25 Nov Healthcare Coverage for All
HEALTHCARE COVERAGE FOR ALL
Authors: James Houser (USA, Co-chair), Shereen Abu Manneh (Jordan), Shrikant Peters (South Africa), Sriram Ramachandran Sheshaadri. Reviewed by Tavy Alford (IHF Intern).
A country’s health is impacted by many factors, including the environment, access to nutrition, the economy, lifestyle, culture, and access to preventative and corrective healthcare services. Moreover, a countries healthcare is equally as influenced by its broader setting, including the clinical and financial needs of its population, political and monetary infrastructures, and education systems. This blog post will discuss how different countries organize their health care and payor systems to provide clinical care to all their citizens.
Ensuring that all people in the United States have access to healthcare has been a long-standing challenge. Healthcare in the United States can be obtained regardless of one’s ability to pay. However, navigating healthcare is significantly different for every citizen depending on their insurance provider and the mechanism of payment.
Of those insured in the United States, approximately 60% are insured via private health insurance, and 40% is insured by government1. Government-based insurance programs include Medicare, Medicaid, and the Military. Ten percent of the U.S. population is not insured and must either seek free care or pay for treatment out of pocket1. Noting the financial coverage models via insurance is essential in the United States, as each payor only covers specific health services.
Payment innovation has been increasingly common on payors as well, where providers and payors collaborate to identify new payment models to cover healthcare while prioritizing services. Most recently, many companies have been focusing on increasing access and the utilization of primary care to decrease the necessity of secondary or tertiary care. These efforts are due to notable trends of increased health care spending seen in the treatment of disease versus prevention. According to the Centres for Medicare and Medicaid Services, health expenditures are primarily allocated to Hospital Care (31%), Physician Services (15%), and Retail Prescription Drugs (10%).
While payment penalties and bundles are notable payor innovations, it is the Accountable Care Organizations (ACOs) that have gained increasing popularity in recent years. The rise of ACOs has been related to more than the need to reduce cost. ACOs are timely in that more providers have been transitioning to employed models. ACOs also help provider networks work close with payors to share in high-performance savings that are realized with decreased utilization. Improvements in quality and performance increase market shares and help develop programs that enable citizens to receive proactive care.
Healthcare for citizens that are not insured is difficult to navigate. Without the guidance of insurance companies, many uninsured individuals must learn about their options by reaching out directly to providers. Pending the non-insured patient’s ability to pay and the provider’s status as for-profit or non-profit, the uninsured individual may be at risk of being redirected to seek care elsewhere. Even if citizens try to pay for care out of pocket, the lack of cost transparency in the United States has led it to be exceedingly difficult to identify a fair market price for treatment. Patients without insurance may be more likely to avoid treatment or obtain treatment through channels that legally cannot deny care, including the emergency department2.
Jordan has a population of 10 million people. Although it is one of the smaller countries in the Middle East, Jordan boasts a high-quality healthcare system and is considered the main destination for medical tourism in the Middle East and North Africa (MENA) region.
The healthcare system in Jordan includes public and private sectors. Currently there are 121 hospitals in Jordan offering services to Jordanian and non-Jordanian patients. The number of private hospitals is 73, while the government has 33 hospitals, 13 hospitals for the Royal Medical Services and 2 university hospitals. This shows the importance of the private healthcare sector, which exceeds 60%.
Almost all of the country’s neighbours have suffered from internal and/or external crises, and due to Jordan’s stability, a large number of refugees have fled to Jordan, thereby contributing to the increased population growth rate of the country and generating considerable pressure on the Kingdom’s infrastructure, including on its healthcare infrastructure. Jordan’s number of residents increased by an enormous 46% in the last decade from 5.1 million in 2004 to 9.5 million in 2015. Of those 9.5 million residents, 2.9 million (31%) were non-citizens3.
The influx of the Syrian refugees had a major adverse impact on the quality of healthcare services in Jordan, with an acute strain on public facilities, especially those in the northern governorates and Amman. This influx led to challenges in accessing existing primary health care facilities for both refugees and Jordanians.
A number of different health insurance schemes exist in Jordan, the majority of insured Jordanians are covered through the Civil Insurance Program (CIP) administered by the Ministry of Health (MoH), the Military Insurance Program (MIP) administered by the Royal Medical Services (RMS) under the Jordan Armed Forces, and private insurance. 38.1% of insured Jordanians are covered by the RMS, 34.4% by the CIP/MoH, and 12.1% are covered by private insurances. In addition to this, 6.9% receive complementary healthcare which puts the total Jordanians covered by CIP/MoH at 41.3% of insured Jordanians. This means that the government is the principal financer of health services, operating the two major insurers in Jordan4.
Direct out-of-pocket (OUP) health expenditure makes up about one-quarter of total healthcare spending, which is considerably high for a middle-income country.
According to the National Health Accounts (2015), the government is the main source of healthcare financing, with the Ministry of Finance contributing JD893 million in 2015, or 38.1% of total financial flows. The second largest source of funding is households, contributing JD731 million or 31.1%, which is the share of out-of-pocket payments. On the receiving end, private facilities receive most of the healthcare financial flows in Jordan, reaching JD735 million in 2015, making up 32.7% of total financial flows. After private facilities, MoH facilities and RMS facilities received JD573 million and JD383 million respectively, making up 25.5% and 17% of total financial flows4.
It is interesting to note that the majority of funds flowing into MoH facilities originate from MoH, showing how MoH is both a purchaser and provider of services. Given that the CIP is under the MoH, then we can consider the MoH to be the insurer, purchaser, and provider of services. The case is similar to the RMS.
South Africa has a population of approximately 60 million people and is classified as a middle-income country. Despite having a developed, complex, and industrialised economy, the country experiences marked levels of inequality and unemployment, which have been exacerbated by the COVID pandemic. As of 2021, the GINI coefficient for the country is 63.0, and the unemployment rate is 34,4%, the highest ever recorded for the country5.
The country emerged in 1994 from a history of separate development between the races under the system of Apartheid. Since then, the former black homelands and white provinces have been united into a single democratic country with 9 new provinces, each with their own provincial health departments, tasked with delivering curative care to the population. The new national health department focused via the African National Congress National Health Plan initiatives on improving access to universal primary healthcare6.
Over 8% of South Africa’s GDP (currently valued at $317 Billion) is spent on healthcare. The public healthcare sector is funded by general tax revenue, and services 84% of the population, but only accounts for half of all healthcare expenditure, with the other half dedicated to servicing the healthcare needs of only 16% of citizens with medical insurance. Thus, there is more than $5000 dollars spent per person in the private sector, and less than $1000 dollars spent per person in the public sector. There are widespread concerns of long waiting times and poor quality of healthcare in the public sector and overinflated prices in the private sector, which has an oligopoly of only three major provider groups7.
National government has recently passed the National Health Insurance Act, which will create a single, governmental entity which will be the only legal purchaser of healthcare in the country, using mandatory prepaid funds derived from general taxation, to purchase comprehensive services from both previously private and public facilities on behalf of citizens and those with official refugee status. This single purchaser will dictate the reimbursement costs of healthcare in the country, and pool risk between wealthy and the poor, as well as the healthy and unwell. There will be no out of pocket payments for attendance of NHI facilities, if the designated referral system processes are followed8.
A major caveat to this is that the benefit package comprehensively can only increase as economic growth of the country allows for, as the taxpayer base remains proportionally small. National structures to monitor quality standards and improvement are being setup to accredit hospitals for NHI participation.
India is one of the second most populous country in the world with a population of approx. 1.4 billion people. Several factors are driving the growth of the Indian healthcare sector including an aging population, a growing middle class, the rising proportion of lifestyle diseases, an increased emphasis on public-private partnerships as well as accelerated adoption of digital technologies, including telemedicine, besides heightened interest from investors and increased FDI inflows over the last two decades.
In India, health is both a federal and state subject and hence the healthcare maturity in a state is directly proportion to the economy of the state. States that are populous, industrious, and enjoying good economic status have better healthcare facilities than the alternative.
The public spending on healthcare is around 1.2% of GDP, while many comparable countries, spend more than 5%.
The low allocation of funds for public healthcare and the demand for quality healthcare has led to an explosion of private players in this space. Private players are categorized into 3 models:
- Large corporate chains that have Pan Indian presence typically in Metro and Tier 1 cities
- Regional corporate chains that have state level presence across all major towns
- Standalone chains in a particular city9
Geographically also, India is a vast country and there is disproportionate distribution of healthcare facilities. 80% of the healthcare facilities are present in Metros and tier 1 cities whereas only 20% of the patient base is from the same location. This leads to a large domestic medical travel trend where patients travel across cities for healthcare needs10.
The public healthcare system offers a tiered approach of treatments
India is a large under and uninsured market. While the Government funds most treatments for free, there are multiple plan that are run by state governments.
The largest of which is the Ayushman Bharat plan, which aims to provide universal healthcare coverage for all. While there are still state government insurance plans to provide coverage to citizens, these are now getting amalgamated with broader federal initiatives.
Apart from this, there are multiple plans that target the employees of various governmental departments. These act as universal coverage for them with the government acting as aggregator of value. While most of these are self-funded programs, there is a shift to some insurance companies managing these as well.
The awareness and explosion of health insurance in the last decade has also increased with individuals and corporates purchasing them for their employees. This has led to a demand for quality healthcare and improving footfalls to the private healthcare space10.
In summary, we see how it is difficult to compare healthcare by country without considering some of the many factors that affect both the populations of that country, and the unique needs of their healthcare and financial systems. Comparing the quality of the healthcare coverage was not discussed today and is equally as complex to measure.
The summary table below notes the differences in hospital beds per 10,000 citizens, healthcare expense per GPD, and the GINI Coefficient per country11, 12, 13. These measures highlighted some examples of access to hospital level care but fail to note access to primary care services. GINI Coefficient is noted below to provide an anchor when assessing the diversity needed in insurance solutions to mitigate income inequity.
- S. health care coverage and spending – FAS. (n.d.). Retrieved October 10, 2021, from https://sgp.fas.org/crs/misc/IF10830.pdf.
- Emergency medical treatment & labor act (EMTALA). CMS. (n.d.). Retrieved October 10, 2021, from https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA.
- UNICEF, Jordan. 2017. “The Cost and Financial Impact of Expanding the Civil Insurance Program to Vulnerable Jordanians and Syrian Refugees.”
- Jordan Strategy Forum. 2020. Enhancing the Competitiveness of the Health Sector in Jordan. Jordan Strategy Forum.
- Statistics South Africa. Mid-Year Population Estimates 2021. Available at http://www.statssa.gov.za/publications/P0302/P03022021.pdf.
- Chopra, M., McCoy, D. and Davies, G.R., 1994. The ANC National Health Plan. South African Medical Journal,84(4), pp.226-227. Available at https://pubmed.ncbi.nlm.nih.gov/7974050/.
- Solanki, G.C., Wilkinson, T., Cornell, J.E., Besada, D. and Morar, R.L., 2020. The Competition Commission Health Market Inquiry Report: An overview and key imperatives. South African Medical Journal, 110(2), pp.88-91. Available at https://journals.co.za/doi/pdf/10.7196/SAMJ.2020.v110i2.14455.
- Matsoso, M.P. and Fryatt, R., 2012. National health insurance: The first 18 months: legislation and financing. South African health review, 2012(1), pp.21-33. Available at https://journals.co.za/doi/abs/10.10520/EJC133701.
- Indian Brand Equity Foundation. Healthcare Industry in India. Retrieved from https://www.ibef.org/industry/healthcare-india.aspx
- India National Health Authority. https://pmjay.gov.in/resources/publication