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Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

In this paper we develop a theory of crop insurance. We start by reaffirming the risk-spreading role of competitive crop insurance markets. It is argued, however, that once the problems of imperfect information are recognized, a competitive crop insurance market may not exist at all. Two candidates present themselves. First is market insurance with the public sector as a source of (costly) information gathering and dissemination, and second, is the direct provision of crop insurance by the public sector. We focus on the latter and develop a model of public insurance as a decentralized plan where the farmer determines factor utilization taking the insurance contract as given. In turn, the insurance agency, taking factor utilization as determined by the farmer, chooses the optimal contract so as to maximize the value of aggregate output in the economy.

Since independence, India has struggled to provide its people with universal health coverage. Whether defined in terms of financial protection or access to and effective use of health care, the majority of Indians remain irregularly and incompletely covered. Finally, and most recently, a new generation of Government-Sponsored Health Insurance Schemes (GSHISs) has emerged to provide the poor with financial coverage. Briefly, the main objective of these new GSHISs was to offer financial protection against catastrophic health shocks, defined in terms of an inpatient stay. Between 2007 and 2010, six major schemes have emerged, including one sponsored by the Government of India (GOI) and five state-sponsored schemes. This new wave of schemes provides fully subsidized coverage for a limited package of secondary or tertiary inpatient care, targeting below poverty populations. Similar to the private voluntary insurance products in the country, ambulatory services including drugs are not covered except as part of an episode of illness requiring an inpatient stay. The schemes have organized hospital networks consisting of public and private facilities, and most care funded by these schemes is provided in private hospitals. Ostensibly, the objective of any health insurance scheme is to increase access, utilization, and financial protection, and ultimately improve health status. Due to lack of evaluations and analyses of household data, the authors of this book do not examine the impact of health insurance in terms of these objectives. This book is not meant to highlight problems of the GSHISs, but rather to raise potential challenges and emerging issues that should be addressed to ensure the long-term viability of these schemes and secure their place within the health finance and delivery system.

The goal of this study was to examine the demographics sex and marital status of inpatients with schizophrenia and bipolar and compare differences in patients’ chances of possessing adequate health coverage to cover hospital expenses. Data from the National Hospital Discharge Survey was extracted and analyzed. For hospital discharges of patients age 18 and older 702,626 hospital discharges were included in the study representing a weighted population of 77,082,738 hospital discharges. Prediction model was applied to test the ability of the independent variables sex and marital status to predict differences in health coverage in multinomial logistic regression (MLR) test. Results indicate that sex and marital status were significant predictors of health coverage type that patient owned. Male, unmarried and with unknown marital status patients were more likely to be either uninsured or publicly insured. Public health policy legislation efforts need to address public-health-insurance provisions that limit the coverage of treatment for psychiatric patients.

The Affordable Care Act (ACA) aimed to achieve nearly universal health insurance coverage in the United States through a combination of insurance market reforms, mandates, subsidies, health insurance exchanges, and Medicaid expansions, most of which took effect in 2014. This paper estimates the causal effects of the ACA on health insurance coverage in 2014 using data from the American Community Survey. We utilize difference-in-difference-in-differences models that exploit cross-sectional variation in the intensity of treatment arising from state participation in the Medicaid expansion and local area pre-ACA uninsured rates. This strategy allows us to identify the effects of the ACA in both Medicaid expansion and non-expansion states. Our preferred specification suggests that, at the average pre-treatment uninsured rate, the full ACA increased the proportion of residents with insurance by 5.9 percentage points compared to 2.8 percentage points in states that did not expand Medicaid. Private insurance expansions from the ACA were due to increases in both employer-provided and non-group coverage. The coverage gains from the full ACA were largest for those without a college degree, non-whites, young adults, unmarried individuals, and those without children in the home. We find no evidence that the Medicaid expansion crowded out private coverage.

We examined the effect of the expansion of Medicaid eligibility under the Affordable Care Act on health insurance coverage and labor supply of low-educated and low-income adults. We found that the Medicaid expansions were associated with large increases in Medicaid coverage, for example, 50 percent among childless adults, and corresponding decreases in the proportion uninsured. There was relatively little change in private insurance coverage, although the expansions tended to decrease such coverage slightly. In terms of labor supply, estimates indicated that the Medicaid expansions had little effect on work effort despite the substantial changes in health insurance coverage. Most estimates suggested that the expansions increased work effort, although not significantly.

In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides an opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.

Long-term care expenditures constitute one of the largest uninsured financial risks facing the elderly in the United States and thus play a central role in determining the retirement security of elderly Americans. In this essay, we begin by providing some background on the nature and extent of long-term care expenditures and insurance against those expenditures, emphasizing in particular the large and variable nature of the expenditures and the extreme paucity of private insurance coverage. We then provide some detail on the nature of the private long-term care insurance market and the available evidence on the reasons for its small size, including private market imperfections and factors that limit the demand for such insurance. We highlight how the availability of public long-term care insurance through Medicaid is an important factor suppressing the market for private long-term care insurance. In the final section, we describe and discuss recent long-term care insurance public policy initiatives at both the state and federal level.

We develop frameworks for welfare analysis of Medicaid and apply them to the Oregon Health Insurance Experiment. Across different approaches, we estimate low-income uninsured adults’ willingness to pay for Medicaid between $0.5 and $1.2 per dollar of the resource cost of providing Medicaid; estimates of the expected transfer Medicaid provides to recipients are relatively stable across approaches, but estimates of its additional value from risk protection are more variable. We also estimate that the resource cost of providing Medicaid to an additional recipient is only 40 percent of Medicaid’s total cost; 60 percent of Medicaid spending is a transfer to providers of uncompensated care for the low-income uninsured.