Cost-sharing in health insurance and its impact in a developing country: evidence from a quasi-natural experiment (original) (raw)
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Though the impact of co-payments on health care demand is well documented in developed countries, evidence from developing countries is rare. In this paper, we contribute to this scarcity by analysing the impact of increasing co-payments in a developing country, namely Vietnam. In 2007, the Vietnam government reintroduced a co-payment of 20 percent for individuals with voluntary health insurance. Because individuals with compulsory health insurance and the uninsured were exempted from the increase in co-payments, this policy can be regarded as a quasi-natural experiment. We use a difference-indifference approach to examine whether the increase in co-payment effectively reduces the demand for health care services. We find it has no significant negative impact on health care demand. This finding holds with different control groups, outcomes and estimators.
Re‐examining the effects of public health insurance: The case of nonpoor children in Vietnam
Health Economics, 2020
This paper focuses on the effects of a 2005 health insurance reform in Vietnam. Through this reform, public health insurance was newly offered to nonpoor children under 6 years old, but it required the use of community health facilities. This requirement potentially limited the value of the insurance. Employing difference-in-discontinuities and triple-difference methods and using data from 2002, 2004, and 2006, I show that, despite health coverage among nonpoor children increasing by nearly three times, there is little or no evidence that the reform significantly increased health care utilization, changed care locations from private to public sites, lowered out-of-pocket costs, or improved health status for nonpoor young children. My results suggest a "bypassing" phenomenon whereby nonpoor families skipped free health care at low-quality facilities.
BioMed Research International
Background. In recent years, health insurance (HI) has been chosen by many low- and middle-income countries to obtain an important health policy target—universal health coverage. Vietnam has recently introduced the Revised Health Insurance Law, and the effects of the voluntary health insurance (VHI) and heavily subsidised health insurance (HSHI) programmes have not yet been analysed. Therefore, this study is aimed at examining the impact of these HI programmes on the utilisation of health care services and out-of-pocket health expenditure (OOP) in general and across different health care providers in particular. Methods. Using the two waves of Vietnam Household Living Standard Surveys 2014 and 2016 and the difference-in-difference method, the impacts of VHI and HSHI on health care utilisation and OOP in Vietnam were estimated. Results. For both the VHI and HSHI groups, we found that HI increased the probability of seeking outpatient care, the mean number of outpatient visits, the to...
Heterogeneity in health insurance demands: a Vietnamese retrospective
2017
Expanding health insurance coverage is a strategy that many low- and middle-income countries (LMICs) are pursuing to reduce risks of catastrophic healthcare expenditure, improve access to health care, and diversify sources of healthcare financing. Due to fiscal constraints, many LMICs have assigned an important role to voluntary health insurance to cover their large informal-sector populations. In most cases, they have implemented a one-size-fits-all approach to implementing their voluntary schemes, including standardized premiums (and premium subsidies in some cases) and standard benefit packages. Although there may be good non-economic reasons for such strategies, they can impose significant costs in terms of both coverage levels and fiscal burdens if demands for health insurance are heterogeneous. Unfortunately, there are few if any studies for LMICs assessing the degree of heterogeneity in demands for health insurance, in part due to the local nature of most health insurance data sets. This study utilizes a unique 1996 data set from Vietnam in which detailed household, commune, and health-provider data were collected from seven provinces (one from each region), together with data on the stated willingness to purchase hypothetical health insurance products with randomized premiums and randomized inclusion of a pharmaceutical benefit. The study finds evidence of substantial heterogeneity in demands for health insurance, particularly with respect to location. Whereas the overall estimates of the average price elasticity of demand range between -0.37 and -0.50 (depending on the statistical model and whether estimates are adjusted or unadjusted), the province/region-specific estimates obtained with an interactive probit model range between -0.12 and -1.00. Estimated willingness-to-pay for a pharmaceutical benefit, while positive overall, is too low to cover the cost of such a benefit and is only significantly positive in 1-3 provinces (depending on the statistical model). A relatively simple regression model with dichotomous variables representing provinces/regions captures the main features of this heterogeneity, suggesting that market segmentation may be a practical option in this case.
Evaluating pricing health insurance in lover-income countries: A field experiment in India
2024
Universal health coverage is a widely shared goal across lower-income countries. We conducted a large-scale, 4-year trial that randomized premiums and subsidies for India's first national, public hospital insurance program, RSBY. We find roughly 60% uptake even when consumers were charged premiums equal to the government's cost for insurance. We also find substantial adverse selection into insurance at positive prices. Insurance enrollment increases insurance utilization, partly due to spillovers from use of insurance by neighbors. However, many enrollees attempted to use insurance but failed, suggesting that learning is critical to the success of public insurance. We find very few statistically significant impacts of insurance access or enrollment on health. Because there is substantial willingness-to-pay for insurance, and given how distortionary it is to raise revenue in the Indian context, we calculate that our sample population should be charged a premium for RSBY between INR 500-1000 rather than a zero premium to maximize the marginal value of public funds.
Impact of Public Health Insurance on Out-of-Pocket Health Expenditures of the Near-Poor in Vietnam
Health Services Insights, 2021
Out-of-pocket payment is one of the indicators measuring the achievement of Universal Health Coverage. According to the World Health Organization, for countries from the Asia Pacific Region, out-of-pocket payments should not exceed 30%-40% of total health expenditure. This study aimed to identify factors influencing out-of-pocket payment for the near-poor for outpatient healthcare services as well as across health facilities at different levels. The data of 1143 individuals using outpatient care were used for analysis. Healthcare payments were analyzed for those who sought outpatient care in the past 6 months. The Heckman selection model was used to control any bias resulting from self-selection of the insurance scheme. The finding revealed that health insurance reduces average out-of-pocket payments by about 21% ( P < .001). Using private health facilities incurred more out-of-pocket payments than public health facilities ( P < .001). The study suggested that health insurance...
Health Economics, Policy and Law, 2014
Thailand is among the first non-OECD countries to have introduced a form of Universal Health Coverage (UHC). This policy represents a natural experiment to evaluate the effects of public health insurance on health behaviours. In this paper, we examine the impact of Thailand’s UHC programme on preventive activities, unhealthy or risky behaviours and health care consumption using data from the Thai Health and Welfare Survey. We use doubly robust estimators that combine propensity scores and linear regressions to estimate differences-in-differences (DD) and differences-in-DD models. Our results offer important insights. First, UHC increases individuals’ likelihood of having an annual check-up, especially among women. Regarding health care consumption, we observe that UHC increases hospital admissions by over 2% and increases outpatient visits by 13%. However, there is no evidence that UHC leads to an increase in unhealthy behaviours or a reduction of preventive efforts. In other words,...
2019
How can developing countries increase health insurance? We experimentally assessed three approaches that simple theory suggests could increase coverage and potentially reduce adverse selection: temporary price subsidies, registration assistance, and information. Temporary subsidies attracted lower-cost enrollees, in part by reducing strategic coverage timing. While subsidies were active, coverage increased more than eightfold, at no higher unit cost to the government; after subsidies ended, coverage remained twice as high, again at no higher cost. However, subsidies are not sufficient to achieve universal coverage: the most intensive intervention-a full one-year subsidy combined with registration assistance-resulted in only 30 percent enrollment.
Health Economics, 2006
Many low-income countries are implementing non-profit medical insurance to increase access to health services, especially among low-income households, and to raise additional revenue for financing public health services. This paper estimates the effect of insurance on outof-pocket health expenditures using the Vietnam Living Standards Surveys for 1993 and 1998 and appropriate models for panel data. Our findings suggest that health insurance reduces health expenditure when unobserved heterogeneity is accounted for. Failure to capture unobserved heterogeneity produces contrary results that are consistent with previous cross-sectional studies in the literature. After accounting for unobserved heterogeneity, we also find that the reduction in expenditure is more pronounced for individuals with lower incomes, but the benefits are modest in the range of 17 to 20%.
Health Policy, 2011
Objectives: To assess the impact on equity and effectiveness of introducing targeted subsidies for the poor into existing voluntary health insurance schemes in Low Income Countries with special reference to cross-subsidisation. Methods: A functional model was constructed using routine collected financial data to analyse changes in financial flows and resulting shifts in cross-subsidization between poor and non-poor. Data were collected from two sites, in Cambodia at Kampot operational health district and in the Lao People's Democratic Republic at Nambak district. Results: Six key variables were identified as determining the financial flows between the subsidy and the insurance schemes and with health providers: population coverage, premium rate, facility contact rate, capitation rate, cost of treatment and changes in administration costs. Negative cross-subsidization was revealed where capitation was used as the payment mechanism and where utilisation rates of the poor were significantly below the non-poor. The same level of access for the poor could have been achieved with a lower Health Equity Fund subsidy if used as a direct reimbursement of user charges by the Health Equity Fund to the provider rather than through the Community Based Health Insurance scheme. Conclusions: Purchasing premiums for the poor under these conditions is more costly than direct reimbursement to the provider for the same level of service delivery. Negative crosssubsidization is a serious risk that must be managed appropriately and the benefits of a larger risk pool (cross-subsidization of the poor) are not evident. Benefits from combined coverage may accrue in the longer term with an expanded base of voluntary payers or when those with subsidized premiums are lifted out of poverty.