The Dilemma of Underutilized Health Insurance: A Matched Case-Control Study Investigating Reasons in Iran’s Free  Universal Health Insurance

Elham  Khatooni; Elham  Ahmadnezhad; Alireza  Olyaeemanesh; Reza  Majdzadeh

doi:10.18502/ijph.v52i12.14325

Elham Khatooni Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
Elham Ahmadnezhad National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran
Alireza Olyaeemanesh National Institute of Health Research, Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
Reza Majdzadeh Department of Epidemiology and Biostatistics, School of Public Health, Knowledge Utilization Research Center and Community-Based Participa-tory Research, Tehran University of Medical Sciences, Tehran, Iran

DOI: https://doi.org/10.18502/ijph.v52i12.14325

Keywords: Health sector reform; Financial protection; Health insurance; Universal health coverage

Abstract

Background: In May 2014, the Iranian government announced it would cover all uninsured Iranians. Despite free-of-charge insurance, the studies found that the coverage still needed to be completed (93%). This study aimed to understand why certain population groups remain without insurance despite the accessibility of free-of-charge coverage. This issue is not unique to Iran; it is prevalent in many other countries where, despite free coverage, not all individuals avail themselves of it, thereby exposing themselves to risks.

Methods: In a matched case-control study, 89 non-insured patients were compared with 178 hospital-based controls with health insurance (2:1). The samples were recruited at one of the leading public hospitals in the country (Imam Khomeini Hospital Complex in Tehran) in 2019. Two insured controls were selected and matched for age (± five years) and sex for each person without insurance. A conditional logistic regression was performed to assess the magnitude of effects and the goodness of fit test used to examine the model.

Results: Unemployment (Odds Ratio (OR)=8.33, 95% Confidence interval (CI): 1.05-50.0), being single (OR=3.69, CI: 1.18-11.55), low economic status (OR=1.85, CI: 1.02-3.33) and attitude towards performance of health insurance (OR=0.86, CI: 0.75-0.99) were affected not having health insurance.

Conclusion: Approaches that cover the entire population may struggle to ensure no one is left without needed services. There is a need for greater focus on vulnerable groups to achieve universal health coverage conscientiously. Moreover, improved services and education can positively shape public perceptions of insurance efficacy, affecting their enrollment choices.