Statistical inference of progressivity dominance: an application to health care financing distributions.

This paper employs a distribution-free statistical test suitable for comparisons based on dependent samples to analyse changes in health care financing distributions on Finnish data. In distinction to the more general summary index approach used in most studies of progressivity measurement, the difference between the Lorenz curve of income inequality and the concentration curves of various taxes and payments is used to evaluate progressivity dominance and changes in progressivity. Sample weights are applied to account for the effect of sampling design and non-response. The analysis demonstrates that the dominance approach can be successfully applied to various types of distributional problems besides comparisons concerning differences in income distributions. As an empirical application the paper presents estimation results for the progressivity of various health care financing sources using data from the 1987 and 1996 Finnish Health Care Surveys.

Equity in the delivery of health care in Europe and the US.

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Health care and economic well-being: estimating equivalence scales for public health care utilization.

Inconsistency between the income concept and the needs associated with its use can yield seriously misleading welfare assessments in comparisons concerning different household types. Equivalence scales are typically estimated from expenditure data that make them compatible with welfare adjustments involving cash income. However, if the welfare analysis extends to economic benefits other than cash income, the equivalence scale must be adjusted to account for needs relevant to the particular form of benefit. This paper derives needs-based equivalence scales for public health care utilization. The scales are estimated from the health care utilization data of different services. In addition, redistributional analysis is used to investigate the effects of adopting various income concepts and allowing for health care needs in the equivalence scale. The results clearly reveal the conceptual importance of accounting for health status, household size and age in welfare comparisons concerning non-cash transfers. It is also shown that the redistributive effect of public health care is heavily dependent upon assumptions made about its scope.

Equity in the finance of health care: some further international comparisons.

This paper presents further international comparisons of progressivity of health care financing systems. The paper builds on the work of Wagstaff et al. [Wagstaff, A., van Doorslaer E., et al., 1992. Equity in the finance of health care: some international comparisons, Journal of Health Economics 11, pp. 361-387] but extends it in a number of directions: we modify the methodology used there and achieve a higher degree of cross-country comparability in variable definitions; we update and extend the cross-section of countries; and we present evidence on trends in financing mixes and progressivity.

The redistributive effect of health care finance in twelve OECD countries.

The OECD countries finance their health care through a mixture of taxes, social insurance contributions, private insurance premiums and out-of-pocket payments. The various payment sources have very different implications for both vertical and horizontal equity and on redistributive effect which is a function of both. This paper presents results on the income redistribution consequences of the health care financing mixes adopted in twelve OECD countries by decomposing the overall income redistributive effect into a progressivity, horizontal inequity and reranking component. The general finding of this study is that the vertical effect is much more important than horizontal inequity and reranking in determining the overall redistributive effect but that their relative importance varies by source of payment. Public finance sources tend to have small positive redistributive effects and less differential treatment while private financing sources generally have (larger) negative redistributive effects which are to a substantial degree caused by differential treatment.

Micro-level analysis of distributional changes in health care financing in Finland.

OBJECTIVES: In the early 1990s the Finnish economy suffered a severe recession at the same time as health care reforms were taking place. This study examines the effects of these changes on the distribution of contributions to health care financing in relation to household income. Explanations for changes in various indicators of health care expenditure and use during that time are offered. METHOD: The analysis is based partly on actual income data and partly on simulated data from the base year (1990). It employs methods that allow the estimation of confidence intervals for inequality indices (the Gini coefficient and Kakwani's progressivity index). RESULTS: In spite of the substantial decrease in real incomes during the recession, the distribution of income remained almost unaltered. The share of total health care funding derived from poorer households increased somewhat, due purely to structural changes. The financial plight of the public sector led to the share of total funding from progressive income taxes to decrease, while regressive indirect taxes and direct payments by households contributed more. CONCLUSIONS: It seems that, aside from an increased financing burden on poorer households, Finland's health care system has withstood the tremendous changes of the early 1990s fairly well. This is largely attributable to the features of the tax-financed health care system, which apportions the effects of financial and functional disturbances equitably.

Health care and income distribution in Finland.

This paper examines the effects of health care on income redistribution in Finland. In contrast to earlier studies in this area, the redistributive effect is analysed with noncash transfers from health care utilisation included in household income. Distributional consequences of changing health care financing towards one system or another are analysed in terms of municipality provided public services and sickness insurance based public services. Our results show that, overall, the public health care system distributed income from the rich to the poor. The poorest one-third of the population financed only about one-third of the public health care services they utilised. The distributional implications were, however, markedly different depending on the definition of income used. Whereas health care financing had only a marginal redistributive effect, the effect was substantially increased as noncash transfers from health care utilisation were taken into account.