LOVE,TOIL, AND HEALTH INSURANCE: WHY AMERICAN HUSBANDS RETIRE WHEN THEY DO

The provision of health insurance has previously been shown to be an important determinant of retirement timing among older Americans, but the existing literature has largely ignored some aspects of the interspousal dependence of health insurance benefits. Specifically, the literature examines only how retirement may affect the health insurance available to the potential retiree but not how it might affect a spouse's options. Using data from the Health and Retirement Study, I find that the impact a husband's retirement might have on a wife's health insurance options has a statistically significant impact on a husband's rate of retirement that is independent of considerations of his own health insurance options. In households where the wife is the only one at risk of losing affordable health insurance if the husband retires, the husband is 30% less likely to retire than if neither spouse is at risk (a 5 percentage point decrease in the retirement rate). Based on these findings, prior research is missing one avenue that changes to the Medicare eligibility age and health insurance policy changes through the Affordable Care Act might impact the labor supply of older workers. (JEL I13, J26, J32)     

DOES COBRA'S RETROACTIVE COVERAGE FEATURE ENCOURAGE DELAYED ENROLLMENT?

The Consolidated Omnibus Reconciliation Act (COBRA) of 1985, which aimed to protect individuals experiencing employment separation from losing employer‐provided health insurance, contains a feature that is unusual among health insurance markets. Individuals eligible for COBRA have 60 days following employment separation to elect coverage, and if they elect, coverage is retroactive back to the date of employment separation. This paper investigates whether employment separators take advantage of COBRA's retroactive coverage provision by delaying enrollment until after incurring medical expenses. Results indicate that an individual whose household incurs medical expenses during the months after employment separation is approximately 1?10 percentage points more likely to subsequently enroll in COBRA, depending on the magnitude of expenses. (JEL I18, I11)     

The economics of crowd out under mixed public/private health insurance

It is well known that public insurance sometimes crowds out private insurance. Yet, the economic theory of crowd out has remained unstudied. Here, I show that crowd out causes two countervailing effects: (a) the intensive margin effect-since high demanders are crowded out, the private market now has a larger proportion of low demanders on the intensive margin (The intensive margin are those who have already bought private insurance), and so will drop quality to lower the price to the low demanders liking; and (b) the extensive margin effect-before the public insurance expansion, the private sector had lowered quality to make insurance more affordable at the extensive margin (The extensive margin is the next group of people who would buy private insurance if the price decreased), but now that public insurance crowds out the extensive margin, quality can then be raised back up to the high demanders liking.If the extensive margin effect dominates, then a new phenomenon of push out occurs, in which crowd out causes the private sector to raise quality and to increase the number of uninsured low demanders not eligible for public insurance. If the intensive margin effect dominates, then crowd out will cause the private sector to lower quality, causing the phenomenon of crowd-in, in which the number of uninsured low demanders that take-up private insurance increases.These two countervailing effects have important implications for any government policy that desires to eradicate all uninsurance. First, if push out is dominant, then the private sector will respond to the public insurance by pushing out and leaving some people newly uninsured. If crowd-in is dominant, then all people can be insured and the government can do it at a lower-than-anticipated level of expansion due to the private sector crowding in.Received: April 2002, Accepted: February 2003, JEL Classification: I11, I38The views herein do not necessarily reflect the views or policies of AHRQ, nor the U.S. Department of Health and Human Services. I thank Pedro Pita Barros, Hugh Gravelle, and Lise Rochaix-Ranson, and participants at the 2nd Health Economics Workshop at the Universidade Nova de Lisboa for helpful comments.     

THE IMPACT OF INSURANCE SUBSIDIES ON SELF‐EMPLOYMENT: DO STATE NON‐GROUP HEALTH INSURANCE REGULATIONS MATTER?

This paper tests whether the effect of tax‐based subsidies for self‐employed health insurance on the level of self‐employment differs with the type of non‐group insurance regulatory regime at the state level. Using a panel of tax returns from 1999 to 2004, we estimate fixed effects instrumental variable regressions for the probability of being self‐employed, allowing the effect of the after‐tax price of self‐employed health insurance to differ by regulatory regime. Our results suggest that states with community rating and guaranteed issue regulations had significantly smaller increases in the fraction of taxpayers reporting some amount of self‐employment income as a result of a decrease in the after‐tax price of self‐employed health insurance. However, there is suggestive evidence that heavily regulated states experienced a larger increase in exclusive self‐employment, particularly among older taxpayers. (JEL J24, H24, I18)     

International risk sharing and commodity prices

Abstract Cole and Obstfeld (1991) exposited a classic result where equilibrium movements in the terms of trade could make ex ante risk‐sharing arrangements unnecessary: a unity elasticity of substitution across goods and production specialization. This paper extends their model to N countries and M commodities (N > M). Here the terms of trade provides insurance against commodity‐specific shocks, not country‐specific shocks. Using commodity‐level production data at the national level and world commodity prices, we document significant terms of trade variability and positive responses of nation‐specific production to terms of trade improvements. The endogenous terms of trade insurance mechanism highlighted in CO is virtually non‐existent.     

Healthcare-related characteristics of low vs normal folate levels among women of child-bearing age

Abstract

Objective:

Despite the institution of mandatory folic acid fortification in the US, folate deficiencies still occur and are associated with an increased risk of several conditions. Since little is known regarding the relationship between folate status and other clinical, demographic, and healthcare-related characteristics, the objective of the study was to compare healthcare-related characteristics among US child-bearing age women with low vs normal red blood cell (RBC) folate levels.

Research design and methods:

Data from the 2003–2006 National Health and Nutrition Examination Survey (NHANES) were used to conduct a retrospective cohort study. Women (aged 18–45 when surveyed) were categorized in two cohorts for comparison: normal RBC folate level (≥140?ng/ml, NFL) and low RBC folate level (<140?ng/ml, LFL).

Results:

Of the 2816 subjects, 5.9% were assigned to the LFL cohort and were significantly younger (28 vs 30 years, p?=?0.01); a greater proportion were 18–25 years old (55.7% vs 39.9%, p?<?0.001) or African-American (55.1% vs 22.3%, p?<?0.01). A lower proportion of LFL women were insured (67.3% vs 75.5%, p?=?0.01) with low rates of private insurance (39.5% vs 53.1%, p?<?0.01), while Medicaid/SCHIP coverage was similar (16.8% vs 15.1%, p?=?0.56). Predictors of low folate levels included aged 36–45 years (OR: 2.14 [95% CI: 1.04, 4.39]) and never being married (2.65 [1.34, 5.24]), while a household income ≥ $75,000 reduced the likelihood of having low folate levels (0.20 [0.06, 0.73]).

Limitations:

The proportion of women with low folate levels was small, with the sample size limiting the ability to adjust for other factors during analysis. Medical histories were based on patient interviews and are subject to recall bias.

Conclusion:

LFL women are younger and have low rates of private insurance coverage compared to women with normal folate levels. Differences in age, marital status, and household income are associated with folate status.     

The impact of private hospital insurance on the utilization of hospital care in Australia

We use the Australian National Health Survey to estimate the impact of private hospital insurance on the propensity for hospitalization as a private patient. We account for the potential endogeneity of supplementary private hospital insurance purchases and calculate moral hazard based on a difference-of-means estimator. We decompose the moral hazard estimate into a diversion component that is due to an insurance-induced substitution away from public patient care towards private patient care, and an expansion component that measures a pure insurance-induced increase in the propensity to seek private patient care. Our results suggest that on average, private hospital insurance causes a sizable and significant increase in the likelihood of hospital admission as a private patient. However, there is little evidence of an expansion effect; the treatment effect of private hospital insurance on private patient care is driven almost entirely by the substitution away from public patient care towards private patient care. We discuss the implications for policies that aim to expand supplementary private insurance coverage for the purpose of reducing excess demand on the public healthcare system.     

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.     

Decision theories and probabilistic insurance: an experimental test

This paper reports the results of an experiment in which probabilistic insurance, as proposed by Kahneman and Tversky (1979), is compared both with full insurance and no insurance. The experimental results conform to the intuitive prediction that risk-averse agents who are indifferent between full insurance and no insurance, will prefer full insurance to probabilistic insurance and probabilistic insurance to no insurance. The first conclusion is incompatible with the predictions of expected utility theory, and the second with Kahneman and Tversky's prospect theory. We also show that Loomes and Sudgen's regret theory can easily accommodate these intuitive results. JEL Classification: C91, D81. We are most grateful to Graham Loomes and two anonymous referees for their very helpful comments. Financial support from the Ministerio de Ciencia y Tecnología, under project BEC2001-0535, and from the Generalitat Valenciana under project GRUPOS03/086, is gratefully acknowledeged.     

Optimal Income Taxation with Risky Earnings: A Synthesis

We study optimal nonlinear income taxation when earnings can differ because of both ability and luck, so the income tax has both a redistributive role and an insurance role. A substantial literature on optimal redistribution in the absence of risk has evolved since Mirrlees's original contribution. The literature on the income tax as a social insurance device is more limited. It has largely assumed that households are ex ante identical so unequal earnings are due to risk alone. We provide a general treatment of the optimal income tax under risk when households differ in ability. We characterize optimal marginal tax rates and interpret them in terms of redistribution, insurance, and incentive effects. The case of ex ante identical households and the no‐risk case with heterogeneous abilities come out as special cases.     

Medical insurance with rank-dependent utility

Summary. A well-known result in the medical insurance literature is that zero co-insurance is never second-best for insurance contracts subject to moral hazard. We replace the usual expected utility assumption with a version of the rank-dependent utility (RDU) model that has greater experimental support. When consumers exhibit such preferences, we show that zero co-insurance may in fact be optimal, especially for low-risk consumers. Indeed, it is even possible that the first-best and second-best contracts are identical. In this case, there is no “market failure”, despite the informational asymmetry. We argue that these RDU results are in better accord with the empirical evidence from US health insurance markets. Received: February 26, 2001; revised version: October 4, 2002 RID="*" ID="*"The authors would particularly like to thank Simon Grant, John Quiggin, Peter Wakker and an anonymous referee for valuable comments and suggestions on earlier drafts. The paper has also benefitted from the input of seminar audiences at The Australian National University, University of Auckland, University of Melbourne and University of Sydney. Ryan also gratefully acknowledges the financial support of the ARC, through Grant number A000000055. Correspondence to:R. Vaithianathan     

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.     

International Integration, Risk and the Welfare State

How does international integration affect the welfare state? Does it call for a leaner or an expanded welfare state? International integration may affect the distortions caused by welfare state activities but also the risks motivating social insurance mechanisms. This paper addresses these potentially counteracting effects in a fully specified intertemporal two–country stochastic endowment model, focusing on the implications when product market integration reduces trade frictions across national product markets. It is shown that lower trade frictions may increase the marginal costs of public funds, which gives an argument for reducing (steady–state) public consumption. However, tighter integration of product markets unambiguously leads to more variability in private consumption, and this gives a case for expanding the social insurance provided via state–contingent public sector activities (automatic stabilizers). JEL classification: E30; F10; H11     

巨灾风险证券化及在中国保险市场的应用

在分析了巨灾风险的损失频率与损失幅度的特点、传统保险与再保险对抗巨灾风险的局限性等方面的基础上，重点介绍了巨灾风险证券的几种产品类型，分析了各种风险转移方式的优缺点。最后，根据中国保险市场的特点，从应用环境和应用条件两个方面提出了开展巨灾风险证券化应用的若干设想。     

Insurance with Frequency Trading: A Dynamic Analysis of Efficient Insurance Markets

This paper extends existing insurance results on the type of insurance contracts needed for insurance market efficiency to a dynamic setting. It introduces continuously open markets that allow for more efficient asset allocation. It also estimates the role of preferences and endowments in the classification of risks, which is done primarily in terms of the actuarial properties of the underlying risk process. The paper further extends insurability to include correlated and catastrophic events. Under these very general conditions the paper defines a condition that determines whether a small number of standard insurance contracts (together with aggregate assets) suffice to complete markets or one needs to introduce such assets as mutual insurance. Journal of Economic Literature Classification Numbers: D81, D99, G11.     

Unemployment Insurance under Moral Hazard and Limited Commitment: Public versus Private Provision

This paper analyzes a model of private unemployment insurance under limited commitment and a model of public unemployment insurance subject to moral hazard in an economy with a continuum of agents and an infinite time horizon. The dynamic and steady‐state properties of the optimum private unemployment insurance scheme are established. The interaction between public and private unemployment insurance schemes is examined. Examples are constructed to show that for some parameter values increased public insurance can reduce welfare by crowding out private insurance more than one‐to‐one and that for other parameter values a mix of both public and private insurance can be welfare maximizing.     

WILL TAX‐BASED HEALTH INSURANCE REFORMS HELP THE SELF‐EMPLOYED STAY IN BUSINESS?

The self‐employed face a tax‐induced disadvantage relative to wage and salary workers when it comes to the payment of health insurance premiums. This paper uses a panel of individual tax return data to test whether lower health insurance premium costs because of an expanded tax incentive result in longer periods of self‐employment. The results suggest that households claiming the deduction are indeed less likely to exit self‐employment. Equalizing the treatment of health insurance premiums for the self‐employed and wage workers by allowing full deductibility from Self‐Employment Contributions Act (SECA) taxes would result in a 7% decrease in the probability of exit. (JEL H32, I18, L26)     

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.