Social Health Insurance and the Use of Formal and Informal Care in Developing Countries: Evidence from Ghana’s National Health Insurance Scheme

This paper studies the relationship between the use of formal and informal health care in a developing country setting by examining the introduction of a social health insurance scheme in Ghana. We estimate the effects of gaining coverage on changes in care seeking behaviour and show how these effects differ by age and wealth status. District-level differences in the implementation of the insurance scheme provide exogenous variation in access to insurance and allow us to address issues with selection into coverage. Results indicate that insurance access strongly increased use of formal care and reduced out-of-pocket expenditures on health services.     

Consequences of increased third-party payments for health care services.

The growth of third-party programs to pay the costs of health care has occurred in an unplanned manner. As a result, the country presently is faced with a number of uncoordinated payment programs that sometimes work against each other. While the expansion of health insurance programs has provided the financing necessary to keep our health care system up-to-date, and while such programs doubtlessly have reduced the financial barriers to seeking health care for some population segments, health insurance also has produced some problems. Generally, the contribution of health insurance to these problems is subtle and cannot be quantified. Yet, policymakers increasingly are recognizing that there are factors at work in our health care system that, if continued unabated, will exacerbate the country's health care cost problem. Many of these factors owe their existence to the socially unacceptable incentives provided by most health insurance programs. This article focuses on some of the adverse consequences of health insurance programs and indicates that the future of private health insurance depends upon how these problems are addressed.     

PUBLIC RESPONSIBILITY AND INEQUALITY IN HEALTH INSURANCE COVERAGE: AN EXAMINATION OF AMERICAN STATE HEALTH CARE SYSTEMS

This article examines the effect of the three publicness dimensions on inequality in health insurance coverage across 50 American state‐level health care systems. The analysis validates a Gini‐coefficient measure of Americans' unequal distribution of health insurance coverage across nine income groups and compares public ownership, financing, and control of health care systems across all 50 states from 2002 to 2010. There is a significant and negative relationship between public ownership and inequality in health insurance coverage, although the substantive impact of ownership is relatively small. Both public financing and control substantially reduce inequality in health insurance coverage across income groups. However, both of these must be present in order to be effective at reducing inequality. This article expands our understanding of the link between different institutional arrangements and inequality in health insurance coverage in hybrid health care systems.     

Health care reform content and process:propositions from the states

Health care reform and cost containment have become central campaign and policy issues in the United States. Although focus now centers on federal health care reform policy, state governments have been actively introducing health care reform legislation. Some of the health care reform initiatives on the state level have influenced deliberations on the federal level and President Clinton's health care reform initiatives will spur further state experimentation regardless of legislative success in Congress, In 1992 nearly all 50 states had either legislation introduced, or special task forces assigned that addressed health care reform issues. This exploratory research compares the content and process of health reform in four states that attempted major reform in 1992—Florida, Washington, Michigan, and Wisconsin—and draws propositions for state reform based on comparisons of content and process. The four states chosen represent geographic diversity and a balance between legislation seeking partial change and legislation calling for universal health care reform. The principal reform bills in each state are compared and assessed on the degree to which they address eight reform elements; high tech medicine, administration, tort reform, long-term care, regulation, insurance mandates, small business insurance, and insurance portability. These initiatives are also compared on a series of reform process variables that relate to the political process for adopting reform: degree of health sector support, type of political strategy used, reform champion, degree of cooperation among policy stakeholders, and timing of initiative. Based on these four cases the phased/partial approach seems to have a greater chance for legislative success than immediate universal reform. Florida's partial, consensus-building approach resulted in the only signed bill of the four states. Washington's bill, which also took a partial approach, passed the state senate before ultimate defeat in 1992 and eventual passage in 1993. Neither of the more ambitious universal health care reform packages introduced in Wisconsin or Michigan got out of committee. Although some of the plans were thorough, none adequately addressed the tradeoff between increasing access to care and containing costs. In addition, this study will demonstrate that universal health care legislation, does not necessarily equate to comprehensive health care reform. The propositions derived from this research have implications for future state health care reform efforts, as well as for federal health care reform policy in terms of the substantive content of reform proposals and the political process by which they are advanced.     

Health care finance in the US: Past,present, and future

Presently the US is the only major industrialized nation that does not insure universal access to health care for all of its citizens. Although the US spends one out of every eight dollars on health care, over one-eighth of all Americans lack basic health insurance coverage. Another concern is health care cost inflation. The quest for comprehensive health care coverage for all Americans began shortly after the turn of the century and has received varying degrees of support since then. Since the historical course of health policy in the US has followed an evolutionary rather than revolutionary course, unless consistent policies are developed to rationalize the incentives facing consumers, providers, and insurers, alike, the future path of American health policy will continue to be characterized by disjointed incrementalism. National health insurance can provide decision makers with a tool to structure and focus the American health care system. In order for cost control measures to be effective they must be coordinated with measures to promote universal access, and vice versa. NHI can be a catalyst to focus attention on the dual goals of access to care and cost containment.     

The health care state in the information age

The computerization of the medical record has important implications for the governance of health care, and the importance of health care means that changes wrought there are indicative of changes in government as a whole. This paper draws on work in public policy, medical sociology and studies of science and technology, as well as on cross–national empirical research in Britain and France. It describes the recent development of information policy in health care as an exercise in state–building, realized specifically in the governance of the health professions. The paper concludes with a discussion of what is both new and not so new in the form and extent of state power which emerges.     

The oregon plan: Toward a model for the future of health care financing

The State of Oregon has proposed a new method of financing health care services for its citizens. Oregon proposes to fund only the most cost-effective services. But in addition to narrowing the offering of health services funded by the State, Oregon proposes to fund all of the State's poor for services, no matter the family status. This broadened number of poor (everyone at the federal poverty level and below, single or married, children or not) will provide health care for more than 200,000 additional Oregonians. The supplementary legislation, SB 534 and SB 935, combined with broadened health care coverage for the poor (SB 27) will cover an additional 478,000 Oregonians. Nearly 95 % of its citizens will have some form of health insurance in Oregon.     

Developments in health care finance

Costs, quality, and access are the central themes in health care policy in the United States. In the 1980s the predominate issue is becoming access, and the likelihood for universal health coverage, or a national health insurance program, is growing. This paper explores how the America health care system got to this point and examines the present conditions, the trends, and the consequences of those trends.     

Achieving Equity in Health through Community-based Health Insurance: India's Experience with a Large CBHI Programme

This article analyses equity in enrolment, renewal of enrolment, and utilisation of community-based health insurance with special reference to the Yeshasvini health care programme. The analysis employs a primary survey conducted in rural Karnataka using a random sample of 4109 households. The study identifies quantifiable variables covering various dimensions of vulnerability and assesses their relationship with enrolment, renewal of enrolment, and utilisation using logistic regression techniques. The results demonstrate that inequities do exist even though they are less pronounced in utilisation than in enrolments and renewals. While community-based health insurance (CBHI) may be used as a mechanism to reach the disadvantaged population, they can not be considered as substitute for government-created health infrastructure.     

Toward Disorganized Governance in Public Service Provision? The Case of German Sickness Funds

Over many years now, the concept of “network” or “new governance” pervades the literature on public administration. It suggests a growing role for network-based governance downgrading both command-and-control bureaucracy and, if more implicitly, New Public Management (NPM). Challenging this reading, the article explores the relationship between network-based and (quasi-)market governance by investigating the policies of German health care insurance organizations, the so-called sickness funds, epitomizing the international movement towards focal agencies run at arm's length of Government. These policies reflect new forms of hybrid coordination in public service provision, leading into what can be coined disorganized governance and be characterized as a regime of hybrid coordination shaped by a nervous interplay of partnership-building and disruptive segregation, with important repercussions on the overall outcomes in the provision of health care.     

Reforming New Zealand's health care system

In common with many OECD countries, New Zealand has been engaged in a process of reforming the nation's health care system. In New Zealand's case the reforms have been particularly far reaching and effected within a remarkably short time frame. In 1991 the policy framework was made public, and the legislation to underpin the changes enacted in 1993. Shadow bureaucracies anticipating the reforms were set up as early as 1991, however, thus allowing for the changes to be effected in advance of legislation. Thus in the space of a few years, the social security model of health care, which had been in place for over half a century, was transformed into a system characterised by managed competition. This article begins by briefly describing the social security model of health care, and its inherent problems. I go on to analyze the reforms, focusing on the problems of the previous system that the reforms were intended to address. The major planks of the new system are identified, namely the separation of purchasing of health services from provision and creating a competitive market; the distinction between “personal” and “population” health services; establishment of a core of services to which all citizens are entitled; and the integration and capping of funding for health services, and increasing cost-sharing. Of these policies, only the separation of purchasing and provision of health care and the integration of funding for health services have to date been fully implemented, the remainder having been delayed, modified or abandoned. The health care system has arguably been only partially reformed, therefore.     

Managed care systems in the people's republic of china

This article attempts to determine whether or not managed care is the way forward for health services systems reforms in urban China. It first highlights the problems of the present Chinese urban health care financing system, which is largely based on third party fee-for-service reimbursement. It then analyses the salient features of three existing managed care systems in China -private plans, plans under the existing public and labor medical insurance systems, and the newly introduced pilot Employees Medical Insurance Scheme. Available evidence tend to suggest that all of them have been quite effective in controlling cost escalation, and that there have been some improvement in terms of equity under the new Employees Medical Insurance Scheme.     

THE ENTERPRISE FORMULA,NEW PUBLIC MANAGEMENT AND THE ITALIAN HEALTH CARE SYSTEM: REMEDY OR CONTAGION?

Health care services represent an extraordinary experimental ground for introducing wider political and institutional transformations of the state. The adoption of entrepreneurialism into European health care systems has strengthened technocratic decision making over traditional mechanisms of political control. In Italy, in the midst of a severe legitimacy crisis affecting the administrative and political systems at the beginning of the 1990s, New Public Management ideas seemed ‘the’ remedy against the pathological politicization of distributive politics. Much hope has been placed since in a new and ascending group of general managers, entrusted with the ambitious mission of running health care services more efficiently and with the unenviable expectation of resuscitating public trust in welfare institutions. By analysing the 1992 Amato government’s landmark health care reform in its substantive changes, this paper explores the last decade’s main reform trajectories of Italian health care reforms that irreversibly transformed its institutional arrangements and organizational structure, namely the enterprise formula and the regionalization of the health care sector. The paper suggests that the political turmoil of 1992–94 served as catalyst for radical policy change and argues that the single most important explanation for the enactment of New Public Management‐type reforms rests in a new executive reinterpretation of its legislative prerogatives and function.     

Financing the health care of the aged.

The Medicare and Medicaid programs, which were enacted through the 1965 amendments to the Social Security Act, placed the federal government in the central role of assuring access of the aged and the poor to needed medical care. In this article the trends in the sources of financing medical care services for the aged are examined. The distinction in terms of insurance coverage between acute care services and long-term care services is highlighted. The effect of the programs in terms of reducing the aged's direct financial cost of medical care, increasing their access to medical services, and improving their health status is explored. The unanticipated increase in the cost of these programs has led to a change in emphasis in public policy, from assuring access to mainstream medical care to containing the cost of providing care. The direction of new federal policies is analyzed, and it is concluded that no longer will it follow the private sector's specifications of the conditions and arrangements under which health services are provided to program beneficiaries.     

Health care reform in Israel: An historical and sociopolitical conundrum

A new and comprehensive National Health Insurance Law was implemented in Israel on January 1, 1995. This major health care reform initiative culminated an effort lasting several decades to assure broad universal health care coverage for the population as a matter of national law. Issues that affected the development of the reform package included 1) the formation of sick funds that provide care to over 96% of the population as part of other powerful sociopolitical organizations, 2) the historical development of parallel private July 16, 1995 and governmental health care systems before Israel became a state in 1948 and the post-state maintenance of multiple health care delivery systems, and 3) the close interactions of health care systems and the political processes and parties of the nation. This paper describes the effects of these forces on resisting changes that were widely accepted as being necessary to expand access, control rising health care costs, and improve the efficiency of the nation's health care system.     

Health care benefits in the public sector: An examination of availability,size, and managerial effects among north carolina municipalities

This study focuses on the extent to which health care benefits are used in North Carolina municipal governments. As such, it not only maps out the existence of these practices, but also the conditions and circumstances in which they occur. Health care practices (Basic dental and medical coverage, employee assistance programs, and child care provisions) are examined.

Since group health coverage is nearly universal (albeit the type and extent of coverage varies), it was not examined in this survey. With the exception of pre-paid dental insurance (41 percent) and unpaid maternity leave (31 percent), limited use is made of the various health care programs surveyed.

Population and workforce size effects are marginal.The presence of a city manager or town administrator, on the other hand, results in two or three fold the use as occurs in mayor-council cities.     

Competition and health care policy: experience and expectations

Since 1970 federal policymakers have tried to strengthen competition and incentive-based market forces as alternatives to regulation in containing health costs. The effort to stimulate the growth of health maintenance organizations (HMOs) throughout the country has had limited results, and federal plans to promote competition by enacting changes in the health insurance market have so far come to little. Coalitions in some localities have shown growing interest in flexible HMO variants, however, and the intellectual force of the HMO critique of mainstream practices remains strong. Moreover, the federal government has shown new interest in prospective reimbursement of hospitals--a proposal that draws from both HMOs--competition--and hospital rate-setting programs--regulation--the element of prospectivity.     

Medical malpractice problem.

The medical malpractice problem is extremely complex and is perceived very differently by health care providers, patients, and other segments of society. As a widely recognized problem, it is of relatively recent origin. Its potential societal consequences include disruption of health services, waste and maldistribution of economic and human resources, and a severe strain on a variety of our traditional social institutions. The "crisis" of malpractice is a product of many forces, including a disturbing level of negligent and improper medical care, frequently unrealistic patient expectations, and the growing "philosophy of entitlement" which is rampant among Americans. Responses to the problem have sometimes been ill-advised and emotional. Most often, the problem is seen as one of inadequate or overpriced malpractice insurance, though careful analysis suggests that insurance issues are merely symptoms of the real problem. Nevertheless, insurance-based solutions have proven to be politically expedient and have produced at least temporary alleviation of the problem. Ultimately, though, other approaches will be necessary, and careful, objective research is required to identify and test long-term options.     

Health care and the elderly.

Western values have long emphasized an interventionist approach to problems of health and health care. Yet, as medical technology becomes increasingly expensive and as the number of older people grows, proposed changes often are now governed more by considerations of cost than by quality of services. This tension between cost and quality also affects public willingness to invest in social components of health care despite their importance in enhancing quality of life. The tension emerges in sharpest contrast as scarce resources are allocated by gatekeepers in health maintenance organizations and in the arrangements for long-term care. With respect to financing, what seems to be needed is a creative mix of voluntary inputs from the community, private initiatives, and new programs of public entitlements. With respect to quality of care, what has often been overlooked is the recognition that gains in the quality of life require programs that encourage older people's continued involvement and participation in social life and in active and healthy life-styles. This article discusses the evolving balance between these two types of interventions: the medical and the social.