1. Health Care Financing: Insurance Health Economic Course Series: 3 of 12 www.diankusuma.wordpress.com

2. Experience with exemption schemes User fees: –Decreased necessary utilization, –Especially of the poor and vulnerable (regressive) Exemptions: –Inaccurate –High administrative costs, slow –Adverse incentives depending on where revenu was retained Problem of catastrophic expenditure remains

3. Risk and Gambling Which of the following would you accept? –A lunch voucher for $10 –A lottery ticket worth $1 with a 1 in 3.000.000 chances of winning $ 10.000.000 –One years bicycle insurance worth $50. paying $400 if your bike is stolen (10% chance in Palembang)

4. Rational Gambler ProbabilityValue Uncertain Event Expected Value Lunch voucher 1$10=$10 Lottery ticket0,00000033$10.000.000=$3,3 Bike Insurance 0,1$400=$40

5. Role of Insurance = Use if contracts to redistribute risk of health care expenditure costs, whereby Insurer accepts fixed payment (premium) from insured Insurer contracted to make payments for uncertain events when they happen (to patient or provider) Demanded when expected value of costs is larger or equal to premium, but most people willing to pay more for security (risk averse)

6. Premiums Premium = Average expenditure on benefits (expected value) + administration costs (+profits) Number insured Paid in advance!

7. Types of insurance General Taxation Earmarked taxation Social insurance Community Insurance Private insurance FinanciersTax payers Employee and employer taxpayers CommunityIndividuals Earmarked contributions NoYes Entitlement linked to contributions No Yes

8. Key Issues 1.Adverse selection 2.Moral hazard 3.Willingness to pay 4.Management of risk

9. Adverse selection A process that occurs due to asymmetric information between insurer and insured  Impossible to know individual risk  average risk basis for premium for people with different risks  Those with low risks drop out  leaving only individuals with high risks  drop-out of those with lower risks increases the premiums per remaining insured  Process continues until no one is insured Solution -Compulsion / group joining the scheme -Risk-rating (age, sex, medical history)

10. Risk-rating and cream-skimming In order to avoid adverse selection, insurers could opt for risk selection –E.g. Insure specific groups or set premiums according to risk Risk of exclusion: Of those with high probability of illness Of those with chronic disease or current illness –Direct (e.g. targeted marketing) –Indirect (high premiums excluded people)

11. Moral Hazard Excess demand resulting from services being free after the premium has been paid:  Lack of incentives to reduce probability and magnitude of claimed benefits (over-consumption)  Cost of insurance payments exceed the premium  Insurance scheme unsustainable  Process continues until no one is insured! Solution Co-payments Limiting benefits package Waiting periods No-claims-bonus

12. Willingness to pay Surveys indicate that communities are willing to pay moderate to be insured But often experience is different: –Concept of insurance new, –Limited trust in insurance providers –Willingness to pay for others may be new –Ability to pay Solution: –Education –Subsidized schemes –Compulsory schemes

13. Management of risk Health care risk difficult to assess –Uncertain across small population groups (15.000) –Difficult to measure extent of uncertainty –Costs often unknown –Epidemics unexpected  Challenge of setting sustainable and affordable premiums Solutions: –Regulation –Capacity building –Re-insurance

14. The aims of Financing Reforms 1.Improve the amount of resources available (including stability/sustainability) 2.Improve the efficiency and equity of the allocation of resources (and thus eventually health outcomes) 3.Reduce catastrophic expenditure (risk- sharing/pooling, prepayment) 4.Support broader health sector aims such as responsiveness / quality improvement

15. Example: community financing Volunteer or paid community member manages the scheme Households pay into the scheme and receive benefits when needed Usually small scale Usually focus on hospitals, although can also be used for primary care Provider / community initiated

16. Experience? Raise revenues? –Low coverage (WTP) (most less than 5%, a few >80%) Sustainable? –High turnover members and schemes –Better when linked to existing insurance –Moral hazard can be reduced, but there can be problems with cost control –Sustainability affected by resources, external aid, providers, solidarity, trust, and prior institution

17. Experience? Equity and efficiency? (evidence base weak) –Membership rules vary, but generally voluntary –Adverse selection –Poor can be under-represented –May discourage use of some preventive services, favor curative care –Limited benefits due to size & supply –Complex to manage

18. Key issues Embedded within s national financing strategy Working through existing, trustworthy institutions Enabling rather than blueprint approach As “mandatory” as possible for all groups (cross- subsidization) Special provision for poor Links with providers Re-insurance Capacity support

19. Process? Inequalities may exist while different systems developing? User fees Introduction of community insurance Encouraging private insurance for rich/middle income groups Introduction of social insurance Universal coverage?

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