The effect of National Health Insurance on household out-of-pocket expenditure structure

• Main Authors: Yu-Chun Ku, 顧于君
• Other Authors: Christy Pu
• Format: Others
• Language: en_US
• Published: 2016
• Online Access: http://ndltd.ncl.edu.tw/handle/03865494022722311905

碩士 === 國立陽明大學 === 公共衛生研究所 === 104 === Research objective Taiwan implemented the National Health Insurance (NHI) program in 1995. The main objective of the NHI is to provide financial risk protection for the public. It is thus necessary to determine whether the NHI program has successfully reduced out-of-pocket (OOP) expenditure. Despite some studies on OOP are available, most of these studies only focused on how NHI affect the level of OOP expenditure, and very limited studies can be found on how OOP structure changes after the implementation of NHI. The structure of OOP is important because studies have shown that certain OOPs may be more related to essential treatments while others may not be as critical for improving quality of life. In order to estimate the actual benefits of implementing NHI, this study aims to investigate whether the implementation of NHI program affects the level and structures of OOP in Taiwan. Apart from OOP expenditure structure, we also evaluated the impact of NHI program on private health insurance spending. Study design We used the data of Taiwan Survey of Family Income and Expenditure (SFIE) released by the Directorate-General of Budget, Accounting and Statistics (DGBAS). The SFIE is conducted annually and consists of a national representative sample. Household is the unit of the analysis. We first identified people who were insured under the Government Employee Insurance (GEI) prior to 1995 (the year of NHI implementation). This group of people should be least affected by the implementation of NHI. Their household OOP structure was then compared to that of households without any form of social insurance prior to 1995 (the control group). To reduce selection bias, we used coarsened exact matching (CEM) to match the two groups using a number of available variables, including basic demographic variables, household income, occupation of the household head, family structure and residential location. The final study sample consists of 10,078 households in the control group and 5,893 households in the case group. We then conducted a differences-in-differences (DID) analysis with fractional response regressions to determine the effect of NHI on OOP structure. Principal findings The DID analysis showed that there was a statistically significant negative effect of NHI on OOP (a reduction of 1.24 percentage points in total household expenditure). The largest reduction was found in health care services (-0.69%), and pharmatheuticals (-0.43%). However, the structure of OOP expenditure has not reached a statistical significant change. Although private health insurance is not considered OOP under the international health accounting standard OOP, we still tested whether the implantation of NHI affected private health insurance purchases. We found a statistically significant positive effect of NHI on private health insurance purchases (an increase of 2.83 percentage points in the household budget share). In addition, we discovered that the NHI program had higher impact on households with lower socioeconomic status compared with higher socioeconomic status households. Conclusions The NHI program in Taiwan successfully reduced total OOP, and the breakdowns of household OOP has reduced for both health care services and pharmatheuticals. In addition, we found that the lower the socioeconomic status, the larger the decrease on OOP expenditure. This finding suggests that the NHI program has attained its preliminary goal for providing financial risk protection for the public. The structure of OOP expenditure has no significant change after the implementation of NHI. This indicates that the structures of NHI payment is similar to the original medical demand. Our results showed a significant positive spillover effect of NHI on private health insurance purchases, possible explanation may be that people gain more awareness on the importance of health insurance. Implications for policy or practice Implementing NHI is a major objective for many countries conducting health sector reform. Taiwan’s NHI reduced health financial burden by changing the level of OOP but leaving OOP structure unchanged, giving people a more complete health care systems. Key words Out-of-pocket, National Health Insurance, Difference-in-difference, Medical spending