Disparities in health services and outcomes by National Health Insurance membership type for ischemic heart disease and stroke in Indonesia: analysis of claims, 2017-2022.

Background: Ischemic heart disease (IHD) contributed to around 8.9 million deaths and stroke accounting for about 6.2 million deaths each year. This study examines disparities in health services and outcomes for IHD and stroke among different membership types within the national health insurance.

Methods: We analyzed over 30,000 inpatient claim data for IHD and stroke patients from 2017 to 2022 in Indonesia. The associations were assessed between National Health Insurance (Badan Penyelenggara Jaminan Sosial, BPJS) membership types and five dependent variables including treatment/diagnosis, severity, mortality, length of stay, and claim cost. Membership types included the poorest members subsidized by the national budget (Penerima Bantuan Iuran Anggaran Pendapatan dan Belanja Negara, PBI APBN); near poor, subsidized by local governments (Penerima Bantuan Iuran Anggaran Pendapatan dan Belanja Daerah, PBI APBD); informal non-workers (Bukan Pekerja, BP), informal workers (Pekerja Bukan Penerima Upah, PBPU), and formal workers (Pekerja Penerima Upah, PPU).

Results: For treatment access, PBI APBN members with IHD had lower odds of receiving percutaneous coronary interventions (PCI) compared to other groups, though this difference was not statistically significant in the multivariate models. For stroke patients, access to head computed tomography (CT) scans-critical for diagnosing stroke type-was similar across all membership types. Length of stay varied by condition; PBI APBN members experienced longer hospital stays for IHD but shorter stays for stroke. However, claim costs were significantly higher for non-subsidized groups (BP, PBPU, PPU) compared to the PBI APBN group for both IHD and stroke patients. Regarding health outcomes, non-subsidized IHD patients (BP, PBPU, PPU) had significantly lower odds of severe cases with adjusted odds ratios (AORs) of 0.70, 0.76, and 0.66, respectively, and mortality (AORs of 0.61 and 0.64 for BP and PPU) compared to the subsidized PBI APBN group. For stroke patients, although severity levels were comparable across membership types, non-subsidized patients (BP, PBPU, and PPU) had significantly lower odds of mortality, with AORs of 0.66, 0.73, and 0.54, respectively.

Conclusions: Non-subsidized members had lower severity and mortality for IHD and stroke but higher treatment costs, while the poorest (PBI APBN) faced longer stays and worse outcomes-highlighting persistent disparities in Indonesia's national health insurance system. Addressing these inequities requires targeted policies to improve access, care efficiency, and quality for the poorest populations. Strengthening community-based lifestyle promotion and tobacco control can further reduce the burden of IHD and stroke and help close these gaps over time.