Thailand’s $1 health insurance schemeBy Bangkok Pundit Nov 11, 2010 11:59PM UTC
Yeah, that’s the gimmick: I was in Thailand. Anyway, here’s the thing. Thaksin Shinawatra was ousted four years ago. His Thai Rak Thai party was outlawed. The military regime that followed, and the subsequently elected Democrats, have done everything they can to root out Mr Thaksin’s political legacy. But Mr Thaksin’s 30-baht ($1 copayment) insurance system, which gives almost every poor Thai access to decent medical care, has remained, and there is no prospect of its being removed. The system, imperfect as it is, drove the number of Thais with no health insurance down from 16.5m in 2001 to 2.9m in 2005 [subscription required] — just 4% of the population.
Thai elites deployed their own version of “futility” rhetoric in opposition to the scheme, claiming doctors would simply charge under-the-table fees to clients using the 30-baht scheme. With rare exceptions, that didn’t happen. Even in the poorest slums in Thailand [PDF, no subscription requried], people can now go to the doctor. Poor Thais no longer have to watch the country’s world-class medical system provide foreign medical tourists (like me) with state-of-the-art care while they themselves cannot afford to see a doctor when their kid gets sick. They’ve gained access to the medical system, and no political force will dare take it away from them.
But the Thai example is also helpful in pointing out some differences. The most important, I think, is the simplicity of the Thai scheme. A 30-baht copayment for every treatment is something the poorest illiterate farmer in north-east Thailand can understand. That simplicity has helped buy those poor farmers’ support, support so intense that Mr Thaksin might still win an election in Thailand today if he were not living in exile and subject to an arrest warrant. In contrast, Obamacare is so complicated that it has failed to win the support of many of the people it will insure. They don’t know what it does. And that’s one major reason why Democrats, unlike Thaksin Shinawatra, haven’t reaped the political benefits of providing universal health insurance.
BP: Actually, after the coup the military-installed civilian government changed the 30 Baht scheme to make it free as they viewed the 30 Baht scheme to be a marketing gimmick (they replaced it with the term universal healthcare – this not being a marketing gimmick of course). It is one thing to come up with a good policy, but it is another thing to sell it properly as the article
The second link (where no subscription is required) is to a journal article entitled “Health care utilisation under the 30-Baht Scheme among the urban poor in Mitrapap slum, Khon Kaen, Thailand: a cross-sectional study” published in International Journal for Equity in Health. The conclusion:
At 86%, the overall coverage of the 30-Baht Scheme looks impressive among the population of Mitrapap slum in Khon Kaen. The vast majority of households enrolled in the 30-Baht Scheme say their access to health services has improved since the introduction of the scheme. Furthermore, most state that they are satisfied with the health services they receive.
However, a number of equity issues persist. The current user fee exemption mechanism fails to distinguish the poor from the poorest and actually favours those with an income above the national poverty line compared to those below. It also fails to exempt all those over 60 years of age – an exemption that should be automatic and easy to administer as all patients have to present the Gold Card and their Thai identity card whenever they seek health care at a registered facility. In addition, the main motivation for choosing a 30-Baht Scheme registered service is cost, with little concern for the quality of services dispensed.
Despite the apparent success of the scheme in decreasing direct health care costs, indirect costs such as loss of income are still a problem for about a third of households. This research highlights a number of areas for further investigation, notably how best to define who is ‘poor’ and subsequently to improve exemption mechanisms to better target this group. It would also be of value to ascertain why those aged above 60 years are not automatically excluded from paying user fees.
Despite Gold Card holders overwhelmingly stating that they are happy with the services they receive, this may not necessarily be a true indicator. Lack of education , power imbalances  or social concerns may be playing a role in making people unwilling to speak openly. A deeper qualitative analysis into peoples’ views could corroborate these findings.
The abolition of the very popular 30-Baht Scheme at the end of 2006 by General Sonthi Boonyaratglin’s Government after the ousting of Prime Minister Thaksin who had introduced the scheme in the first place was motivated by political reasons and not because it was seen as a failure.
BP: As the journal article notes, the introduction of the 30-Baht scheme has not made Thailand a utopia with the best medical care, but as the article also notes “coverage increased from 71.0% of the national population in 2001 to 94.3% by 2004″ (and to around 96% by 2005 – see The Economist‘s reference above). And people wonder why Thaksin was popular….