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  5. Strategies For, and Impacts Of, Increasing Health Insurance Coverage
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Strategies For, and Impacts Of, Increasing Health Insurance Coverage

Paper Session

Saturday, Jan. 7, 2023 8:00 AM - 10:00 AM (CST)

New Orleans Marriott, Mardi Gras Salon F, G & H
Hosted By: International Health Economics Association
  • Chair: John Cawley, Cornell University

Effect of Health Insurance in India: A Randomized Controlled Trial

Gabriella Conti
,
University College London
Alessandra Voena
,
Stanford University
Kosuke Imai
,
Harvard University
Cynthia Kinnan
,
Tufts University
Morgen Miller
,
University of Chicago
Anup Malani
,
University of Chicago
Shailender Swaminathan
,
Public Health Foundation of India

Abstract

Household financing of healthcare in LMICs like India is challenging. Many households are pushed into poverty by health costs, and care is often foregone. To address these issues, the Indian government in 2008 launched Rashtriya Swasthya Bima Yojana (RSBY), a publicly-financed hospital-insurance program for below-poverty-line households. In 2018 India replaced RSBY with Pradhan Mantri Jan Arogya Yojana (PMJAY), a plan covering all persons below the poverty line plus nearly 260m above it.

We conducted a large RCT between 2013 and 2018 to study the impact of expanding hospital insurance eligibility under RSBY -- an expansion subsequently implemented in PMJAY. Specifically, our experiment offered access to RSBY to above-poverty-line households. The study was conducted in the state of Karnataka, and the sample included 10,879 households in 435 villages. Ours is the largest health insurance experiment in emerging economies and the first to examine spillover effects. Households were randomly assigned to different access options: free insurance, sale of insurance, sale plus cash transfer, or control. To estimate spillover effects, the fraction of households offered insurance varied across villages.
We report four main findings. First, the opportunity to purchase insurance led to 59.91% uptake and access to free insurance to 78.71% uptake. Second, both access to and enrollment in insurance increased utilization, but many beneficiaries were unable to use their insurance and the utilization effect dissipated over time. Third, we find positive spillover effects on utilization, which suggest learning from peers. Fourth, across a range of measures we estimate no significant impacts on health.
Our findings have important implications. On the one hand, improved educational materials and increased investment in IT should be considered to alleviate the reported failures. On the other hand, marketing on encouraging a little utilization in a wide number of areas would allow an effective use of spillover effects.

The Impact of China’s Critical Insurance Illness Program on Health Care Use and Health Outcomes

Padmaja Ayyagari
,
University of South Florida
Jiaosi Li
,
University of South Florida

Abstract

Although China has made considerable progress towards universal health insurance coverage, high out-of-pocket medical expenditures remain a concern. To address this concern, the Critical Illness Insurance (CII) program was introduced in 2012. The CII program serves as supplementary insurance to enrollees of the New Rural Cooperative Medical Insurance Scheme (NCMS) and the Urban Residents Medical Insurance (URMI) program. In this study, we examine the impact of the CII program on inpatient expenditures, inpatient utilization, and health outcomes of older adults. We use data from the China Health and Retirement Longitudinal Study (CHARLS) combined with information on the date of implementation of the CII program implementation across different regions (prefectures) which we collected from local government websites. To account for the staggered implementation of CII across regions, we employ the doubly-robust difference-in-differences estimator proposed by Callaway and Sant'Anna (2020). We find that the CII program significantly reduced out-of-pocket inpatient expenditures among older adults. We also find a reduction in inpatient utilization, but this overall effect masks considerably heterogeneity across regions. The findings for health outcomes are somewhat mixed. We find improvements in self-rated health and activities-of-daily-living limitations but no significant improvements in mental health or metabolic diseases such as heart disease, diabetes, or hypertension. Results from event-study specifications and placebo tests support the causal interpretation of our estimates. Our findings suggest that the CII program was successful in improving the financial protection of older adults.

Voluntary Health Insurance and Socioeconomic Status as Drivers to Healthcare Utilization and Catastrophic Health Expenditure in Rural Tanzania

Alphoncina Kagaigai
,
University of Oslo
Amani Anaeli
,
Muhimbili University
Amani Thomas Mori
,
University of Bergen
Sverre Grepperud
,
University of Oslo
Tron Anders Moger
,
University of Oslo

Abstract

Background: Over 150 million people, mostly from low and middle-income countries (LMICs) suffer financial catastrophe each year because of high out-of-pocket (OOP) health payments. In Tanzania, the OOP payments account for about 24% of total health expenditure. This paper aimed to analyze the role of wealth (socioeconomic status) on healthcare utilization rates and the incidence of catastrophic health expenditure (CHE) among members and non-members of the improved Community Health Fund (iCHF) in rural Tanzania.
Methods: A survey was conducted in 722 households in two Districts of Bahi and Chamwino in Dodoma region. CHE was defined as households’ health expenditure exceeding 40% of total non-food expenditure i.e. capacity to pay (CHECP40) or 10% of total household expenditure (CHET10). The concentration index (CI) was used to assess socioeconomic inequalities in the distribution of healthcare utilization and CHE. Logistic regression was used to assess the association between CHE and iCHF membership status and wealth status.
Results: 50% and 29% of iCHF members and nonmembers utilized outpatient care in the previous month, while 19% and 15% utilized inpatient care in the previous twelve months, respectively. However, the level of inequality was higher for inpatient care (members, CI=0.38; non-members CI=0.29), compared to outpatient care (members, CI=0.09; nonmembers CI=0.16). Overall, 20% and 15% of the households experienced CHET10 and CHECP40, respectively. However, when disaggregated by iCHF membership status the incidence of CHET10 and CHECP40 was 21% and 15% among non-members and 18% and 13% among the members. The least poor households experienced more incidence of CHET10 and CHECP40 than the poorest in both the nonmember group (CI= 0.21 and 0.18) and iCHF member group (CI=0.26 and 0.30) respectively.

Wealth Impacts on Health Expenditures

Berna Tuncay Alpanda
,
Ozyegin University
Rohan Best
,
Macquarie University

Abstract

Studies of health care expenditure often exclude explanatory variables measuring wealth, despite the intuitive importance and policy relevance. We use the Household, Income and Labour Dynamics in Australia Survey to assess impacts of income and wealth on health expenditure. We investigate four different dependent variables related to health expenditure and use three main methodological approaches. These approaches include a first difference model and introduction of a lagged dependent variable into a cross-sectional context. The key findings include that wealth tends to be more important than income in identifying variation in health expenditure. This applies for spending on health practitioners and on private health insurance. It also applies for being unable to afford required medical treatment. In contrast, the paper includes no evidence of different impacts of income and wealth on spending on medicines, prescriptions, or pharmaceuticals. The results motivate two novel policy innovations. One is the introduction of an asset test for determining rebate eligibility for private health insurance. The second is greater focus on asset testing, rather than income tests, for a wide range of general welfare payments that can be used for health expenditure. Australia’s world-leading use of means testing can provide a test case for many countries.

Discussant(s)
Winnie Yip
,
Harvard University
John Ataguba
,
University of Manitoba
John Ataguba
,
University of Manitoba
JEL Classifications
  • I0 - General
  • I1 - Health