DOI: https://doi.org/10.21203/rs.3.rs-1548535/v2
Background: Korea has instituted a private health insurance (PHI) scheme that covers the remaining expenses uncovered by the National Health Insurance (NHI). No study has yet estimated the extent to which PHI coverage lowers the economic burden of household access to health care. The current study intends to evaluate the design of Korea's PHI system in terms of coverage using a catastrophic health expenditure (CHE) indicator and compare it with NHI.
Methods: This study determined the difference between the number of households subscribed to PHI and the number of households that paid benefits. Also, it compared the effects of reduced CHE through NHI benefits with those of PHI. Furthermore, it compared PHI benefit rates by income class. Finally, it analyzed the benefit contribution of NHI and PHI to CHE reduction through a two-part model with hierarchical regression.
Results: Results indicated that of the 5,644 households studied, 3,769 subscribed to PHI, but only 246 households received benefits. The NHI reduced CHE incidence by 15.17%, whereas PHI only reduced CHE by 1.22%. The NHI scheme indicated reduced inequality as it provided more benefits to the low-income class, whereas the PHI paid more to the high-income class. The NHI coverage has protected households from CHE and improved equality to some extent; however, PHI coverage has had little effect on relieving CHE and has deteriorated equality.
Conclusions: Korean private insurance companies, which are mostly subsidiaries of for-profit conglomerates, only pay for pre-contracted diseases, therefore, most patients do not receive benefits. Thus, Korea's private insurance system needs to improve to provide benefits to patients more generously and alleviate the financial burden of medical use.
Table 1. General characteristics of samples
Variables |
N (%) |
||||
Total |
Insured in private health insurance |
Paid benefits |
|||
Characteristics of householders |
Gender |
Men |
4,305 (76.28) |
3,051 (80.95) |
193 (78.46) |
Women |
1,339 (23.72) |
718 (19.05) |
53 (21.54) |
||
Age |
< 29 |
187 (3.31) |
90 (2.39) |
13 (5.28) |
|
30~39 |
676 (11.98) |
454 (12.05) |
52 (21.14) |
||
40~49 |
1,166 (20.66) |
761 (20.19) |
83 (33.74) |
||
50~64 |
1,727 (30.6) |
1,013 (26.88) |
93 (37.80) |
||
> 65 |
1,888 (33.45) |
1,451 (38.5) |
5 (2.03) |
||
Education |
Higher than college |
1,703 (30.17) |
1,123 (29.8) |
114 (46.34) |
|
High school |
2,185 (38.71) |
1,487 (39.45) |
92 (37.4) |
||
Less than middle school |
1,756 (31.11) |
1,159 (30.75) |
40 (16.26) |
||
Marital status |
Married |
3,929 (69.61) |
2,856 (75.78) |
186 (75.61) |
|
Single |
1,715 (30.39) |
913 (24.22) |
60 (24.39) |
||
Job type |
Employee |
2,430 (43.05) |
1,507 (39.98) |
157 (63.82) |
|
Employer/self-Employed |
1,356 (24.03) |
896 (23.77) |
61 (24.80) |
||
Unemployed |
1,858 (32.92) |
1,366 (36.24) |
28 (11.38) |
||
Characteristics of households |
Income level |
5th (rich) |
1,128 (19.99) |
741 (19.66) |
75 (30.49) |
4th |
1,128 (19.99) |
724 (19.21) |
61 (24.8) |
||
3rd |
1,129 (20.00) |
695 (18.44) |
71 (28.86) |
||
2nd |
1,129 (20.00) |
760 (20.16) |
33 (13.41) |
||
1st (poor) |
1,130 (20.00) |
849 (22.53) |
6 (2.44) |
||
Private health insurance |
No |
1,875 (33.22) |
- |
- |
|
Yes |
3,769 (66.78) |
3,769 (66.78) |
- |
||
Type of national health insurance |
Employee |
3,731 (66.11) |
2,465 (65.40) |
172 (69.92) |
|
Self-employed |
1,481 (26.24) |
971 (25.76) |
70 (28.46) |
||
Medical Aid |
432 (7.65) |
333 (8.84) |
4 (1.63) |
||
Presence of disabled |
No |
5,037 (89.25) |
3,322 (88.14) |
235 (95.53) |
|
Yes |
607 (10.75) |
447 (11.86) |
11 (4.47) |
||
Presence of four major diseases |
No |
4,259 (75.46) |
2,762 (73.28) |
210 (85.37) |
|
Yes |
1,385 (24.54) |
1,007 (26.72) |
36 (14.63) |
||
Number. of chronic diseases (mean, S.D.) |
0.567, 0.678 |
0.610, 0.701 |
0.610, 0.701 |
||
Number of samples |
5,644 |
3,769 |
246 |
* The Pearson chi2 test between paid benefit and other characteristics results p < 0.05.
Table 2. National health insurance benefits, out-of-pocket expenses, and private health insurance benefits by income quintile
Income quartile |
National health insurance benefits (dollar) |
Out-of-pocket expenses (dollar) |
Private health insurance benefits (dollar) |
||||||
|
n |
Mean |
S.D. |
n |
Mean |
S.D. |
n |
Mean |
S.D. |
1st (poor) |
1,096 |
2,375.82 |
4,541.33 |
1,096 |
1,209.17 |
1,694.55 |
6 |
1,351.0 |
1,755.47 |
2nd |
1,113 |
2,463.50 |
4,362.19 |
1,113 |
1,627.60 |
2,106.19 |
33 |
762.11 |
666.34 |
3rd |
1,106 |
1,925.73 |
3,407.04 |
1,106 |
1,566.22 |
1,931.47 |
71 |
864.78 |
1,827.95 |
4th |
1,098 |
1,644.84 |
3,044.78 |
1,098 |
1,657.88 |
2,062.06 |
61 |
851.90 |
1,696.51 |
5th (rich) |
1,103 |
1,707.51 |
3,559.46 |
1,103 |
1,710.57 |
2,150.51 |
75 |
3,643.41 |
9,508.58 |
Total |
5,516 |
2,024.12 |
3,839.85 |
5,516 |
1,554.74 |
2,003.41 |
246 |
1,706.84 |
5,545.17 |
Exchange rate: 1dollar = Korean Won 1,146.9 (2021.08.10)
Table 3. Summary results of incidence and the positive gap of catastrophic health expenditure based on out-of-pocket expenses, total healthcare payment, and private health care payments
|
Based on out-of-pocket expenses |
Based on total health care payment |
National health insurance coverage |
|||||||||
Threshold |
10% |
20% |
40% |
|
10% |
20% |
40% |
|
10% |
20% |
40% |
|
Incidence measures |
|
19.26% |
8.03% |
2.43% |
|
34.43% |
19.95% |
9.53% |
|
15.17% |
11.92% |
7.10% |
Intensity measures |
|
2.76% |
1.52% |
0.62% |
|
10.83% |
8.23% |
5.48% |
|
8.06% |
6.70% |
4.86% |
|
14.39% |
19.14 |
26.17% |
|
31.51% |
41.38% |
57.84% |
|
23.46% |
33.71% |
51.29% |
|
|
Based on out-of-pocket expenses |
Based on private health care payment |
Private health insurance coverage |
|||||||||
Incidence measures |
|
19.26% |
8.03% |
2.43% |
|
20.48% |
8.65% |
2.73% |
|
1.22% |
0.62% |
0.30% |
Intensity measures |
|
2.76% |
1.52% |
0.62% |
|
3.05% |
1.73% |
0.73% |
|
0.28% |
0.20% |
0.11% |
|
14.39% |
19.14% |
26.17% |
|
14.94% |
20.15% |
27.62% |
|
1.39% |
2.38% |
4.30% |
Note: is incidence, is positive gap, is mean positive gap of catastrophic health expenditure using out-of-pocket payments; is incidence, is positive gap, is mean positive gap of catastrophic health expenditure using total healthcare payment rather than out-of-pocket payments; is incidence, is positive gap, is mean positive gap of catastrophic health expenditure using private healthcare payments; is incidence, is positive gap, is mean positive gap of national health insurance coverage, is incidence, is positive gap, is mean positive gap of private health insurance coverage.
Table 4. Coverage effects of national health insurance and private health insurance on catastrophic health expenditure (hierarchical regression analysis)
|
Model 1 |
Model 2 |
Model 3 |
||||||||||
Incidence |
Positive gap |
Incidence |
Positive gap |
Incidence |
Positive gap |
||||||||
OR |
S.E. |
f. |
S.E. |
OR |
S.E. |
|
S.E. |
OR |
S.E. |
|
S.E. |
||
Private Health Insurance coverage () |
- |
- |
- |
- |
- |
- |
- |
- |
1.467* |
0.252 |
0.068** |
0.022 |
|
National Health Insurance coverage () |
- |
- |
- |
- |
16.743*** |
1.762 |
0.936*** |
0.009 |
16.728*** |
1.769 |
0.933*** |
0.009 |
|
Gender (Male) |
Female |
1.018 |
0.138 |
-0.054 |
0.115 |
1.053 |
0.230 |
0.041 |
0.045 |
1.045 |
0.228 |
0.034 |
0.045 |
Age (< 29) |
30–39 |
0.611 |
0.159 |
0.119 |
0.286 |
0.841 |
0.313 |
-0.088 |
0.113 |
0.830 |
0.309 |
-0.087 |
0.113 |
40–49 |
0.754 |
0.184 |
0.132 |
0.260 |
1.031 |
0.360 |
0.008 |
0.102 |
1.015 |
0.355 |
0.004 |
0.102 |
|
50–64 |
0.987 |
0.241 |
0.036 |
0.256 |
1.433 |
0.504 |
0.014 |
0.101 |
1.427 |
0.502 |
0.024 |
0.101 |
|
> 65 |
1.231 |
0.313 |
0.106 |
0.262 |
1.542 |
0.574 |
0.004 |
0.103 |
1.541 |
0.573 |
0.017 |
0.103 |
|
Education level |
High school |
1.485*** |
0.166 |
0.215* |
0.101 |
1.025 |
0.171 |
0.006 |
0.040 |
1.024 |
0.171 |
0.009 |
0.040 |
(> college) |
< middle school |
1.089 |
0.111 |
0.111 |
0.100 |
0.914 |
0.134 |
0.001 |
0.039 |
0.917 |
0.134 |
-0.001 |
0.039 |
Marital status (married) |
Single |
0.629*** |
0.082 |
-0.023 |
0.111 |
0.742 |
0.155 |
-0.075 |
0.043 |
0.741 |
0.155 |
-0.073 |
0.043 |
Job type (employee) |
Employer/self-employed |
1.202 |
0.119 |
0.207* |
0.088 |
1.024 |
0.153 |
0.005 |
0.035 |
1.020 |
0.153 |
0.001 |
0.035 |
Unemployed |
1.455*** |
0.141 |
0.286*** |
0.082 |
1.159 |
0.175 |
0.018 |
0.032 |
1.155 |
0.175 |
0.017 |
0.032 |
|
Income level (rich)* |
Quintile 4 |
2.034*** |
0.298 |
0.013 |
0.171 |
1.866*** |
0.378 |
0.114 |
0.067 |
1.893** |
0.384 |
0.126 |
0.067 |
Quintile 3 |
4.187*** |
0.586 |
0.136 |
0.159 |
3.196*** |
0.628 |
0.102 |
0.063 |
3.238*** |
0.637 |
0.114 |
0.063 |
|
Quintile 2 |
9.299*** |
1.329 |
0.524*** |
0.157 |
4.709*** |
0.975 |
0.205*** |
0.062 |
4.771*** |
0.991 |
0.215*** |
0.062 |
|
Quintile 1 (poor) |
17.057*** |
2.740 |
0.848*** |
0.163 |
6.392*** |
1.558 |
0.283*** |
0.064 |
6.489*** |
1.585 |
0.293*** |
0.064 |
|
Private health insurance (no) |
Yes |
1.159 |
0.104 |
-0.057 |
0.067 |
1.105 |
0.161 |
0.027 |
0.026 |
1.100 |
0.160 |
0.023 |
0.026 |
Type of national health insurance (employee) |
Self-employed |
0.935 |
0.077 |
-0.116 |
0.067 |
0.939 |
0.119 |
0.004 |
0.026 |
0.941 |
0.119 |
0.002 |
0.026 |
Medical Aid |
0.645*** |
0.081 |
0.073 |
0.093 |
0.635* |
0.141 |
-0.188*** |
0.037 |
0.639 |
0.141 |
-0.186*** |
0.037 |
|
Disabled (no) |
Yes |
1.007 |
0.105 |
0.121 |
0.077 |
0.863 |
0.154 |
-0.017 |
0.031 |
0.861 |
0.154 |
-0.017 |
0.030 |
Four major diseases (no) |
Yes |
2.848*** |
0.225 |
0.386*** |
0.058 |
1.609*** |
0.202 |
0.001 |
0.023 |
1.591*** |
0.200 |
-0.001 |
0.023 |
Number of chronic diseases |
|
1.618*** |
0.121 |
0.061 |
0.065 |
1.354** |
0.158 |
-0.012 |
0.025 |
1.365** |
0.160 |
-0.008 |
0.025 |
Constants |
0.045*** |
0.012 |
1.561*** |
0.282 |
0.022*** |
0.008 |
0.254* |
0.112 |
0.226*** |
0.008 |
0.237* |
0.112 |
|
Model fits |
0.2708*** |
0.144*** |
0.6437*** |
0.866*** |
0.6443*** |
0.866*** |
*p < .05; **p < .01; ***p < .001