The Dual System: Incentivising the uptake of Private Health Insurance? Policy 701. Policy Report. Krysta McDonald

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1 uptake of Private Health Insurance? The Dual System: Incentivising the uptake of Private Health Insurance? Policy 701 Policy Report Krysta McDonald

2 Executive Summary Public spending on health is increasing at a high rate every year, while at the same time there has been a gradual decline in health insurance coverage (Business Desk, 2012, May 23; Ryall, 2007). The ageing of the population is set to place an added burden on the public system (Frizelle, 2005). The government currently has minimal involvement in the activities of the private health insurance industry, with limited regulatory controls in place and no incentive schemes to encourage uptake of private health insurance (Blumberg, 2006). Given the rising public health costs, declining rates of private health insurance coverage may be of concern. This project has employed the analytical framework of comparative institutional analysis (Mintrom, 2012) in seeking to draw lessons from the Private Health Insurance Incentives Scheme in Australia. Utilising the framework of analysis of government failure as a component of this lesson-drawing exercise, assisted in identifying possible sources of government failure that could arise from greater government involvement. It is recommended that a 30% subsidy on private health insurance premiums should not be considered at this stage, whilst a tax penalty on high earners without private health insurance could go a long way in securing a greater level of equity. 2

3 Table of Contents Executive Summary... 2 Introduction... 4 Background... 5 Emergence of the Dual System... 5 Policy and the Private Health Insurance Industry in New Zealand... 6 Declining rates of coverage... 6 Current contentions... 7 Previous work in this area... 8 Analytical Frameworks Analysis and Findings Comparative Institutional Analysis Goals/Alternatives Matrix for this Project New Zealand Australia Analysis of Government Failure Information and co-ordination problems the PHIIS was to address Undue political interference and provider capture Perverse incentives and unintended outcomes Government involvement Discussion Recommendations Conclusion Declaration of Interest References

4 Introduction Health care expenditure in New Zealand is increasing at a high rate year on year; while at the same time there has also been a steady decline in coverage rates of private health insurance (Business Desk, 2012, May 23; Ryall, 2007). The New Zealand government currently has minimal involvement in regulating the private health insurance industry, and no government-induced incentives exist to encourage greater population uptake of private health insurance (Ashton, 2005). The findings presented in this report will be of use to policy makers in relevant government departments, concerned with the on-going escalation of health care costs in New Zealand. It shall begin with a discussion of the policy history in this area, and will then proceed with presenting the analytical techniques employed in seeking to draw lessons from the experience of the Private Health Insurance Incentives Scheme in Australia. In closing, recommendations will be made based on the findings of this project. Essentially it will be shown, that the introduction of a subsidy on private health insurance premiums in New Zealand may not be the most appropriate policy tool to employ in this area. Considerations are given to possible alternative government actions. 4

5 Background Emergence of the dual system The origins of New Zealand s dual funding and provision of healthcare find themselves in the Social Security Act of 1938 (Ashton, 2005; Bowie, 1999). The New Zealand government set out with the goal of providing free health services for all New Zealanders. However, after much debate with a highly-opposed medical profession, concessions were made to allow general practitioners to continue charging patients co-payments above the government subsidies for their services (Quin, 2009). While this represented the emergence of the dual system of public and private funding of healthcare, the first dedicated private health insurance company did not emerge until 1961, with the establishment of Southern Cross Healthcare; a not-for-profit health insurer which offered reimbursement for the majority of private surgical hospital and anaesthetist fees (Smith, 2000). The private health insurance offered was embraced by 50% of the population, and the number of private hospital beds also expanded, thus cementing a public-private mix of health services in New Zealand (Ashton, 2005; Bowie, 1999). While currently at around 6% of total health funding in New Zealand the input of private health insurance may represent a small contribution, in the National Party s health discussion paper Better, Sooner, More Convenient, they have affirmed this contribution to be a small but important part of overall health spending (Ryall, 2007, p. 8). 5

6 Policy and the Private Health Insurance Industry in New Zealand Many countries, including Australia, have recognised the important role that private health insurance plays in funding health services and have taken an active role in both regulating the industry, and incentivising the uptake of private health insurance (Colombo & Tapay, 2003; Colombo & Tapay, 2004). The New Zealand health insurance industry however, since the tax deductibility of premiums was abolished in the 1980s, does not receive any direct financial assistance from the government and is at present unregulated (Ashton, 2005). This results in insurers having significant flexibility in setting premiums according to risk (that is by age, gender and health status etc.) (Blumberg, 2006). It has been acknowledged that private health insurance markets that are not subject to some form of government regulation, and that do not have any targeted incentives, often present access problems for high-risk individuals (Colombo & Tapay, 2004). Declining rates of coverage Rates of private health insurance coverage have steadily declined from around 50% of the population in the 1980s, to in recent years covering only around a third of the population (Health Funds Association of New Zealand (HFANZ), 2010). In fact, as published in the New Zealand Herald on 23 May 2012, New Zealand just recently reached a six-year low in health insurance coverage, declining to just 30% of the population (Business Desk, 2012, May 23). Considering that the New Zealand Treasury has recently projected that public spending on health is likely to double as a percentage of GDP to 12% by 2050 (Ryall, 2007), the declining contribution of private health insurance to the funding of health services in New Zealand 6

7 may present an additional burden to the public system. A further pressing issue is that New Zealand is currently going through a period of demographic transformation, whereby the proportion of the population over 65 years of age, who represent significant users of healthcare, is set to double by around 2050 (Frizelle, 2005; Gauld, 2005), shown in figure 1. Figure 1: Projections of the over 65 years population New Zealand Source: Statistics New Zealand (2000). It is this age-group in particular for which private health insurance premiums are largely prohibitive, due both to lower incomes in this older age-group and their classification as high-risk individuals by insurers when setting premiums (Blumberg, 2006; Parke, 2012; Southern Cross Health Society, 2010). As a result, these potentially complex and expensive patients are increasingly the responsibility of the public system. Current contentions The private health insurance industry in New Zealand have repeatedly called for the New Zealand government to implement greater incentives to increase the uptake of private health insurance, as has been done in Australia (HFANZ, 2011; Styles, 2012). One particular 7

8 incentive that they have proposed is for the government to introduce a subsidy for the over 65 population to obtain health insurance, thus alleviating some of the strain that is currently being placed on the public system (Styles, 2012). The HFANZ (2011) has been explicit in saying that they consider it the responsibility of the New Zealand government to ensure the on-going functioning of the health system as a whole; both the public and private systems. Contrary to this, others have argued that the solution to the current rising health costs in New Zealand is not to maximise the number of people with private health insurance, as this may in fact lead to a greater use of public services (Dare, 2012; Parke, 2012, March 16). Previous work in this area Two studies in New Zealand are worth recognising. The first is a report released by the New Zealand Treasury largely in response to calls from the health insurance industry for the government to subsidise health insurance premiums, entitled Costs of subsidising private health insurance (Treasury, 2002). The report concluded that the government did not look favourably on a subsidy, as through modelling the potential costs against the potential savings to the public system, the government was not likely to break even, let alone benefit (Treasury, 2002). This was said to be due to the fact private health insurance in many cases covers different services to those that are provided by the public system; owing to the complementary rather than substitutive nature of private healthcare in New Zealand (Treasury, 2002). 8

9 The second report was commissioned by Southern Cross Society in 2004, which entreated the need for a 30% rebate on health insurance (as had been introduced in Australia just prior) based on 3 key rationales: 1. Increased uptake of insurance would take pressure off the public system 2. Under the existing arrangements, health insurance coverage may halve in the next 10 years; collapse of the industry would then constitute a major cost to the government 3. A subsidy would be fairer, in recognising the fact that people with private health insurance are paying for their health care twice; once through taxation, once through insurance premiums (Southern Cross Society, 2004) The first report places significant emphasis on cost-benefit analysis, with the primary benefit criterion being reduced cost to the public system. The second invokes other criteria against which to measure the policy tool, namely; fairness, cost-benefits, and supporting the long-term viability of the health insurance industry. The project presented in this report allowed for a shift away from the predominance of costbenefit analysis, to address different criteria against which to measure possible policy responses to what appears to be a struggling market in New Zealand. The criteria of equity, administrative simplicity, and efficiency (assessed as being the effectiveness of the various policies in increasing private health insurance coverage, against the cost to government) will be employed when considering possible policy responses arising from this project. 9

10 Analytical Frameworks In assessing options for government action in this area, this project will apply the analytical framework of Comparative Institutional Analysis (as proposed by Mintrom (2012)) to the case of the Private Health Insurance Incentives Scheme in Australia in comparison with the current arrangements in New Zealand. According to Mintrom (2012), this approach is particularly effective in drawing lessons from practice in selecting policy tools that may address an existing problem. Additionally, utilising the framework of Analysis of Government Failure through careful application as a component of Comparative Institutional Analysis (Mintrom, 2012, p. 197) will assist in identifying any possible sources of government failure arising as a result of the Private Health Insurance Incentives Scheme (PHIIS) in Australia that have potential to be replicated in the New Zealand environment should any of the policy options be transferred. Use of the framework of Analysis of Government Failure is also an acknowledgement that good policy design must be informed by an awareness of the potential for government failure and how the risk of it could be reduced (Mintrom, 2012). Analysis and Findings Comparative Institutional Analysis In choosing Australia as a case for comparison, consideration was given to a subjective notion of its proximity to New Zealand and political similarities (Rose, 1991), which allowed for the isolation of the particular institutional arrangement of interest (the PHIIS), in line with a most similar case selection technique outlined by Seawright & Gerring (2008). Australia and New Zealand share a similar social and political history, and importantly, the 10

11 rate of private health insurance coverage in Australia prior to the introduction of PHIIS was similar to the current rate seen in New Zealand (30.1% and 30.0% respectively) (Business Desk, 2012, May 23; Harley, Vaithianathan, Crossley & Cobb-Clark, 2002). Additionally, both countries have a dual public-private system of health care financing and provision (HFANZ, 2010). In doing in-depth case study research on government involvement in the private health insurance industry in Australia, existing academic literature, media publications along with public and government documents were sought to provide insight into the effectiveness of the PHIIS in achieving the intended outcomes or not. Goals/Alternatives Matrix for this Project The following matrix shows how each of the policy tools to be addressed in comparison between Australia and New Zealand in this section, fared against each of the criteria outlined earlier in the report. Explanations follow. Table 1: Policy alternatives against set criteria Policy Alternatives Australia New Zealand Criteria Tax penalty for high earners Universal 30% subsidy on premiums Decentralised no incentives Equity HIGH NEUTRAL LOW Efficiency NEUTRAL LOW NEUTRAL Administrative simplicity NEUTRAL LOW HIGH 11

12 New Zealand Government involvement in the New Zealand private health insurance industry is minimal, and New Zealand private health insurers currently practice in an unregulated environment (Ashton, 2005; Blumberg, 2006). The sole source of regulation of private insurance in New Zealand is the Human Rights Act (HRA) of 1993, which requires insurers to adhere to the governing rule that no individual can be refused issue of an insurance policy (Blumberg, 2006). This arrangement however, allows for private health insurance companies to set premiums according to a person s age and health status (risk rating) (Blumberg, 2006). Such an arrangement presents an equity issue, where access to private health insurance is limited to those who can afford the premiums; thus there is a trend of increasing coverage with increasing income (Blumberg, 2006). It can also be seen to be inequitable in that people with private health insurance often do not have to endure the same waiting times for treatment than those seeking treatment within the public system. As the New Zealand Ministry of Health has as one of their overarching principles to ensure timely and equitable access for all New Zealanders to health and disability services, regardless of ability to pay, the current arrangement can be seen to run counter to this aim (King, 2000, p.vii; Ashton, 2005) Measuring the current situation against the criterion of efficiency, it can be seen that this arrangement has raised some efficiency concerns. The provision under some insurance plans to cover the out-of-pocket expenses for private patients utilising publicly subsidised services (eg. pharmaceuticals and general practice services), has led to a higher uptake of such services by people with private health insurance thus representing an additional cost to the public system (Blumberg, 2006). Given the minimal state involvement 12

13 in this arrangement, it does however offer huge simplicity in administration, and no regulatory or administrative body has thus had to be established and funded. Australia In direct contrast to the current institutional arrangement in New Zealand, private health insurance is considered a predominant national health policy issue in Australia, and the government has intervened in the industry both in regulating its processes and in incentivising the uptake of private health insurance by the general population (Colombo & Tapay, 2003; Stoelwinder, 2002). Regulation of the private health insurance industry in Australia, while beyond the scope possible in this project, is carried out by the Australian government under the National Health Act of 1953 (Colombo & Tapay, 2003). Briefly, the Private Health Insurance Administration Council (PHIAC) regulates the industry according to its adherence to the principles of community rating (all individuals pay the same premiums for the same products, not according to risk) and acceptance of all applicants without discrimination (Colombo & Tapay, 2003; PHIAC, 2012). While this regulatory arrangement may present a confounding factor (when compared to New Zealand where no regulatory framework exists) in considering the effectiveness of the PHIIS, it is important to note that the regulation of the private health insurance industry in Australia has been long-standing. Importantly, the PHIIS was introduced over a definite period of time in Australia, specifically at a time when coverage rates in Australia had reduced to just 30.1% of the population where they currently stand in New Zealand. It is 13

14 therefore theoretically possible to isolate the effects of the introduction of this scheme in the Australian context and posit its potential for transfer to the New Zealand context. The PHIIS was rolled out (with staged amendments) over the period of Private health insurance coverage increased significantly over this time, from 30.1% to 46% (Harley et al., 2002; Australian Bureau of Statistics, 2007) as is shown in figure 2. Figure 2: Proportion of the population in Australia with private health insurance Source: Private Health Insurance Administration Council, Quarterly coverage statistics, March 1984-March The first stage of the scheme involved both a stick tax penalties for high earners who did not have private health insurance; and a carrot - a 30% rebate on premiums for people on low incomes (Butler, 2002; Vaithianathan, 2004). The second stage involved an amendment to the first, where the subsidy became universal (no longer means-tested) and was rolled out in 1998 (Butler, 2002). The third phase was implemented in 2000 and involved an amendment to the community rating system whereby insurers were now allowed to increase premiums by a specified amount for each additional year that a person delayed 14

15 taking out private health insurance after the age of 30 (a stick ) (Vaithianthan, 2004). As the third incentive relates to a pre-existing regulation in Australia, it is thus beyond the scope of this project. The first 2 incentives (tax penalties for high earners and the universal 30% rebate) are the policy tools assessed as part of the analysis presented here. Policy tool 1: Tax penalty for higher earners The first tool, the tax penalty, perhaps introduced a greater level of equity into the system in that higher earners, who might reasonably be able to afford their own private health insurance, would be forced to contribute more toward the cost of their treatment in the public system through direct taxation. Empirical evidence suggests however, that the threat of a tax penalty to high earners did little to increase the uptake of private health insurance, and in so much as it represented a means of raising funds by the government, is therefore neutral against the criterion of efficiency (Butler, 2002). It is postulated that such a policy tool would not be too overly complicated administratively; however changes to the tax system would invariably require more complexity in administration. Policy tool 2: 30% rebate on insurance premiums In relation to the second tool, the universal 30% rebate, equity is a more complicated criterion (Palmer, 2000). On the one-hand the subsidy has the potential of creating greater equity of access, however on the other hand it could be argued that less well-off people who continue to have to use the public system are in fact required to meet part of the costs of those who utilise private care (as the subsidy is funded out of tax revenue), therefore this 15

16 tool is neutral on the equity factor (Palmer, 2000). With regards to effectiveness, while the universal 30% rebate did reverse the declining rates in private health insurance coverage, the increase was not as much as the government had hoped to achieve for the significant investment of funds, and the rate of increase was least for the over 60 age group (Butler, 2002; Vaithianathan, 2004). From empirical evidence, it appears that the amendment to the community rating system (as alluded to earlier, and beyond the scope of this project) may have had the greatest impact on inducing a greater uptake of private health insurance (Butler, 2002). Thus the subsidy scores low against the efficiency measure. On administrative simplicity, this subsidy appears to be rather complex to administrate in that there are 3 different ways in which a person can receive the rebate (Commonwealth Department of health and Aged Care, 1999). A low score against the administrative efficiency criterion. Analysis of Government Failure The PHIIS was established by the Australian government largely in response to concerns about the long-term viability of the private health insurance industry, and the added strain that this may place on the public system (Colombo & Tapay, 2003). Information and co-ordination problems the PHIIS was to address The PHIIS was intended to reverse the problem of consistently declining rates of private health insurance in Australia, owing to rising premiums in an ailing market (Colombo & Tapay, 2003). Adverse selection was becoming an increasing issue in this matter, in that the 16

17 young and healthy were progressively opting out of private health insurance increasing the relative risk of the insured pool, driving premiums up even more (Colombo & Tapay, 2003). Undue political interference and provider capture In Australia, although the premium subsidy represents a significant cost to the government (potentially outweighing the benefits to the public system), the political reality is that it has widespread public support so politicians are unlikely to do away with it (Stoelwinder, 2002). In New Zealand it is worth noting that it is the private health insurance industry that has made calls for the government to institute the 30% rebate on premiums, therefore such a policy would serve private business interests also (Ashton, 2005). If such a subsidy were introduced in the New Zealand context and yet did not produce the outcomes hoped for, the public support (as in Australia) combined with the lobbying support of the industry would create an expensive policy that would be politically difficult to retreat. Perverse incentives and unintended outcomes In Australia, the community rating system has resulted in a proliferation of different policies which appear to be targeting different risk categories; giving insurers one means to charge premiums according to risk (Colombo & Tapay, 2003). New Zealand does not have the community rating system, however of concern in the New Zealand context is the fact that a number of private health insurance policies provide coverage for out-of-pocket expenditures when the insured use publicly-subsidised services (eg. GPs). Increasing uptake 17

18 of private health insurance may in turn increase uptake of these publicly subsidised services, presenting an added strain on public funds (Blumberg, 2006). Government involvement In Australia, the 30% premium subsidy represents a significant cost to the government and has not produced the outcomes that were intended (Stoelwinder, 2002). It may in this sense be more cost-effective to do away with this measure and rely on the other policy tools which have added greater value to increasing uptake of Private Health Insurance. Government involvement in the activities of the private health insurance industry in Australia is expensive, and policy makers are currently considering ways to reduce their involvement in a regulatory capacity, perhaps by encouraging self-regulation within the industry (Colombo & Tapay, 2003). Introduction of a publicly-provided subsidy necessitates government involvement, and given the difficulty of retrenching this policy in Australia, may mean that a similar policy in New Zealand would foster longer-term government involvement. Discussion Based on the analysis presented in this report (against the criteria of equity, efficiency and administrative simplicity) a subsidy on private health insurance does not measure up. In addition, it should be acknowledged that introduction of such a subsidy may serve the interests of the private insurance industry to a greater extent than it will relieve pressures on the public system. Contrary to the contestations of the private health insurance industry, 18

19 a subsidy on private health insurance premiums may not be the best use of funds in this time of economic constraint and increasing costs. The first recommendation arising out of this project is: The introduction of a subsidy on private health insurance should not be considered at this stage in New Zealand. The current arrangement in New Zealand is inequitable, as private health insurance is largely only accessible to those with the ability to pay the often high premiums. This situation runs counter to the principle of timely and equitable access for all as outlined in the New Zealand Health Strategy. A tax penalty for people with high-incomes without private health insurance performed better against the criteria utilised in this study, therefore the second recommendation is: Consideration should be given to the introduction of a tax penalty for people on higher incomes who do not have private health insurance. While beyond the scope of this report, further investigation should be made into the additional burden that certain insurance policies may place on the public system. In particular, policies that provide out-of-pocket reimbursement to the insured for services subsidised by the public system. Blumberg (2006) has recommended that regulations prohibiting coverage of this kind may go a long way to reducing additional pressures on the public system. The final recommendation then is: Stakeholder analysis should be conducted to assess the relative acceptability of introducing restrictions on offering insurance policies that provide reimbursement of patient co-payments for publicly subsidised services. 19

20 Recommendations 1. The introduction of a subsidy on private health insurance should not be considered at this stage in New Zealand. 2. Consideration should be given to the introduction of a tax penalty for people on higher incomes who do not have private health insurance. 3. Stakeholder analysis should be conducted to assess the relative acceptability of introducing restrictions on offering insurance policies that provide reimbursement of patient co-payments for publicly subsidised services. 20

21 Conclusion There is no magic bullet for increasing the uptake of private health insurance in New Zealand that is both equitable, and cost-effective. By drawing on comparative institutional analysis with the PHIIS scheme in Australia when compared to New Zealand s system of minimal state involvement, this project has shown that on equity, efficiency and simplicity grounds, a subsidy on private health insurance premiums falls short of expectations. Additionally, utilising the framework of analysis of government failure has revealed that such a policy tool may be vulnerable to undue political interference from various stakeholders. The introduction of a tax penalty on high earners without private health insurance may go a long way to fostering greater equity, and additionally, may provide an important revenue stream for reinvestment into the public health system. This project has allowed for analysis in this area which moves beyond the prevalence of cost-benefit analysis, to considerations of equity and simplicity of administration in possible future government involvement in this area. As the Australian government has recently announced changes to the private health insurance subsidy that are positioned to generate cost-savings for the government (subsidy will be means-tested from 1 July 2012(The Australian, 2012)), future analysis in the area should engage once again in comparative institutional analysis with Australia to assess these changes against the criteria of effectiveness and equity. 21

22 Website A website has been developed for this project and can be found at: You can also contact the author at Declaration of Interest The author of this report was recently employed as a Senior Customer Services Consultant at Sovereign Assurance Company Limited. This report constitutes a requirement of formal academic study toward the Degree of Masters of Public Policy at the University of Auckland and in no way represents the position of Sovereign Assurance Limited. 22

23 References Ashton, T. (2005). Recent developments in the funding and organisation of the New Zealand health system. Australia and New Zealand Health Policy 2005, 2(9). doi: / The Australian. (2012, February 15). Private health insurance means test passed. The Australian. Retrieved from Australian Bureau of Statistics. (2007, September 2007). Health Expenditure: Private health insurance. Retrieved from d3646ca2570ec000c46e4!opendocument Blumberg, L. J. (2006). The Effect of Private Health Insurance Coverage on Health Services Utilisation in New Zealand. Retrieved from Bowie, R. (1999). A brief history and future of health insurance. Healthcare Review Online 3(4). Retrieved from Insurance/139 Business Desk. (2012, May 23). NZ private health insurance uptake hits 6-yr low. The New Zealand Herald. Retrieved from Butler, J. R. G. (2002). Policy change and private health insurance: Did the cheapest policy do the trick? Australian Health Review, 25(6), Colombo, F. & Tapay, N. (2003). Private health insurance in Australia: A case study. OECD health working papers no. 8. Retrieved from Colombo, F. & Tapay, N. (2004). Private health insurance in OECD countries: The benefits and costs for individuals and health systems. OECD health working papers no. 15. Retrieved from Commonwealth Department of Health and Aged Care. (1999). 30% rebate and private health insurance incentives scheme. Retrieved from 23

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