Abstract
As for all health systems, in Russia, the demand for medical care is greater than its health system is able to guarantee the supply of. In this context, removing services from the state guaranteed package is an option that is receiving serious consideration. In this paper, we examine the attitudes of the Russian population to such a reform. Exploiting a widely-used methodology, we explore the population’s willingness to pay for cooperative health insurance. Distinguishing between socioeconomic and demographic factors, health-related indicators and risk aversion we find, consistent with other literature, positive income and risk aversion effects. We interpret the former as evidence that the Russian population is not opposed to the idea of progressive redistribution, to pool the costs of health-related risks; and the latter as evidence that risk-averse individuals demand more insurance coverage. In exploring these results further, we show that cognitive bias is important: overestimating the benefits leads to the purchase of additional insurance, while underestimating lowers demand for insurance. Our overall conclusion is that the introduction of a supplementary cooperative health insurance scheme in Russia could increase the accessibility of healthcare, lower the tendency for informal payments, incentivize the personal maintenance of good health and create a new source of funding for public healthcare.
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Notes
The survey was sponsored by the UCL School of Slavonic and East European Studies (UCL SSEES). The authors were directly involved in helping to formulate the attitudinal instruments within the survey.
The statistical error of the survey does not exceed 3.4%.
It is worth noting that, in Russia, all VHI plans are similar. Basically, under VHI, all services in clinics and hospitals that work with a particular insurance company are available for a policy holder except dental care and treatment of self-inflicted injuries. If/once the cost of services exceeds the level of insurance coverage during a year, the insurance is terminated. Since all VHI plans are very similar, the situation when the choice of services included in the cooperative health insurance influences a person’s choice of policy is very unlikely.
The fact that individuals might have different perceptions of quality is not of primary importance here since his/her unique perception is one of the subjective factors on which an individual bases his/her WTP.
A subsequent question (5D) asked respondents to provide an estimation of a lower price of insurance at which they would question the quality of services provided.
In our regressions, this sample is reduced further due to missing information for illness (N = 299) and the information required to calculate the Arrow–Pratt measures (N = 261).
Results are available from the authors upon request.
Respondents were asked to choose between six responses reflecting their subjective income status.
Choice of cooperative health insurance could in practice be influenced by having/not having voluntary health insurance (VHI). Question 7 asked about reasons for not being willing to participate in the cooperative health insurance scheme. It was an open-ended question and only 5 out of 326 individuals with VHI (1.5%) stated that VHI was a reason for not wanting to participate in the new proposed scheme. Given such a low proportion (1.5%) we did not specifically control for VHI as a possible factor influencing choice of the new scheme.
The ‘cannot answer’ choice in Q5A is coded as missing and the ‘over 9000’ (13 observations) choice is changed to the arbitrary selected figure of 10,000 in order to substitute a qualitative answer with a numeric value.
To preserve space we only assess the impact of cognitive bias on the multinomial regression (from Table 2) but the results (available on request) based on the other two specifications are not qualitatively affected.
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Acknowledgements
We are grateful to participants in RANEPA seminars for helpful comments on this paper.
Funding
Russian Presidential Academy of National Economy and Public Administration, Moscow (RANEPA). We are grateful also to the UCL School of Slavonic and East European Studies (UCL SSEES) for financing the data collection.
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Appendices
Appendix 1: Original coding of and responses to Q5a
Card shown | Amount, RUR | % of respondents who chose this card | Number of respondents who chose this card |
---|---|---|---|
1 | 500 | 17.68 | 58 |
2 | 1000 | 27.74 | 91 |
3 | 1700 | 7.93 | 27 |
4 | 2500 | 13.11 | 43 |
5 | 3500 | 6.40 | 21 |
6 | 4500 | 6.10 | 20 |
7 | 5500 | 6.10 | 20 |
8 | 7000 | 3.05 | 10 |
9 | 9000 | 0.30 | 1 |
10 | Over 9000 | 3.96 | 13 |
99 | Cannot answer | 7.62 | 25 |
Appendix 2: Distribution of answers to the lottery question (q8), N = 1602
How much would you be willing to pay for the lottery ticket? (Rubles) | Frequency | Percentage | Cumulative percentage |
---|---|---|---|
Cannot answer | 222 | 13.86 | 13.86 |
I would not participate in the lottery | 895 | 55.87 | 69.73 |
10 | 20 | 1.25 | 70.97 |
15 | 1 | 0.06 | 71.04 |
20 | 17 | 1.06 | 72.10 |
25 | 1 | 0.06 | 72.16 |
30 | 22 | 1.37 | 73.53 |
35 | 1 | 0.06 | 73.60 |
40 | 3 | 0.19 | 73.78 |
50 | 74 | 4.62 | 78.40 |
60 | 1 | 0.06 | 78.46 |
70 | 2 | 0.12 | 78.59 |
80 | 1 | 0.06 | 78.65 |
99 | 1 | 0.06 | 78.71 |
100 | 143 | 8.93 | 87.64 |
150 | 16 | 1.00 | 88.64 |
200 | 45 | 2.81 | 91.45 |
250 | 8 | 0.50 | 91.95 |
300 | 22 | 1.37 | 93.32 |
500 | 42 | 2.62 | 95.94 |
700 | 1 | 0.06 | 96.00 |
1000 | 41 | 2.56 | 98.56 |
2000 | 8 | 0.50 | 99.06 |
3000 | 10 | 0.62 | 99.69 |
5000 | 5 | 0.31 | 100.00 |
Total | 1602 | 100 |
Appendix 3: Distribution of Arrow–Pratt measure, A–P, for the sample N = 299
A–P | Frequency | Percentage | Cumulative percentage |
---|---|---|---|
− 0.0000471 | 1 | 0.38 | 0.38 |
0 | 7 | 2.68 | 3.07 |
0.0000244 | 5 | 1.92 | 4.98 |
0.0000471 | 17 | 6.51 | 11.49 |
0.0000573 | 17 | 6.51 | 18.01 |
0.0000612 | 6 | 2.30 | 20.31 |
0.0000621 | 2 | 0.77 | 21.07 |
0.0000630 | 14 | 5.36 | 26.44 |
0.0000640 | 3 | 1.15 | 27.59 |
0.0000649 | 40 | 15.33 | 42.91 |
0.0000654 | 1 | 0.38 | 43.30 |
0.0000656 | 1 | 0.38 | 43.68 |
0.0000658 | 16 | 6.13 | 49.81 |
0.0000660 | 1 | 0.38 | 50.19 |
0.0000661 | 4 | 1.53 | 51.72 |
0.0000663 | 3 | 1.15 | 52.87 |
0.0000664 | 1 | 0.38 | 53.26 |
0.0000665 | 2 | 0.77 | 54.02 |
0.0000667 | 120 | 45.98 | 100.0 |
Total observations | 261a | 100 |
Appendix 4: Summary statistics for socioeconomic and health-related factors, N = 299
Variable | Definition | Mean | SD | Min | Max |
---|---|---|---|---|---|
Gender | 0 = Females 1 = Males | 0.485 | 0.501 | 0 | 1 |
Age | Age of respondent | 42.043 | 14.999 | 18 | 88 |
Age squared | Squared age of respondent | 1991.876 | 1386.492 | 324 | 7744 |
Good self-assessed health | 1 = respondent states that he/she is in good health 0 = otherwise | 0.421 | 0.495 | 0 | 1 |
Chronic illness | 1 = respondent has one or more chronic illnesses 0 = respondent does not have any chronic illnesses | 0.321 | 0.468 | 0 | 1 |
Work | 1 = respondent has a job 0 = otherwise | 0.719 | 0.450 | 0 | 1 |
Student | 1 = respondent attends university 0 = otherwise | 0.030 | 0.171 | 0 | 1 |
Pensioner | 1 = respondent is retired 0 = otherwise | 0.164 | 0.371 | 0 | 1 |
Unemployed (reference) | 1 = respondent is unemployed 0 = otherwise | 0.087 | 0.282 | 0 | 1 |
Married | 1 = respondent is married 0 = otherwise | 0.689 | 0.464 | 0 | 1 |
Divorced | 1 = respondent is divorced 0 = otherwise | 0.114 | 0.318 | 0 | 1 |
Single | 1 = respondent is single 0 = otherwise | 0.134 | 0.341 | 0 | 1 |
Widower (reference) | 1 = respondent is a widow(er) 0 = otherwise | 0.064 | 0.244 | 0 | 1 |
Capital | 1 = respondent lives in a capital of a region 0 = otherwise | 0.197 | 0.399 | 0 | 1 |
Town | 1 = respondent lives in a town with population of more than 100,000 0 = otherwise | 0.164 | 0.371 | 0 | 1 |
Small town | 1 = respondent lives in a town with population of less than 100,000 0 = otherwise | 0.331 | 0.471 | 0 | 1 |
Village | 1 = respondent lives in a village 0 = otherwise | 0.207 | 0.406 | 0 | 1 |
Moscow (reference) | 1 = respondent lives in Moscow or Saint Petersburg 0 = otherwise | 0.100 | 0.301 | 0 | 1 |
Primary education (reference) | 1 = respondent attained primary education 0 = otherwise | 0.080 | 0.272 | 0 | 1 |
Secondary education | 1 = respondent attained secondary education 0 = otherwise | 0.599 | 0.491 | 0 | 1 |
Higher education | 1 = respondent attained higher education 0 = otherwise | 0.321 | 0.468 | 0 | 1 |
Income category 1 (reference) | 1 = we hardly live, we have no money for food 0 = otherwise | 0.010 | 0.100 | 0 | 1 |
Income category 2 | 1 = we have enough money for food but not for clothes 0 = otherwise | 0.064 | 0.244 | 0 | 1 |
Income category 3 | 1 = we have enough money to buy food and clothes but not durable goods (like TV and refrigerator) 0 = otherwise | 0.605 | 0.490 | 0 | 1 |
Income category 4 | 1 = we can buy durable goods (like TV and refrigerator) but we cannot afford a car 0 = otherwise | 0.261 | 0.440 | 0 | 1 |
Income category 5 | 1 = we can buy a car but there are still things we can’t afford 0 = otherwise | 0.060 | 0.238 | 0 | 1 |
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Kaneva, M., Gerry, C.J., Avxentiev, N. et al. Attitudes to reform: Could a cooperative health insurance scheme work in Russia?. Int J Health Econ Manag. 19, 371–394 (2019). https://doi.org/10.1007/s10754-019-09260-3
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DOI: https://doi.org/10.1007/s10754-019-09260-3
Keywords
- Cooperative health insurance
- Willingness to pay
- Risk aversion
- Solidarity
- Cognitive bias
- Russia
- Health reform