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1.  Effect of private insurance incentive policy reforms on trends in coronary revascularisation procedures in the private and public health sectors in Western Australia: a cohort study 
The Australian federal government introduced private health insurance incentive policy reforms in 2000 that increased the uptake of private health insurance in Australia. There is currently a lack of evidence on the effect of the policy reforms on access to cardiovascular interventions in public and private hospitals in Australia. The aim was to investigate whether the increased private health insurance uptake influenced trends in emergency and elective coronary artery revascularisation procedures (CARPs) for private and public patients.
We included 34,423 incident CARPs from Western Australia during 1995-2008 in this study. Rates of emergency and elective CARPs were stratified for publicly and privately funded patients. The average annual percent change (AAPC) in trend was calculated before and after 2000 using joinpoint regression.
The rate of emergency CARPs, which were predominantly percutaneous coronary interventions (PCIs) with stenting, increased throughout the study period for both public and private patients (AAPC=12.9%, 95% CI=5.0,22.0 and 14.1%, 95% CI=9.8,18.6, respectively) with no significant difference in trends before and after policy implementation. The rate of elective PCIs with stenting from 2000 onwards remained relatively stable for public patients (AAPC=−6.0, 95% C= −16.9,6.4), but increased by 4.1% on average annually (95% CI=1.8,6.3) for private patients (pdifference=0.04 between groups). This rate increase for private patients was only seen in people aged over 65 years and people residing in high socioeconomic areas.
The private health insurance incentive policy reforms are a likely contributing factor in the shift in 2000 from public to privately-funded elective PCIs with stenting. These reforms as well as the increasing number of private hospitals may have been successful in increasing the availability of publicly-funded beds since 2000.
PMCID: PMC3729369  PMID: 23870450
Health insurance; Coronary artery disease; Revascularisation procedures; Health policy
2.  Relation between private health insurance and high rates of caesarean section in Chile: qualitative and quantitative study 
BMJ : British Medical Journal  2000;321(7275):1501-1505.
To explore the circumstances and factors that explain the association between private health insurance cover and a high rate of caesarean sections in Chile.
Qualitative analysis of audiotaped in-depth interviews with obstetricians and pregnant women; quantitative analysis of data from face to face semistructured interview survey conducted postnatally (with women who had given birth in the previous 24-72 hours), and of a review of medical notes at a public hospital, a university hospital, and a private clinic.
Santiago, Chile.
Qualitative arm: 22 obstetricians, 21 pregnant women; quantitative arm: 540 postnatal women.
Main outcome measures
Rates of caesarean section in different types of institutions; consultants' views on private practice; work patterns in private practice; women's reasons for choosing private care; women's preferences on method of delivery.
Private health insurance cover requires the primary maternity care provider to be an obstetrician. In the postnatal survey, women with private obstetricians showed consistently higher rates of caesarean section (range 57-83%) than those cared for by midwives or doctors on duty in public or university hospitals (range 27-28%). Only a minority of women receiving private care reported that they had wanted this method of delivery (range 6-32%). With the diversification in the healthcare market, most obstetricians now have demanding peripatetic work schedules. Private maternity patients are a lucrative source of income. The obstetrician is committed to attend these private births in person, and the “programming” (or scheduling) of births is a common time management strategy. The rate of elective caesarean sections was 30-68% in women with private obstetricians and 12-14% in women not attended by private obstetricians.
Policies on healthcare financing can influence maternity care management and outcomes in unforeseen ways. The prevailing business ethos in health care encourages such pragmatism among those doctors who do not have a moral objection to non-medical caesarean section.
PMCID: PMC27552  PMID: 11118176
3.  The impact of CHIP premium increases on insurance outcomes among CHIP eligible children 
Within the United States, public insurance premiums are used both to discourage private health policy holders from dropping coverage and to reduce state budget costs. Prior research suggests that the odds of having private coverage and being uninsured increase with increases in public insurance premiums. The aim of this paper is to test effects of Children’s Health Insurance Program (CHIP) premium increases on public insurance, private insurance, and uninsurance rates.
The fact that families just below and above a state-specific income cut-off are likely very similar in terms of observable and unobservable characteristics except the premium contribution provides a natural experiment for estimating the effect of premium increases. Using 2003 Medical Expenditure Panel Survey (MEPS) merged with CHIP premiums, we compare health insurance outcomes for CHIP eligible children as of January 2003 in states with a two-tier premium structure using a cross-sectional regression discontinuity methodology. We use difference-in-differences analysis to compare longitudinal insurance outcomes by December 2003.
Higher CHIP premiums are associated with higher likelihood of private insurance. Disenrollment from CHIP in response to premium increases over time does not increase the uninsurance rate.
When faced with higher CHIP premiums, private health insurance may be a preferable alternative for CHIP eligible families with higher incomes. Therefore, competition in the insurance exchanges being formed under the Affordable Care Act could enhance choice.
PMCID: PMC3946024  PMID: 24589197
Health insurance; Premium; Health care reform
4.  Transitions from Private to Public Health Coverage among Children: Estimating Effects on Out-of-Pocket Medical Costs and Health Insurance Premium Costs 
Health Services Research  2011;46(3):840-858.
To assess the effects of transitions from private to public health insurance by children on out-of-pocket medical expenditures and health insurance premium costs.
Data Sources
Data are drawn from the 1996 and 2001 panels of the Survey of Income and Program Participation. We construct a nationally representative, longitudinal sample of children, ages 0–18, and their families for the period 1998–2003, a period in which states raised public health insurance eligibility rates for children.
Study Design
We exploit the Survey of Income and Program Participation's longitudinal design to identify children in our sample who transition from private to public health insurance. We then use a bootstrapped instrumental variable approach to estimate the effects of these transitions on out-of-pocket expenditures and health insurance premium costs.
Principal Findings
Children who transition from private to public coverage are relatively low-income, are disproportionately likely to live in single-mother households, and are more likely to be Black or of Hispanic origin. Child health status is highly predictive of transitions. We estimate that these transitions provide a cash-equivalent transfer of nearly U.S.$1,500 annually for families in the form of reduced out-of-pocket and health insurance premium costs.
Transitions from private to public health coverage by children can bring important social benefits to vulnerable families. This suggests that instead of being a net societal cost, such transitions may provide an important social benefit.
PMCID: PMC3097405  PMID: 21306364
Medicaid; State Children's Health Insurance Program; health insurance; crowd-out; medical expenses; Survey of Income and Program Participation
5.  Low-Income Fathers’ Access to Health Insurance 
We examine the prevalence and correlates of health insurance status among low-income fathers, a group not previously studied in this context. In a sample of 1,653 low-income fathers from a national urban birth cohort study, 29% had private, 14% had public, and 58% had no insurance. Privately insured fathers had greater levels of human capital than did publicly insured fathers; the latter more closely resembled uninsured fathers than they did privately insured fathers. Multinomial logistic regression analysis indicates that being older, being employed, being married, and having a job offering health insurance all increase the likelihood of having private (vs. no) insurance, and that being disabled and married to or cohabiting with the child’s mother increase the likelihood of having public (vs. no) insurance. Public policy should focus on increasing access to health insurance among low-income men, which may improve their health, productivity, and ability to support themselves and their children.
PMCID: PMC2659739  PMID: 19202254
Health insurance; low-income fathers; physical health; men’s health; mental health
6.  Is expanding Medicare coverage cost-effective? 
Proposals to expand Medicare coverage tend to be expensive, but the value of services purchased is not known. This study evaluates the efficiency of the average private supplemental insurance plan for Medicare recipients.
Data from the National Health Interview Survey, the National Death Index, and the Medical Expenditure Panel Survey were analyzed to estimate the costs, changes in life expectancy, and health-related quality of life gains associated with providing private supplemental insurance coverage for Medicare beneficiaries. Model inputs included socio-demographic, health, and health behavior characteristics.
Parameter estimates from regression models were used to predict quality-adjusted life years (QALYs) and costs associated with private supplemental insurance relative to Medicare only. Markov decision analysis modeling was then employed to calculate incremental cost-effectiveness ratios.
Medicare supplemental insurance is associated with increased health care utilization, but the additional costs associated with this utilization are offset by gains in quality-adjusted life expectancy. The incremental cost-effectiveness of private supplemental insurance is approximately $24,000 per QALY gained relative to Medicare alone.
Supplemental insurance for Medicare beneficiaries is a good value, with an incremental cost-effectiveness ratio comparable to medical interventions commonly deemed worthwhile.
PMCID: PMC1079833  PMID: 15766380
7.  Health insurance coverage, medical expenditure and coping strategy: evidence from Taiwan 
The health insurance system in Taiwan is comprised of public health insurance and private health insurance. The public health insurance, called “universal national health insurance” (NHI), was first established in 1995 and amended in 2011. The goal of this study is to provide an updated description of several important aspects of health insurance in Taiwan. Of special interest are household insurance coverage, medical expenditures (both gross and out-of-pocket), and coping strategies.
Data was collected via a phone call survey conducted in August and September of 2011. A household was the unit for survey and data analysis. A total of 2,424 households covering all major counties and cities in Taiwan were surveyed.
The survey revealed that households with smaller sizes and higher incomes were more likely to have higher coverage of public and private health insurance. In addition, households with the presence of chronic diseases were more likely to have both types of insurance. Analysis of both gross and out-of-pocket medical expenditure was conducted. It was suggested that health insurance could not fully remove the financial burden caused by illness. The presence of chronic disease and inpatient treatment were significantly associated with higher gross and out-of-pocket medical expenditure. In addition, the presence of inpatient treatment was significantly associated with extremely high medical expenditure. Regional differences were also observed, with households in the northern, central, and southern regions having less gross medical expenditures than those on the offshore islands. Households with the presence of inpatient treatment were more likely to cope with medical expenditure using means other than salaries.
Despite the considerable achievements of the health insurance system in Taiwan, there is still room for improvement. This study investigated coverage, cost, and coping strategies and may be informative to stakeholders of both basic and commercial health insurance.
PMCID: PMC3519736  PMID: 23206690
Taiwan; Health insurance coverage; Medical expenditure; Coping strategy
8.  The effectiveness of consumer choice in the Medicare supplemental health insurance market. 
Health Services Research  1991;26(2):223-246.
This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.
PMCID: PMC1069821  PMID: 2061057
9.  Paying for long-term care. 
Western Journal of Medicine  1994;160(1):64-69.
Everyone agrees that insurance for long-term care is inadequate in the United States. Disagreement exists, however, on whether such insurance should be provided through the private or public sector. Private insurance generally uses the experience-rating principle that persons with higher risk of illness are charged higher premiums. For private insurance for long-term care, this principle creates a dilemma. Most policies will be purchased by the elderly; yet, because the elderly have a high risk of needing long-term care, only about 20% of them can afford the cost of premiums. A public-private partnership by which the government partially subsidizes private long-term-care insurance is unlikely to resolve this dilemma. Only a social insurance program for long-term care can provide universal, affordable, and equitable coverage.
PMCID: PMC1022265  PMID: 8128712
This article bridges the literatures on the economic consequences of divorce for women with that on marital transitions and health by focusing on women's health insurance. Using a monthly calendar of marital status and health insurance coverage from 1,442 women in the Survey of Income and Program Participation, we examine how women's health insurance changes after divorce. Our estimates suggest that roughly 115,000 American women lose private health insurance annually in the months following divorce and that roughly 65,000 of these women become uninsured. The loss of insurance coverage we observe is not just a short-term disruption. Women's rates of insurance coverage remain depressed for more than two years after divorce. Insurance loss may compound the economic losses women experience after divorce, and contribute to as well as compound previously documented health declines following divorce.
PMCID: PMC3511592  PMID: 23147653
11.  Insurance coverage and access: implications for health policy. 
Health Services Research  1978;13(4):369-377.
Data are presented from a recent survey of the United States population comparing the characteristics and levels of access to medical care of persons under 65 years who have group or individual private health insurance, public health insurance, or no third-party coverage. The uninsured group appeared to fall between the privately insured and publicly insured groups on measures of social and economic status. Persons with publicly subsidized forms of insurance coverage utilized services at the highest rates, and uninsured persons used them at the lowest rates. Neither of these groups was as satisfied with the convenience or the quality of the care it obtained as the privately insured group. Implications of these findings for national health insurance and other health policy initiatives are discussed.
PMCID: PMC1072079  PMID: 738895
12.  Health Insurance and Length of Stay for Children Hospitalized With Community-Acquired Pneumonia 
Disparities in patterns of care and outcomes for ambulatory-care sensitive childhood conditions such as community-acquired pneumonia (CAP) persist. However, the influence of insurance status on length of stay (LOS) for children hospitalized with CAP remains unexplored.
Secondary analysis of children (<18 years) hospitalized with CAP sampled in the Kids’ Inpatient Database (KID) for years 1997, 2000, 2003, and 2006. Insurance status (private, public, uninsured) was based on claims data. Hospital LOS was calculated in days. Taking into account the complex sampling design, negative binomial regression models produced adjusted estimates of incidence rate ratios (IRR) for hospital LOS for children by insurance status.
There was little variation in the categories of insurance status of children hospitalized with CAP between 1997 and 2006, with at least 40% privately insured, at least 40% publicly insured, and at least 5% uninsured in each sampled year. In all years, publicly insured children had a significantly longer hospital stay than privately insured children, and uninsured children had a significantly shorter hospital stay than privately insured children. These observed differences persisted after multivariate adjustment.
Differences in LOS between uninsured, publicly insured, and privately insured children with CAP raise concerns about potential differences in hospital discharge practices related to insurance status and type. As healthcare reform is implemented, policy makers should strengthen efforts to reduce these disparities in order to achieve health for the population.
PMCID: PMC3877930  PMID: 21972214
13.  Cost, Coverage, and Comparative Effectiveness Research: The Critical Issues for Oncology 
Journal of Clinical Oncology  2012;30(34):4275-4281.
A new national initiative in comparative effectiveness research (CER) is part of a broad and long-term evolution toward greater reliance on scientific evidence in clinical practice and medical policy. But CER has been controversial because of its high profile in the health care reform effort, its instantiation in a prominent new national research institute, and lingering concerns that the ultimate goal of CER is to empower the government and private insurers to reduce health care costs by restricting access to expensive new medical tests and treatments. This article presents an analysis of the policy development behind CER and focuses on its potential impact on insurance coverage and payment for oncology services. By itself, CER will not solve the tension that exists between the goal of innovative, personalized care and the eroding affordability of cancer treatment in the United States. But CER does offer an important opportunity for progress. Oncologists have taken important first steps in acknowledging their responsibility for addressing cost issues; as a professional society, they should now move forward to assume leadership in the effort to integrate clinical evidence with considerations of cost effectiveness to guide clinical practice and insurer policies.
PMCID: PMC3504329  PMID: 23071229
14.  Medical Home Disparities for Children by Insurance Type and State of Residence 
Maternal and child health journal  2012;16(Suppl 1):S178-S187.
The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.
PMCID: PMC3444255  PMID: 22453328
Medical home; Public insurance; Disparities; Health policy; National Survey of Children’s Health
15.  Who Can't Pay for Health Care? 
In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care.
To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.
Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.
U.S. adults age 18 and older (N=6,722).
Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.
The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.
Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.
PMCID: PMC1490134  PMID: 15987324
health care affordability; insurance coverage; low-income populations; functional impairment
16.  Health insurance system and payments provided to patients for the management of severe acute pancreatitis in Japan 
The health insurance system in Japan is based upon the Universal Medical Care Insurance System, which gives all citizens the right to join an insurance scheme of their own choice, as guaranteed by the provisions of Article 25 of the Constitution of Japan, which states: “All people shall have the right to maintain the minimum standards of wholesome and cultured living.” The health care system in Japan includes national medical insurance, nursing care for the elderly, and government payments for the treatment of intractable diseases. Medical insurance provisions are handled by Employee’s Health Insurance (Social Insurance), which mainly covers employees of private companies and their families, and by National Health Insurance, which provides for the needs of self-employed people. Both schemes have their own medical care service programs for retired persons and their families. The health care system for the elderly covers people 75 years of age and over and bedridden people 65 years of age and over. There is also a system under which the government pays all or part of medical expenses, and/or pays medical expenses not covered by insurance. This is referred to collectively as the “medical expenses payment system” and includes the provision of medical assistance for specified intractable diseases. Because severe acute pancreatitis has a high mortality rate, it is specified as an intractable disease. In order to lower the mortality rate of various diseases, including severe acute pancreatitis, the specification system has been adopted by the government. The cost of treatment for severe acute pancreatitis is paid in full by the government from the date the application is made for a certificate verifying that the patient has an intractable disease.
PMCID: PMC2779366  PMID: 16463206
Medical care system; Acute pancreatitis; Japan’s health insurance system; Government payment system
17.  The provision of chiropractic, physiotherapy and osteopathic services within the Australian private health-care system: a report of recent trends 
Chiropractors, physiotherapists, and osteopaths receive training in the diagnosis and management of musculoskeletal conditions. As a result there is considerable overlap in the types of conditions that are encountered clinically by these practitioners. In Australia, the majority of benefits paid for these services come from the private sector. The purpose of this article is to quantify and describe the development in service utilization and the cost of benefits paid to users of these healthcare services by private health insurers. An exploration of the factors that may have influenced the observed trends is also presented.
A review of data from the Australian Bureau of Statistics, Australian Health Practitioner Regulation Agency, and the Australian Government Private Health Insurance Administration Council was conducted. An analysis of chiropractic, physiotherapy and osteopathic service utilisation and cost of service utilisation trend was performed along with the level of benefits and services over time.
In 2012, the number of physiotherapists working in the private sector was 2.9 times larger than that of chiropractic, and 7.8 times that of the osteopathic profession. The total number of services provided by chiropractors, physiotherapists, and osteopaths increased steadily over the past 15 years. For the majority of this period, chiropractors provided more services than the other two professions. The average number of services provided by chiropractors was approximately two and a half times that of physiotherapists and four and a half times that of osteopaths.
This study highlights a clear disparity in the average number of services provided by chiropractors, physiotherapists, and osteopaths in the private sector in Australia over the last 15 years. Further research is required to explain these observed differences and to determine whether a similar trend exists in patients who do not have private health insurance cover.
PMCID: PMC3896731  PMID: 24428934
Chiropractic; Physiotherapy; Osteopathy; Allied health; Healthcare utilisation
18.  Does type of health insurance affect health care use and assessments of care among the privately insured? 
Health Services Research  2000;35(1 Pt 2):219-237.
OBJECTIVE: To inform the debate about managed care by examining how different types of private insurance-indemnity insurance, PPOs, open model HMOs, and closed model HMOs-affect the use of health services and consumer assessments of care. DATA SOURCES/DATA COLLECTION: The 1996-1997 Community Tracking Study Household Survey, a nationally representative telephone survey of households, and the Community Tracking Study Insurance Followback Survey, a supplement to the Household Survey, which asks insurance organizations to match household respondents to specific insurance products. The analysis sample includes 27,257 nonelderly individuals covered by private insurance. STUDY DESIGN: Based on insurer reports, individuals are grouped into one of the four insurance product types. Measures of service use include ambulatory visits, preventive care use, hospital use, surgeries, specialist use, and whether there is a usual source of care. Consumer assessments of care include unmet or delayed care needs, satisfaction with health care, ratings of the last physician visit, and trust in physicians. Estimates are adjusted to control for differences in individual characteristics and location. PRINCIPAL FINDINGS: As one moves from indemnity insurance to PPOs to open model HMOs to closed model HMOs, use of primary care increases modestly but use of specialists is reduced. Few differences are observed in other areas of service use, such as preventive care, hospital use, and surgeries. The likelihood of having unmet or delayed care does not vary by insurance type, but the reasons that underlie such access problems do vary: enrollees in more managed products are less likely to cite financial barriers to care but are more likely to perceive problems in provider access, convenience, and organizational factors. Consumer assessments of care-including satisfaction with care, ratings of the last physician visit, and trust in physicians-are generally lower under more managed products, particularly closed model HMOs. CONCLUSIONS: The type of insurance that people have-not just whether it is managed care but the type of managed care-affects their use of services and their assessments of the care they receive. Consumers and policymakers should be reminded that managed care encompasses a variety of types of insurance products that have different effects and may require different policy responses.
PMCID: PMC1089097  PMID: 10778811
19.  Comparison of the Effects of Public and Private Health Expenditures on the Health Status: A Panel Data Analysis in Eastern Mediterranean Countries  
Background: Health expenditures are divided in two parts of public and private health expenditures. Public health expenditures contain social security spending, taxing to private and public sectors, and foreign resources like loans and subventions. On the other hand, private health expenditures contain out of pocket expenditures and private insurances. Each of these has different effects on the health status. The present study aims to compare the effects of these expenditures on health in Eastern Mediterranean Region (EMR).
Methods: In this study, infant mortality rate was considered as an indicator of health status. We estimated the model using the panel data of EMR countries between 1995 and 2010. First, we used Pesaran CD test followed by Pesaran’s CADF unit root test. After the confirmation of having unit root, we used Westerlund panel cointegration test and found that the model was cointegrated and then after using Hausman and Breusch-Pagan tests, we estimated the model using the random effects.
Results: The results showed that the public health expenditures had a strong negative relationship with infant mortality rate. However, a positive relationship was found between the private health expenditures and infant mortality rate (IMR). The relationship for public health expenditures was significant, but for private health expenditures was not.
Conclusion: The study findings showed that the public health expenditures in the EMR countries improved health outcome, while the private health expenditures did not have any significant relationship with health status, so often increasing the public health expenditures leads to reduce IMR. But this relationship was not significant because of contradictory effects for poor and wealthy peoples.
PMCID: PMC3937925  PMID: 24596857
EMR Countries; Public Health Expenditures; Private Health Expenditures; Panel Data
20.  Why not private health insurance? 1. Insurance made easy 
How realistic are proposals to expand the financing of Canadian health care through private insurance, either in a parallel stream or an expanded supplementary tier? Any successful business requires that revenues exceed expenditures. Under a voluntary health insurance plan those at highest risk would be the most likely to seek coverage; insurers working within a competitive market would have to limit their financial risk through such mechanisms as "risk selection" to avoid clients likely to incur high costs and/or imposing caps on the costs covered. It is unlikely that parallel private plans will have a market if a comprehensive public insurance system continues to exist and function well. Although supplementary plans are more congruous with insurance principles, they would raise costs for purchasers and would probably not provide full open-ended coverage to all potential clients. Insurance principles suggest that voluntary insurance plans that shift costs to the private sector would damage the publicly funded system and would be unable to cover costs for all services required.
PMCID: PMC1230586  PMID: 10497613
21.  Old Bones, New Data: Emmett Hall, Private Insurance and the Defeat of Pharmacare 
Healthcare Policy  2009;4(3):16-24.
A paper by Selden and Sing (2008) reminds us of what was at stake 45 years ago, when Emmett Hall recommended universal public medical insurance over private–public alternatives. While focusing exclusively on the United States, it also helps to explain why universal pharmacare is being diverted into that same private–public dead end through public “catastrophic” coverage. Governments finance, through many different programs, most US health expenditure. Spending programs – Medicaid, Medicare and others – primarily benefit the unhealthy and unwealthy. However, benefits of the largest program, the tax exemption for private insurance, are heavily tilted towards the highest incomes and are essentially unrelated to health. This pattern (also found in Canada) may help explain political support for private insurance, despite its excessive administrative cost and inability to cover those in greatest need.
PMCID: PMC2653703  PMID: 19377352
22.  Core and comprehensive health care services: 4. Economic issues. 
This article reviews the economic dimensions of the CMA's decision-making framework on core and comprehensive services. The framework was developed in a policy context characterized by three government objectives: reduction, reallocation and reassignment of health care resources. One economic-evaluation tool for the determination of core services is cost-effectiveness analysis. Some of the critical demand-side and supply-side considerations include the perceived value of medical services, the availability of private insurance and the supply of health care providers. The article concludes that shifting services to the private sector should not be viewed as a panacea for reducing the costs and improving the economic efficiency of the health care system, or for increasing patient access to, or the cost-effectiveness of high-quality care.
PMCID: PMC1337856  PMID: 7743446
23.  Development of a health care policy characterisation model based on use of private health insurance 
The aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy.
Population-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy.
Of eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages.
An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy.
PMCID: PMC1312311  PMID: 16274489
24.  Health Insurance Coverage and Impact: A Survey in Three Cities in China 
PLoS ONE  2012;7(6):e39157.
China has one of the world's largest health insurance systems, composed of government-run basic health insurance and commercial health insurance. The basic health insurance has undergone system-wide reform in recent years. Meanwhile, there is also significant development in the commercial health insurance sector. A phone call survey was conducted in three major cities in China in July and August, 2011. The goal was to provide an updated description of the effect of health insurance on the population covered. Of special interest were insurance coverage, gross and out-of-pocket medical cost and coping strategies.
Records on 5,097 households were collected. Analysis showed that smaller households, higher income, lower expense, presence of at least one inpatient treatment and living in rural areas were significantly associated with a lower overall coverage rate. In the separate analysis of basic and commercial health insurance, similar factors were found to have significant associations. Higher income, presence of chronic disease, presence of inpatient treatment, higher coverage rates and living in urban areas were significantly associated with higher gross medical cost. A similar set of factors were significantly associated with higher out-of-pocket cost. Households with lower income, inpatient treatment, higher commercial insurance coverage, and living in rural areas were significantly more likely to pursue coping strategies other than salary.
The surveyed cities and surrounding rural areas had socioeconomic status far above China's average. However, there was still a need to further improve coverage. Even for households with coverage, there was considerable out-of-pocket medical cost, particularly for households with inpatient treatments and/or chronic diseases. A small percentage of households were unable to self-finance out-of-pocket medical cost. Such observations suggest possible targets for further improving the health insurance system.
PMCID: PMC3377611  PMID: 22723954
25.  The Australian mental health system: An economic overview and some research issues 
This article is concerned with the key economic characteristics of Australia's mental health system. First, some brief conceptual and empirical descriptions are provided of Australia's mental health services, both as a total system, and of its two principal components, viz. public psychiatric institutions and private psychiatry services. Expenditures on public psychiatric hospitals clearly demonstrate the effect of deinstitutionalisation. Data from 1984 on private practice psychiatry indicate that per capita utilisation rates peaked in 1996 and have since fallen. Generally, since 1984 gross fees have not risen. However, for both utilisation and fees, there is evidence (of a statistical kind) that there are significant differences between the states of Australia, in these two variables (utilisation and fees). Emphasis is also placed on the economic incentives that arise from health insurance and the heterogeneous nature of mental illness. The effects of these incentives are regarded as by-products of the health insurance mechanism; and another effect, "unmet need" and "met non-need", is a somewhat unique problem of an informational kind. Discussion of many of these issues concludes on a somewhat negative note, e.g. that no empirical results are available to quantify the particular effect that is discussed. This is a manifestation of the lacunae of economic studies of the mental health sector.
PMCID: PMC2459150  PMID: 18477408

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