Health Policy 92 (2009) 250–258 Contents lists available at ScienceDirect Health Policy journal homepage: www.elsevier.com/locate/healthpol Who is giving up the free lunch? The insured patients’ decision to access health insurance benefits and its determinants: Evidence from a low-income country Ardeshir Sepehri a,∗ , Sisira Sarma b , John Serieux a a Department of Economics, University of Manitoba, Winnipeg, MB R3T 5V5, Canada b Department of Epidemiology & Biostatistics, The University of Western Ontario, London, Ontario N6A 5C1, Canada article info Article history: Received 27 November 2008 Received in revised form 7 April 2009 Accepted 7 May 2009 Keywords: Health insurance Barriers to access Hospitalization Vietnam abstract Objectives: This paper examines the determinants of the insured’s decision to use their health insurance card when seeking outpatient and inpatient health care in Vietnam. Methods: Uses Vietnam’s latest Household Living Standard Survey data and random- intercept logistic regression to assess the influence of the observed individual, household and commune/ward factors on the insured’s decision to access health insurance benefits while controlling for the unobserved commune/ward-specific factors. Results: Compared to the compulsory enrollees, the voluntary enrollees and the beneficiaries of the Health Care Fund for the Poor are less likely to use their card when seeking inpatient care. An individual’s likelihood of accessing insurance benefits varies inversely with income and the level of education, suggesting that the outpatient care provided to the insured is of inferior quality. Conclusions: Although health insurance has the potential of increasing access and reducing the financial burden of health care utilization, Vietnam’s experience clearly suggests that these benefits may not be fully realized as long as the quality of care remains low and the high opportunity costs of accessing insurance benefits deter the insured from accessing benefits. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction In recent years, several low-income countries have established, or are in the process of establishing, a national health insurance system. The great merit of health insur- ance is that it reduces the monetary cost of accessing health services, enabling individuals with substantial unmet needs to access otherwise unaffordable care [1,2]. More- over, health insurance protects households against the financial burden of illness, especially large out-of-pocket expenses resulting from catastrophic illnesses while it is ∗ Corresponding author. Tel.: +1 204 474 6241; fax: +1 204 474 7681. E-mail address: sepehri@cc.umanitoba.ca (A. Sepehri). raising additional resources for the public sector. How- ever, access to the potential benefits of health insurance may be curtailed if indirect financial and non-financial barriers, such as travel and lodging expenses, the lost income, and lack of knowledge of what providers offer, impede the insured from seeking care [3–5]. But, even if care is actually sought, the insured may still face a wide range of hurdles before accessing the health insurance benefits. Some of these barriers include the cumbersome paperwork involved in accessing insurance benefits, the limited portability of the insurance scheme, the biased treatment and poor attitude of health staff towards the insured patients before accessing the health insurance ben- efits [5,6] Although much has been written on barriers to access that prevent individuals from seeking appropriate 0168-8510/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2009.05.005