Our research investigates the effects of the 2005 universal health insurance program for children under age 6 in Vietnam on health care utilization, household out-of-pocket (OOP) spending and self-reported health outcomes using data from the Vietnam Household Living Standard Survey in 2002–2004–2006–2008. We use difference-in-differences to compare children eligible for the program to older children who are ineligible for the program. Results indicate that the program increased insurance coverage by 250% for children age 0–5 relative to the pre-policy period. We found large increases in both outpatient visits and hospital admissions. Health insurance availability also increased outpatient visits at both public and private facilities, suggesting that public and private health care services are complements. Although health insurance was associated with a decrease in inpatient OOP spending for children aged 3–5, it did not reduce outpatient OOP spending for children in general. Health insurance was associated with modest improvements in self-reported health outcomes. Our research suggests that expanded access to insurance among Vietnamese children improved access to care and health outcomes, though it did not necessarily reduce OOP spending.

For almost a century, the Netherlands was marked by a large market for voluntary private health insurance alongside state-regulated social health insurance. Throughout this period, private health insurers tried to safeguard their position within an expanding welfare state. From an institutional logics perspective, we analyze how private health insurers tried to reconcile the tension between a competitive insurance market pressuring for selective underwriting and actuarially fair premiums (the insurance logic), and an upcoming welfare state pressuring for universal access and socially fair premiums (the welfare state logic). Based on primary sources and the extant historiography, we distinguish six periods in which the balance between both logics changed significantly. We identify various strategies employed by private insurers to reconcile the competing logics. Some of these were temporarily successful, but required measures that were incompatible with the idea of free entrepreneurship and consumer choice. We conclude that universal access can only be achieved in a competitive individual private health insurance market if this market is effectively regulated and mandatory cross-subsidies are effectively enforced. The Dutch case demonstrates that achieving universal access in a competitive private health insurance market is institutionally complex and requires broad political and societal support.

The existence of different forms of out-of-pocket payments (OOPs) for pharmaceuticals across the globe provokes the question whether they can achieve more negative or positive consequences. A systematic literature review was conducted to assess the association between drug cost sharing and health care services utilization, health care costs as well as health outcomes. Studies published in The Cochrane Library, PubMed, Embase were searched with such keywords as: drug, pharmaceutical, cost sharing, out of pocket, co-payments paired with the following: impact, health outcomes, health care costs and utilization. The final review included 18 articles. A total of 11 publications reported the association between drug cost sharing and health care utilization patterns, of which nine found a statistically significant direct relationship. In all 10 publications concerned the association between drug copayments and health care costs. Majority were limited to the impact on the drug budget. Seven studies looked into the link between drug cost sharing and health outcomes, of which five reported statistically significant inverse relationship. There is some evidence for the association between drug copayments, health outcomes and health care services consumption. The optimal system of OOPs’ payments for pharmaceuticals needs to prevent drugs’ overconsumption and mitigate the risks of excessive cost sharing’s burden.

The Irish health care system is unusual within Europe in not providing universal, equitable access to either primary or acute hospital care. The majority of the population pays out-of-pocket fees to access primary health care. Due to long waits for public hospital care, many purchase private health insurance, which facilitates faster access to public and private hospital services. The system has been the subject of much criticism and repeated reform attempts. Proposals in 2011 to develop a universal health care system, funded by Universal Health Insurance, were abandoned in 2015 largely due to cost concerns. Despite this experience, there remains strong political support for developing a universal health care system. By applying an historical institutionalist approach, the paper develops an understanding of why Ireland has been a European outlier. The aim of the paper is to identify and discuss issues that may arise in introducing a universal healthcare system to Ireland informed by an understanding of previous unsuccessful reform proposals. Challenges in system design faced by a late-starter country like Ireland, including overcoming stakeholder resistance, achieving clarity in the definition of universality and avoiding barriers to access, may be shared by countries whose universal systems have been compromised in the period of austerity.

One goal of the Affordable Care Act is to increase insurance coverage by improving competition and lowering premiums. To facilitate this goal, the federal government enacted online marketplaces in the 395 rating areas spanning 34 states that chose not to establish their own state-run marketplaces. Few multivariate regression studies analyzing the effects of competition on premiums suffer from endogeneity, due to simultaneity and omitted variable biases. However, United Healthcare’s decision to enter these marketplaces in 2015 provides the researcher with an opportunity to address this endogeneity problem. Exploiting the variation caused by United Healthcare’s entry decision as an instrument for competition, we study the impact of competition on premiums during the first 2 years of these marketplaces. Combining panel data from five different sources and controlling for 12 variables, we find that one more insurer in a rating area leads to a 6.97% reduction in the second-lowest-priced silver plan premium, which is larger than the estimated effects in existing literature. Furthermore, we run a threshold analysis and find that competition’s effects on premiums become statistically insignificant if there are four or more insurers in a rating area. These findings are robust to alternative measures of premiums, inclusion of a non-linear term in the regression models and a county-level analysis.

This article investigates the impact of Certificate of Need (CON) laws on competition in the inpatient care market. One of the major criticisms of these laws is that it may hinder competition in the health care market, which can lead to higher prices. However, from a theoretical standpoint, CON laws could also promote competition by limiting excessive expansion from incumbents. Our main conclusion is that CON laws by and large enhanced competition in the inpatient market during the period of our study. This indicates that the effects of CON laws to hinder predatory behavior could dominate its effects of preventing new entrants into the inpatient care market. We do not find statistically significant evidence to reject the exogeneity assumption of either CON laws or their stringency in our study. We also find factors such as proportion of population aged 18–44, proportion of Asian American population, obesity rate, political environment, etc., in a state significantly impact competition. Our findings could shed some light to public policy makers when deciding the appropriate health programs or legislative framework to promote health care market competition and thereby facilitate quality health care.