Equity of health care financing in South Korea: 1990–2016

Background The National Health Insurance in Korea has been in operation for more than 30 years since having achieved universal health coverage in 1989 and has gone through several policy reforms. Despite its achievements, the Korean health insurance has some shortfalls, one of which concerns the fairness of paying for health care. Method Using the population representative Household Income and Expenditure Survey data in Korea, this study examined the yearly changes in the vertical equity of paying for health care between 1990 and 2016 by the source of financing using the Kakwani index, considering health insurance and other related policy reforms in Korea during this period. Results The study results suggest that direct tax was the most progressive mode of health care financing in all years, whereas indirect tax was proportional. The out-of-pocket payments were weakly regressive in all years. The Kakwani index for health insurance contributions was regressive but now is proportional to the ability to pay, whereas the Kakwani index for private health insurance premiums turned from progressive to weakly regressive. The Kakwani index for overall health care financing showed a weak regressivity during the study period. Discussion The overall health care financing in Korea has transformed from a slight regressivity to proportional over time between 1990 and 2016. It is expected that these changes were closely related to the improved equity of health insurance contributions from 1998 to 2008, which was the result of a merger of the health insurance societies and an amendment in the health insurance contribution structure. These results suggest that standardizing insurance managing organizations and financing rules potentially has positive implications for the equity of healthcare financing in a country where the major method of health care financing is social health insurance.

Equity in Out-of-Pocket Payments for Healthcare Service Delivery in Urban and Rural Households: Evidence from Iran

Background: Out-of-pocket payments for medical services may undermine access to medical services and equity in healthcare financing. Objectives: The present study aimed to determine the distribution of the burden of out-of-pocket payments for healthcare services among the households in Qazvin province, Iran. Methods: This descriptive-analytical study was conducted on the urban and rural households in Qazvin province, Iran during 2019 - 2020. Data were obtained from the Statistics Center of Iran (2019 - 2020). The optimal sample size was calculated to be 992 households, and the households were selected via three-stage random cluster sampling. Data were collected using a valid questionnaire and via face-to-face interviews with the household owners. The fair financial contribution index (FFCI), concentration index, and Kakwani index were estimated in the Stata software. Results: The estimated parameters indicated that during the study period (March 21, 2019-March 20, 2020), the FFCI value of the rural and urban households was 0.782 and 0.854, respectively. The out-of-pocket payment concentration index based on income rank was estimated at 0.188 in rural households (P < 0.05) and 0.031 in the urban households. In addition, the Kakwani index of the urban and rural households was calculated to be -0.165 and -0.84, respectively. Conclusions: According to the results, out-of-pocket payments were unequally distributed among the households in Qazvin province in 2019 - 2020. These payments were mostly concentrated on the 5th - 7th deciles of urban households. On the other hand, the out-of-pocket payments during the study period were regressive. To promote financial equity, Qazvin health policymakers must run payment exemptions for low-income groups and also expand the medical insurance coverage and universal coverage of healthcare services.

Tax Progressivity of Personal Wages and Income Inequality

The paper examines tax progressivity and income inequality using Census Bureau Current Population Survey (CPS) personal income data. The Kakwani index is used to derive tax progressivity for All, Male, Female, White and African American personal wage income of CPS respondents, respectively. The tax progressivity results show a tax system that is partly progressive and mostly regressive. Due to its regressive nature, the tax system did not display tax progressivity for the entire period under analysis for personal wage income respondents as well as when broken-down by race and gender in the United States for years 1996 to 2011.

Dental Expenditure, Progressivity and Horizontal Inequality in Chinese Adults：Based on the 4th National Oral Health Epidemiology Survey

Background: The financial burden of oral diseases is a growing concern as the medical expenses rise worldwide. The aim of this study was to investigate the dental expenditure, analyze its progressivity and horizontal inequality under the general health finance and insurance system, and identify the key social determinants of the inequality for Chinese adults. Methods: A secondary analysis used the data of 13,464 adults from the 4 th National Oral Health Epidemiological Survey (NOHES) in China was undertaken. The dental expenditure was collected and divided into out-of-pocket and health insurance payments. Horizontal inequality index and Kakwani index were used to analyze the horizontal inequality and progressivity, respectively. The decomposition model of the concentration index was set up to explore the associated socioeconomic determinants. Results: The results showed that a mean dental expenditure per capita of Chinese adults was $20.55 (95% Confidence Interval-CI: 18.83,22.26). Among those who actually used dental service, the cost was $100.95 (95%CI: 93.22,108.68). Over 90% of dental spending was due to out-of-pocket expenses. For self-reported oral health, the horizontal inequality index was -0.1391 and for the decayed tooth (DT), it was -0.2252. For out-of-pocket payment, the Kakwani index was -0.3154 and for health insurance payment it was -0.1598. Income, residential location, educational attainment, oral hygiene practice, self-reported oral health, age difference were the main contributors to the inequality of dental expenditure. Conclusion: Dental expenditure for Chinese adults was at a lower level due to underutilization. The ratio of payments of dental expenditure and utilization was disproportional, whether it was out-of-pocket or insurance payment. Individuals who were more in need of oral care showed less demand for service or not required service in time. For future policy making on oral health, it is worth the effort to further promote the awareness of the importance of oral health and utilization of dental service.

Dental Expenditure, Progressivity and Horizontal Inequality in Chinese Adults：Based on the 4th National Oral Health Epidemiology Survey

Background: The financial burden of oral diseases is a growing concern as the medical expenses rise worldwide. The aim of this study was to investigate the dental expenditure, analyze its progressivity and horizontal inequality under the general health finance and insurance system, and identify the key social determinants of the inequality for Chinese adults. Methods: A secondary analysis used the data of 13,464 adults from the 4 th National Oral Health Epidemiological Survey (NOHES) in China was undertaken. The dental expenditure was collected and divided into out-of-pocket and health insurance payments. Horizontal inequality index and Kakwani index were used to analyze the horizontal inequality and progressivity, respectively. The decomposition model of the concentration index was set up to explore the associated socioeconomic determinants. Results: The results showed that a mean dental expenditure per capita of Chinese adults was $20.55 (95% Confidence Interval-CI: 18.83,22.26). Among those who actually used dental service, the cost was $100.95 (95%CI: 93.22,108.68). Over 90% of dental spending was due to out-of-pocket expenses. For self-reported oral health, the horizontal inequality index was -0.1391 and for the decayed tooth (DT), it was -0.2252. For out-of-pocket payment, the Kakwani index was -0.3154 and for health insurance payment it was -0.1598. Income, residential location, educational attainment, oral hygiene practice, self-reported oral health, age difference were the main contributors to the inequality of dental expenditure. Conclusion: Dental expenditure for Chinese adults was at a lower level due to underutilization. The ratio of payments of dental expenditure and utilization was disproportional, whether it was out-of-pocket or insurance payment. Individuals who were more in need of oral care showed less demand for service or not required service in time. For future policy making on oral health, it is worth the effort to further promote the awareness of the importance of oral health and utilization of dental service.

A paradoxical situation in regressivity or progressivity of out of pocket payment for health care: which one is a matter of the health policy maker’s decision to intervention?

Background Equity in health financing as one main aspect of health equity plays an essential role on the path toward universal health coverage. Out of pocket payment (OOP), a source with high share to total health expenditure, is an inequitable mechanism for health financing. Main body The OOP has been considered regressive (Kakwani index with a negative value) in nature. However, in some studies especially in developing countries, it is reported to be progressive (Kakwani index with a positive value). The main questions are: Is the progressive OOP equitable? What causes this contradiction? What can we do for the proper interpretation? And what are policy implications of this issue? In this commentary we briefly elaborate on these issues. We present several reasons for progressivity of OOP, and several methodological and policy issues for addressing it. Conclusions Even if the OOP is progressive and the share of poor people is low, this may financially limit their access to health services, increase their risk of incurring catastrophic health expenditure (CHE), and even pushing them more into poverty. In order to provide a comprehensive picture of equity in health financing, other financial protection indicators such as the redistributive effect, re-rating, exposure to CHE, and impoverishment due to health expenditure should also be estimated and reviewed.