The Economics of Public Health Care Reform in Advanced and Emerging Economies Benedict Clements Fiscal Affairs Department, IMF November 2012 This presentation represents the views of the author and should not be attributed to the IMF, its Executive Board, or its management. 1
This presentation is based on the book, The Economics of Public Health Care Reform in Advanced and Emerging Economies, which draws on contributions from leading scholars in health economics from both advanced and emerging economies 2
Outline I. Fiscal context of health care reform II. Trends and outlook for public health spending III. Health care reform in advanced economies IV. Health care reform in emerging economies V. Summary 3
I. The fiscal context of health care reform 4
I. Debt ratios remain at historic levels in advanced economies 140 Public Debt, percent of GDP 120 100 World War II Great Recession 80 Advanced 60 40 20 Emerging 0 1880 1885 1890 1895 1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 5
I. Substantial adjustment is needed to bring debt ratios to appropriate levels in advanced economies 20 Illustrative Adjustment Needs, percent of GDP 15 10 8.0 5 0-5 6
I. Emerging economies are in a stronger overall fiscal position, but some countries are vulnerable 10 Illustrative Adjustment Needs, percent of GDP 8 6 4 Emerging Latin America 2 1.1 0-2 -4-6 7
II. Trends and outlook of public health spending 8
II. Led by public sector, large spending increases in advanced economies over past 40 years Health spending in 27 advanced economies (percent of GDP) 12 10 Periods of Acceleration 8 Private 6 4 Public 2 0 1970 1975 1980 1985 1990 1995 2000 2005 9
II. Increases in public health spending were much smaller in emerging economies 6 Health spending in 23 emerging economies (percent of GDP) 5 4 3 Private 2 1 Public 0 1970 1975 1980 1985 1990 1995 2000 2005 10
II. Main drivers of public health spending Population aging explains about one fourth of the increase in spending-to-gdp ratios Excess Cost Growth (ECG) the difference between real health expenditure growth and real GDP growth explains the rest Technology Health policies and institutions Other factors 11
II. Public spending pressures in advanced countries are substantial 6 5 Projected increases in public health spending (percent of GDP), 2011-2030 Aging Excess cost growth Weighted average=3.0 Unweighted average=2.2 4 3 2 1 0 12
II. Excess cost growth accounts for most of the increases in public health spending in advanced Europe and the US 9 8 7 United States IMF advanced EU estimate European Commission advanced EU estimate 2012 6 5 4 3 2 1 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030 13
II. Projected increases in public health spending add significantly to the already large adjustment needs 20 Illustrative Adjustment Needs and Age-related Spending, percent of GDP 15 Projected increases in health spending Projected increases in pension spending Illustrative adjustment needs 10 3% 1% 5 8% 0-5 14
II. Projected increases lower for emerging economies, especially emerging Asia 2.5 Projected increases in public health spending (percent of GDP), 2011-2030 Aging 2.0 Emerging Latin America Excess cost growth Weighted average=1.0 Unweighted average=1.1 1.5 1.0 0.5 0.0 15
II. Age-related spending puts pressure on the adjustment needs of some emerging economies 10 Illustrative Adjustment Needs and Age-related Spending, percent of GDP 8 Emerging Latin America 6 4 2 1% 1.9% 0 1.1% -2-4 -6 16
III. Health care reform in advanced economies 17
III. Three Methodologies Case studies Event analysis Econometric analysis linking indicators of health care systems and excess cost growth (ECG) 18
III. Our results suggest five viable options to contain public health spending growth Budget caps (Italy, Japan, and Sweden) Greater sub-national government involvement (Canada and Sweden), gate-keeping and casebased payment (Germany and Italy) grouped under public management and coordination 19
III. Our results suggest five viable options to contain public health spending growth Competition and choice (Germany and Japan) Greater reliance on private financing, especially of complementary health care outside public package (Australia, Canada, and France) Restricting the supply of health inputs and outputs (Canada) 20
III. which have the potential to contain projected increases in public spending 0.6 Average Reform Impacts on Public Health Spending (percent of GDP), 2030 (Decrease Relative to Benchmark Projections) 0.5 0.49 0.4 0.37 0.3 0.26 0.2 0.1 0.08 0.05 0.0 Competition and choice Contracting and public management Budget caps Demand side Supply constraints 21
III. but subject to some caveats Simulated reform impacts need to be interpreted with caution Savings may not be large enough to avoid sizeable increases in spending some countries Therefore, deeper health reforms or cuts in other spending may be required to support required fiscal adjustment Reforms should ensure that health outcomes and access to care by the poor are not adversely affected 22
III. Some reforms don t work in containing spending growth Price controls Deregulation of insurers Greater availability of information on the quality and price of health services to patients 23
III. Reform options depend on country characteristics and projected growth For countries that rely more heavily on competition and choice: Low Excess Cost Growth (0-0.6): Canada, Czech Republic, France, Germany, Japan, and Slovakia Staying the course with marginal reforms Moderate Excess Cost Growth (0.6-1.0): Australia, Austria, Belgium, and Netherlands Tightening budget constraints Strengthening gate-keeping Increasing cost-sharing 24
III. Reform options depend on country characteristics and projected growth High Excess Cost Growth (greater than 1.0): Greece, Korea, Luxembourg, Switzerland, and United States Tightening budget constraints Increasing central oversight Strengthening regulations of the workforce and equipment Strengthening gate-keeping 25
III. Reform options depend on country characteristics and projected growth For countries that rely more heavily on public insurance and provision: Low Excess Cost Growth (0-0.6): Denmark, Ireland, Italy, and Sweden Moderate Excess Cost Growth (0.6-1.0): Norway and Spain Enhancing efficiency Tightening budget caps Improving priority setting Tightening macro-controls (including increasing central oversight) Broadening insurance for over-thebasic health care (increasing the share of health expenditures financed out of private insurance) Improving priority setting 26
III. Reform options depend on country characteristics and projected growth High Excess Cost Growth (Greater than 1.0): Iceland, Finland, Portugal, New Zealand, and the United Kingdom Strengthening supply constraints on workforce and equipment Extending the role of private health insurance for over-the-basic health care Increasing choice among providers 27
III. Potential reforms not included in the analysis Improved health information technology (HIT) could help improve efficiency Greater emphasis on primary and preventive care could also contribute to expenditure containment 28
IV. Health care reform in emerging economies 29
IV. Emerging economies lag behind in health outcomes and coverage 85 80 Life Expectancy Infant Mortality 35 30 25 10 9 8 7 (% of GDP) Out-Of-Pocket Private Insurance Public Insurance 75 70 20 15 6 5 4 10 3 65 5 2 1 60 Advanced Emerging Europe Emerging Latin America Other emerging 0 0 Advanced Emerging Europe Emerging Latin America Other emerging 30
IV. Reform challenges differ between emerging Europe and emerging Latin America and Asia In emerging Europe, coverage is almost complete; disease patterns mirror those in advanced economies; fiscal space is limited; must focus on efficiencyenhancing reforms In emerging Latin America and emerging Asia, disease patterns are transitioning from CDs to NCDs; these countries have greater fiscal space and need to expand coverage in a fiscally sustainable manner 31
IV. Emerging economies should learn from the experiences of advanced economies Cost containment is one of the biggest challenges following a successful coverage expansion (Korea, Taiwan Province of China) The private sector can play an important role Improving efficiency is the key to long-term system performance 32
IV. A single payer system has several advantages This is suggested by reform experiences in both advanced and emerging economies (Estonia, Thailand, Korea, Taiwan Province of China) It allows for more extensive risk pooling, and can help improve efficiency and control cost It provides a better platform to achieve equity It can also perform well in terms of promoting choice when combined with private provision 33
IV. Health reform in emerging Europe Many countries have successfully contained spending through reforms (Estonia, Hungary, Latvia, Russia and Ukraine) There is scope for additional micro-level reforms to improve efficiency Promoting healthy behaviors is also important 34
IV. Health reform in emerging Latin America and Asia Benefit packages should be restricted to most essential services as coverage expands (China, India and Mexico) Expansion should be tax-financed if labor market informality is high Improvements in the composition of spending can lead to better health outcomes without incurring additional costs 35
V. Summary 36
V. Summary For advanced economies: Fiscal adjustment needs are large and the projected increases in health spending account for a large share Health reforms can help contain projected spending increases The most effective strategy involves a mix of macrolevel controls and micro-level reforms to improve spending efficiency 37
V. Summary For emerging economies: Fiscal adjustments needs are less pressing, but some economies are vulnerable Efficiency-enhancing reforms should be a priority, especially for emerging Europe Coverage expansion in emerging Latin America and Asia should not jeopardize fiscal sustainability 38
Available at IMF Bookstore and Amazon.com There is also an accompanying video Thank you! 39