Best practices of selected EU countries concerning the provision of healthcare services to people not covered by social health insurance IPA Social Security Co-ordination and Social Security Reforms Skopje, 9 November 2009 Willy Palm Dissemination development Officer
A partnership that reflects evidence-based policy-making International agencies WHO Regional Office for Europe, the European Investment Bank, the World Bank, the Open Society Institute National and regional governments Belgium, Finland, Greece, Norway, Spain, Sweden and Slovenia, as well as the Veneto Region of Italy Academia the London School of Economics and Political Science (LSE), the London School of Hygiene & Tropical Medicine (LSHTM)
Country monitoring Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of each health care system and of reform and policy initiatives in progress or under development. produced by country experts based on a common template covering the whole European region and selected countries elsewhere 3
Health systems and policy analysis We run and publish comprehensive, systematic, comparative healthcare systems analysis on a range of topical issues and policy aspects Validated evidence research Tailored to policy-making needs Freely accessible 4
Dissemination Disseminating generated evidence to decision-makers in the health sector is an essential component of our mission to inform the policy process. Publications Web Personal interaction (policy dialogues) 5
Observatory Venice Summer school Our Summer School brings together high level policy-makers in a stimulating environment where experiences can be openly discussed and information freely exchanged. While there is some formal teaching, the emphasis is on a participative approach. Human Resources for Health (2007) Hospital Re-engineering (2008). Innovation and Health Technology Assessment: Improving Health System Quality (2009) EU integration and health systems (2010) 6
Overview Framing the problem of uninsurance Universal coverage: what do we understand by it? Broad approach to universal cover Population coverage Service coverage Cost coverage Solidarity vs. financial sustainability? 7
The uninsured: expelled from paradise From I. Kickbush 8
USA: 45 million uninsured (2008)
Health insurance premiums outpacing normal inflation
Insurance coverage decreasing
American Medical Association (AMA) 158 th Annual Meeting, June 15, 2009 "If we do not fix our health care system, America may go the way of GM -- paying more, getting less and going broke, The AMA agrees with Obama on the need for health care reforms but has reservations about the creation of a "public option" paid for by the government to ensure coverage for the 46 million uninsured Americans. 12 12
Social inequalities in health and access to health care 30 25 Diabetes mellitus US black, m deaths / 100,000 20 15 10 5 0 US black, f US white, m US white, f Sweden, m Sweden, f 20-24 25-29 30-34 35-39 40-44 45-49
US - Federally Qualified Health Center (FQHC) Health Center Consolidation Act (1996) safety net providers: community-based health centers providing comprehensive PHC and preventive care to persons of all ages, regardless of their ability to pay 20% co-insurance with sliding-fee scale based on patients' family income and size Medicare patients, poor (homeless, migrants, non-us citizens, etc.), 40% uninsured To reduce the patient load on hospital emergency rooms 14
Rates of uninsurance in European Union 0.3% Germany (but 10% private) 1% (+ 2.2% defaulters) Netherlands (previously 35% private) 1.6% Switzerland 2% Austria 2.1% Poland 5% Estonia 12.9% Bulgaria (1 mln.) 15
91 88 878584 82 82 82 818078 78 77 77 76 7674 Public funding of total health expenditure (OECD countries 2006) 73 71 71 71 71 70 7068 6862 6056 46 44 Luxembourg Czech Republic United Kingdom Denmark 1 Norway Iceland Netherlands 1 Sweden Japan France Ireland New Zealand 2 Italy Germany Austria Finland OECD 3 Belgium 1 Turkey 4 Spain Hungary Portugal Canada Poland Slovak Republic Australia Greece Switzerland Korea United States Mexico -22-18 -9-8 -8-5 -2-4 -2 1-5 -4 4 3 1 4 3 7 3 0 n.a. n.a. 2 4 5 6 8 8 11 10 16 100 75 50 25 0-25 0 25 % total expenditure on health Percentage points 1. Data refer to current expenditure. 2. 2003. 3. The OECD average excludes Belgium and Slovak Republic. 4. 2005. 2. Source: OECD Health Data 2008.
Increase: public spending as a % of total expenditure on health 1996 new states 2005 new states 1996 old states 100 90 80 70 60 50 40 30 20 10 0 Source: WHO 2007 CYP ROU IRL MLT AUT PRT ITA UK FRA FIN 2005 old states 100 90 80 70 60 Decrease: public spending as a % of total expenditure on health 50 40 30 20 10 0 SVK BGR EST HUN BEL LVA GER POL LTU SVN GRC SPA SWE LUX CZE NLD DNK
The founding fathers of universal coverage in Europe Otto von Bismarck 1815-1898 Nikolai Alexandrovich Semashko 1874-1949 William Henry Beveridge 1879-1963 18
CZE FRA LUX EST SVN GER SVK BEL HUN NLD UK SWE DNK IRL MLT ITA PRT ESP FIN ROU LTU POL AUT CYP GRC LVA BGR Mix of contribution mechanisms, 2005 Taxes Social insurance Private health insurance Out of pocket payments Source: WHO 2007 100% 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0%
Can payroll contributions continue to account for at least 90% of Germany s SHI revenue? What options to avoid harmful impact on labor market and competitiveness? 40% average contribution rate 35% 30% 25% 20% 15% 10% 2004 2007 2010 2013 2016 2019 2022 2025 2028 2031 2034 2037 2040 basis scenario 1 scenario 2 Source: Dirk Sauerland, WHL Graduate School of Business and Economics, presentation to 6 th European Conference on Health Economics, 6-9 July 2006, Budapest
Social health insurance (Bismarck) Tax funded (Beveridge) CEE and NIS (Shemasko) Public actors Purchasing side Semi-public actors Integrating private insurers User charges Complementary HI Purchaser-provider split More regional and local devolution Public actors Move to social health insurance and purchasing model (single multiple) Informal payments Provision side Mainly private actors More selective contracting, performance-based payments, integrated care models Mainly public actors Autonomisation, contracting in private provision, outsourcing, PPP Public actors Private practice
Beveridge or Bismarck? It doesn t matter whether the cat is black or white. As long as it catches mice! Deng Xiao Ping 22
The notion of solidarity «The very notion of solidarity, on which our social security systems are based, demands an universalisation of its extent. It is contradictory to the idea of solidarity itself, to limit it to a certain group to which one belongs When this limited solidarity occurs among the rich, to the exclusion of the poor, it is not solidarity at all. It is protectionism and collective selfishness, not deserving the name social.» Van Langendock J (2007) The Right to Social Security 23
Health financing within overall system Resource generation Health financing system How health financing can influence goals Equity in utilization and resource distribution Quality Health system goals (WHR2000) Health gain Equity in health Stewardship Revenue collection Pooling Purchasing Benefits Efficiency Transparency and accountability Financial protection Equity in finance Service delivery Choice Responsiveness Core values Participation Solidarity Equity
Reform and public policy objectives Cutler (2002): successive waves of healthcare reform Ensuring universal access to medical care Centralised regulation-based cost containment by various rationing mechanisms Decentralised market- and incentive-based systems 25
Choice and competition in health insurance selective contracting variable contributions (premiums) free choice collective contracting fixed contributions no free choice multiple payers single payer Netherlands Switzerland Germany Belgium Czech Rep. Slovak Rep. Austria France Luxembourg Poland Estonia Hungary Slovenia
Renewed interest in universal coverage Move towards more private competitionbased health insurance systems Non-active and non-contributing groups in universal SHI-systems (problem of defaulters) Small but persistent pockets of uninsured Depth of universal coverage (cost-sharing) 27
Universal coverage: what do we understand by it? as a situation in which the entire population of a country has access to appropriate health care services when needed and at an affordable cost, irrespective of sex, ethnic, social or any other background nor financial or health status. Primary coverage Predominantly public funding Compulsory (opting out not allowed) Broad benefit basket Access (and resource allocation) based on need (not capcity to pay) 28
Universality continuum Minimum level of care Equality in access to care Emergency care Basic benefit basket Positive selectivity measures 29
Access to healthcare services (the filter model) 1 Population coverage 2 3 Content of the benefit basket Cost-sharing arrangements 4 Geographical factors 5 Choice among available providers 6 Organisational barriers Busse et al. 2007 7 Preferences
100% 90% 80% 70% 60% 50% The well-known 20/80 distribution actually the 5/50 or 10/70 problem 5 5 5 5 10 10 10 How can we predict who these 5 or 10% are? 53,2 40% 15,6 30% 20% 50 8,8 5,6 10% 0% % of population % of expenditure 6,9 4 2,5 3,4
Fragmentation of pooling limits insurance potential of public funds Source: J. Kutzin, WHO EURO 32
25 Private health insurance as a proportion of total expenditure on health, 2005 Source: WHO 2007 20 15 10 5 0 SVK BGR EST CZE SWE LTU POL LVA HUN ITA UK LUX DNK MLT GRC FIN BEL PRT CYP ROU ESP IRL AUT GER SVN FRA NLD Substitutive Complementary (user charges) Complementary (services) Supplementary Mixed complementary/supplementary
The new Dutch basic health insurance: a social insurance with private mechanisms or a private insurance with social safeguards? Employer Income-related contribution 50% Government Healthcare allowance (means tested) Insured Tax contribution 5% Flat-rate premium 45% average: 1000 p.a. Annual deductible of 150 Pooling fund Insurer Risk equalisation payment
The basic health insurance in the Netherlands: balancing between competition and solidarity Nationally operating private health insurers (profit not-for-profit) Free choice of insurer Nominal premium Collective contracts (-10%) Product choice: In kind reimbursement Deductibles (150-500 ) Complementary insurance Insurance obligation Uniform basic package Obligation to insure Prohibition of risk rating Premium subsidy for lower incomes Income-related (employers)contribution + public funding of aged -18 Statutory system of risk structure compensation Catastrophic illnesses excluded (AWBZ) 35
Universalisation of SHI systems From mandatory insurance to mandate to insure (NL, D) Corollary: obligation to accept subscribers Operating choice? Increasing solidarity-base lifting contribution ceilings, extending scope, restricting opting out (F, D) Abolishing waiting periods Aligning cover for different schemes, groups (B, IRL) Eligibility based on residence (F, LTV, etc.) F basic universal coverage (CMU): residual category State-funding of certain groups (non-active) Children, pensioners, unemployed, students, social assistance, etc.. 36
Defaulters Stabilising SHI right (D, F, B): annual right, revert to last insurance Collection: monitoring payment of contributions Small insurance base may impede on willingness to contribute (BLG, ROM) Enforcement policies (CH, NL) Administrative fines, claim back premium subsidies Suspend cover, deny care Disentangling entitlements to care from payment of contributions (HUN) Recuperation through taxes 37
Migrants (assylum seekers, illegal residents, internal migrants) Special schemes (D, F for illegals): Often restricted to emergency - essential care Integration in general scheme (F for assylum seekers after 3 months) Socially excluded groups Administrative as well as language and cultural barriers, discrimination Special health centres Use of health mediators Important role for local authorities, social assistance bodies 38
Service and cost coverage Definition of services (benefit basket) Most cited gaps: dental and mental care Level of coverage (cost sharing) Generalisation of user charges (D) Regressiv: increasing inequalities in access no evidence of efficiency gains or LT cost savings Different types: co-insurance, co-payment, deductibles, extra billing, informal payments Conditions and modalities (incl. type of provider) Procedure for inclusion of new treatments (e.g. HTA) Margin for purchasers? Package and co-pay design Treatment models Complementary insurance 39
Access problems due to financial difficulties in Poland (2000-05) hospital 2 2 3 sanatorium rehabilitation 10 11 11 14 17 22 2005r. 2003 r. medical examinations 8 9 13 2000 r. physicians visits 15 17 25 dental prosthetics 15 15 17 dental care 31 30 38 medicines 33 34 36 0 10 20 30 40 50 % gospodarstw domow ych 40
Latvia (2005): even with universal coverage access problems can persist Xu K, Saksena P, Carrin G, Jowett M, Kutzin J, Rurane A, 2009
Out-of-pocket expenditure: protection mechanisms User charge exemptions Age (children, elderly) Social status Health status (e.g. pregnancy, chronic illness) Income level Exemption treshold (OOP ceiling), but Scope? Uniform or income-related? Preferential reimbursement Extra billing prohibition + third party payer 42
Latvia (2006): average household OOP per month per quintile Xu K, Saksena P, Carrin G, Jowett M, Kutzin J, Rurane A, 2009
Catastrophic expenditure
Changes in financial protection following a change in priorities (Estonia) Percent of households incurring high level of outof-pocket spending Percent of households impoverished by out-ofpocket health spending Percent of households 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 3.4% 6.4% 7.4% Percent of households 1.5% 1.2% 0.9% 0.6% 0.3% 1.0% 1.3% 1.4% 0.0% 1995 2001 2002 0.0% 1995 2001 2002 Source: Habicht et al. (2006). Detecting changes in financial protection: creating evidence for policy in Estonia. Health Policy and Planning 21(6): 421-31.
Private health insurance Substitutive insurance Life-insurance rules (age-at-entry rating) + transferability of age reserve (D) Legally fixed substitutive basic tarif (D) Complementary insurance Open enrolment/life-long insurance/premium regulation (IRL, SVN, B) Risk adjustment system (IRL, SVN) Free complementary health insurance + voucher system (F) Tax credits only for contracts with social safeguards (F) Prohibition of re-insurance (D, F) Informal payments? Solidarity with statutory system? 46
Comparison of health status and access to health care among privately and publicly insured people in Germany, 2001-2005 Prevalence of: People aged 65+* Chronic disease** Self-reported poor health** GP contact** Specialist contact (OP) Difficulties in paying for OP prescription drugs** Public (%) 22 23 21 81 47 26 Private (%) 11 11 9 55 45 7 Sources: Mielck and Helmert 2006 and *Schneider 2003 ** Statistically significant after controlling for differences in age, gender and income 47
12 Total health expenditure as % of gross domestic product (GDP) 11 10 9 8 7 6 5 Austria Belgium Denmark Finland France Germany Greece Ireland Italy Luxembourg Netherlands Norway Spain Sweden Switzerland United Kingdom EU members before May 2004 Eur-A 4 3 1970 1980 1990 2000 2010 2020 48
Solidarity vs. sustainability? Financial protection and equity of finance are key Universal access and solidarity central in most European systems Solidarity (integration, financing, benefits) Trade-off: macro-economic context (constraints) Collecting capacity Health as priority in public financing Increasing financial pressure (cost, public finances) Looking for efficiency gains/savings Issues Increasing role for out of pocket (with exemptions and ceilings) and for private voluntary insurance Fragmentation of pools 49
10 9 8 7 6 5 4 3 2 1 0 Source: WHO Public health expenditure as % of GDP 50 France Cyprus Latvia Estonia Bulgaria Poland Romania Lithuania Slovakia Greece Malta Hungary Slovenia Spain Czech Republic Finland Ireland Luxembourg Italy Belgium Portugal United Kingdom Sweden Netherlands Austria Germany Denmark 1997 2007
General public expenditure as % of GDP 70 60 50 40 30 20 10 0 Source: WHO 51 Slovakia Estonia Latvia Lithuania Ireland Romania Luxembourg Spain Cyprus Bulgaria Poland Malta Slovenia United Kingdom Germany Czech Republic Netherlands Portugal Finland Italy Austria Belgium Hungary Denmark France Sweden Greece 1997 2007
Health expenditure as % of total public expenditure 20 18 16 14 12 10 8 6 4 2 0 Source: WHO 2007 52 Cyprus Latvia Poland Bulgaria Greece Romania Hungary Estonia Lithuania Finland Czech Republic Slovenia Malta Italy Sweden Belgium Slovakia Portugal Spain Austria United Kingdom France Netherlands Luxembourg Ireland Germany Denmark 1997 2007
Different health priorities in a similar fiscal context Country Total public spending as % of GDP Public health spending as % of total public spending Out-of-pocket spending as % of total health spending France 52.4 16.5 6.7 Czech Republic 44.9 13.5 11.9 UK 44.1 16.3 11.6 Cyprus 40.3 7.0 45.9 Ireland 36.4 17.2 11.6 Estonia 35.5 11.8 20.4 Source: adapted from Kutzin 2008; WHO data for 2007 53
Switzerland Priority to health in the government budget 20 15 10 5 0 Azerbaijan Tajikistan Georgia Armenia Cyprus Uzbekistan Russia Latvia Albania Kyrgyzstan Poland Ukraine Greece Austria Belarus Kazakhstan Bulgaria Romania Israel Finland Moldova Estonia Bosnia-Herz Hungary Netherlands Slovakia Turkmenistan Belgium Denmark Italy Luxembourg Spain Serbia Slovenia Portugal Malta France Sweden Turkey Croatia Czech Rep Lithuania UK Ireland FYR Macedonia Germany Norway Iceland Source: WHO estimates for 2004 54 Health as % of total government spending
Why it s important: public spending on health matters (for our objectives) The more that governments spend on health, the lower the burden of outof-pocket spending on their population (with variation: policy matters too!) 80% 70% TJK AZE GEO OOPS as % total health spending 60% 50% 40% 30% 20% 10% ARM KGZ ALB UZB KAZ TKM CYP LVA RUS MDA BGR ROU UKR EST POL BIH GRC LTU BLRAUT SVK ESP TURFIN ISR HUN BEL ITA MKD IRL NLD LUX HRV CHE PRT GBR SVN CZE SCG MLT DNK NOR ISL SWE FRA DEU R 2 = 0.80 0% 0.0% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% Public spending on health as %GDP 55 Source: WHO estimates for 2003, European Member-States w population > 600,000
Out-of-pocket payments as % of total health expenditure (2002) BIH, 50 Bulgaria, 46 Russia, 44 Moldova, 42 Serbia, 38 Romania, 34 Turkey, 34 Ukraine, 29 Belarus, 26 Croatia, 19 FYROM, 15 Albania, 61 0 10 20 30 40 50 60 70 WHO / WB estimate 2005 56
Poverty still widespread in large parts 100 90 80 70 60 Absolute poverty rates (%), around 2003 Above US$ 2.15 but below US$ 4.30 Below US$ 2.15 a day 23 22 34 37 35 44 50 48 45 40 30 20 10 0 36 25 21 26 28 21 19 15 12 0 3 3 5 4 2 4 5 6 46 33 28 16 24 19 26 9 2 3 69 73 74 56 42 5 49 55 Hungary Poland Latvia Estonia Lithuania Bosnia TFYR Macedonia Bulgaria Serbia Romania Albania Belarus Ukraine Russian Federation Republic of Moldova Kazakhstan Uzbekistan Kyrgyzstan Tajikistan Azerbaijan Georgia Armenia CEE5 BALTIC STATES SOUTH-EASTERN EUROPE WESTERN CIS CENTRAL ASIA CAUCASUS Source: Alam et al. (2005)
Monitoring and analysis Emphasis on vulnerable populations Homeless Irregular employment Migrants Ethnic minorities Refugees Addicts (alcohol, narcotics) Sex workers 58
Strengthening social safety nets Ensuring protection from catastrophic expenditure Tackling informal payments, especially where they are regressive Ensuring benefit systems respond rapidly when people become unemployed Ensuring affordability of pharmaceuticals Especially where currency depreciations increase price Especially for people with chronic illness Tackling profiteering and counterfeit drugs Transferring taxes on drugs to taxes on tobacco (or airline tickets?) 59
HiAP: intersectoral action on health determinants The entry point for Health in All Policies The so called determinants of health influence the health of the population and individuals Changes in the determinants may result in changes in the health of the population and individuals Some determinants are amenable to policy changes! (Dahlgren and Whitehead 1991) 60
Health is wealth: the virtuous circle sickness health wealth poverty
Thank you for your attention Analysing Health Systems and Policies
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