Universal Health Insurance systems and the provision of health services for people with disabilities
A National Disability Authority Working Paper
This working paper was commissioned by the National Disability Authority and prepared by Gavin Davidson, Berni Kelly and Geraldine Macdonald, School of Sociology, Social Policy and Social Work, Queen’s University Belfast, and Alison Martin, Maria Rizzo, Oluwaseye Abogunrin and Louise Lombard, Matrix Evidence, London. The views and opinions contained in the report are those of the authors and do not necessarily reflect the views or opinions of the National Disability Authority.
1.0 Key messages
- The proposed Universal Health Insurance system, with equal access to health care for all, based on need and not on the ability to pay, could greatly improve the provision of health services for people with disabilities in Ireland.
- However, benefits are not guaranteed. The introduction of Universal Health Insurance has been associated with increased health spending and mixed effects on health outcomes.
- People with disabilities have higher level of health needs than the general population. Any deficiencies with the Universal Health Insurance system introduced in Ireland could disproportionately disadvantage people with disabilities.
- Key concerns at a systems level in introducing Universal Health Insurance include the costs, vis-à-vis other models; the extent of coverage and the regulatory, licensing and risk management of the model.
- With regard to the impact on people with disabilities key concerns centre around equitable access to services, access to insurance and the potential for excessive supplementary or out-of-pocket payments for the individual.
- The potential main benefits of the proposed system (universal coverage and equal access) could be undermined by the potential limitations (under-funding, not including the full range of needs/services, barriers to access).
- Out-of-pocket payments disproportionately impact on people with disabilities because of their higher levels of health needs. Strategies to mitigate against this effect need to be carefully considered.
- People with disabilities must be able to negotiate the insurance process and receive the appropriate services to meet their needs.
- It will be important to provide sufficient support and information for people with disability, and avoid prolonged disputes about eligibility for services.
- There must be no incentives for insurers to selectively recruit people with lower levels of health needs or to impose financial disincentives for people accessing services.
- Comprehensive regulation and monitoring of Universal Health Insurance services should take into account the specific needs of people with disabilities.
- Findings suggest that population health programmes including screening and preventative health programmes need to be protected through tax-based financing and provided for outside of an insurance based model.
Bismarck and Beveridge systems - One method of distinguishing health care funding systems is between Bismarck and Beveridge systems (Björnberg et al., 2009). Bismarck systems, implemented in countries such as France and Germany, are characterised by the use of a range of Social Health Insurance providers who are usually independent of the providers of health services. Beveridge systems are also sometimes referred to as single payer systems, where the payer is usually the government, such as in Canada and the UK. In these countries, the funding and service provision tends to be managed, although not necessarily provided, through one organisation.
Disability – The definition of disability is an evolving and, at times, contested concept. In the Disability Act 2005 s2 (1) disability is defined as “a substantial restriction in the capacity of the person to carry on a profession, business or occupation in the State or to participate in social or cultural life in the State by reason of an enduring physical, sensory, mental health or intellectual impairment”. In Article 1 of the United Nations Convention on the Rights of Persons with Disabilities it is stated that “Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others”. The World Health Organization (2011, p.5) uses the International Classification of Functioning, Disability and Health which suggests that “problems with human functioning are categorized in three interconnected areas: impairments are problems in body function or alterations in body structure – for example, paralysis or blindness; activity limitations are difficulties in executing activities – for example, walking or eating; participation restrictions are problems with involvement in any area of life – for example, facing discrimination in employment or transportation. Disability refers to difficulties encountered in any or all three areas of functioning”.
Public health and government insurance (tax-based) – another label for Beveridge systems as defined above, which acknowledges that some Beveridge systems use general taxation to fund health care (e.g., in the UK) and some use a single national insurance scheme (e.g., in Canada).
Private Health Insurance – along with Bismarck and Beveridge systems of funding health care the third main system is through private health insurance. Individuals have to purchase their own insurance which is set by privately operated companies and based on their estimated risk of needing care (Saltman et al., 2004).
Risk equalisation – in systems where there is more than one insurance provider, people with relatively high needs for care may not be equally distributed between the insurance providers. A risk equalisation system attempts to transfer funding between the providers so that people with higher needs are not penalised.
Single-payer health insurance - refers to systems where there is just one payer/provider of insurance, usually the government (Goodman et al., 2005).
Single tier health care - refers to a system that provides the same level of health care to all. People are generally not able to buy additional or faster access to health care through paying more, although this may be allowed for non-essential services. In two or multi-tier systems only a basic level of health care is provided for all. People are then able to purchase additional insurance for faster access to a higher level of service provision (Loewy and Loewy, 2004).
Social Health Insurance – is a method of financing and managing health care in which a range of insurance providers regulated by the state, use contributions from individuals, employers and sometimes government to commission health services. It is a method of pooling risk as contributions are means tested (Saltman et al., 2004).
Universal Health Insurance – although the terms ‘social health insurance’ and ‘universal health insurance’ are often used interchangeably in the literature Social Health Insurance does not necessarily provide universal coverage. Universal Health Insurance is a form of Social Health Insurance that provides universal coverage.
In March 2011 the newly elected coalition Government for Ireland announced, in the Programme for Government, that “This Government will introduce Universal Health Insurance with equal access to care for all. Under this system there will be no discrimination between patients on the grounds of income or insurance status. The two-tier system of unequal access to hospital care will end. The Universal Health Insurance system will be designed according to the European principle of social solidarity: access will be according to need and payment will be according to ability to pay. The principle of social solidarity will underpin all relevant legislation” (Government for National Recovery, 2011, p.32). It was also specified that “Insurance with a public or private insurer will be compulsory with insurance payments related to ability to pay. The State will pay insurance premia for people on low incomes and subsidise premia for people on middle incomes. Everyone will have a choice between competing insurers” (p.34).
The Government has used the term Universal Health Insurance and so this will be the term mainly used in this report, although Social Health Insurance is often used interchangeably with it in the international literature. However, the two terms are not entirely synonymous. Social Health Insurance is not necessarily universal, and so Universal Health Insurance may be understood to be a form of Social Health Insurance which is compulsory for all. According to Wagstaff (2009) Social Health Insurance systems provide coverage in exchange for earnings-related contributions levied largely on formal sector workers; tax financed systems, by contrast, rely on general government tax (and nontax) revenues. (Wagstaff, 2009, p 25)
This extremely significant policy development has important implications for the provision of health services for people with disabilities. It represents an excellent opportunity to design a system of health insurance, with the involvement of people with disabilities, which will more fully meet their needs. It also provides the opportunity to ensure the provision of health services is compliant with Article 25 of the United Nations Convention on the Rights of Persons with Disabilities, which the Government is committed to ratifying. Article 25 states that “persons with disabilities have the right to the enjoyment of the highest attainable standard of health without discrimination on the basis of disability”. On the other hand, there is also the risk that the new system could be under-funded, difficult to access and negotiate, and may not take into account the full range of needs of people with disabilities. This reinforces the need for the involvement of people with disabilities, and consideration of the available international research evidence, throughout the planning and implementation process.
The World Health Organization and World Bank (2011) have identified that many people with disabilities still do not have equal access to health care, other disability related services, education and employment opportunities, and continue to experience higher levels of exclusion from the activities of everyday life. In Ireland, the National Disability Authority (NDA) (2005) has previously identified inequalities in access and use of mainstream health services and highlighted
“the substantial and wide-ranging health impacts of disability. These include (i) greater risk as a consequence of having a reduced income due to exclusion from the labour force and being caught in the ‘benefits trap’, (ii) the additional costs of being disabled, (iii) increased incidence of other disabling conditions and illnesses, (iv) lack of access to acute, rehabilitative and population health services, (v) experience of a range of barriers to accessing care (financial, physical, organisational, transport, communication, informational including the inadequate knowledge of health care providers and attitudinal), (vi) experience of un-coordinated and fragmented provision, exacerbated by the involvement of multiple health and social providers and (vii) limited provision due to the focus of health services being on the individual’s impairment rather than the health issue or condition” (p.5).
The main aim of this paper is to present an overview of the available evidence on how Universal Health Insurance may affect the provision of health services for people with disabilities. The paper appraises and summarises international evidence; considers and discusses the implications of the research for Irish policy makers and practitioners and identifies gaps/limitations in the research. The structure of the report is as follows: the key messages are followed by the glossary of terms. Section 4 defines the issue and the context, and in Section 5 we discuss why it is important. Section 6 briefly outlines the methodology used to identify the relevant evidence and the findings are presented in Section 7. Section 8 sets out the limitations of the research and in Section 9 the implications from the research are then discussed and applied to the Irish context. Further details of the methodology and evidence tables of the included studies are available from the National Disability Authority.
The Government’s current proposal suggests that the current system of multiple insurance providers will continue. However, Universal Health Insurance can also be implemented using a single insurance provider. The World Bank (2009) has acknowledged that there is not yet sufficient evidence to conclude which system works best and it would appear that this decision is often influenced by a range of other considerations such as historical, contextual and ideological factors. Both single and multiple insurer systems have been criticized. Single health insurance systems have been criticized for not using their monopoly powers to manage and contain costs through promoting the most efficient service providers. Multiple insurers need risk equalization, which can prove controversial, and also need well informed service users and robust governance arrangements to ensure quality standards across providers.
It is also important to consider heath service reform and the introduction of Universal Health Insurance in particular in the wider societal context. The introduction of Universal Health Insurance may have the potential to address some of the wider discrimination and social exclusion issues relevant to people with disabilities, but there are still significant barriers to address, and change is needed at all levels in society. Saltman (2004, p.17) used a pyramid to demonstrate the levels that need to be considered when designing a universal/social health insurance system:
Figure 1. Pyramid of Universal Health Insurance system levels (adapted from Saltman, 2004, p.17)
It may also be useful throughout the process of change to keep in mind some of the principles that have been proposed for developing health services for people with disabilities. These may be a useful guide for informing the complex and difficult decisions that will be needed during the further planning and implementation of Universal Health Insurance.
In 2005, the NDA provided a more specific set of principles for health services for people with disabilities, stating that funding should:
- “ensure the level and quality of provision, which meets the requirements of national and international human rights and equality instruments
- be equivalent to that of other health facilities
- target health inequalities, reflecting socio- economic need
- be dependent on the provision of a quality of service that meets stringent national standards
- deliver value for money
- be flexible to address changing need
- support innovation
- be withdrawn from services which do not provide a nationally agreed quality of provision
- be linked to addressing the needs of the individual
- work within an investment framework, considering the costs to the individual, family, community and wider society of not providing resources to support the recovery and social inclusion of persons with disabilities
- be informed by the impacts of budgetary cuts in the disability sector on the individual, family and community” (p. 50-51).
It should be noted that while the paper is investigating Universal Health Insurance systems, there are other types of systems that may generate the same benefits of universal coverage, such as the National Health Service approach in the UK, but are funded through general taxation. These systems have in common their universal coverage and that most of the associated services are provided free at the point of delivery. This point should be highlighted from the start as the main benefits of Universal Health Insurance systems may in fact, be due to this universal coverage and access rather than the insurance system per se.
4.0 What is the issue?
The central issue is how the introduction of Universal Health Insurance in Ireland may impact on the provision of health services for people with disabilities. The World Health Organization and World Bank (2011) reported that the choice of financing influences the type and level of services that are available and, crucially, whether people are protected from the financial risks of using the services they need. They also state that although it is important to ensure access to appropriate health care for everyone, the current research suggests that people with disabilities have more health needs and more unmet needs than those without disability.
In order to provide the background to this issue a brief overview of the range of different systems used to fund health services will be provided before the current system in Ireland is presented.
4.1. Brief Overview of Range of Health Care Funding Systems
One method of distinguishing health care funding systems is between Bismarck and Beveridge systems (Björnberg et al., 2009). Bismarck systems, implemented in countries such as France and Germany, are characterised by the use of a range of insurance providers who are usually independent of the providers of health services. The proposed system for Ireland would fit with this model. Beveridge systems are also sometimes referred to as single payer systems, where the payer is usually the government, such as in Canada and the UK. In Beveridge systems, the funding and service provision tends to be managed, although not necessarily provided, through one organisation. A third system is based on private health insurance, as in the US. In reality most countries use a combination of these different approaches in varying degrees.
O’Ferrall (2009) explains that the key difference between Universal Health Insurance and private health insurance systems is that, in universal systems, payment is usually means-tested, everyone is covered and has equal access to services based on need. In contrast, with private insurance, the individual pays based on their assessed risk of needing services, and those who cannot afford it are excluded. O’Ferrall (2009) suggests there are five main advantages to Universal Health Insurance: it enables a one-tier system of hospital care which is fairer and more efficient; it facilitates the delivery of GP services free at the point of delivery for all; it focuses attention on the person using the service rather than the service provider; it makes service provision transparent and therefore accountable; and it promotes social solidarity.
Thomas et al. (2010) identified a range of possible designs within Universal Health Insurance systems. What they refer to as a ‘pure’ system involves payroll and income deductions into a dedicated insurance fund. Contributions to the fund are means tested with people below a certain income not paying at all. The second variation also involves payroll and income deductions but these are subsidised from general taxation. A third way uses a ‘mixed bag’ of funding from a range of taxation, including possible new sources of tax revenue such as carbon taxes. The final variation they present is for there to be a flat rate for all with some Government contribution for those on lower incomes.
The World Health Organization (2010) has identified three interrelated problems that tend to restrict countries that are attempting to move to a universal system of coverage. The first is the level of resources available for the provision of health services. This may be an extremely relevant issue in the Irish context. The second problem is that methods of addressing limited resources, including additional payments for certain services create disincentives for people on lower incomes to access services and so undermine the key equal access aim of universal coverage. The third barrier that the World Health Organization identified is the inefficient and inequitable use of resources, which further reduces the amount of effective care that can be provided. Addressing these three issues - ensuring there is sufficient funding, reducing or ending any supplementary payment at the point of delivery, and promoting efficiency - are fundamental to the successful transition to a universal system.
In order to consider the transition to Universal Health Insurance in Ireland the current system will be outlined, and then what is known about the proposed system examined.
4.2. Current Health Services Funding System in Ireland
The current system in Ireland uses a range of funding mechanisms: taxation, (which provides approximately 70% of health funding); fee-per-service payments (providing approximately 15% of funding); and private insurance coverage (used by around 50% of people in Ireland, although it accounts for just 10% of healthcare funding). Approximately 30% of people are eligible for a medical card. This facilitates free access to health care for certain disadvantaged groups including many people with disability, although these patients may have considerably longer waits for care than those with private cover (O’Ferrall, 2009). McDaid et al (2009) report a more detailed breakdown of total health expenditure by source of funding from 2006: 78% from taxation and other government income; 12% out of pocket payments; 8% private health insurance; 1% social insurance ; and 1% other private funds. The Department of Health and Children’s (2010a) report Resource Allocation, Financing and Sustainability in Health Care: Evidence for the Expert Group on Resource Allocation and Financing in the Health Sector (Volume II) estimated direct out of pocket payments by households to be 10-15% of total expenditure.
There are currently a range of private health insurers in Ireland. The publicly owned Vhi Healthcare (previously VHI - Voluntary Health Insurance) provides approximately 80% of private cover. Other providers include Aviva and Quinn Healthcare. The private insurance market is regulated by the Health Insurance Authority. Risk equalisation payments have been used between the insurance providers to ensure that there is no disincentive to insuring people with potential higher levels of need. However, in recent years, the need for risk equalisation has led to a series of legal challenges mainly questioning the fairness and legality of the arrangements. In 2008 the Supreme Court ruled that the current risk equalisation scheme was unconstitutional and so an interim system has been in place since then (McDaid et al., 2009). A “strong and reformed system of community rating and risk equalisation” is part of the new planned system (Government for National Recovery, 2011, p. 33).
4.3. The planned system of Universal Health Insurance for Ireland
The Programme for Government in March 2011 outlined the planned steps towards universal coverage. The first is to remove fees for general practitioner (GP) care and so introduce universal primary care. The second major objective is to have a universal insurance system in place by 2016. By enabling access to hospital care for all, this will provide services equivalent to what only the privately insured have at present. It is also proposed that the current responsibilities and roles of the Health Service Executive move to the Minister of Health and the Department of Health. Although mental health and services for older people are identified as priorities, there is little detail in the Programme for Government about how the specific and complex health needs of people with disabilities will be addressed within the proposed system. However, the first group to have free access to primary care will be claimants of free drugs under the Long-Term Illness scheme, followed by those under the High-Tech Drugs Scheme, which would include many people with disabilities.
There are many details of the planned system that are still unknown, not least what people are likely to have to pay and exactly what services will be provided. The specific proposals for people with disabilities, especially those who may be high- and long-term users of health services, have also not yet be clarified. Nonetheless the Minister for Health, James Reilly, has added some further information through press releases and, most recently, in response to questions in the Dáil. In a press release on 24th March 2011 the Minister stated “I am acutely aware that, in designing any new payment system, it will be necessary to build in safeguards for ‘quality’ and to ensure that the payment system does not encourage ‘cherry picking’ of straightforward cases. “Money follows the patient” will be an important stepping stone to Universal Health Insurance”. On the 13th April 2011 he provided some idea of the overall timeframe by saying “What I’m setting out to do is guarantee equal access to healthcare for everybody in our country as quickly as possible but absolutely within the next 10 years”. In June the Special Delivery Unit was established to address waiting times.
Since then, in the Dáil, the Minister has provided an update in response to a series of questions on the introduction of Universal Health Insurance. He stated that “One should bear in mind it took the Dutch 20 years to achieve their model. We are learning from their mistakes and what they did right. Therefore, we do not need to reinvent the wheel. None the less, Ireland is a very different country, geographically, culturally and in terms of population. We know there are many variations on the Dutch system that will not work here but that the core of it can and will. We must ensure we have a properly regulated health insurance market before we proceed. There are many aspects to be considered. There will be many full debates as the various parts of the programme are put together so we can realise what I believe is a worthy aspiration, namely, that everybody in the country will have access to medical care based on need, not on what they can afford”.
O’Ferrall (2011), although endorsing most of the Government’s plans, has suggested that having a number of insurance providers requires a complex risk equalisation scheme. Because of this, a single payer system should still be considered. However, this possibility has not featured in any of the statements from Government. O’Ferrall (2011) also points out that the National Health Service in the UK was established in a time of economic crisis and so the current climate should not be viewed as an insurmountable barrier to major reform.
4.4. Community and long term care
The introduction of Universal Health Insurance would seem an ideal opportunity to consider how the full range of health and social care services are funded to avoid the creation of perverse incentives. An example of this is when people access expensive hospital care that is free to them, so they can avoid paying charges for cheaper community care. It is also an opportunity to ensure the benefits of a more equitable health system are not undermined by continuing inequities in social care.
This report, and the proposals for Universal Health Insurance in the Programme for Government focus on the impact on health services, mainly access to primary care and hospital care. The arrangements for the full range of community and social care services that people with disabilities need are not addressed in detail. The Programme for Government does include some plans for developing care of older people, community care and integrated care, and these other developments will have implications for people with disabilities. It stated:
“Investment in the supply of more and better care for older people in the community and in residential settings will be a priority of this Government. Additional funding will be provided each year for the care of older people. This funding will go to more residential places, more home care packages and the delivery of more home help and other professional community care services.
The Fair Deal system of financing nursing home care will be reviewed with a view to developing a secure and equitable system of financing for community and long-term care which supports older people to stay in their own homes.
The integration of care in all settings is key to efficient health care delivery, in which the right care is delivered in the right place. Integration of care will be the responsibility of an Integrated Care Agency under the aegis of the Minister for Health. This agency will oversee the flow of centrally tax-funded resources between the different arms of the system so that there are incentives for care to occur in the best setting” (Government for National Recovery, 2011, p. 36).
The commitment to integrated care suggests that this issue will be explored, and so some of the relevant issues are identified here. In order to consider these issues the alternative ways of funding social care are summarised first. Following this, we further examine how these arrangements work in practice in a number of different countries. A number of terms are used to describe these services, including social care, community care, and long term care.
The Office for Economic Co-operation and Development (OECD, 2011) has identified three main approaches to funding long term care (LTC):
- universal coverage within a single programme;
- mixed systems; and
- means-tested safety-net schemes.
The OECD (2011, pp. 215-228) provides a summary for each system, as follows:
Universal coverage within a single programme
Several countries provide LTC coverage through a single system, which provides publicly-funded nursing and personal care to everyone who is eligible because of their need for care. In Nordic countries, social long-term care insurance is separate from health systems, but in other countries, such as Belgium, LTC is included as part of healthcare. Some systems limit LTC to the elderly, such as Japan or Korea. Others, such as the Netherlands or Germany, make LTC available for everyone assessed as needing care regardless of age.
People receiving LTC are required to make co-payments or to pay user charges or up-front deductibles even in universal coverage systems. However, those earning below a certain income are partly or fully exempt from payment, resulting, effectively, in a comprehensive collective coverage of LTC costs.
There are three main sub-models for LTC within a single programme:
- tax-based models (e.g., Nordic countries), which use taxes to provide universal long-term care services as part of welfare and health-care services for the entire population
- public long-term care insurance models (e.g., Germany, Japan, Korea, the Netherlands, and Luxembourg), providing comprehensive coverage of services from stand-alone, dedicated social insurance. The funding channels for LTC are different from those for health care, are mandatory for all or most of the population, and are mainly financed from payroll contributions, supported by general taxation and
- personal care and nursing care through the health system (e.g., Belgium), with most LTC provided by nurses within a medical structure of care
Under mixed systems, LTC coverage is provided through a mix of different universal programmes and benefits, either provided universally or means-tested. Many of the countries in this group do not have a comprehensive single programme for LTC, but offer a range of LTC benefits, programmes, or entitlements for different groups or settings. One form of mixed system, such as in Ireland, Australia and France, benefits are given to everyone who is assessed as needing care, but the amount they receive depends on their income In some cases, additional benefits such as nursing care are covered by the health system or local government.
Means-tested safety net schemes
Under means-tested schemes, LTC services and benefits are publicly funded for people who have less than a certain threshold of income and assets. Care is then prioritised for those with the greatest need. The criteria to determine eligibility for services varies from country to country, and there may be a gap between LTC eligibility and other social assistance available. This system is seen in the US, with Medicaid funding most LTC services.
The current system in Ireland is a mixed system using a wide range of service providers for social care services. Some of these are free, based on need and some are charged for, based on means testing. The historical development of services and the wide range of providers have created both geographical variations in the level of services available and inequities in paying for care.
Single programme universal systems, in contrast to the mixed system in Ireland, are better at ensuring equitable access to care based on need rather than income. However, there is variation in the extent of out-of-pocket costs. Systems that separate out health and social care budgets tend to reduce the use of the more expensive health services, but this separation, if not managed well, may impact on continuity of care.
In 2002 the Department of Social and Family Affairs commissioned a report that suggested that the social insurance model would be appropriate for funding long-term care in Ireland. It argued that:
- “Social insurance would provide a stable and lasting framework for long-term care provision. It would also raise public awareness of long-term care issues. This could help to encourage further private provision to supplement the basic social insurance benefits. In particular, it would facilitate a partnership scheme.
- Social insurance would eliminate means-testing for those whose contributions qualify them for benefits, but social assistance benefits would still be required for those who do not make contributions.
- The public may be more willing to pay additional social insurance contributions than higher taxes to fund long-term care.
- Social insurance contribution income is affected by the economic cycle. Hence, it may be necessary to supplement the social insurance fund from general tax revenues or borrowing during an economic downturn.
- We conclude that social insurance financing for long-term care would provide a reasonable “fit” in the Irish context. Moreover, the strong entitlement to benefit that social insurance financing would confer, along with earmarking of the contributions made to pay for the benefit, would, we believe, engender good public support.
- However, we would not consider it appropriate that the level of long-term care benefits provided should vary as between social insurance and social assistance beneficiaries, as this could imply the provision of different standards of care as between the two groups” (p.16).
Three countries will be now explored in more depth. The Netherlands and Germany are examined because they currently have long term care statutory insurance schemes. Australia is also included, for two main reasons: its current system is similar to Ireland’s; and it has just concluded a major review of this issue, which has recommended a National Disability Insurance Scheme. This may provide a useful model for Ireland. Table 1 summaries the three countries’ systems (based on the OECD, 2011 report) and the issues in each country are discussed.
Eligibility for coverage
Source of funding LTC
Types of benefits provided
Public LTC spend, % of GDP
|Netherlands||Universal programme within a single system||Public LTC insurance - social insurance|
Exceptional Medical Expenses Act
The Algemene Wet Bijzondere Ziektekosten (AWBZ)
|Contributions and additional tax contributions||All||Cash and in-kind, home and institutional care||3.5|
|Germany||Universal programme within a single system||Public LTC insurance – social insurance|
Long-term care insurance
|Tax, premiums, financing from Lander budgets||All||Cash and in-kind, home and institutional care||0.9|
|Australia||Universal||Multiple programmes: income-related benefits|
Home and Community Care (HACC)
Residential care by ACATs (aged care assessment teams)
60% federal, 40% local, state and territorial governments for HACC
|In-kind, home and institutional care||0.8|
Some further details of these countries’ systems are provided in Section 7. Across all three countries, demographic, political and economic change has affected the development of the systems. In the Netherlands, Glendinning and Moran (2009) reported that the “social insurance scheme has...faced growing financial pressures. Insurance contributions and additional charges for services have been increased. The social insurance scheme no longer funds domestic help; this is now the responsibility of local municipalities, thus risking fragmentation between practical help and personal and nursing care. The responsibilities of families for supporting sick and disabled relatives have also been spelt out. Changes in assessment practices and in methods of calculating payments to providers for individually tailored service packages have also been made, in further attempts to increase sustainability” (p. 2).
They also report that Germany has had to undertake “the first major structural reforms of its long-term care insurance scheme since the scheme’s introduction in 1994. A growing gap between the capped insurance benefits and the actual costs of care, and deficits in the insurance funds themselves, together led to increases in levels of both contributions and benefits in 2008. Measures to support family carers have also been strengthened. Further increases in benefit levels are planned; however, the insurance scheme is likely to be in deficit again by 2015” (p. 2).
In Australia, the response to rising costs over the last decade has been to try to move responsibility for funding long-term residential care increasingly to individual service users. Charges for other community care services have also increased. However, the Productivity Commission (Australian Government, 2011, p. 2) has recently completed a review of the funding of long term care and recommended the introduction of a National Disability Insurance Scheme. It argued that “most families and individuals cannot adequately prepare for the risk and financial impact of significant disability. The costs of lifetime care can be so substantial that the risks and costs need to be pooled” (p. 2). It therefore recommended that “There should be a new national scheme — the National Disability Insurance Scheme (NDIS) — that provides insurance cover for all Australians in the event of significant disability... The scheme should involve a common set of eligibility criteria, entitlements to individually tailored supports based on the same assessment process, certainty of funding based on need, genuine choice over how their needs were met (including choice of provider)... Services would be provided by non-government organisations, disability service organisations, state and territory disability service providers, individuals and mainstream businesses. Increased funding, choice and certainty are the key features of the recommended scheme.”
The current systems in the Netherlands and Germany, and the proposed system in Australia, may therefore be useful to consider when planning how social care should be funded in Ireland.
The rest of this report returns to the focus on the provision of health services for people with disabilities. However, it is important to emphasise that the funding arrangements across all aspects of care need to be considered if a truly equitable system that does not discriminate against people on the basis of disability is to be created.
5.0 Why is it important?
The introduction of Universal Health Insurance in Ireland is of high importance because all aspects of the new funding system have the potential to impact positively or negatively on access to and provision of health services for people with disabilities. The different aspects of the funding system include the inputs to the system, the processes and the outcomes.
Inputs include the level of funding allocated, the purchaser/provider split, the necessary legislation, and the decisions about what services to provide and to whom. The processes include the administrative arrangements for ensuring coverage through the different providers, how needs will be assessed, how services will be provided, the level of service user involvement, and support for negotiating the system. The outcomes include health outcomes as well as satisfaction, social inclusion, choice and control. These themes will be explored further in the findings, but the general issues for why this development is so important are considered here.
Internationally, the World Health Organization and World Bank (2011) have highlighted the increasing evidence which suggests that, as a group, people with disabilities experience poorer levels of health than the general population. They also report that:
“Social deprivation was a major contributor to these health inequalities, and people with mental health problems and learning disabilities were at a high risk of poverty. The lack of health promotion, service access, and equal treatment were also cited as significant barriers. Disabled people identified fear and mistrust, limited access to general practice lists, difficulty negotiating appointment systems, inaccessible information, poor communication, and diagnostic overshadowing. Service providers identified issues such as fear, ignorance, and inadequate training” (p. 61).
It is therefore argued that changes to policy and legislation designed to ensure equal access to health care have to address a range of issues relating to accessibility, affordability, availability and quality. They also highlight that people with disabilities can have particular problems negotiating the administration of health insurance. These include higher rates of difficulty with obtaining the appropriate exemptions and/or special rate; completing insurance forms; getting the relevant information about insurance and entitlements; and receiving reimbursement.
In Ireland, the Report of the Expert Group on Resource Allocation and Financing in the Health Sector concluded in 2010 that:
“reform of the present system is necessary on the grounds that it is not equitable and that it does not encourage appropriate behaviours. The Group took the view that such reform could take place either through a Social Health Insurance system or by the development of the mainly tax-funded system currently in place. What matters crucially is the effectiveness of the system which is put in place and not whether it is financed by taxation or social insurance. The Group identified the main characteristics of a quality health-care financing system as:
- equity and fairness, i.e. those who can afford to pay more, should pay more;
- transparency, i.e. everyone should be able to understand the system and know what they are entitled to receive;
- promotion of good attitudes to care, e.g. encourage patients to be registered with a GP, and to seek help when needed (requiring pre-payment for at least some services);
- consistency with policy objectives (e.g. promotion of integrated care);
- sustainability (e.g. promotion of treatment of chronic disease within the community).
In relation to the financing of the health-care system, the Group found that the
current financing system lacks transparency, gives rise to serious inequities in access to care, and results in numerous anomalies in terms of incentives for users of care” (Department of Health and Children, 2010b, pp. x-xi).
O’Ferrall (2009) also emphasised the importance of getting the design and funding of the new system right because, if the revenue generated is insufficient, it would require supplementation from general taxation and/ supplementary payments for services. This would reintroduce the inequalities of the current arrangements.
In his press release on 24th March 2011 the Minister of Health asserted just how important this change will be:
“As the new Minister for Health, my primary goal is to radically reform the health system so as to guarantee equal access to healthcare for everybody in our country. It is my firm view that this can only be achieved through a single-tier system. One that gives access based on need - not on ability to pay. Hence, commitment to introduce Universal Health Insurance for the whole population of Ireland. The introduction of Universal Health Insurance will be the most profound reform of our health system since the foundation of the State”.
We have carried out a Rapid Evidence Assessment (REA) for this review. REAs provide more thorough syntheses than narrative reviews, and are valuable where a robust synthesis of evidence is required, but the time or resources for a full systematic review are not available. The reviewers develop and then specify search strategies in collaboration with clients and other key stakeholders. The details of the search strategies, keywords used, the inclusion and exclusion criteria, and a flow chart of the process are all provided in Appendix 1. As part of the REA each study is briefly quality assessed using standardised instruments.
We searched a number of databases to identify a range of different studies of relevance to this review:
- Medical databases: Cochrane Library, Embase, Medline, PsycInfo
- Social science databases: Campbell Library, SocIndex, Web of Science
- Economics databases: CRD (NHS EED), EconLit
We also searched a number of websites for additional relevant reports or documents. These included:
- AARP (American Association of Retired Persons) http://www.aarp.org/
- Australian Government Productivity Commission http://www.pc.gov.au
- Center for Intergenerational Studies http://cis.ier.hit-u.ac.jp/
- European Health Management Association http://www.ehma.org
- National Disability Authority http://www.nda.ie/
- Organisation for Economic Co-operation and Development (OECD) http://www.oecd.org
- Public Health Agency of Canada http://www.phac-aspc.gc.ca
- The Commonwealth Fund http://www.commonwealthfund.org
- the European Centre for Social Welfare Policy and Research http://www.euro.centre.org/
- The International Network Health Policy & Reform http://hpm.org/
- The International Social Security Association http://www.issa.int
- The Swiss Confederation http://www.thinkswiss.org/
- The World Health Organization http://www.who.int/
Summaries of all studies identified from the databases were imported into a database, duplicate studies removed, and then those studies that were directly relevant to the topic were shortlisted for more detailed examination of their full texts. Additional reports from the ‘grey literature’ website searches were also screened and those determined to be relevant were also assessed in detail.
Relevant data from each study were summarised into structured tables, which are presented in Appendix 2. Each included study was also assessed for overall methodological quality and for relevance to this review, and given a high, mid or low quality score. The details of the quality assessment criteria are reported in Appendix 1. The limitations of the existing research are considered in Section 9.0. In general, the available evidence is limited, and the literature on this subject often focuses more on the political and ethical issues involved rather than on developing an empirical evidence base to better inform policy and service delivery.
The literature searches focused on the following countries that have Universal Health Insurance systems similar to that proposed for Ireland: France, Germany, Netherlands and Switzerland. Australia and Canada were also included as comparisons because developments in these countries are also of relevance to the accompanying state of evidence papers on supported decision making and personal budgets. We kept the searches focused on countries of particular interest, but did not exclude studies that related to other OECD countries if they met the other inclusion criteria.
The first section of the findings provides overview data on the health funding arrangements in the identified countries. Each country summary starts with a summary from the Commonwealth Fund (2010) International Profiles of Healthcare Systems report, and then any especially pertinent aspects of the funding system are highlighted.
7.1. Country summaries: Bismarck approach
“Health care in the Netherlands is regulated publicly and delivered privately, in a system of “managed competition.” All residents are required to purchase a standard health insurance package from a private insurer, covering physician and hospital care and pharmaceuticals. Wage-related contributions are pooled in a central fund and redistributed to the insurers according to a sophisticated risk-adjustment formula. Insurers also charge their own community-rated premiums. Limited cost-sharing applies to secondary care. Most people purchase complementary private insurance for services not covered by the standard benefit package, such as adult dental care and physiotherapy. Long term care is covered through a separate statutory insurance program [similar to that proposed for Australia]. GPs operate mostly in small practices with gate-keeping responsibilities for a registered panel of patients. They are generally self-employed and paid through both fixed capitation rates and fee-for-service. Most specialists are hospital-based, self-employed, and paid on a capped fee-for-service basis that integrates the specialist honorarium costs and the hospital treatment costs. Hospitals are mostly private and non-profit. One major current initiative is the introduction of bundled payments for the care of chronic conditions in order to promote disease management and integrated care” (Commonwealth Fund, 2010, p. 2).
The current system in the Netherlands has been promoted as a potential model for Universal Health Insurance in Ireland. An example of good practice in the Dutch system is the website run by the Dutch Government, which provides data on all the available insurers, service user satisfaction data, and performance indicators for service providers (van de Ven and Schut, 2008). The Euro Health Consumer Index, which compares the service user ‘friendliness’ of 33 health care systems, placed the Netherlands first in 2009 (Björnberg et al., 2009). An important factor leading to this high rating may be that the Netherlands has one of the best and most structured arrangements for service user involvement at the policy and planning level. Practice at the individual level also emphasises the central role of the service user.
However, some concerns have also been identified about the Dutch model. Vaillancourt Rosenau and Lako (2008) suggested that it may not be very effective at controlling costs, as premiums are rising and insurance companies are reporting large losses. The NDA (2010, p. 53) has also identified that the managed competition between insurance providers does not necessarily increase competition and choice. The Dutch reforms may not have helped people to compare companies and move easily between them, and the system of managed competition may in fact have led to a less competitive market. In considering the application of the Dutch system to the Irish context, Borowitz et al. (2011, p. 25) have also urged caution, stating that, although the proposed system in Ireland seems more equitable, it is still not clear whether it will improve efficiency. The Dutch model, which was theoretically likely to improve efficiency, has struggled to show such improvements in practice. Expenditure has increased rapidly in the Netherlands because of a loss of central control over prices and quantity of health care provided. Competition has failed to make providers more efficient. The challenge for Ireland is to make the new system work well. Unless this happens, Borowitz et al. believe the reforms will lead to equitable access to an inefficient system.
“France has a social insurance system financed by employer–employee payroll taxes and central taxes. Statutory insurance covers all residents for hospital and ambulatory care, prescription drugs, and, to a lesser extent, dental and optometry care. Cost-sharing requirements apply to all publicly covered services, although these are waived for patients with any of 30 chronic diseases. Additionally, roughly nine of 10 residents have complementary private insurance that covers most cost-sharing charges under the public system; they either obtain this insurance themselves (usually through employment) or, if they have low income, have it provided by the government. Roughly two-thirds of hospital beds are public or non-profit, and physicians in these hospitals are salaried; the remaining third are for-profit, with physicians paid fee-for-service. Ambulatory care is provided mostly by self-employed physicians paid fee-for-service. Since 2004, registration with primary care physicians who act as gatekeepers has been encouraged through higher co-payments for self-referrals, and roughly 90 percent of the population is now registered. A further primary care reform has been the 2009 introduction of pay-for-performance, with GPs able to earn up to €5,000 for achieving quality targets on prevention, chronic disease management, and drug prescriptions” (Commonwealth Fund, 2010, p. 1).
The NDA (2003) reported that, under the French Social Health Insurance system, people with disabilities are treated within the general health services. These include a range of prevention, early detection, diagnosis, treatment and rehabilitation services.
“Most German residents receive statutory coverage through one of 180 competing non-governmental social insurers (or “sickness funds”). The statutory system is financed through employer and employee contributions, which, since 2009, are pooled into a central fund and redistributed among the sickness funds according to a sophisticated risk adjustment formula. Sickness funds offer a uniform benefit package covering most medical care, including physician and hospital services, prescription drugs, and dental care. The components of this benefit package are determined by the Federal Joint Committee along with representatives from payer and provider organizations. Self-employed, high income and civil-service residents may opt for private insurance as an alternative to the statutory insurance system, and roughly 10 percent of the population does so. Complementary private insurance is also purchased to cover amenities and cost-sharing charges under the statutory system, particularly for dental care. Ambulatory doctors mostly operate in solo practices and are paid fee-for-service with varying degrees of bundling. Gate-keeping is optional but is incentivized through cost-sharing arrangements, and often by sickness funds. Roughly half of hospitals are publicly owned and half privately owned. Hospital doctors are generally salaried and are not allowed to treat outpatients except in certain circumstances. For several chronic conditions, a set of disease management programs guided by national evidence-based recommendations has been introduced; these are implemented by sickness funds through contracts with providers” (Commonwealth Fund, 2010, p. 2).
A unique aspect of the insurance system in Germany is that higher-income households have the option to opt out of the Universal Health Insurance system and buy private cover. In 2009, ten percent chose to opt out (Schoen et al., 2010).
"Switzerland operates a regulated private insurance market, with individuals mandated to purchase a minimum insurance package from among competing non-profit insurers. Premiums are collected by insurers and then redistributed based upon a risk-adjustment formula. The basic benefit package includes hospital and physician care and prescription drugs. The 26 cantons (similar to U.S. states) have responsibility for planning the health services within their borders and subsidizing hospitals, nursing homes, and home care organizations. Residents generally have free choice of a GP and access without a referral to specialists (unless enrolled with a gate-keeping managed care plan). Some managed care plans operate capitation models, where physicians or physician groups are paid on a capitation basis; otherwise, ambulatory physicians are paid on a fee-for-service schedule negotiated between insurers and providers or their organizations at the canton level. Hospital-based physicians are paid a mix of salary (by mandatory insurance policies) and fee-for-service (by supplemental insurance policies). Hospitals are for the most part publicly owned or publicly subsidized. Recent reforms have established a single set of regulations for both public and private hospitals” (Commonwealth Fund, 2010, p. 4).
Switzerland is often characterised as having very high quality and also very expensive health services. In addition to the compulsory insurance there is also a compulsory sickness, old-age and disability insurance. Despite this, out-of-pocket spending is still relatively high, and includes contributions to the costs of long-term care (Commonwealth Fund, 2010).
7.2. Country summaries: Beveridge approach
“Australia achieves universal coverage through Medicare, a tax-funded public insurance program that covers most medical care, including physician and hospital services and prescription drugs. Most health services are financed and regulated by the federal government, although the states and territories have responsibility for public hospital care. Besides Medicare, roughly half of Australians receive additional coverage through private insurance, which the government subsidizes and which covers such services as dental care and private hospitals. Most doctors operate in private practice and are paid on a fee-for-service basis, and GPs act as gatekeepers to specialized care. Roughly two-thirds of hospital beds are in public hospitals and the rest in private, although private patients can be treated in public hospitals. Physicians in public hospitals either earn a salary and can receive additional fees for seeing private patients, or are in private practice and receive hourly compensation for treating public patients. Current policy goals include developing a new management structure for public hospitals around local area networks, increasing the federal government’s contribution to public hospitals, introducing performance reporting, and strengthening primary care” (Commonwealth Fund, 2010, p. 1).
As discussed in Section 4, there have been problems with the Australian system of long term care funding for people with disabilities. The Australian Government’s Productivity Commission has recently undertaken an inquiry into a National Disability Long-term Care and Support Scheme. This was in response to the finding that disability services were “underfunded, unfair, fragmented, and inefficient, and gives people with a disability little choice and no certainty of access to appropriate supports” (Australian Government, 2011, p. 2). The proposed solution in Australia is a new National Disability Insurance Scheme that would provide: disability insurance cover for all; fund long-term high quality care and support; provide accessible information and address stigma; promote quality standards and best practice; assess needs to determine individual support packages; and would encourage the development of innovative approaches to support.
“All citizens receive health coverage through Medicare, yet there is no single Canadian health system—rather, each province is responsible for delivering care within its borders according to a broad set of principles laid out in the Canada Health Act and in accordance with any intergovernmental funding agreements. Medically necessary hospital and physician services are fully covered across provinces, although there are variations in prescription drug coverage. Roughly two-thirds of Canadians have private insurance, but private coverage for services covered under Medicare is not allowed; instead, private insurance covers such services as dental care, prescription drugs, and home care. Medicare is financed through general taxation, much of which is distributed by the federal government to the provinces via transfer payments; responsibility for financing and delivering health care is therefore split between the two levels of government. Most doctors operate in private practices and are paid on a fee-for-service basis, although an increasing number of providers receive alternative forms of funding and are moving toward more integrated models of care. Ownership of hospitals varies across jurisdictions in Canada; in general, they are almost all not-for-profit and are owned by religious orders, universities, governments, municipalities, or municipal corporations. Hospital-based doctors are generally paid fee-for-service. Recent policy focuses on areas including improving waiting times, strengthening primary care, and broadening the adoption of health information technology” (Commonwealth Fund, 2010, p. 1).
7.3. Findings from the literature review
We found few research reports on Universal Health Insurance internationally. The studies that were identified tended to be either highly focused on people with a particular long term disease or disability, or were general comparisons of different countries. This means that it is difficult to be sure about the likely impact of Universal Health Insurance on access to services and the quality of care for people with disabilities in Ireland.
We identified just 16 studies from the review of the international literature that have been included in the literature review section of this report. These are summarised below, in three main sections:
- inputs – the structure of healthcare under Universal Health Insurance;
- processes – implementation of Universal Health Insurance by healthcare organisations or staff; and
- outcomes – the impact of Universal Health Insurance on people with disabilities.
This way of organising the findings is based on Donabedian’s (2005) structure-process-outcome framework for identifying and understanding all the factors involved in health systems. He argued that whilst outcomes “remain the ultimate validators of effectiveness and quality” (Donabedian, 2005, p.694) they do not provide much information about how they have been achieved and in some areas, such as attitudes and satisfaction, outcomes can be difficult to define and measure. He therefore argued that two other complementary approaches should be considered – examining the process of care and the structures or inputs employed. Evaluation of the inputs or structures involves consideration of “the settings in which [the process of care] takes place and the instrumentalities of which it is the product…It is concerned with such things as the adequacy of facilities and equipment, the qualification of medical staff and their organization; the administrative structure and operations of programs and institutions providing care; fiscal organization and the like” (p.695). The key point is that consideration of all three areas is necessary to provide a complete evaluation of the quality of an intervention. The framework was summarised by Yen and Lo (2004): “Structure refers to the manner in which the organization is managed and staffed, process refers to how care is delivered and outcome is the result or effect of the care rendered” (p.75).
The symbols after the author/s name indicate the assessed quality: [++] for high; [+] for mid; and [-] for low). More details of the quality assessments are included in section 11, and more details of the 16 studies are reported in the evidence tables in section 12.
Figure 2. Inputs for Universal Health Insurance
Four research studies reported on national level issues around Universal Health Insurance although we also identified three reports with useful data on funding of Universal Health Insurance compared with alternative systems or services covered by such funding. These are summarised in Tables 2, 3 and 4, below.
Skinner and Rovere (2010) ranked 28 OECD countries according to the degree to which they rely on a pluralistic public-private social insurance approach to achieving Universal Health Insurance coverage for their population. The five countries ranking highest for proportion of total health expenditure from Social Health Insurance were the Czech Republic, France, Netherlands, Luxembourg and Germany. Data on sources of funding for healthcare for the countries included in our review are presented in Table 2.
Predominant type of health insurance
% of total health care expenditure from SHI, 2007
% of total health care expenditure from PHG, 2007
% of total health care expenditure from PHI, 2007
% of total health care expenditure out of pocket, 2007
SHI = social health insurance; PHG = public health and government insurance (tax-based); PHI = private health insurance
Wagstaff and Morena Serra (2008) found in a study of 28 Eastern European and Central Asian countries over the period 1990-2004 found that social health insurance led to greater levels of health expenditure and lower national employment than in countries with tax-financed systems. In a study covering OECD countries 1960-2006, Wagstaff (2009) similarly found higher levels of spending and lower national employment associated with social health insurance models. This study also looked at the association between preventable early deaths and a social health insurance model. One cause of preventable early death, breast cancer, was found to be higher in social health insurance countries - this was statistically significant at the 10% but not at the 5% level. The author hypothesised that countries with social health insurance may invest less in public health screening and health promotion programmes. This is consistent with findings for Colombia by Arbalaez et al (2004) that the introduction of social health insurance led to fragmentation of responsibility and discontinuities in prevention and treatment of tuberculosis.
This suggests the importance of insuring that population health programmes including prevention and screening are safeguarded in the promised move in Ireland to a health insurance model.
Wagstaff concluded that adopting Social Health Insurance rather than tax financing may be associated with increases in health spending per person by 3 to 4% and reductions in total employment by up to 6%. As part of his study, he summarised the type of funding for primary and secondary care providers according to type of health insurance. These data are presented in table 3.
Predominant type of health insurance
Payment for primary care providers
Payment for secondary care providers
|France||SHI||Capitation + fee for service||Global budget||No|
|Switzerland||SHI||Fee for service||Global budget + daily rate||No|
|Australia||PHG||Fee for service||DRG episode + fee for service (Outpatients)||Yes|
|Canada||PHG||Fee for service||Global budget||Yes|
|Italy||PHG||Capitation + fee for service||DRG episode||Yes|
|New Zealand||PHG||Capitation + fee for service||Global budget||Yes|
|Norway||PHG||Salary, capitation + fee for service||DRG episode||Yes|
|UK||PHG||Capitation + fee for service + allowances||DRG episode||Yes|
DRG episode= diagnosis related group: each inpatient admission is coded to the condition or procedure that was the reason for admission and payment based on a tariff for each DRG.
The AARP European Leadership Study on long term care (AARP 2006) summarised how health and long-term care services are funded in France, Norway, the Netherlands and the UK. These are presented in Table 4. The report found that contributory social insurance was the preferred method to finance long term care in Germany, Luxembourg, the Netherlands, Japan and Korea. Funding is universal, based on employer/individual insurance contributions with a dedicated financing source (which is the insurance payments in contrast to general revenue systems which are based on general taxation). Scandinavian countries including Norway use a social democratic model, funded by general taxation, and run via municipal programmes. Coverage is universal but varying degrees of cost sharing are required, so these systems are ‘budgeted’, and can lead to informal rationing of care. In contrast, the UK, US, Australia and New Zealand rely on means-tested programmes which only cover people with income and assets below a threshold, and are financed through general taxation.
Nursing home care covered?
Home nursing covered?
Personal care covered?
Home help covered?
Financial support for family caregivers?
|Norway||Universal coverage||Substantial co-payment; pay 75-80% of public pension||no||no||usually means tested||Public pension credit; paid leave; respite care|
|Netherlands||Universal coverage||Means tested||Nominal co-payment||Means tested; pay up to €150 per week||Means tested; pay up to €150 per week||Paid leave; respite care|
|UK||Universal||Means tested||yes||variable||variable||Public pension credit; caregiver assessment; respite care|
|France||Hybrid||Means tested||no||Means tested; pay up to €3000 per month||Means tested; pay up to €3000 per month||Public pension credit|
Short term: Partially funded under Medicare;
Long term: Means tested under Medicaid
|Means tested under Medicaid||variable||variable||Variable respite care|
Koch et al. (2010) surveyed people with a disability in eight countries with different healthcare financing systems. They included Germany, France and the Netherlands as countries with Universal Health Insurance. Public or statutory insurance alone was the most prevalent form of health care insurance in Germany (78% of respondents funded their healthcare in this way). A combination of public statutory and private insurance was the most common form in the Netherlands (used by 81% of respondents). Private insurance alone was the most common form in France (used by 89% of respondents). The percentage of people with disabilities who required intensive medical care, for illness, injury or disability did not vary greatly regardless of type of health care financing system: i.e. one in five of all respondents from these three countries had required intensive medical care for illness, injury or disability. This was slightly fewer than people in Australia (25%) or the UK (27%), but similar to those in Canada (19%), New Zealand (22%) and the US (23%) (Koch et al. 2010 [+]).
Costs of Universal Health Insurance
Cuellar et al. (2000[+]) summarised the long term care insurance aspect of Universal Health Insurance in Germany, which was introduced in place of a means-tested system in 1994 and is administered by sickness funds. The premium is fixed at 1.7% of salary or pension, with employers and pension funds paying half the cost and the insured person paying the other half. Eligibility for services is based on functional status and is established in federal law.
A total of 1.2 million people received ambulatory care in 1998, of whom 50% had substantial disability, 38% severe disability and 11% very severe. Half a million people had institutional care, of whom 37% had substantial disability, 41% severe and 22% very severe. Cash or service payments for home or institutional care increased with severity of disability, ranging from €200 per month for home care for people with substantial disability to €1,400 per month for institutional care for the very severely disabled. Up to €1,650 was also available for people who qualified for institutional care and met hardship criteria.
Three quarters of those eligible received home care and three-quarters of those preferred cash payments (such as for family caregiving) rather than services. Care costs are covered in nursing homes but not room or board in Universal Health Insurance payments and residents have to pay any excess charges themselves. Younger disabled people who are cared for in specialised institutions are covered mainly by social assistance.
They concluded (pp. 22-23) that there were a number of lessons from the use of a separate long-term care form of Universal Health Insurance: “First, it is not a law of nature that new social programs, especially non-means-tested ones for long term care, must cost far more than originally estimated. The German long-term care insurance program has an enrolment fairly close to what was originally projected, and spending has been lower than anticipated. Second, the political success of the program can be tied to some of its design characteristics. Most importantly, the German reform plan provided substantial fiscal relief to the regional and municipal governmental units that funded long-term care. Since there was no maintenance-of-effort requirement, the Länder were enthusiastic proponents of the new long-term care program. In addition, the German insurance program established an entitlement to a specific set of benefits that people could understand and believed they would receive if they met the eligibility criteria. Thus, the population was able to see, in a very concrete way, what benefits they would receive for their new contributions. The program offset the limited range of services that could be covered as an entitlement by providing a cash alternative, which can be used for any purpose and thus has maximum flexibility. Third, in the face of large increases in provider capacity, assuring quality of care has been a challenge. The program must balance the need for quality assurance against the costs of extensive quality monitoring, both on the part of agencies and on the part of providers who must meet the requirements and collect the data. In addition, efforts to improve quality will most likely lead to higher prices. This may push more people to the cash option, where quality is barely monitored at all. Fourth, Germany’s strong insistence on a uniform national program has meant that there is very little variation in services across geographic areas or across individuals in the same disability category. This also has resulted in a fairly rigid program that does not flexibly tailor benefit levels to individual needs or take into account local needs and desires. Fifth, establishing boundaries between acute and long-term care is difficult because individuals have a combination of acute and long-term care needs. Maintaining a separate funding stream for long-term care protects those funds against being swallowed up by the much larger and more powerful acute care system but creates problems of cost shifting and coordination. Sixth, Germany also illustrates the classic conflict between equity and efficiency. Germany’s cash payments can be justified on an equity basis in that they make family caregivers better off. On moral grounds, policymakers want to reward informal caregivers for their sacrifices. But from an efficiency perspective, long-term care funds are spending a great deal of money to accomplish relatively little behavioral change. Extensive informal care is being provided, now as before. For people receiving the cash benefit, it is not clear that much has changed in the way they receive care, although some observers think that it is too early to tell”.
(Cuellar et al. 2000[+]).
Extent of coverage
The AARP European Leadership study (2006[+]) compared the coverage of community health and social care in Norway and the Netherlands, where there is universal coverage, with the UK, France and the US, which have generally means-tested access to these services. Private long term care insurance was rarely available in any country. Even in Norway and the Netherlands, most home-based services such as home nursing, home help and personal care are either not funded or are means-tested.
The proportion of the population aged 65 years and older who received home care was similar for the five countries, regardless of whether or not they had universal coverage: 2.4 to 6.6% of older people in all five countries had nursing home care; 2.7 to 5% had residential care or assisted living; and 10 to 20% had home care.
Universal Health Insurance also made no substantial difference to whether older people received consumer directed home care. Formal services were received by elderly people in Norway, the Netherlands, the UK and the US, and a cash alternative was available in the Netherlands, the UK, France and the US. In general, relatives, but not spouses, could be hired to offer care. Funding options for family caregivers varied by country but Universal Health Insurance made no consistent impact on the type of funding. Paid leave was only available in the two countries with Universal Health Insurance (Norway and the Netherlands); however public pension credits were available in Norway, the UK and France; and respite care was available in Norway, the Netherlands, the UK, and some US states.
Some problems associated with the use of Universal Health Insurance for long term care were identified by Cuellar et al. (2000[+]) in Germany. As funding for long term care is separate from acute care funding, there has been some cost shifting, which has meant that the goal to favour rehabilitation services instead of long-term care has not been met. The programme was designed to encourage competition between providers, but this has not happened as planned, although the number of providers has increased.
Chiang et al. (2011[++]) summarised the services that were available in 29 developed countries for people with low vision. Data was summarised by region, making it difficult to determine whether service provision was different for countries with or without Social Health Insurance. Only seven of 22 countries with data reported that vision services were fully funded by the government, with a further 14 countries offering fee-based services that were subsidised at a national (3 countries) or local level (11 countries). Adults and children with disabilities were the group most likely to have difficulties accessing services in nine of the 29 countries, more than ethnic minorities (7 countries), refugees (6 countries), older people (6 countries) and people on low income (8 countries).
7.3.2. Processes – the implementation of Universal Health Insurance
We identified no studies that reported on implementation of Universal Health Insurance by individual staff within an organisation. We identified only one study that reported on the implementation of Universal Health Insurance at a service level.
Implementation by organisations
Although we found no studies that directly reported on how healthcare organisations had implemented Universal Health Insurance, one study did report on what services might be available at a national level. Hurst et al. (2007[++]) surveyed the opinions of general physicians in the UK, Switzerland, Norway and Italy, on availability of healthcare resources and rationing of care. All four countries have universal health coverage, but this is financed in different ways. Overall, 87.7% of respondents felt that resources were sometimes not available for patients. In general, respondents from countries with lower insurance coverage reported greater scarcity of resources. There were no overall trends in the respondents’ answers regarding which countries reported most or least rationing or scarcity of resources for end of life care, dialysis, stroke rehabilitation, nursing home care or mental health services. However, some patterns about specific services were identified. Overall, dialysis was the service least likely to be restricted, and nursing home care the most likely to be scarce.
Physicians in Switzerland were least likely to report scarcity for end of life care, dialysis, stroke rehabilitation and nursing home care, but were more likely than physicians in the UK and Italy to report scarce mental health services. Physicians from Italy reported most scarcity of end of life care, dialysis, and stroke rehabilitation; but least scarcity of mental health services. Almost half of physicians in Switzerland (45%) thought that people with mental incapacity were more likely to be denied treatment than those without incapacity, similar to respondents from the UK (39%) and Italy (44%) but lower than those from Norway (61%). One-third of Swiss physicians (30%) thought people requiring chronic care were likely to be denied treatment, similar to the UK (32%) but less than Norway or Italy (both 47%).
7.3.3. Outcomes – the impact of Universal Health Insurance on people with disability
We identified 12 studies that reported on outcomes for people with disability in countries with Universal Health Insurance. The outcomes reported related to access to services, access to and choice about insurance, and costs of care.
Access to services
People with disability have greater need of healthcare than those without disability. We found conflicting evidence about whether Universal Health Insurance can facilitate access to services.
Glazier et al. (2009[++]) calculated the likelihood that people in Canada, a country with universal coverage of tax-funded health care, would need a visit to their GP or a specialist in a two-year study period. Compared with people who rated their health as very good or excellent, people who rated their health as poor or fair, or who had two or more chronic conditions, were significantly more likely to have visited the GP or a specialist. However, people with a disability or with depression were no more likely than people with excellent or very good health to make GP or specialist visits. The authors concluded that universal (tax-funded) health insurance appeared to be successful in achieving equity of access to GPs.
In contrast, Gulley et al. (2008[+]) compared healthcare experiences of adults with and without disability in the US, a country without Universal Health Insurance or Social Health Insurance, and Canada, which has universal coverage. Access to health care for people in Canada was similar to that of people with the same level of disability in the US who had health insurance. People with severe or non-severe disability in Canada were significantly more likely than those without disability to have unmet health care needs, to have needed medication that they could not afford, to be less satisfied with the care they received, and to view the quality of their care as fair or poor. People with severe disability in Canada were more likely than those with non-severe disability to have unmet health care needs (32.5% of severely disabled compared with 23% of non-severely disabled), or to be unable to afford medication (22% of severely disabled compared with 10% of non-severely disabled). However, people without insurance in the US had significantly worse access to all aspects of health care than those with insurance, or people in Canada.
A third study also concluded that Universal Health Insurance might not reduce the link between disability and poverty. Holly et al. (2003[++]), calculated inequality in access to healthcare for people with disability in Switzerland, a country with Universal Health Insurance plus supplementary insurance. Inequality was assessed in terms of comparative mortality, illness and disability. Men and women were more likely to have a disability if they had manual professions rather than non-manual; were of low income rather than high income; and, for men but not women, had only completed compulsory education rather than higher education. This suggests that there is an association between poverty or low educational attainment and disability. However, this study could not establish whether disability is a cause of poverty and low education, or whether poverty leads to disability.
The basic Universal Health Insurance package in Switzerland differs from that of other countries by including some services such as complementary medicine given by doctors, and by not covering some services including dental care, in-vitro fertilisation for infertility, heart-lung transplantation, some types of psychotherapy, or home help within maternity services. Supplemental insurance mainly covers inpatient care and gives patients the opportunity to choose their doctor. Individuals with a low income may decide to purchase basic insurance with a low premium. However, these cheaper packages may require the individual to contribute a higher initial payment for each claim, and may therefore deter insured people from seeking all the care they perhaps need. The authors reported an almost complete lack of evidence on equity of access to health care among the very old, 80% of whom have some form of disability.
Access to insurance
Universal Health Insurance is often introduced with an aim of increasing competition among insurers. For this to be effective, people need to be able and motivated to switch from more expensive insurers or those offering less comprehensive coverage to those offering lower premiums or broader coverage. Two studies investigated access to insurance for people with disabilities.
The two studies reported on the proportion of people who switched insurers under Universal Health Insurance in the Netherlands. Both studies found no significant difference in actual switching rates for people with or without disabilities. However, people with a disability who felt that their health was poor were anxious about whether new insurers might accept them, and may therefore feel inhibited about seeking better deals. It is unclear from the evidence whether the similar rates of switching insurer’s means that these fears are not justified.
De Jong et al. (2008[++]) found that people with chronic illness or disability were less likely than the general population to switch insurer. The proportion switching was 14% of the chronically ill compared with 20% of the general population, although this difference was not statistically significant. People with a disability were as likely as the general population to switch if they felt their health was good, but were significantly less likely than the general population to switch if they felt their health was bad (p < 0.0001).
Reitsma-van Rooijen et al. (2011 [++]) compared rates of switching health insurers among the general population and people with chronic illness in the Netherlands in 2007 to 2009. There was no significant difference in the proportion of either group who switched insurer, with 5% to 6% changing in 2007, 4% in both groups in 2008 and 2% to 3% in 2009. However, the general population were significantly less likely than those with chronic illness to think that it was impossible for them to switch insurers; to fear that new insurers would not accept them for cover; or to worry that they might have administrative problems if they changed insurer.
In countries where SHI schemes compete with each other for enrolees, usually under a risk-adjusted capitation system (as currently in the Czech Republic, Germany, the Netherlands, the Slovak republic and Switzerland), there is the added worry of risk-selection, so that depending on the risk-adjustment formula some groups will prove less profitable and may be avoided by insurers and therefore underserved (van de Ven et al. 2003, van de Ven et al 2007)." (p. 10)
It is likely that people with a disability or chronic illness would be most at risk of falling between cracks in the system.
It would be interesting to explore further how well risk-adjustment formulas treat pre-existing conditions disability. While risk equalisation for customers drawn from different age bands may be fairly straightforward, more sophisticated risk equalisation formulas may be required to address differences in the proportion of people with disabilities or with pre-existing conditions between the customer bases of competing insurers.
Lack of clarity and certainty for customers with disabilities may also follow from any perception by insurance companies that they are less desirable customers (even if the risk equalisation formula fully balances the risks across all insurers). People with disabilities need the security that they will be covered for medical treatment as required, rather than having to negotiate their coverage with the insurance company before arranging for their treatment.
Supplementary or out-of-pocket payments
People with health care insurance may have to pay money out of pocket for a range of different reasons. These may include:
- standard deductibles (e.g. people pay the first €100 of any claim)
- shortfalls between reimbursement and what it costs the individual (e.g. Vhi pays €150 for a visit to a Consultant, and some Consultants may charge more)
- areas of expenditure that are excluded (nursing home non-care costs in Germany; GP services in Ireland)
Two studies reported on supplementary payments that people with disability are required to make in countries with Universal Health Insurance (Koch et al., 2010[+]; Dewey et al., 2004[+]). Although both studies found substantial out-of-pocket costs could be required, no consistent association was seen with type of healthcare funding. This means that there is no good reason to think that these costs will necessarily increase when Universal Health Insurance is introduced in Ireland. A third study found no increased likelihood that people with a disability in France would take out additional insurance to cover out-of-pocket costs, compared with the general population. However, this may be because they could not afford the cost of the additional insurance, rather than not needing it.
Koch et al. (2010[+]) summarised the views of people with disabilities in eight countries on their healthcare system and how much out of pocket costs they have to pay. Overall, people in those countries where out of pocket expenses are lower are more satisfied with their health care systems. Most people in the UK (63%) had no such expenses in the past 12 months, and 36% thought only minor changes were needed to the system. At the other extreme, 30% of people in the US and 25% of those in Germany thought their health care systems needed to be completely rebuilt, and only 9% (US) and 8% (Germany) paid no out of pocket expenses. Satisfaction scores were high in the Netherlands and France, where 41% of people in both countries thought only minor changes were needed, although twice as many people in the Netherlands (33%) had no expenses, compared with those in France (17%).
There was little association between the type of financing of health care and how many people with disabilities had out of pocket expenses. Most people in France had only private insurance (89%) but 42% paid more than $1,000 in the last year in additional expenses and only 17% made no extra payments. Most people in the UK (83%) had only publicly funded health care, with few paying extra and only 9% paying more than $1,000 per year in out of pocket expenses. However, 63% of people in New Zealand and 78% in Germany also had just publicly funded care, yet only 10% in New Zealand and 8% in Germany paid nothing, and 13% (Germany) to 15% (New Zealand) paid over $1,000 per year.
Dewey et al. (2004[+]) calculated out of pocket costs incurred by people in the first year after a stroke in Australia, a country with Universal Health Insurance. Almost all patients incurred some out of pocket costs, averaging A$1,100 for the first year, but ranging up to A$32,411. The greatest average cost was for respite care (A$2,394 in the first year), but other costs included prescription fees, private therapy, aids and equipment, home modifications, personal transport costs and community rehabilitation centre fees.
One method to protect patients from excessive out-of-pocket costs is for them to take out complementary health insurance to cover such costs. Saliba et al. (2007[++]) surveyed people with a disability in France and found that they were no more or less likely to consider purchasing complementary health insurance than the general population. However, the French health care system exempts co-payments for 30 serious diseases, so people with one or more of these conditions may have less need for additional insurance to cover out of pocket expenses.
8.0 Limitations of the existing research
We identified very few studies that directly addressed the likely impact of the introduction of Universal Health Insurance on people with disability in Ireland or other countries. Although several reports summarised the healthcare systems in countries with Universal Health Insurance, we found only 16 studies from the literature review that were relevant to the topic.
The studies we identified were of two main types. A number of general reports compared healthcare and health insurance broadly across several countries. These studies provide useful comparisons but tended to be too general, with too many variables to allow any conclusions to be drawn about the likely impact of any one factor on access to or quality of care offered to people with disability.
The other type of study provided very focused data on the experiences of care for people with a specific type of chronic disease or disability in one or more country with Universal Health Insurance. These studies provide a snapshot of what healthcare might be like for these groups, but are difficult to generalise to the wider population and those with different types of disability in the Irish context.
9.0 Implications from the research
There is clear international evidence that people with disabilities have higher level of health needs than the general population and experience higher levels of poverty and social exclusion (World Health Organization and World Bank, 2011; Gulley et al., 2008). This means that any deficiencies with the Universal Health Insurance system introduced in Ireland could disproportionately disadvantage people with disabilities. There is also international evidence that people with disabilities are more likely to experience difficulties in accessing health services (Chiang et al., 2011) and so issues of access need to be addressed. Wagstaff notes criticisms of social health insurance systems for their lack of coverage among certain groups due to long establishment processes, systematic variations in benefits packages and variation of care across subpopulations. (Wagstaff, 2009, p 2) These are issues of critical importance to people with disabilities.
The argument that a Universal Health Insurance system promotes value for money and quality of care by facilitating people to move easily between providers and so encouraging competition does not seem to be supported by clear evidence in the research literature. Wagstaff’s (2009) analysis of OECD countries found that the introduction of Universal Health Insurance was associated with an increased health spending per person, decreased employment rates and could have a negative effect on other measures of health.
In Germany there has not been the anticipated level of competition (Cuellar et al., 2000). In the Netherlands the research does not suggest any difference in general between rates of switching for people with and without disabilities. However, people with disabilities who are experiencing health problems are significantly less likely to switch insurer (De Jong et al., 2008) and are more likely to be anxious about the possibility of needing to switch (Reitsma-van Rooijen et al., 2011).
Universal Health Insurance also necessitates risk equalisation and, as the difficulties already encountered in Ireland demonstrate, this can be a complex and controversial process. Unless there is an effective risk equalisation system in place there is the risk that insurance providers will discourage people with disabilities from having their cover with them or, in other words, an incentive to ‘cherry pick’.
The evidence is not clear on whether a specific compulsory insurance for disability and long-term care would help promote and ring-fence funding for health services for people with disabilities, or add further complexity to the system. Even with this system, in Germany funding has still shifted from rehabilitation services to acute care (Cuellar et al., 2000)
In the absence of sufficient funding being generated through Universal Health Insurance, there are concerns that part of the shortfall would be made up by people have to make out-of-pocket expenses. This would disproportionately affect people with disabilities. Research by Koch et al. (2010) and Dewey et al. (2004) suggests that this is a concern regardless of the funding system. The main issue may be more about getting the right level of funding, rather than whether this is obtained through Universal Health Insurance, a specific compulsory disability insurance, or taxation. A related concern from the Swiss system is the possibility of insurers imposing financial penalties on people making a claim. This would definitely create a disincentive to access services and so have a great impact of those with higher health needs.
The changes to the system in Ireland also offer the opportunity to explore other related possibilities such as the offering of cash alternatives to services, as in Netherlands and Germany for example. The introduction of personal budgets in the Programme for Government will facilitate this, but there may be wider applications. Providing financial incentives for people with disabilities to engage in education, training and employment would also seem a positive development to explore.
The literature therefore offers few solutions to the question of what service provision will be like for people with disabilities when Universal Health Insurance is introduced in Ireland. However, it has identified a number of concerns that have been raised in multiple countries with Universal Health Insurance, including:
- how to ensure adequate funding of health and social services under the new funding system – an issue particularly challenging in times of economic crisis;
- how to ensure that people with disabilities have equitable access to all the services they need;
- how to promote efficiency in healthcare service provision;
- how to avoid “cherry-picking” by health insurers so that people with disabilities are able to access affordable and comprehensive insurance packages;
- how to minimise the need for supplementary or out-of-pocket payments at the point of care which would disproportionately affect high users of services; and
- how best to regulate health insurers and promote fair competition between insurers and between healthcare providers.
The introduction of a new system of Universal Health Insurance offers the opportunity to thoroughly evaluate the impact of this development on the provision of health services for people with disabilities. It will be important that a comprehensive monitoring system is introduced to ensure that any negative impact on people with disabilities is immediately identified and addressed.
10.1. Included studies
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Chiang, P.P.-C. et al., 2011. A global survey of low vision service provision. Ophthalmic Epidemiology, 18(3), pp.109-121.
Cuellar, A.E. & Wiener, J.M., 2000. Can social insurance for long-term care work? The experience of Germany. Health Affairs, 19(3), pp.8 -25.
Dewey, H.M. et al., 2004. “Out of pocket” costs to stroke patients during the first year after stroke - results from the North East Melbourne Stroke Incidence Study. Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia, 11(2), pp.134-137.
Glazier, R.H. et al., 2009. Universal Health Insurance and equity in primary care and specialist office visits: a population-based study. Annals of Family Medicine, 7(5), pp.396-405.
Gulley, S.P. & Altman, B.M., 2008. Disability in two health care systems: access, quality, satisfaction, and physician contacts among working-age Canadians and Americans with disabilities. Disability and Health Journal, 1(4), pp.196-208.
Holly, A. & Benkassmi, M., 2003. Health and Health Care Inequalities in Switzerland: A Brief Review of the Literature. http://www.ruig-gian.org/ressources/comeliau-health_ineq-CH-Holly-Benkassmi.pdf. Available at: http://www.unrisd.org/80256B3C005BCCF9/(httpPublications)/CB79D3646056853EC1256E200037E3E0?OpenDocument [Accessed September 8, 2011].
Hurst, S. et al., 2007. Physicians’ views on resource availability and equity in four European health care systems. BMC Health Services Research, 7(1), p.137.
de Jong, J., van den Brink-Muinen, A. & Groenewegen, P., 2008. The Dutch health insurance reform: switching between insurers, a comparison between the general population and the chronically ill and disabled. BMC Health Services Research, 8(1), p.58.
Koch,K., Schumann C, Sawicki P., 2010. The German health care system in international comparison: the patient perspective. Dtsch Arztebl Int; 107(24): 427–34 DOI: 10.3238/arztebl.2010.0427
Reitsma-van Rooijen, M., de Jong, J. & Rijken, M., 2011. Regulated competition in health care: Switching and barriers to switching in the Dutch health insurance system. BMC Health Services Research, 11(1), p.95.
Saliba, B. & Ventelou, B., 2007. Complementary health insurance in France Who pays? Why? Who will suffer from public disengagement? Health Policy, 81(2-3), pp.166-182.
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10.4. Grey literature reports excluded on full text:
Becker and Zweifel, 2007. Age and choice in health insurance: Evidence from Switzerland. http://www.soi.uzh.ch/research/wp/2004/wp0410.pdf
Busse and Schlette, 2004. Focus on health and aging, pharmaceutical policy and human resources. http://www.hpm.org/Downloads/reports/HPDs/health_policy_dev_2.pdf
Chronic Illness Alliance, 2009. Response to "A healthier future for all Australians". http://www.chronicillness.org.au/downloads/CIAresponsetoNHHRCSept09_000.pdf
Commonwealth of Australia, 2009. Primary Healthcare Reform in Australia. http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/nphc-draftreportsupp-toc/$FILE/NPHC-supp.pdf
Hayward and Colman, 2003. The Tides of Change: Addressing Inequity and Chronic Disease in Atlantic Canada. http://www.phac-aspc.gc.ca/canada/regions/atlantic/pdf/Tides_Inequity_and_Chronic_Disease.pdf
Henke and Schreyogg, 2004. Towards sustainable healthcare systems: Strategies in insurance schemes. http://www.issa.int/pdf/publ/Henke-brochure.pdf
Jacobs, R and Goddard, M, 2000. Social Health Insurance systems in European countries. Centre for Health Economics, University of York.
Lagarde and Palmer, 2011. The impact of user fees on access to health services in low- and middle-income countries (Review). http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009094/pdf
Li, 2006. Healthcare Financing Policies of Australia, New Zealand and Singapore. http://www.legco.gov.hk/yr05-06/english/sec/library/0506rp06e.pdf
Lisac, 2007. Reform of the Long Term Care System. http://hpm.org/en/Surveys/Bertelsmann_Stiftung_-_Germany/10/Reform_of_the_long-term_care_system.html?content_id=251&search.x=55&p_c:66=66&search=start+search&p_i=92&search.y=8&a=sh&language=en
Littmann-Wernli, 2009. Home care vs. Institutionalized care - the Swiss way. Monitoring long term care of the elderly. http://www.euro.centre.org/data/1253899058_47868.pdf
McColl and Stephenson, 2008. A scoping review of disability policy in Canada: Effects on community integration for people with spinal cord injuries. http://chspr.queensu.ca/downloads/Reports/Disability%20Policy%20in%20Canada-final%20report-May09.pdf
Mirolla, 2004. The Cost of Chronic Disease in Canada. http://www.gpiatlantic.org/pdf/health/chroniccanada.pdf
Muiser, 2007. The new Dutch health insurance scheme: challenges and opportunities for better performance in health financing. http://www.who.int/health_financing/documents/dp_e_07_3-new_dutch_healthinsurance.pdf
OECD, 2011. Long term care in the Netherlands. http://www.oecd.org/dataoecd/61/44/47877903.pdf
OECD, 2011. OECD Health Data 2011. http://www.oecd.org/dataoecd/45/53/43216301.pdf
OECD, 2011. Switzerland - Long term care. http://www.oecd.org/dataoecd/61/28/47878092.pdf
Okma, 2009. Recent changes in Dutch health insurance: Individual mandate or social insurance. http://www.policyarchive.org/handle/10207/bitstreams/21907.pdf
Peytremann-Bridevaux and Burnand, 2009. Inventory and perspectives of chronic disease management programs in Switzerland: an exploratory survey. http://www.ijic.org/index.php/ijic/article/viewFile/329/657
Polder, Barendregt and van Oers, 2006. Healthcare Costs in the Last Year of Life - The Dutch Experience. http://rivm.openrepository.com/rivm/bitstream/10029/5548/1/polder.pdf
Rodwin et al., 2006. Universal Health Insurance in France: How sustainable - Essays on the French Health System. http://wagner.nyu.edu/health/universal.pdf
Schut and van den Berg, 2009. Sustainability of long-term care financing in the Netherlands. http://cis.ier.hit-u.ac.jp/Japanese/society/conference090114hosei/Paper_Erik_Schut_and_Bernard_vandenBerg.pdf
Squires, 2009. The Swiss healthcare system. http://www.thinkswiss.org/attachments/-01_swiss_health_care_system.pdf
Staines, A. et al., 2011. Implementing Social Health Insurance in Ireland: Report of a meeting and workshop held in Dublin, on December 6th 2010. Dublin: Dublin City University.
Steele, Dewa, Lon and Lee, 2007. Education level, income level and mental health services use in Canada: Associations and policy implications. http://www.longwoods.com/content/19177
Thomas, Normand and Smith, 2008. Social Health Insurance: Further options for Ireland. http://www.adelaide.ie/cms/cms/uploads/files/SHI%20Further%20Options.pdf
von Campenhausen, 2011. Costs of illness and care in Parkinson's disease: An evaluation in six countries.
Worz, Foubister et al. Mapping Health Services Access - National and Cross Border Issues (HealthACCESS Phase 1). http://www.ehma.org/files/HA_Summary_Report_01_02_06.pdf