Various articles have discussed the impact of health insurance on healthcare utilisation in detail. However, the most remarkable study, which highlighted the positive relationship between access to healthcare and utilisation, came from the Rand Health Insurance Experiment (RHIE) in the United States. One of the main strengths of this study was its control of selection bias by randomly distributing the participants into different insurance plans with different co-insurance rates. Although this study was one of the few that were globally accepted, the RHIE study was conducted long ago (1970s). Recent studies have supported the findings (Freeman, Kadiyala et al. 2008), but these studies focused mainly on the influence of insurance on increasing consumption of medical care services rather than access to medical care, which is not within the scope of this thesis as illustrated previously in section 2.8.
Other evidence from developed countries includes the study by Schoen, Osborn et al. (2010) that generally concluded that health insurance had a positive impact on access to medical care in countries including Australia, Canada, France, New Zealand, the Netherlands and the United States. However, they did not link the impact to the type of insurance (public, private or a hybrid). Aside from long waiting hours, another concern in developed countries was the difficulty of being able to access medical care after working hours except via emergency departments (Schoen et al., 2010). Similar evidence was sourced in the study of outpatient services that was conducted in Ireland and Swaziland, in which private health insurance increased utilisation of healthcare services (Onwujekwe, 2001, Schellhorn, 2001). However, all of the above mentioned studies did not consider if the positive impact of insurance is true for minorities, and these studies did not consider the role of private health insurance to assist the impact truly because the role of private health insurance has to be understood in the context of its role as illustrated previously in section 2.5. However, there is evidence regarding the relation between insurance and increased utilisation of medical care for minority populations in the United States, where the role of private insurance is similar to that of CEBHI, as illustrated in section 2.12. There is evidence that health insurance increases utilisation of medical care and reduces the disparity in access to medical care for minorities with different ethnic groups (Kasper et al., 2000, Weinick et al., 2000, Mahmoudi and Jensen, 2012).
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There has been some controversy about this issue with moderate evidence for the impact of private health insurance on access and healthcare utilisation in developing countries, including Vietnam, China and Colombia (Ekman et al., 2008, Lei and Lin, 2009, Alvarez et al., 2011). However, one of the studies, which supported private health insurance increasing utilisation of healthcare, came from Indonesia. It was found that health insurance increased the demand for healthcare services (Hidayat, 2008) although the study objective was to study the conditional and unconditional demands of utilisation of medical care with insurance. In addition, this study was similar to other studies that did not identify if the demand on access to medical care is the same for minorities or different ethnic groups, nor did it determine the characteristics of workers enrolled in private health insurance, such as their insurance status, income or education.
Recently, Abu Dhabi, one of the United Arab Emirates States, implemented compulsory health insurance plans on both Nationals and expatriates, with different health insurance benefits between the two groups. Differences in the benefits packages have been classified as three insurance schemes: one for nationals (Thiqa), one for unskilled labourers and lower paid employees (Basic), and one for higher skilled expatriates (Enhanced). The impact of the new insurance schemes on access to medical care lacks evidence, but the new schemes have covered over 95% of Abu Dhabi’s population (General Secretariat of the Executive Council et al., 2008 ), despite disparity in the utilisation of medical care amongst policyholders. A study found there to be a difference in the utilisation of medical care amongst these schemes (Koornneef et al., 2012). The nationals who have the most generous scheme (Thiqa), utilise the medical services more than those in the least generous scheme (Basic). The study used the number of claims per member per year, as an indicator for utilisation of medical care. However, the difference in utilisation (3 claims per year for Basic members versus 14 claims per year for Thiqa members) could be explained by the difference between Nationals and expatriates in their socio-economic factors such as age. For example, the average age for nationals and expatriates is different, since the Thiqa scheme covers all nationals including those over 65 years, whereas the expatriates are a younger population (Koornneef et al., 2012). In addition, there is a difference between nationals and expatriates in the co-payment, since the Basic scheme requires paying higher co-payments than Thiqa products (Koornneef et al., 2012).
However, some of the strongest evidence from developing countries about the influence of health insurance on healthcare utilisation does not come from private health insurance but from either SHI (Ekman et al., 2008, Michielsen et al., 2011), or government-subsidized
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health (Yip and Berman, 2001, Hugh R. Waters, 1999) or national health insurance programs (Liao, 2008). In addition, even the evidence from private health insurance was for other forms, such as community based health insurance (Jutting, 2004) or micro health insurance (Sekabaraga et al., 2011). A new study from Thailand found that SHI increased healthcare utilisation in the context of ethnic minority immigrants, as evidenced by an increase in health insurance coverage and a corresponding increase in use of medical care (Hu, 2010). However, the same study also showed that ethnic minority immigrants had the lowest health insurance coverage and the least healthcare use compared to other groups. In other words, there is inequality in healthcare use between citizens and ethnic minority immigrants (Hu, 2010). The study also possibly overestimates the number of ethnic minority immigrants with health insurance coverage, as well as their use of medical care (Hu, 2010).
As illustrated, this access measure is one of the most common access measures to have been highlighted in the literature, from both developing and developed countries. Therefore, this access measure is used as one of the main access measures in this thesis (Accesss3).
In summary, most of the evidence of the impact of health insurance on access to medical care comes from developed countries, where the role of private health insurance is to provide supplementary or complementary medical care services. There are a few studies from developing countries, but these usually either have limitation in their scope, such as the one from the UAE, or in the context of social health insurance. Furthermore, no study has been identified that takes into consideration the personal and workplace characteristics of minority workers on the impact of health insurance, and only a few studies consider the three measures of access to medical care.
Below is an elaboration on the reasons behind introducing CEBHI in Saudi Arabia. This is very important step before comparing the CEBHI with Employment Sponsored Insurance (ESI) implemented in the United States, and the steps taken by CEBHI to mitigate the disadvantages of ESI.