Private Health Insurance in Social Health Insurance Countries - Implications for Canada

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1 Access Access to to Care, Care, Access Access to to Justice: Justice: The The Legal Legal Debate Debate over over Private Private Health Health Insurance Insurance in in Canada Canada University University of of Toronto Toronto --September September 16, 16, Private Health Insurance in Social Health Insurance Countries - Implications for Canada Stefan Greß, Ph.D. Institute for Health Care Management University of Duisburg-Essen, Germany University of Duisburg-Essen Implications for Canada 1

2 Functions of of Private Health Insurance (PHI) (PHI) 6 Alternative PHI 6 Part of the population is not covered by social health insurance (SHI) at all 6 Part of the population may choose between PHI and SHI 6 Supplementary PHI 6 Services not or only partly covered in SHI 6 Co-payments in SHI 6 Complementary or Double-Cover PHI 6 Complementary coverage although there is coverage of SHI Unusual in Western European social health insurance systems (only exception: Netherlands) University of Duisburg-Essen Implications for Canada 2

3 Calculation of of Premiums Risk Solidarity Income Solidarity Income-Related Community-Rated YES YES SHI D Standard Contracts PHI YES NO SHI NL Risk-Rated NO PHI D and NL NO University of Duisburg-Essen Implications for Canada 3

4 Alternative PHI: PHI: Markets and and Regulation 6 Access to PHI 6 Germany: Self-employed, civil servants and employees above income threshold may opt out of social health insurance 6 Netherlands: Self-employed and employees above the income threshold have to opt out of social health insurance 6 Standard Contracts 6 No legal obligation of insurers to accept applicants however: government aims to increase access and affordability of PHI 6 Germany: Maximum premium for standard contract to increase affordability 6 Netherlands: Standard contract to increase access. Government controls premiums. Mandatory cost-sharing for insurers. University of Duisburg-Essen Implications for Canada 4

5 Alternative PHI: PHI: Market Outcomes 6 Effects on fairness in health care finance 6 Self-selection in Germany 6 Risk-pooling in NL is limited to lower income groups 6 Effects on equity in delivery of health care services 6 Preferred treatment for PHI patients in Germany 6 Alternative PHI does not lead to preferred treatment in the NL 6 Effects on cost containment 6 Financial burden on SHI due to self selection in Germany but also cross-subsidies through higher reimbursements. 6 Social health insurance contains costs more effectively than private health insurance University of Duisburg-Essen Implications for Canada 5

6 Supplementary PHI: PHI: Markets and and Regulation 6 Size of the market depends on the extent of the benefits package of social health insurance 6 Health care services 6 Co-payments 6 Both sickness funds and private health insurers (forprofit and not-for-profit) offer supplementary PHI 6 Very little public regulation possible in EU-countries University of Duisburg-Essen Implications for Canada 6

7 Supplementary PHI: PHI: Market Outcomes 6 Effects on access to health care 6 Access problems for bad risks 6 Government solution in France 6 Market solution: Group contracts 6 Effects on cost containment in SHI 6 Governments increasingly rely on supplementary PHI to fill the gaps left by decreasing public expenditures on SHI 6 If supplementary PHI covers co-payments, their task to fight moral hazard in SHI is difficult to fulfill University of Duisburg-Essen Implications for Canada 7

8 Implications for for Canada 1/4 1/4 6 Private health insurers usually charge risk-related premiums 6 If they do so, there is no risk solidarity and no income solidarity 6 As a consequence, sick people and poor people are less likely to be covered by private health insurance 6 This might be socially unacceptable University of Duisburg-Essen Implications for Canada 8

9 Implications for for Canada 2/4 2/4 6 There are several instruments to increase risk solidarity and access in private health insurance 6 If private health insurance is regulated extensively to increase risk solidarity it might look very similar to a public programme 6 It is probably more efficient from a public policy point of view to introduce a public programme right away University of Duisburg-Essen Implications for Canada 9

10 Implications for for Canada 3/4 3/4 6 Preferential treatment of patients with private health insurance coverage depends very much on provider remuneration 6 If there are two parallel systems and providers gain more from treating private patients than from treating public patients, preferential treatment for the former will almost certainly follow University of Duisburg-Essen Implications for Canada 10

11 Implications for for Canada 4/4 4/4 6 Preferential treatment of persons with private health insurance will only occur if something is amiss in the public system 6 Strong demand for private health insurance is a good indicator for policy makers to come up with solutions for problems in public programmes University of Duisburg-Essen Implications for Canada 11

12 Thank you youvery verymuch muchfor for your yourattention! University of Duisburg-Essen Implications for Canada 12

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