No health benefits in co-payments – 台北時報

By Lee Jwo-leun 李卓倫

On Friday last week, the National Health Insurance (NHI) Committee discussed making an adjustment to co-payments, the nominal fee charged to the beneficiary for medical services.

The authoritative study on co-payments in medical systems was a randomized allocation experiment conducted by the RAND Corp in the US in the 1980s. The study found that for every 10 percent increase in medical fees, overall medical services decreased by only 2.2 percent. That is, the increase in co-payments had little effect on the use of generic drugs, and the difference in the use of patented medicines was not statistically significant.

Patients do not choose to see a doctor because of lower co-payments, and the doctors, not the patients, determine the treatment that is provided.

Although economic studies have demonstrated that the co-payment system does not have the desired effect, the idea is resurrected whenever the NHI system is in trouble. Co-payments provide simple answers to supply and demand within a healthcare system, but they cannot resolve complex healthcare issues.

However, they do have the added benefit of supplementing the NHI fund.

University of British Columbia professor Robert Evans calls the beneficiaries of the co-payment system “zombie masters,” and he proposed five types: There are those who hope to contribute less to funding healthcare; those who hope to have improved access to healthcare; those who provide care and hope to be better paid; those who hope to become paid by the healthcare system; and those who advocate on behalf of any of those in the above four groups.

Co-payments do not reduce healthcare expenditure, they simply shift costs from one group of people to another, and thus decide which group of people gets priority access to medical and health benefits. Their overall effect on public health is often negative, and the greater the extent to which co-payments benefit the third and fourth types of beneficiary, the higher the overall cost of medical care.

The first and second types of beneficiary want to pay less to receive more. These groups advocate for the adoption of user charges, but user charges for the uninsured are a different kettle of fish from the “financial risk sharing” of those with insurance.

The political reality is not a question of whether the healthy and the wealthy should subsidize the sick and the poor through the NHI mechanism, as the healthcare system must and will definitely do so. The political reality is that co-payments shift the financial burden from the insurance premium payer to the healthcare user. This means that the beneficiaries of co-payments are the rich and healthy, while the less healthy and less wealthy stand to lose.

People should not present what is essentially an income transfer policy as subsidies to low-income households.

Those in the third and fourth groups want to see increased contributions to the medical system. Co-payments can add to overall healthcare fees, and this additional money finds its way into the pockets of physicians and other medical personnel. When increased co-payments for a given drug inflate the overall drug cost, pharmacists benefit through higher dispensing fees, and there will be more jobs and money available for hospital managers and accounting, legal, financial and quality control personnel.

High co-payments in the US and France have increased the popularity of policies where the policyholder pays a portion of the medical expenses out of pocket and the health insurer pays the remaining amount. Politicians use co-payments to have the public share the financial burden, generating financial resources in addition to insurance premiums and taxes, or vow to “eliminate the abuse of medical resources” for the sake of furthering their careers.

A democratic society can discuss whether to allow sick people to pay more for medical treatment and whether redistribution of income should be central to its health insurance’s ethos, but co-payments should not be presented as somehow being in the public interest and people should not believe political rhetoric in the service of private beneficiaries.

Lee Jwo-leun is an associate professor in the Department of Senior Citizen Service Management at National Taichung University of Science and Technology.

Translated by Lin Lee-kai

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