qotd: The impact of Taiwan's single payer system on amenable mortality

BMC Health Services Research

August 4, 2010

The impact of universal National Health Insurance on population health: the experience of Taiwan

By Yue-Chune Lee, Yu-Tung Huang, Yi-Wen Tsai, Shiuh-Ming Huang, Ken N Kuo, Martin McKee and Ellen Nolte

Background

Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan's population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.

Methods

Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.

Results

Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64 percent per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. (This result is consistent with our expectations as 77% of the working age population were already covered by the pre-existing social insurance; thus they were inevitably going to be affected less by the introduction of NHI.) NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.

Conclusions

NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Policy Implications

These findings have implications for other countries that do not have universal health insurance coverage. The implementation of NHI in Taiwan was associated with a sustained reduction in deaths from causes amenable to health care, which surpassed the underlying decline in other causes. It is reasonable to expect that the introduction of universal coverage elsewhere might also have beneficial effects.

Looking ahead, while the Taiwanese NHI has succeeded in terms of cost (3.4% of GDP), satisfaction (77.5% satisfied in 2007), low administrative cost (1.49%), and equitable financial burden, the system is not without problems. For example, as a publicly-managed program, it is difficult to insulate it from political interference, a factor that has contributed to a continuing financial deficit. Thus, the existing budget may be inadequate to sustain the current level of performance.

http://www.biomedcentral.com/1472-6963/10/225/abstract

Full article (provisional):

http://www.biomedcentral.com/content/pdf/1472-6963-10-225.pdf

United States has worst rate of amenable mortality:

http://www.pnhp.org/news/2008/january/united_states_has_wo.php

Comment:  Taiwan's 1995 introduction of a single payer system of universal National Health Insurance provides us with a natural experiment on the impact of single payer reform on health outcomes. The results are dramatic. The rate in reductions of deaths due to disorders that are amenable to health care were nine times the reductions in deaths from non-amenable causes. Nine times!

The United States should be especially interested in these results since, in a study of nineteen industrialized nations, we have the worst rate of amenable mortality (link above). We have over 100,000 excess deaths per year due to disorders amenable to health care.

Will the Patient Protection and Affordable Care Act (PPACA) erase this blemish on our health care system? Most of our dysfunctional financing system will remain in place. Some will receive care under an expansion of Medicaid, but as a chronically underfunded program with insufficient numbers of willing providers, access problems are inevitable. Others will receive care under the private plans in the insurance exchanges, but financial barriers to access will remain because of the low actuarial values of the plans and inadequate subsidies. There is little reason to believe that the tweaks of PPACA will have much impact on amenable mortality.

After enacting a single payer system, Taiwan not only greatly reduced amenable mortality, but it was done at a fraction of our spending, with great patient satisfaction, with extremely low administrative costs, and with a financing system that is equitable. Maybe Taiwan needs to spend more, but just think of what we could have with the amount that we are already spending. Besides, saving 100,000 lives a year seems to be a worthy policy goal.

qotd: Threat of destabilization of the private insurance market

The New York Times

August 2, 2010

Covering New Ground in Health System Shift

By Robert Pear

Administration officials are eager to demonstrate and deliver what they see as the benefits of the new law (Patient Protection and Affordable Care Act). But they face a delicate task: they do not want to destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers.

For the moment, President Obama has the upper hand. Congress gave him sweeping power to regulate the industry for the benefit of consumers. Administration officials said they would be tough on the industry, but, for the law to succeed, they need large numbers of insurance companies to compete in the new regulated marketplace.

Sabrina Corlette, a research professor at the Health Policy Institute of Georgetown University, said: "In 2014, we can say good riddance to bottom-feeder insurance plans, which have built a business around selling policies to healthy young people. They often provide inadequate coverage when people get sick. But if these plans pull out of the market before 2014, we want to be sure that viable alternatives are available."

http://www.nytimes.com/2010/08/03/health/policy/03insurance.html?hp

Comment:  "...bottom-feeder insurance plans, which have built a business around selling policies to healthy young people (and which) often provide inadequate coverage when people get sick..." That quotation describes the products being sold in the individual insurance market by WellPoint, the largest insurer in the nation. 

Imagine WellPoint improving those plans so that they do provide adequate benefits, with a choice of physicians and hospitals, without excessive cost sharing, and that they would include everyone regardless of preexisting conditions. Imagine the premiums that they would have to charge. Then imagine many companies developing similar quality insurance products to create a robust market of plan choices within the insurance exchanges.

Keep imagining because these products will have to exist only in our minds since the private insurance industry will never again be able to make them a reality if they are going to cover everyone with premiums we can afford.

For those who have employer-sponsored plans that seem to be working, keep in mind that these plans have cherry picked the large but highly select group of the inexpensive healthy workforce and their young healthy families. Also keep in mind that the employee cost of these plans is not only the payroll deduction, but also the forgone wage increases that pay for the employer contribution, and now to be added are the taxes that will be paid to support the subsidies for those who purchase their plans through the exchanges. Nobody is getting off cheap.

If the Obama administration is going to "regulate the industry for the benefit of consumers," then they can't help but "destabilize or disrupt the existing market in a way that makes insurance less available or more expensive to consumers."

Why should we worry about a destabilized market of private plans, when our real concern is how are we going to pay for the health care that any of us might need? The obvious solution would be to replace the private plans with a single payer national health program - an improved Medicare for all. The fate of the private insurers should be the least of our concerns.

qotd: Sen. Sanders to introduce bill for single payer waiver

Rutland Herald

August 1, 2010

Sanders promises to seek health care waiver from Obama for Vermont

By Susan Smallheer

U.S. Sen. Bernard Sanders, I-Vt., pledged to personally take Vermont's case for a statewide single-payer health care system to President Obama if the Legislature authorizes it next year.

Sanders, speaking at a health care rally at the Hetty Green Park in downtown Bellows Falls on Saturday afternoon, said that he and other members of Congress would also introduce legislation that would roll back to 2014 the current 2017 restriction for states to apply for a waiver in order to implement their own systems. He said Democratic Reps. Dennis Kucinich of Ohio and John Conyers of Michigan would be co-sponsoring the legislation with him.

http://www.rutlandherald.com/article/20100801/NEWS02/708019832/1003/NEWS02

Comment:  Although the Patient Protection and Affordable Care Act would allow states to apply for waivers to implement their own systems, they cannot do so until 2017, three years after they are required to implement the private insurance exchanges. Many have asked if Sen. Sanders still intends to introduce legislation to move that date up so that states would not have to set up the exchanges only to replace them soon thereafter with a single payer system. The answer is yes.