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“Some for All” or “All for Some”? – When Needs Meet Values

Melodie Yun-Ju Song

Instructor: Dr. Steven Birch

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Introduction:

Various insurance designs provide people with healthcare services around

the world - not one country has the same design in terms of extent of cost-sharing,

role of private insurance, categories of core benefits, deductibles, and out-of-pocket

expenses, etc. The design of a healthcare system effects the distribution of resources,

ease to access, utility, and overall and wellbeing of the population. The statement that

equity in distribution of healthcare services leads to equality in health outcomes

makes for a compelling argument that applies to two distinct operative approaches.

One operative approach is value-based. In the value-based system like the

US, the protestant way of life promotes hard-work and self-providing values, in

alignment with that is the healthcare system design. In this systems, employers

purchase private insurance packages to provide employees and their families with

coverage at a premium. For the poor, vulnerable, and marginalized, the government

provides tax-financed healthcare to care for them.

The second operative approach is needs-based. In a needs-based system like

Taiwan and Japan, health systems are social health insurance-based, it operates like a

fire-station or a national railway service under which everyone utilizes healthcare

services based on the occurrence of illness regardless of employment. To an extent,

the genre can also be categorized as a system that puts needs as value.

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Health economics historians have categorized both genres of health

insurance to illustrate the effectiveness of each system. Wagstaff and colleagues have

excluded the US because of its ‘uniqueness’ and grouped 29 OECD countries to 4

groups to compare the differences between Social Health Insurance (SHI) and

tax-financed systems in terms of health spending, health outcomes, and labor market

outcomes1. Results showed that SHI may encourage informality in labor markets

(Wagstaff, 2010, p. 27). In health spending, SHI raised per capita total health

spending by 3-4% and reduced formal-sector share of employment by 8-10%; in

terms of health outcomes, women has 5-6% of potential years life lost (PYLL) after

breast cancer diagnosis (Wagstaff, 2010).

In the advent of the Affordable Care Act in 2010, US researchers explored

how health insurance designs affects access to care and costs by income2, results show

that US adults, whether with or without health insurance, incur higher medical costs

than any other 10 countries while acquiring very little life-expectancy gain from per

capita expenditure. To explore how unsustainable the increasing healthcare cost is,

Himmilstein and colleagues conducted a 5-state random data-mining on bankruptcies,

noting that 46.2% (639 cases) of US bankruptcies filed in 2007 alone were medically

1 Wagstaff A. 2009. Social Health Insurance vs. Tax-Financed Health - Evidence from the OECD. Development Research Group, Human Development and Public Services Team, The World Bank. (p. 5) 2 Schloen C, Osborn R, Squires D., Doty M.M., Pierson R., Applebaum S. 2010. How Health Insurance Design Affects Access to Care and Costs, by Income, In Eleven Countries. Health Affairs 29(12): 2323-2334.

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induced, and most debtors were ‘well-educated, owned homes, and had middle-class

occupations’3. In Japan, Cuba, and other countries with single-payer systems, there

medical-cost related bankruptcies are rare and mostly unheard of4.

In a value-based system, providing all care for some of the vulnerable has

its merits (i.e. Medicaid and Medicare in the US), but how does this system fair

compared to needs-based countries like Japan and Taiwan, both of which provide

some care for all? As a future health policy-maker, I use this paper to explore the pros

and cons of systems that provides “some services for all” or “all for some”.

Definitions:

Some for all - basic healthcare, cancer screening, regular dental checkups,

maternal checkups, preventative services and coinsurance on drug provision for

everyone.

All for some - full healthcare services for the poor, the veterans; pregnant women,

children, the elderly.

Single-payer system - refers to government controlled, socialized healthcare

financing systems.

Market-driven - competitive healthcare financing systems of the private market.

3 Himmelstein D., Thorne D., Warren E., Woolhandler S. 2009. Medical Bankrupcy in the United States, 2007: Results of a National Study. The American Journal of Medicine, 122(8):741-746. 4 Hodberg D. Single Payer Systems. May 2013. Retrieved from Amy Ridenour’s National Center Blog on December 10th http://www.conservativeblog.org/amyridenour/2013/5/28/yes-people-do-go-bankrupt-from-medical-bills-in-single-payer.html

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Quadrants of Analysis

Acknowledging that there are four distinct features to healthcare in the

realm of economics5, namely “government intervention”, “uncertainty”, “asymmetric

knowledge”, and “externalities”, healthcare systems design originated more with

ideologies than evidence from hard science. To demonstrate the possibility of how

different approaches can potentially affect the market, health expenditure, health

outcomes, and overall wellbeing, this paper discusses about adverse selection, moral

hazards, risk-sharing, externalities, and the demand for care.

Four quadrants to guide the analysis as shown below:

A. Some for all, government operated single-payer system

B. Market-driven some for all

C. All for some, government operated single-payer system

D. Market-driven all for some

Table One: Quadrant of healthcare financing approaches

Some for all All for some

Single-payer system A C

Market-driven B D

5 Randhawa P, Chan K. 2009. Health Economics 101. Global Health Education Consortium. 1-60. (Page 12).

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Analysis

Human health and economic well-being is a bidirectional relationship.

Strong economic performance leads to higher individual incomes, in turn increasing

positive behavior related to the acquisition of health promoting services and

subsequently, improved/sustained wellbeing. Health also affects economics for good

health increases human capital6 and stimulates individual productivity that leads to

over economic growth rate7. Whether countries provide health insurance based on

values or needs, the outcomes are often not predictable until polices are carried out for

a long number of years.

By looking at what health economists care about in the current environment,

this analysis discusses the factors (adverse selection, moral hazards, risk-sharing,

externalities, and demands for care)8 in each quadrant that might drive the outlook of

these individual approaches. Depending on incentive to provide healthcare, the below

provides an overview of each hypothetical approach to assist policy-maker in

choosing optimal healthcare system fitting to the country/region’s values and needs.

6 Sachs, J. D., Warner, A., Åslund, A., & Fischer, S. (1995). Economic reform and the process of global integration. Brookings papers on economic activity,1995(1), 1-118. 7 Summers, L. (2007). Beware moral hazard fundamentalists. Financial Times,23. 8 Culyer A., and Mansurova L. (2007). Top articles in health economics. Institute for Work and Health. Retrieved on November 20th from http://www.economicsnetwork.ac.uk/health/Top_articles_in_health_economics_4_(ac05.09.07).doc.

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A. Some for all, government operated single-payer system:

Adverse selection occurs when consumers are knowledgeable and/or

presume themselves knowledgeable about their own health status to opt out of the

insurance scheme or prefer to pay lower premiums because of perceived low-risk on

adverse health events. In this quadrant, government-run single-payer system creates a

pool without an opt-out option. It not only enlarges the pool of potential enrollees to

pool risks, the positive externalities are larger than would a smaller pool. In recent

years, the debate of whether the government should provide universal HPV

vaccination for girls above 13 for the prevention of cervical cancer sparked

considerable debates among ethicists and public health policy-makers. In terms of

cost-effectiveness, it is proven that prevention saves money for the healthcare system

in the long run.

In a health economics perspective where a country has high HPV

prevalence rate, providing basic healthcare services such as cancer-screening (i.e.

Pap-smear) and prophylactic vaccinations (i.e. Human Papillomavirus vaccine)

combined with school-wide sex-education were offered for women through public

channels, the risk of getting HPV would decrease and in turn provide

positive/protective externalities to women and men.

In the prevention of infectious diseases, there are little concerns of moral

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hazards. The ex-ante moral hazard, which refers to reduced consumption of

preventative care and changes in lifestyle does not apply to infectious disease

prevention because the cost of ‘vaccination’ is much less than the cost of ‘treatment

due to illness’ (i.e. radiotherapy, chemotherapy, surgery to treat cervical cancer).

Ex-post moral hazard, however, which refers to ‘the increased consumption of health

services, and the use of more expensive services once illness occurs’, appears unlikely

because vaccinations are one-time, dosage-based treatments that does not require

follow-up.

In terms of chronic-illness, the single-payer system creates substantial

debate in increased use in medical services (i.e. ambulatory care9, elderly in-patient

visits, psychiatric services) in the population who need it the most10. Pauly argues that

those paid premium would demand for greater services and given the presence of

moral hazard, ‘any effort to extend health insurance coverage, private or public, is

likely to have the effect of reducing the economic welfare across the population’

(Pauly, 1963; Kelman and Woodward, 2012).

In a some-for-all single-payer system, restricting supplier-induced demand

can be induced by reigning not by capitation fees but a reduction in healthcare

9 Lai H-Y, Hwang S-J, Chen Y-c, Chen T-J, Lin M-H, Chen L-K. 2009. Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese national health insurance program. Clinical Therapeutics. 31(8); 1859-1870. 10 Jowett M., deolalikar A., Martinsson P. 2004. Health Insurance and treatment seeking behavior: evidence from a low-income country.

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providers’ income. In Taiwan, public provision of physicians and a regulation in

restricting foreign healthcare provider practicing in Taiwan provides the healthcare

industry with calculable flow of healthcare providers. Although there is a high

turn-over rate in nurses averaging at 3 years lifetime practice11, the healthcare

workforce is abundant to support the increasingly aging population.

Another aspect of some-for-all is that even though high-cost unforeseen

procedures such as HIV/ART drug provision, chemotherapy treatment, and

psychiatric services are excluded from the premium, it is likely that the private

insurance company has little incentive to provide coverage for people with HIV,

cancer, or psychiatric conditions. In circumstances when private insurance is allowed,

only the wealthy would be able to afford a private “too-good-to-be-true” premium

package while the poor and those in need would rare if ever gain access to expensive

services. On the other hand, in circumstances when single-payer systems regulates

private insurance from taking part in the healthcare industry, the government as a

single-payer act as the only negotiator in procuring costly treatment and services from

pharmaceutical companies. Such is the case in Taiwan when Merck negotiated with

the National Health Insurance (NHI) and the FDA to import the HPV vaccination. A

11 Yin, J. C. T., & Yang, K. P. A. (2002). Nursing turnover in Taiwan: a meta-analysis of related factors. International Journal of Nursing Studies, 39(6), 573-581.

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3-dose vaccination that originally cost 200 USD was sold to Taiwan for 30 USD12.

The price of inefficient moral hazard, elimination of risk aversion, a

positive externality/spillover, reduced healthcare provider costs, and single-payer

price negotiation are all benefits of the “some for all single payer approach”.

B. Market-driven some for all

Although inherently the healthcare system cannot follow principles of

economics to function because of risk, selection, and social justice (Krugman, 2005),

there are economists that advocate for cash-transfers instead of insurance to

encourage maximization of utility for the individual. Based on information asymmetry,

uncertainty, and adverse behaviors of at-risk populations that inherently creates

negative externalities in health (i.e. spread of HIV from bare-backing, obesity due to

sedentary lifestyles and unhealthy diet behaviors), leaving the healthcare market for

the private sector will drive healthcare costs to incalculable heights.

However, from a welfare theory standpoint, distinguishing between

“efficient” and “inefficient” moral hazard allows us to acknowledge the existence of

moral hazard but understand the ‘inefficient moral hazard is that component of the

utilization increases attributable solely to the increase in income’, which translates to

‘unambiguous increase in welfare’ instead of a net welfare decrease that Pauly

12 Song YJ. 2010. Stakeholder Analysis of the HPV Vaccination in Taiwan. Unpublished Master’s Thesis.

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assumed (Nyman, 2003; Kelman and Woodward, 2012). We could also assume that

money tells us nothing about the associated distribution in utility unless the marginal

utility of money wealth is constant across all income classes (Reinhardt, 2001).

Furthermore, Nyman notes that “for low-income consumers in wealthy

countries, or for most consumers in poor countries, the efficient portion of moral

hazard tends to dominate the inefficient portion.”13

As Gerald Friedman noted, ‘treating it like other commodities, economists

have promoted cost-sharing, market-competition, insurance oversight of healthcare

providers that have inflated the administrative burden while denying more […]

access.’14. Where market decides what is the content included in the ‘some’ package,

consumers have inadvertently allowed healthcare system to rising costs and

restrictions on access.

Adverse selection in a market-driven “some for all” where premiums are

low would result in those who could afford the premium (i.e. employees of small

companies who cannot afford to develop its own insurance package) to opt in to ‘not

so optimum’ coverage. For instance, software giants in the Northwest such as

Microsoft, Google, and Amazon that have enough pool to design its own insurance

13 Nyman J.A. The theory of demand for Health Insurance. Stanford University Press. P. 156. 14 Friedman G. The unhappy marriage of economics and health care. Physicians for a national health program website. Retrieved on December 1st from http://pnhp.org/blog/2013/05/06/gerald-friedman-the-unhappy-marriage-of-economics-and-health-care/

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plan, with the condition that it is tax-deductible, remained outside of the ‘some for all’

pool but lean towards ‘all for some’ model. To date, Seattle will be the only state

without the Small Business Health Options Program (SHOP)15, an option that allows

small employers to have federal tax credits to reduce cost for their employees.

Moral hazard in this approach sets in as the Northwest providers and hospitals

enjoys the sustainable amount of regular consumers from big tech companies,

resulting in supplier-induced demand for minuscule surgeries, treatments, and

checkups covered by insurance companies.

Another issue tied to moral hazard include “supplier reimbursement”, in

these premiums paid by technology giants, retrospective private insurer imbursement

is the preferred model by hospitals, insurance companies, and they are meeting no

objectives from the rich tech companies who are able to afford it. This subsequently

lead the healthcare industry to bloom in the Northwest. There are now over 113

hospitals in Washington State16, physician, nursing, and administrative salaries are

among the highest , but the health outcomes are only ranked 14th of all 51 States. This

suggest that high overhead cost contributed to the rising cost in care, although happily

shared by those who can afford it, it is taking away the equity (or equality in health

15 Stiffler L. Lack of Health-insurance options frustrates small businesses. December, 2013. The Seattle Times Healthcare forum. Retrieved on December 14th from http://seattletimes.com/html/healthcare/2022452537_acasmallbizxml.html 16 Washington State Hospital Association. 2012. Retrieved on December 5th from http://www.wsha.org/chronology.cfm

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outcomes) for the uninsured.

The Market-driven approach does not cater to the needs of the population

but only to those who can afford to pay. A system based on willingness to pay instead

of needs will drive insurance costs higher and encourage tier-based treatment where

physicians provide repeated or unnecessary care for the insured and pushing

low-quality service onto the uninsured.

C. All for some, government operated single-payer system

This approach takes note of various insurance schemes focusing on the poor,

marginalized, and the elderly. In the US system, Medicare and Medicaid were

implemented to take care of the poorest and the frail, a value-based approach that

promotes risk-pooling, tax-financed health insurance system that takes up hundreds of

billions of dollars per year. A system financing the sick without supporting the general

population is unsustainable as it is unfair. At the same time, a system that pools risk

among the elderly is also as unsustainable as it is costly.

The idea of an all for some, especially a system that was designed for the

weak and marginalized, was the leading reason tax-payers question the legitimacy of

adopting risk-pooling strategies in health when the majority are not sick enough (yet)

to enjoy the benefits. The debate continues when the government advocates for

expanding the pool, a notion that worries middle-classed citizens and small-business

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owners because the idea of ‘expanding the pool’ is synonymous to ‘paying more for

no extra utilization’. Given a choice, most tax-payers would happily opt-out of a

paying taxes for health because the immediate benefits are unknown and unattainable.

As a result, the idea of risk-sharing becomes an idealistic notion instead of a

practical one because altruistic externalities on supporting the weak and the

vulnerable can only go so far. On the other hand, the consumers of Medicaid and

Medicare with its distinct demographic nature and needs are being treated as

second-tier consumers in the healthcare financing system despite their care plans

cover a majority of services and checkups that most uninsured tax-payers are unable

to enjoy. In a system as such, the needs of the uninsured are often unmet (i.e. above

poverty line but not poor enough to enroll into Medicaid); in some instances, the

moral hazards of increased uptake among enrollees versus the unenrolled have been a

constant debate over the last 4 decades.

In the famous RAND study, it is shown that people use more services if

they are opt-in. In this randomized experiment, Manning and colleagues found that a

‘catastrophic insurance plan reduces expenditures 31% relative to zero out-of-pocket

price’, therefore rejecting the hypothesis that less favorable coverage of outpatient

services increases total expenditure17. The Oregon Health Insurance Experiment

17 Manning WGM, Newhouse J.P., Duan N., Keeler E.B, Leibowitz A, and Marquis M.S. Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment. The American

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(OHIE), a more recent randomized control trial conducted by Baicker and colleagues

suggests that the poor who were enrolled into Medicaid had substantively higher

healthcare utilization (i.e. primary and preventive care, and hospitalizations), lower

out-of-pocket medical expenditures, fewer bills sent to collection, and better

self-reported physical and mental health18. In the second year of OHIE, results shown

that the biggest benefit is a continual (and forecasted) financial protection for the

ensured (i.e. less bankruptcy, less debt), better satisfaction and trust in the healthcare

system, and more comfortable with going to the doctors. Although the study suggest

that there were no significant improvement in the physical health outcomes in chronic

health conditions such as diabetes and cardiac diseases, it is likely that chronic

diseases itself takes longer timeframe to show significant improvement19.

The above results are substantial in providing evidence that some for all

system carries lots of negative weight because the insurance has a normative value

associated with cost-sharing but the demands for care in the group are being called

into question. The positive externalities are unclear, except for witnessing less

deaths20 and extending the lives of the elderly; and the opportunity cost for the

Economic Review, 77(3): 251 -277. 18 Baicker K. et al. The Oregon Health Insurance Experiment: Evidence from the first Year. The Quarterly Journal of Economics. 2012, 127(3): 1057-1106. 19 Baicker et al. The Oregon Experiment – Effects of Medicaid on Clinical Outcomes. The New England Journal of Medicine. 2013, 368: 1713-1722. 20 Kronick R. Health Insurance coverage and Morality Revisited. Health Services Research. 2009, 44(4):1211-1231.

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tax-payers are too high to afford for the long term.

D. Market-driven all for some

In a Market-driven all-for-some, it is expected that inequity will be the most

severe. All-for-some premiums will generate disparities between different

socioeconomic statuses when only a few can afford good premiums. People in lower

socioeconomic status are associated with less purchasing power, risky behaviors, and

higher rates of obesity. The marginal utility for the rich is greater than the marginal

utility for the poor if insurance are provided by private insurance companies at a fixed

premium, therefore, a market catered according to the ability to pay is bound to drive

people with lower-socioeconomic status away from the pool. By not participating in

the health insurance program, people are choosing to averse to risk from other

unforeseen accidents/incidences (i.e. auto-insurance, home-insurance).

Under-insurance and over-insurance may occur at the same time in a

country that adopts market-drive some-for-all’s. The drivers of supply (i.e. health care

providers, in-patient beds, equipment, new technologies) will induce an overuse of

medical services for those covered for all services, the resources allocated to a

tummy-tuck could be used for other purposes such as providing a cataract operation

for the poor and unemployed; an expensive lung transplant for the rich can provide

thousands of people with smoking cessation education and nicotine patches.

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There are conflicting results in the field of health economics on the

correlation between health insurance coverage and mortality. One study examined the

relationship between insurance status and mortality using survival analysis and

suggested that ‘there is little evidence to suggest that extending insurance coverage to

adults would have a large effect on the number of deaths in the United States.’21

However, most studies showed that un-insurance is associated with mortality22; one

study suggests that the hazard ratio for mortality among the uninsured after

controlling for demographics (i.e. age, gender, BMI, adverse health behaviors,

education, income, and race/ethnicity) was 1.423.

In any circumstance, the values that drive what is operating the healthcare

insurance market is not equivalent to achieving equality in health outcomes. The

misalignment of the drivers of supply and drivers of demand (i.e. population

demographic such as age structure, health status, health behavior, and education,

poverty) will cause great distress to the society as it creates advanced treatment and

unnecessary diagnostic guidelines to an overdrive while marginalizing those that need

basic services like preventative education, vaccination, and low-cost health services

that reduces the development of chronic diseases for high-risk populations.

21 Kronick R. 2009. Health Insurance Coverage and Mortality Revisited. HSR: Health Services Research 44(4):1211-1231. 22 Zalavsky A.M., Ginsburg J.A., Schneider E.C., Weissman J.S., Ayanian J.Z. (2000) Unmet Health needs of uninsured adults in the United States. Journal of American Medical Association. 284(16)- 2061- 2069. 23 Wilper A.P., Woolhandler S., Lasser K.E., McCormick D., Bor D.H., Himmelstein D.U. (2009)

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Discussion:

Most countries adopt the four quadrants of approach to health insurance

either in combination with the private market or with a single-payer only system for

the general population. In this paper, the pros and cons of each approach in terms of

risk aversion, moral hazard, risk-sharing, externalities, and the induced-demand as

well as demand for care from consumers were discussed.

The merits of a single-payer system in assuaging information asymmetry,

negative externalities, and uncertainty provides a less complicated insurance scheme

for both the government, the healthcare providers, and the managerial staff. Within the

system, a market-incentivized pharmaceutical industry are regulated to reduce

supplier-induced demand by reducing unnecessary marketing costs as one would

expect in a market-driven healthcare environment. The single-payer system allows for

easy-negotiation to lower costs on drug procurement, and suppliers will be

less-incentivized to induce demand if the system was designed to pay fixed-rate

prospective reimbursements like a post-office or any government-operated socialized

system would.

Taking lessons learned from OECD countries, the RAND experiment, and

the Oregon experiment, it is evident that overall financial protection, although not

entirely translatable in the healthcare insurance system, presents itself as a positive

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externality for the society, given that health can be both an item of consumption and

an item of investment – with more health investment (i.e. exercise, diet, education)

and consumption (i.e. vaccination, warm-clothing, clean water) outside of the hospital,

the less need there is to consume healthcare.

Causally, the less life-threatening infectious diseases and less chronic

diseases for the insured, the less costly the healthcare system would be. These are

goals obtainable under the condition that government maintains cost-containment in

response to the growing supplier-induced demand from both physicians and

pharmaceutical industries, as evident in developing-countries that newly adopted

national health insurance schemes such as Taiwan and Vietnam, as well as countries

with socialized medical care such as Japan and Cuba .

In other words, the debate for benefits of insurance for all in a private

market is nonsensical because it is a debate between values and needs. The

complexity of healthcare needs government regulations on cost containment and a

realignment of values with needs than merely debates on the benefits of health

outcomes in mere monetary terms.

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Conclusion:

In the advent of growing elderly populations, wider inequity among the

population, and larger gaps in health outcomes between the rich and poor, there is a

dire need to address the merits of a some-for-all approach or an all-for-some approach

to the distribution of healthcare. Hierarchically, a single-payer some for all fairs better

than a single-payer system with ‘all-for-some’ insurance; a market-driven some-for-all

is better than a market-drive all-for-some.

The choices to make for health policy makers are not ‘as easy as A, B, C’. It

is important to recognize that public-funded all-for-some can still risk creating

inequalities if the underlying social forces (or social determinants of health) remains

unchallenged24 because ‘the distribution of the effectiveness of interventions aimed at

changing those causes’. The misalignment of our societies’ values and needs

represents itself in health and healthcare delivery, to create a system that allows for a

common goal in health outcomes will need a thorough examination of each country’s

short-term and long-term goals in terms of what constitutes wellbeing for the

individual, the community, the society in the global arena.

24 Birch S. 1999. The 39 Steps: The Mystery of Health Inequalities in the UK. Health Economics 8: 301-308.

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References:

1. Reinhardt, UE. 2001. Can efficiency in health care be left to the market? Journal

of Health Politics, Policy and Law. 26(5): 967 – 992.

2. Wagstaff A. 2009. Social Health Insurance vs. Tax-Financed Health - Evidence from

the OECD. Development Research Group, Human Development and Public

Services Team, The World Bank. (p. 5)

3. Schloen C, Osborn R, Squires D., Doty M.M., Pierson R., Applebaum S. 2010. How

Health Insurance Design Affects Access to Care and Costs, by Income, In Eleven

Countries. Health Affairs 29(12): 2323-2334.

4. Himmelstein D., Thorne D., Warren E., Woolhandler S. 2009. Medical Bankrupcy

in the United States, 2007: Results of a National Study. The American Journal of

Medicine, 122(8):741-746.

5. Hodberg D. Single Payer Systems. May 2013. Retrieved from Amy Ridenour’s

National Center Blog on December 10th

http://www.conservativeblog.org/amyridenour/2013/5/28/yes-people-do-go-ba

nkrupt-from-medical-bills-in-single-payer.html

6. Sachs, J. D., Warner, A., Åslund, A., & Fischer, S. (1995). Economic reform and the

process of global integration. Brookings papers on economic activity,1995(1),

1-118.

7. Summers, L. (2007). Beware moral hazard fundamentalists. Financial Times,23.

8. Culyer A., and Mansurova L. (2007). Top articles in health economics. Institute for

Work and Health. Retrieved on November 20th from

http://www.economicsnetwork.ac.uk/health/Top_articles_in_health_economics_

4_(ac05.09.07).doc.

9. Lai H-Y, Hwang S-J, Chen Y-c, Chen T-J, Lin M-H, Chen L-K. 2009. Prevalence of the

prescribing of potentially inappropriate medications at ambulatory care visits by

elderly patients covered by the Taiwanese national health insurance program.

Clinical Therapeutics. 31(8); 1859-1870.

10. 1 Jowett M., deolalikar A., Martinsson P. 2004. Health Insurance and treatment

seeking behavior: evidence from a low-income country.

11. Yin, J. C. T., & Yang, K. P. A. (2002). Nursing turnover in Taiwan: a meta-analysis of

related factors. International Journal of Nursing Studies, 39(6), 573-581.

12. Song YJ. 2010. Stakeholder Analysis of the HPV Vaccination in Taiwan.

Unpublished Master’s Thesis.

13. Nyman J.A. The theory of demand for Health Insurance. Stanford University Press.

P. 156.

14. Friedman G. The unhappy marriage of economics and health care. Physicians for

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a national health program website. Retrieved on December 1st from

http://pnhp.org/blog/2013/05/06/gerald-friedman-the-unhappy-marriage-of-ec

onomics-and-health-care/

15. Stiffler L. Lack of Health-insurance options frustrates small businesses. December,

2013. The Seattle Times Healthcare forum. Retrieved on December 14th from

http://seattletimes.com/html/healthcare/2022452537_acasmallbizxml.html

16. Washington State Hospital Association. 2012. Retrieved on December 5th from

http://www.wsha.org/chronology.cfm

17. Manning WGM, Newhouse J.P., Duan N., Keeler E.B, Leibowitz A, and Marquis

M.S. Health Insurance and the Demand for Medical Care: Evidence from a

Randomized Experiment. The American Economic Review, 77(3): 251 -277.

18. Baicker K. et al. The Oregon Health Insurance Experiment: Evidence from the first

Year. The Quarterly Journal of Economics. 2012, 127(3): 1057-1106.

19. Baicker et al. The Oregon Experiment – Effects of Medicaid on Clinical Outcomes.

The New England Journal of Medicine. 2013, 368: 1713-1722.

20. Kronick R. Health Insurance coverage and Morality Revisited. Health Services

Research. 2009, 44(4):1211-1231.

21. Zalavsky A.M., Ginsburg J.A., Schneider E.C., Weissman J.S., Ayanian J.Z. (2000)

Unmet Health needs of uninsured adults in the United States. Journal of

American Medical Association. 284(16)- 2061- 2069.

22. Wilper A.P., Woolhandler S., Lasser K.E., McCormick D., Bor D.H., Himmelstein D.U.

(2009)

23. Birch S. 1999. The 39 Steps: The Mystery of Health Inequalities in the UK. Health

Economics 8: 301-308.