Financial protection is claimed to be an important objective of health policy. Yet there is a lack of clarity about what it is and no consensus on how to measure it. This impedes the design of efficient and equitable health financing. Arguably, the objective of financial protection is to shield nonmedical consumption from the cost of healthcare. The instruments are formal health insurance and public finances, as well as informal and self-insurance mechanisms that do not impair earnings potential. There are four main approaches to the measurement of financial protection: the extent of consumption smoothing over health shocks, the risk premium (willingness to pay in excess of a fair premium) to cover uninsured medical expenses, catastrophic healthcare payments, and impoverishing healthcare payments. The first of these does not restrict attention to medical expenses, which limits its relevance to health financing policy. The second rests on assumptions about risk preferences. No measure treats medical expenses that are financed through informal insurance and self-insurance instruments in an entirely satisfactory way. By ignoring these sources of imperfect insurance, the catastrophic payments measure overstates the impact of out-of-pocket medical expenses on living standards, while the impoverishment measure does not credibly identify poverty caused by them. It is better thought of as a correction to the measurement of poverty.
In the wake of the 2008 financial collapse, clearinghouses have emerged as critical players in the implementation of the post-crisis regulatory reform agenda. Recognizing serious shortcomings in the design of the over-the-counter derivatives market for swaps, regulators are now relying on clearinghouses to cure these deficiencies by taking on a central role in mitigating the risks of these instruments. Rather than leave trading firms to manage the risks of transacting in swaps privately, as was largely the case prior to 2008, post-crisis regulation requires that clearinghouses assume responsibility for ensuring that trades are properly settled, reported to authorities, and supported by strong cushions of protective collateral. With clearinghouses effectively guaranteeing that the terms of a trade will be honored—even if one of the trading parties cannot perform—the market can operate with reduced levels of counterparty risk, opacity, and the threat of systemic collapse brought on by recklessness and over-complexity. But despite their obvious benefit for regulators, clearinghouses also pose risks of their own. First, given their deepening significance for market stability, ensuring that clearinghouses themselves operate safely represents a matter of the highest policy priority. Yet overseeing clearinghouses is far from easy and understanding what works best to undergird their safe operation can be a contentious and uncertain matter. U.S. and EU authorities, for example, have diverged in important ways on what rules should apply to the workings of international clearinghouses. Secondly, clearinghouse oversight is critical because these institutions now warehouse enormous levels of counterparty risk. By promising counterparties across the market that their trades will settle as agreed, even if one or the other firm goes bust, clearinghouses assume almost inconceivably large and complicated risks within their institutions. For swaps in particular—whose obligations can last for months, or even years—the scale of these risks can be far more extensive than that entailed in a one-off sale or a stock or bond. In this way, commentators note that by becoming the go-to bulwark against risk-taking and its spread in the financial system, clearinghouses have themselves become the too-big-to-fail institution par excellence.
Important health system challenges in the east and southeast Asian countries/territories of Japan, South Korea, Taiwan, Hong Kong, Malaysia, China, Thailand, Vietnam, Indonesia, the Philippines, Laos, Myanmar, and Cambodia exist. The most commonly adopted health system among these areas is social health insurance. The high-income, aging societies of Japan, South Korea, and Taiwan have adopted single-payer/single-pipe systems with a single uniform benefit package and a single fee schedule for paying providers for services included in the benefit package. All three have achieved universal coverage with relatively equitable access to affordable care. All grapple with overutilization, aging populations, and hospital-centric and curative-focused care that is ill-suited for addressing an increasing chronic disease burden. Rising patient expectations and demand for expensive technologies contribute to rising costs. Korea also faces comparatively poorer financial risk protection. China, Thailand, Vietnam, Indonesia, and the Philippines have also adopted social health insurance, though not single-payer systems. China and Thailand have established noncontributory schemes, whereby the government heavily subsidizes poor and non-poor populations. General tax revenue is used to extend coverage to those outside formal-sector employment. Both countries use multiple, unintegrated schemes to cover their populations. Thailand has improved access to care and financial risk protection. While China has improved insurance coverage, financial risk protection gains have been limited due to low levels of service coverage, fee-for-service payment systems, poor gatekeeping, and the fee schedule that incentivizes overprescription of tests and medicine. Indonesia, Vietnam, and the Philippines use contributory schemes. Government revenue provides insurance coverage for the poor, near-poor, and selected vulnerable populations; the rest of the population must contribute to enroll. Therefore, expanding insurance coverage to the informal sector has been a significant challenge. Instead of social health insurance, Hong Kong and Malaysia have two-tiered health systems where the public sector is financed by general tax revenue and the private sector is financed primarily by out-of-pocket payments and limited private insurance. There is universal access to care; free or subsidized, good-quality public-sector services provide financial risk protection. However, Hong Kong and Malaysia have fragmented delivery systems, weak primary care, budgetary strains, and inequitable access to private care (which may offer shorter wait times and better perceived quality). Laos, Cambodia, and Myanmar’s health systems feature high out-of-pocket spending, low government investment in health, and reliance on external aid. User fees, low insurance coverage, unequal distribution of health services, and fragmented financing pose pressing challenges to achieving equitable access and adequate financial risk protection. These countries/territories are diverse in terms of demographics, epidemiological profiles, and stages of economic development, and thus they face different health system challenges and opportunities. This diversity also suggests that these nations/territories will utilize different types of health systems to achieve universal health coverage, whereby all people have equitable access to affordable, good-quality care with adequate financial risk protection.