Insurance enrollment

Medicare Membership Blues Remedies MIT News

Some countries with national health insurance schemes face a basic problem: there are not enough people enrolling in these programs, and those who do tend to have worse health than the last. mean. It is a public health issue, but also a fiscal issue. When more healthy people enroll in health care plans and thus pay premiums, those plans gain a better tax base.

What is a good way to meet this challenge? A study recently published in Indonesia and led by economists at MIT provides new insights, which could apply globally. The study included a three-pronged experiment in which people received either encouragement to enroll through grants, assistance with the enrollment process, or information on the benefits of the program.

For starters, full grants for program participants increased enrollment by 18.6 percentage points, the experience revealed.

“We’re seeing that the grants are making a difference,” says Benjamin Olken, MIT economist and co-author of the article detailing the results of the experiment.

But the experience also produced what Olken sees as an equally important idea: the simple challenge of navigating the health insurance enrollment process is a serious problem. The help with registration alone increased enrollments by 3.5%, but many more people tried and failed to enroll in the program, highlighting how countries’ administrative capacity – to keep up with people and helping them with bureaucracy – makes a difference.

“One of the lessons of this article is the importance of state infrastructure,” says Olken. “Investing in this underlying infrastructure isn’t the most exciting thing, but it’s really essential. “

The article titled “The challenges of universal health insurance in developing countries: evidence from Indonesian national health insurance” was published in the September issue of American Economic Review.

The co-authors are Abhijit Banerjee, Ford International Professor of Economics at MIT; Amy Finkelstein, John and Jennie S. MacDonald Professor of Economics at MIT; Rema Hanna, Jeffrey Cheah Professor of Southeast Asian Studies at Harvard Kennedy School; Olken, Jane Berkowitz Carlton and Dennis William Carlton professor of microeconomics at MIT; Arianna Ornaghi, Assistant Professor of Economics at the Hertie School in Berlin; and Sudarno Sumarto, economist for the Indonesian Government’s National Team for Accelerating Poverty Reduction (TNP2K) and researcher at the SMERU Research Institute in Jakarta, Indonesia.

Temporary grants, long-term impact

Indonesia introduced its national health insurance policy in 2014. The program fully subsidizes care for the poorest and relies on better-off citizens to enroll and pay monthly premiums, to fund much of the program. The system resembles those of several other countries, including Ghana, Kenya, the Philippines and Vietnam.

All of these countries, including Indonesia, require citizens to enroll in their health insurance programs, but they only lightly enforce this mandate. One year after the launch of the Indonesian program, less than 20% of targeted citizens had signed up and the ratio of claims to premiums received was 6.45 to 1.

The genesis of the MIT experiment came from discussions between the research team and representatives of the Indonesian government, with the aim of finding ways to boost enrollment. The researchers ultimately conducted their three-part experiment with around 6,000 Indonesian citizens, starting in 2015, and then tracking participants’ enrollment status for around 20 months after the experiment ended.

The first part of the experiment provided participants with grants lasting a year and a half size, while comparing the results to a control group. While logic would predict an increase in enrollment due to the grants, as it has actually happened, the experiment produced an intriguing twist – once the grants end, the people who received them are twice as likely to pay for it. coverage only to people who have never received a grant.

“One encouraging thing about this result is that temporary grants have long-term impacts,” says Olken. “People join the program, get their coverage for free for a year, then have to start paying, and a lot of them keep paying. … They recognize that there is value in this program.

A related key point is that by thus attracting more premium paying participants, the grants attract largely healthier people to the program. This helps to limit the problem of “adverse selection”, in which people in poor health are more likely to opt for health insurance programs, creating a tax burden by incurring relatively larger expenses for these programs. Anti-selection is one of the reasons health insurance mandates exist, although they are not always tightly enforced.

“Temporary grants can reduce this type of adverse selection,” says Olken.

When failure is an option

Meanwhile, the second leg of the experiment, which offered in-person assistance to people trying to enroll in the online health insurance program, offered its own revealing data points. Researchers have found that more than half of all people who try to register are ultimately unsuccessful.

“I don’t think that’s something anyone knew exactly, because they had never measured it before,” Olken observes.

This suggests that the registration process itself is very important. More generally, Olken notes, this also suggests that the bureaucratic capacity associated with these large national programs is a very important factor in their success. Governments need to properly identify citizens while developing methods to help them register more easily, the researchers conclude.

“Make it easier for people [enroll online] at home only works if you have the underlying administrative infrastructure, ”says Olken. “These various social protection systems have a foundation, and part of that foundation is having information about who is who and what investments are in that infrastructure.”

Perhaps surprisingly, the third part of the Indonesian experience, in which people were given information about the program and its benefits, did not seem to affect enrollment rates – although many people may not know. not much about politics in the first place.

“The experience is different from the background information,” says Olken, acknowledging that the latter did not encourage people to get coverage.

Overall, the success of national health insurance schemes depends on many factors, from a government’s ability to bear the costs to the efficiency of a country’s health system. But given how critical registrations are to the fiscal soundness of such systems, the Indonesian experience shows promising avenues for improvement – and indicates the need for further study of registration issues in countries around the world.

“We have to understand what we can do about it,” says Olken.

The study was funded, in part, by the Australian Department of Foreign Affairs and Trade and the Korea International Cooperation Agency.


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