Why Did the ACA Co-Op Program Fail? Lessons for the Health Reform Debate.

The ACA created a new type of nonprofit health insurance entity, the "Consumer Operated and Oriented Plan" ("co-op"). Most of the newly created co-ops soon lost money, and only 4 of the original 23 remain. We interviewed key stakeholders and conducted in-depth case studies of 3 of these co-ops. We discovered that politicians and regulators made it unlikely the program could succeed, that most of the co-ops did not have the management capacity to overcome these political obstacles, and that even those with good managers lacked the needed fiscal resilience. We also considered lessons suggested for those proposing a newly created "public option." The main one is that a successful public option requires a supportive political environment, strong management, and significant fiscal capacity, none of which comes easily. A better route may be a quasi-public option in which the government subcontracts the operation of its newly created plan to a private firm. Although it is uncertain whether federal regulators have the capacity to hold such private for-profit firms accountable, pragmatism suggests that a combination of public-sector regulation and private-sector implementation may be the most direct path toward a US version of affordable universal coverage.

Feasibility of community-based health insurance in rural tropical Ecuador.

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50% of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3%. With affiliation, 92.2% of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

Feasibility of community-based health insurance in rural tropical Ecuador / Factibilidad de un seguro de enfermedad comunitario en una zona rural tropical de Ecuador

OBJECTIVE: The main objective of this study was to assess people's willingness to join a community-based health insurance (CHI) model in El Páramo, a rural area in Ecuador, and to determine factors influencing this willingness. A second objective was to identify people's understanding and attitudes toward the presented CHI model. METHODS: A cross-sectional survey was carried out using a structured questionnaire. Of an estimated 829 households, 210 were randomly selected by two-stage cluster sampling. Attitudes toward the scheme were assessed. Information on factors possibly influencing willingness to join was collected and related to the willingness to join. To gain an insight into a respondent's possible ability to pay, health care expenditure on the last illness episode was assessed. Feasibility was defined as at least 50 percent of household heads willing to join the scheme. RESULTS: Willingness to join the CHI model for US$30 per year was 69.3 percent. With affiliation, 92.2 percent of interviewees stated that they would visit the local health facility more often. Willingness to join was found to be negatively associated with education. Other variables showed no significant association with willingness to join. The study showed a positive attitude toward the CHI scheme. Substantial health care expenditures on the last illness episode were documented. CONCLUSIONS: The investigation concludes that CHI in the study region is feasible. However, enrollments are likely to be lower than the stated willingness to join. Still, a CHI scheme should present an interesting financing alternative in rural areas where services are scarce and difficult to sustain.

OBJETIVO: El objetivo principal de este estudio fue evaluar la voluntad de los habitantes de El Páramo, una zona rural en el Ecuador, de participar en un seguro de salud comunitario y determinar los factores que influían en dicha voluntad. Otro objetivo fue identificar la comprensión y las actitudes de la población hacia el modelo presentado. MÉTODOS: Se llevó a cabo una encuesta transversal usando un cuestionario estructurado. De unos 829 hogares, 210 se escogieron aleatoriamente mediante un muestreo por conglomerados en dos etapas. Se analizaron las actitudes hacia un esquema de seguro de enfermedad, se recopiló información sobre los factores que posiblemente influían en la voluntad de participar y se correlacionaron con esta última. Para comprender la posible capacidad de pago de un entrevistado, se evaluó el gasto en atención de la salud en el último episodio de enfermedad. Se definió "factibilidad" como la existencia de voluntad de participar en el esquema de seguro de enfermedad en al menos 50 por ciento de los jefes de hogar. RESULTADOS: La voluntad de participar en un modelo de seguro de enfermedad por un costo de US$ 30 por año fue de 69,3 por ciento. El 92,2 por ciento de los entrevistados declararon que, en el caso de adherirse al programa, concurrirían al establecimiento de salud local más a menudo. El nivel educativo presentó una correlación negativa con la voluntad de participar, pero otras variables no mostraron ninguna asociación significativa con ella. El estudio reveló una actitud positiva hacia el esquema del seguro de enfermedad. Se documentaron gastos de atención de salud importantes en el último episodio de enfermedad. CONCLUSIONES: La puesta en marcha de un seguro de enfermedad en la zona de estudio es factible. Sin embargo, es probable que la participación real sea inferior a la voluntad de participar declarada. Aun así, un esquema de seguro de enfermedad podría representar una opción financiera interesante en las zonas rurales donde los servicios son escasos y difíciles de mantener.