IS THERE A ‘SECESSION OF THE WEALTHY’? PRIVATE HEALTH INSURANCE UPTAKE AND NATIONAL HEALTH SYSTEM SUPPORT

The purchase of private health insurance (PHI) as a means to partially supplement the National Health System (NHS) coverage is often regarded as a potential signal for a declining support for the NHS. Exploiting the fact that PHI is typically purchased by the most affluent, in this paper we test the so called ‘secession of the wealthy’ hypothesis whereby the likelihood of expressing ‘lack of support for the NHS’ increases with having supplementary PHI. Using empirical data from Catalonia, we draw upon an empirical strategy that circumvents an obvious simultaneity problem by estimating both a recursive bivariate probit as well as an IV probit. After controlling for insurance premium, household income and other socio‐demographic determinants, we find that the purchase of PHI reduces the propensity of individuals to support the NHS. We also find evidence that PHI is a luxury good and sensitive to fiscal incentives.     

Premium subsidies and demand for private health insurance: results from a regression discontinuity design

This article investigates the impact of a private health insurance (PHI) subsidy on the demand for PHI in the context of the Australian health care system. In particular, we focus on the subpopulation of elderly Australians and exploit discontinuous increases to the universal ‘PHI rebate’ that occur when people turn 65 and 70 years. Using a regression discontinuity design, we find the policy has little effect on take-up of PHI and is best interpreted as a wealth transfer to elderly Australians who already have insurance.     

How effective is “lifetime health cover” in raising private health insurance coverage in Australia? An assessment using regression discontinuity

The Australian government introduced three major private health insurance policy initiatives in recent years. These are, in chronological order, (i) the Private Health Insurance Incentives Scheme (PHIIS), which imposes a tax levy on high-income earners who do not have private health insurance and provides a means-tested subsidy schedule for low-income earners who purchase PHI; (ii) a 30% premium rebate for all private health insurance policies to replace the means-tested component under PHIIS; and (iii) lifetime health cover, which permits a limited form of age-related risk rating by insurance funds. Together, these policy changes have been effective in encouraging the uptake of PHI; the percentage of the population covered by PHI rose from 31% in 1999 to 45% at the end of 2001. The difficult issue, however, is in disentangling the effects of the three policy changes, given that they were introduced in quick succession. This article attempts to evaluate the effect of lifetime health cover using a regression discontinuity design, an approach that makes use of cross-section data that allows the effect of lifetime health cover to be isolated via local regression. The results suggest that the importance of lifetime health cover appears to be grossly over-rated in previous studies. Our estimates indicate that it accounts for roughly 22–32% of the combined effects of all the policy initiatives introduced in the late 1990s. While these figures suggest that its effect is clearly significant, it is nonetheless nowhere near the effect often associated with lifetime health cover.     

Can a Mixed Health Care System be Desirable on Equity Grounds?*

Should health care provision be public, private, or both? We consider this question in a setting where people differ in their earnings capacity and face some illness risk. We assume that illness reduces an individual's time endowment when waiting for treatment. Treatment can be obtained in a competitive private sector (through private insurance) or in the National Health Service (NHS) where it is provided free of charge but after some (endogenous) waiting time. The equilibrium in the health care sector consists of a waiting time in the NHS such that no patient wants to switch health care provider. This equilibrium is governed by two public policies: the income tax system and the size of the NHS. We find that: (i) a mixed system with a small NHS is never desirable; (ii) actuarially fair sickness insurance is never desirable either; (iii) a mixed system with a sufficiently large NHS may improve on a pure public system if the dispersion of earnings capacities is large enough; and (iv) the welfare gains from such a mixed system are not likely to be significant.     

Supplementary private health insurance and health care utilization of people aged 50+

Does supplementary private health insurance (PHI) coverage influence health care utilization in countries where the coverage ratio with public health insurance is high? I estimate this effect using the Survey of Health, Ageing and Retirement in Europe. Handling the potential endogeneity of supplementary insurance coverage and the large fraction of zero observations in the utilization models influences the empirical results. I show that the effect of PHI coverage on inpatient and outpatient care utilization is not trivial even in countries with generous public health funding. The main finding is that supplementary PHI coverage increases dental care utilization, but decreases the visits to general practitioners. Private insurance is estimated to have little and insignificant influence on the utilization of inpatient care and outpatient specialist care. The magnitude of the effect of supplementary PHI on health care utilization varies with the characteristics of the health care systems.     

The Demand for Private Medical Insurance in the UK: A Cohort Analysis

This paper examines the determinants of the demand for private health insurance in the United Kingdom from 1978 to 1996 using a pseudo-cohort panel. The focus is on the impact of public and private sector quality, generational change, and past purchase on demand. The results indicate that there has been generational change in buying behaviour, that the number of senior doctors employed in the public sector impacts upon demand for the private alternative, and that there is limited impact of habit in purchase. Changes to the structure of labour contracts in the NHS may affect demand for the private alternative.     

The determinants of the demand for private health insurance under Medicare

Since the introduction of Medicare in 1984, the proportion of the Australian population with private health insurance has declined considerably. Insurance for health care consumption is compulsory for the public health sector but optional for the private health sector. In this paper, we explore a number of important issues in the demand for private health insurance in Australia. The socio-economic variables which influence demand are examined using a binary logit model. A number of simulations are performed to highlight the influence and relative importance of various characteristics such as age, income, health status and geographical location on demand. A number of important policy issues in the private health insurance market are highlighted. First, evidence is provided of adverse selection in the private health insurance pool, second, the notion of the wealthy uninsured is refuted, and finally it is confirmed that there are significant interstate differences in the demand for private health insurance.     

Determinants of private health insurance coverage among Mexican American men 2010–2013

Abstract

Background: Private health insurance (PHI) represents the largest source of insurance for Americans. Hispanic Americans have one of the lowest rates of PHI coverage. The largest group in the US Hispanic population are Mexican Americans; they account for about two in every three Hispanics. One in every three Mexican Americans aged 64 years and under did not have health insurance coverage. Mexican Americans have the most unfavorable health insurance coverage of any population group in the nation.

Objectives: The objective is to determine the factors associated with the gap in PHI coverage between Mexican American and non-Hispanic American men.

Methods: This study used the National Health Interview Surveys (2010–2013) as the sample. A non-linear Oaxaca-Blinder decomposition was run, estimating the explained and unexplained gap in PHI coverage between the groups. Several robustness tests of the model were also included.

Results: This study estimates that 44.4% of employed Mexican American men are covered by PHI compared to 79.5% of non-Hispanic American men. Nearly 60% of employed Mexican American men were found to be foreign born, 35% have an educational attainment less than a high school degree, and 40% are likely to have language barriers. Decomposition results show that income, low educational attainment, being foreign-born, and language barriers diminished the probability of private health insurance coverage for Mexican Americans, and that 10% of the gap is unexplained.

Conclusions: Most of the difference in the PHI rate between Mexican American men and non-Hispanic men is explained by observable differences in group characteristics: education, language, and immigration status. About 10% of the difference can be attributed to discrimination under the traditional interpretation of an Oaxaca-Blinder decomposition. The PHI rate gap is large and persistent for Mexican American men.     

中国居民医疗保险购买行为研究-基于商业健康保险的角度

本文通过健康保险市场供需双方行为分析,构建居民医疗保险购买行为模型,利用中国健康与营养调查数据(2000—2006),运用部分观测的二元Probit估计方法(Bivariate Probit with partial observability),从实证的角度分析商业健康保险市场中供需双方各自的风险选择行为,以及城乡地区居民对商业健康保险的潜在需求行为及其宏微观影响因素。本文发现:(1)城乡居民都存在显著的逆向选择行为;(2)城乡社会医疗保障对居民商业健康保险需求行为有显著的促进作用;(3)影响居民商业健康保险行为的其他因素还包括,个人的风险偏好和经济购买力。     

Private,Social, and Self‐Insurance for Long‐Term Care in the Presence of Family Help

We study the political determination of the level of social long‐term care insurance when voters can top up with private insurance, saving and family help. Agents differ in income, probability of becoming dependent and of receiving family help, and amount of family help received. Social insurance redistributes across income and risk levels, while private insurance is actuarially fair. The income‐to‐dependency probability ratio of agents determines whether they prefer social or private insurance. Family support crowds out the demand for both social and, especially, private insurance, as strong prospects of family help drive the demand for private insurance to zero. The availability of private insurance decreases the demand for social insurance but need not decrease its majority‐chosen level. A majority of voters would oppose banning private insurance.     

Leaving the market or reducing the coverage? A model-based experimental analysis of the demand for insurance

This study develops a theoretical, and experimental analysis addressing the issue of premium variations on the demand for insurance. Accounting for risk attitudes, our contribution disentangles the decision to buy insurance from the conditional demand (the non-null demand for insurance). Partially validating our theoretical predictions, our experimental results show that, when it has an effect, a non-massive increase in the premium (either in the unit price or the fixed cost) exclusively results in an exit from the insurance market (the risk lovers first, then the risk averters). Moreover, our study highlights a key feature of risk-seeking agents' behavior; they exhibit behavior consistent with gambling and opportunism rather than a lack of interest in insurance.     

Anti-insurance: Analysing the Health Insurance System in Australia

This paper develops a model to analyse the Australian health insurance system when individuals differ in their health risk and this risk is private information. In Australia private insurance both duplicates and supplements public insurance. We show that, absent any other interventions, this results in implicit transfers of wealth from those most at risk of adverse health to those least at risk. At the social level, these transfers represent a mean preserving spread of income, creating social risk and lowering welfare – what we call anti-insurance. The recently introduced rebate on private health insurance can improve welfare by alleviating anti-insurance.     

Health insurance and lifestyles

This article contributes to the discussion surrounding the existence of ex ante moral hazard and propitious selection in a voluntary private health insurance scenario. Moreover, it provides an estimation of the determinants of lifestyle choices and of private health insurance demand. A multivariate probit is estimated for health insurance demand and lifestyle decisions to take into account the potential endogeneity of these decisions. The results indicate that there is evidence of ex ante moral hazard in deciding to do sports and eating healthy snacks. Hence, no propitious selection has been found for these decisions. Another relevant result shows that there is no individual heterogeneity for the lifestyle choices, except for smoking, and private health insurance choice. Evidence from the results also supports the idea that there are nonobservable variables playing a role in the lifestyle decisions. These results provide some directions for policymakers, such as the promotion of precautionary behaviours and the use of implicit lifestyle drivers to promote healthy choices by people.     

More health care utilization with more insurance coverage? Evidence from a latent class model with German data

We analyse the impact of optional deductibles, private supplementary health insurance and income on the demand for health care utilization, measured as the number of physician visits with data from the German Socio-Economic Panel (SOEP). With a set of newly available variables for the years 2002, 2004 and 2006 that measure individual health more accurately and including risk-attitudes towards health we find that possible endogeneity of the insurance choice is not a problem. A latent class approach that takes into account the panel structure of the data reveals that especially individuals who have few doctor visits, the low users, respond strongest to insurance status and income. In this group we find that more insurance increases the demand for physician visits and there is a pro-rich inequity in health care utilization. No such effects are found for the high users.     

Risk Aversion and Trade‐Union Membership*

If trade unions provide only their members with insurance against income variations, as a private good, this insurance will provide a stronger incentive for more risk‐averse employees to become union members. Using data from the German Socio‐Economic Panel (SOEP) and various direct measures of individual risk attitudes, we find robust evidence of a positive relationship between risk aversion and the likelihood of union membership for full‐time employees. This association is particularly strong for males and in West Germany.     

THE ROLE OF RETIREE HEALTH INSURANCE IN THE EMPLOYMENT BEHAVIOR OF OLDER MEN*

Using data from the Health and Retirement Survey, we estimate preference and expectations parameters of a structural model of the employment and medical care decisions of older men in order to evaluate the role of health insurance. The budget constraint incorporates detailed cost‐sharing characteristics of private health insurance and Medicare as well as rules and requirements associated with Social Security and private pensions. Simulations imply that changes in health insurance, including access and restrictions to retiree health insurance and Medicare, have a modest impact on employment behavior among older males, with the greatest effect on men in bad health.     

Why Subsidise Private Health Insurance?

What are the economic rationales for the public subsidy of private health insurance? Inducing more people to purchase private cover has the potential to create a positive fiscal externality, as it frees up the limited public beds and other public resources for people who cannot afford private health insurance. Investigating this quantitatively, based on short‐run demand estimates, we find that the subsidy cannot be justified on the basis of this externality effect alone. We estimate that the optimal subsidy is actually negative, that is, a tax on private health insurance premiums. On the other hand, the externality does finance some of the costs. We then consider a long‐run dynamic version, consistent with the government's stated rationales for the reforms. In this context, the subsidy might be justified, or at least largely offset, by the fiscal externality. We then discuss other rationales for a subsidy and implementation issues.     

Do Consumers Purchase Too Much Health Insurance? The Role of Market Power in Health‐Care Markets

Several authors have suggested that consumers purchase too much health insurance in private markets. We readdress this issue within a model that combines excess health‐care demand due to health insurance with market power due to monopolistic production of health‐care services. We evaluate the market equilibrium in terms of consumer welfare and social welfare. The consumer welfare criterion suggests that in the market equilibrium consumers in fact purchase too much health insurance coverage. The social welfare criterion, in contrast, suggests that because profits of the health‐care industry are properly accounted for, consumers should purchase more insurance coverage than they choose to do in the market equilibrium.