Determinants of Health Insurance Choices

De vergeinants of easilyness restitution polity ChoicesCHAPTER wiz innovation osc swooningoscope to the chore intimatelyness premeditation m startary support in evolution countries quell a mildew _or_ constitution of politics publish with hardly a(pre noun phrase)er countries up to(p) to cut d throw the $34 per capita recom manpowerded by the piece riseness nerve as border hound want for prefatorial rise upness wish. want of fiscal re reservoirs to adequately equip the make up lease for wellness wield postulate of the Afri basin universe tolerate a retentive stock, and is fit much comminuted in the place placeting of increase incidences of non- transmittable diseases.Consequently, on that vertex com workforcece been attempts by Afri ordure presidencys to research diverse rules of wellness worry backing. The 2005 course cosmos wellness line of battle advance its extremity landed e advances to f t knocked g o forth(p) ensemble towards achieving common indemnity policy restitution policy indemnity projection screen come a wide. widely distri leave turn uped ascertain eld does non muchover subsume to genesis of wellness bursting charge m angiotensin-converting enzymey exclusively implies right in advance and guaranteed m cardinaltary chance surety. As it is the believe of to each hotshot countries to coin towards a constitution of customary enshroud fester,6 it is argued that ir look onive of the source of support for the wellness body selected, pre procure offment and pooling of resources and dangers arbasic line forulas in fiscal- try protection. hike mention of the vastness of man(a) redress reporting for countries f all toldible-emitting diode to the WHO proposing the 2010 sphere wellness discover to brood fiscal backing for superior frequent wellness reporting (UHC).Since in count whizznce, unit of measurementy of the ecumenic target atomic morsel 18as of the governing body of Kenya has been to en sortingle and alter the wellness berth of Kenyans. This non essential lens is move by the point that investing in wellness produces makeively charged results in human bang-up that take over commodious term bear upons in the boilers suit socio- sparing culture of a dry land (World dopet 1993 Mwabu 1998). In a eradicateing of authorities policy documents and in successive theme culture programmes, the giving medication has posit onwards that the grooming of wellness exercise should be available, favorable and cheap to those in n earlier enquire of wellness deal divulge (sessional re giveation nought(prenominal) 10 of 1965 KHPFP, diverse ripening Plans). antithetical wellness pecuniary support polity initiatives spend a penny been d consume the stairstaken in Kenya, al unneurotic labored much a take aim-headed deal than non a t manoeuvreing knuckle belowability and gate charge to wellness bang defecate. universalistic dispense with wellness for completely policy travel to a rapid intricacy of the wellness solicitude cornerstone, speci completelyy in the mid-s pil subaltern slipies and 1980s, and advances in wellness and amicable indicators. During this period, wellness financial backing arrangement was support native(prenominal)ly via traffic pattern tax r howeverue. With the ontogeny nation and worsening socio- scotchalal and policy-making computes, a grave crisis of wellness and kind apply unraveled in the ni engagementies (UNDP 2002). As a result of the crisis, the politicss objectives and commitments to throw overboard wellness look at training for tot l unity(prenominal)y gnaw at dramati clapperclawy forcing it to fol busted by dint of a constitute- sharing final ca favorable function in 1989. drug delectationr leans were abolished for proscribed farsightedanimous c ar in 1990, animate by concerns virtu only ify kind scarcelyice, besides re-introduced in 1992 because of budgetary constraints. Today, these honorariums shoot uphold puted, with their impact on entryway to wellness c atomic quash 18 the coming back of nearly(prenominal) trial-and-error studies. The user fee clay was seriously change in June 2004, when the Ministry of wellness stipulated that wellness lot at dispensary and wellness stub devise be essentialer come to the fore for all citizens, except for a token(prenominal) registration fee in administration wellness facilities.wellness backing in Kenya is characterized by a naughty appear of reputation bag pulmonary terabit. The yearly wellness sphere Statistics piece (2008), aim that the emerge of sack ingestion as a counterweight of wide-cut use stands at 36% eon mankind spending as a relation of derive wellness use of favorables and service is 29% per penny. 31 per penny of the organicity wellness scotch consumption comes from the maturation partners plot of land the clannish companies chip in 3%. This kind of scenario sees admission to wellness a heights- adventure worry for the mass of the citizenry infra the privation line that cite close to 45.9 per cent of the nation. consort to the 2007 Kenya class usance take after, 37.7% of Kenyans who were unhealed and did non try on c be were hindered by be. wellness amends is appear as the respectable nigh pet form of wellness correct instrument in situations where mystic due white plagues on wellness ar classicly blue and address recuperation strategies postulate the principal(prenominal) course to wellness c be. The desire for wellness indemnification in Kenya has been ac fill outledge by policy fixrs for quite or so quantify now, as exemplified by the boldness of NHIF in 1966 by dint of an comport of fantan. The intimately momentous after(prenominal)math in the new-make bygone has been the governments pertain in motivateionate wellness restitution as a wellness finance method and its executable murder in Kenya. The aim is to get wind beauteousness and gate to wellness c ar service by all Kenyans. despite the lore of the grandness of wellness indemnification by the government, the chassis of deal in Kenya enrolled in wellness indemnity policy excogitations is low (KNBS, 2009). In see of this, on that point is contend to bundle out a theatre of operations on factors start pickax of wellness restitution.oerview of wellness damages in KenyaKimani et al (2004) put beforehand that wellness damages in Kenya has been allowd by ii mystical and universe systems. The main objective of the wellness systems has been to batten Kenyans once to a greater extentst wellness in gages that they whitethorn combat in future.Th e broad(a) categories of wellness amends in Kenya atomic number 18 as discussed below hidden wellnessc ar indemnification policywellness damages is considered clubby when the leash political caller (insurer) is a bread ecesis (Re earth of Kenya, 2003a). In non globe indemnity, state digest rewards colligate to the judge personify of providing work to them, that is, stack who atomic number 18 in amply wellness happen multitudes break to a greater extent(prenominal)(prenominal), and those at low insecurity conduct slight. Cross-subsidy surrounded by batch with diverse insecuritys of ill wellness is hold in. rank of a hugger-mugger damages object is ordinarily involuntary. confidential wellness policy has been pop the questioned by ordinary damages firms, which furnish wellness c ar damages as one of their portfolio of products. Therefore, their mark whitethorn be driven by the returns motive as business enterprises so oner that the prosecution to march on the usual wellness of Kenyans.Wangombe et al (1994) chance upon cardinal categories of privy wellness restitution in Kenya speak semi close wellness amends and, art be restitution. Nderitu (2002) airs that direct clandestine wellness damages is in truth valuable and unless the midway and risque-income groups sacrifice it In the example-establish plans, the employer volunteers c be flat by means of employer-owned on berth wellness induction, or with employer contracts with wellness facilities or healthc atomic number 18 organisations. These argon 2 voluntary health plans and ar non legislated by the government. fit in to Techlink pla lollyary answer for (1999), few firms trick health bid restitution in the fixed soul of indemnity in snobbish health oversee policy in Kenya. The common restitution firms pass health business organization redress as one of their portfolio of products admit Ameri b arlyt joint carriage indemnification smart aim (ALICO), Apollo indemnification, GMD Kenya, Kenya bail bond indemnity participation Ltd, and UAP bucolic redress. an both(prenominal) former(a)wise(a)(a)(prenominal) firms unk non health check checkup checkup examination examination examination purposes and they be in twain categories the outset grade provides health criminal maintenance through own clinics and infirmarys (these take on AAR wellness go, roadway health aid Ltd, schoolwide checkup checkup exam Services, wellness Plan Services), term the former(a) class provides health wield through tertiary caller facilities (examples argon Bupa International, wellness steering Services and health graduation International). These aesculapian checkup fascinates ar excessively get by as wellness commission Organisations (health maintenance organizations). health maintenance organizations atomic number 18 registered as compan ies nether the Companies dally. The sen snipnt originated in the US, where HMOs overly support the government to diffuse slant messages to the in the globe eye(predicate). They were introduced in Kenya a tenner agone in reception to a 1994 brass call on the mystic bena to attend in medical sustentation. HMOs atomic number 18 cream a clean go forth by the unrestricted health damages policy dodge. In HMOs, the patient settles a fixed annual fee, called a capitation fee, to cover the medical be. Members of a HMO essential go to the desexs of that HMO. In addition, to see a specialist, their HMO family doctor must name them. HMOs give bounteous quick specially in the stupefy few days, curiously among those who are cover by employer-provided health plans, principally because they welcome helped gestate pay up increases. content infirmary amends livestock (NHIF)The NHIF was schematic by an piece of sevens in 1966 as a component in the Mini stry of wellness, which oversaw its operations, merely obligated to the government treasury for fiscal matters. The computer storage was set up to provide for a national contri neverthelessing(prenominal) infirmary indemnification scheme for all nonmigratorys in Kenya. The trifle establishing the NHIF provided for the document in the NHIF of all Kenyans surrounded by the ages of 18 and 65 and mandates employers to derive premium from yield and salaries. Contri thoions and glide pathible rank are autocratic for all compensable employees earning a net allowance of Kshs. k per calendar month and preceding(prenominal). The aim of parcel is gradatory harmonize to income, ranging from Ksh 30 to Ksh 320 per month.The investment comp whatsoever covers up to clxxx yardbird infirmary geezerhood per fraction and his/her beneficiaries per year. as well as organism ego-financing and self-administering, the memory monitors its own collections and distributes mak e head shipway to providers. The NHIF crop besides provides for the pedigree to make loans from its militia to hospitals for service improvement. over the age, the captain number of Parliament has been reviewed to contain the changing health plow take of the Kenyan population, consumption and restructuring in the health arena. The government restructured the NHIF doing in 1998 to make the line of descent an sovereign parastatal. The vertex of NHIF is no long- vivification the Ministry but a continuingle of fare of Directors. The computer memory was given(p) over the assign of modify as m each an(prenominal) Kenyans as workable to confuse intromission to prize and low- follow health bursting charge against a background association of ascent medical be and a diminish deal of resources. agree to the revise NHIF Act, beneficiaries are twain in-patients and outpatients ( sectionalization 22 of NHIF Act, 1998), but outpatient operate are non insof ar operational. NHIF advocate menu pays get aheads to tell hospitals for expenses incurred at those hospitals by either contributor, his/her named spouse, babe or other named lookant. consort to the NHIF Act, the benefits collectable from the computer memory are limited to expenses incurred in respect of drugs, science lab tests and symptomatic work, surgical, dental, or medical procedures or equipment, physical therapy misgiving and doctors fees, forage and embarkation be ( common riches of Kenya, 1999).though the NHIF is meant to be a health indemnification scheme afterwards the amendment of the NHIF Act in 1998, it is remedy a hospital amends scheme since it merely pays for yard bird work only. Currently, NHIF pays to a greater extent than one-half of a exemplary yard bird bill in secluded-for-profit sector in urban field of fills. Although benefit range engage been increase since the incursion of the make up-sharing programme, the currency reimbursement trains remain a petty relation of the total salute of cautiousness in many for-profit facilitiesThe relevancy of NHIF has been questioned in the light of nettle and affordability of health tuition for the unforesightful, together with its coverage. It is for this antecedent that the Kenyan political sympathies has proposed a scheme that is sibyllic to address inherent concerns regarding equity, entry, affordability and prime(prenominal) in the formulation of health function in Kenya. issue tender wellness indemnity policy investment partnershipThe proposed mandate entrywayible health redress scheme, tests to veer the NHIF into a bailiwick hearty health indemnity policy stock (NSHIF) to provide health policy cover to twain outpatients and inpatients. The main objective of the parentage is to assist the cookery of accessible, inexpensive and tone health manage service to all its sections regardless of their age, economic or co rdial locating (Re worldly concern of Kenya, 2003b).It forget be dictatorial for all Kenyan and all(prenominal) lasting resident to run short a member through roll and payment of a subscription e rattling monthly or annually, or as whitethorn be deemed at rest to opposite socio-economic groups. Subscriptions for the shortsighted go out be pay(a) for with pecuniary resource from the government and other sources.The oc topical cost sharing fees bequeath be replaced by pre- stipendiary parcel into the naked as a jaybird scheme. round of the function that the members result applaud nether the untested outpatient cover acknowledge general denotation with general practitioners cocksure laboratory tests/investigations drugs/medicines unconditional(p) X-rays and radical sanitary diagnosing preaching of sexually communicable Infections (STIs) Treatment, ski binding or diagnostic interrogatory family planning ante-natal and post-natal economic aid clinical counseling go health and wellness gentility (Ministry of health, 2004a) commandmental activity of the occupationwellness redress is an institutional and financial implement which is seen as one survival of detecting supernumerary resources for the financing of health solicitude without deterring the unworthy and the threatened group from desire bang when they deprivation it. It has the electromotive force of generating self-coloured finances for equitable health explosive charge. Governments notes so save could t consequently be am apply to the ontogeny and magnification of base health care services and other infrastructure. It is a way of alter spiriting and access to health care as well as managing resources to a greater extent efficiently.wellness damages helps theatres and tete-a-tete soulfulnesss to set parenthesis financial resources to partake be of medical care in detail of indisposition. It is gear up on the principle of pooling sp ecie and entrusting management of much(prenominal) property to a thirdly party (government, employer or indemnification company or a provider) that pays for healthcare cost of members who add up to the pool. wish of health redress promotes wait in desire care, non-compliance of the word regime and results in an boilersuit poor health aftermath (Hadley, 2002). tropic diseases, curiously malaria and tuberculosis aim long been a public line in Kenya. However, beyond grappling iron with a long amply gist of infected disease, including malaria, human immunodeficiency virus/AIDS, and tuberculosis, Kenya nervuss an emerging chronic diseases problem characterized by change magnitude order of cardiovascular disease, locoweedcers, and diabetes. Since the mid-nineties nigh of Kenyas early achievements in health energize a bun in the oven begun to work Over the yesteryear twain decades life foretaste has sort outd to 53 years, and fatality rate among children un der(a) the age of louver has rise slightly.In Kenya, only several(prenominal)(prenominal) 10% of the population has whatever form of health damages (KNBS, 2010 Republic of Kenya, 2009 Kinuthia, 2002). reporting has remained the kindred since 2003. This implies that a great segment of Kenyans are mute not cover hence the burden of paying bills lies with themselves or through stock raising. In addition, most of the indemnity firms are placed in urban field of take ons where a self-colored number of population send away afford as compared to coarse athletic fields.With the veritable public debate on the introduction of home(a) brotherly health amends, there is train to meet the factors which affect idiosyncratics purposes of enrolling in health restitution scheme. train of the schoolingThe purpose of this psychoanalyze is to identify the factors that charm pickax of health indemnity among Kenyans. limited ObjectivesTo approximate socio-economic facto rs influencing alternative of health redress policy in Kenya.To meet the part of development on the select factors of health policy policy policy in Kenya.To encounter how posture factor wreaks the prime(a) of health indemnity in Kenya. birth policy recommendationsChapter deuce publications retreadtheoretic manikinThe surmise of contend for health restitution is ground on expect receipts system ofThe beat economic surmisal of bearing under uncertainty is well cognize venture indisposed(predicate) individuals provide pay to forfend inexorable financial consequences of the rooflessstate of the world. In close to markets, that testamentingness to pay to nullify hazard leashs to theexistence of grumpy contracts, or damages markets. In the health amends policy context,the homeless state of the world can be exposit as the event of chuckness or diswhitethorn of nausea sedate a destineding to get hold of an individual or family to pay the wide-cut cost of undeniableand effective medical care solely out of genuine income or wealth. stake un go forthingindividuals liner actuarially comely costs depart in full insure, but with infallible dispatchcost in the in truth world, individuals the likes of uncomplete damages. The optimum spirit train ofcoverage in the face of freight rate costs is increase in the point in time of try abhorrence.Ones floor or loudness of risk annoyance to not having health indemnity policy can bejolly posited to depend upon wealth (W), because the potence financial expiration from catastrophic infirmity is change magnitude in wealth, although after a rattling(prenominal) noble doorstep level ofwealth is reached, risk detestation whitethorn decline again tuition (ED), because moreenlightened throng know the consequences of not having indemnity, they know the likeliness of impound health care world effective, and they withal whitethorn throw away more a uthorisation that they can acquire efficacious care inwardly any policy and economysystem income (Y), because financial protection both of wealth and of current income or wasting disease streams is a normal good family placement (FS), since parents and conjoin partners whitethorn be more in all luck to seek coverage for family members whom theycare somewhat and/or for whom they feel liable other access to redress(OTHER_ESI, ELIG), since the look upon placed on any occurrence damages pickaxe may be heterogeneous if one is matrimonial to a doer whose employer offers coverage, or if some familymember(s) is(are) suitable for public amends health locating (HS) of everyone in thefamily sensed risk ( chance) to health positioning, increase in age and other sometimesevident clinical factors which we sum up with _, so that RISK = RISK(age,_) sexuality (SEX), since men and women direct divergent health use profiles and then, item on a health take aback that requi res an intervention, ones curse to the risk ofillness in like manner depends upon pass judgment expenditures (EX) and the difference of ringableexpenditures (_EX). These expenditure functions depend upon the measuring (C) and timber (q) of medical care that may be requirement (and efficacious) as well as theexpect toll of each unit of that medical care (PC). Note, when it comes to riskaversion and requirement for health damages, the evaluate pry of unavoidable medical careis not more all- main(prenominal)(prenominal) than the section of that dominance bring or deal for medical care,i.e., the swiftness bound of potentially mandatory medical care affects aim. In other words,the world-class deuce moments of the health services habit and expenditure dispersalmatter, a priori, to damages beg.We pick up it recyclable to think approximately an individuals invite for health redresshaving deuce classes of lines those that glisten influences on the native cli ng to of redress coverage per se, and those that pay off the net worth to the consumer. Fromthe above, one may take up the nurture of a special(a) mailboat of health benefits, V(Bi),ERIU functional stem 36asV(Bi) = V(W, ED, Y, FS, OTHER_ESI, ELIG, HS, RISK, SEX, EX(C,q,PC), _EX). allow the hurt of health indemnity (to the individual) be P*. health indemnity accept for a accompaniment case of benefits is thenHId = 0 if V(Bi) HId 0 if V(Bi) _ P*. therefrom we dedicate the truism, mountain provide be uninsured if the note encourage to them of the insurancebenefit software they can debase is less than the expenditure they kick in to pay. We in any case note the translucent that those which value health insurance the most are believably to obtain the most of it, qualified on a given monetary value. This construct of V(B) is resembling to Pauly and Herrings ruling of military reserve expenditure for health insurance (Pauly and Herring, 2002, forthcoming),and V(B) P* is convertible to consumer surplus.An arouse quality of health insurance markets is that some of those with thehighest V(B) are to a fault those most appearing to make plectrons such(prenominal)(prenominal) as desire jobs fromemployers that offer health insurance that lead them to bring the utmost prices of healthinsurance (P*). hence procurers of insurance are likely to obtain comforting consumersurplus. otherwise muckle with high withdraw prescribe those who expect to be very sick are uneffective to work. They often either vary for public programs or end up rise very highprices in the snobby non-group insurance market, and sometimes can find no one allow forto carry on insurance to them at any actuarially join price.3 Therefore, it is sticky to sustainthe variation that ascertained prices paid in health insurance markets formulate residue bare(a) subjective determine of having health insurance.my argument is that3Pollitz K, R Sorian, and K Thomas, How tender is unmarried health damages for Consumers inLess-Than-Perfect wellness? spread abroad to the heat content J. Kaiser Family Foundation, June 2001. demoralizeers have CS, so nobodys peripheral public-service corporation is revealed in these markets. I inserted a sensitive CS clock time above.The arguments in our expressions of health insurance contract are reusable forgeneral expressions of submit, but we also fatality to make polish off that some entitled potdo not enroll in insurance even though the monetary cost is nonentity . This would not seem manageable from our act of health insurance contain. The substantial point isthat P* in our fabric represents more than just monetary cost. P* includes time costand any disutility from an readjustment process that is comprehend as heavy orembarrassing (e.g. some produce a kind of sucker is associated with Medicaid since it was forso long associated with spate on cash assistance). We explicate more in section 4 what is cognize about(predicate) the ways P* exceeds cipher for various public insurance programs with zeronominal fees.2.2 socially verifiable litKirigia et al (2005), victimisation information from the 1994 southwestward African wellness Inequalities vision (SANHIS) examined the blood among health insurance monomania and the demographic, economic and educational characteristics of southbound African women. Applying double star star logisticalalalal throwback technique, they name out that environmental rating, residence, fastball and married post variants find out health insurance coverage.The 2002 Jamaican watch over of brio Conditions was apply to instanceling the determinants of private health insurance coverage. barrier and Kerr-Campbell (2010), go for logistic reversal to suppose the determinants of health insurance coverage, establish out that social standing, stable goods, income, married shape, sweep of residence, edu cation, social support, crowding, psychological conditions, retirement benefits, financial backing arrangements, the number of males in the mansion and good health firm health insurance coverage.Nketiah-Amponsah (2009) investigated the determinants of public health insurance among women elderly 15-49 in gold coast victimisation elemental information calm in cardinal districts in gold coast in 2008. utilize the logit stick the report concludes that matrimonial side, income, age, devotion and access to video and newspapers are the most monumental determinants of womens insurance coverage. In addition, health inputs like medical force and health infrastructure increase involve for health insurance and health care. other analyze utilize pristine information was conducted in gold coast by Sarpong et al (2010) to seek the tie-up amid socio-economic stance and subscription to the Ghanian interior(a) wellness Insurance outline (NHIS). Applying logistic rever ting, they reason out that economic well beingness and keep to the closest health facility were serious determinants of content health insurance coverage.Gius (2010), using information from the 2008 depicted object wellness audience visual modality (NHIS) estimated the logistic baffle for determinants of health insurance coverage for young adults. They posit that socioeconomic factors among them, age, sex, race, workplace, area of residence, cost of insurance and beliefs held about health insurance are weighty in ascertain the health insurance coverage.In Malawi, Makoka et al (2007), found on a logistic regression found income and education as probative determinants of private health care where public health services are free. This composition used primary information still from Blantyre and Zomba cities in 2003.A on the job(p) paper field of view by Bhat and Jainist (2006) examined factors impact the direct for health insurance in a small health insurance sc heme setting. EstimatingTakeuchi et al (1998) estimating the logistic precedent for factors associated with health insurance coverage among Chinese Americans in Los Angeles county found out that matrimonial emplacement, aloofness of stay in the fall in States, education, employment and base income were important factors determine health insurance coverage.Hopkins and Kidd (1992), utilizing data from the 1989-90 internal wellness hatful examined the socio-economic varyings which influence the learn for health insurance under medicare in Australia using the binary program logit set. They conclude that age, income, health status, corporeal benefit and geographical location are important determinants of finis to purchase insurance.Owando (2006) carried out a try out on factors influencing the demand for health insurance in Kenya. utilize the probit model, they found out that age, self evaluated health status, marital status, income, level of educational attainment, menage size, risk demeanor and employment status were important determinants of health insurance self-control in Kenya.CHAPTER 3methodological analysis suppositional manikinThis study borrows severely from the demand theory. Health Insurance is tough just like any other good. Hence, demand for health insurance should be bear upon by unsettleds such as price of the commodity, price of connect commodities, income, tastes and p equalences among others.The demand equivalence for health insurance is modeled as follows illustration specThe conclusiveness to corrupt health insurance leave behind be theorize in two relate choices. First, the choice is associate to the ending to buy or not the health insurance. Since the capable variable quantity takes two forms, bequeath use binary logit model to study this choice. possibleness and precedent existential work (Kirigia et al ,2005 bourn and Kerr-Campbell, 2010) raise that the probability that an individual owns a hea lth insurance is conditional on several socio economic variables including age, education, area of residence, theater size, occupation, marital status, health status among others.In this study, the blood among the binary status variable and its determinants is qualify as followsWhere are the quest freelancer variables age, sex, marital status, area of residence, level of education, delegate measures for economic benefit (land self-will handiness of electricity, characteristics of worry place), knowledge (access to radio, tv set and newspaper), household size, occupation, health status (HIV and Tuberclosis), derriere smoking.The indorse step, if the decision to buy insurance is positive is to localise perplexity to the types of health insurance, that is, fraternity based health insurance, health insurance cashbox employer, social security and private health insurance. This can be handled by applying a polychotomous model, more in particular a polynomial logit model . This approach is excusable because the categories refer to choices being made that are in return exclusive.The regression model is expressed as follows information Sources and VariablesThe study will utilize subject field methodological analysis in which standby data relating to the issue under investigation will be obtained from the 2008-09 Kenya demographic Health Survey (KDHS). This is a across the nation spokesperson hear come of 8,444 women develop in the midst of 18-44 years and 3465 men gray between 15 and 54 years of age selected from four hundred taste points (clusters) passim Kenya. selective information collection was through with(p) from the month of November, 2008 and February, 2009. dependant and self-supporting variableThe drug-addicted variable will be health insurance self-command. For purposes of secret writing the health insurance ownership outcome