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The Pharmacare Act, Bill C-64, was passed by Canada's House of Commons in June 2024 and is awaiting final approval by the Senate. However, the bill does not establish universal, public pharmacare as recommended by the government's Advisory Council and previous national inquiries. Instead, it fills the gaps in Canada's existing systems of drug payment, which is financed through private insurance plans. The bill also falls short in establishing the Canadian Drug Agency, leaving it vulnerable to interference and potentially toothless. Amendments are needed to align the bill with recommendations for a cost-effective and robust universal, public pharmacare program. [Extracted from the article]

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]

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]

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]

In 1991, Dannon employees had the choice to stay with their current health care plan or switch to a new plan which offered a lower premium and less hospital cost coverage that better fit the needs of most employees. Both plans were the same in all other respects. Only 25% of employees chose the new lower-premium plan over the old plan. This article reports a collaborative effort between The Dannon Company and Cornell University's Center for Advanced HR Studies to identify the patterns of employee choices, and the effects of those choices on the actual costs that employees incurred. The actual decisions of 287 Dannon employees were examined, and the out-of-pocket costs that they actually incurred in the two years after the plan was introduced were calculated. [ABSTRACT FROM AUTHOR]

Health insurance policy is a current topic of concern for the United States. The classroom game discussed here provides students with a thorough understanding of some of the policy options under debate, in addition to demonstrating the classic problem of adverse selection. Students received probabilities of encountering a variety of medical expenses, based on their randomly assigned fictitious person's age and health status. In each round, students made insurance decisions and then rolled dice to determine outcomes for each possible medical expense. The experiment considered insurance with an individual mandate, insurance without an individual mandate, insurance where students could purchase à la carte coverage mimicking proposed insurance riders for certain coverage, and insurance where pre-existing conditions were not covered. [ABSTRACT FROM AUTHOR]

The article discusses the study on the cumulative expenses of the retirees on their health care expenses after reaching 70 years old until their demise. It mentions the use of self-reported expenses of the retirees involved in the studies while excluding their insurance premiums and Medicare. Findings of the study indicated that while the out-of-pocket health care expenses are catastrophic for some retirees, the expenses are not as high as perceived by others.

This study sought to investigate household sociodemographic characteristics as predictors of patterns of health insurance premiums and medical expenses of consumers using the 2014 Consumer Expenditures Survey. This study found that age, being married, educational attainment, and log of family salary income were associated with higher family spending on both health insurance premiums and medical expenses. Government employment status was associated with lower spending on health insurance premiums and medical expenses. Findings from this research are informative for both households in determining health insurance premiums and medical expenses throughout the life course as well as financial advisors in personal financial planning and counseling focused on health care. [ABSTRACT FROM AUTHOR]

An essay is presented which addresses the U.S. Patient Protection and Affordable Care Act (ACA), health care reform, and the efforts to lower health care costs in America as of 2017. Health insurance affordability in the U.S. is addressed, along with insurance coverage costs for lower and moderate income Americans. Medicaid insurance eligibility expansions and reductions in the number of uninsured people in America are assessed, along with insurance premiums and cost-sharing.

We study insurance take-up choices by consumers who face medical expense risk and who know they can default on medical bills by filing for bankruptcy. For a given bankruptcy system, we explore the total and distributional welfare effects of health insurance mandates compared with the pre-mandate market equilibrium. We consider different combinations of premium subsidies and out-of-insurance penalties, confining attention to budget-neutral policies. We show that when insurance mandates are enforced only through penalties, the efficient take-up level may be incomplete. However, if mandates are also supported with premium subsidies, full insurance coverage is efficient and can also be Pareto improving. Such policies are consistent with the incentive structure for insurance take-up set in the ACA. Pareto improvement is possible because the legal requirement that medical providers dispense acute care on credit, together with the bankruptcy option, yields effective subsidies for medical care utilized by the uninsured. Those subsidy funds, however, can serve the initially uninsured better when they are given as ex ante subsidies on insurance premiums. [ABSTRACT FROM AUTHOR]

Background: Increasing demand for services and rising health care costs create pressures within the Australian health care system and result in higher health insurance premiums and out-of-pocket costs for consumers. Objective: To measure changes in consumer views on the quality of the Australian health care system, contributors to rising costs and attitudes towards managing these costs. Methods: Two computer-assisted telephone interviews were conducted in 2006 (533 respondents) and 2015 (1318 respondents) and results compared. Results: More respondents in 2015 rated the Australian health care system ‘very adequate’ than in 2006 (22.3% vs 8.3%; Odds Ratio OR 3.2, 99% CI 2.1, 5.1) with fewer ‘concerned’ or ‘fairly concerned’ about the health care costs (69.0% vs 85.7%; OR 0.37, 99% CI 0.25, 0.53). The 2015 respondents were more likely to identify new treatments for cancer (77% vs 65.7%; OR 1.75, 99% CI 1.30, 2.35) and community expectations for access to the latest technologies (73.8% vs 67%; OR 1.39, 99% CI 1.04, 1.86) as contributors to rising health care costs. While more 2015 respondents agreed that patients should pay a greater part of the health care costs, this remained a minority view (37.9% vs 31.7%; OR 1.32, 99% CI 0.99, 1.76). They were less likely to agree that doctors should offer medical treatments regardless of the cost and chance of benefit (63.6% vs 82.9%; OR 0.36, 99% CI 0.25, 0.50). Conclusions: Satisfaction with the Australian health care system has increased over time. Consumers recognise the cost pressures and have lower expectations that all services should be provided regardless of their costs and potential benefit. Public consultation on the allocation of health care resources and involvement in health care decision-making remains important. There should be community consultation about the principles and values that should guide resource allocation decisions. [ABSTRACT FROM AUTHOR]

The Affordable Care Act requires health insurers to rebate any amounts less than 80%–85% of their premiums that they fail to spend on medical claims or quality improvement. This study uses the new comprehensive reporting under this law to examine changes in insurers’ financial performance and differences in their quality improvement expenditures. In the ACA’s second year (2012), insurers’ median medical loss ratios continued to increase and their median administrative cost ratios dropped, producing moderate operating margins in the group markets but a small operating loss in the individual market, at the median. For-profit insurers showed larger changes, in general, than did nonprofits. For quality improvement, insurers reported spending a significantly greater amount per member in their government plans than they did on their self-insured members, with spending on commercial insurance being in between these two extremes. The magnitude and source of these differences varied by corporate ownership. [ABSTRACT FROM AUTHOR]

Objective To demonstrate how expanding services covered by a 'bundled payment' can also expand variation in the costs of treating patients under the bundle, using the Medicare dialysis program as an example. Data Sources/Study Setting Observational claims-based study of 197,332 Medicare hemodialysis beneficiaries enrolled for at least one quarter during 2006-2008. Study Design We estimated how resource utilization (all health services, dialysis-related services, and medications) changes with intensity of secondary hyperparathyroidism ( sHPT) treatment. Data Extraction Methods Using Medicare claims, a patient-quarter level dataset was constructed, including a measure of sHPT treatment intensity. Principal Findings Under the existing, narrow dialysis bundle, utilization of covered services is relatively constant across treatment intensity groups; under a broader bundle, it rises more rapidly with treatment intensity. Conclusions The broader Medicare dialysis bundle reimburses providers uniformly, even though patients treated more intensively for sHPT cost more to treat. Absent any payment adjustments or efforts to ensure quality, this flat payment schedule may encourage providers to avoid high-intensity patients or reduce their treatment intensity. The first incentive harms efficiency. The second may improve or worsen efficiency, depending on whether it reduces appropriate or inappropriate treatment. [ABSTRACT FROM AUTHOR]

Abusive head trauma (AHT) is a serious health problem that results the highest mortality among children who are maltreated. Many AHT survivors suffer from long-term sequelae and require medical treatment. However, the knowledge of AHT-attributable health services utilization and costs at national level are limited. To estimate health services utilization and costs attributable to AHT among children aged 0–4 years in Taiwan. Sixty-three fatal and 664 survival AHT cases were identified using Taiwan national population database between 2003 and 2015. A total of 2656 non-AHT children were exactly 4:1 matched to the survival cases based on their birth year, gender, the calendar year of the index date, insured location, and health insurance premium (social economic status indicator). Health services utilization and costs were calculated on an annual basis for 3 years after the index date. AHT-attributable health services utilization and costs during 3-year follow-up period was evaluated by regression models. AHT diagnosis was positively associated with inpatient admissions, length of stay, emergency room (ER) visits, and outpatient visits. AHT-attributable medical costs were 1.64–17.27 times, 1.25–5.22 times, and 1.77–2.36 times greater for inpatient, ER, and outpatient during 3-year period than matched controls, respectively. Fatal AHT cases had higher inpatient utilization and greater medical costs than AHT survivors. Children with AHT had greater health services utilization and higher costs for years. Strategies to reduce the burden of AHT on health care system are imperative. • AHT-attributable medical utilization remains high even after 3-year post-diagnosis. • Survivors' inpatient cost was 17 times more than controls within 1 year after AHT. • The median survival time of fatal cases after the AHT diagnosis was only 37 days. • Inpatient cost for fatal AHT is 5 and 28 times higher than survivors and controls. [ABSTRACT FROM AUTHOR]

Highlights: [•] We model the employee's contribution scheme for a firm that offers multiple health insurance plans. [•] Plans differ in the level of quality. [•] We determine the relationship between the contribution scheme and the plan premiums. [•] We test our hypothesis using data from firms in the EHBS that offer both HMO and PPO plans. [•] We find that increases in the plan's premium affect the amount of the premiums passed on to employees. [ABSTRACT FROM AUTHOR]

We provide an explanation for the widespread finding that capitated managed care plans attract comparatively healthy, low cost enrollees relative to traditional unmanaged plans. Using disaggregated commercial insurance claims from the Thomson-Reuters MarketScan database, we show that managed care plans spend proportionally less on those types of services that are predicted to be more profitable to ration tightly using a selection index developed by Ellis and McGuire that captures the derivative of profits with respect to reduced spending on disaggregated services. Conventional diagnosis-based risk adjusted premiums reduce selection incentives by about 50% relative to premiums that are not risk-adjusted. [ABSTRACT FROM PUBLISHER]

The article discusses research on the cost of teachers' health care in the U.S. Based on the data from the Bureau of Labor Statistics (BLS), the costs for teachers' health insurance across school districts have increased at an average rate of 4 percent above inflation from 2004 to 2012. Using the same data, the researchers have determined that insurance costs for teachers are 26 percent higher than private-sector professionals.

To assess the effects of transitions from private to public health insurance by children on out-of-pocket medical expenditures and health insurance premium costs. Data are drawn from the 1996 and 2001 panels of the Survey of Income and Program Participation. We construct a nationally representative, longitudinal sample of children, ages 0-18, and their families for the period 1998-2003, a period in which states raised public health insurance eligibility rates for children. We exploit the Survey of Income and Program Participation's longitudinal design to identify children in our sample who transition from private to public health insurance. We then use a bootstrapped instrumental variable approach to estimate the effects of these transitions on out-of-pocket expenditures and health insurance premium costs. Children who transition from private to public coverage are relatively low-income, are disproportionately likely to live in single-mother households, and are more likely to be Black or of Hispanic origin. Child health status is highly predictive of transitions. We estimate that these transitions provide a cash-equivalent transfer of nearly U.S.$1,500 annually for families in the form of reduced out-of-pocket and health insurance premium costs. Transitions from private to public health coverage by children can bring important social benefits to vulnerable families. This suggests that instead of being a net societal cost, such transitions may provide an important social benefit. [ABSTRACT FROM AUTHOR]

The article reports on the planned move of Patient Protection and Affordable Care Act (PPACA) to approach on universal insurance coverage with better safety-net programs for the uninsured citizens in the U.S. It highlights the purpose of health care reform law for citizens with low-income such as medical care cost and hospital payments. Safety-net programs are providing the uninsured with access to reasonable costs of insurance premiums.

Cash income offers an incomplete picture of the resources available to finance household consumption. Most American families are covered by an insurance plan that pays for some or all of the health care they consume. Only a comparatively small percentage of families pays for the full cost of this insurance out of their cash incomes. As health care has claimed a growing share of consumption, the percentage of care that is financed out of household incomes has declined. Because health care consumption is more important for some groups in the population than others, the growth in spending and changes in the payment system for medical care have reduced the value of standard income measures for assessing relative incomes of the rich and poor and the young and old. More than a seventh of total personal consumption now consists of health care that is purchased with government insurance and employer contributions to employee health plans. This paper combines health care spending and insurance reimbursement data in the Medical Expenditure Panel Study and money income and health coverage data in the Current Population Survey to assess the impact of health insurance on the distribution of income. Our estimates imply that gross money income significantly understates the resources available to finance household purchases. The estimates imply that a more complete measure of resources would show less inequality than the income measures that are currently used. The addition of estimates of the value of health insurance to countable incomes reduces measured inequality in the population and the income gap between young and old. If the analysis were extended over a longer period, it would show a sizeable impact of insurance on inequality trends in the United States. [ABSTRACT FROM AUTHOR]

Each year the Kaiser/HRET Survey of Employer Health Benefits takes a snapshot of the state of employee benefits in the United States, based on interviews with public and private employers. Our findings for 2009 show that families continue to face higher premiums, up about 5 percent from last year, and that cost sharing in the form of deductibles and copayments for office visits is greater as well. Average annual premiums in 2009 were $4,824 for single coverage and $13,375 for family coverage. Enrollment in high-deductible health plans held steady. We offer new insights about health risk assessments and how firms responded to the economic downturn. [ABSTRACT FROM AUTHOR]

Responding to the increasing cost of employer-provided health insurance, some employers have instituted a number of cost-savings efforts such as reduced benefits, limited access, increased copayments, differential premiums and wellness programs. Of interest in this article are cost abatement efforts that focus on lifestyle behaviors that can adversely influence insurance costs. If such efforts are to succeed, it will require employee acceptance of these efforts. This article presents information that identifies lifestyle behaviors that might reasonably receive support for such differential treatment. [ABSTRACT FROM AUTHOR]

Consumer-directed health care is a potentially promising tool for moving toward more efficient use of health care resources. Tax policy has long been biased against health plans with significant patient cost sharing. Tax advantages created by health savings accounts (HSAs) began to change that, and proposed tax reforms could go even further. We assess various critiques of these plans, focusing on why they benefit not just the healthy and wealthy. Lower costs and more efficient health spending would help all patients and reduce uninsurance. Potential negative distributional effects are important but can be remedied more efficiently without distorting insurance design. [ABSTRACT FROM AUTHOR]

Some epidemiological literature has observed that air pollution effects on health differed across regional or individual socioeconomic position. This study evaluated whether regional and individual socioeconomic position, as indicated by health insurance premiums, modified the effect of air pollution on hospital visits for asthma. Effects of ambient air pollutants (particulate matter, carbon monoxide, sulfur dioxide, nitrogen dioxide, and ozone) on 92,535 emergency out-patient hospital visits for asthma in Seoul, Korea during 2002 were estimated using case-crossover analysis, adjusting for time trend, weather conditions, and seasonality. Next, interactions between air pollutants and Korean National Health Insurance premium (1) for the individual patient and (2) averaged across the patient’s residence district, were entered, first singly then jointly, in the models. Relative risks of emergency outpatient hospital visits were all positively and significantly associated with interquartile increases for selected lags for all air pollutants. In the regression model with interaction terms for both individual premium and regional-average premium, associations with all five-air pollutants ranged from 1.03 to 1.09 times higher among the lowest premium districts compared to the highest premium districts. Of all the pollutants, nitrogen dioxide showed the strongest associations in lower premium districts compared to the higher premium districts. Individual socioeconomic position did not modify the associations in either the single or joint interaction models. In Seoul, community but not individual socioeconomic conditions modified risk of asthma hospital visits on high air pollution days. [ABSTRACT FROM AUTHOR]

Consumers, when ill, often have the choice of being treated for free in a public hospital or at a positive price in a private hospital. To compensate for the positive price, private hospitals offer a higher quality treatment. Private hospitals and doctors also have a degree of monopoly power in their pricing. In this setting, it is shown that the introduction of an insurance premium subsidy does not affect the number of consumers treated in the private hospital, rather the private hospital and the doctor respond to the subsidy by increasing the prices they charge and the quality of the private hospital experience. [ABSTRACT FROM AUTHOR]

This paper examines recent trends in benefits and premiums for individual health insurance products purchased by Californians. There is much variability in the coverage available in the individual insurance market, with correspondingly wide variability in premiums. Despite concerns about increased consumer cost sharing, the average share of health spending covered by these products has remained constant between 1997 and 2002. Whether this trend can continue in the face of higher health costs is unclear. [ABSTRACT FROM AUTHOR]

To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems. Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities. This is an observational study with data collection over a six-year period. The study used semistructured interviews with local respondents, combined with monitoring of local media, to track changes in health care systems over time and their impact on community residents. Interviewing began in 1996 and was carried out at two-year intervals, with a total of approximately 2,200 interviews. The interviews provided a variety of perspectives on employer decision making concerning health benefits; these perspectives were triangulated to reach conclusions. The tight labor market during the study period was the dominant consideration in employer decision making regarding health benefits. Employers, in managing employee compensation, made independent decisions in pursuit of individual goals, but these decisions were shaped by similar labor market conditions. As a result, within and across our study sites, employer decisions in aggregate had an important impact on local health care systems, although employers' more highly visible public efforts to bring about health system change often met with disappointing results. General economic conditions in the 1990s had an important impact on the configuration of local health systems through their effect on employer decision making regarding health benefits offered to employees, and the responses of health plans and providers to those decisions. [ABSTRACT FROM AUTHOR]

Health care spending per privately insured person increased 9.6 percent in 2002, a slight reduction from the 10 percent increase in 2001. This is the first time in five years that the spending trend did not accelerate. Nonetheless, health care spending grew nearly four times faster than the U.S. economy grew in 2002. Growth in hospital spending accounted for the largest portion of the overall increase (51 percent) for the second straight year. Moreover, hospital price inflation--which accelerated significantly in 2002-accounted for a larger share of hospital spending growth in 2002 than in 2001. Premium increases accelerated again in 2003, despite 2002's slight deceleration of the overall spending trend. [ABSTRACT FROM AUTHOR]