silicone sheet for inter-positional arthroplasty in moderate or severe cases of osteoarthrosis of the temporo-mandibular joint (TMJ). To also determine any remaining indications from this method. Patients and methodsThis retrospective study included patients that underwent surgery between 2008 and 2016. Pre- and post-operative mouth opening (MO), according to inter-incisal distance (mm) and pain score (PS: 0=no pain to 4=very severe pain) were recorded for 24 patients. Patients were divided according to thickness of the silicone sheet (group A: 1.0 mm, group B: 1.5 mm). ResultsThe cohort included 22 females (92%). Mean age at surgery was 55 years±13 (26–80). Mean length of follow-up was 26 months±24 (6–80). Mean improvement in MO was 8.2 mm (+33%) and of PS was 1.7 (−68%). MO was not improved for two patients and worsened for one. PS score improved for all patients. No statistical difference was found between groups A and B. There was also a tendency for degradation of outcomes over time. ConclusionThe poor reputation of prosthetic discoplasty was not as evident in our series, even though anatomical and functional status seemed to deteriorate over time. This is because total-joint prosthetic replacement is often proposed instead. However, for elderly or fragile patients that have severe pain, and regarding cost-benefit aspects, conventional arthroplasty can still be discussed, especially since French national health-care insurance does not yet support TMJ prosthetic replacement for osteoarthrosis.

Perceptions of healthcare quality in Ghana: Does health insurance status matter?

This study’s objective is to provide an alternative explanation for the low enrolment in health insurance in Ghana by analysing differences in perceptions between the insured and uninsured of the non-technical quality of healthcare. It further explores the association between insurance status and perception of healthcare quality to ascertain whether insurance status matters in the perception of healthcare quality. Data from a survey of 1,903 households living in the catchment area of 64 health centres were used for the analysis. Two sample independent t-tests were employed to compare the average perceptions of the insured and uninsured on seven indicators of non-technical quality of healthcare. A generalised ordered logit regression, controlling for socio-economic characteristics and clustering at the health facility level, tested the association between insurance status and perceived quality of healthcare. The perceptions of the insured were found to be significantly more negative than the uninsured and those of the previously insured were significantly more negative than the never insured. Being insured was associated with a significantly lower perception of healthcare quality. Thus, once people are insured, they tend to perceive the quality of healthcare they receive as poor compared to those without insurance. This study demonstrated that health insurance status matters in the perceptions of healthcare quality. The findings also imply that perceptions of healthcare quality may be shaped by individual experiences at the health facilities, where the insured and uninsured may be treated differently. Health insurance then becomes less attractive due to the poor perception of the healthcare quality provided to individuals with insurance, resulting in low demand for health insurance in Ghana. Policy makers in Ghana should consider redesigning, reorganizing, and reengineering the National Healthcare Insurance Scheme to ensure the provision of better quality healthcare for both the insured and uninsured.

Effect of Optimization of Medical Treatment on Long-Term Survival of Patients With Heart Failure After Implantable Cardioverter Defibrillator and Cardiac Resynchronization Device Implantation (from the French National EGB Database)

Prognosis of heart failure with reduced ejection fraction (HFrEF) is improved by drug optimization according to guidelines; however, little is known regarding such optimization in HFrEF patients with an implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT). This study aimed to describe implementation of this optimized strategy and its impact in patients implanted with an ICD/CRT. Using a 1/97th representative sample of the French national health-care insurance system claims database, a retrospective cohort study was conducted including HFrEF patients implanted with ICD or CRT between January 2009 and December 2014. HFrEF treatments were analyzed before and after ICD/CRT implantation. Heart failure (HF) hospitalization and survival were examined at 1, 3, and 5 years: 378 patients (135 CRT, 243 ICD) with a mean age of 68 ± 13 years were included. Mean follow-up was 23 months [11-42]. At baseline, 36% of patients had no or only 1 HFrEF drug among β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and mineralocorticoid receptor antagonists, whereas 26% of patients received an optimal treatment (all 3 classes). At 3 months after ICD/CRT implantation, the prescription rate of HFrEF drugs was higher than baseline but returned to preimplantation levels at the end of follow-up. HF hospitalization rate was higher in the nonoptimized patient group (28% vs 14%, p = 0.001). Optimal HFrEF treatment was associated with better survival (hazard ratio = 0.59 [0.4-0.86], p = 0.006). In conclusion, HFrEF drugs are underprescribed before and after ICD/CRT implantation despite the demonstration that HFrEF drug optimization also reduces death and HF hospitalization in this population.

Hospital Mergers and the Incorporation of Non-Competition Concerns

National competition authorities have assessed many hospital mergers over the years. During merger control proceedings, the authority determines the negative effects of the merger in the form of a potential price increase and decrease in the quality of care provided by the hospital. These assessments are difficult. Merger control can lead to heated debates and questions over whether the analysis is correct and considers all possible outcomes. To provide a full analysis of the effects of a hospital merger for all relevant actors (patients, the hospital itself, health insurers, the government, and hospital staff) the Social Cost and Benefit tool can be used. This framework is applied in other fields of economics, but it can be useful in cases that involve public interest and non-competition concerns. One could call the tool the Competition Cost and Benefit Analyses (CCBA) tool when it is adjusted for use in a merger case. This article demonstrates how the CCBA can be used and how the unique features of a national healthcare and health insurance system can be taken into account during its use. This article applies the framework to the Netherlands due to recent developments in that country and the call for more focus on public interests in merger control of Dutch hospitals. Keywords: Merger Control, Hospitals, Price, Quality

Price Comparison Of New Drugs In Japan, Eu And Us

Japan has the following pricing guidance: a premium is possible to be applied for an Orphan Designated drug if the premium has not been applied to its comparator. The objective of this study is to compare National Healthcare Insurance (NHI) prices of Orphan Designated drugs with Reference Countries' prices (listed in US: Red Book; UK: MIMS; Germany: Rote Liste; France: Vidal) at the time of NHI price listing. NHI price information was obtained from official websites of the Ministry of Health, Labor and Welfare (MHLW). We investigated if new drugs listed from April 2014 to December 2016 had reference countries' prices and Orphan Designation, and selected NHI prices of new drugs which have at least one or more reference countries' prices, in addition to Orphan Designation. We compared the selected NHI prices with "Foreign Average Price (FAP)", the average of all existing reference countries' prices the "EU Average Price (EUP)", the average of all existing prices of UK, Germany and France and the "US Price (USP)." A total of 181 new drugs were listed on the NHI price list from April 2014 to December 2016. Out of 181 drugs, 120 drugs (66%) had at least one or more reference countries' prices, of which 48 drugs (40%) received Orphan Designation. In addition, among the Orphan Designated drugs, 83%, 65% and 91% were priced lower than FAP, EUP and USP, respectively. For other drugs, 88%, 71% and 94% were priced lower than FAP, EUP and USP, respectively. In the past three years, NHI pricings for new drugs in Japan tended to be lower than Reference Countries' prices, even of new drugs for unmet medical needs. Further guidance to value new drugs, especially Orphan Designated drugs, would be necessary for the pricing system in Japan.

Management and cost analysis of cancer patients treated with G-CSF: a cohort study based on the French national healthcare insurance database

Objectives: To describe the management and costs associated with G-CSF therapy in cancer patients in France.Methods: This study analyzed a representative random population sample from the French national healthcare insurance database, focusing on 1,612 patients with hematological or solid malignancies who were reimbursed in 2013 or 2014 for at least one G-CSF treatment dispensed in a retail pharmacy. Patient characteristics and treatment costs were analyzed according to the type of cancer. Then the costs and characteristics of patients associated with the use of different G-CSF products were analyzed in the sub-set of breast cancer patients.Results: The most frequent malignancies in the database population were breast cancer (23.3%), hematological malignancies (22.2%), and lung cancer (12.4%). The reimbursed G-CSF was pegfilgrastim in 34.1% of cases, lenograstim in 26.7%, and filgrastim in 17.9%. More than one G-CSF product was reimbursed to 21.3% of patients. The total annual reimbursed health expenses per patient, according to the type of G-CSF, were €27,001, €24,511, and €20,802 for patients treated with filgrastim, lenograstim, and pegfilgrastim, respectively. Ambulatory care accounted for, respectively, 35%, 38%, and 41% of those costs. In patients with breast cancer, ambulatory care cost was €7,915 with filgrastim, €7,750 with lenograstim, and €6,989 with pegfilgrastim, and the respective cost of G-CSF was €1,733, €1,559, and €3,668.Conclusion: All available G-CSF products have been shown to be effective in cancer patients, and both daily G-CSFs and pegylated G-CSF are recommended in international guidelines. Nevertheless, this analysis of G-CSF reimbursement indicates that the choice of product can markedly affect the total cost of ambulatory care.

Economic impact of ulipristal acetate on surgical procedures for uterine fibroids in France

ObjectiveTo assess the budget impact of using ulipristal acetate (UPA) 5 mg to treat women with uterine fibroids (UF) causing moderate to severe symptoms.DesignWe modelled trends in the number of...

National trends in use and costs of oral anticancer drugs in France: An 8-year population-based study.

During the last decade, many oral anticancer drugs (OAcDs) have been marketed, providing interesting but potentially costly pharmaceutical alternatives to intravenous treatments. This study aims to provide updated information on their use and costs. A cross-sectional yearly repeated study was conducted from 2006 to 2014 using the representative sample of the French national health care insurance system claims database (EGB). OAcD use was described for each year, among prevalent (ie, patients with at least 1 OAcD reimbursement) and incident users (ie, patients with no OAcD reimbursement within the prior year) and according to their pharmacological classes (Hormone Therapy [HT], Cytotoxic Therapy [CT], Targeted Therapy [TT], and others). Demographic characteristics were described for both users; comorbidities and direct medical costs were described for incident users only. The yearly prevalence and incidence of OAcD use, mainly represented by HT, remained stable from 2006 to 2014 (1.2%; 0.4%). Compared with users of other OAcD classes, the proportion of TT users substantially increased over the 8-year study period (+9.3%), and TT incident users had more severe comorbidities at treatment initiation. The health expenditures were the most important in TT users with median monthly medical direct costs varying from 2995€ to 4968€ per patient between 2006 and 2014. With the development of new OAcDs, the TTs use reaches a wider population of patients but is responsible for increasing health expenditures.

Outpatient Antibiotic Prescriptions with High Risk of Bacterial Resistance in France: A National Healthcare Insurance Database Analysis

Outpatient Antibiotic Prescriptions with High Risk of Bacterial Resistance in France: A National Healthcare Insurance Database Analysis

Road traffic crash risk associated with prescription of hydroxyzine and other sedating H1-antihistamines: A responsibility and case-crossover study

BackgroundH1 antihistamines differ from each other by their ability to cross the blood-brain barrier. The resulting sedating effect can be sought in therapy but may be a driving hazard. The aim of this study was to estimate the impact of sedating H1-antihistamines on the risk of road traffic crash, with a particular focus on hydroxyzine which is also indicated as an anxiolytic in France. MethodsThe study consisted in extracting and matching data from three French nationwide databases: the national healthcare insurance database, police reports and the police national database of injurious crashes. All sedating H1-antihistamines, including hydroxyzine, were considered in the study. A case-control analysis, in which responsible drivers were cases and non-responsible were controls was performed. A case-crossover analysis, comparing for the same subject exposure during a period immediately before the crash with exposure during an earlier period, was also conducted. ResultsThe extraction and matching procedures over the July 2005-December 2011 period led to the inclusion of 142,771 drivers involved in an injurious road traffic crash. The responsibility study found an increased risk of being responsible for an injurious road traffic crash in hydroxyzine users who were registered with a long-term chronic disease (mostly psychiatric disorders) on the day of the crash (OR=1.67 [1.22–2.30]). Among them, the risk was even higher in drivers with highest exposure levels (OR=2.60 [1.23–5.50]). There was no impact of sedating H1 antihistamine treatment initiation on the risk of crash. ConclusionEven if it is difficult to disentangle the part of the increased risk that would be causally related to hydroxyzine and the part related to behaviours of patients with a heavy psychiatric disorder, our study raises the alarm on the crash risk linked to hydroxyzine utilization in countries in which the anxiolytic indication is widespread.

Use of topical glucocorticoids: a population-based cohort study.

Little is known about the prescriptions of topical glucocorticoids in the general population. To report an overall picture of topical glucocorticoid prescriptions in France. This study used the Echantillon Généraliste de Bénéficiaires (EGB) database, a 1/97th random sampling of the French population covered by the main national healthcare insurance system (approximately 90% of the whole population). All patients prescribed topical glucocorticoids over a 5-year period (1 January 2011 to 31 December 2015) were identified using a specific code list for topical glucocorticoids. Over the 5-year study period, 662 531 individuals were recorded for at least 1 day in the EGB. Among them, 220 345 (33.3%) were prescribed at least once topical glucocorticoid. The prevalence of topical glucocorticoid prescription increased regularly from 2011 (11.7%) to 2015 (12.5%). A total of 922 026 tubes of topical glucocorticoids were dispensed, mainly high-potency glucocorticoids, and were mainly prescribed by general practitioners (73.1%). A total of 1713 (0.8%) patients were prescribed at least 24 tubes over a calendar year. These patients were more frequently men (P < 0.001) and older (P < 0.001) than the overall population of patients prescribed topical glucocorticoids. The 124 844 tubes prescribed to these patients had stronger potency than those prescribed to the overall population (P < 0.001) and were mostly prescribed by general practitioners (68.1%). The reasons for prescription were available for only 371 patients (21.7%) and were mainly psoriasis, auto-immune bullous dermatoses and eczema. About 12% of the French general population is prescribed topical glucocorticoids at least once each year. Most prescriptions are issued by general practitioners, dermatologists being the prescribers in less than one-quarter of cases.

Oh, as for the Health Insurance…it’s good, but…: rural elders in Agate, Ghana, discuss the National Healthcare Insurance Scheme

This paper investigates the Ghanaian National Healthcare Insurance Scheme (NHIS) through interviews with 28 elders over 50 years old with pre-existing illnesses in Agate, a rural village in Ghana. Our goals were to obtain snapshot views of the lives, in relation to health, wellness, and NHIS, of participants. Elders possessed reasonable information about NHIS. For most enrollees, NHIS provided peace of mind against financially-related health challenges, however, inability to afford non-covered medicines sometimes interfered with treatment. Most interviewees, insured or not, reported continuing chronic health problems. Based on qualitative data, we describe possibilities to improve elder experiences including: transportation to medical care, increased drug coverage, and faith-based health partnerships.

The Role of Dispensing by Japanese Community Pharmacists in Reducing Medicine Costs

This study investigated the economic efficacy of separation of drug prescribing and dispensing (separation system). We examined whether daily medical expenses on prescriptions for former drugs, generic drugs, medical devices, and the number of drugs are curtailed due to the separation system, whose function is to separate the manager between prescribing and dispensing drug, and the effect of mutual check between prescribing doctors and dispensing pharmacists. Participation in the separation system is legally optional for Japanese medical institutions. It causes that the growth rate of the separation system in administrative districts is wide range. Furthermore, this study investigated the separation system in Japanese administrative districts with available open public data. We examined the separation system effect using National Healthcare Insurance data for 2011–2015. We tested whether the separation system growth rate for each Japanese administrative district was correlated to former drug significantly, generic drug, medical device price, and the number of drugs on prescriptions. The results show that growth of the separation system influenced the daily expense of prescribed former drugs and medical devices and the correlations were significant. Contrastively, the number of drugs and the expense of generic drugs on prescriptions were not significantly correlated with the separation system growth rate. Therefore, the separation system was effective at curtailing expenses of daily former drugs and medical devices but little effective at curtailing the number of daily drugs and generic drugs expense.

Distribution of medical status and medications in elderly patients treated with dental implant surgery covered by national healthcare insurance in Korea

BackgroundThe purpose of this study was to investigate the distribution of systemic diseases and medications in patients older than 65 years of age who visited the hospital for implant treatment, as well as to investigate basic information about surgical complications that may occur after insured implant treatment.MethodsA total of 126 patients over 65 years of age were treated for implant surgery from October 1, 2013 to October 30, 2016. Electronic chart review was conducted to obtain medical records, which included sex, age, systemic diseases, medication(s) being taken, and control of the medications. Five patients were excluded due to lack of medical records giving information about systemic disease.ResultsOf the 126 patients, 112 (88.9%) were taking medication due to systemic disease and 9 patients (7.1%) were not. The sex distribution was 71 women and 55 men and the highest proportion of patients were between 65 and 69 years old. The most common diseases were, from most to least frequent, hypertension, cardiovascular disease, diabetes, and osteoporosis. The drug groups that can cause major complications after dental treatment were classified as hemorrhagic, osteoporotic, and immunosuppressive agents, and were taken by 45 (35.7%), 22 (17.5%) and 4 (3.2%) patients, respectively.ConclusionGiven that 88.9% of the elderly patients who were eligible for insurance implant treatment had systemic disease, it is necessary to carefully evaluate patients' medical histories and their general conditions in order to prevent emergencies during implant surgery.

Campaigning for All Indonesians: The Politics of Healthcare in Indonesia

Many scholars argue that democratization fosters redistribution through electoral competition and inclusiveness. (1) By extending the franchise to the poor, they argue, democracy provides electoral incentives that promise social protection for its citizens. In addition, voters can penalize governments when they fail to carry out their promises. However, regime type is not sufficient to explain social policy outcomes. Although democracy does provide incentives for politicians to promise social protections to the newly enfranchised poor, it does not guarantee the enactment or implementation of inclusive social reform policies. What then explains social policy expansion in developing countries? This article explores this question by examining Indonesia's implementation of universal healthcare reform in January 2014. As a new democracy and emerging economy, Indonesia provides an interesting case study for analyzing what enabled the implementation of universal healthcare expansion. After thirty-two years of authoritarian rule, Indonesia started democratizing after the fall of President Soeharto in 1998. More than ten years later, in 2011 the Indonesian government passed the Social Security Administering Bodies bill (Badan Perencanaan Pembangunan Nasional, BPJS), which enabled the National Social Security System Law [Sistem Jaminan Sosial Nasional, SJSN) to be implemented. In 2004, the last year of Megawati Sukarnoputri's presidency (2001-04), parliament had enacted the SJSN law, which could have provided comprehensive reform of the existing social care system. This law covered four social security programmes--health insurance, employment injury, old-age pensions and death benefits--and seemed to provide a springboard for comprehensive social policy reform to include formal and informal sector workers, the unemployed and the poor. However, the SJSN law was not put into effect immediately. Implementing this law required detailed provisions of social security programmes to be determined by presidential regulations, including policy options for benefits and benefit parameters. While government agencies and the House of Representatives had discussed the law, no progress was made until October 2011. Neither President Susilo Bambang Yudhoyono nor the existing social security agencies and ministries were enthusiastic about the reform. (2) Nevertheless, the House of Representatives passed the BPJS bill and Presidential Decree 111/2013 was subsequently issued. Both pieces of legislation enabled the Indonesian government to establish a comprehensive healthcare programme beginning on 1 January 2014. Other social security programmes were subsequently implemented on 1 July 2015. Under this social welfare reform, all Indonesian citizens--as well as residents of the country--are required to join the national healthcare insurance scheme, and the Indonesian government aims to achieve universal healthcare coverage by 2019. Why did the implementation of universal healthcare take ten years after the initial enactment? I argue that social welfare reform has an institutional prerequisite, such as an advocacy coalition, which represents the broad interests of society. An advocacy coalition is a group of actors from various public and private organizations who share a set of beliefs and who seek to realize their common goals over time. (3) Without such a coalition, electoral competition does not necessarily provide incentives for politicians to undertake inclusive social welfare reform. In concrete terms, the 2004 SJSN reform bill was introduced in a top-down manner by the government without a broad societal consensus. In contrast, the 2011 BPJS reform was a bottom-up initiative. The successful implementation of the BPJS law demonstrates that the coordinated efforts of an advocacy coalition going beyond their own narrow interests can pressure politicians into implementing inclusive social welfare reforms. This article consists of four sections. …