Social health insurance development in Mongolia: Opportunities and challenges in moving towards Universal Health Coverage

Mongolia achieved high population coverage under mandatory health insurance relatively quickly. This fact was viewed by policy‐ and decision‐makers as a central issue for health financing reform in Mongolia. Health insurance brought many new features for health service planning, provision, funding and resource management. Based on initial achievements, health insurance came to be strategically considered as the vehicle for achieving universal coverage. The article analyses developments in Mongolia's health insurance over the last decade along with the core policy dimensions of Universal Health Coverage. It examines various reform approaches and the numerous amendments to laws that have been implemented during this period and discusses new opportunities as well as challenges. The analytical review and findings discussed suggest that Mongolia has a need for evidence‐based policy decisions and informed political support, with health insurance backed by robust institutional and administrative capacities. More generally, it also emphasizes that health policy goals and objectives can be attained by strengthening and making transparent and publicly‐accountable all health system financing functions and arrangements. The policy analysis, experiences, lessons and proposed strategies presented with regard to Mongolia intend to stimulate wider discussions on health insurance development as well as promote continuing focused research on specific aspects of health insurance and public financing reform.     

Party control, policy reforms, and the impact on health insurance coverage in the U.S. states

Objectives. One of the major policy concerns at the federal and state level is the rising number of individuals without health insurance. The purpose of this article is to investigate whether party control of government and various state reforms impact the percentage of the state population without health insurance.Methods. Using data from 1987–2007, I empirically examine whether party control and five state policy reforms reduce the uninsured population.Results. The results show that Republicans are more effective than Democrats at the state level at reducing insurance gaps and that three of five policy reforms explored appear to significantly expand insurance coverage.Conclusions. The results provide valuable insight into which components of health-care reform at the national level may help address the health insurance problem.     

Health insurance coverage of Hispanic adults: An assessment of subgroup difference and the impact of immigration

This research explores the health insurance coverage of various Hispanic subgroups in comparison to non-Hispanic whites and blacks. The impact of immigration status is also considered as we hypothesize that nativity, duration, and naturalization tap a possible process of structural acculturation that increases access to insurance coverage for Hispanic groups. We find that the immigration variables impact the type of insurance reported. However, race/ethnic disparities continue to exist, with the various Hispanic subgroups more likely to report miscellaneous government health insurance or no health insurance coverage as compared to non-Hispanic whites.     

Welfare reform and elderly immigrants' health insurance coverage: the roles of federal and state medicaid eligibility rules

Immigrants' access to federally-funded Medicaid became limited after welfare reform imposed restrictive noncitizen eligibility rules. This study used a representative sample from the Current Population Survey (N?=?105,873) and state-level data to examine the effects of these policy changes on elderly immigrants. Triple difference-in-differences analyses show that federal restriction of eligibility had a significantly negative association with elderly immigrants' Medicaid coverage, and generous state eligibility had significantly positive relationships with Medicaid and any health insurance coverage. Findings indicate the important role of eligibility on elderly immigrants' health insurance coverage. Results call for social workers' actions to expand elderly immigrants' Medicaid eligibility.     

Private Health Insurance in Chile: Basic or Complementary Insurance for Outpatient Services?

A private health insurance system has existed in Chile since 1981 and has covered over a quarter of the population of that country since 1995. This article examines that system in economic terms. The analysis focuses on the incentive effects of state regulations governing the formulation of private health insurance policies and the relationship with the state health service. The imbalance in policy termination rights and the unrestricted possibility to return to the state system emerge as central functional elements. The article postulates that the private system represents, for many, not a full coverage scheme but an additional policy for outpatient benefits, regardless of its officially stated aims.     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

Divergence in the development of public health insurance in Japan and the Republic of Korea: A multiple‐payer versus a single‐payer system

Japan and the Republic of Korea achieved universal health insurance coverage for their populations in 1961 and 1989, respectively. At present, Japan continues to operate a multiple‐payer social health insurance system, while the Republic of Korea has moved to an integrated single‐payer national health insurance structure. This article analyzes the influence of political economy in shaping the policy divergence found between these two Bismarckian health insurance systems. Issues addressed include differences in political power, the policy influence of business, the extent to which regional autonomy has developed and regional traits have been preserved, the level of political democratization, the form of political leadership, and the scale of development of the health insurance system. The article offers policy lessons derived from the two countries' experiences.     

Welfare Reform and Elderly Immigrants' Health Insurance Coverage: The Roles of Federal and State Medicaid Eligibility Rules

Immigrants' access to federally-funded Medicaid became limited after welfare reform imposed restrictive noncitizen eligibility rules. This study used a representative sample from the Current Population Survey (N?=?105,873) and state-level data to examine the effects of these policy changes on elderly immigrants. Triple difference-in-differences analyses show that federal restriction of eligibility had a significantly negative association with elderly immigrants' Medicaid coverage, and generous state eligibility had significantly positive relationships with Medicaid and any health insurance coverage. Findings indicate the important role of eligibility on elderly immigrants' health insurance coverage. Results call for social workers' actions to expand elderly immigrants' Medicaid eligibility.     

Social Insurance and Older Adults in China: Effect of Education and Household Income on Coverage Following the 2009 Health Reform

Abstract

Education and income have been considered two primary determinants to affect individuals’ health outcomes. China initiated a comprehensive health reform in 2009, with the goals to provide equal access yet sufficient healthcare to all residents. However, social disparities continue to persist following this large reform. This research hypothesized that older adults’ years of education and income are determinants of participation in each social insurance scheme following the 2009 health reform. Multilevel logistic regression models were used with a nationally representative sample (n?=?5,274) to investigate the education and income disparities in each social insurance scheme for older adults, with random effects among provinces at the national level. The analyses show that years of education was not associated with enrollment in three social insurances, with the exception of the association between 11?years of formal education or above and the rural coverage. Participants with higher levels of household income had greater odds of having urban social insurances, but had lower odds of having the rural scheme. Further research should continue to investigate the disparities of enrollment of each social insurance. Chinese policy makers should consider these social factors carefully to reach a true universal coverage.     

Explaining Different Paths in Social Health Insurance Countries – Health System Change and Cross‐border Lesson‐drawing between Germany,Austria and the Netherlands

The issues of ‘policy diffusion’ or ‘policy transfer’ and ‘mutual learning’ have become important topics in comparative research on social policy and health systems. In current debates on explaining reform in ‘Bismarckian’ social (health) insurance systems, however, these issues have been neglected. In particular, the role of ‘negative lesson‐drawing’ in the sense of avoiding mistakes of others has not often been considered. This article compares health system change in Germany, Austria and the Netherlands, three countries with health systems of the social insurance type. In contrast to the existing literature, our analysis stresses that these countries have taken different reform paths since the 1990s. By applying a most similar systems design, we analyze how far cross‐border lesson‐drawing has contributed to health system divergence in the three countries. The empirical basis of the analysis is semi‐structured qualitative expert interviews, a method appropriate for tracing processes of lesson‐drawing. We argue that in order to fully understand the diverging reform trajectories, we need to take into account how political decision‐makers refer to (negative) experiences of other countries. Generally, national driving forces for health system change were at the heart of many crucial reforms during the period studied. Nevertheless, we claim that it was the German bad practice role model that kept the reform paths of Austria and Germany apart in the Austrian health reform discussion between 2000 and 2005.     

The role of mutuals and community-based insurance in social health protection systems: International experience on delegated functions

The institutional architecture for the provision of social health protection varies across countries, as do the actors and organizations involved. In some countries, mutual benefit societies and community-based health insurance organizations (CBHI) play a role in this area. In the 1990s, these were promoted particularly as a means of extending social security coverage, especially in sub-Saharan Africa. In the current context, the adoption of the 2030 Agenda for sustainable development, as well as renewed political will to realize universal coverage, has led to a questioning of the role of mutuals/CBHI. However, the literature on the roles they play in national social security systems remains limited. For this scoping review, 49 documents were analysed, covering 18 countries worldwide, focused on the delegation of functions to mutuals/CBHI in national social health protection systems. The results reveal the dynamics of the delegation of functions within social protection systems over time and their implementation processes. These provide areas for reflection that can inform policy processes.     

The Fiscal Crisis of National Health Insurance in the Republic of Korea: In Search of a New Paradigm

In 2001, National Health Insurance (NHI) in Korea, the social insurance system for health care with universal population coverage, experienced a serious fiscal crisis as its accumulated surplus was depleted. This fiscal crisis is attributed to its chronic imbalance: health care expenditure has increased more rapidly than have insurance contributions. The recent failure in implementing pharmaceutical reform was a further blow to the deteriorating fiscal status of the NHI. Although the NHI has since recovered from the immediate fiscal crisis, this has mainly been because of a temporary increase in government subsidy into the NHI. The strong influence of the medical profession in health policy‐making remains a major barrier to the introduction of policy changes, such as a reform of the payment system to strengthen the fiscal foundations of the NHI. Korea also has to restructure its national health insurance in an era of very rapid population ageing. A new paradigm is called for in the governance of the NHI: to empower groups of consumers and payers in the policy and major decision‐making process of the NHI. The fiscal crisis in Korean national health insurance sheds light on the vulnerability of the social health insurance system to financial instability, the crucial role of provider payment schemes in health cost containment, the importance of governance in health policy, and the unintended burdens of health care reform on health care financing systems.     

社会医疗保险对老年人健康水平的影响：基于浙江省的实证研究

本研究根据2010年浙江省城乡老年人口生活状况调查的数据认为,对于老年人的社会医疗保险问题,不仅要关注保险覆盖面的扩大,更应关注不同保险项目参保老人之间的健康平等。在揭示医疗服务使用与健康水平负向关系这一主效应的基础上,研究发现,职工医保作为moderator可以改善使用较多医疗服务老人的健康水平,新农合的作用则相反。研究希望对医疗保险的改革思路进行反思,全民医保的改革思路不仅是医疗服务可及性的提高,更应该是不同社群享有平等的医疗福利,并最终促进健康结果的平等。     

Question worth 20 million lives: Why federal housing assistance has not had its Obamacare

The equitable character of a policy determines its progressiveness, yet some domestic policies are more equitable than others. The question of how and why this is the case is addressed by studying federal housing and health policies in the United States, a critical case known for its rampant inequalities in both sectors. Although social equity is a fundamental aspect of welfare provision, explaining differences in coverage and government support among policy areas remains a weakness in the literature. This comparative historical analysis shows that both housing assistance and health care suffered from inequities almost as early as their inception. But a progressive reform took shape with the Affordable Care Act (ACA) and extended coverage to 20 million people formerly uninsured. This essay tackles an unsolved puzzle: Why has such grand policy reform never taken place in housing where more than 20 million people are eligible for assistance but do not receive help? We found that it is largely explained by housing assistance distinctiveness with regard to its weak constituency, racial connotation and low public concern. We conclude with the analytical payoffs of studying social equity, both for political scientists and observers of social affairs.     

Obamacare and the Politics of Universal Health Insurance Coverage in the United States

In the USA, universal coverage has long been a key objective of liberal reformers. Yet, despite the enactment of the Patient Protection and Affordable Care Act (PPACA) (commonly known as ‘Obamacare’) in 2010, the USA is not set to provide health care coverage to all, even if and when that reform is fully implemented. This article explores this issue by asking the following question: Why was a clear commitment to universal coverage, the norm in other industrialized countries, excluded as a core objective of the PPACA and how has post‐enactment politics at both the federal and the state level further shaped coverage issues? The analysis traces the issue of universal coverage prior to the debate over the PPACA, during the 2008 presidential race, and during consideration of the bill. The article then looks at the post‐enactment politics of coverage, with a particular focus on how states have responded to the planned use of the Medicaid programme to expand access to care. The article concludes by discussing how an explanation of the limits of the PPACA, in terms of both its commitment to universal coverage and, more importantly, the failure to provide comprehensive health insurance to all, requires an understanding of complex institutional and policy dynamics.     

The construction of the medical insurance system in the Republic of Korea, 1963–1989

The task of bringing a whole population into medical insurance coverage is a challenging one for a country's health policy makers. The outcomes of health policy differ significantly from one country to another depending on each state's socio-economic and political background. Health policy in Korea is to a great extent incremental in character and the consequence of a variety of causal events. This is why it has been difficult to apply the established social welfare theories to the Korean case. In any event, the Korean national medical insurance system, constructed between 1963 and 1989, reveals some similarity to that in Japan, i.e., compartmentalization of financial and administrative units as well as inequality in contributions and benefits. The system also reflects Korea's traditional Confucian value which emphasizes mutual dependence between family members.     

Social Health Insurance: Key Factors Affecting the Transition Towards Universal Coverage

Several low- and middle-income countries are interested in extending their existing health insurance for specific groups to eventually cover their entire populations. For those countries interested in such an extension, it is important to understand the factors that affect the transition from incomplete to universal coverage. This paper analyses the experience of eight countries in the implementation of social health insurance. It highlights the importance of the socioeconomic and political context, particularly in relation to the level of income, structure of the economy, distribution of the population, ability to administer and level of solidarity within the country, but also stresses the important stewardship role government can play in facilitating the transition to universal coverage via social health insurance.     

Health Care in Asia and the Pacific: Increasing the focus on social health insurance

This paper focuses on health insurance reform within the broader frameworks of both social security and health services system development. In most countries in Asia and the Pacific, it is indeed the reform of the health services system, through policy changes in health care financing, that has led to an increased focus on health insurance. The underlying issue in this reform is the shift in responsibility that has taken place in most countries in the region over recent years. In the past, governments were responsible for financing health care for their populations. This shifted to defining, legislating and implementing an appropriate health care financing mechanism, presenting several challenges: to reach universal health insurance coverage through new initiatives for new populations, mainly the informal sector accounting for the majority of the population in almost all these countries; to apply provider payment systems that enable control over costs and the volume of utilization; and to strengthen primary health care as a foundation for rational utilization and more resources for prevention, including prevention of chronic diseases among the ageing population. This approach will require an active partnership between health insurance schemes and government that should reflect the new division of responsibilities to guarantee access to high-quality health care for all.     

Extension of social insurance coverage to informal economy workers in China: An administrative and institutional perspective

This article reviews administrative issues in the context of decentralized social protection in China. In particular, what are the main obstacles to expanding social insurance coverage for workers in the informal economy? Over the last two decades, China has achieved remarkable progress toward universal social protection when this target was set as a national policy priority. However, the social insurance enrolment of informal economy workers still lags significantly behind. This article reviews the application of the International Labour Organization’s definition of informality in the Chinese context and overviews existing pension and health insurances in China. This article discusses the impact of China’s inter‐governmental fiscal relations and decentralized social protection in the multilevel government system. The article highlights that under a system of decentralized managed social insurance many informal economy workers choose to opt out of the system because of low benefits and high compliance costs. This result in deficits in social insurance coverage amongst informal economy workers.