Efectos de la expansión del seguro sanitario público en la cobertura pública y el aseguramiento privado: evidencia de los adultos mayores en Argentina

After the summer chronicle of the EvaluAES table at the XLIII AES Conference, the EvaluAES group resumed the school year with a new entry that summarizes the progress of a work started during the stay of Juan Virdis at the University of Granada, under the supervision of Dolores Jimenez Rubioand the collaboration of Alessio Gaggero. Juan and his co-authors decided that the last XIII EvaluAES Workshop could be a good opportunity for another researcher, in this case, Manuel Serrano Alarcón (European Commission, Joint Research Center), dedicate quality time to your draft document and offers you constructive criticism to underpin your ongoing research. Before giving way to the protagonists of this entry, we remind you that in December the summary call of the XIV EvaluaAES Workshop to be held in the spring of next year. Soon, news; and now, the narrative interventions of Juan and Manuel. If you would like to expand, audiovisual intervention is available here.

EvaluAES group working committee

job summary

In this work we exploit the Argentine institutional design to study the phenomenon of the expansion of public health insurance on participation in public coverage and the effect known as displacement (or displacement effect) of public health insurance on private insurance.

In Argentina, 61% of the population has mandatory health coverage through institutions called Obras Sociales, which are accessed by registered workers, retirees and pensioners along with their family group, without making voluntary contributions. (Budget Office of the Congress of the Argentine Nation, 2021). In addition, the population has the possibility of contracting private health insurance through the payment of voluntary premiums. However, 36% of the population does not have Obra Social or voluntary insurance coverage, and must access the health system through out-of-pocket expenses or go to state-run hospitals and care centers, which do not have a homogeneous benefit plan and are subject to capacity or medical specialty restrictions.

Mandatory coverage during the active stage is a charge from Social Works organized by branch of activity. When people reach retirement age (60 years for women and 65 for men) and receive a retirement or pension from the National State, they access a public Social Work called the Comprehensive Medical Assistance Program (PAMI). Given that mandatory public insurance coverage in people who have reached retirement age is significantly higher than coverage in the active stage, we suggest evaluating whether this increase causes a decrease in voluntary insurance affiliation.

We use data from the Permanent Household Survey, carried out by the National Institute of Statistics and Censuses (INDEC) from Argentina. The data set involved joining more than 30 waves of the survey, obtaining 1,236,163 observations with information on health coverage and relevant socioeconomic variables. Regarding the empirical strategy, initially we considered it appropriate to carry out a discontinuous regression analysis, using the retirement age as a cut-off point. However, as can be seen in Figure 1, starting at retirement age, there is a steep change in the proportion of people who have mandatory health insurance. For this reason, after carrying out the first analyzes and evaluating the mechanisms through which people become eligible to obtain health coverage, we consider it appropriate to estimate a Regression design (Card and others, 2017), which allows identifying a sudden change in the slope of a target variable at a specific point in a continuous variable.

Figure 1. Health insurance coverage due to proximity to retirement age in Argentina (2016-2023)

Overall, we find a significant increase in the number of people with mandatory health insurance coverage upon reaching retirement age, and a decrease in voluntary insurance coverage. The most interesting results emerged when analyzing the data by income segments and educational level. We found that people with the lowest incomes experienced the largest increase in insurance coverage, while the effect of displacement manifested itself more clearly in households with a medium educational level, which we used as proxy socioeconomic level.

These results could be explained by the existence of a significant portion of the population without mandatory insurance coverage at middle socioeconomic levels that has the resources to contract voluntary insurance. This effect was not observed in the lowest strata, due to a lower economic capacity to contract voluntary insurance, nor in the highest strata, where there is a high rate of affiliation to mandatory insurance during the active stage, as a result of low labor informality. . . In conclusion, our work shows that the “almost” universal provision of public insurance for older adults in Argentina is associated with an increase in health coverage and a reduction in coverage disparities between different socioeconomic level subgroups.

Comments from Manuel Serrano Alarcón:

The study by Juan and co-authors analyzes the impact of the expansion of public health insurance at retirement age on health coverage in Argentina. In particular, it focuses on the effect displacement on the demand for private insurance.

We can consider this effect as an indirect or intended effect of the policy. The research question is very interesting since to provide a global evaluation of the effects of the policy one must look not only at the immediate or intended effects (increase in public insurance coverage) but also at the second order effects (reduction ). of the demand for private insurance).

The researchers use a robust methodology exploiting a rich panel of data. The results show that the expansion of public health insurance increases public coverage and reduces private coverage. However, to assess the full impact of the policy, it would be useful to also analyze the effect on total health coverage, that is, has the increase in public coverage increased total health coverage or has it been fully offset by the decrease in the coverage? private? Do more people have health insurance when they retire or do they only change private insurance for public insurance? If the legislator’s ultimate objective is to improve access to medical care, this variable would indicate whether the policy has met that objective.

Finally, I think it would also be beneficial to quantify the effects of the policy in more detail. This would allow us to estimate the flexibility of demand between public and private insurance, and finally carry out a cost-benefit analysis of the reform. For example, one could calculate whether the expansion of public coverage with a cost of x million, has improved (or not) total coverage by a certain percentage.

In conclusion, the study by Juan and his colleagues is an important contribution to the literature on the expansion of public health insurance and its impact on health coverage. His analysis is highly relevant at a time when public health systems are under pressure, and his focus on the effect of displacement It helps us understand how the demand for public and private services interact.