Assessing barriers to health insurance and threats to equity in comparative perspective: The Health Insurance Access Database

The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990–2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems’ performance with regards to health insurance access and equity.This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.In 2008, the WHO Commission on Social Determinants of Health published its landmark report stating that “inequities are killing people on a ‘grand scale’” [1]. Among the report’s recommendations for action, improving access to (public, universal) health insurance looms large, and not only in developing countries. Indeed, over the past decade, health spending in many developed countries has grown faster than gross domestic product, leading governments to search for alternative financing structures, notably through increased private expenditures [2].However, some of the policy instruments used to reach those goals, such as restricting eligibility criteria for public insurance and increasing reliance on unregulated private health insurance (PHI) or cost sharing arrangements, may in fact have had the unexpected effect of erecting supplementary barriers to health insurance coverage. Moreover, as the impact of these policies is generally not randomly distributed in the population, these transformations have