Cost-effectiveness of national health insurance programs in high-income countries: A systematic review

OBJECTIVES National health insurance is now common in most developed countries. This study reviews the evidence and synthesizes the cost-effectiveness information for national health insurance or disability insurance programs across high-income countries. DATA SOURCES A literature search using health, economics and systematic review electronic databases (PubMed, Embase, Medline, Econlit, RepEc, Cochrane library and Campbell library), was conducted from April to October 2015. STUDY SELECTION Two reviewers independently selected relevant studies by applying screening criteria to the title and keywords fields, followed by a detailed examination of abstracts. DATA EXTRACTION Studies were selected for data extraction using a quality assessment form consisting of five questions. Only studies with positive answers to all five screening questions were selected for data extraction. Data were entered into a data extraction form by one reviewer and verified by another. EVIDENCE SYNTHESIS Data on costs and quality of life in control and treatment groups were used to draw distributions for synthesis. We chose the log-normal distribution for both cost and quality-of-life data to reflect non-negative value and high skew. The results were synthesized using a Monte Carlo simulation, with 10,000 repetitions, to estimate the overall cost-effectiveness of national health insurance programs. RESULTS Four studies from the United States that examined the cost-effectiveness of national health insurance were included in the review. One study examined the effects of medical expenditure, and the remaining studies examined the cost-effectiveness of health insurance reforms. The incremental cost-effectiveness ratio (ICER) ranged from US$23,000 to US$64,000 per QALY. The combined results showed that national health insurance is associated with an average incremental cost-effectiveness ratio of US$51,300 per quality-adjusted life year (QALY). Based on the standard threshold for cost-effectiveness, national insurance programs are cost-effective interventions. CONCLUSIONS Although national health insurance programs have been introduced in most developed countries, only a few studies have examined their cost-effectiveness. All the selected studies revealed strong evidence to support health insurance programs or health reforms in the United States. The average ICER in this study is below the standard threshold for cost-effectiveness used in the US. The small number of relevant studies is the main limitation of this study.