Inequity in Health Care Financing in Iran: Progressive or Regressive Mechanism?

OBJECTIVE

Having progressive health finance mechanism is very important to decrease inequity in health systems. Revenue collection is one of the aspects of health care financing. In this study, taxation system and health insurance contribution of Iranians were assessed.

MATERIALS AND METHODS

Data of 2012 household expenditures survey were used in this study, and payments of the families for health insurances and tax payments were extracted from the study. Kakwani index was calculated for assessing the progressivity of these payments. At the end, a model was designed to find the effective factors.

RESULTS

We found that taxation mechanism was progressive, but insurance contribution mechanism was very regressive. The portion of people living in urban regions was higher in the payments of insurance and tax. Less educated families had lower contribution in health insurance and families with more aging persons paid more for health insurance.

CONCLUSION

Policy makers must pay more attention to the health insurance contribution and change the laws in favour of the poor.

Of neoliberalism and global health: human capital, market failure and sin/social taxes

This article tells a different but equally important story about neoliberalism and global health than the narrative on structural adjustment policies usually found in the literature. Rather than focus on macroeconomic structural adjustment policies, this story draws our attention to microeconomic taxation policies on tobacco, alcohol and sugar now widely recognised as the best strategy to control the global non-communicable disease epidemic. Structural adjustment policies are the product of the shift from statist to market-based development models, which was brought about by neoliberal thinkers like Peter Blau and Deepak Lal. In contrast, taxation policies are the result of a different epistemological rupture in international development: the move from economies and physical capital to people and human capital, advocated by Gary Becker and others. This move was part of wider change, which saw Chicago School economists, under the influence of rational choice theory, redefine the object of their discipline, from the study of markets to individual choices. It was this concern with people and their choices that made it possible for Becker and others to identify the importance of price for the demand for tobacco, alcohol and sugar. The same concern also made it easier for them to recognise that there were inefficiencies in the tobacco, alcohol and sugar markets that required government intervention. This story, I suggest, shows that structural adjustment policies and pro-market ideology do not exhaust the relationship between neoliberalism and global health and should not monopolise how we, as political and social scientists, conceive it.

Preventing type 2 diabetes: Changing the food industry

Improving our global diet by working with the food industry is a fairly complex task. Previously the global food manufacturing companies and governments were the major players. However, matters have shifted rapidly so that food retailers, food manufacturers, the restaurant-food service sector, and agribusinesses are now the major players. The current modern system of packaged processed food has now penetrated the globe-rich and poor, rural and urban are all in reach of this food system. Consequently, working with this complex sector when possible and an array of governmental regulatory large-scale options to improve our diet have increased in importance. Taxation of unhealthy foods and beverages, marketing controls, and front of the package labeling are the primary current options. Evaluations of the impacts of both public and industry initiatives are needed.

Trends in Sugar-Sweetened Beverages: Are Public Health and the Market Aligned or in Conflict?

Adverse health consequences of consuming sugar-sweetened beverages are frequently cited as an example of market failure, justifying government intervention in the marketplace, usually in the form of taxation. However, declining sales of sugar-sweetened beverages in Australia and a corresponding increase in sales of drinks containing non-nutritive sweeteners, in the absence of significant government regulation, appear to reflect market forces at work. If so, the public health challenge in relation to sugar-sweetened beverages may have less to do with regulating the market and more to do with harnessing it. Contrary to assertions that consumers fail to appreciate the links between their choice of beverage and its health consequences, the health conscious consumer appears to be driving the changes taking place in the beverage market. With the capacity to meet consumer expectations for convenience and indulgence without unwanted kilojoules, drinks containing non-nutritive sweeteners enable the "small change" in health behaviour that individuals are willing to consider. Despite the low barriers involved in perpetuating the current trend of replacing sugar-sweetened beverages with drinks containing non-nutritive sweeteners, some public health advocates remain cautious about advocating this dietary change. In contrast, the barriers to taxation of sugar-sweetened beverages appear high.

After Piketty?

In this paper, I take Capital in the Twenty-First Century by Thomas Piketty as the starting point for a set of twelve policy proposals that could bring about a genuine shift in the distribution of income towards less inequality. In designing the set of proposals, I draw on the experience of reducing inequality in postwar Europe and on an analysis as to how the economic circumstances are now different in the twenty-first century, highlighting the role of technical change and the rise in capital emphasized by Piketty. The proposed measures span many fields of policy, and are not confined to fiscal redistribution, encompassing science policy, competition policy, public employment, a guaranteed return on small savings, a capital endowment, as well as more progressive taxation of income and wealth transfers, and a participation income. Inequality is embedded in our social structure, and the search for a significant reduction requires us to examine all aspects of our society. I focus on inequality within countries, and what can be achieved by national governments, with the UK specifically in mind. The primary audience is those concerned with policy-making in national governments, but implementation should not be seen purely in these terms. There are different levels of government, and certain proposals, particularly those concerned with taxation, may only be feasible if pursued by a group of countries in collaboration. The last of the twelve proposals - for a basic income for children - is specifically directed at the European Union. Finally, actions by individuals as consumers, as workers, or as employers, can all contribute to reducing inequality.

Piketty's capital and social policy

Piketty's Capital (2014) primarily describes and analyses changes in the distribution of wealth and annual incomes. This paper focuses on his policy proposals that make up Part Four of the book. Piketty defends the 'social state' but he discusses it largely in terms of distribution and redistribution between tax units. This neglects the important role of social policy in promoting recognition and redistribution of income and opportunities that is related to gender, race, disability and sexual orientation. Nor does Piketty consider inequalities in health which effect life-time incomes, nor the impact of housing policies on house prices and the distribution of wealth. It is argued that Piketty's approach to social security is simplistic and plays down the complexity of competing policy goals. On taxation, Piketty defends progressive taxation and proposes a global capital levy. The latter proposal runs into formidable problems in seeking global taxation in a world of nation states. Rather than seeking a policy that is, for the foreseeable future, wholly politically impractical, a case is made for less idealistic but more practical and urgent tax coordination between nations to address the widespread avoidance of taxation that large corporations and the very wealthy are now permitted - taxation on which the future of the social state depends. The importance of human and social capital, which are largely set aside by Piketty, are discussed. Finally,it is argued that his approach to policy is to describe trends and propose amelioration of growing inequality rather than to identify causes of the trends and propose policies that might address the causes. Nevertheless, the importance of his work in bringing issues of inequality to the fore, especially among economists, is recognized and applauded.

Small business activity does not measure entrepreneurship

Entrepreneurship policy mainly aims to promote innovative Schumpeterian entrepreneurship. However, the rate of entrepreneurship is commonly proxied using quantity-based metrics, such as small business activity, the self-employment rate, or the number of startups. We argue that those metrics give rise to misleading inferences regarding high-impact Schumpeterian entrepreneurship. To unambiguously identify high-impact entrepreneurs we focus on self-made billionaires (in US dollars) who appear on Forbes Magazine's list and who became wealthy by founding new firms. We identify 996 such billionaire entrepreneurs in 50 countries in 1996-2010, a systematic cross-country study of billionaire entrepreneurs. The rate of billionaire entrepreneurs correlates negatively with self-employment, small business ownership, and firm startup rates. Countries with higher income, higher trust, lower taxes, more venture capital investment, and lower regulatory burdens have higher billionaire entrepreneurship rates but less self-employment. Despite its limitations, the number of billionaire entrepreneurs appears to be a plausible cross-country measure of Schumpeterian entrepreneurship.

Health economists, tobacco control and international development: On the economisation of global health beyond neoliberal structural adjustment policies

This article addresses the increasing influence of economic rationalities in global health over the past 30 years by examining the genealogy of one economic strategy - taxation - that has become central to international anti-smoking initiatives in the global South. It argues that this genealogy sits uncomfortably with the usual story about economics and global health, which reduces the economisation of international health to neoliberal structural adjustment policies aimed at stabilisation, liberalisation and privatisation and laments their detrimental effect on health. While not disputing these policies' importance and damaging impact, the genealogy of tobacco taxes outlined in this article shows that the economisation of global health is not only about neoliberal structural adjustment policies but also about sin taxes, market failures and health economics. By stressing how changes in health like the global South's epidemiological transition can impact on economics and how beneficial taxation can be for health, it also shows that the relation between economics and health is not always unidirectional and detrimental to the latter. In doing so, the article contributes to the critique of the often mechanical use of neo-liberalism to explicate change and calls for other stories about the economisation of global health to be told.

Impact of cigarette minimum price laws on the retail price of cigarettes in the USA

INTRODUCTION

Cigarette price increases prevent youth initiation, reduce cigarette consumption and increase the number of smokers who quit. Cigarette minimum price laws (MPLs), which typically require cigarette wholesalers and retailers to charge a minimum percentage mark-up for cigarette sales, have been identified as an intervention that can potentially increase cigarette prices. 24 states and the District of Columbia have cigarette MPLs.

METHODS

Using data extracted from SCANTRACK retail scanner data from the Nielsen company, average cigarette prices were calculated for designated market areas in states with and without MPLs in three retail channels: grocery stores, drug stores and convenience stores. Regression models were estimated using the average cigarette pack price in each designated market area and calendar quarter in 2009 as the outcome variable.

RESULTS

The average difference in cigarette pack prices are 46 cents in the grocery channel, 29 cents in the drug channel and 13 cents in the convenience channel, with prices being lower in states with MPLs for all three channels.

CONCLUSIONS

The findings that MPLs do not raise cigarette prices could be the result of a lack of compliance and enforcement by the state or could be attributed to the minimum state mark-up being lower than the free-market mark-up for cigarettes. Rather than require a minimum mark-up, which can be nullified by promotional incentives and discounts, states and countries could strengthen MPLs by setting a simple 'floor price' that is the true minimum price for all cigarettes or could prohibit discounts to consumers and retailers.

Political impediments to a tobacco endgame

Any serious consideration of exploring a tobacco endgame in the USA must build upon the enviable track record of reducing tobacco use through a mixture of federal and state policies. This foundation may pose particular challenges in approaching an endgame, including questions of national political feasibility, public support, limitations of sub-federal experimentation and recruitment of future political champions. Advocates must demonstrate a compelling need for a dramatic expansion beyond existing efforts, amid competition from alternative issues and little apparent public appetite for such an initiative.

Building a strategy for obesity prevention one piece at a time: the case of sugar-sweetened beverage taxation

Obesity is a major public health issue in Canada that is reaching historically high levels in spite of efforts, targeted primarily at individual behaviour, to promote changes in diet and physical activity. Urgency for change at the population level compels moving "upstream" toward multilevel, societal approaches for obesity prevention. Public health researchers, advocates and policy makers are increasingly recognizing the current food environment, including availability, pricing, and marketing of foods and beverages, promotes overconsumption of unhealthy food and beverage choices and have identified the food environment as a point for intervention for obesity prevention. In April 2011, a consensus conference with invited experts from research, policy and practice fields was held. The conference aimed to build consensus around policy levers to address environmental determinants of obesity, including next logical steps toward further policy action. Using economic policies, such as taxation of sugar-sweetened beverages (SSB), was discussed as one opportunity to promote healthy eating. This article reports on the consensus discussion that led to recommendations to tax sugar-sweetened beverages as one step in a multipronged comprehensive approach to obesity prevention. This recommendation is based on a synthesis of available evidence, including evidence regarding political feasibility, and potential impacts of a tax. In addition, we present additional primary research using current SSB consumption data to model the economic and behavioural impact of such a tax in Canada.

Nutrient Demand in Food Away from Home

Food away from home (FAFH) and, specifically fast food, has been targeted by academics and public policy officials alike as a major contributor to the obesity epidemic. Criticized as high in energy, fat and sugars, the implication is that consumers demand the combination of nutrients in FAFH in excess. If market-based policies intended to correct the perceived market failure in nutrient demand are to be successful, information on nutrient elasticities is required. Moreover, co-dependent relationships between nutrient intake and bioeconomic outcomes - obesity, physical activity and health status - are found to be important in the public health literature, but are not typically included in econometric studies of FAFH demand. Nutrients, however, do not have market prices. This study derives a set of implicit nutrient prices and estimates the elasticities of demand for nutrients in FAFH that takes into account the endogeneity of bioeconomic outcomes. Our estimation results show that fat is the only macro-nutrient that is elastic in demand, and all cross-price elasticities are small, so nutrient-based price policies may indeed be effective in modifying FAFH choices. Simulation results confirm this hypothesis, and also support the use of policies that subsidize positive health outcomes.

Do cigarette prices motivate smokers to quit? New evidence from the ITC survey

AIMS

To examine the importance of cigarette prices in influencing smoking cessation and the motivation to quit.

DESIGN

We use longitudinal data from three waves of the International Tobacco Control Policy Evaluation Survey (ITC). The study contrasts smoking cessation and motivation to quit among US and Canadian smokers and evaluates how this relationship is modified by cigarette prices, nicotine dependence and health knowledge. Different price measures are used to understand how the ability to purchase cheaper cigarettes may reduce the influence of prices. Our first model examines whether cigarette prices affect motivation to quit smoking using Generalized Estimating Equations to predict cessation stage and a least squares model to predict the change in cessation stage. The second model evaluates quitting behavior over time. The probability of quitting is estimated with Generalized Estimating Equations and a transition model to account for the 'left-truncation' of the data.

SETTINGS

US and Canada.

PARTICIPANTS

4352 smokers at Wave 1, 2000 smokers completing all three waves.

MEASUREMENTS

Motivation to quit, cigarette prices, nicotine dependence and health knowledge.

FINDINGS

Smokers living in areas with higher cigarette prices are significantly more motivated to quit. There is limited evidence to suggest that price increases over time may also increase quit motivation. Higher cigarette prices increase the likelihood of actual quitting, with the caveat that results are statistically significant in one out of two models. Access to cheaper cigarette sources does not impede cessation although smokers would respond more aggressively (in terms of cessation) to price increases if cheaper cigarette sources were not available.

CONCLUSIONS

This research provides a unique opportunity to study smoking cessation among adult smokers and their response to cigarette prices in a market where they are able to avoid tax increases by purchasing cigarettes from cheaper sources. Higher cigarette prices appear to be associated with greater motivation to stop smoking, an effect which does not appear to be mitigated by cheaper cigarette sources. The paper supports the use of higher prices as a means of encouraging smoking cessation and motivation to quit.

The Effect of Capital Gains Taxation on Home Sales: Evidence from the Taxpayer Relief Act of 1997

The Taxpayer Relief Act of 1997 (TRA97) significantly changed the tax treatment of housing capital gains in the United States. Before 1997, homeowners were subject to capital gains taxation when they sold their houses unless they purchased replacement homes of equal or greater value. Since 1997, homeowners can exclude capital gains of $500,000 (or $250,000 for single filers) when they sell their houses. Such dramatic changes provide a good opportunity to study the lock-in effect of capital gains taxation on home sales. Using 1982-2008 transaction data on single-family houses in 16 affluent towns within the Boston metropolitan area, I find that TRA97 reversed the lock-in effect of capital gains taxes on houses with low and moderate capital gains. Specifically, the semiannual sales rate of houses with positive gains up to $500,000 increased by 0.40-0.62 percentage points after TRA97, representing a 19-24 percent increase from the pre-TRA97 baseline sales rate. In contrast, I do not find TRA97 to have a significant effect on houses with gains above $500,000. Moreover, the short-term effect of TRA97 is much larger than the long-term effect, suggesting that many previously locked-in homeowners took advantage of the exclusions immediately after TRA97. In addition, I exploit the 2001 and 2003 legislative changes in the capital gains tax rate to estimate the tax elasticity of home sales during the post-TRA97 period. The estimation results suggest that a $10,000 increase in capital gains taxes reduces the semiannual home sales rate by about 0.1-0.2 percentage points, or 6-13 percent from the post-TRA97 average sales rate.

Self-reported price of cigarettes, consumption and compensatory behaviours in a cohort of Mexican smokers before and after a cigarette tax increase

OBJECTIVE

To assess the impact of a 2007 cigarette tax increase from 110% to 140% of the price to the retailer on cigarette price and consumption among Mexican smokers, including efforts to offset price increases.

METHODS

Data were analysed from the 2006 and 2007 administrations of the International Tobacco Control (ITC) Policy Evaluation Survey in Mexico, which is a population-based cohort of adult smokers. Self-reported price of last cigarette purchase, place of last purchase, preferred brand, daily consumption and quit behaviour were assessed at baseline and follow-up.

RESULTS

Self-reported cigarette prices increased by 12.7% after the tax increase, with prices for international brands increasing more than for national brands (13.5% vs 8.7%, respectively). Although the tax increases were not fully passed onto consumers particularly on national brands, no evidence was found for smokers changing behaviour to offset price increases. Consistent declines in consumption across groups defined by sociodemographic and smoking-related psychosocial variables suggest a relatively uniform impact of the tax increase across subpopulations. However, decreased consumption appeared limited to people who smoked relatively more cigarettes a day (>5 cigarettes/day). Average daily consumption among lighter smokers did not significantly decline. A total of 13% (n=98) of the sample reported being quit for a month or more at follow-up. In multivariate models, lighter smokers were more likely than heavier smokers to be quit.

CONCLUSIONS

Results suggest that the 2007 tax increase was passed on to consumers, whose consumption generally declined. Since no other tobacco control policies or programmes were implemented during the period analysed, the tax increase appears likely to have decreased consumption.

Tax Compliance Inventory: TAX-I Voluntary tax compliance, enforced tax compliance, tax avoidance, and tax evasion

Surveys on tax compliance and non-compliance often rely on ad hoc formulated items which lack standardization and empirical validation. We present an inventory to assess tax compliance and distinguish between different forms of compliance and non-compliance: voluntary versus enforced compliance, tax avoidance, and tax evasion. First, items to measure voluntary and enforced compliance, avoidance, and evasion were drawn up (collected from past research and newly developed), and tested empirically with the aim of producing four validated scales with a clear factorial structure. Second, findings from the first analyses were replicated and extended to validation on the basis of motivational postures. A standardized inventory is provided which can be used in surveys in order to collect data which are comparable across research focusing on self-reports. The inventory can be used in either of two ways: either in its entirety, or by applying the single scales independently, allowing an economical and fast assessment of different facets of tax compliance.

Registered indians and tobacco taxation: a culturally-appropriate strategy?

Taxation of tobacco is a widely-used strategy that prompts smoking cessation among adults and reduces cigarette consumption among continuing smokers. Registered Indian tobacco use prevalence is at least double that of the rest of Canadians and is in part due to the lower cost of tobacco products purchased on reserve by Registered Indians (RIs) as they are tax exempt. Although registered Indian communities have the ability to collect tax on tobacco products and direct the use of these revenues, this strategy is rarely utilized. Tobacco taxation could have substantial health and economic benefits to RI communities, but perhaps is not culturally-appropriate. In order to better support RI communities, governments and other organizations need to examine this policy instrument in the context of RI populations.

Smoking practices in New York City: the use of a population-based survey to guide policy-making and programming

To inform New York City's (NYC's) tobacco control program, we identified the neighborhoods with the highest smoking rates, estimated the burden of second-hand smoke exposure, assessed the early response to state taxation, and examined cessation practices. We used a stratified random design to conduct a digit-dialed telephone survey in 2002 among 9,674 New York City adults. Our main outcome measures included prevalence of cigarette smoking, exposure to second-hand smoke, the response of smokers to state tax increases, and cessation practices. Even after controlling for sociodemographic factors (age, race/ethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx. Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. Among smokers with a child with asthma, only 33% reported having a no-smoking policy in their homes. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid. These data were used to inform New York City's smoke-free legislation, taxation, public education, and a free nicotine patch give-away program. In conclusion, large, local surveys can provide essential data to effectively advocate for, plan, implement, and evaluate a comprehensive tobacco control program.