Irish Findings on Financial Protection Bridget Johnston Mapping the Pathways to Universal Healthcare https://medicine.tcd.ie/health-systems-research/ Centre for Health Policy and Management, Trinity College Dublin 22 September 2015

Using the new WHO Approach Measuring Financial Protection Using the new WHO Approach

Methodology WHO methodology - allows cross country comparisons Household Budget Survey 2009 4th quarter 2009 – 3rd quarter 2010 CSO Representative sample with 5,891 households Currently out in the field, will update as soon as possible (Spring 2016) On 1 Jan 2010: 50 cent prescription charge introduced for medical card holders Drug payment scheme up from €100 to €120 Highlight Jon’s comments about WHO methods Briefly describe data set – collected by CSO, between ----, and the sample size Remind them that this is older data and that the findings will be updated next year when the next wave of data becomes available At the time of collection, …... Tell them what the mean SER was and

Methodology Out of Pocket costs Drugs, other medical products and equipment, outpatient, dental, diagnostic tests and paramedical services and inpatient fees Poverty line Housing consumption expenditures added to food-based poverty line Equivalised poverty line = €120.53 Subsistence expenditure level (Mean = €171.80 ) Households classified as poor if expenditure<subsistence expenditure (1.84%) Capacity to pay (CTP) Expenditure beyond household subsistence expenditure (mean = €567.80)

Out-of-pocket spending as a share (%) of total household consumption by expenditure quintile, 2009-2010 Appears progressive, but does not pick up on unmet need. Some individuals maybe unable to pay for access to care and this will be be measured with this approach

Breakdown of total out-of-pocket spending by type of health service and expenditure quintile, 2009-2010 Payment for drugs and outpatient fees are the most significant drivers of out of pocket costs. Drugs are largest proportion of OOPs for the 2 lowest expenditure quintiles. Another interesting finding from this figure is that dentistry spending is very uneven across the consumption expenditure quintiles. They are a much larger proportion of OOPs amongst the higher expenditure quintiles than they are amongst the 2 lowest expenditure quintiles. A reasonable explanation for this is that people in the lower quintiles are going without dentistry because of the high cost of access. Most dentistry requires private out-of-pocket spending and the limited amount that was available to medical card holders was one of the first items to be cut in the health adjustments to the financial crisis.

Share of the population (%) experiencing catastrophic and impoverishing health spending, 2009-2010 This includes households that have OOPs that put them very close to the poverty line. The level included in this report is 120% of the subsistence level for the household

Absolute numbers of people affected, 2009-2010 Category Total number 95% Confidence Intervals Further impoverished by OOPs 24,761 11,753 37,770 Impoverished by OOPs 3,759 -2,473 9,990 At risk of impoverishment from OOPs 34,739 20,721 48,757 No risk 2,671,025 2,573,210 2,768,839 No OOP 1,328,208 1,259,846 1,396,569 Catastrophic spending (40% of CTP) 47,592 34,879 60,304

Proportion experiencing catastrophic, impoverishing and further impoverishing OOPs by expenditure quintile, 2009-2010 Catastrophic spending appears to be regressive in nature, with the lowest income quintile having a significantly higher proportion of households experiencing this type of spending.

Out-of-pocket spending by households experiencing catastrophic, impoverishing, or further impoverishing OOPs by type of health service and expenditure quintile

Summary of Results The findings suggest OOPs are largely for goods and services not normally covered by a medical card or GP visit card Patterns of spending vary across expenditure quintiles Caution is needed when interpreting results Will not capture unmet need Data was collected in 2009-2010 so does not capture any of the policy changes that have occurred since then Unmet need – those who need care but do not (cannot) pay to access it

The Role of Private Health Insurance How well does PHI financially protect people from catastrophic spending? New WHO threshold: 17% of households with catastrophic spending were also paying for PHI 60% of equivalised expenditure: 30% of households with catastrophic spending were also paying for PHI Does not cover many out of pocket payments Less related to household income than OOPs Is PHI affordable? What impact does paying for it have on households? 51% of households were paying for PHI Protection from catastrophic spending Unlike PHI in countries like France and Slovenia, PHI in Ireland does not cover many OOPPs…

National poverty line and Private Health Expenditure Measuring Affordability National poverty line and Private Health Expenditure Affordability

Methods Private health expenditure Out-of-pocket costs Private Health Insurance Poverty line 60% of median equivalised household expenditure Poverty line = €187.44 Subsistence expenditure (Mean = €400.62 ) Households classified as poor if expenditure<subsistence expenditure (18.46%) Capacity to pay (CTP) Expenditure beyond household subsistence expenditure (mean = €338.97) Describe what PHE is - Describe the poverty line SE – poverty line * equivalised household size

Private health expenditure as a share of total household expenditure by expenditure quintile, 2009-2010 In total, private health expenditure accounted for slightly higher than 5 percent of household consumption expenditure in 2009-2010. Distribution of health expenditures across consumption expenditure quintiles looks progressive, with the rate of spending as a share of total household consumption expenditure increasing as overall consumption expenditure levels grew. Nevertheless, such findings need to be interpreted with care. Given the prevalence of the use of user fees for accessing care at primary and secondary levels, apparent progressivity may in fact reflect differential access. In other words, poorer households may decide not to access health care services where they have to pay for them. In contrast, richer households may be comfortable paying to get the access that they require. Such market dynamics may show the rich spending not only more, but also a higher proportion, of their income. This does not mean that the system is equitable in terms of access and great care must be taken attaching merit to progressivity in this area. Furthermore, all analysis around catastrophic or impoverishing expenditure must take into account that poorer households may choose to defer necessary care. Unmet need will not be picked up by this mode of analysis.

Distribution of total private health expenditure by type of health service and expenditure quintile, 2009-2010 The graph shows distribution of PHE in total and by CEQ. Overall, private health expenditure was highest for private health insurance (PHI) premiums and over the counter (OTC) drugs at 42% and 14%, respectively. Patterns in spending on these services between consumption expenditure quintiles, however, are not similar. For households in the lowest consumption expenditure quintile, almost half of total private health spending (48.3%) was on PHI. This figure increases to 53.9% for households in the second consumption expenditure quintile and then decreases as a total proportion of spending for the third (46%), fourth (42%) and fifth (37%) consumption expenditure quintiles. It can also be assumed that households in the higher consumption expenditure groups are also able to purchase PHI policies with superior benefits, while poorer households are probably maintaining basic coverage in most cases. Spending on OTC drugs as a proportion of total private health expenditure was highest for households in the lowest consumption expenditure quintile (approximately 24.9%) and fell steadily across the higher consumption expenditure quintiles.

Households’ private health expenditure and capacity to pay, 2009-2010 9% had negative CTP, 2% had PHE that exceeded CTP. Overall, more than 15% of households were not able to afford or were spending more than 40% of their total CTP. When you include households that have PHE that puts them very close to the poverty line (120% of the subsistence level for the household) In total, 17.8% of household experienced, or were at risk of experiencing, levels of spending on healthcare that they cannot afford (the top of the yellow line)

Paying for Private Health Insurance - At any cost? 29% of households with negative capacity to pay were paying for private health insurance 80% of households with private health expenditure exceeding capacity to pay were paying for private health insurance 31% of households at risk of private health expenditure exceeding capacity to pay were paying for private health insurance 50% of households with unaffordable private health expenditure were paying for private health insurance Overall, more than 50% of households experiencing difficulties affording their PHE were paying for PHI. Breakdown of the figures…

Absolute numbers of people affected, 2009-2010 Category Total number 95% Confidence Intervals Negative CTP for PHE 428,224 375,288 481,161 PHE exceeding CTP 82,234 60,450 104,019 At risk of PHE exceeding CTP 327,232 284,099 370,364 No risk of PHE exceeding CTP 2,358,173 2,271,004 2,445,342 No PHE 866,627 808,253 925,001 Unaffordable PHE 701,983 650,473 753,493 Negative capacity to pay – household where expenditure levels were lower than the subsistence expenditure level. Earlier in bar chart…

Share of the households experiencing unaffordable PHE by expenditure quintile, 2009-2010

Breakdown of spending by households with unaffordable PHE by type of health service and expenditure quintile, 2009-2010

Quintile Absolute Numbers 1 129,461 2 135, 776 3 45,206 4 22,615 5 Absolute numbers with unaffordable PHE who have private health insurance costs by expenditure quintile, 2009-2010 Quintile Absolute Numbers 1 129,461 2 135, 776 3 45,206 4 22,615 5 6,668 339,726 in total

In summary Overall, the most significant proportion of spending for households with unaffordable private health expenditure went towards PHI. Lowest consumption quintile disproportionately affected More than 50% of households with unaffordable private health expenditure are paying for private health insurance

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