A Further Analysis of Determinants of Health Insurance Coverage

This study uses state-level data to identify key factors influencing geographic differentials in the percentage of the population without health insurance coverage, with particular emphasis placed on the impact of the percentage of the population that is either self-employed or independent contractors. Not surprisingly, the cross-section analysis finds that the percentage of a state's population without health insurance was a decreasing function of median family income in the state, the female labor force participation rate in the state, and the percentage of the state's population age 65 and older, while being an increasing function of the percentage of households in the state with only a female head of household present (no husband present) and the percent of the state's population classified as Hispanic. Reflecting the emphasis in this study, the empirical estimates all also reveal that the percentage of a state's population without health insurance is an increasing the percentage of the state's population that filed a federal personal income tax return that included a Schedule C, which is used in this study as a proxy for self-employment and independent contractors.     

A Simple Exposition of the Social Security Trust Fund

Health insurance policy is a current topic of concern for the United States. The classroom game discussed here provides students with a thorough understanding of some of the policy options under debate, in addition to demonstrating the classic problem of adverse selection. Students received probabilities of encountering a variety of medical expenses, based on their randomly assigned fictitious person’s age and health status. In each round, students made insurance decisions and then rolled dice to determine outcomes for each possible medical expense. The experiment considered insurance with an individual mandate, insurance without an individual mandate, insurance where students could purchase à la carte coverage mimicking proposed insurance riders for certain coverage, and insurance where pre-existing conditions were not covered.     

Adverse Selection and the Decline in Private Health Insurance Coverage in Australia: 1989–95

The decline in private health insurance coverage over the period 1989–95 is analysed using the ABS National Health Surveys. Individuals' health status and health risk behaviours are found to be significant determinants of their decision to purchase private health insurance. At a point in time, the pool of the insured is very heterogeneous, with a mix of both good and bad health risks. It is found that the decline in insurance coverage over the period 1989–95 coincided with an increase in the degree of 'adverse selection' within the insured population.     

The micro-firm health insurance hypothesis

The objective of this study is to investigate the ‘micro-firm health insurance hypothesis’, a hypothesis that the greater the percentage of domestic firms that are ‘very small’, i.e. have four or fewer employees, the greater the percentage of the US population that will be without health insurance. The focus of this study is based on the premise that very small firms (as defined), ‘micro-firms’, which constitute 58.6% of all private sector firms in the US, face bargaining-power, financial, and competitive constraints that tend to limit their ability to provide group health insurance benefits to their employees, with the result being that employees at very small firms are relatively more likely than employees at larger firms to be without a health insurance fringe benefit. Weighted Least Squares (WLS) estimates provide strong empirical support for the hypothesis.     

The problem of the uninsured

The problem of the uninsured cannot be fully understood without considering the role of non-market alternatives to ‘market insurance’ called ‘self-insurance’ and ‘self-protection’ (SISP), including the public ‘health care safety-net’ system. We tackle the problem by formulating a ‘full-insurance’ paradigm that accounts for all four interacting insurance measures. We apply two versions of the full-insurance model to estimate, via calibrated simulations, the impacts of SISP on the fraction of uninsured, health spending, and health levels, and to assess how the mandated Affordable Care Act might affect these outcomes in comparison with the CBO projections in 2010. The results indicate that policy analyses which overlook the role of the real price of market insurance relative to the shadow prices of SISP in determining the decision to insure can grossly distort the capacity of mandated reforms like the ACA to insure the uninsured, contain overall health care costs, and improve health and welfare outcomes.     

The relationship between the markets for health insurance and medical malpractice insurance

This article evaluates the interdependence of medical malpractice insurance markets and health insurance markets. Prior research has addressed the performance of these markets, individually, without specifically quantifying the extent to which they are linked. Increasing levels of health insurance losses could increase the scale of potential malpractice claims, boosting medical malpractice losses, or could embody an improvement in medical care quality, which will reduce malpractice losses. Our results for a state panel data set from 2002 to 2009 demonstrate that health insurance losses are negatively related to medical malpractice insurance losses. An additional dollar of health insurance losses is associated with a $0.01–$0.05 reduction in medical malpractice losses. These findings have potentially important implications for assessments of the net cost of health insurance policies.     

The effect of non-employment-based health insurance program on firm's offering of health insurance: Evidence from the social health insurance system in China

To achieve universal health insurance coverage, many developing countries have established a segmented health insurance system, which contains separate programs for workers with formal employment and residents without formal employment. A potential concern with such a segmented system is that the establishment of a non-employment-based insurance program may generate a disincentive for firms to provide health insurance benefits to workers. In this study, we empirically examine this crowd-out effect of a non-employment-based insurance program, the Urban Residents Basic Medical Insurance (URBMI), in China. Exploiting city-by-year variations in the roll-out process of the program and utilizing a unique administrative dataset on Chinese firms, we find that the enactment of URBMI reduced a firm's offering of an employment-based health insurance program by a statistically significant 0.94-1.29 percentage point. This crowd-out effect was stronger among domestic private firms, new firms, and firms that are individual-owned.     

Using the stochastic health state function to forecast healthcare demand and healthcare financing: Evidence from Singapore

Typically, healthcare financing for an ageing population requires projections on healthcare demand and cost. However, projecting healthcare demand based on projected elderly does not consider changes in population health state over time. This paper proposes a new approach to forecast health variables using a stochastic health state function and the well‐established Lee–Carter stochastic mortality model. With the estimated health state at each age over time, we project the hospitalization rate, healthcare demand, and financing cost for Singapore using historical life tables and hospital admission data. Our findings show that while hospital insurance claims increase owing to an aging population, improving health state could save costs from hospital insurance claims. This has policy implications: more attention should be given to preventive healthcare such as health screening to improve the overall health state of the population.     

中国城镇医疗体制改革前后的医疗融资比较

The health financing schemes is the foundation for the nation’s health care system, and the health insurance is a main one of some options for financing health care. This article compares two health care financing schemes in urban areas before and after the health reform, and targets at the impacts facing coverage groups, the financing methods, decision-making power or financial management (i.e. the distribution of responsibility and rights between the central government and local governments), payment arrangement and cost containment of health care financing mechanisms. Prior to reform, the equal access and universal coverage of health care services were implemented through the employment-based health insurance in a state-controlled economy with guaranteed full employment and central control in general. The decentralization reforms of fiscal system and tax sharing reforms disrupts the past economic foundation, the rebuilding health insurance system which still benefits the employed bring the limited coverage. The next trend is to make transition from health insurance covering only part of the employed population to what are in effect national health services covering the whole population in urban areas.      

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.     

中国城镇社会医疗保障改革的理论探索

With its transition to a market-oriented economy, China has gone through significant changes in health care delivery and financing systems in the last three decades. Since 1998, a new public health insurance program for urban employees, called Basic Medical Insurance Program (BMI), has been established. One theme of this reform was to control medical service over-consumption with new cost containment methods. This paper attempts to evaluate the effects of the reformed public health insurance on health care utilization, with in-depth theoretical investigation. We formulate a health care demand model based on the structure of health care delivery and health insurance systems in China. It is assumed in the model that physicians have pure monopoly power in determining patients’ health care utilization. The major inference is that the insurance co-payment mechanism cannot reduce medical service over-utilization effectively without any efforts to control physicians’ behavior. Meanwhile, we use the calibrated simulation to demonstrate our hypothesis in the theoretical model. The main implication is that physicians’ incentive to over utilize medical services for their own benefits is significant and severe in China.      

Ex Post Welfare under Alternative Health Care Systems

The implications of a societal aversion to inequality for the optimal structure of the health care system are studied. The agents are assumed to be ex ante identical, but to differ ex post in the state of their health. Inequality aversion is introduced by postulating a strictly concave ex post social welfare function. It is shown that the optimal public health care system allocates health care differently than would private health insurance; specifically, people who are relatively unhealthy with and without treatment receive more health care, and people who are relatively healthy with and without treatment receive less health care. The aggregate quantity of health care under the optimal public health care system can be either greater or smaller than under private health care insurance. If the public health care system is optimally designed, allowing agents to purchase supplementary private health care insurance cannot raise social welfare and is likely to decrease it.     

Consumer Resistance Against Regulation: The Case of Health Care

Regulation fostering Managed Care alternatives in health insurance is spreading. This work reports on an experiment designed to measure the amounts of compensation asked by the Swiss population (in terms of reduced premiums) for Managed-Care type restrictions in the provision of health care. It finds that restrictions on the freedom of physician choice would require an average compensation of more than one-third of the premium, while generic substitution even meets with a small willingness to pay. Marked preference heterogeneity is an argument against regulation imposing uniformity of contract in Swiss social health insurance.     

Public provision of health insurance and aggregate saving in an overlapping generations model with endogenous health risk: The South Korean case

This paper examines the effect of expanding public health insurance in South Korea on medical expenditures and aggregate saving using an overlapping generations model with endogenous health risk. South Korea had a substantial underinsured population, which is aging rapidly. Higher public health insurance benefits reduce individual medical expenditure and health risks but lead to a modest decline in individual and aggregate saving. Even after the expansion, the medical care coverage remains incomplete, and the elderly face a substantial risk of out-of-pocket medical expenditures.     

Health,Social Insurance and Income

Health, a form of human capital, can be defined by longevity and physical wellbeing. Social policy decisions require an understanding of the factors that contribute to the creation of health inequalities. To learn more about socioeconomic variables and health capital, this paper examines the relationship between three key variables: health, social insurance, and income, for the Swedish population. Using a randomized research survey design, data from 3,600 participants of a larger Swedish study, conducted in 2005, was analyzed. A linear model of Three Stage Least Squares was chosen to correct for simultaneous bias in the Health, Social Insurance, and Income (HSI) Model. Findings confirm the importance of socioeconomic, behavioral and environmental factors in explaining health inequalities. The results clearly show men, educated people, nonsmokers, individuals that exercise and youngsters possess higher health status than other people. The dependency on social insurance is mainly caused by poor health; a higher degree of social insurance dependency was offset by income increases due to age and higher professional level.      

Social Risk in Health Insurance: A Reflection on the Economies of Scale and Scope in Health Insurance

Social risk causes distortion in the health insurance market. In the presence of social risk, health insurance must be inflated with a safety loading. This implies that policyholder will choose incomplete risk transformation and that health insurers have to build up large capital reserves. By using cross-diversification and enlarging the insurance pool with other kinds of risk (utilising economies of scope in addition to scale production), the problem of social risk will reduce. It is shown how this is possible by using the capital market as a diversification pool     

Does non-employment based health insurance promote entrepreneurship? Evidence from a policy experiment in China

Previous researchers have shown that employment-based health insurance lowers job mobility and deters entrepreneurship. The Urban Resident Basic Medical Insurance (URBMI) program, piloted in 2007 in China and fully established in 2009, offers health insurance to about 271 million urban residents without formal employment. Before the implementation of URBMI, most urban residents obtained health insurance through their employers, and therefore a large number of unemployed and self-employed individuals were uninsured. Thus, URBMI creates a new insurance option that does not depend on formal employment and may promote entrepreneurship. We take advantage of this policy change to evaluate the effect of URBMI on self-employment. Using 2000–2011 data from the China Health and Nutrition Survey and a difference-in-differences approach with propensity score weighting, we found that URBMI increased self-employment rate by at least 8.73% for the overall population. The result was mainly driven by the URBMI’s impact on unhealthy workers, individuals with 12 years of schooling or less, and workers above 30 years old.     

Minimum standards, insurance regulation and adverse selection: evidence from the Medigap market

This paper examines the implications of minimum standards for insurance markets. I study the imposition of binding minimum standards on the market for voluntary private health insurance for the elderly. The central estimates suggest that the introduction of the standards was associated with an 8 percentage point (25%) decrease in the proportion of the population with coverage in the affected market, with no evidence of substitution toward other, unregulated sources of insurance coverage. To explore possible factors contributing to the impact of the minimum standards, I develop comparative static predictions of the impact of imposing minimum standards in an insurance market with adverse selection. The observed changes in market equilibrium associated with the minimum standards are broadly consistent with these predictions, providing evidence of the existence of adverse selection in this insurance market. More importantly, they suggest that the presence of adverse selection—which in principle may provide an economic rationale for minimum standards—in practice may have exacerbated the declines in insurance coverage associated with the minimum standards.     

The politics of redistributive social insurance

This paper analyses the political support for a social insurance that includes elements of redistribution when there exists an imperfect private insurance alternative. Individuals differ both in their income and risk. The social insurance is compulsory and charges an income-related contribution with pooling of risks. The private insurance is voluntary and charges a contribution based on individual risks. However due to the adverse selection problem, private insurance companies provide only partial insurance. Adopting a non-expected utility model, we show that there is a general majority support for social insurance and that this support is increasing with risk aversion. We also show that a mixed insurance is politically impossible, regardless of the degree of redistribution of social insurance and the joint distribution of risk and income in the population. Lastly, we analyse how the political support for social insurance is affected by any change in its redistributive component and the possibility of using genetic tests.     

城镇低保户医疗服务利用和医疗保障制度设计对就医行为的影响——基于兰州、西宁和白银城镇家庭调查数据的分析

解决低保户看病难问题事关社会底线公平。文章基于2005年三个西北城市的17 690个样本对低保户就医问题展开实证研究,分析结果表明,由于中国医疗机构扭曲的激励机制和偏重住院报销的给付结构,低保户和非低保户两个群体都倾向于自己购药处理日常病患,而减少了门诊利用,经常面临生存危机的低保户由此拖延病情直至病情严重;个人账户既不能横向分散不同人群的疾病风险,也不能纵向分散个人在生命周期不同阶段的疾病风险;职工基本医疗保险能够显著增加中青年低保户对住院服务的利用,但对老龄低保户没有效果。