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HEALTH-UNINSURED INDIVIDUALS and Health Insurance in Bulgaria

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HEALTH-UNINSURED INDIVIDUALS and Health Insurance in Bulgaria HEALTH-UNINSURED INDIVIDUALS and Health Insurance in Bulgaria REPORT 2009 Statements and views expressed in this Report are the sole responsibility of the respective sections authors and do not necessarily reflect Open Society Institute of Sofia views and policies. Authors should be quoted in any republishing of this material, in full or in part. © 2009 ISBN 978-954-9828-83-2 This Analysis has been prepared under Public Budgets Monitoring Project assigned by Open Society Institute, Sofia. Report Team includes: Dessisslava Kouznetsova – Project Manager, Management and Public Policies Program, Open Society Institute, Sofia Ekaterina Markova, Ph.D., Res. Assoc. – Author, Part 1, Institute of Sociology, Bulgarian Academy of Sciences Vassil Kirov, PhD, Res. Assoc. – Author, Part 1, Institute of Sociology, Bulgarian Academy of Sciences Boyan Zahariev – Author, Part 2, Open Society Institute, Sofia Mimi Vitkova, MD – Author, Parts 3 and 4 Hristo Hinkov, MD – Author, Medical Services Quality as a Factor of Citizens’ Insurance Ivailo Ivanov – Author, Part 5 Georgy Angelov – Author, Part 6, Open Society Institute, Sofia Referees Assoc.Prof. Evgeniya Delcheva, MD Prof. Vesselin Borissov, MD, D.Sc. TABLE OF CONTENTS EXECUTIVE SUMMARY 4 I. HEALTH-UNINSURED INDIVIDUALS IN BULGARIA – PROFILE AND CAUSES 7 Methodological remarks 7 Health-uninsured individuals profile 9 Strategies of health-uninsured individuals to cope with the situation 14 Use of health services 16 Health status and general information on respondents 17 Health-uninsured individuals – Main Conclusions 19 II. POVERTY ANALYSIS AMONG HEALTH-UNINSURED INDIVIDUALS IN BULGARIA 21 Poverty definitions 22 Multidimensional poverty 22 1) Monetary poverty 23 2) Subjective poverty 24 3) Educational marginalization (educational poverty) 26 4) Housing poverty 27 5) Health marginalization (health poverty) 29 6) Multi-dimensional poverty 32 III. HEALTHCARE IN EUROPEAN UNION MEMBER-STATES AS PART OF THE SOCIAL PROTECTION SYSTEM 34 Reforming national health systems in Western Europe 35 Reforming national health systems of Central and Eastern Europe 41 IV. HEALTH INSURANCE SYSTEM IN THE REPUBLIC OF BULGARIA 43 Legal provisions on health insurance in the Republic of Bulgaria – a concise review 43 Characteristics of the Bulgarian health insurance model 44 Mandatory health insurance 44 Voluntary supplementary health insurance 48 Health Insurance System financing (mandatory health insurance) 51 Health insurance revenues 51 Health insurance expenditures (NHIF expenditures) 53 Health insurance budget within the general parameters of healthcare financing 59 Issues and challenges faced by health insurance in Bulgaria having a direct bearing to system financing, participation and fairness 61 Health insurance – main conclusions 71 V. ACCESS TO HEATHCARE OF HEALTH-UNINSURED INIDIVIDUALS 75 Health insurance status of non-compliant citizens 75 Social protection system for disadvantaged persons regarding their health insurance 77 VI. HEALTH INSURANCE SYSTEM, HEALTH-UNINSURED INDIVIDUALS AND MACRO- DEVELOPMENTS 82 Political aspects of the reform 82 BNB reserve 82 The crisis and the healthcare budget 83 Health-uninsured individuals and the crisis 84 APPENDICES 86 EXECUTIVE SUMMARY This analysis of health-uninsured persons in Bulgaria is part of a series of Sofia Open Society Institute-funded surveys on public budgets and reviews of Government policies in various areas conducted in recent years. There are no official data on either the profile of health-uninsured individuals in Bulgaria or the strategies that such Bulgarian citizens apply with respect to their health. This creates a serious problem to setting forth measures on collecting overdue health insurance liabilities, attracting health insurance system dropouts and supporting those that actually do not stand the chance of restoring their health insurance rights due to low income levels. These issues hold strong social charge under economic crisis circumstances. Back in mid-2007 when monitoring was initiated, economic growth forecasts had been optimistic. The focus then was on matters related to health insurance system liabilities of Bulgarian citizens residing abroad, at that time about 500 000 people, as quoted in various sources. While conducting this monitoring exercise (end 2008 being the deadline for analysis), two major changes in health insurance policies had been introduced, namely: - Setting out the health insurance rights of Bulgarian citizens residing abroad and conditions of restoring these rights, in 2008; and - Rising heal insurance rates from 6% to 8%, starting 2009. Within the specified analysis term, National Health Insurance Fund data indicate that the number of health-uninsured individuals has remained the same – about one million individuals. This is a precedent for an EU member-state. The publication herein focuses on data collected for the health-uninsured urban population in Bulgaria. It presents their profile and the reasons for them being health- uninsured. Data collected has prompted the need to hear views on the problems faced by these people, namely on: the health insurance system itself; poverty among health-uninsured individuals; and Government policies and their adequacy in terms of current situation, all these at the background of an economically dynamic environment. Survey information on health-uninsured persons and data from the Multi-target Household Survey1 conducted jointly by the World Bank and Open Society Institute, Sofia, are used to analyze poverty levels among health-uninsured individuals thus complementing the big picture of health-uninsured persons’ social status. Health insurance system is reviewed and the key problems having a bearing to system fairness are analyzed. Social measures put in place by the Government to support health- uninsured individuals are presented as data on individuals that have benefited from such measures. Main reasons for denying access to these options are also established. 1 This survey was conducted in 2007. A macroeconomic analysis to complement the big picture of system outsiders is presented. Health system problems and limits associated with health non-insurance are also explored. Emphasis is placed on the main challenges to system budget and revenues under the conditions of increased health insurance rates, and economic crisis. Conclusions on health-uninsured individuals and relevant problematic areas may be summarized as follows: · Socio-demographic distribution of urban individuals surveyed claiming of being health-uninsured shows that the likelihood of them being young people of low or secondary education level, coming from low income households and predominantly belonging to the Roma ethnic group is high. About half of health-uninsured persons, about 60%, belong to the Turkish ethnic group, over 80% belong to the Roma ethic minority and only 21.5% are ethnic Bulgarians whose poverty state is so severe that renders them incapable of overcoming it all by themselves. · Overall, health-uninsured people do not comprehend the nature of the solidarity system. They do not believe they should pay for something they do not use. Wealthy household percentage (5.6%) confirms the hypothesis that financial issues are not the only cause of health insurance system dropouts, who may or may not be doing it on their own accord. · Health-uninsured individuals do not fill in applications for social health aid. Individuals with no health insurance do not take advantage of the social measures put in place by Government. Due to stringent access criteria regulating social health aid, the system for protection of socially disadvantaged people turns emergency medical services into the only healthcare accessible to a large portion of such vulnerable group members. The health insurance system requires full revision with respect to such people. · A number of factors affect negatively motivation to participate in the health insurance system. Among them are limited access to outpatient medical experts (NHIF regulated and standardized; in practice this impedes such access due to the need of specialized referral slips); poor quality of medical services; additional payments for health services; corruption in health services, and poor attitude towards patients. · Methods applied to limit expenditures (through regulatory standards) in mandatory health insurance regarding outpatient care do not reflect the actual medical needs of the population and restrict access to this healthcare level. HEALTH-UNINSURED INDIVIDUALS IN BULGARIA 5 Limitations to outpatient care access lead to rise in demand of direct access to hospitals and are one of the reasons for the increased number of hospitalized patients. Thus, measures aiming at restricted specialized outpatient and diagnostic care in fact push up costs of the most expensive medical care – hospital treatment. · While healthcare price has risen in the years, financial burden has shifted towards households instead of public funds, which is in contrast to the approach in developed European countries. This is an indication that a reassessment of both health insurance model and taxation formula applied is required in order to increase public funds allocation to healthcare and reduce individual payment rates. · Under deteriorating economic conditions, shrinking of grey economy and expected drop in transfers from abroad, identifying main health-uninsured groups and developing a designated policy targeting such individuals acquires an even higher priority. What are the
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