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Table 2 Main HIAD indicators and their potential impact on population health and health inequalities

From: Assessing barriers to health insurance and threats to equity in comparative perspective: The Health Insurance Access Database

Indicator or policy instrument Potential impact on population health and health inequalities Reference
Public health insurance
Enrolment Automatic enrolment in public insurance reduces non-financial barriers to coverage (such as time-consuming, hard to understand paperwork or lack of awareness of eligibility) and increases participation rates [49, 50]
Renewal The need for frequent (annually or less), active (i.e. needing action from the insuree) renewal increases the likelihood of losing coverage [5154]
Cost-sharing (out-of-pocket expenses) Greater cost-sharing leads to decreases in service use [5558]
  Drug use appears particularly sensitive to this, as are economically vulnerable individuals and those with chronic diseases [5970].
Private health insurance and private expenditures on health
Legality of private insurance for this service A measure of the public prohibition of a parallel private (insurance and provision) market (see duplicative insurance below). [2]
Minimum level of coverage mandated by law The evidence suggests that a minimum coverage mandate (such as mental health parity) increases equitable access to services [71]
Source of financing Greater reliance on (unregulated) individually risk-rated insurance decreases coverage and access, but this may vary by service [7274]
Tax funded subsidies Have a positive effect on coverage, though this may vary by service [75, 76].
Enrolment Lack of regulation surrounding enrollment practices poses significant threats to coverage and access to health services [77, 78]
Renewal Lifetime coverage ensures the highest levels of coverage. Low levels of public regulation increase the likelihood of lost coverage and limited access [52, 79, 80]
General mechanisms
Type of coverage (1) Aside from strictly public coverage, most countries favor a mix of public and private sources for health insurance coverage. [2]
  PHI can be:  
  (2) A duplicate of public insurance, providing a private alternative for services already covered under the public system.  
  (3) A complement or top-up for services already covered under the public system, as in France; (4) A supplement to public insurance for services uninsured under the public system, as in Canada;  
  (5) A substitute to public insurance (e.g. for those with high incomes in Germany who can opt-out);  
  (6) A primary source of health insurance, as in the U.S.
Our preliminary results have already found evidence of other coverage types in addition to these
Level of compulsion for health insurance Mandated insurance improves access to services, but may not decrease health inequalities, unless it constitutes a mandate for public health insurance [81, 82]