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This article estimates the effect of labor-market concentration on labor compensation across the US private sector since 2000. The authors distinguish between concentration in local labor markets and local product markets while guarding against bias from confounded product-market concentration. The analysis extends beyond wages to rates of employment-based health insurance coverage. Reported results suggest negative effects of labor-market concentration on labor compensation. These effects are exacerbated when product-market concentration is higher or when workers are older. [ABSTRACT FROM AUTHOR]

Was the Affordable Care Act (ACA) effective in the U.S. territories? This paper explores this question by examining the impact of the ACA's dependent mandate and Medicaid expansion in Puerto Rico. The dependent mandate led to a 4.3 percentage point increase in health insurance coverage for Puerto Rican young adults due to increased employer-sponsored insurance coverage, and the Medicaid Expansion increased Medicaid coverage by 2.4 percentage points. The impact of both policies in Puerto Rico is smaller than in the mainland, highlighting the importance of considering how federal legislation affects territories with economic and health environments dissimilar to the mainland. [ABSTRACT FROM AUTHOR]

Background: Although one's socioeconomic status affects health outcomes, limited research explored how South Korea's National Health Insurance (NHI) system affects mortality rates. This study investigated whether health insurance type and insurance premiums are associated with mortality. Methods: Based on the National Health Insurance Service-Health Screening cohort, 246,172 men and 206,534 women aged ≥ 40 years at baseline (2002–2003) were included and followed until 2019. Health insurance type was categorized as employee-insured (EI) or self-employed-insured (SI). To define low, medium, and high economic status groups, we used insurance premiums at baseline. Death was determined using the date and cause of death included in the cohort. Cox proportional hazard models were used to analyze the association between insurance factors and the overall and cause-specific mortality. Results: The SI group had a significantly higher risk of overall death compared to the EI group (adjusted hazard ratio (HR) [95% confidence interval]: 1.13 [1.10–1.15] for men and 1.18 [1.15–1.22] for women), after adjusting for various factors. This trend extended to death from the five major causes of death in South Korea (cancer, cardiovascular disease, cerebrovascular disease, pneumonia, and intentional self-harm) and from external causes, with a higher risk of death in the SI group (vs. the EI group). Further analysis stratified by economic status revealed that individuals with lower economic status faced higher risk of overall death and cause-specific mortality in both sexes, compared to those with high economic status for both health insurance types. Conclusion: This nationwide study found that the SI group and those with lower economic status faced higher risk of overall mortality and death from the five major causes in South Korea. These findings highlight the potential disparities in health outcomes within the NHI system. To address these gaps, strategies should target risk factors for death at the individual level and governments should incorporate such strategies into public health policy development at the population level. Trial registration: This study was approved by the Institutional Review Board of Chungbuk National University Hospital (CBNUH-202211-HR-0236) and adhered to the principles of the Declaration of Helsinki (1975). [ABSTRACT FROM AUTHOR]

How accurate are Americans' perceptions of the material benefits associated with union membership, and do these perceptions influence their support for, and interest in joining, unions? We explore these questions in a preregistered, survey experiment conducted on a national sample, representative of the US population on a number of demographic benchmarks (n = 1,430). We find that Americans exhibit large and consistent underestimates of the benefits associated with unionization, as compared to evidence from the Bureau of Labor Statistics and peer-reviewed academic research. For example, 89% of Americans underestimated the life-time income premium associated with union membership, 72% underestimated the percentage of union members who receive health insurance from their employer, and 97% overestimated the average union dues rate. We next randomly assigned half of the participants to receive a brief, informational correction conveying results of academic and government research on the material benefits associated with union membership, or not. Those who received the correction reported 11.6% greater interest in joining a union, 7.8% greater support for unions, and 6.9% greater interest in helping to organize a union in their workplace, as compared to the control group. These results suggest that, overall, Americans tend to underestimate the material benefits associated with unionization, misperceptions of these benefits are causally linked to Americans' support for unionization, and correcting these misperceptions increases a range of pro-union sentiments in the American mass public. [ABSTRACT FROM AUTHOR]

Many community-rated health insurance markets include risk equalization (also known as risk adjustment) to mitigate risk selection incentives for competing insurers. Empirical evaluations of risk equalization typically quantify selection incentives through predictable profits and losses net of risk equalization for various groups of consumers (e.g. the healthy versus the chronically ill). The underlying assumption is that absence of predictable profits and losses implies absence of selection incentives. This paper questions this assumption. We show that even when risk equalization perfectly compensates insurers for predictable differences in mean spending between groups, selection incentives are likely to remain. The reason is that the uncertainty about residual spending (i.e., spending net of risk equalization) differs across groups, e.g., the risk of substantial losses is larger for the chronically ill than for the healthy. In a risk-rated market, insurers are likely to charge a higher profit mark-up (to cover uncertainty in residual spending) and a higher safety mark-up (to cover the risk of large losses) to chronically ill than to healthy individuals. When such differentiation is not allowed, insurers face incentives to select in favor of the healthy. Although the exact size of these selection incentives depends on contextual factors, our empirical simulations indicate they can be non-trivial. Our findings suggest that – in addition to the equalization of differences in mean spending between the healthy and the chronically ill – policy measures might be needed to diminish (or compensate insurers for) heteroscedasticity of residual spending across groups. [ABSTRACT FROM AUTHOR]

The article "Voluntary Health Insurance in the GSVG" provides an overview of the various options for voluntary health insurance within the framework of the GSVG. The GSVG provides, among other things, for continued insurance coverage upon leaving mandatory insurance and the possibility of establishing health insurance coverage for certain family members. In addition, § 9 GSVG allows for the receipt of sickness benefits in the event of incapacity for work due to illness through the conclusion of supplementary insurance. Continued insurance coverage immediately follows the end of the previous health insurance to ensure uninterrupted insurance coverage. Continued insurance in the statutory health insurance is an important instrument to enable uninsured individuals to be included in the solidarity community and protect them from the risks and premiums of private health insurance. [Extracted from the article]

The purpose of this study is to incorporate the international health insurance model/models for a symbiotic benefits to medical tourists and health insurance companies. This study is based on the extensive analysis of articles published regarding health insurance for tourists and medical tourism. Objective of study is "to adopt the health insurance models for growth of health insurance premium and medical tourism in India". Content analysis has been adopted in this study. Literature confirms that the influx of medical tourism is positively related with growth of health insurance, when innovative model/models of health insurance are incorporated strategically for the medical tourists in India. According to the study results, adoption and implementation of international based model/models of health insurance for medical tourists is a trigger point for the growth of health insurance fund in India and it changes the perception of medical tourists towards India as economical destination in case of medical emergencies. The scope of study is to recognize international health insurance model/models in digitalized era for the growth of health insurance premium and medical tourism in India. [ABSTRACT FROM AUTHOR]

Incentive-based health insurance applications have been implemented to trigger lower insurance premiums when the individual follows healthy living habits. It has been recognised that this benefit notwithstanding, consumers' perceptions related to such applications in the life-insurance field and health tracking are not necessarily positive. Recent research has recognised that psychological ownership, a mental state wherein one feels a technology or application to be his or her own, plays a crucial role in individuals' willingness to adopt and use new technologies. It has been suggested that many digital applications and platforms possess unique empowering and co-creative features that offer special potential to facilitate the emergence of psychological ownership and satisfy the underlying needs. The aim of our study, proceeding from these premises, was to identify and thematize hurdles to take-up of incentive-based health insurance applications with regard to meeting needs that drive development of psychological ownership. We achieved this by conducting a thematic analysis of perceptions of consumers who were not willing to adopt a specific application of the relevant type. The resulting framework, which recognises 14 thematized hurdles in all, holds important implications for scientific and managerial use both. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to estimate the effect of the state‐based reinsurance programs through the section 1332 State Innovation Waivers on health insurance marketplace premiums and insurer participation. Data Source: 2015 to 2022 Robert Wood Johnson Foundation Health Insurance Exchange Compare Datasets. Study Design: An event study difference‐in‐differences (DD) model separately for each year of implementation and a synthetic control method (SCM) are used to estimate year‐by‐year effects following program implementation. Data Collection/Extraction Methods: Not applicable. Principal Findings: Reinsurance programs were associated with a decline in premiums in the first year of implementation by 10%–13%, 5%–19%, and 11%–17% for bronze, silver, and gold plans (p < 0.05). There is a trend of sustained declines especially for states that implemented their programs in 2019 and 2020. The SCM analyses suggest some effect heterogeneity across states but also premium declines across most states. There is no evidence that reinsurance programs affected insurer participation. Conclusion: State‐based reinsurance programs have the potential to improve the affordability of health insurance coverage. However, reinsurance programs do not appear to have had an effect on insurer participation, highlighting the need for policy makers to consider complementary strategies to encourage insurer participation. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic in 2020 enhanced the need for commercial health insurance to address the sudden and overwhelming healthcare costs faced by families. This also led to an increase in the demand for health insurance services requiring insurance companies to innovate and develop suitable services. However, in the context of China, despite the huge potential for growth, health insurance market faces numerous challenges such as inadequate availability of tailored services, educational issues, income limitations, and emphasis on social insurance. To examine the issues and consider areas for improvements, this research investigated the impacts and effects of commercial health insurance from a macro perspective and considered potential recommendations to enhance the effective demand. This paper performed an empirical investigation by using the short panel data for regression analysis. The data was collected over ten years (2010 to 2019) involving 31 provinces in China to establish a fixed effect model. It employed FE and FGLS method to compare and analyze the impact of 9 factors while the health insurance premium was set as the dependent variable. Results showed that domestic economic development led to increasing residents' wealth and consumption levels has increased, including healthcare investments. Elevating the awareness of people through education can promote the development of the commercial health insurance demand, but the influence of urbanization level and the aging of the population remain to be demonstrated. [ABSTRACT FROM AUTHOR]

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many--one in four--are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the "headline number" of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured. [ABSTRACT FROM AUTHOR]

Using data from the US Census Bureau's Household Pulse Survey, we analyzed the likelihood of loss of health insurance and enrollment into new health coverage during the early months of the COVID‐19 pandemic. Loss of employment was associated with a significant increase in the likelihood of loss of health insurance and, specifically, an increase in the likelihood of employer‐sponsored health insurance. However, individuals in Medicaid expansion states experienced a lower likelihood of loss of health insurance compared with individuals in nonexpansion states. At the same time, there was a statistically significant increase in Medicaid enrollment in expansion states, by 3.2 percentage points. Reemployment or acquiring employment was associated with a gain in health insurance coverage. During an economic downturn, eligibility, and coverage gaps leave many without affordable coverage options, and the pandemic will likely bring renewed attention to gaps in Medicaid coverage in nonexpansion states. [ABSTRACT FROM AUTHOR]

The presence of ex-ante moral hazard could undermine the potential gain from expanding health insurance coverage in developing nations. To test the proposition, this study utilizes a nationally representative longitudinal survey with Indonesia's health insurance for poor policy in 2014 as the quasi-experimental case study. The country represents developing nations that undergo a massive and rapid expansion of health insurance coverage. The empirical approach combines a matching and difference-in-differences method to obviate potential bias of the selectivity nature of health insurance provision and time-invariant unobserved factors. The findings suggest the presence of ex-ante moral hazard in the form of the less people using trash cans associated with the introduction of the subsidized health insurance premium. The results add empirical findings of a negative side effect of expanding health insurance coverage in developing nations. [ABSTRACT FROM AUTHOR]

We estimate the effect of employers providing health insurance and contributing towards health insurance premiums on employee job tenure. Using merged 2008–2018 data from the Job Tenure Supplement and Annual and Social Economic Supplement of the Current Population Survey, we find that employer health insurance is associated with one additional year of job tenure. We find that a thousand dollar increase in employer contributions to health insurance is associated with at least 83 additional days of job tenure, compared to less than 10 additional days for a thousand dollar increase in wages. [ABSTRACT FROM AUTHOR]

How should payment systems of means-tested benefits be designed to improve the financial situation of needy recipients most effectively? We study this question in the context of mandatory health insurance in Switzerland, where recipients initially receive either a cash transfer or subsidized insurance premiums (a form of in-kind transfer). A federal reform in 2014 forced cantons (i.e. states) to universally switch to in-kind provision. We exploit this setting based on a difference-in-differences design, analyzing eight years of rich individual-level accounting data and applying a machine learning approach to identify cash recipients prior to the reform. We find that switching from cash to in-kind transfers persistently reduces the likelihood of late premium payments by about 20% and of government debt collection for long-term missed payments by approximately 12%. There is no evidence for a negative spillover effect on the timely payment of the non-subsidized co-pay bills for health services after the regime change. [ABSTRACT FROM AUTHOR]

Migrant workers are an important component of China's labor market, playing a vital role in economic development and social stability. In the face of significant health risks related to their work, migrant workers remain largely under-represented in China's health insurance system despite their eligibility to participate in several programs. To achieve China's goal of universal healthcare coverage, migrant workers are targeting populations. The objective of this paper is to understand the factors associated with migrant workers' participation in health insurance programs. This analysis draws from a survey of 3,342 migrant workers that was conducted by China Agricultural University in 2013. A multinomial logit model was performed to identify the determinants of migrant workers' health insurance participation. Our findings suggest that the highest rates of un-insurance were observed for females, the elderly, those with lower levels of education, income, or lower self-reported health status, and migrant workers in the construction industry. They are the most vulnerable populations and susceptible to various health and occupational hazards. Besides the high enrollment rates of migrant workers in the New Rural Cooperative Medical Scheme, the scheme's lack of portability needs a complete "Inter-province" balancing reimbursement networking platform to be built. Furthermore, establishing a multi-level medical security system that is accessible and affordable may serve the goal of improving health insurance participation among migrant workers. [ABSTRACT FROM AUTHOR]

Objectives: In January 2014, the Affordable Care Act (ACA) preexisting condition protections prohibited coverage denials, premium increases, and claim denials on the basis of preexisting conditions. This study aimed to examine changes in coverage and premiums and out-of-pocket spending after the implementation of the preexisting condition protections under the ACA.Methods: We identified adults aged 18 to 64 years with (n = 59 041) and without preexisting conditions (n = 61 970) from the 2011-2013 and 2015-2017 Medical Expenditure Panel Survey. We used a difference-in-differences and a difference-in-difference-in-differences approach to assess the associations of preexisting condition protections and changes in insurance coverage, premium contributions, and out-of-pocket spending after the ACA. Simple and multivariable logistic or multivariable 2-part models were fitted for the full sample and stratified by family income (low ≤138% federal poverty level [FPL]; middle 139%-400% FPL; and high > 400 FPL).Results: The ACA increased nongroup insurance coverage to a similar extent for individuals with or without preexisting conditions at all income levels. Decreases in premium contributions were observed to a similar extent among families with nongroup private coverage regardless of declinable preexisting condition status, whereas no significant changes were observed among families with group coverage. We found greater decreases in out-of-pocket spending for individuals with preexisting conditions than those without conditions among both individuals covered by nongroup and group insurance, and a greater difference was observed among those covered by nongroup insurance (difference-in-difference-in-differences -$279; 95% confidence interval -$528 to -$29).Conclusions: The ACA protections were associated with decreases in out-of-pocket spending among adults with preexisting conditions. [ABSTRACT FROM AUTHOR]

Background: The government of Sierra Leone introduced Social Health Insurance Scheme as a measure to remove financial barriers that beset the people in accessing health to ensure universal coverage. Under this policy, the citizens were encouraged to subscribe to the scheme to avoid out of pocket payment for healthcare at the point of use. This study was conducted to find out the predictors of willingness among the people to pay for health insurance premium. Methods: A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data was collected for this study through the use of semi-structured questionnaire with a sample size of 1185 respondents. Data was analysed into descriptive and inferential statistics using the contingent valuation model. Statistical analysis was run at 5% significant level using Stata version 14.0 software. Results: The results showed that majority of the respondent are willing to join and pay a monthly premium of Le 10 000 (US$1.03) with an estimated mean contribution of about Le 14 089 (US$1.44) and the top five predictors of willingness to pay (WTP) were household monthly income, age, district of resident, gender, and educational qualification. Conclusion: The findings on predictors of WTP premium of Sierra Leone National Social Health Insurance (SLeNSHI), suggests that the socio-demographic characteristics of the population are important in premium design and payment. Efforts at improving the socio-economic statuses of the population could be helpful in premium design and payment. [ABSTRACT FROM AUTHOR]

Nearly 30% of documented agricultural workers, that is, those who are authorized to work in the U.S. and may be eligible for government‐sponsored Medicaid coverage, lacked health insurance coverage in 2016. We estimate the impact of the 2014 state‐level Medicaid expansions that were part of the Affordable Care Act (ACA) on farm workers' health insurance coverage, health care utilization, and labor supply. Using confidential individual‐level data from the National Agricultural Workers Survey (NAWS) for the decade between 2007 and 2016, we employ a difference‐in‐differences econometric model to compare workers in states that expanded Medicaid in 2014 to workers in states that did not. We find that, following the ACA Medicaid expansions, documented agricultural workers experience a 12‐percentage point (24%) increase in the likelihood of having health insurance, which is entirely driven by an increase in the likelihood of having a government‐sponsored health insurance plan. We do not detect a decrease in private (employer‐sponsored or worker‐acquired) health insurance coverage. Further, we find no evidence that the ACA Medicaid expansions led to a decline in farm workers' labor supply; in fact, our results imply that there was a small increase in farm workers' hours. In a number of falsification tests, we also show that the Medicaid expansions do not appear to have an impact on undocumented (unauthorized) farm workers' health care utilization, and there was no increase in Medicaid payments for health services among this group of farm workers who were largely ineligible for Medicaid. [ABSTRACT FROM AUTHOR]

In recent years, the mass media (such as TV shows and movies) plays an important role in communication with the general public. In this paper, we investigate the impact of a recent movie from China, 'Dying to Survive', on the demand for commercial health insurance. To explore this impact, a fixed-effect model and instrumental variable estimation are utilized, and the causal effect of movie-based health risk communication on commercial health insurance demand is studied. The result shows that the cumulative box office value of a movie has a significantly positive impact on the income from commercial health insurance premium, with a one- or two-day lag. This movie has encouraged viewers to purchase short-term commercial health insurance rather than long-term insurance. In addition, the heterogeneity of the impact exists for movie arrangement rate, average family size, urbanization rate, medical resource level, and per capita disposable income. The results show that sufficient health risk communication can improve the social 'visibility' of health risk. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic exposed the weaknesses of the U.S. health care system's reliance on private, employer-based health insurance. The crisis in health care access and affordability has increased support for a public option--the choice to purchase a state-initiated health plan with publicly determined rates. Congressional gridlock, however, may dim the chances for a federal public option. States have stepped into the policy vacuum, proposing forty-nine bills to establish state public options since 2010, including three that became law. This article provides a comprehensive survey and taxonomy of state public option proposals from 2010-2021, identifying three main models: (1) Medicaid Buy-In Public Options; (2) Marketplace-Based Public Options; and (3) Comprehensive Public Options. Though each model serves different policy goals and varies in scope, the defining aim of all public option plans is to improve access to affordable health coverage by applying public payment rates to the private insurance market. We seek to answer whether state public option plans are legally viable and "worth it" for states to pursue. The answer is yes to both, but, surprisingly, the degree of legal difficulty is inversely related to the scope of the plan's reach--the broadest plans have fewer legal hurdles than narrower plans. Moreover, the policy effects increase with the scope of the plan and the robustness of the controls on provider payment rates. Public options with modest provider rate controls may have too little impact on affordability and costs, falling short of their defining goal of improving affordability. As a result, the legal and political difficulty of enacting such plans may not be worth it. State public option plans may be most effective when they cover a broad swath of the population and pursue robust provider rate controls. In short, for state public option plans to be worth it, bigger is better. [ABSTRACT FROM AUTHOR]

This paper examines the demand for micro health insurance in rural Cambodia in terms of the willingness to purchase health insurance and pay premiums. Data from interviews with 270 households in six villages in Siem Reap, Cambodia in September 2017 is analyzed using logit regression. It finds that the factors determining the willingness to purchase micro health insurance are different from those determining the willingness to pay premiums. Also, socioeconomic attributes, including household income, poverty identification, and education, each influence the willingness to purchase health insurance and the willingness to pay premiums differently. Finally, health or medical conditions in households, including number of illnesses or injuries, payment method for medical expenses, and use of medical institutions, affects the willingness to purchase health insurance and premiums. [ABSTRACT FROM AUTHOR]

The growing interest in insurance poses a threat to insurance companies. As the number of individuals seeking insurance coverage increases, the number of individuals adversely selecting the insurer also increases, which can lead to the insurance product being unprofitable. Thus, this study explores designing an insurance product – a combined life insurance and health insurance product that will reflect the actual claims of an individual to his/her policy – that will hopefully help prevent unprofitability of the insurance product. This is done by applying incentives and penalization, or the bonus-malus system, to the insurance benefit while leaving the premium constant. Assuming that premiums for life insurance and health insurance are constant, transition and pricing models are derived. Considering two forms of combination of life and health insurance: a combined life and hospitalization income insurance and a combined life and medical insurance, we illustrate the derived model assuming Makeham distribution for life insurance claims and Poisson distribution and gamma distribution for the hospitalization income insurance and medical insurance claims, respectively. The proposed design gives a new framework for combining life and health insurance, as well as a methodology for combining other types of insurances. [ABSTRACT FROM AUTHOR]

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We present and empirically implement an equilibrium labor market search model where risk-averse workers facing medical expenditure shocks are matched with firms making health insurance coverage decisions. We use our estimated model to evaluate the equilibrium impact of many health care reform proposals, including the 2010 Affordable Care Act (ACA). We use the estimates of the early impact of the ACA as a model validation. We find that income-based subsidies for health insurance premiums are crucial for the sustainability of the ACA, while the ACA can still substantially reduce the uninsured rate without the individual or the employer mandate. [ABSTRACT FROM AUTHOR]

India is one of the important countries in world trade as far as the service sector is concerned. The health insurance sector continues to be one of the most dynamic and fast-evolving constituents of the Indian Insurance Industry. This paper makes an attempt to examine the expectations and perceptions of policyholders regarding health insurance service quality of public and private sector general insurance companies. The data is collected from 800 health insurance policyholders in Greater Mumbai region, Maharashtra, India using simple random sampling technique. Structured questionnaire is used for collecting primary data. Secondary data is collected from journals, books, websites etc. The top 8 general insurance companies including the public and private sector, operating in India, was selected. The study is based on the SERQUAL model developed by Parasuraman et al. The study is based on five factors of health insurance service quality viz; Reliability, Empathy, Access, Responsiveness and Tangibles. Statistical tools used in the study are Parametric Paired 't' test, mean and standard deviation. The study revealed that there is a significant difference in the expectations and perceptions of policyholders regarding Health Insurance Service Quality factors (Reliability, Empathy, Access, Responsiveness and Tangibles) in both public and private sector general insurance companies. Also, all differences are positive, which denotes that customer's expectations exceed customer's perception. The general insurance company should try to bridge the gap between expectations and perceptions of the customers to satisfy the customers and to retain them. Customer satisfaction depends on the agreement between expectations and perceptions of service quality. [ABSTRACT FROM AUTHOR]

This article considers the extent to which Affordable Care Act state Medicaid expansions alleviated the burden of out-of-pocket costs associated with obtaining health insurance and medical care using data from the 2011 to 2016 Current Population Survey Annual Social and Economic Supplement. Using a difference-in-differences framework, the analysis examines effects of the Medicaid expansions on out-of-pocket expenditures for health insurance premiums and medical care, comparing expenditures across expansion and nonexpansion states before and after the expansions were implemented, performing separate analyses for individuals with family income at various eligibility cutoff levels in the first and second years of expansion implementation. The findings suggest that the expansions were associated with a relatively larger likelihood of having zero premium expenditures and of having zero nonpremium medical out-of-pocket expenditures for low-income individuals. These findings suggest that the expansions were effective in reducing medical out-of-pocket expenditures. [ABSTRACT FROM AUTHOR]

A central pillar of universal health coverage (UHC) is to achieve financial protection from catastrophic health expenditure. There are concerns, however, that national health insurance programmes with premiums may not benefit impoverished groups. In 2003, Ghana became the first sub-Saharan African country to introduce a National Health Insurance Scheme (NHIS) with progressively structured premium charges. In this study, we test the impact of being insured on utilization and financial risk protection compared with no enrolment, using the 2012-13 Ghana Living Standards Survey (n = 72 372). Consistent with previous studies, we observed that participating in health insurance significantly decreased the probability of unmet medical needs by 15 percentage points (p.p.) and that of incurring catastrophic out-of-pocket (OOP) health payments by 7 p.p. relative to no enrolment in the NHIS. Households living outside a 1-h radius to the nearest hospital had lower reductions in financial risk from excess OOP medical spending relative to households living closer (-5 p.p. vs -9 p.p.). We also find evidence that in Ghana, the scheme was highly pro-poor. Once insured, the poorest 40% of households experienced significantly larger improvements in medical utilization (18 p.p. vs. 8 p.p.) and substantively larger reductions in catastrophic OOP health expenditure (-10 p.p. vs. -6 p.p.) compared with that of the richest households. However, health insurance did not benefit vulnerable persons equally from financial risk. Once insured, poor, low-educated and self-employed households living far from hospitals had significantly lower reductions in catastrophic OOP medical spending compared with their counterparts living closer. Taken together, we show that enrolment in the NHIS is associated with improved financial protection but less so among geographically remote vulnerable groups. Efforts to boost not just insurance uptake but also health service delivery may be needed as a supplement for insurance schemes to accelerate progress towards UHC. [ABSTRACT FROM AUTHOR]

The current research aimed to advance the psychological reactance theory literature by extending this framework to older adults (N = 525) age 55 or older. In doing so, this project tests two principles of reactance theory as well as exploring the relationship between reactance and a behavioral outcome. Results demonstrated that the threat of additional driver's license requirements, issue involvement, and the personal relevance of the threatened freedom increased freedom threat perceptions. In turn, freedom threat perceptions were positively associated with reactance. Reactance was positively associated with agreeing to sign a petition protesting the proposed requirements. The same pattern of findings was replicated within the context of maintaining low cost health insurance premiums. In addition to these main effects, two interactions (additional test requirements * issue involvement and additional test requirements * personal 2 relevance) were explored. Results are discussed with an emphasis on the theoretical and practical implications for psychological reactance theory among older adults. [ABSTRACT FROM AUTHOR]