What role for voluntary health insurance?
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1 What role for voluntary health insurance? Sarah Thomson Senior Research Fellow, European Observatory Deputy Director, LSE Health Moscow, 28 th June 2011
2 Outline what role for VHI? complementary VHI covering user charges complementary VHI covering excluded services what can we learn from the experience of other countries?
3 Health financing i policy goals promote protection against financial risk distribute the burden of funding the system relative to individual id capacity to contribute t distribute health services (by distributing system resources) )in relation to need promote efficiency (in organisation, service delivery, administrative i ti arrangements) promote quality be transparent, understandable, accountable Source: WHO/Kutzin data/assets/pdf_file/0004/78871/e91422.pdf
4 Can we lower public spending and improve efficiency? the question should be: how can we ensure a good return from public expenditure (growth)? it is difficult to increase out of pocket payments (OOP) without undermining policy goals could VHI help to relieve fiscal pressure and contribute to policy goals?
5 What role for VHI? Market driver VHI role VHI covers Examples coverage breadth substitutive groups excluded or opting out Germany, Chile, NL pre-2006 coverage complementary Canada, NL, excluded services scope (services) Hungary coverage complementary statutory user Croatia, France, depth (user charges) charges Latvia, Slovenia consumer satisfaction supplementary faster access & consumer choice Ireland, Poland, UK Gaps in statutory coverage create space for VHI but are not sufficient for market development
6 Large VHI markets globally countries in which VHI = >10% of total health spending, South Africa USA Bahamas Uruguay Brazil Namibia Zimbabwe Chile Canada Dom Republic France Slovenia Jamaica Argentina Saudi Arabia are few and far between
7 VHI & OOP as % of total health spending in the EU (2009) PHI OOP Mainly complementary cover of user charges Mainly substitutive France L Slovenia Germany Ireland Cyprus Netherlands Spain Austria Belgium Portuga uxembourg Maltaa Hungary Greecee Finland Denmark UK l Italy Latviaa Lithuaniaa Bulgariaa Estonia Sweden Cz Republic Poland Romaniaa Slovakiaa Mainly supplementary but some complementary
8 % population p covered by VHI in the EU (2008) Mainly complementary cover of user charges % EE RO LT AT SI SE NO PL BG IT HU DE UK EL FI LV PT ES CY DE MT DK AT DK IE LI BE SI LU FR NL Source: Thomson and Mossialos 2009
9 A role for complementary VHI covering user charges? Requirements statutory user charges: unavoidable, unpredictable, e, expensive e regulation for affordable access to VHI careful design to avoid undermining value in public spending Risks inadequate financial protection equity concerns Efficiency concerns labour market costs? EU legal challenges As in substitutive markets: As in substitutive markets: regulation has intensified over time
10 VHI in France % health care costs publicly financed: 80% in 1980, 75.5% in 2009 VHI market dominated d by non-profit insurers 2000: government vouchers for low-income people to buy VHI (CMU-C) C) 2005: tax subsidies for people just above the CMU-C threshold (ACS) still 4 million people without VHI (financial barriers most common reason for not having VHI) the quality of VHI coverage has declined d concerns for financial protection
11 VHI in France regressive VHI premiums: 3% of income for the richest quintile, 10% of income for the poorest quintile income-related inequality in likelihood of having VHI (97% in richest quintile vs 65% in the poorest quintile) and quality of VHI coverage variation in health care use and foregone care by VHI status concerns for equity
12 Variation in health status by VHI status, France (2008) VHI CMU-C VHI No VHI Average to very poor health Chronic condition Functional limitation Source: Perronin et al 2011
13 Variation in use of health care by VHI status, France (2008) 90 VHI CMU-C VHI No VHI 80 % visiting a GP or specialist or foregoing care in the last months; % visiting a dentist in the 60 last 24 months GPs Dentists Specialists Foregone care Source: Perronin et al 2011
14 VHI in France user charges are a blunt tool, reducing necessary & unnecessary use in equal measure France has (some) value-based user charges intended to steer patients towards high-value care and away from low-value care examples: lower user charges for more effective drugs, referral to specialists, following care protocols VHI undermines this policy tool high transaction costs of tax subsidies for poor concerns for efficiency
15 Lessons from France avoid creating financial barriers to highvalue care (especially for poor and regular users) align incentives: protect t value-based user charges from VHI plan regulation to secure access to VHI: who will supply VHI? what rules are needed? tax subsidies for the poor?
16 Regulation of VHI in the EU Access to VHI Open enrolment & lifetime cover: BE, DE (basic substitutive policy only), IE, SI Prohibition of age limits: n/a Affordability Community-rated premiums: BE & EE (non-profit), HU, IE, SI Risk equalisation to support community rating: IE, SI Tax-financed vouchers for VHI: FR (poor households) Premium caps: DE (basic substitutive policy only) Quality of coverage Cover of pre-existing conditions: BE, IE Minimum or standard benefits: DE (basic substitutive policy only), IE Cost sharing caps: DE (basic substitutive policy only)
17 A role for complementary VHI covering excluded services? Requirements clear exclusions technical capacity political will willingness to supply VHI high population uptake Risks political l opposition no market will develop concerns for financial protection, equity & efficiency
18 International ti experience Canada (outpatient prescriptions): 13.5% of total spending, 67% of population, 90% via employment (voluntary?), financial i protection ti and equity concerns Netherlands (dental, physio): 5.1% of total spending, 91% of population, p efficiency concerns Hungary (physio, sporting equipment): 2.1% of total spending, 6% of population, expensive tax subsidies, efficiency concerns
19 Catastrophic health spending: poor Estonians don t spend on dental care Inpatient t care 80 Outpatient, excluding 70 dental care 60 Dental care % Supplies, excluding 30 dentures Over-the-counter drugs Prescription drugs Expenditure quintile (poor - wealthy) 2009;data a for 2007 Source: Võrk et al
20 If VHI is to contribute to health financing policy goals there must be a strategy for the market strategy & policy design should ensure complementarity with statutory coverage & avoid cross-subsidies from public to private otherwise VHI will not relieve fiscal pressure & may undermine value in public spending the larger the market, the larger the challenges & the need for careful & dynamic regulation if VHI is not accessible & affordable to those who need it, it is of limited use to health policy makers
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