J Asian Med Stud Assoc.

2020;8(4):41-47

Effectiveness of various health insurances in tackling

health problems of the 21st century: a systematic review
Nico Gamalliel1, Reynardi Larope Sutanto1, Mochammad Izzatullah1, Gita Fajri Gustya1

1
Faculty of Medicine, Abstract
Universitas Indonesia,
Jakarta, Indonesia
One of the key factors in reaching ‘healthy lives’ based on the
Goal 3 of Sustainable Development Goals is the access to
Correspondence should
medical care. Many countries have been implementing their own
be addressed to
health insurance in order to facilitate access for good quality
Mochammad Izzatullah.
medical care. Some studies indicated that health insurance has a
Faculty of Medicine,
positive effect on improving the health quality especially in
Universitas Indonesia.
terms of mortality rates. However, several other studies revealed
Address: Jl. Salemba Raya
that there is an inverted effect of owning health insurance and
No.6, Jakarta 10430,
health quality. Therefore, this systematic review aims to
Indonesia.
investigate about the research regarding the relationship of
E-mail: health quality and health insurance. The keyword for this review
[email protected] was "Insurance, Health"[Mesh]) AND "Health Care Quality,
Access, and Evaluation"[Mesh] on the database of Pubmed. By
Cite this article as: using this keyword, we found 6 papers related to our topic. Then,
we evaluated it by using STROBE method. From six papers we
Gamalliel N, Sutanto RL,
reviewed, all of them state that ownership of health insurance
Izzatullah M, Gustya GF.
may indicate better prognosis of the patient, regardless of the
Effectiveness of various
disease. Furthermore, the government of countries may consider
health insurances in
administering a social insurance system, or at least the
tackling health problems
government may increase people’s participation in health
of the 21st century: a
insurance. Future studies must be conducted due to the fact that
systematic review. J Asian
the paper we review are varies in term of research location and
Med Stud Assoc.
population target
2020;8(4):41-47
Key words: health insurance, health care, health care quality,
Received: 11 Jun 2019;
health care access, health care evaluation
Accepted: 10 May 2020.

factors in reaching ‘healthy lives’ is the

access to medical care. Health insurance
Introduction has been implemented across many
countries in order to facilitate access for
Health insurance can be said to have good quality medical care. Risk-sharing
a strong relation in achieving Goal 3 of mechanisms such as social insurance is said
Sustainable Development Goals (SDGs), to provide resources to access healthcare
“Ensure healthy lives and promote well- and to promote health. On the other hand,
being for all at all ages”.1 One of the key social insurance protects individuals and

41
J Asian Med Stud Assoc
Review Article

households against while the potentially

devastating direct financial costs of illness.2
Materials and Methods
The ultimate aim of health
insurance is to improve the quality of The systematic review was
health.3 The impact of health insurance on conducted using keywords "Insurance,
health care utilization is said to be closely Health"[Mesh]) AND "Health Care
associated with the characteristics of the Quality, Access, and Evaluation"[Mesh] on
system, such as premiums, benefits, the database of Pubmed. From there, we
location of healthcare services, and for proceed to look for studies which are
whom the services are intended.4Some related to our topic by using our inclusion
health insurance programs, for example, the criteria. The inclusion criteria include:
one in Indonesia which is called Jaminan studies which were published within the
Kesehatan Nasional, raise debate about its past five years, observational studies, and
effectiveness in increasing the utilisation of studies which look upon the effects of
health services, especially among the poor.5 health insurance on the health of the users.
On the other hand, exclusion criteria were
Some studies indicated that health also used. These include: inaccessible
insurance has a positive effect on articles, articles written in languages other
improving the health quality of patients. A than English or Indonesian, and irrelevant
study showed women managed under articles.
national health insurance scheme of Nigeria
had better maternal and perinatal indices.6 Afterwards, we begin to collect
Insurance coverage also associated with important data from each study, including:
decreased in-hospital mortality.1 Another author(s) name, year of publication,
study indicated there is inverted effect STROBE score, type of insurance used,
between ownership of health insurance and research design, location, sample size, type
health quality, where enrolees of Ohio of disease assessed, method of analysis,
Appalachian Medicaid were more likely to result, and limitations of the study. The
have health problems such as hypertension, review was done qualitatively by three
cardiovascular disease, and overall poorer assessors and conclusions were then drafted
health than non-Medicaid enrollees.7 after consensus had been achieved. All of
this process could be viewed on Figure 1.
The link between health insurance
and this ultimate goal therefore should be
thoroughly investigated. Current studies
mostly investigated the relation between Results
participation in health insurance and
mortality or survival in certain diseases The search was conducted via the
especially the non-communicable disease database of Pubmed. Titles were screened
such as cancers, diabetes, heart-related for relevancy and duplication. Contents
diseases, and so on Advanced investigation were screened for inclusion and exclusion
and research about the link between health criteria. Articles went over criteria were
insurance and health problems in general, fully assessed for eligibility and study
not only based on certain disease, is needed design. Lastly, six suitable observational
in order to find out and improve efficacy of studies were reviewed and included in this
health insurance. Here explained systematic review. Articles were assessed
systematic review of literature showing link with STROBE’s criteria to ensure its
of health insurance and health problems. quality. STROBE result of all articles could
be seen in Appendix (in Supplementary

42
J Asian Med Stud Assoc
Review Article

Material), while the entire process can be hypercholesterolemia and hypertension.

seen in Figure 1. Included study design and These two events will lead to an acute
the respective characteristics of each study cardiac arrest. A severe acute cardiac arrest
are further shown in Table 1. results in the demand of a thoracic aortic
operation.9 The same result is also
explained through a study by Hiroi, et.al. In
this study the researcher discovers the
correlation of H. pylori infection gastritis
with the coverage of insurance. The result
is positive which means that the usage of
insurance will decrease the event of H.
pylori infection gastritis.10

There are other studies that showed

significant improvement of healthcare
outcomes when using health insurance.
Those studies include the study conducted
by Stecker et al in 2017 that showed the
significant reduction in out-of-hospital
cardiac arrest in patients with health
insurance.11 Another study is conducted by
Figure 1. Flow chart of the systematic review Saunders et al, in which the samples used
are 934 individuals with urine albumin-to-
creatinine ratio ≥ 30 mg/g, which is a
diagnostic value of albuminuria. The study
also discusses cardiovascular mortality as
Discussion
one of the complications of kidney disease.
Based on the study conducted by The aim of the study is to compare the rate
Xie, et.al in 2017, which explains about the of mortality between uninsured, individuals
relationship between lowering cost share with public insurance, and individuals with
and the rates of self-management in private insurance. Individuals with public
diabetes, shows that people who use the insurance and those who are uninsured
high-cost share group has a lower risk of showed higher rates of all-cause mortality
hyperglycaemia rather than the low-cost compared with individuals with private
share group. This means that people who insurance. Also, similar pattern can be seen
pay for the insurance more will have a in cardiovascular mortality rates. However,
better condition and receive more health the cardiovascular mortality rate between
service than people who pay only a little those individuals are not significant.12
amount of money for insurance.8
There is one study that also
Other study conducted by Andersen compares two medical insurances in China,
ND, et.al. reveals that people who suffer those are New Cooperative Medical
cardiac arrest and are underinsured will Scheme (NCMS) and the Urban
have a higher risk for thoracic aortic Employees’ Medical Insurance (UEMI).
operations. This condition could happen NCMS is mainly for rural residents. The
due to the fact that underinsured people will study is conducted by Wang et al. The result
receive less medication and less
screening. Less medication and less
screening in this study mean that people
will have a higher rate of

43
J Asian Med Stud Assoc
 Table 1. Included study designs and characteristics
Author and Type of Research Location Sample size Disease Method of Results Limitation of Study
Year of Insurance Design Analysis
Publication
(STROBE)
Review Article

Xie Y, et al; 2017 Private Observational Netherlands 7,155 patients Type I SAS 9.4: t-test, Higher rate of Pharmacy fills do not
(19.33/22) Retrospective (3,575 low-cost Diabetes Pearson’s chi- continued testing necessarily confirm
share group, Mellitus square, modified strip fills in low- actual use of dispensed
3,580 high-cost Poisson model cost share group testing strips, all
share group) than high-cost patients were from a
share group (89% single large commercial
vs 82%, P<0.001) insurer
Andersen MD, et Private and Retrospective United 826 patients; Acuity Mann-Whitney Underinsured Study only includes
al; 2017 government States 736 had of rank sum test, patients were at patient who underwent
(16.16/22) al insurance; 90 Thoracic chi-square test; greatest risk of operation; does not
logistic
(Medicare, were Aortic requiring account for unmeasured
regression, Cox
USA) underinsured Operatio nonelective confounders, such as
proportional-
ns thoracic aortic social variables; single-
hazards
operations (OR: institution analysis
regression;
2.67; P<0.0001)

J Asian Med Stud Assoc

STATA 11.1
Hiroi S, et al; Japanese Retrospective Japan 81,119 and Helicoba SAS 9.4 Insurance Success rate of
2017 (19.1/22) health observational 170,993 cter coverage may eradication was
insurance patients in two pylori reduce the obtained from previous
databases; gastritis prevalence of H. studies, potential bias
pylori infection. of health insurance
claims database
Stecker EC, et al; Government Retrospective Multnomah Adult residents Out-of- PASS 13, SAS Health insurance Single urban
2017 al observational County, of Multnomah Hospital 9.4 expansion was geographic area as
(18.94/22) (Affordable study Oregon, County Cardiac associated with location, underpowered
Care Act) United (636,000) Arrest significant regression-based
States reduction in techniques, assumption
OHCA incidence. that OHCA can be a

44
(middle-aged surrogate of SCA
population:
 Table 1. Included study designs and characteristics (cont’d)
102 per 100,000 to
85 per 100,000
with P = 0.01;
elderly population:
275 per 100,000 to
Review Article

269 per 100,000

with P = 0.70)
Saunders MR, et Government Cohort United 934 individuals Albumin Cox model, Higher crude rates The study only had
al.; 2016 and private observational States with uria Schoenfeld of all-cause access to a single
(16.4/22) insurance UACR ≥ 30 residuals mortality in the UACR and eGFR
mg/g; uninsured and determination, rather
individuals with than using multiple
public insurance measures; limited time,
compared with data can be biased since
those with private uninsured individuals
insurance (17.8 may have subsequently
and 24.1 vs 10.4, lost their insurance.
respectively);
similar pattern can

J Asian Med Stud Assoc

be seen in
cardiovascular
mortality rates.
Wang Z, et al; New Cohort PD Center, 564 Peritoniti SPSS 17.0; chi- Biomedical Data were from a single
2015 (17.43/22) Cooperative prospective Wuhan no. patients(415 s square test, parameters for center and the sample
Medical 1 Hospital, (77.0%) with unpaired t-test, diseases were was small.
Scheme China UEMI and 149 Kaplan-Meier inferior in patients
(NCMS) and (23.0%) with method, Cox with NCMS
the Urban NCMS); has regression model. compared with
Employees’ received patients with
Medical continuous UEMI. (P<0.05)
Insurance ambulatory PD
(UEMI) for >3 months

45
Review Article

of this study is that individuals with NCMS understandable given the nature of
are more inferior to those with UEMI in systematic review as a qualitative literature.
biomedical parameters, which include
haemoglobin levels, phosphorus in blood,
nutrition, and residual renal function. For
example, individuals with NCMS have Conclusion
lower haemoglobin levels that can be due to
low-income-related-malnutrition. This review using systematic
Hypophosphatemia does exist in methods shows that ownership of health
individuals with NCMS which also insurance may indicate better prognosis of
correlates with economic status in rural the patient, regardless of the disease.
residents. In conclusion, individuals with Furthermore, the government of countries
NCMS do have higher rate of mortality may try to consider administering a social
associated with peritoneal dialysis insurance system, or at least the
compared with individuals with UEMI due government may try to increase people’s
to different economic status.13 participation in health insurance. It is
recommended that the community may
The study conducted by Wang et al consider enrolling in health insurance for
also correlates with other studies that better access to the health care services thus
compare uninsured and insured individuals higher health quality., etc. These attempts
like the study conducted by Stecker et al may be one of many ways to achieve a
and Saunders et al. Those three studies better health level for the community.
showed significant differences in patients Further research should be conducted with
with insurance or those with private more homogeneous data, especially related
insurance when compared to public to location the research conducted. Future
insurance. Higher economic status (those research could fruitfully explore this issue
with private insurance) associated with by conducting the study in developing
more compliance in check-ups and drug country, , seeing that most of the studies
intake compared to those with lower related to the linking between health
economic status. However, compared to insurance and health quality conducted in
those who were uninsured, individuals with developed countries. More databases may
insurance (public or private) do have a also be used in order to get more studies
higher survival rate almost in all studies. related to the relation between health
insurance and health quality.
Even though a profound connection
between quality health insurance and health
outcomes of its users could be seen, this
systematic review has several limitations. Acknowledgement
Firstly, the studies included were quite
heterogeneous in location, sample size, as None.
well as in type of insurances and diseases.
This heterogeneity could become a Conflict of Interest
potential source of bias. However, this
should be understandable given the small None declared.
amount of current literature on the effects
of health insurance. Secondly, as a Sources of Funding
systematic review, it could be susceptible to
bias arising from author competing None.
interests of its assessors. This is

46
J Asian Med Stud Assoc
Review Article

References risk factors by county type and health

insurance status: results from the 2008
1. United Nations. (2015). Goal 3: Ensure Ohio family health survey. Public
healthy lives and promote well-being Health Reports. 2015; 30(1):87–95.
for all at all ages. Retrieved from
8. Yiqiong X, Agiy A, Bowman K,
Sustainable Development Goals
DeVries A. Lowering cost share may
website:
improve rates of home glucose
https://www.un.org/sustainabledevelop
monitoring among patients with
ment/health/
diabetes using insulin. Journal of
2. Stone, G. S., Tarus, T., Shikanga, M., Managed Care & Specialty Pharmacy.
Biwott, B., Ngetich, T., & Andale, T. 2017; 23(8) : 884-891
The association between insurance
9. Andersen ND, et.al. Insurance status
status and in-hospital mortality on the
predicts acuity of thoracic aortic
public medical wards of a Kenyan
operations. The American Association
referral hospital. Global Health Action.
of Thoracic Surgery. 2014; 148(5):
2015;7(1): 23137.
2082-2086.
3. Schoeps, A., Lietz, H., Sie, A.,
10. Hiroi S, Sugano K, Tanaka S,
Savadogo, G., De Allegri, M., Muller,
Kawakami K. Impact of health
O., & Sauerborn, R. (2015). Health
insurance coverage for Helicobacter
insurance and child mortality in rural
pylori gastritis on the trends in Japan:
Burkina Faso. Global Health Action.
retrospective observational study and
2015; 8 :10.
simulation study based on real-world
4. Wang, W., Temsah, G., & Mallick, L. data. British Medical Journal Open.
The impact of health insurance on 2017;7(7).
maternal health care utilization:
11. Stecker EC, Reinier K, Rusinaru C, Uy-
evidence from Ghana, Indonesia and
Evanado A, Jui J, Chugh SS. Health
Rwanda. Health Policy and Planning.
insurance expansion and incidence of
2017; 32: 366–375.
out-of-hospital cardiac arrest: a pilot
5. Vidyattama, Y., Miranti, R., & study in a US metropolitan community.
Resosudarmo, B. The role of health Journal American Heart Association.
insurance membership in health service 2017; 6(7) : e005667.
utilisation in Indonesia. Bulletin of
12. Saunders MR, Ricardo AC, Chen J,
Indonesian Economic Studies. 2014 ;
Chin MH, Lash JP. Association
50(3) : 393–413.
between insurance status and mortality
6. Lawani, L. O., Iyoke, C. A., Onoh, R. in individuals with albuminuria: an
C., Nkwo, P. O., Ibrahim, I. A., & observational cohort study. BMC
Ekwedigwe, K. C. Obstetric benefits of Nephrology. 2016;17: 27.
health insurance: A comparative
13. Wang Z, Zhang Y, Xiong F, Li H, Ding
analysis of obstetric indices and
Y, Gao Y, Zhao L, Wan S.Association
outcome of enrollees and non-enrollees
between medical insurance type and
in southeast Nigeria. Journal of
survival in patients undergoing
Obstetrics and Gynaecology. 2016;
peritoneal dialysis. BMC Nephrology.
36(7): 946–949.
2015; 16:33.
7. Kariisa, M., & Seiber, E. Distribution of
cardiovascular disease and associated

47
J Asian Med Stud Assoc