cases in order to avoid waiting for SUSIF authorization. Therefore, some of these surgeries may represent accumulated non-acute cases. The SUSIF data also do not capture surgeries/inpatient cases covered through private health insurance. However, private health insurance covers less than 1.5 % of the population and is mainly employer-financed. Therefore, it is unlikely to cover the poorest population, the focus of this study.<sup>14</sup> It is also possible that there is misreporting of acute surgeries for the MAP patients vs. UBP patients due to different reimbursement rates between the two programs, i.e., the providers would be fully reimbursed for the MAP patients but only partially reimbursed for the UBP patients.

Finally, in spite of the MAP’s great impact, it still only managed to raise utilization rates of the insured poor closer to the level of the national average at the approximate measures,<sup>15</sup> which is still below the average of many other comparable nations. The recent Georgia Health Utilization and Expenditure Survey (HUES) shows that the poorest quintile’s share of inpatient care utilization was still 30% lower than the national average inpatient utilization.<sup>16</sup>

# **_Limitations_**

This paper is only able to examine the impact of the MAP on _acute_ surgeries/inpatient services, due to data limitations. Acute cases are covered under both MAP and UBP, and the difference in coverage is that MAP beneficiaries do not need to make any co-payment while non-MAP users have to make a co-payment of 25%–50%. Since in both cases SUSIF pays providers at least a portion of the costs, SUSIF keeps the utilization record of the acute cases. This is not the case for planned surgeries, for which non-MAP beneficiaries have to pay total costs out-of-pocket unless these are covered by other private health insurance plans. Since SUSIF does not pay for those services, it does not keep the records for those surgeries; therefore, the comparison between MAP users vs. non-MAP users for planned surgeries was not possible. Due to the very small number of cases of delivery during the study period—e.g., two cases of delivery among women with scores between 100,001 to 110,000—this study could not examine the impact of the MAP on utilization of delivery services.

# **6. HAVE THE POOREST AMONG THE BENEFICIARIES TRULY BENEFITED?**

Section 5 estimates the impact of the MAP in the neighborhood of the threshold, which has little implication for the utilization of services by the poorest among the beneficiaries. This section focuses on whether the MAP benefits have reached the poorest of the poor. It is not the case that all welfare programs reach the individuals who need them most. In this case, there are factors that affect the poorest differently in their seeking of inpatient care. Figure 4 illustrates different pathways that affect inpatient service utilization. The poorest tend to be less educated, and therefore are likely to be less informed about the MAP. In addition, high travel costs are usually associated with seeking inpatient care, creating a potential financial barrier; and third, the poorest include those living in remote or mountainous areas, where the supply of physicians and medical

> 14 Ministry of Labor, Health and Social Assistance, 2007. Georgia Health Utilization and Expenditure Survey conducted during June 2006 to July 2007.

> 15 According to WHO Health data base for all, Georgia has less than 2 outpatient visits per person, less than 6 inpatient visits per 100 people, and less than 2 surgical procedures per 100 people per year in 2004.

> 16 Ministry of Labor, Health and Social Assistance  et al, 2007. Georgia Health Utilization and Expenditure Survey.

12