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Determinants of Public Healthcare Expenditure & Fiscal Sustainability Projections

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OECD Governance
OECD Governance

This presentation was made by Thomas Brändle and Carsten Colombier, Switzerland, at the 4th meeting of the Joint DELSA/GOV-SBO Network on Fiscal Sustainability of Health Systems, held in Paris on 16-17 February 2015.

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Federal Department of Finance FDF Federal Finance Administration FFA Determinants of Public Health Care Expenditure & Fiscal Sustainability Network Fiscal Sustainability of Health Systems, OECD, Paris, February 2015 Thomas Brändle* & Carsten Colombier** Swiss Federal Department of Finance (FFA) *University of Basel, Faculty of Business and Economics. **FiFo – Institute for Public Economics, University of Cologne.
2 Federal Department of Finance FDF Federal Finance Administration FFA Motivation Swiss healthcare expenditure from 1960 to 2012 (in GDP %) • Expenditure share government & mandatory healthcare insurance: about 60% • Public expenditure share in total healthcare expenditure is about 30% • Cantonal expenditure share in public healthcare expenditure is about 66% Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
3 Federal Department of Finance FDF Federal Finance Administration FFA Outline • What are the determinants of cantonal public health care expenditure between 1970-2012?  Panel data analysis for Swiss cantons • How will public healthcare expenditure be affected by population ageing and non- demographic cost drivers until 2060?  Long-term projections • Which are the implications for assessing fiscal sustainability? Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
Federal Department of Finance FDF Federal Finance Administration FFA What are the determinants of cantonal healthcare expenditure between 1970- 2012? Panel data analysis for Swiss cantons
5 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • Panel dataset for all 26 Swiss cantons between 1970 and 2012. • Dynamic bias-corrected LSDV estimator (Bruno 2005): • Demand-side  GDP per capita and unemployment rate  Socio-demographic drivers • Share of the population above 64 years • Share of the population below 6 years • Share of the foreign population • Supply-side  Medical progress, proxied by the mortality rate  Physicians` density Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
6 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • Political-institutional determinants based on political economics literature  Parliament size (common pool)  Composition of the pool of politicians in terms of gender  Institutional restrictions that aim at discipling politicians` budgetary discretion (fiscal rules and mandatory referenda)  Election cycles and ideology • Major Swiss healthcare reforms  Introduction of a mandatory healthcare insurance (1996)  Long-term care finance reform (2011) and hospital finance reform (2012)  Use of global budgets. Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
7 Federal Department of Finance FDF Federal Finance Administration FFA Results I Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
8 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • What determinants seem to be relevant to public healthcare expenditure (expected sign & statistically significant) • Real GDP per capita • Unemployment rate • Share of foreigners • Share of women in parliament • Population variables • Difficult to disentangle from time fixed effects Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
Federal Department of Finance FDF Federal Finance Administration FFA How will public healthcare expenditure be affected by population ageing and non-demographic cost drivers until 2060? Long-term projections
10 Federal Department of Finance FDF Federal Finance Administration FFA Methods and data Scenarios are based on the following cost drivers • Population ageing • Relationship between the rising life expectancy and the health status of the population • Relationship between GDP and healthcare expenditure • Healthcare as a luxury good (demand-side) • Purchasing power increases with GDP => incentives for medical innovations are increased (supply-side) • Baumol‘s cost disease • Scarcity of healthcare and long-term care personnel Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
11 Federal Department of Finance FDF Federal Finance Administration FFA Results Level 2009 2060 Change 2009-60 (in %) Total healthcare 11.3 15.8 +4.5 40 Government (incl. social welfare) 3.5 5.6 +2.1 60 Confederation 0-4 0.6 +0.1 50 Cantons 2.3 3.9 +1.7 70 Communes 0.3 0.6 +0.3 100 Old-age insurance helplessness allowance (AHV-HE) 0.1 0.3 +0.2 200 Disability and old-age insurance contributions (IV/ AHV-Beiträge) 0.3 0.2 -0.1 -33 Mandatory basic healthcare insurance (OKP) 3.3 4.6 +1.3 39 Healthcare expenditure by source of financing in reference scenario (in GDP % and in %)
12 Federal Department of Finance FDF Federal Finance Administration FFA Results Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015 Breakdown of public healthcare expenditure by healthcare area in reference scenario (in %) 17 33 72 63 11 4 0% 20% 40% 60% 80% 100% 2009 2060 Long-term care from 65 Healthcare Long-term care below 65
13 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Key results • Importance of macroeconomic development. • Some role for the composition of the pool of politicians. • No role for institutional restrictions on budgetary behavior. • Consequences of recent reforms not clear. • Ageing will become increasingly important • Retirement of baby boomers • Medical progress • Crucial determinant of healthcare expenditure • But difficult to measure Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
14 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Evaluation of fiscal sustainability • Cantonal budgets most severly affected by additional cost burden • Cantonal share of public HCE in 2009: 66%; in 2060: 70% • Public healthcare expenditure seriously affected by long-term care from 65 • LTC-share in public HCE in 2009: 17%; in 2060: 33% • Expenditure (in GDP %) of communes and old-age insurance helplessness allowance double and triple resp. up to 2060 • Sustainabiliy of federal health budget not jeopardised as outlays are practically limited to individual premium reduction Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
15 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Policy measures • Monitoring: Regular analyses and projections on public healthcare expenditure. • Proposals for policy makers related to the Swiss comprehensive health care strategy (Health 2020). • Fostering preventive measures, e.g. improvement of health education. • Fostering organisational innovation, e.g. ehealth, quality standards and coordinated care models. • Prevention of shortage of skilled health labor force. • Ensure adequate financing of long-term care (e.g., a social insurance solution). Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015

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Determinants of Public Healthcare Expenditure & Fiscal Sustainability Projections

  • 1. Federal Department of Finance FDF Federal Finance Administration FFA Determinants of Public Health Care Expenditure & Fiscal Sustainability Network Fiscal Sustainability of Health Systems, OECD, Paris, February 2015 Thomas Brändle* & Carsten Colombier** Swiss Federal Department of Finance (FFA) *University of Basel, Faculty of Business and Economics. **FiFo – Institute for Public Economics, University of Cologne.
  • 2. 2 Federal Department of Finance FDF Federal Finance Administration FFA Motivation Swiss healthcare expenditure from 1960 to 2012 (in GDP %) • Expenditure share government & mandatory healthcare insurance: about 60% • Public expenditure share in total healthcare expenditure is about 30% • Cantonal expenditure share in public healthcare expenditure is about 66% Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
  • 3. 3 Federal Department of Finance FDF Federal Finance Administration FFA Outline • What are the determinants of cantonal public health care expenditure between 1970-2012?  Panel data analysis for Swiss cantons • How will public healthcare expenditure be affected by population ageing and non- demographic cost drivers until 2060?  Long-term projections • Which are the implications for assessing fiscal sustainability? Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 4. Federal Department of Finance FDF Federal Finance Administration FFA What are the determinants of cantonal healthcare expenditure between 1970- 2012? Panel data analysis for Swiss cantons
  • 5. 5 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • Panel dataset for all 26 Swiss cantons between 1970 and 2012. • Dynamic bias-corrected LSDV estimator (Bruno 2005): • Demand-side  GDP per capita and unemployment rate  Socio-demographic drivers • Share of the population above 64 years • Share of the population below 6 years • Share of the foreign population • Supply-side  Medical progress, proxied by the mortality rate  Physicians` density Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 6. 6 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • Political-institutional determinants based on political economics literature  Parliament size (common pool)  Composition of the pool of politicians in terms of gender  Institutional restrictions that aim at discipling politicians` budgetary discretion (fiscal rules and mandatory referenda)  Election cycles and ideology • Major Swiss healthcare reforms  Introduction of a mandatory healthcare insurance (1996)  Long-term care finance reform (2011) and hospital finance reform (2012)  Use of global budgets. Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 7. 7 Federal Department of Finance FDF Federal Finance Administration FFA Results I Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 8. 8 Federal Department of Finance FDF Federal Finance Administration FFA Determinants of public health care expenditure • What determinants seem to be relevant to public healthcare expenditure (expected sign & statistically significant) • Real GDP per capita • Unemployment rate • Share of foreigners • Share of women in parliament • Population variables • Difficult to disentangle from time fixed effects Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 9. Federal Department of Finance FDF Federal Finance Administration FFA How will public healthcare expenditure be affected by population ageing and non-demographic cost drivers until 2060? Long-term projections
  • 10. 10 Federal Department of Finance FDF Federal Finance Administration FFA Methods and data Scenarios are based on the following cost drivers • Population ageing • Relationship between the rising life expectancy and the health status of the population • Relationship between GDP and healthcare expenditure • Healthcare as a luxury good (demand-side) • Purchasing power increases with GDP => incentives for medical innovations are increased (supply-side) • Baumol‘s cost disease • Scarcity of healthcare and long-term care personnel Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 11. 11 Federal Department of Finance FDF Federal Finance Administration FFA Results Level 2009 2060 Change 2009-60 (in %) Total healthcare 11.3 15.8 +4.5 40 Government (incl. social welfare) 3.5 5.6 +2.1 60 Confederation 0-4 0.6 +0.1 50 Cantons 2.3 3.9 +1.7 70 Communes 0.3 0.6 +0.3 100 Old-age insurance helplessness allowance (AHV-HE) 0.1 0.3 +0.2 200 Disability and old-age insurance contributions (IV/ AHV-Beiträge) 0.3 0.2 -0.1 -33 Mandatory basic healthcare insurance (OKP) 3.3 4.6 +1.3 39 Healthcare expenditure by source of financing in reference scenario (in GDP % and in %)
  • 12. 12 Federal Department of Finance FDF Federal Finance Administration FFA Results Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015 Breakdown of public healthcare expenditure by healthcare area in reference scenario (in %) 17 33 72 63 11 4 0% 20% 40% 60% 80% 100% 2009 2060 Long-term care from 65 Healthcare Long-term care below 65
  • 13. 13 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Key results • Importance of macroeconomic development. • Some role for the composition of the pool of politicians. • No role for institutional restrictions on budgetary behavior. • Consequences of recent reforms not clear. • Ageing will become increasingly important • Retirement of baby boomers • Medical progress • Crucial determinant of healthcare expenditure • But difficult to measure Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 14. 14 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Evaluation of fiscal sustainability • Cantonal budgets most severly affected by additional cost burden • Cantonal share of public HCE in 2009: 66%; in 2060: 70% • Public healthcare expenditure seriously affected by long-term care from 65 • LTC-share in public HCE in 2009: 17%; in 2060: 33% • Expenditure (in GDP %) of communes and old-age insurance helplessness allowance double and triple resp. up to 2060 • Sustainabiliy of federal health budget not jeopardised as outlays are practically limited to individual premium reduction Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015
  • 15. 15 Federal Department of Finance FDF Federal Finance Administration FFA Implications for fiscal sustainability Policy measures • Monitoring: Regular analyses and projections on public healthcare expenditure. • Proposals for policy makers related to the Swiss comprehensive health care strategy (Health 2020). • Fostering preventive measures, e.g. improvement of health education. • Fostering organisational innovation, e.g. ehealth, quality standards and coordinated care models. • Prevention of shortage of skilled health labor force. • Ensure adequate financing of long-term care (e.g., a social insurance solution). Public Healthcare Expenditure; Brändle/ Colombier; OECD February 2015