How do poor people get health insurance

The conditions under sub-regulation 1 for ascertaining who is an indigent shall be incorporated in the registration form of a district scheme. A person assigned the duty by a district scheme of registering persons for the scheme, shall elicit the information required under the sub regulation 1 for the classification of indigents as part of the registration process.

Every district scheme shall keep and publish a list of indigents in its area of operation and submit the list to the NHIA for validation [ 38 ]. Though all these criteria are restrictive, the 1b criterion which DHISs referred to as homelessness, defined as lacking a roof and not having any one to provide care, to qualify the core poor for premium exemption [ 39 ], disqualifies almost everybody.

The reality is that homelessness is nearly non-existent in the districts. In farming communities, a number of them were engaged as labourers by farmers to sow and harvest crops. They were also engaged by boat owners during the bumper harvest in fishing communities.

Some did menial jobs and did not have a stable income while others were totally unemployed and usually lived on the occasional benevolence of family members or friends. The core poor normally live in family houses, with friends or in dilapidated houses. Apart from the cities, homelessness does not exist.

I did not find a normal homeless person in the 15 communities I visited during my fieldwork. Everybody including the core poor had a home. Homelessness is mostly a characteristic of mentally disturbed people who roam cities and towns.

In her study of community concepts of poverty in the CR of Ghana, Aryeetey and her colleagues also observed that homelessness is an inappropriate condition for granting exemption to the poor [ 28 , 40 ]. As has been observed, the effectiveness of SHISs is the ability to reduce genuine exclusion [ 41 ]. We therefore question the motive for setting a criterion which disqualifies almost all potential beneficiaries as the basis for granting the core poor exemption. The relevant questions are: If the poor are the primary target of the NHIS, why set a criterion that excludes them?

Whose definition of the core poor should count: the one by policy makers or the one by the community? Analysis of these questions reveals insights regarding the motivation to establish a criterion that eliminates potential beneficiaries: lack of commitment.

If policy makers were genuinely committed to exempting the core poor, they would have ensured that all the criteria reflect the conditions of the target group and guide collectors on how to register them. Why these actions were not taken is explained by looking at the political situation at the time that the NHIS was introduced and taking into account the financial implications of granting exemptions to all those who would qualify.

The Population Census showed that 5. The Population and Housing Census also showed that These nation-wide figures roughly agree with our survey results which show that children years form In the case of the core poor, the Ghana Living Standard Survey shows that about a third Considering the core poor alone, it means that the government would have to pay premiums for about 2. For a country already overstretched with unfulfilled needs in other sectors, such as education and roads, the money to cover all these exemptions was simply not available.

The homelessness criterion thus seemed a strategy to lessen the financial burden of enrolling all core poor while serving as propaganda to accumulate political capital for the pending election. Also, the NHIS policy-making process was characterised by political rhetoric [ 19 , 45 ]. What was important at that time was to win votes and not practicalities of implementing the exemption policy. If this had not been the case, and politicians were truly committed they could have ensured that all the criteria set reflect the reality of the core poor.

Poverty needs to be defined by the community. This view starts from the assumption that opinion and community leaders understand local conditions of poverty and are in a better position to devise effective guidelines that could be used to identify them.

A critical analysis of various methods of identifying poor households, concluded that the community criteria of classifying the poorest members correlated with mean testing and the proxy mean testing considered as the gold standard [ 28 ].

One can hardly reach another conclusion than that the realities of implementing the exemption policy for the poor was intentionally disregarded.

First, policy makers recognised that no matter how low the cost of premium, the core poor cannot pay so provided exemption to ensure their inclusion in the NHIS. But the exemption is not reaching them. When DHIS staff and collectors were asked why they did not enrol the core poor, they demonstrated lack of commitment to the equity goal when discussing the issue.. Their first response was normally the problem of identification.

But we occasionally give exemptions when health providers refer patients who cannot pay their hospital bill to us. Thus just like previous exemption policies which were not successful, only a few core poor benefit from exemptions under the NHIS. The core poor are unable to claim the exemption they are entitled to. How is this possible? Contrary to the general opinion that inadequate exemption for the core poor is mainly due to identification difficulties, we argue that the explanation runs deeper.

The DHIISs could have used local indicators of poverty such as unemployment, no visible source of income and consistent support from another person which share commonalities with what is stated in the NHIS policy 1a and 1d. Ignoring these community indicators of poverty and using homelessness as the decisive criterion proved a convenient tool to exclude nearly all core poor without seeming unreasonable.

Throughout my fieldwork I did not see the DHISs organising any activity to identify the core poor for premium exemptions. The following comment by a DHIS staff illustrates their attitude towards exemptions for the core poor: We need money so if we go to communities and tell them about exemption for the core poor, how do we get revenue to meet some of our expenditure? Additionally, collectors who were expected to recommend the core poor to the DHISs to be certified as qualified for exemption usually do not disseminate information about exemptions.

They focus mainly on premium collection. This practice defeats the purpose of the NHIS as a safety net, which is expected to provide the poor with access to healthcare when ill and not when they are unable to pay for their healthcare.

The premium contributes significantly to their internally generated fund IGF which they need to meet some of their recurrent expenditure. These created disincentives to exempt people especially the core poor whose endorsement solely depends on the staff. Further, many community members told me they were not even aware of the exemption policy. In their study on exemptions of Community Health Fund in Tanzania observed that the managers often refuse request for exemptions because they felt it reduces their revenue [ 34 ].

He observes that they generally display a high margin of discretion and their actions effectively become public policy rather than the objectives of the documents developed at the policy level. Similarly, in this study DHIS staff and collectors can be described as stress-level bureaucrats who used their discretion and decide which aspects of the NHIS policy needs to be pursued: revenue generation or exemption.

As has been pointed out by earlier researchers, there should be trade-offs to achieve both goals [ 48 ]. They were more concerned about increasing their IGF to enhance their image and not to vigorously look for people to exempt since giving exemptions means they lose revenue. This is not to say that nothing is being done to improve the applicability of the exemption policy, but the moral urgency required of both past and present governments seems to be lacking. The LEAP started in March by the Government of Ghana as a social cash transfer programme to vulnerable households across the country.

It is still in its trial phase and has reached only 35, individuals [ 50 ]. Eligibility is based on poverty and having a household member in at least one of these three demographic categories: single parent with orphan or vulnerable child, elderly poor, or person with extreme disability and unable to work.

Initial selection of households is done through a community-based process and verified centrally with a proxy means test.

It must be noted that none of the core poor covered by the project in intervention communities in March , benefited from the LEAP programme. This suggest that despite the improvement in the exemption criteria, it still does not adequately resolve the problem of excluding the poor from the scheme.

Notwithstanding this limitation, we believe the inclusion of events at the national level make our findings reflect the enrolment of the poor in the NHIS and the reasons for their low coverage in the whole of Ghana. That said, the conclusions should be interpreted with care. This study has shown that though the NHIS is a social security programme targeted at the poor, the socio-economic and political context in which it operates exclude them from the scheme.

We recommend that community leaders should be engaged to develop criteria that reflect local conditions of poverty. They understand local conditions of poverty and are in a better position to devise effective guidelines for identifying the poorest members instead of policy makers who might not be familiar with local situations. Moreover, the majority of the core poor are excluded from the NHIS essentially because they could not demand exemption provided them.

They are the silent ones in society who cannot challenge policy makers and DHISs for not granting them exemptions for which they qualify. User-fees refer to out-of-pocket payments for some healthcare services at the point of utilisation.

The policy aimed at improving drug supplies in public health facilities and led to out-of-pocket payment for full cost of drugs in public health facilities. The Livelihood Empowerment against Poverty LEAP Programme started in March and expanded in and as a social cash transfer programme which provides cash and health insurance to extremely poor households across Ghana.

Nyonator F, Kutzin J. Health for some: the effect of user-fee in Volta Region of Ghana. Health Policy Plan. Cost recovery in Ghana: are there any changes in healthcare seeking behaviour? A price to pay.

Part 1: The impact of user charges in the Ashanti-Akim district, Ghana. Int J Health Plann Manage. Article Google Scholar. Part 2: The impact of user charges in the Volta Region of Ghana.

Hutchful E. Ghana adjustment experience: The paradox of reform. Google Scholar. Turshen M. Privatising Health Services in Africa. New Brunswick. Jersey, London: Rutgers University Press; World Health Organisation. Geneva: World Health Organisation; Health Econ.

Article PubMed Google Scholar. Geneva: WHO; Amporfu E. Private hospital accreditation and inducement of care under the Ghanaian National Insurance Scheme. Health Econ Rev. Asante F, Aikins M. Does the NHIS cover the poor?

National health insurance coverage and socio-economic status in a rural district of Ghana. Trop Med Int Health. Goodman H, Waddington C. Financing healthcare. Oxford: Oxfam UK and Ireland; Book Google Scholar. Ministry of Health. Policy framework for the establishment of health insurance in Ghana. Revised Edition. Accra: Ministry of Health; Longitudinal studies of health behavior describe positive e. However, there is a socioeconomic gradient in health improvement. In other words, populations with lower socioeconomic status lag behind populations with higher socioeconomic status in positive gains from health behavior trends.

Health behaviors are important in that they account for differences in mortality. Poverty affects health in many different ways through complex mechanisms that we are just beginning to understand and describe. Living in poverty does not necessarily predetermine poor health.

Instead, poverty affects both the likelihood that an individual will have risk factors for disease and its ability and opportunity to prevent and manage disease. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med. Thinking of poverty as a risk regulator rather than a rigid determinant of health allows family physicians to relinquish the feeling of helplessness when providing medical care to families and individuals with low income.

Family physicians are uniquely positioned to devise solutions to mitigate the development of risk factors that lead to disease and the conditions unique to populations with low income that interfere with effective disease prevention and management. Strong primary care teams are critical in the care of patients with low income. These populations often have higher rates of chronic disease and difficulty navigating health care systems. They benefit from care coordination and team-based care that addresses medical and socioeconomic needs.

In the United States, there is a move toward increased payment from government and commercial payers to offset the cost of providing coordinated and team-based care.

Some payment models provide shared savings or care coordination payments in addition to traditional fee-for-service reimbursement. The practice transformations from COPC and payment models based on targets and meaningful use alter how we approach patient panels and communities.

By recognizing and treating disease earlier — and actively partnering with local public health services like health educators, community health workers, and outreach services — family physicians can help prevent costly, avoidable complications and reduce the total cost of care. Care team members can positively affect the health of patients with low income by creating a welcoming, nonjudgmental environment that supports a long-standing therapeutic relationship built on trust.

For example, a patient with low income may arrive 15 minutes late to an appointment because they have to rely on someone else for transportation.

A patient may not take prescribed medication because it is too expensive. A patient may not get tests done because their employer will not allow time off from work. A patient may not understand printed care instructions because of low-literacy skills. Such patients may be turned away by staff because their tardiness disrupts the schedule, or they may even be dismissed from the practice altogether because of repeated noncompliance.

Physicians and care team members should learn why the patient was noncompliant and promote an atmosphere of tolerance and adaptation. Patients with low socioeconomic status and other marginalized populations rarely respond well to dictation from health care professionals.

Instead, interventions that rely on peer-to-peer storytelling or coaching are more effective in overcoming cognitive resistance to positive health behavior changes. Such activities are typically hosted by local hospitals, faith-based organizations, health departments, or senior centers.

Family physicians regularly screen for risk factors for disease. Once socioeconomic challenges are identified, physicians and their care teams can work with patients to design achievable, sustainable treatment plans. For example, crowding, infestations, and lack of utilities are all risk factors for disease. Knowing that a patient is homeless or has poor, inadequate housing will help guide care.

Family physicians direct the therapeutic process by working with the patient and care team to identify priorities so treatment goals are clear and achievable. It is likely that a patient with low income will not have the resources e.

For example, for a patient with limited means and multiple chronic conditions — including hypertension and diabetes — start by addressing these conditions. Colon cancer screening or a discussion about beginning statin therapy can come later.

It may be easier for this patient to adhere to an insulin regimen involving vials and syringes instead of insulin pens, which are much more expensive. Celebrate success with each small step that takes a patient closer to disease control and improved self-management. In many states, the expansion of Medicaid has allowed individuals and families with low income to become insured — perhaps for the first time.

A newly insured individual with low income will not necessarily know how or when to make, keep, or reschedule an appointment; develop a relationship with a family physician; manage medication refills; or obtain referrals. They may be embarrassed to reveal this lack of knowledge to the care team. Physicians and care team members can help by providing orientation to newly insured patients within the practice.

For example, ensure that all patients know where to pick up medication, how to take it and why, when to return for a follow-up visit and why, and how to follow their treatment plan from one appointment to the next. Without this type of compassionate intervention, patients may revert to an old pattern of seeking crisis-driven care often provided by the emergency department or a local hospital. Resources that make it easier for busy physicians to provide support to families with low income include the following:.

Follow-up calls are made to ensure clients connect successfully with the resource referrals. Local hospitals, health departments, and faith-based organizations often are connected to community health resources that offer services such as installing safety equipment in homes; providing food resources; facilitating behavioral health evaluation and treatment; and providing transportation, vaccinations, and other benefits to individuals and families with low income.

Practices can make a resource folder of information about local community services that can be easily accessed when taking care of patients in need. This simple measure incorporates community resources into the everyday workflow of patient care, thus empowering the care team. Much of the research about the effects of poverty on health is limited to identifying health disparities. This is insufficient. Family physicians can serve a critical role in this research because we have close relationships with patients with low income.

Family physicians are community leaders, so we can advocate effectively for initiatives that improve the quality of life in neighborhoods with low income. Other efforts may be specific to the community served.

For example, a vacant lot can be converted to a basketball court or soccer field. A community center can expand programs that involve peer-to-peer health coaching. A walking program can be started among residents in a public housing unit. Family physicians have local partners in advocacy, so we do not have to act in isolation. As a result of the Patient Protection and Affordable Care Act ACA , nonprofit hospitals regularly report community needs assessments and work with local health departments to establish action plans that address identified needs.

Local CHNAs are typically available online, as are the associated action plans. Am Fam Physician. Commission on Social Determinants of Health. Closing the gap in a generation. Health equity through action on the social determinants of health. Accessed March 22, How engaged are family physicians in addressing the social determinants of health? Health Equity. Explaining health care reform: questions about health insurance subsidies.

January 16, Need health insurance? ACA open enrollment: For consumers considering short-term policies. October 25, National Association of Health Underwriters. Find an agent. October 8, Jost, Timothy.

The Commonwealth Fund. Young adult coverage. Updated January 31, Your Privacy Rights. To change or withdraw your consent choices for VerywellHealth. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page.

These choices will be signaled globally to our partners and will not affect browsing data. We and our partners process data to: Actively scan device characteristics for identification. I Accept Show Purposes. If you qualify for this sort of subsidization—usually from an employer or the government—this is a great way to obtain health coverage that fits your budget.

These types of coverage may be appealing at first glance, but they can leave you in the lurch if and when you have a significant medical claim. Affordable Care Act Subsidy.

Short-Term Health Insurance. Job-Based Health Plan. Spouse's Health Plan. Parent's Health Plan. Was this page helpful? Thanks for your feedback! Sign Up. What are your concerns? Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Related Articles. Health Insurance Rule Changes for Retiring Before Age 65?

COBRA vs. Obamacare: Which Is Better? Best Health Insurance Companies for Retirees of Lost Your Health Insurance? Not Open Enrollment?