Public Health Insurance Schemes Research Articles

Focus: A threat to democracy

FOCUS ❐ TRADE AGREEMENTS AND THE LABOUR MOVEMENT and undermine public services, social and environmental protection and trade union rights’. The agreements will contain clauses protecting investor ‘rights’. The idea is that businesses are to be compensated if governments legislate or regulate in a way that interferes with businesses’ profits (actual or anticipated). The investor-state dispute settlement (‘ISDS’) mechanism governing breaches of these clauses is – justifiably – one of the report’s major focuses. Disputes are to be adjudicated ‘in closed tribunals for which there is no appeal and arbitrators are free to determine compensation and allocation of costs’. The report goes on: ‘[t]he tribunal consists of 3 private-sector lawyers who also serve as corporate advocates – there are no conflict of interest rules and the jurisprudence is essentially arbitrary’. Taking these things together – the secret content of the agreements, the conferring of rights on businesses, the secret hearings, and the idea that business interests fetter government policy – the report argues that these agreements ‘lock in’ neoliberal policies politically and legally. It says: ‘[t]he regime is expressly designed to prevent a reversal of neoliberal policies and the corporate power it consolidates by threatening sanctions against countries whose governments attempt to re-erect these barriers or create new forms of social and/or ecological protection in response to the pressure of labour and social movements’. The authors illustrate this argument by looking at specific policy areas that have been damaged as a result of trade agreements, for example water and fishing rights in Canada and (troublingly ) the Slovakian government’s failure to regulate healthcare insurers. The report notes: ‘When the newly elected government of Slovakia in 2006 restricted the power of private health insurers to distribute or repatriate profits, several foreign health care providers sued for damage suing the NetherlandsSlovakia BIT. The Dutch company Achmea was eventually awarded USD 25 million in damages and costs, and succeeded in enforcing the order through the Luxembourg courts, which have blocked EUR 29 million of the government’s assets in its banks. The story doesn’t stop there. In February 2013, Achmea initiated proceedings against the government of Slovakia to block draft legislation which would establish a single public health insurance scheme. The law is still in draft form and envisages various options to accomplish this goal. Achmea’s claim for compensation for expropriation under a law which has not been adopted and under which it has therefore suffered no damages constitutes a preemptive strike to block future legislation’. Under the terms of free trade agreements governments lose their power to legislate in the interests of workers INTERNATIONAL union rights Page 12 Volume 21 Issue 3 2014 ‘T rade Deals that Threaten Democracy’ is a mildly-named new report from the International Union of Food, Agricultural, Hotel, Restaurant, Catering, Tobacco and Allied Workers Associations (‘IUF’). The report examines regional and bilateral agreements and explains their harmful effects not just on democracy but also on government policy, the rule of law, trade union rights and social and environmental protection. The brochure: ‘seeks to provide trade unionists with an overview of what is behind the negotiations on the EU-US and TransPacific trade and investment agreements and their likely impact. It explains why we need to organize to defeat these treaties, to roll back the layers of protection shielding transnational capital from democratic regulation and to begin putting in place a system of global rules which effectively enforces respect for human rights over the private claims of investors’. The report gives a troubling account of trade agreements, exposing the particular threats of two proposed mega-treaties – the US-EU Transatlantic Trade and Investment Partnership (TTIP) and the twelve-nation TransPacific Partnership Agreement (TTP) – and suggests why (and how) the trade union movement must defeat them. Only policymakers and transnational businesses have been let in on the contents of the TTIP and TTP negotiations. Indeed, the report notes that the tests are: ‘officially secret; [and] documents relating to the negotiations will be kept under government protection for decades’. But while the report therefore lacks specific source material its contents aren’t just speculative : the authors draw on the 3,200 currentlyexisting bilateral and regional trade and...

Managing genetic tests, surveillance, and preventive medicine under a public health insurance system

There is a prospect in the medium to long term future of substantial advancements in the understanding of the relationship between disease and genetics. We consider the implications of increased information from genetic tests about predisposition to diseases from the perspective of managing health care provision under a public health insurance scheme. In particular, we consider how such information may potentially improve the targeting of medical surveillance (or prevention) activities to improve the chances of early detection of disease onset. We show that the moral hazard implications inherent in surveillance and prevention decisions that are chosen to be privately rather than socially optimal may be exacerbated by increased information about person-specific predisposition to disease.

Effect of health insurance on the use and provision of maternal health services and maternal and neonatal health outcomes: a systematic review.

Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n = 11), Asia (n = 9), Latin America (n = 8), and Turkey. The studies included examples from national or social insurance schemes (n = 7), government-run public health insurance schemes (n = 4), community-based health insurance schemes (n = 11), and private insurance (n = 3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of over-provision of caesarean sections in response to providers' payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and statistical limitations. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. However, more rigorous causal methods are needed to identify the extent to which the use of these services increases among the insured. Better measurement of quality and the use of cross-country analyses would solidify the evidence on the impact of insurance on the quality of maternal health services and maternal and neonatal health outcomes.

The impact of cardiovascular profile on persistence associated with antihypertensive medications

Antihypertensive drug treatment (AHT) is effective in reducing the risks of cardiovascular events, but long-term persistence is required to achieve these benefits. The aim of the present study was to evaluate persistence with antihypertensive treatment in France. A total of 6924 patients, first prescribed for hypertension in 2008, were retrospectively studied from the principal French National Public Health Insurance Scheme database. Persistence was defined as remaining on therapy at the end of the 12 months postindex date. Cox proportional hazards regression models controlled for demographics and cardiovascular profile. Over 1year, 65% of patients were persistent and 16% maintained the initial therapy. When correcting for significant factors determining persistence, a 13% risk reduction of discontinuation is observed with angiotensin II antagonists (AIIAs) and 11% with angiotensin-converting enzymes inhibitors (ACE) compared with thiazide diuretics. Persistence therapy depended significantly on the cardiovascular profile. In the secondary prevention subgroup (18% of the study population), no statistically significant differences were observed between thiazide diuretics and the four major classes. In contrast, a 19% risk reduction of discontinuation is observed with AIIA and with ACE compared with thiazide diuretics for primary prevention patients without diabetes or hyperlipidaemia. When choosing AHT agents for patients with essential hypertension, practitioners are primarily driven by the cardiovascular profile of patients. The study suggests that the therapeutic decision must encompass the individual 'persistence risk', the latter not being independent from the cardiovascular risk.

Changing Origins of Inequalities in Access to Health Care Services in Turkey: From Occupational Status to Income

AbstractHealth care reforms have always been critical political arenas within which the parameters of citizens' access to health care services and thus the new terms of social bargain that backs social policies are negotiated. Despite the relative success of Turkey in establishing public health insurance schemes and developing a public capacity for health care service delivery since the late 1940s, Turkey's health care system has largely failed to institute equality of access to health care services. With the promise of abolishing the inequalities, the ruling Justice and Development Party (AKP) launched Turkey's Health Transformation Program in 2003. Since then, Turkey's health care system has been undergoing a significant transformation. On the one hand, with the unification of all public health insurance schemes under a compulsory universal health insurance scheme and the equalization of benefit packages for all publicly insured, the program has succeeded in abolishing the occupational status-based inequalities in access to health care services. On the other, this article suggests that the program has changed the main origin of inequalities in service access from occupational status to income. As the country suffers from an uneven distribution of income, it is argued that these incomebased inequalities in access pose a significant threat to the realization of the social citizenship ideal in Turkey.

Pathologie respiratoire et profession chez les travailleurs indépendants

In occupational health insurance, co-payment exemptions for severe chronic respiratory failure and reimbursements for domiciliary oxygen therapy can be used as markers of severe chronic respiratory insufficiency. The purpose of this study was to determine whether there is a difference in the prevalence of markers of respiratory disease between different occupations. We conducted an analysis of the reimbursement database of the French Régime Social des Indépendants (public health insurance scheme for self-employed workers), focusing on gender, occupation and place of residence. The dependent variable was a marker of severe chronic respiratory insufficiency. A survey was conducted of 153,334 insured workers (average age: 49 years; male-female ratio: 2.3:1). The prevalence rate was 0.70%. The prevalence was higher among a) those living in areas of high unemployment (odds ratio (OR) = 1.526; confidence interval (CI): 1.296; 1.798), b) those living in rural areas (OR = 1.703; CI: 1.241; 2.337), and c) those belonging to the following groups: bakery workers (OR = 2.526; CI 1.783; 3.580), tobacconists [corrected] (OR = 2.287; CI: 1.640; 3.187), dental technicians (OR = 2.105; CI: 1.055; 4.200), metal workers (OR = 1.997; CI: 1.250; 3.190), hauliers (OR = 1.916; CI: 1.383; 2.654), bricklayers (OR = 1.814; CI: 1.346; 2.445), stallholders and market traders (OR = 1.811 CI: 1.305; 2,512), hospitality, café and restaurant workers (OR = 1.478 CI: 1.108; 1.972), and construction workers (OR = 1.400; CI: 1.002; 1.954). Markers of Severe Chronic Respiratory Insufficiency are strongly associated with occupational status. Preventive measures against respiratory insufficiency must be further developed for those occupations with the highest prevalence.

Insurance Rebates, Incentives and Primary Care in Australia

Australia has a universal, compulsory, public health insurance scheme that includes insurance rebates for private fee-for-service medical practitioner services. Recent sweeping changes to the rebates for general practitioner (GP) services provide an opportunity to observe the effects of widespread insurance changes on the behaviour of GPs and aggregate outcomes such as quantities, prices and co-payments. In this paper, we study the effect of two important changes to subsidies for GP services, the first of which increased the rebates payable for services provided to specific patient groups, and the second of which increased rebates payable for all patients. Using economic theory, predictions of the effect of the rebate increase on quantities, prices and co-payments are produced that depend on the structure of the market. Using time-series data, we then present short-run empirical evidence that suggests that the supply curve for GP services is backward-bending.

Mainstreaming health insurance for people with disabilities

Abstract Many low- and middle-income countries have introduced public health insurance schemes to increase access to health care and provide financial protection against the costs of care for disadvantaged groups. Using national health household survey data from Vietnam and an appropriate two-part model, this paper examines the targeting effectiveness of public health insurance schemes and their impact on health care utilization for persons with disabilities. Results suggest that current community-based targeting methods are not effective, and that insurance mechanisms are an unsatisfactory buffer for inpatient-related costs to which persons with disabilities are prone. A higher level of disability targeting is recommended, both in terms of eligibility and benefits.

HPV vaccination in France: Uptake, costs and issues for the National Health Insurance

IntroductionTwo vaccines for primary prevention of cervical cancer are available in France, Gardasil® and Cervarix®, since 2007 and 2008 respectively. Currently, the French guidelines indicate vaccination of girls aged 14 with a catch-up program for females from 15 to 23 years old. In France, the reimbursement rate for these vaccines is 65% of the vaccine price, resulting in Gardasil® being the fifth highest drug expenditure of the main scheme of the French National Health Insurance in 2008. The purpose of this study is to provide data on vaccination coverage and costs in France until 31 December 2009. In addition, the current vaccination coverage rate is compared with the coverage rates assumed in cost-effectiveness studies. MethodsData were extracted from the National Health Insurance Information System (SNIIRAM). The SNIIRAM records all reimbursements of medical costs to patients – including drugs – by the French public Health Insurance Schemes since 2004. The analysis was performed for the period of July 2007 until December 2009 using the data of the general scheme of National Health Insurance covering about 88% of the French population, i.e., 56.5 million people. Vaccination rates for one or three doses were determined for the target and catch-up population using the 2009 reference population from the general health insurance scheme as the denominator. ResultsThe cumulative number of doses reached 2,900,000 at the end of 2009. About 1,200,000 girls and young women have been reimbursed for at least one vaccine dose, of these 96.5% females aged 14–23 years. Among the target group, reimbursement for at least one dose remained low, from 50.8% for girls aged 14 years in 2007 to 41.7% and 20.5% for girls aged 14 years in 2008 and 2009 respectively. In terms of complete vaccination, only 33.3% of girls of the age of 14 years in 2007 and 23.7% in 2008 were reimbursed for 3 doses of HPV vaccine. The maximum uptake in the catch-up group for both 1 and 3 doses was observed for women born in 1992 (15 years in 2007) with 52.5% and 35.6% respectively. ConclusionLow rates of coverage have been observed both in the target and catch-up groups in France. Considering this, the cost-effectiveness of vaccination in combination with opportunistic screening or organized screening needs to be re-evaluated.

Access to Diabetes Care and Medicines in the Philippines

In the Philippines, diabetes is rapidly becoming a major public health issue, as in other low- and middle-income countries. Availability and affordability of care and medicines are crucial to control diabetes. This study describes the situations of diabetes patients and identifies possible barriers to diabetes care and medicines in the Philippines. Quantitative and qualitative data were collected from multilevel respondents using different semistructured questionnaires/checklists. The study revealed that many patients took intermittent medication based on their own judgment, and/ or selected certain pieces of medical advice, subjectively weighing symptoms against household budget. The current public health insurance scheme and decentralized health systems did not promote access to diabetes care. Investing in regular care is expected to be less expensive both for individuals and for society in the long-term. Insurance outpatient coverage and application of standard treatment/management guidelines will be of help to encourage providing and receiving regular care.

Public Insurance and Financial Risk Protection: Lessons from Thailand

Thailand achieved universal coverage in access to health care in 2002. Since then, there has been a dramatic reduction in the prevalence of catastrophic health expenditures reflecting the capacity of the main public health insurance schemes to protect their members against financial risk from medical care costs. This policy brief draws on evidence from a recent study of the Social Health Insurance (SHI) and Universal Coverage (UC) schemes, identifying the key features of these schemes which have contributed to the reduction in catastrophic expenditures. Qualitative approaches were applied including documentary reviews and in-depth interviews conducted with three groups of stakeholders: purchasers, providers and patients. Conclusions: The combination of deepening coverage from the comprehensive package to include high cost services, and a provider payment system which reduces the incentives for providers to avoid high cost patients, appear to have been key factors in ensuring that UC and SHI members are protected from the risk of financial catastrophe from health care payments. This predominance of the policy objectives of financial risk protection and equity across schemes is illustrated by the recent decision to extend coverage to include RRT, an intervention that does not pass the conventional cost-effectiveness threshold, but which has been shown to have an impoverishing impact on households. Having a clear policy direction on financial risk protection, a comprehensive benefit package, and an active purchasing function based on evidence and clinical monitoring capacities, together provide an important foundation for successful financial risk protection.

Diabetes treatment and control: the effect of public health insurance for the poor in Mexico.

To analyse the effect of enrolment in the public health insurance scheme known as Seguro Popular [People's Insurance] on access to health resources, treatment and blood glucose control among poor adults with diabetes in Mexico. We analysed cross-sectional data from the 2006 National Health and Nutrition Survey and compared health care access and biological health outcomes, specifically glycosylated haemoglobin (HbA1c) levels, among adults with diabetes who were enrolled in the Seguro Popular (treatment group) and those who had no health insurance (control group). Standard propensity score matching was used to create a highly comparable control group. Adults with diabetes who were enrolled in the Seguro Popular had significantly more access than comparable uninsured adults to some type of blood glucose control test (by a difference of 9.5 percentage points; 95% confidence interval, CI: 2.4-16.6) and to insulin injections (3.13 more per week; 95% CI: 0.04-6.22). Those with insurance were also significantly more likely to have appropriately-controlled blood glucose levels (HbA1c <or= 7%) than their uninsured counterparts (by a difference of 5.6 percentage points; 95% CI: 0.9-10.3). Very poor glucose control (HbA1c > 12%) was found in a significantly smaller proportion of adults in the insured group than in the uninsured group (by a difference of 17.5 percentage points; 95% CI: 6.5-28.5). The Seguro Popular appears to have improved access to health care and blood glucose control among poor adults with diabetes in Mexico, and it may have had a positive effect on the management of other chronic health conditions, but its long-term effects are yet to be demonstrated. Although the findings are most relevant to Mexico, they may also be applicable to other developing countries seeking to improve health-care coverage for the poor by expanding their public health insurance programmes.

The implications of benefit package design: the impact on poor Thai households of excluding renal replacement therapy

AbstractWhen the Thai universal coverage (UC) scheme was established, the government decided to exclude renal replacement therapy (RRT) for end‐stage renal disease (ESRD) patients from the benefit package, though RRT was included in two other public health insurance schemes. Access to RRT for UC members thus depended on the ability to pay. This study assessed the economic impact of RRT costs on Thai households of different economic status focusing on three issues: (1) the use of RRT; (2) the financial burden of health care payments and (3) household strategies for coping with RRT costs. In‐depth case studies of 20 households covered by the UC scheme and having ESRD patients were undertaken using three qualitative data collection approaches: semi‐structured and in‐depth interviews, and direct observation. Poorer and richer households in urban and rural areas of Nakorn Ratchasima province, a large province in the Northeast where more than 20 per cent of households live below the national poverty line, were purposively selected. The study was conducted in early 2005 and households were visited every 2 weeks for 3 months. Interviews were transcribed and analysed using a thematic approach. The decision to exclude RRT from the UC benefit package created financial barriers to RRT and had a substantial economic impact on poorer ESRD patients. Inadequate dialyses and erythropoietin injections to correct anaemia appeared to be a major cause of death for poorer patients. Household expenditure on RRT took 25–68 per cent of total income or 31–52 per cent of total expenditure, which meant all poorer patients faced catastrophic health spending. In contrast, richer patients had adequate dialyses, resulting in a higher survival rate and quality of life than poorer counterparts. Various coping strategies were employed by poorer patients; these included reducing frequency of dialyses, reducing food consumption, using public transportation to hospitals and taking high interest loans. The RRT cost burden not only impacted patients but also their household members and relatives who provided financial support. Given the two UC policy objectives of equitable access to health care and financial risk protection, the catastrophic impact of RRT costs on poorer households questions the appropriateness of excluding RRT from the UC benefit package. This issue requires further serious attention by the Thai government. Copyright © 2009 John Wiley &amp; Sons, Ltd.

Public health insurance in Uganda still only a dream

Three months ago, Uganda planned to launch a compulsory public health insurance scheme, the first in the country. It didn't happen. The plan was to initially cover about 2 million employed Ugandans (6% of the population), including 300 000 government workers. Employees would have contributed about

The Politics of Reproductive Health in Peru: Gender and Social Policy in the Global South

This article analyzes the politics of reproductive health policymaking in Peru in the context of healthcare reform initiatives undertaken since the early 1990s. In Latin America womens body politics are emerging within a complex architecture of institutionalized social stratification and religious lobbies. The case of Peru is approached from a gendered specifically South-World analysis revealing the deep embedding of a vast constellation of reproductive healthcare issues within the nascent social welfare policy-making process. Through limited national public health insurance schemes a new social policy model based on a targeted poverty-reduction paradigm is now partially addressing the reproductive health needs of the majority of Peruvian women. Policy implementation however is highly contested fragile and has been subject to setbacks and deadly abuses. The article shows that in addressing developing countries such as Peru the role of international actors and the impact of unconsolidated democratic institutions are two key variables in the comparative analysis of social policy regime formation. (authors)

의약분업이 건강보험 급여비에 미친 영향

Korean health care system introduced the reform for separation between prescribing and dispensing of drugs (SPD reform) in the latter part of the year 2000. The objective of this paper is to look at what change this reform has brought about in the financial situation of Korean public health insurance scheme, particularly in terms of insurance benefit outlay. Since the inception of the reform is a development of more than five years ago, its impact on the finance situation would now start to become apparent. Hypothesis is set in this study for each of three components of drug reimbursement in health insurance, i.e. average price level, composition of drugs and their overall volume. In terms of the classification of health care services by mode of production, the impact of the SPD reform is confined mainly to the last two among three drug reimbursement fields including inpatient department, out-patient department and pharmacy. Pure impact of the SPD reform was estimated to be more or less than 1.7 trillion won, 13.1% of the total outlay of the Nation Health Insurance in 2001, and more than 2.0 trillion won, 14.9% of the total outlay of the Nation Health Insurance in 2003. Both dispensing fees for the pharmacists, which had been newly introduced on occasion of the SPD reform, and larger share of expensive drugs in the medicines prescribed by doctors were confirmed to be main drivers of the augmentation of drug reimbursement.

La régulation de la demande de soins : le rôle de l’assurance maladie dans la formation de la consommation de biens et services de santé

The regulation of health care demand : health insurance and the frame of individual health expenses According to the « moral hazard » hypothesis, a health insurance scheme which provides a high level of compensation of health expenditures offsets any incentive for individuals to restrain their resort to the health care system. Most of those studies find a strong and positive correlation between the size of the health insurance coverage and the amount of health expenditures. According to new figures that we also report, the gap between average ambulatory health expenditures of individuals who own a private supplementary health insurance scheme and of those who benefit only from the public health insurance scheme is estimated by + 29%. Part of this gap relies on the improvement of the health insurance coverage of low income people who entered the CMU. However, these outcomes bring a ground for policies which aim at monitoring the health care demand, using an adequate regulation of the reimbursement provided by the public and private insurance schemes. JEL classification : I11, I18

A Note on Private vs. Public Health Insurance Schemes for the Elderly: Partial vs. General Equilibrium Effects

A Note on Private vs. Public Health Insurance Schemes for the Elderly: Partial vs. General Equilibrium Effects

The Process of Health Legislation Reform in the Republic of Slovenia

AbstractSlovenia was among the first European countries to introduce laws and regulations in the social security field, including public health. The current health legislation is the culmination of a century-long development of the health care system through different periods and diverse political and economic conditions affecting the region. The present organization of the health care system reflects the pattern of partnership which already existed in the former Yugoslavia. The ultimate goal of all countries is to implement health care activities within a system ensuring active participation and partnership of citizens who are universally covered by a public health insurance scheme, health legislators and providers of health services. Slovenia has therefore not been confronted with any major difficulties in implementing health care system reforms. By amending and modifying its health legislation Slovenia will build upon its good points, improve clarity and integrate certain approaches important for the functioning of its health care system in the European Union when Slovenia becomes a full member. Changes are directed towards:strengthening inter-sectoral cooperation and health and safety at work;creating environments supporting a healthy life style and emphasizing personal responsibility for one's own health;— maintaining a unified public health insurance scheme and sufficient financing through employer and employee contributions;— introducing voluntary health insurance;— developing in a controlled way an efficient and effective private medical practice;— strengthening of management in public health institutions and increasing staff's responsibility for business success.— implementing quality improvement systems.

Reforming health care financing in urban China

This article examines the structure and problems of financing health care in the urban areas in China in light of the recent market-oriented reforms. It highlights the characteristics and major weaknesses of the existing financing and delivery systems, and examines a number of reform options and their effects on the various stakeholders of the health care system in terms of cost, quality and equity. Preliminary reports on the performance of the new systems are cited. The author recommends (1) the development of a tripartite contributory health insurance system for the better-off enterprises, (2) major changes within the existing Public Health Insurance Scheme, which will remain to cover the newly established civil service, (3) the temporary retention of the Labour Insurance Medical Care Scheme to cover the workers in ailing state corporations, and (4) the promotion of voluntary organizations to provide services to the indigence. He predicts that current reform efforts would not be effective in containing ...