The Impact of Health Insurance in Low- And Middle-Income Countries

Chapter 5: Impact of Health Insurance on Access, Use, and Health Status in Costa Rica

89 Impact of Health Insurance on Access, Use, and Health Status in Costa Rica James Cercone, Etoile Pinder, Jose Pacheco Jimenez, and Rodrigo Briceno Chapter 5 Costa Rica, as a middle-income country that has largely achieved universal health coverage, allows for analysis of the differences in behavior and care for the small share of citizens who remain uninsured. This chapter sheds light on the impact of being covered by insurance in a country where access is guaranteed even if uninsured and on the costs and benefits of covering the last 10%–20% of the population with insurance or other approaches. A country of 4.5 million people, Costa Rica has a per capita gross domestic product (GDP) of US$5,600 (US$10,700 in purchasing power parity terms), and in 2007 it spent about 7.1% of GDP on health care. In 2008 the infant mortality rate was less than 10 deaths per 1,000 live births, and average life expectancy was 80 years for women and 76 years for men. Average life expectancy exceeds that of the United States by a year, even though U.S. GDP per capita is four times that of Costa Rica. Costa Rica has mandatory health insurance coverage, established in 1941, and a comprehensive primary health care model that reaches all citizens. The Caja Costarricense del Seguro Social (the Caja) is an autonomous government institution that is both insurer and provider of care. Nearly 90% of the country’s 4.5 million people are covered. The health insurance system is based on traditional Bismarkian social insurance, with an expanded role of the central government to cover the uninsured population. It provides equal access to health care services, irrespective of income or contribution. The formal sector contributes 90 Chapter 5 14.75% of payroll income to sustain the system. The poor and indigent are covered by the “noncontributory” and “insured by state” regimes, which have led to equal access to health services for the poor and wealthy, something not seen in any of Costa Rica’s neighboring countries. In addition, the absence of copayments removes another possible barrier to equal access. Main characteristics of the Costa Rican health system Structure The Costa Rican health system includes a wide range of entities; the most relevant for this study are the Ministry of Health, the National Insurance Institute (INS), and the Caja. The ministry oversees the performance of the essential public health functions and exercises the stewardship role in the health sector, while the INS offers protection against occupational risks and traffic accidents as well as accident liability and a voluntary insurance plan for health care. The Caja is the key institution for this study. It manages and organizes mandatory health insurance and is an autonomous institution with technical, administrative , and functional independence. It manages the compulsory health insurance funds that come from payroll taxes and provides the highest proportion of health care services in the country, covering roughly 90% of the population with a broad package of services. Besides health services, it provides social security protection to insured individuals and poor households through the Disability, Old Age, and Funeral regime. In Costa Rica there is an administrative purchaser-provider split between the financial network and the provider network of the Caja. Nearly all provision is through the Caja network; however, the Caja also contracts with private providers and nongovernmental organizations for some services. The network of providers belongs to the Caja, which is organized as a pyramidstyle network with primary care at the bottom and tertiary hospital care at the top. Primary care consists of 104 health regions and 953 basic care teams (Equipos Básicos de Atención Integral en Salud, or EBAIS). Each EBAIS covers 3,500–4,000 people and consists of a general practitioner, an auxiliary level nurse, and a primary care technician. All members must be registered with a primary care provider. Recently, the Caja has expanded its purchasing options, and some primary care services , such as minor surgeries and diagnoses, are purchased from nonpublic agents. Secondary care consists of 10 major clinics, 13 suburban hospitals, and 7 regional facilities specializing in hospital services. Tertiary care has three general hospitals and five specialized hospitals (women, children, geriatrics, psychiatry, and rehabilitation). General and regional hospitals have a set number of people in their Impact of Health Insurance on Access, Use, and Health Status in Costa Rica91 catchment...