The effect of pharmaceutical co-payment increase on the use of social assistance-A natural experiment study

Austerity, economic hardship and access to medications: a repeated cross-sectional population survey study, 2013-2020

BACKGROUND

In Finland, austerity measures included an increase in medication and healthcare copayments and a decrease in many social security allowances. This study examines whether austerity coincided with an increase in socioeconomic inequality in access to medications (going short of medications because of lack of money) and whether medication access problems increased more than other forms of economic hardship (going short of food or physician visits).

METHODS

Pooled cross-sectional population surveys collected in 2013-2015, 2018 and 2020 (n=139 324) and multinomial logistic regression, with interaction between study year and economic activity (EA) (full-time work vs part-time work/retirement; old age retirement; unemployment; disability/illness; family; student), were used to estimate the effect of EA on the probability of experiencing economic hardship (no hardship/hardship including medication problems/hardship excluding medication problems) and how it varies across years.

RESULTS

Working-age adults outside full-time employment have a higher risk of economic hardship than full-time workers, and old age retirees have a lower risk. In 2018, when austerity was most pronounced, economic hardship including medication problems increased for the disabled/ill (women and men), unemployed (women) and part-time workers/retirees (men), significantly more than for full-time workers. Hardship excluding medication access problems either decreased or remained unchanged.

CONCLUSION

Austerity coincided with increasing economic hardship among vulnerable groups, thus exacerbating socioeconomic inequalities. Strengthening the role for medication access problems suggests that medication copayment increases contributed to this accumulating disadvantage.

The impact of national comprehensive medical reform on residents' medical expenses: Evidence from China

Residents' high medical expenses is the core challenge that needs to be solved urgently in China's medical reform for a long time. Based on the panel data of 30 provinces in Chinese Mainland during 2011-2019, we evaluate the impact of China's national comprehensive medical reform pilot policy on residents' medical expenses by using the difference-in-differences model. The results show that the pilot policy was generally conducive to reducing residents' medical expenses, resulting in a reduction of 2.13% in per capita medical expenses for inpatients, but the effect on per capita medical expenses for outpatients was insignificant. Mechanism analysis shows that hospital competition and institutional environment played a moderating role in the effect of the pilot policy on residents' medical expenses reduction. The more intense the hospital competition and the better the institutional environment, the more significant of the reduction effect. In addition, the reduction effect of the pilot policy was greater in the central provinces, the provinces with poor medical infrastructure, and the provinces with strong financial strength. This study provides useful policy insights for deepening medical reform and reducing residents' medical expenses.

Socioeconomic inequalities in insulin initiation among individuals with type 2 diabetes - A quasi-experimental nationwide register study

Background

Inequalities in access to care can translate to or strengthen existing inequalities in health if people of lower socioeconomic positions do not have equal access to care. I study insulin initiation among individuals with type 2 diabetes and examine whether a reform increasing the co-payment of non-insulin antidiabetics in Finland in 2017 had an inequitable effect on the initiation. In the treatment of type 2 diabetes, insulin is recommended only in later stages and remains covered by the National Health Insurance at a rate of 100%.

Data and methods

I evaluated the effect of the reform with Cox proportional hazard modelling using nationwide person-level register data from 2011 to 2019. Exploiting a quasi-experimental design rising from the introduction of the reform allows for consideration of causality.

Results

I found that the risk of insulin initiation was lower in the later years of the study period. Additionally, individuals in lower socioeconomic positions had a higher risk of initiation. However, I did not find inequalities in how the reform affected the risk of insulin initiation between income quintiles.

Conclusions

Co-payments are unlikely to be the most influential factor behind persisting inequalities in insulin initiation among individuals with type 2 diabetes in Finland. Lower risk in the later years aligns with developing treatment practices of type 2 diabetes.

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Individuals with type 2 diabetes in lower socioeconomic positions had a higher risk of insulin initiation.

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The risk of insulin initiation was lower in the later years of the study period (2011-2019) in all income quintiles.

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No inequalities in the impact of the co-payment increase in non-insulin antidiabetics in insulin initiation were found.

Citizens' opinions and experiences related to costs and reimbursements for medications in times of retrenchment: cross-sectional population surveys in 2015 and 2017

Background

Finland has universal coverage for prescription medications under the National Health Insurance. Eligibility schemes target higher reimbursements to individuals with chronic illness. Nevertheless, co-payments always apply, and austerity reforms implemented in 2016 and 2017 led to further increases in co-payments. We examined the extent to which people with chronic illness experienced financial difficulties in purchasing medications, how perceptions of fairness regarding the national reimbursements differs by exposure to policies and medicine use, and in what way do these experiences and opinions vary between surveys collected before and after the reforms.

Methods

We used two waves of Medicines Barometer (2015 and 2017, pooled n = 10,801), a national, biennial, cross-sectional population survey. Logistic regression analyses were performed with experiences of financial difficulties and perceptions of fairness as dependent variables. We compared people with and without prescription medication use, eligibilities, and/or diabetes (exposure groups), controlling for age, gender, survey type and geographic area (NUTS2). To examine the modifying effect of study year, we fitted models with an interaction term between group and year.

Results

Respondents with diabetes or eligibility based on chronic illness had a notably higher risk than other respondents with at least some prescription medication use to have experienced financial difficulties in affording medications. The share of respondents experiencing difficulties increased the most among people with diabetes. Three-quarters of respondents were either critical or unsure of whether the reimbursements for medications were fair and just. People with recent prescription medication use tended to be more sceptical than people without. Overall, scepticism tended to be more prevalent in 2017 than in 2015.

Conclusions

Despite the protective policies in place, individuals with chronic illness were disproportionately burdened by costs of medications already before the reforms. Among individuals with diabetes, financial difficulties were even more prevalent in 2017 than in 2015, which is likely attributed to the particularly high co-payment increases targeted to type 2 diabetes medicines. Perceived fairness of the processes and outcomes of policies and regulations is a key dimension of trust in public policy. Thus, increasing scepticism implies that retrenchment may also have implications in terms of public legitimacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01631-6.