Universal Public Coverage Research Articles

Changes in the coverage of essential services along the rural provincial border as a result of informal collaboration

The Sustainable Deveopment Goals prioritize universal essential public services as the second most important development goal after human basic needs in a global perspective. Indonesia implements a public service provision standard with a territorial approach and a set of minimum population requirement that lead to urban bias, resulting in border areas failing to meet the requirements for the provision of public services. Daerah Istimewa Yogyakarta Province is one of Indonesia's provinces with more than 70% of its border areas being rural, and more than 40% of border villages having limited essential public services. Because of the territorial delivery system for essential public services, formal cross-border services require a significant amount of resources. Using quantitative approach by indexing essential public services availability, this paper examines changes of essential public services coverage when cross-border services are provided informally. The case of Pustu Panggang informal crossborder service delivery provides lessons on how informal collaboration works. Although it involves misdeeds and omissions, the application of informal collaboration in cross-border services increases essential public service coverage by 57 percent in Daerah Istimewa Yogyakarta Province's rural border areas. As a result, informal collaboration should be viewed as a low-cost coping strategy in Indonesia's efforts to provide universal public service coverage.

Examining access to health insurance and health care along the life course to shed light on interactions between farm households’ social needs, social policy and the farm business

AbstractRural studies scholars have highlighted the important role farm households play in propping up the farm business along the life course. Yet, little is known about how challenges facing farm households impact the farm business and how social safety nets may interact with household and business development trajectories. We use the example of US farm households’ access to health insurance and health care to develop empirical insights into these research gaps. We draw on a life course conceptual framework integrating the European and US literature and conduct bivariate analysis using age categories as the dependent variable on a primary dataset of 1,114 surveyed farm families. Difficulties meeting health care needs affected respondents at any age. Variations in trade‐offs between consumption, savings and investments as farm households make health‐related decisions hint at compounding effects over the life course on farm structure and transition timing. With biggest differences between households under and over 65 years of age (the threshold for universal public coverage), our findings highlight the importance of considering how social policies shape farm families’ (in) ability to meet their social needs and the connections to farm persistence.

After More Than 50 Years, Pharmacare (and Dental Care) are Coming to Canada.

In March 2022, the New Democratic Party (NDP), Canada's social democratic party, and the centrist Liberal government signed a supply and confidence agreement. In return for the NDP agreeing to vote with the government on all crucial issues until June 2025, the Liberals pledged to bring in both pharmacare and dental care programs. Pharmacare, universal public insurance coverage for prescription drugs, had been promised for more than 50 years but never implemented, while public dental care was an almost completely neglected issue. This article explains the long genesis of pharmacare, the need for public dental care, and the political circumstances that led to the agreement. However, at this point, details about both plans are largely absent. As a result, how well those plans will serve the needs of Canadians is yet to be determined.

Equal long-term care for equal needs with universal and comprehensive coverage? An assessment using Dutch administrative data.

The Netherlands is one of the few countries that offer generous universal public coverage of long‐term care (LTC). Does this ensure that the Dutch elderly with similar care needs receive similar LTC, irrespective of their income? In contrast with previous studies of inequity in care use that relied on a statistically derived variable of needs, our paper exploits a readily available, administrative measure of LTC needs stemming from the eligibility assessment organized by the Dutch LTC assessment agency. Using exhaustive administrative register data on 616,934 individuals aged 60 and older eligible for public LTC, we find a substantial pro‐poor concentration of LTC use that is only partially explained by poorer individuals' greater needs. Among those eligible for institutional care, higher‐income individuals are more likely to use—less costly—home care. This pattern may be explained by differences in preferences, but also by their higher copayments for nursing homes and by greater feasibility of home‐based LTC arrangements for richer elderly. At face value, our findings suggest that the Dutch LTC insurance “overshoots” its target to ensure that LTC is accessible to poorer elderly. Yet, the implications depend on the origins of the difference and one's normative stance.

Income-related disparities in private prescription drug coverage in Canada.

Canada does not have universal public coverage for prescription drugs, which leaves an important role for private insurance plans. However, we do not have recent data on the characteristics of Canadians who report holding such coverage, particularly differences based on household income. We performed a study to examine the relation between household income and private drug insurance coverage in Canada. We used data from the 2015-2016 cycle of the Canadian Community Health Survey to investigate the relation between household income and holding private drug insurance. We constructed modified multivariate Poisson regression models with robust error variances, including several potential confounders. Overall, 59.4% of respondents reported having private drug insurance. We found a strong dose-response relation between household income level and private drug insurance coverage: 19.8% of those with a household income less than $20 000 reported private coverage, compared to 76.2% of those with a household income of $80 000 or more. Higher-income households are much more likely to hold private drug insurance coverage in Canada. This likely contributes to differential access to medicines and health outcomes by different income groups.

Medication coverage for lawmakers may worsen access for everyone else

Despite numerous recommendations for universal public coverage of prescription drugs in Canada based on evidence that millions of Canadians cannot afford medications, no province or territory has adopted first dollar coverage for all residents. However, one group unaffected by the lack of public coverage are lawmakers. Lawmakers receive excellent drug coverage plans for themselves and their immediate families. Evidence suggests that lawmakers' decisions are influenced by their personal circumstances; in this case, they are insulated from the effects of poor access to medications by their drug coverage plans. In contrast, a patchwork system of 46 programs across Canada provides some drug coverage to vulnerable populations. Reducing the disparity in prescription drug access between Canadian lawmakers and the public may promote progress towards better medication access for everyone. This could be achieved either by reducing lawmaker coverage or improving upon the public patchwork system. Since the goal should be to improve the overall access of medications for all Canadians, lawmakers included, the latter method is preferred. A universal drug plan with first dollar coverage could replace the current patchwork system and expand coverage to all Canadians.

Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada.

Estimated effects of adding universal public coverage of an essential medicines list to existing public drug plans in Canada.

Pharmacare researchers win Bruce Squires Award.

The authors of the article “Estimated cost of universal public coverage of prescription drugs in Canada” have won CMAJ ’s Bruce Squires Award, presented annually for the research paper published in the journal that is most relevant to medical practice and most likely to impact health care

Wealth-related versus income-related inequalities in dental care use under universal public coverage: a panel data analysis of the Japanese Study of Aging and Retirement.

BackgroundThere is a substantial body of evidence of income-related inequalities in dental care use, attributed to the fact that dental care is often not covered by public health insurance. Wealth-related inequalities have also been shown to be greater than income-related inequalities. Japan is one of the exceptions, as the the universal pubic health insurance system has covered dental care. The aim of this study was therefore to compare wealth- and income-related inequalities in dental care use among middle-aged and older adults in Japan to infer the mechanisms of wealth-related inequalities in dental care use.MethodsData were derived from the Japanese Study of Aging and Retirement, a survey of community-dwelling middle-aged and older adults living in five municipalities in eastern Japan. Of the participants in the second wave conducted in 2009, we analyzed 2581 residents. Dental care use was measured according to whether the participant had been seen by a dentist or a dental hygienist in the past year. The main explanatory variables were income and wealth (financial assets, real assets and total wealth). The need for dental care was measured using age, the use of dentures and chewing ability. The concentration indices for the distribution of actual and need-standardized dental care use were calculated.ResultsAmong the respondents, 47.9 % had received dental care in the past year. The concentration index of actual dental care use (CI) showed a pro-rich inequality for both income and wealth. The CIs for all three wealth measures were larger than that for income. A broadly comparable pattern was seen after need-standardization (income: 0.020, financial assets: 0.035, real assets: 0.047, total wealth: 0.050).ConclusionsThe results showed that wealth-related inequalities in dental care use were greater than income-related inequalities in Japan, where most dental care is covered by the public health insurance system. This suggests that wealth-related inequalities in dental care use cannot be explained by economic budget constraints alone. Further studies should investigate the mechanisms of wealth-related inequalities in dental care use.

Estimated cost of universal public coverage of prescription drugs in Canada.

With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada. We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator. Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes. The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government.

Accountable care organizations in the USA: Types, developments and challenges

A historically fragmented U.S. health care system, where care has been delivered by multiple providers with little or no coordination, has led to increasing issues with access, cost, and quality. The Affordable Care Act included provisions to use Medicare, the U.S. near universal public coverage program for older adults, to broadly implement Accountable Care Organization (ACO) models with a triple aim of improving the experience of care, the health of populations, and reducing per capita costs. Private payers in the U.S. are also embracing ACO models. Various European countries are experimenting with similar reforms, particularly those in which coordinated (or integrated) care from a network of providers is reimbursed with bundled payments and/or shared savings. The challenges for these reforms remain formidable and include: (1) overcoming incentives for ACOs to engage in rationing and denial of care and taking on too much financial risk, (2) collecting meaningful data that capture quality and enable rewarding quality improvement and not just volume reduction, (3) creating incentives for ACOs that do not accept much risk to engage in prevention and health promotion, and (4) creating effective governance and IT structures that are patient-centered and integrate care.

Is Canada odd? A comparison of European and Canadian approaches to choice and regulation of the public/private divide in health care

Choice is often touted as a means for change within health care systems. Yet 'choice', in this context, takes at least three distinct forms: choice between providers within a publicly funded health care system; choice between competing insurers within a universal plan; and, lastly, choice as between privately financed health care and universal public coverage. In Canada, it is this last form of choice that is under active debate; particularly in light of the Supreme Court of Canada's decision in Chaoulli, which found a regulation banning private health insurance for medically necessary care was unconstitutional. The argument is frequently made that Canada is an outlier from other countries in having regulation that effectively precludes this kind of choice. This issue is likely to become of concern again in upcoming constitutional challenges where applicants are looking to overturn through judicial challenges Canada's medicare system. This article tests that argument of whether Canada truly is 'odd' from a comparative policy perspective by exploring regulation of choice of privately financed health care in several European countries - the Netherlands, Germany, Sweden, England and France. We highlight commonalities as well as differences, showing the extent to which these countries employ regulation to fetter growth of a large privately financed sector. The article's thesis is that Canada, in employing more intrusive forms of regulation, is not an outlier per se but at one point in a regulatory spectrum.

Gobernabilidad del Sistema Nacional de Salud: mejorando el balance entre los beneficios y los costes de la descentralización. Informe SESPAS 2008

The Spanish National Health System (SNHS) is currently in a complex equilibrium which, even if acceptable in the short term, faces major sustainability and governance challenges; the so far inconclusive outcome of the SNHS decentralization process clearly underlines the importance of seeking new alternatives to effectively bring about the real benefits of decentralization, while taking advantage of the system's economies of scale and achieving its equity objectives. To this end, four lines of action are proposed in this paper: first, redefine the SNHS based on universal public coverage, as a civic right and equal for all; second, reframe the financing system and the role of the Cohesion Fund; third, review the role of central government and its Ministry of Health, and fourth, create of a SNHS Agency headed by a Commissioner, for providing an organizational framework and identity for the SNHS, and serving as the cooperative body of the seventeen Autonomous Communities’ Health Services.

Pushing Right against the Evidence: Turbulent Times for Canadian Health Care

Throughout the history of Canadian Medicare, there have been those who have opposed the universal, publicly funded system and advocated for greater private sector involvement. Amidst widespread public dissatisfaction with some aspects of Canadian health care--wait lists for some medical services, inadequate out-of-hospital drug coverage, and difficulties in accessing primary care--a series of recent events has shifted the public debate toward privately financed medicine, even as more Americans have been drawn toward universal public coverage. Certainly Canadian health care is in need of system reform. However, in a remarkably short time, the debate about the direction of reform has been transformed from one rooted in rigorous policy science, careful consideration of the empirical evidence, and an explicit commitment to universality, solidarity, equity, and the efficiencies of a single-payer, publicly-funded, not-for-profit system to one dominated by support for private and profit-driven systems and cut loose from solid evidence about what promotes equitable, effective, efficient, and sustainable health care. In fact, the move toward privatization rests on the repudiation of evidence-based health policy. Canadian Medicare provides publicly funded, tax-supported coverage for almost all doctor and hospital health care costs. This system developed gradually after World War II and was codified in the 1984 Canada Health Act, which calls for universality, accessibility, comprehensiveness, portability, and public administration of a not-for-profit system. It is crucial to understand that the CHA applies to the public funding (federal and provincial) of designated services, primarily hospital and doctor-delivered care. The delivery of health care has always been provided by a mixture of public and private--not-for-profit and for-profit--providers. Since the beginning of Medicare, doctors have typically been self-employed agents billing a fee fixed through negotiation between the provincial medical association and the provinces. The key to understanding the egalitarian nature of the Canadian health care system is that, while some providers are for-profit, they almost all bill the publicly funded insurance plan so that patients are not required to pay anything when they receive care. User fees, copays, and deductibles are banned for services covered under the public plan. While 70 percent of the total cost of health care is covered by public insurance, there has always been a strong role for private out-of-pocket and employer-based insurance for services not covered publicly, such as podiatry, dentistry, and nonsurgical vision care. All told, about 30 percent of total health care costs in Canada are covered privately. Although combining public and private funding is in line with practice in other OECD countries, the Canadian strategy is unique. In most countries, public funding is for standard level of care, and private funding for a preferential level of care for the same service. Canada alone makes public funding available for some services and relies on private funding for others. In addition, however, both patients and doctors are able to opt out of the public system, although the conditions for doing so vary from province to province. In most provinces, doctors cannot be paid privately for services for which they also bill the public system. Some provinces prohibit the sale of private insurance for services that are covered by the public system--a restriction intended to protect the integrity of the public insurance system. As health care has expanded in scope, and as much of the delivery of care has shifted to home and community, pressures have built on cost and access, just as they have across the entire developed world. Canada has launched various provincial and federal initiatives to reform the system, adapt it to contemporary practice, and ensure its sustainability. The most recent federal initiative was the Commission on the Future of Health Care in Canada, known as the Romanow Report after its author, the former premier of Saskatchewan, Roy Romanow. …

The Massachusetts Health Plan: Public Insurance for the Poor, Private Insurance for the Wealthy, Self-Insurance for the Rest?

The Massachusetts Law for Providing Access to Affordable, Quality, Accountable Health Care represents one of the most ambitious attempts yet by one of the United States to reform its health care financing system.' It is useful, however, to situate this reform in the context of a larger discussion of health care financing reform that has been underway for some time. For at least the past quarter century, three visions of how to reform health care finance in the United States have competed for the allegiance of policy makers. The first of these visions calls for expansion of public insurance to achieve universal coverage, or something very close to it. 2 This model is often characterized as a single-payer model, although universal public coverage does not, of course, require a single payer. Many of the world's social insurance programs in fact have multiple payers.3 One way to achieve universal coverage through public insurance would be to expand the Medicare program to cover the entire population. Universal coverage, however, could also be achieved

A Comparison of the USA Health Care Effort with other OECD Countries

We use a sample of OECD countries in order to better understand why the US health care expenditure as a percentage of its Gross Domestic Product (health care effort) is so far above any other. To this end we employ a descriptive cross-country methodology based partially on econometric estimations, synthetic indicators and the Lerner's formula of market power, that allows us to dismiss as explanatory variables all those factors that were not differential across the sample. We advance the exploratory hypothesis that the availability of a universal public health coverage would increase the price elasticity of demand and thus would reduce the control of prices by the suppliers.

Public health insurance: the collective purchase of individual care

Health insurance does not insure health. It reimburses the costs of health care, and enables potential users of care to pool their risks. But public health insurance is qualitatively different from private, in that risk pooling is not its only or even its primary function. Public systems also redistribute, deliberately, from low to high risk individuals. Perhaps even more important, public insurance is a mechanism for the collective purchase of care. It enables buyers, through their political representatives, to bargain with providers over both price and quantity of care, and thus to control overall system costs, in a way that individual patients cannot. This paper contrasts the experience of public insurance in Canada with private coverage in the U.S., to show how universal public coverage, used as a ‘collective purchasing agency’, has led to both better coverage and lower costs. Current policy changes in the U.S., described as ‘competitive’, are in fact efforts to create private collective purchasing agencies to bargain with providers on behalf of individuals. Yet economic analysis has been largely incapable of grasping this process, continuing to treat public and private insurance alike as simply reductions in the price of care faced by individual consumers, and thus generating erroneous predictions and analyses of the behaviour of public systems. It has encouraged a fruitless concern with the prices faced by patients, while ignoring the overwhelming significance of the structure and objectives of the insurer. This failure may be traceable to fundamental flaws in the concept of a transactor in economic theory.