1. Irish Findings on Financial Protection
Bridget Johnston
Mapping the Pathways to Universal Healthcare
Centre for Health Policy and Management, Trinity College Dublin
22 September 2015

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

3. 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 )
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

4. 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 = € )
Households classified as poor if expenditure<subsistence expenditure (1.84%)
Capacity to pay (CTP)
Expenditure beyond household subsistence expenditure (mean = €567.80)

5. Out-of-pocket spending as a share (%) of total household consumption by expenditure quintile,
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

6. Breakdown of total out-of-pocket spending by type of health service and expenditure quintile,
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.

7. 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

8. 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

9. Proportion experiencing catastrophic, impoverishing and further impoverishing OOPs by expenditure quintile,
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.

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

11. 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 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

12. 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…

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

14. 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 = € )
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

15. Private health expenditure as a share of total household expenditure by expenditure quintile,
In total, private health expenditure accounted for slightly higher than 5 percent of household consumption expenditure in 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.

16. Distribution of total private health expenditure by type of health service and expenditure quintile,
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.

17. 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)

18. 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…

19. 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…

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

21. Breakdown of spending by households with unaffordable PHE by type of health service and expenditure quintile,

22. 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,
Quintile
Absolute Numbers 1
129,461 2
135, 776 3
45,206 4
22,615 5
6,668
339,726 in total

23. 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

24. Thank You