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PubMed2003

Proposal of the Physicians' Working Group for Single-Payer National Health Insurance.

The United States spends more than twice as much on health care as the average of other developed nations, all of which boast universal coverage. Yet more than 41 million Americans have no health insurance. Many more are underinsured. Confronted by the rising costs and capabilities of modern medicine, other nations have chosen national health insurance (NHI). The United States alone treats health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In this market-driven system, insurers and providers compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs that, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar. We endorse a fundamental change in US health care--the creation of an NHI program. Such a program, which in essence would be an expanded and improved version of traditional Medicare, would cover every American for all necessary medical care. An NHI program would save at least 200 billion dollars annually (more than enough to cover all of the uninsured) by eliminating the high overhead and profits of the private, investor-owned insurance industry and reducing spending for marketing and other satellite services. Physicians and hospitals would be freed from the concomitant burdens and expenses of paperwork created by having to deal with multiple insurers with different rules, often designed to avoid payment. National health insurance would make it possible to set and enforce overall spending limits for the health care system, slowing cost growth over the long run. An NHI program is the only affordable option for universal, comprehensive coverage.

Cost Control↗

PubMed1997

The potential role of risk-equalization mechanisms in health insurance: the case of South Africa.

International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.

Actuarial Analysis↗

PubMed2001

Reinsurance of health insurance for the informal sector.

Deficient financing of health services in low-income countries and the absence of universal insurance coverage leaves most of the informal sector in medical indigence, because people cannot assume the financial consequences of illness. The role of communities in solving this problem has been recognized, and many initiatives are under way. However, community financing is rarely structured as health insurance. Communities that pool risks (or offer insurance) have been described as micro-insurance units. The sources of their financial instability and the options for stabilization are explained. Field data from Uganda and the Philippines, as well as simulated situations, are used to examine the arguments. The article focuses on risk transfer from micro-insurance units to reinsurance. The main insight of the study is that when the financial results of micro-insurance units can be estimated, they can enter reinsurance treaties and be stabilized from the first year. The second insight is that the reinsurance pool may require several years of operation before reaching cost neutrality.

Community Health Planning↗

PubMed2001

Travel insurance claims made by travellers from Australia for dental conditions.

BACKGROUND: Little is known about dental problems suffered by travellers abroad. This study was designed to investigate travel insurance claims made by travellers from Australia for dental conditions, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when dental treatment was sought during travel, use of emergency assistance, type of treatment, and claim outcome, including cost. METHODS: 1,289 claims submitted during 1998-99 to a major Australian-based travel insurance company were examined for dental claims. RESULTS: 104 (8.1%) claims for dental conditions were submitted, of which 45 (43.3%) were made by male and 59 (56.7%) by female travellers. The majority of claimants were in the 60 years and over age group 54 (52.4%). Dental conditions reported required conservative (mostly fillings) 31 (29.8%), endodontic (mostly root canal treatment) 19 (18.3%), prosthodontic 27 (26.0%), periodontal 8 (7.7%), oral and maxillofacial surgery 2 (1.9%) and other or multiple 17 (16.3%) treatments. Use of the travel insurance emergency telephone service for dental conditions was reported in only seven cases (6.7%). Almost two-thirds 64 (61.5%) of claims were accepted. Claims for prosthodontic treatment were significantly less likely to be accepted. The majority of dental conditions did not require further medical investigations, 74 (71.2%). The mean cost of payouts to claims was AU$238.06 for males and AU$182.58 for females. Claims for endodontic and prosthodontic treatment were significantly more expensive than other types of treatment. CONCLUSIONS: Claims for dental conditions represent a noteworthy proportion of travel insurance claims made by Australian travellers abroad. More than three-quarters of claims for dental conditions were for conservative, endodontic or prosthodontic treatment. Travellers should be advised to have a dental check-up before departure overseas and to take care with pre-existing dental conditions, which may not be able to be claimed on travel insurance.

Adult↗

PubMed1977

Private health insurance in 1975: coverage, enrollment, and financial experience.

More improvement in the scope than in the quality of private health insurance coverage took place during 1975. Four-fifths of the population under age 65 was covered for hospital and surgical care, and nearly that proportion was protected against the costs of physicians' in-hospital visits, X-ray and laboratory examinations, and prescribed out-of-hospital drugs. The $33.6 billion in premiums paid by consumers resulted in the return of only $28.9 billion in benefits, which covered just 44% of their total personal health care expenditures. Major-medical insurance, held by an estimated 43% of the population, helped to overcome some of the deficiencies of private insurance--dollar limitations on health care services, ceilings on the duration of hospital stays, and exclusions for some types of care. It also provided economic protection against catastrophic expenses. Premiums and subscription income rose faster than benefits as private insurers attempted to keep their coverage in line with rising health care costs. The overall underwriting gain was due largely to a $952.4 million gain in group business by the insurance companies.

Adult↗

PubMedDate not supplied

A description of outpatient drug use in rural China: evidence of differences due to insurance coverage.

This paper describes the effects of health financing systems (insurance) on outpatient drug use in rural China. 1320 outpatients were interviewed (exit interview) in the randomly selected county, township and village health care facilities in five counties in three provinces of central China. The interview was face to face. Questions were asked by a trained interviewer and were answered by patient him/herself. The main finding was that health insurance appeared to influence drug use in outpatient services. The average number of drugs per visit was 2.56 and drug expenditures per visit was 16.9 yuan. Between insured and uninsured (out-of-pocket) groups, there were significant differences in the number of drugs and drug expenditures per visit. The insured had a lower number of drugs and a higher drug expenditure per visit than the uninsured, implying the use of more expensive drugs per visit than the uninsured. There were also significant differences in the number of drugs and drug expenditures per visit between the types of insurance. One third of the drugs were anti-infectives, most of which were penicillin, gentamycin, and sulfonamides. The results imply that uninsured patients do not receive the same care as the insured do even if they have the same needs. The fee-for-service financing for hospitals and health insurance have changed health providers' and consumers' behaviour and resulted in the increase of medical expenditure.

China↗

PubMed2005

Perceptions of insurance coverage for screening mammography among women in need of screening.

BACKGROUND: Breast carcinoma remains a significant health problem in the U.S., especially among underserved populations. Although screening mammography is recommended for early detection, in 2002, approximately 25% of women age > 40 years had not had a mammogram within the past 2 years. The current study examined perceptions of insurance coverage and cost as barriers to screening mammography within an underserved, predominantly low-income population of women in need of a mammogram. METHODS: Between 1998 and 2002, face-to-face interviews were conducted with 897 women age > or = 40 years. All women were part of a randomized, controlled study evaluating a health education intervention designed to improve mammography screening. They were asked questions at baseline about cost and insurance coverage as barriers to mammography screening. Women's reports of their level of insurance coverage for mammography were compared with actual coverage by their insurance type to determine the accuracy of their perception of insurance coverage for mammography. The relation between perception of insurance coverage and the barrier of cost was investigated. RESULTS: Greater than half of the women who needed a mammogram identified cost as a barrier to mammography; however, 40% of these women had an inappropriate perception of their insurance coverage. Underestimating or not knowing the level of mammography coverage was strongly associated with reporting cost-related difficulty (odds ratio [OR] = 4.57, 95% confidence interval [95% CI], 1.95-10.70 for the underestimate category; OR = 4.42, 95% CI, 1.80-10.88 for the don't know category), regardless of true coverage levels. CONCLUSIONS: Providing women with information regarding their actual coverage for mammograms may reduce the impact of cost as a barrier to screening mammography.

Adult↗

PubMed2001

Health insurance and health services utilization in Ireland.

The numbers buying private health insurance in Ireland have continued to grow, despite a broadening in entitlement to public care. About 40% of the population now have insurance, although everyone has entitlement to public hospital care. In this paper, we examine in detail the growth in insurance coverage and the factors underlying the demand for insurance. Attitudinal responses reveal the importance of perceptions about waiting times for public care, as well as some concerns about the quality of that care. Individual characteristics, such as education, age, gender, marital status, family composition and income all influence the probability of purchasing private insurance. We also examine the relationship between insurance and utilization of hospital in-patient services. The positive effect of private insurance appears less than that of entitlement to full free health care from the state, although the latter is means-tested, and may partly represent health status.

Attitude to Health↗

PubMed1994

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study.

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1999

Experiences of families that applied for government-sponsored child health insurance: report of a follow-up study in New York City.

CONTEXT: This study followed up on a summer 1997 advocacy project by the Children's Defense Fund--New York, which assisted families in New York City in enrolling their children in government-sponsored health insurance programs (Medicaid and Child Health Plus). OBJECTIVE: To determine how many participants from the 1997 project acquired insurance, to document their experiences during the application process, and to solicit their suggestions on improving the application process. DESIGN: Guided telephone interviews in summer 1998 with all families from the 1997 program that could be located. PARTICIPANTS: Fifty-five families from New York City that, with the assistance of the Children's Defense Fund--New York, applied for Medicaid or Child Health Plus in summer 1997. RESULTS: Of the 55 families, 46 acquired insurance for their children at some point during the year. A number of families changed insurance status several times during the year, and some insured originally through government-sponsored programs later acquired private insurance. The families experienced many difficulties in dealing with the health insurance bureaucracies. CONCLUSION: The process of applying for Medicaid and Child Health Plus is more difficult and time consuming than may be realized, and many families may go through the application repeatedly. Current efforts to decrease the number of uninsured children in the US must take into account the bureaucratic barriers faced by families that are eligible for these programs and must consider ways to make the application process less formidable.

Child↗

PubMed1987

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.

Canada↗

PubMedDate not supplied

Insurance coverage and financial burden for families of children with special health care needs.

OBJECTIVE: To examine the role of insurance coverage in protecting families of children with special health care needs (CSHCN) from the financial burden associated with care. METHODS: Data from the 2001 National Survey of Children with Special Health Care Needs were analyzed. We built 2 multivariate regression models by using "work loss/cut back" and "experiencing financial problems" as the dependent variables, and insurance status as the primary independent variable of interest while adjusting for income, race/ethnicity, functional limitation/severity, and other sociodemographic predictors. RESULTS: Approximately 29.9% of CSHCN live in families where their condition led parents to report cutting back on work or stopping work completely. Families of 20.9% of CSHCN reported experiencing financial difficulties due to the child's condition. Insurance coverage significantly reduced the likelihood of financial problems for families at every income level. The proportion of families experiencing financial problems was reduced from 35.7% to 23.0% for the poor and 44.9% to 24.5% for low-income families with continuous insurance coverage (P < .01 for both comparisons). Similarly, the proportion of parents having to cut back or stop work was reduced from 42.8% to 35.9% for the poor (P < .05) and 43.5% to 33.9% for low-income families (P < .01). CONCLUSIONS: Continuous health insurance coverage provides protection from financial burden and hardship for families of CSHCN in all income groups. This evidence is supportive of policies designed to promote universal coverage for CSHCN. However, many poor and low-income families continue to experience work loss and financial problems despite insurance coverage. Hence, health insurance should not be viewed as a solution in itself, but instead as one element of a comprehensive strategy to provide financial safety for families with CSHCN.

Adolescent↗

PubMed2004

The impact of urban health insurance reform on hospital charges: a case study from two cities in China.

During the transition from a centrally planned to a market economy, China's urban health insurance system is being reformed. The control of the rapidly increasing hospital expenses will be a major determinant of the success of the reform. This study aims to examine the impact of the reform on hospital charges by comparing changes between two cities with different insurance systems and identifying determinants for those changes. Data was collected from six hospitals in two cities, one city implemented an urban health insurance reform, the other did not. Acute appendicitis and normal childbirth were used as tracers for calculating hospital charges. Methods included the retrospective review of medical records, interviews with health policy makers and hospital staff, focus group discussions, and the review of hospital and health insurance documents. The results showed that hospital charges per case of acute appendicitis and childbirth increased 101 and 94%, respectively, in the city without reform, and 41 and 34% in the city with reform, between 1995 and 1999. Health insurance arrangements and average LOS were the major determinants for hospital charges. Drugs and non-pharmacological treatments were the major service categories for charge containment. The combined measures of a single insurer, selective contracts, a new payment system, and use of an essential drug list, is regarded as the key features for an effective hospital charge control, and would appear to be successful measures for hospital expenditure containment within health insurance reform.

Acute Disease↗

PubMed2005

The impact of filipino micro health-insurance units on income-related equality of access to healthcare.

BACKGROUND: This study aims to assess the impact of being insured by micro-health insurance units (MIUs) on equality of access to health care among groups with inequitable income distribution. We measure equality by relating income with access to healthcare. The analysis is based on a household survey conducted in five regions in the Philippines in 2002. METHODS: We generated concentration curves and indices (CI) for insured and uninsured households (150 for each cohort in each region). We also elaborated a method to retain the relative income rank of households when data were aggregated across regions, as the regions had quite different nominal income levels. RESULTS: We found a significant effect of household income on access to hospitalizations among the uninsured households (a positive CI), but no such effect among the insured households (CI close to zero). As regards professionally attended deliveries, an increased tendency of poorer households to deliver at home (CI slightly negative) and a lower rate of deliveries in hospital (CI slightly positive and statistically significant) were reported by both uninsured and insured households. Access to consultations was unrelated to income among the insured (CI close to 0), but negatively correlated with income among the uninsured (a positive and significant CI). CONCLUSION: We conclude that MIUs in Philippines improve income-related equality of access to hospitalization and medical consultation in cases of illness. The findings of this study strengthen a claim for government support for the operation of MIUs as successful (albeit micro) suppliers of health insurance.

Cross-Sectional Studies↗

PubMed2003

Self-selection and moral hazard in Chilean health insurance.

We study the existence of self-selection and moral hazard in the Chilean health insurance industry. Dependent workers must purchase health insurance either from one public or several private insurance providers. For them, we analyze the relationship between health care services utilization and the choice of either private or public insurance. In the case of independent workers, where there is no mandate, we analyze the relationship between utilization and the decision to voluntarily purchase health insurance. The results show self-selection against insurance companies for independent workers, and against public insurance for dependent workers. Moral hazard is negligible in the case of hospitalization, but for medical visits, it is quantitatively important.

Adolescent↗

PubMed2004

Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times.

BACKGROUND: In 2002, the Centers for Medicare and Medicaid Services implemented a 5.4% cut in Medicare physician payments, and further reductions are expected in 2004. These cuts have raised concerns that beneficiaries of Medicare will face significant problems obtaining needed physician services. Although there is clear evidence of poor access to care for patients with Medicaid, data measuring access to physicians for patients with Medicare are sparse. Given current lengthy appointment wait times resulting from a relative shortage of dermatologists, we hypothesized that patients with lower-paying coverage might be more likely to experience appointment refusals, longer wait times, or both. METHODS: Because the ability to obtain timely appointments is a key measure of access, we surveyed dermatologists in 12 medium- and large-sized communities to assess wait times for routine new-patient visits. Dermatologists in these areas (or their staff) received a telephone call asking about the next available appointment for a hypothetical patient with a randomly assigned insurance type (ie, Medicaid, Medicare, or fee-for-service private insurance). RESULTS: Of 631 physicians (or staff members) contacted, 612 (97%) agreed to participate. Overall acceptance rates were similar for patients with Medicare (85%) and private insurance (87%), but were much lower for those with Medicaid (32%). Among patients whose insurance was accepted, mean wait times for patients with Medicare and private insurance were 37 days, but patients with Medicaid experienced significant queuing (50 days). There was dramatic geographic variation. In areas where Medicare payments are low relative to commercial payers, there were increases in Medicare rejection rates and wait times. In communities with relatively low Medicaid payment rates, patients with Medicaid faced higher rejection rates and longer wait times. There were also longer overall wait times for female dermatologists and in communities where the concentration of dermatologists was low. CONCLUSION: Although overall access to dermatologists appears comparable for patients with Medicare and private insurance, some access limitations in "hot spots" where Medicare payments are low relative to commercial insurers suggest that patients in these areas may be most sensitive to further payment reductions. Significant access problems for beneficiaries of Medicaid, particularly in areas where Medicaid payments are relatively low, may be a harbinger of the potential consequences of sustained declines in Medicare physician reimbursement.

Appointments and Schedules↗

PubMedDate not supplied

[The role of private insurance in public health care systems: conceptual framework and policies].

The structure of the health care system ans specifically the type and amount of the public and private mix is not a closed issue. This article provides and update of the arguments that justify public intervention in health, and emphasizes the failures of the private insurance market that call for mandatory universal health insurance, although that does not necessarily mean that state has to be the insurer. The relationship between both sectors and the variables determining the relative level of expenditure in both are also analyzed. Following the literature on the public provision of private goods, the level of expenditure in a democracy is seen to depend on the preferences of the median voter, where private insurance usually tops up public insurance. The key variable determining the decision to buy additional private insurance is the difference in quality, defined broadly, between both sectors. Concerning policies, the appropriateness of fiscal incentives to promote the uptake of private insurance is discussed and it is concluded that there is no clear evidence of its suitability. Also, it is argued that models in which the public and private sectors appear totally segregated or totally integrated are preferable to intermediate models, in which both sectors appear combined. Medical coverage bought by an informed agent in exchange for a capitation payment seems a better way to integrate the private sector than through a system of vouchers.

Delivery of Health Care↗

PubMed2004

Insurance and the utilization of medical services.

Most data sets indicate a positive correlation between having health insurance and utilizing health care services. Yet the direction of causality is not at all clear. If we observe a positive correlation between the utilization of health care services and insurance status, we do not know if this is because people who anticipate poor health buy more insurance (or take jobs with generous medical coverage), or because insurance lowers the cost of health care, increasing the quantity demanded. While a few attempts have been made to implement an instrumental variables (IV) strategy to deal with endogeneity, the instruments chosen have not been entirely convincing. In this paper we revisit the IV estimation of the reduced form relationships between insurance and health care utilization taking advantage of what we argue is a good instrument-the individual's self-employment status. Our main finding is that a positive and statistically significant effect of insurance continues to obtain even after instrumenting. Indeed, instrumental variables estimates of the impact of insurance on utilization of a variety of health care services are larger than their non-instrumented counterparts. The validity of this exercise depends on the extent to which self-employment status is a suitable instrument. To argue this case, we analyze panel data on transitions from wage-earning into self-employment and show that individuals who select into self-employment do not differ systematically from those who remain wage-earners with respect to either the utilization of health care or health status. While this finding does not prove that self-employment status is an appropriate instrument, it is encouraging that there appear to be no underlying differences that might lead to self-employment per se affecting health services utilization.

Adult↗