Does an increase in health insurance coverage reduce socioeconomic inequalities in premature mortality? An analysis of the post-reform period in Colombia

Ivan I. D. Arroyave, Erasmus Medical Centre, Rotterdam
Doris Cardona, Universidad CES
Alex Burdorf, Erasmus Medical Centre, Rotterdam
Mauricio Avendano, Erasmus Medical Centre, Rotterdam

Background Recent health care reforms in several middle-income countries have increased health care insurance coverage (HIC). This study examines the impact of a major increase in HIC in Colombia on socioeconomic inequalities in total and cardiovascular disease (CVD) mortality from 1998 to 2007. Methods Data on deaths by educational level from mortality registries were linked to population census data (n=3,984,450) for the period 1998-2007. We used Poisson regression to examine inequalities in mortality by education based on the relative index of inequality (RII). We compared trends in inequalities between periods of moderate (1998-2002) and accelerated (2003-2007) increase in HIC. Findings Lower education was associated with higher total and CVD mortality, and these inequalities widened over the study period. Among men, the RII increased from 2.27 (95%CI [Confidence Interval] 2.23, 2.32) in 1998-2002 to 2.71 (95%CI 2.65, 2.76) in 2003-2007, while among women it increased from 2.62 (95%CI 2.55, 2.71) to 2.87 (95%CI 2.79, 2.95). Within each period, however, inequalities increased at a different rate. In 1998-2002, a period of moderate increase in HIC, inequalities increased every year by 10% in men and 3% in women. In contrast, in 2003-2007, a period of accelerated increase in HIC, inequalities increased by 2% in men and 1% in women. Interpretation Socioeconomic inequalities in mortality widened throughout the post-reform period, but increased coverage may have slowed down increasing trends in inequality. Increasing insurance coverage may not be sufficient to eliminate inequalities, but it may contribute to curb increasing inequality trends.