Supplementary Private Health Insurance Research Articles

Does supplemental private health insurance impact health care utilization and seeking behavior of residents covered by social health insurance? Evidence from China National Health Services Survey

BackgroundSupplemental private health insurance (PHI) plays a crucial role in complementing China’s social health insurance (SHI). However, the effectiveness of incorporating PHI as supplementary coverage lacks conclusive evidence regarding its impact on healthcare utilization and seeking behavior among SHI-covered individuals. Therefore, investigating the effects of supplementary PHI on health care utilization and seeking behavior of residents covered by social health insurance is essential to provide empirical evidence for informed decision-making within the Chinese healthcare system.MethodsData from the 2018 China National Health Services Survey were analyzed to compare outpatient and inpatient healthcare utilization and choices between PHI purchasers and non-purchasers across three SHI schemes: urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), and the new rural cooperative medical scheme (NRCMS). Using the Andersen Healthcare Services Utilization Behavior Model as the theoretical framework,binary logistic regression and multinomial logistic regression (MNL) models were employed to assess the impact of PHI on healthcare utilization and provider preferences.ResultsAmong UEBMI, URBMI, and NRCMS participants with PHI, outpatient visit rates were 17.9, 19.8, and 21.7%, and inpatient admission rates were 12.4, 9.9, and 12.9%, respectively. Participants without PHI exhibited higher rates for outpatient visits (23.6, 24.3, and 25.6%) and inpatient admissions (15.2, 12.8, and 14.5%). Binomial logistic regression analyses revealed a higher probability of outpatient visits and inpatient admissions among UEBMI participants with PHI (p < 0.05). NRCMS participants with PHI showed a lower probability of outpatient visits but a higher probability of inpatient admissions (p < 0.05). Multinomial logistic regression indicated that NRCMS participants with PHI were more likely to choose higher-level hospitals, with a 17% increase for county hospitals and 27% for provincial or higher-level hospitals compared to primary care facilities.ConclusionThe findings indicate that the possession of PHI correlated with increased utilization of outpatient and inpatient healthcare services among participants covered by UEBMI. Moreover, for participants under the NRCMS, the presence of PHI is linked to a proclivity for seeking outpatient care at higher-level hospitals and heightened utilization of inpatient services. These results underscore the nuanced influence of supplementary PHI on healthcare-seeking behavior, emphasizing variations across individuals covered by distinct SHI schemes.

Effect of supplementary private health insurance on out-of-pocket inpatient medical expenditure: evidence from Malaysia.

The vital role of healthcare financing in achieving universal health coverage is indisputable. However, most countries, including Malaysia, face challenges in establishing an equitable and sustainable healthcare financing system due to escalating healthcare costs, an ageing population and a growing disease burden. With desirable pre-payment and risk pooling features, private health insurance (PHI) is considered an alternative financing option to reduce out-of-pocket (OOP) medical expenditure. However, ongoing theoretical and empirical debates persist regarding the adequacy of financial risk protection provided by PHI largely because it depends on its role, the benefit design and the regulations in place. Our study aimed to investigate the effect of supplementary PHI on OOP inpatient medical expenditure in Malaysia. Secondary data analysis was conducted using the Malaysian National Health and Morbidity Survey 2019 dataset. A total of 983 respondents with a history of inpatient hospitalization in the past 12 months were included in the study. Instrumental variable analysis using a two-stage residual inclusion was performed to address endogeneity bias, with wealth status and education level as the instrumental variables. Tobit regression model was used in the second stage considering the censored distribution of the outcome variable. Missing data were handled using multiple imputation. About one-fifth of the respondents had PHI. In this study, we found that having PHI significantly increased OOP inpatient medical expenditure in all three marginal effects. Additionally, age, residential location, ethnicity (citizenship), being covered by government guarantee letter, government funding and employer-sponsored health insurance were other significant factors associated with OOP inpatient medical expenditure. Our findings undermine a key justification to advocate PHI uptake among the population, with a need for the Malaysian government to reassess the role of PHI in healthcare financing and reconsider PHI subsidization policy. Regulations should also be strengthened to enhance the financial risk protection provided by PHI.

Effects of private health insurance on medical expenditure and health service utilization in South Korea: a quantile regression analysis

BackgroundDespite universal health insurance, South Korea has seen a sharp increase in the number of people enrolled in supplemental private health insurance (PHI) during the last decade. This study examined how private health insurance enrollment affects medical expenditure and health service utilization.MethodsUnbalanced panel data for adults aged 19 and older were constructed using the 2016–2018 Korea Health Panel Survey. Quantile regression for medical cost, and quantile count regression for health service utilization were utilized using propensity score-matched data. We included 17 variables representing demographic, socioeconomic, and health information, as well as medical costs and use of outpatient and inpatient care.ResultsWe discovered that PHI enrollees’ socioeconomic and health status is more likely to be better than PHI non-enrollees’. Results showed that private health insurance had a greater effect on the lower quantiles of the conditional distribution of outpatient costs (coefficient 0.149 at the 10th quantile and 0.121 at the 25th quantile) and higher quantiles of inpaitent care utilization (coefficient 0.321 at the 90th quantile for days of hospitalization and 0.076 at the 90th quantile for number of inpatient visits).ConclusionsPHI enrollment is positively correlated with outpatient costs and inpatient care utilization. Government policies should consider these heterogeneous distributional effects of private health insurance.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Indirect (Individual and Societal) and Direct Out-of-Pocket Costs.

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one's ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn's and Colitis Canada's 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.

Unintended consequences of healthcare reform in South Korea: evidence from a regression discontinuity in time design

BackgroundTo address concerns over the financial stability of South Korea’s National Health Insurance (NHI) programme, the government transitioned from an outpatient copayment system to a coinsurance system in 2007. This policy aimed to reduce healthcare overutilization by increasing patients’ financial responsibility for outpatient services.MethodsUsing comprehensive data on NHI beneficiaries, this study employs a regression discontinuity in time (RDiT) design to assess the policy’s impact on outpatient healthcare utilization and expenditures. We focus on changes in overall outpatient visits, average healthcare cost per visit and total outpatient healthcare expenditures.ResultsOur findings indicate that the transition from outpatient copayment to coinsurance led to a substantial increase in outpatient healthcare utilization (up to 90%) while decreasing medical expenditures per visit by 23%. The policy shift incentivized beneficiaries to seek more medical treatments during the grace period and enroll in supplemental private health insurance, which provided access to additional medical services at lower marginal costs.ConclusionsThe policy change and the emergence of supplemental private insurance contributed to moral hazard and adverse selection issues, culminating in South Korea becoming the country with the highest per capita utilization of outpatient health services worldwide since 2012. This study underscores the importance of carefully considering the unintended consequences of policy interventions in the healthcare sector.

The LACE index and risk factors of 14-day versus 30-day readmissions in children.

Risk factors for readmissions in children differ from those for adults, yet little is known about whether the LACE index (Length of stay, Acute admission, Charlson comorbidity index, Emergency department visits in the previous 6 months) developed for adults retains its validity when applied to the prediction of readmissions in children or within shorter intervals of time after discharge. In this retrospective cohort analysis of 4 256 patients aged≤18 hospitalized at one academic medical center in Taiwan, 2019, we first evaluated the performance of a LACE index model and the three other multivariate logistic regression models in their predictions of hospital readmissions in children using the same time intervals of 30 days. We then used multinomial logistic regression to analyze the characteristics and risk factors for readmissions that occur in the first 14 days with those that occur between 15 to 30 days after discharge. The optimal cutoff of LACE index score for children in the current study was 7, which is less than the optimal score of 10 in the original derivation for adults. The predictive model with the least discriminatory power was based on LACE score alone, whereas our model that included only two variables (length of stay and the number of admissions in the past one year) was found to outperform LACE index. Multinomial logistic regression results revealed that children who had supplemental private health insurance had lower readmission rates than those insured by National Health Insurance program only, suggesting a disparity by insurance status. Some risk factors of readmission within 14 days such as acute admissions and supplemental private health insurance were not found to be relevant for longer-term predictions, while age, which was a valid predictor of readmission within 15 to 30 days, did not affect the prediction of shorter-term readmissions. Prior healthcare utilizations and a higher illness burden were found to be greater contributors to readmissions beyond 14 days. Our simpler model outperformed the more complex LACE tool in identifying children at risk of readmission. Shorter-term readmissions can be attributed to different causes than 30-day readmissions, suggesting a need for different screening tools, interventions, and care support. There remains some socioeconomic disparity associated with readmission rates in the current healthcare system.

Effect of supplementary private health insurance on inpatient utilisation: Evidence from Malaysia

Supplementary private health insurance (PHI) provides better access to healthcare, improves health outcomes, potentially lowers the costs for health systems and supports the social security system. Improperly regulated PHI, however, may aggravate inequity of access towards preferential care and encourage moral hazard among PHI purchasers, altering the health-seeking behaviour, which is often observed through the pattern of health care utilisation. We investigated the effect of PHI ownership on private inpatient care utilisation, its frequency of admission and length of stay by conducting secondary data analysis of the Malaysian National Health Morbidity Survey (NHMS) 2015 data, a nationally representative community health survey. Malaysian adults 18 years of age and above who utilised inpatient healthcare facilities were included. In this cross-sectional study, we addressed the endogeneity effect of health insurance by employing instrumental variable estimation and a two-stage residual inclusion analysis. We found a significant increase in private inpatient utilisation among those who owned PHI compared to those who did not (β = 4.39, p < 0.001). There was no significant difference in the frequency of admission and length of stay. The increase in private inpatient utilisation among PHI owners may reflect the demand for timely care and hospitality provided by the private sector, potentially exacerbating the moral hazard behaviour among PHI owners. Further exploration of this issue could impact future healthcare systems financing designs and PHI regulation.

Buying control? ‘Locus of control’ and the uptake of supplementary health insurance

This paper examines the relationship between locus of control (LOC) and the demand for supplementary health insurance (SUPP). Drawing on longitudinal data from Germany, we document robust evidence that individuals internal LOC increases the take up of supplementary private health insurance (SUPP). We find that the effect of one standard deviation increase in the measure of internal LOC on the probability of SUPP purchase is equivalent to a 14 percent increase in household income. Second, we find that the positive association between self-reported health and SUPP becomes small and insignificant when we control for LOC. These results suggest that LOC might be an unobserved individual trait that can partly explain previously documented evidence of advantageous selection into SUPP. Third, we find comparable results using data from Australia, which enhances the external validity of our results.

Can supplementary private health insurance further supplement health.

BackgroundChina advocates a health insurance system with social health insurance (SHI) as the main body and private health insurance (PHI) as the supplement. The study of PHI's complementary role in health is conducive to providing evidence for PHI's policy expansion and encouraging the public to participate in PHI, which is insufficient in China.MethodsWe used the three-wave balanced panel data of the China Health and Retirement Longitudinal Survey (CHARLS). Taking the ownership of supplementary PHI as the independent variable and EQ-5D index scores as the dependent variable, the panel instrumental variable (IV) method was used to analyze the impact of participation in PHI on health. We also assessed the heterogeneity of the health effects of PHI between chronic and non-chronic disease groups and between low- and high-income groups.ResultsThe coverage rate of PHI at baseline was 10.53%. The regression results showed that participating in PHI on the basis of SHI could result in an additional 8.21% health gain (p < 0.001). At the same time, PHI had greater health gain for chronic disease population than for healthy population (9.25 vs. 6.24%, p < 0.001), and greater health gain for high-income population than for low-income population (8.32 vs. 5.31%, p < 0.001).ConclusionParticipating in supplementary PHI can effectively enhance the health status of the insured, and has a more significant effect on patients with chronic diseases. The development of PHI should be further supported, while the health inequality in different income groups should be paid attention to.

A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals

During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the differences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P < 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P < 0.001). A larger proportion of patients in private hospitals had high education (≥ 4 years of college or university) (42.9% vs 35.6%, P < 0.001). Patients in public hospitals had worse disease-specific health problems than those in private hospitals: unadjusted NDI mean difference was 5.2 (95% CI 4.4 – 6.0; P < 0.001) and adjusted NDI mean difference was 3.4 (95% CI 2.5 – 4.2; P < 0.001), and they also had longer duration of symptoms (P < 0.001). Duration of surgery (mean difference 29 minutes, 95% CI 27.1 – 30.7; P < 0.001) and length of hospital stay (mean difference 2 days, 95% CI 2.3 – 2.4; P < 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efficiently. Our findings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status.

The impact of benefits coverage expansion of social health insurance: Evidence from Korea

Despite mandatory social health insurance in Korea, the fraction of total healthcare spending paid out-of-pocket has been considerably high. In 2013, the Korean government expanded benefits coverage of social insurance for patients diagnosed with the costliest disease groups (cardiovascular and cerebrovascular diseases, cancer, and intractable diseases). We analyze individual longitudinal information from the 2010 to 2016 Korea Health Panel to estimate the impact of the policy change on healthcare spending, utilization, and enrollment in private supplemental health insurance. Impacts on other health-related and financial measures are additionally assessed to evaluate the effects in multiple dimensions. Our difference-in-differences approach with entropy balancing weights shows that the expansion of benefits coverage of public health insurance reduced out-of-pocket spending on health by 30% without accompanying increases in healthcare utilization. The impact was smaller for the individuals with high socioeconomic characteristics, who are more likely to use other costly services that remained unaffected by the policy. We do not find evidence that expanding social insurance benefits coverage changed the demand for supplemental private health insurance.

The regulatory, evaluation, pricing and reimbursement pathway for medicines in the UK: combining innovation and access

The United Kingdom has universal healthcare systems, the National Health System (NHS), in its four nations, with healthcare services provided free of charge at the point of delivery. Approximately 10.5% of the UK population has voluntary supplementary private health insurance. While the provision of inpatient medicines is free of charge, medicines provided in the outpatient setting have a dispensing fee in some of the nations, such as the case of England (co-payment). The UK marketing authorisation process is called product licensing and is overseen by the Medicines and Healthcare Products Regulatory Agency (MHRA). There are different licensing routes based on the intended market for launch. MHRA also offers early access schemes and pathways for products targeting unmet medical needs and promising technologies, that aim to accelerate and facilitate market and patient access to products in the UK. These schemes include the option for companies to engage early with regulators and other system partners such as health technology assessment (HTA) agencies. As soon as the technology is authorised, it is available at a list price. Prices for medicines are regulated in legislation and in schemes agreed between the industry association and the Department of Health and Social Care (DHSC). The prices for the NHS are negotiated between the government and the companies. Routine funding decisions in the NHS are guided by HTA evaluations informed by agencies such as the National Institute for Health and Care Excellence (NICE) in England, the Scottish Medicines Consortium (SMC) in Scotland, and the All Wales Medicines Strategy Group (AWMSG) in Wales. Many medicines and other technologies are subject to price negotiations in the NHS, sometimes with confidential price agreements. The NHS in England is legally mandated to routinely fund technologies recommended by NICE that have been evaluated by some of its programmes. The other UK nations have similar arrangements or recognise decisions made in England. The role and contribution of NICE and other HTA agencies in ensuring value for money and evidence-based decision making is well recognised worldwide.

Does supplemental private health insurance incentivize household risky financial asset investment? Evidence from the China Household Financial Survey.

Private health insurance (PHI) is considered a supplement to public medical insurance schemes in China. To the extent that PHI coverage may offset background risk by decreasing medical expenditure risk, it may also incentivize risky financial behaviors. However, empirical evidence confirming this theory is absent in China. We fill this void by examining the impact of supplemental PHI on household risky financial investment using data from the China Household Financial Survey (CHFS). In the first set of analyses, we used bivariate probit (BVP) models with instrumental variables (IVs) to examine the effects of PHI on the extensive margin of household risky financial investment. In the second set of analyses, we used Tobit models with a two-stage residual inclusion (2SRI) framework to examine the effects of PHI on the corresponding intensive margin. The results indicated that supplemental PHI increased the probability of holding risky financial assets. On top of that, PHI increased the percentage of total financial assets allocated to risky financial investment. Such effects were more pronounced on stocks than on other risky products. Our findings provided evidence that purchasing supplemental PHI in China may increase the risk tolerance of financial investment, and risk attitude is a mediating factor between PHI ownership and risky financial investment behavior.

Supplementary private health insurance: The impact of physician financial incentives on medical practice.

In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.

PO-1461 Impact of the COVID-19 pandemic on Radiation Oncology Departments in Brazil

Purpose or Objective: The COVID-19 pandemic brought several challenges to cancer practice, especially to ensure continuity of treatment during this period, minimizing the risks of transmission to a vulnerable population. For Radiation Oncology departments in Brazil, this contingency has become even more complex due to the significant impact observed in different sectors of society, the large number of cases and deaths by COVID-19. This study estimated the impact of the COVID-19 pandemic on Brazilian Radiation Oncology departments and the coping measures used in the country. Materials and Methods: The Brazilian Radiotherapy Society (SBRT) developed a questionnaire with 14 questions, sent to all heads of Radiation Oncology departments in the country, between May and June 2020. These data were evaluated regarding cases confirmed and deaths by COVID-19 in epidemiological week 28, on July 11, 2020. Results: One hundred twenty-six questionnaires from different regions were answered, representing 44% of the country’s services. A drop in the number of patients was observed in 61% of services. This drop was observed both in patients from the public and supplementary private health insurance systems. Regarding patients and employees with COVID-19, we observe that services that primarily treat SUS patients reported significantly fewer cases of the disease. About half of the services had collaborators and patients during radiotherapy with a positive diagnosis of COVID-19. Among the coping measures, the services used intensified hygiene and cleanliness, distance, restrictions on access to companions, and other changes in daily practice. (Figure Presented) Conclusion: There was an important drop in the number of radiotherapy patients in the country during the pandemic, and this impact happened in a similar way among the services, regardless of their characteristics and coping measures adopted during the pandemic.

Impact of the COVID-19 Pandemic on Radiation Oncology Departments in Brazil

PurposeThe COVID-19 pandemic brought several challenges to cancer practice, especially in ensuring continuity of treatment during this period while minimizing the risks of transmission to a vulnerable population. For radiation oncology departments in Brazil, this contingency has become even more complex owing to the significant effect observed in different sectors of society and the large number of COVID-19 cases and deaths. This study estimated the effect of the COVID-19 pandemic on Brazilian radiation oncology departments and the coping measures used in the country. Methods and MaterialsThe Brazilian Radiotherapy Society developed a questionnaire, with 14 questions, that were sent to all heads of radiation oncology departments in the country between May and June 2020. These data were evaluated regarding cases confirmed and deaths by COVID-19 in epidemiologic week 28, on July 11, 2020. ResultsOne hundred twenty-six questionnaires from different regions were answered, representing 44% of the country’s services. A drop in the number of patients was observed in 61% of services. This drop was observed both in patients from the public and supplementary private health insurance systems. Regarding patients and employees with COVID-19, we observed that services that primarily treat Unified Health System patients reported significantly fewer cases of the disease. About half of the services had collaborators and patients during radiation therapy with a positive diagnosis of COVID-19. Among the coping measures, the services used intensified hygiene and cleanliness practices, interpersonal distancing, restrictions on access to companions, and other changes in daily practice. ConclusionsThus, there was an important drop in the number of radiation therapy patients in the country during the pandemic, and this effect was similar among the services, regardless of the characteristics of the patients and the departments’ coping measures adopted during the pandemic.

Buying Control? 'Locus of Control' and the Uptake of Supplementary Health Insurance

This paper analyses the relationship between locus of control (LOC) and the demand for supplementary health insurance. Drawing on longitudinal data from Germany, we find robust evidence that individuals having an internal LOC are more likely to take up supplementary private health insurance (SUPP). The increase in the probability to have a SUPP due to one standard deviation increase in the measure of internal LOC is equivalent to an increase in household income by 14 percent. Second, we find that the positive association between self-reported health and SUPP becomes small and insignificant when we control for LOC, suggesting that LOC might be an unobserved individual trait that can explain advantageous selection into SUPP. Third, we find comparable results using data from Australia, which enhances the external validity of our results.

Buying Control? 'Locus of Control' and the Uptake of Supplementary Health Insurance

We examine the relationship between locus of control (LOC) and the choice of having a supplementary health insurance. Drawing on longitudinal data from Germany, we document the following findings: First, we find robust evidence that an individual's internal LOC is associated with a higher a probability to take up supplementary private health insurance (SUPP). The effect of a one standard deviation change in an individual's internal LOC on the probability to have a SUPP is equivalent to an estimated 14% change in household income. Second, we find that the positive association between self-reported health and SUPP becomes small and insignificant when we control for LOC, suggesting that LOC might be an otherwise unobserved individual trait that can explain advantageous selection into SUPP. Third, we find comparable results using data from Australia which enhances the external validity of our results.

Voluntary private health insurance, health-related behaviours and health outcomes: evidence from Russia

This paper contributes to the discussion around ex-post (increased utilisation of health care) and ex-ante (changes in health behaviours) moral hazard in supplemental private health insurance. Applying a range of methodologies to data from the Russian Longitudinal Monitoring Survey—Higher School of Economics we exploit a selection mechanism in the data to compare the impact of workplace provided and individually purchased supplemental health insurance on the utilisation of health care, on a range of health behaviours and on self-assessed health. We find compelling policy-relevant evidence of ex-post moral hazard that confirms a theoretical prediction and empirical regularity found in other settings. In contrast to other empirical findings though, our data reveals evidence of ex-ante moral hazard demonstrated by clear behavioural differences between those with self-funded supplemental health insurance and those for whom the workplace finances the additional insurance. We find no evidence that either form of insurance is related to improved self-assessed health.

The Longitudinal Impact of Private Health Insurance on the Usage of Outpatient Services Among Aging Koreans

South Korea has a universal national health insurance system; however, its coverage is only about 65%. Consequently, many Koreans have supplemental private health insurance. This study aims to examine 1) how utilization of health care services and out-of-pocket expenditure of outpatient services varies by private health insurance status and 2) whether this relationship changes for these individuals over time. We analyze six waves of the Korean Longitudinal Study of Aging (KLoSA) from 2006 to 2016. Our primary outcomes of interest are the total number of outpatient visits and total out-of-pocket spending on outpatient services per year. Our independent variable of interest is private health insurance holding status. We use simple OLS regressions for each year to test if differences exist and change over time, controlling for age, sex, education, income, and various indicators of health conditions. The difference between those who never had private health insurance and those who always or sometimes had private health insurance becomes larger over time. When comparing total out-of-pocket expenditure, those who always had private health insurance have the lowest spending at the beginning of the study period (2006); however, their spending increases sharply by 2010 and remains higher than the other groups for the rest of the study period. Findings suggest that those who always had supplemental insurance use outpatient services more frequently and spend more out-of-pocket for services as a result. In addition, discrepancies become larger over time. As private health insurance holders age, the risk of higher utilization of outpatient services grows.