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To improve health coverage and revenue collection, several African countries consider tax-for-health-services programs where informal workers pay income tax for health insurance. We examine these programs in Nigeria, investigating whether informal workers support such initiatives, what parameters improve program perception, and what drives preferences about these parameters. Using a conjoint survey experiment with 12,000 informal workers across 12 Nigerian states, we find citizens more likely to support earmarked tax allocation programs, with tax level being most important. Informal workers with less healthcare experience and need, and those feeling distant from government, prioritize tax level and starting date more than others. Our study shows that informal workers in Nigeria generally support earmarked tax-for-health-services programs, but specific design parameters matter. Preferences vary based on healthcare experience and government trust. These findings inform the design of earmarked tax programs to improve healthcare coverage and revenue collection.
Fiduciaries abound in health care. Employers pretend they can act in the best interests of employees when maintaining health plans – even though they pay (directly or indirectly) for claims against those plans. Physicians pretend they can act in the best interests of patients – even when hospitals and group practices pressure them to see more patients and spend less time with them, and even though physicians and their employers are incentivized to order expensive tests and procedures. But what if, instead of ignoring these conflicts of interest, the American healthcare system abandoned the fiduciary fallacy?
Building on recent scholarship showing that targeted legislation, regulation, and self-policing – rather than broad fiduciary duties – better manage these conflicts, I use game theory to analyze different scenarios relating to the financing and provision of health care involving two actors – a provider and a payor. For this analysis, I assume that the actors are rational and behave in their own self-interest until constrained by external rules and social and professional norms. My goal is to advance this scholarship by arguing that broad fiduciary duties are inadequate to address conflicts in our healthcare system, while also proposing paths forward.
This chapter is the first of two focused on the period between 1919 and 1947 bookended by, on the one hand, India’s membership of the new International Labour Organisation in 1919 and, on the other, the birth of independent India in 1947. Together these chapters chart the origins of a social insurance-led model for a future Indian welfare state directed towards an industrial working class. The chapter also documents how - facing rising industrial unrest - the newly elected provincial government of Bombay, the historic centre of India’s textile industry, began to experiment with social insurance. Limited decentralisation under successive Government of India Acts had provided greater autonomy to provinces in the field of labour policy. Bombay was the first to introduce maternity benefits. It then became the first to support sickness insurance for industrial workers as a means of labour force stabilisation. However, given fierce inter-regional competition within India’s textile industry, the adoption of sickness insurance did not proceed because without national coordination Bombay would have been disadvantaged in competition with regions without labour regulation.
This piece takes as a given that we are stuck with our fragmented, inefficient, multi-payor health care system for at least the short run. It then analyzes the deficiencies of three payment mechanisms whereby regulators (including Congress) have invited private sector providers to help ameliorate perceived problems. The first concerns an inadequate supply of nursing home beds in the early ‘70s, the next focuses on Medicare Advantage as a supposedly superior cost containment alternative to traditional Medicare, and the final one involves the ‘devil’s bargain’ struck with the pharmaceutical industry to get prescription drug coverage added to Medicare. All three teach the same lesson: the government needs to be more vigilant not to give away the store when it invites the private sector in.
Currently, the Affordable Care Act helps to provide inexpensive preventive care services to adolescents (10–19 years old) by preventing insurance companies from implementing cost-sharing measures. Some of these services can fall under the realm of mental health preventive care such as anxiety and depression testing. The lack of cost to a patient and their family encourages doctors to offer these services to their young patients. Furthermore, this Affordable Care Act provision - fosters doctor-patient communication because it normalizes mental health services as part of well-being. However, Braidwood Management Inc. v. Becerra threatens to have far reaching implications for preventive care policy and to disrupt health communication efforts to promote positive mental health. This Article uses structuration theory and a conceptual framework of adolescent development to examine the potential ramifications of cost-sharing on adolescent health. The implications of this change in cost-sharing include constraining doctors’ communication behavior in primary care settings and stunting healthy adolescent development. Ultimately, if the Braidwood decision is upheld, it may pose a challenge to a doctor’s ability to communicate with their young patient about mental health.
This article identifies issues relating to the use of genetics and genomics in risk-rated insurance that may challenge existing regulatory models in the UK and elsewhere. We discuss three core issues: (1) As genomic testing advances, and results are increasingly relevant to guide healthcare across an individual's lifetime, the distinction between diagnostic and predictive testing that the current UK insurance code relies on becomes increasingly blurred. (2) The emerging category of pharmacogenetic tests that are predictive only in the context of a specific prescribing moment. (3) The increasing availability and affordability of polygenic scores that are neither clearly diagnostic nor highly predictive, but which nonetheless might have incremental value for risk-rated insurance underwriting beyond conventional factors. We suggest a deliberative approach is required to establish when and how genetic information can be used in risk-rated insurance.
In 2019, the National Evidence-based Healthcare Collaborating Agency (NECA) in Korea established a health technology reassessment (HTR) system to manage the life cycle of health technologies and develop operational measures promoting the efficient use of healthcare resources. The purpose of this study is to introduce the detailed implementation process and practical functional methods of the HTR implemented by NECA.
The HTR is a structured multidisciplinary method for analyzing health technologies currently used in the healthcare system based on the latest information on parameters, such as clinical safety, effectiveness, and cost-effectiveness of optimizing the use of healthcare resources as well as social and ethical issues. All decision-making stages of the HTR are carefully reviewed and transparently managed. The HTR committee makes significant decisions, and the subcommittee decides the details related to the assessment process.
Since the pilot began in 2018, 262 cases have been reassessed, of which, 126 cases (48.1 percent) were health services not covered by the National Health Insurance (NHI). Over the past 5 years, approximately 130 recommendations for the in-use technologies were determined by the HTR committee. In the near future, it will be necessary to officially develop and establish a Korean HTR system and a legal foundation to optimize the NHI system.
Business power is thought to increase over time when private actors are involved in the provision of public goods and services. This paper argues that this is partially true—and that in certain circumstances, state actors can even swiftly regain control of sectors previously ceded to private interests. When the latter fulfill some public functions on behalf or as delegates of the state, policymakers face ever greater pressures to sustain a relationship flawed by principal-agent problems—allowing business actors to derive appreciable political benefits. However, these conditions do not hold true after deregulation—when state actors retreat from a sector and attempt to direct the newly created market through licensing, norms, and standard setting. We demonstrate that deregulation sets the stage for a more competitive environment, making it harder for private interests to cooperate. This, in turn, can allow policymakers to enhance regulatory capacities and seize opportunities to highlight the shortcomings of private provision. After establishing this argument theoretically, we illustrate its implications through the comparative historical analysis of the health insurance sector in two European countries—Belgium and France. Despite their initial similarities, they experience contrasting developments regarding the welfare state’s dependency on private insurers for the provision of crucial collective goods.
Health systems’ insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public–private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.
South Africa offers universal health coverage through large public and private systems. The private system is characterised by a regulated market for health insurance, referred to domestically as medical schemes. From 2000, the private system was undergoing a reform process consistent with theoretical approaches for regulated competition for health insurance. However, from 2008, the reform process was interrupted, leaving in place a partial framework which included open enrolment, community rating and regulated minimum benefits but excluded, inter alia, risk equalisation. The incomplete reform, however, provides an opportunity to examine the system outcomes that result from a partial approach. This paper therefore reviews the system outcomes of the partial reform using a descriptive data analysis. The findings then inform an evaluation of the extent to which the preconditions for regulated competition have been met as indicated by the theory of regulated competition in healthcare. The paper therefore highlights the areas where regulatory interventions need to be prioritised in South Africa to achieve the objectives of regulatory competition that are able to achieve access, fairness and efficiency. The analysis points to significant failures at the level of health insurance competition in South Africa with resulting outcomes consistent with the theory of regulated competition.
This chapter introduces the concept of insurance as a product and explores why people want to purchase insurance in general (and health insurance in particular). The main discussion centers around explaining that health insurance (and all insurance) is primarily financial protection: health insurance does not protect your health but instead protects your wealth from health-related risk. The chapter then moves on to discuss the operations of an insurance company: how premiums are set, the difference between correlated and uncorrelated risk, group insurance, and experience rating. The chapter ends by discussion moral hazard in the context of an individual with insurance coverage. The end of chapter supplement provides a mathematical example of why someone who is risk averse would want to purchase insurance.
This chapter takes the basics of demand developed in Chapter 3 and applies them to understanding how features of a health insurance plan influence individual decision-making in the market for medical care. The chapter unpacks how plan cost sharing characteristics (copayments, coinsurance, and indemnity), as well as pricing change and triggers (deductibles and payment limits) influence demand and individual consumption decisions.
An approachable beginner's guide to health economics that brings the economist's way of viewing the world to bear on the fundamentals of the US healthcare system. The conversational writing style, with occasional doses of humour, allows students to see how applicable economic reasoning can be to unpacking some of the sector's thorniest issues, while accessible real-world examples teach the institutional details of healthcare and health insurance, as well as the economics that underpin the behaviour of key players in these markets. Many chapters are enhanced by 'Supplements' that offer how-to guides to tools commonly used by health economists, and economists more generally. They help form the basic 'economist's toolbox' for readers with no prior training in economics, and offer deeper dives into interesting related material. A test bank and lectures slides are available online for instructors, alongside additional resources and readings for students, taken from popular media and health care and policy journals.
I argue that health insurance emerged as an important aspect of Nixon’s domestic policy agenda as a result of “policy escalation.” By policy escalation, I mean a cascading line of reasoning that causes policy makers focused on one apparently discrete issue to formulate approaches for dealing with other interconnecting policy areas. Policy escalation serves as an internal agenda-setting mechanism: as policy makers contemplate policy changes, they may attempt to imagine the ways in which change will affect the rationale, fiscal position, and execution of programs in other policy areas. In the case of health insurance, the Nixon administration’s proposal for replacing Aid to Families with Dependent Children with a guaranteed minimum income forced policy makers to consider how the new program would interact with the existing Medicaid program. Consideration of this question ultimately led them to formulate an approach to overhauling the nation’s entire health insurance system.
Joan Costa-Font, London School of Economics and Political Science,Tony Hockley, London School of Economics and Political Science,Caroline Rudisill, University of South Carolina
This chapter goes over the decision to purchase health insurance (or not). The way information is presented to individuals has a significant impact on their decision to purchase insurance to protect themselves from the financial consequences of health risks. Eliminating minor inconvenience costs or simplifying the insurance selection process can influence whether or not people purchase insurance. This chapter examines the roles of adverse selection and moral hazard in insurance-related behaviour, as well as the barriers to insurance uptake for individuals ranging from affordability to unobservable quality and information/choice overload. The chapter investigates the role of various nudges in increasing health insurance uptake.
The effect of health insurance coverage on sexual and reproductive health, especially unintended pregnancy, has scantly been researched. Using the 2014 Ghana Demographic and Health Survey, the study examined the links between women’s health insurance enrolment on unintended pregnancy in Ghana.
Method:
The sample consisted of 9,396 women aged 15-49 years, but the analysis was limited to the 4,544 women who were pregnant in the two years preceding the survey. The effects of health insurance enrolment on unintended pregnancy was examined with the propensity score matching. The health insurance enrolment was the treatment variable and unintended pregnancy as the outcome variable.
Results:
This study showed that 66.0% of all women surveyed had health insurance coverage and 31.8% of all women of childbearing age who were currently or had previously been pregnant reported having at least one unintended pregnancy. Thirty percent of insured women had an unintended pregnancy, compared to 37% of uninsured women. The results showed that education, household wealth index, religion, and type of marital union were significant predictor of health insurance coverage among Ghanaian women. The PSM split the women based on their health insurance status. After matching, the difference between the insured and uninsured women reduces significantly. Results demonstrated that, the probability of unintended pregnancy was 0.312 among insured women and 0.351 among those not insured in Ghana. This implies that having health insurance coverage will help in reducing the likelihood of women experiencing unintended pregnancy.
Conclusions:
Results highlight the importance of the target of universal health coverage under the sustainable development goal 3 and demonstrate that expanding existing health insurance schemes within Ghana could contribute to reducing the number unintended pregnancies experienced each year.
Traditionally, older people have been the key targets of Australia’s targeted welfare state. Flat rate pensions and widespread home ownership have ensured relative equality in older life. However, in response to perceived fiscal pressures generated by population ageing, Australia has increasingly shifted its policy settings, encouraging private savings over public risk pooling. Private savings are increasingly supported by public subsidy through tax policy. This has led to overlapping policy priorities, as public subsidies are used both as incentives to promote savings and as social policy instruments to promote adequate living standards in retirement. This conflict is evident in recent policy reviews of taxation, public spending and pension policy. This article explores the development of this conflict and how it manifests in proposals for reform. We argue that the conflation of welfare and taxation goals increasingly creates a dual welfare state that promotes private provision at the expense of both equity and efficiency. We suggest that more explicit identification of the roles of tax policy, and the welfare implications of tax changes, would help to improve policy design.
In Smith v. Rasmussen, an Eighth Circuit case from 2001, the original opinion upheld Iowa’s Medicaid ban on coverage for gender confirming surgery, finding it was reasonable and consistent with the federal Medicaid Act. Craig Konnoth’s feminist rewrite finds that the ban on gender confirming surgery is discriminatory on its face and impermissibly relies on gender stereotypes because it permits coverage of particular procedures for individuals perceived as sufficiently cisgender—such as those who are intersex but have conformed to expectations associated with their sex assigned at birth—but not for others. Konnoth draws on empirical research showing that enforcing gender roles in this context seeks to prevent men from debasing themselves as women and to prevent women from claiming the privileges of men. Heather Walter McCabe’s commentary highlights how litigation related to transgender issues reveals the socially constructed nature of gender and provides useful insight into how gender and sex relate to each other and to theories of antidiscrimination.
In Does v. Gillespie, Medicaid beneficiaries sued the director of the Arkansas Department of Human Services claiming that terminating Planned Parenthood’s Medicaid provider agreements violated their federal right under the Medicaid Act to choose any “qualified” provider that offers covered services. The Eighth Circuit held that the free choice of provider provision in the federal Medicaid Act did not create rights enforceable by individual beneficiaries. In their feminist judgment, Melissa Alexander and Jennifer Oliva argue that the clear language of the Medicaid Act unambiguously demonstrates that Congress intended to confer a private right of enforcement under the free choice of provider provision. Elizabeth Kukura’s commentary emphasizes the importance of focusing on the lived experience of Medicaid beneficiaries who rely on Planned Parenthood for basic health care needs. Kukura highlights the influence of anti-abortion politics and ideology on health care access and the structural forms of discrimination that shape it.
In Doe v. Mutual of Omaha Insurance, a Seventh Circuit case from 1999, the plaintiffs challenged lifetime coverage caps for AIDS-related conditions, which blocked patients with HIV/AIDS from accessing antiretroviral therapies and other lifesaving medical care. Doe and Smith alleged that the caps violated the public accommodations clause of the ADA. The original opinion sided with the insurance company, finding the caps permissible under the ADA, even though the defendant offered no proof they were supported by sound actuarial data. Professor Valarie Blake’s feminist judgment focuses on the plain text of the disability rights statute, relevant legislative history, and valid guidance from the Department of Justice. Blake also highlights the social and cultural context in which gay men and people with AIDS have been subjugated and stigmatized. Professor Christina Ho’s commentary contrasts the disability-rights approach the plaintiffs advanced before the court with the statutory restrictions on health insurance underwriting based on health status-related factors eventually included in the Affordable Care Act passed more than a decade later.