Welfare costs of reclassification risk in the health insurance market

We assess the quantitative importance of reclassification risk in the US health insurance market. Reclassification risk arises because the health conditions of individuals evolve over time, while a typical health insurance contract only lasts for one year. Thus, a change in the health status can lead to a significant change in the health insurance premium. We measure welfare gains from introducing explicit insurance against this risk in the form of guaranteed renewable health insurance contracts. We find that in the current institutional environment individuals are well-sheltered against reclassification risk and they only moderately gain from having access to these contracts. More specifically, we show that employer-sponsored health insurance and public means-tested transfers play an important role in providing implicit insurance against reclassification risk. If these institutions are removed, the average welfare gains from having access to guaranteed renewable contracts exceed 4% of the annual consumption.     

ENTREPRENEURSHIP AND JOB LOCK: THE INTERACTION BETWEEN TAX SUBSIDIES AND HEALTH INSURANCE REGULATIONS

This paper demonstrates that health insurance tax subsidies increase self‐employment, but that the effect differs substantially based on nongroup market regulations and health status. Using the Panel Study of Income Dynamics, I show that households that cannot purchase health insurance because of a preexisting condition do not respond to tax subsidies in states in which they would be denied insurance, but they respond strongly in states in which they face risk‐rated premiums. Households respond similarly to tax subsidies in states with nongroup market regulations similar to those established by the Affordable Care Act, regardless of preexisting conditions. (JEL H20, I13, J30)     

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.     

Implications for unisex statutes and risk-pooling: The costs of gender and underwriting attributes in the automobile insurance market

In this paper, we explore the effects of gender and other demographic features and benefit provisions on insurance premiums using individual data from a property and liability insurer domiciled in Georgia for three types of automobile insurance coverages: collision insurance, comprehensive insurance, and liability insurance. We report the implicit prices of individual and automobile underwriting attributes and find that the effect of gender on the insurance premium for each of our coverage types is significant but has a lower absolute effect than other underwriting attributes, raising questions about the regulatory impact of unisex statutes. Finally, we examine three alternatives open to the regulator who must mandate and monitor insurance pricing under a unisex statute.     

GROWTH OF U.S. HEALTH CARE SPENDING

The share of output allocated to health care has more than doubled since 1960. This paper models the growth in this ratio and finds that the increase in the elderly population whose medical spending is heavily subsidized is a key factor behind this growth. Technological change is a symptom of the medical market structure rather than a cause of medical spending growth. The econometric model in the analysis here is based on a micro model composed of two groups. The first group is a healthier group that makes income transfers in order to finance the sicker group's health insurance premiums. In this model, a technical constraint places an upper bound on the healing ability of the medical good. This upper bound changes through an unobservable endogenous process. Estimating the health care model involves using estimation techniques that bypass the need to make any a priori assumptions about the functional form of the regressions or about the distribution of the residuals. The results suggest that technical change cannot indefinitely induce health care spending growth if no subsidies exist that provide full health care coverage with premiums fully paid by the subsidy. If subsidies provide full coverage and pay the entire premium, then new technical discoveries can induce constantly expanding medical expenditures.     

Medicare for all or medicare for none? A macroeconomic analysis of healthcare reform

In this study, I develop a novel general equilibrium life cycle model composed of finitely-lived households that differ according to age, skill level, and access to employer-provided health insurance. After introducing a “Medicare for all” health insurance system to the model, I examine how the welfare response to this policy change will differ according to household characteristics. Then, I compare this system to a completely privatized health insurance system that achieves universal health insurance coverage through the creation of utilization-based premium subsidies. In general, both systems tend to improve the welfare of young households at the expense of old households. However, when using average value-of-life as the primary measure of welfare, Medicare for all either benefits unskilled households at the expense of skilled households, or makes both worse off. In contrast, the privatized system improves the average value-of-life of all household groups, regardless of skill level or prior access to employer-provided health insurance.     

THE WEALTH EFFECTS OF INCOME INSURANCE

Precautionary savings models suggest that wealth should rise with income risk. Risk is reduced by means-tested transfers, however, which implies that transfer programs should discourage private wealth accumulation. We offer a comprehensive empirical assessment based on variation across states in the generosity of a number of programs, specifically unemployment insurance and means-tested transfers (Aid to Families with Dependent Children and Food Stamps). We use monthly data on married couples from the Survey of Income and Program Participation (SIPP) to regress wealth on income, income risk, and various measures of transfer generosity. The results support the precaution-ary savings model and reveal moderate negative wealth effects of both unemployment insurance and means-tested transfers, with an elasticity of about −0.18.     

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)     

FAMILY SAFETY NETS AND ECONOMIC TRANSITION: A STUDY OF WORKER HOUSEHOLDS IN POLAND

Can Eastern European families most severely impoverished during the transition to capitalism rely on private family safety nets? This question is likely critical for the transition's success, but little is known about family networks in Eastern Europe. We analyze newly available Polish household surveys, conducted both before and after Poland's economic transition, which measure private inter-household transfers. Such transfers are large and widespread in Poland, and in many ways appear to function like means-tested public transfers. They flow from high to low-income households and are targeted to young couples, families with many children and those experiencing illness. Private transfer patterns also suggest that they are responsive to liquidity constraints. Our results from 1987 data indicate that private transfers could fill a non-trivial portion of the income gap left by unemployment. However, we also find evidence from 1992 data suggesting that family networks weakened somewhat after the transition.     

The wealth effects of premium subsidies on moral hazard in insurance markets

Insurance premium subsidies are present in many insurance markets. The Swiss government, for example, paid out CHF 4.26 billion or 0.72% of the Swiss GDP for health insurance premium subsidies in 2011. Analyses of premium subsidies have often highlighted that the increased insurance demand due to premium subsidies increases the effects of moral hazard in the market. Other consequences of premium subsidies, however, have mostly been neglected by the literature. We show in our theoretical model that the wealth effects of premium subsidies decrease the sensitivity of the insured towards the monetary consequences of losses. This leads to less prevention efforts by the insured and thus increases moral hazard in the market. The effect is preserved if the subsidy is financed through proportional taxation. Using two alternative models, we show that providing state-dependent subsidies can either increase or reverse this effect, depending on which state subsidies are paid. We argue that whether demand effects or wealth effects of premium subsidies will dominate the insured׳s behavior depends on the market structure.     

The effect of state health insurance benefit mandates on premiums and employee contributions

The average US state has 40 benefit mandates, laws requiring health insurance to cover particular conditions, treatments, providers or people. We investigate the extent to which these mandates increase the health insurance premiums paid by employers, and the extent to which these higher premiums are passed on to employees in the form of higher employee contributions. We use state-level data on premiums and employee contributions to health insurance from the insurance component of the 1996–2011 Medical Expenditure Panel Survey. Our main analysis is a fixed effects regression that controls for age, race, income, union membership and the presence of state mandate waivers. We find robust evidence that the average mandate increases premiums by approximately 0.6%, and that mandates lead to similar increases in employee contributions for single-coverage health insurance plans. Alternative specifications using an AR(1) error structure estimate a larger effect of mandates, while those using generalized estimating equations estimate smaller effects. We find that mandates requiring insurers to cover a specific benefit, as opposed to a specific type of provider or person, lead to the largest increases in employee contributions.     

HOW DO JAPANESE HEALTH INSURANCE SOCIETIES FINANCE THEIR CONTRIBUTIONS TO THE HEALTH SERVICE SYSTEMS FOR THE ELDERLY?*

We examine how Japanese health insurance societies finance (or distribute) the costs (or cost savings) from an increase (or decrease) in contributions to the Health Service Systems for the Elderly. Three ways are possible: (i) adjusting the premiums of the employee or employer; (ii) providing an optional benefit; and (iii) adjusting reserves by the change in contribution. We find that more than six‐sevenths of the changes are associated with changes in reserves, followed by premiums, and finally optional benefits. The increase in the premium mostly shifted to employees, while employees enjoyed a nearly 60% decrease in total premium.     

MEDICAID AND THE LABOR SUPPLY OF SINGLE MOTHERS: IMPLICATIONS FOR HEALTH CARE REFORM

The Medicaid expansions and health insurance subsidies of the Affordable Care Act (ACA) change work incentives for single mothers. To evaluate the employment effects of these policies ex ante, I estimate a model of labor supply and health insurance choice exploiting variation in pre‐ACA Medicaid policies. Simulations show that single mothers increase their labor supply at the extensive and intensive margin by 12% and 7%, respectively, uninsurance rates decline by up to 40%, and an average family's welfare improves by 1,600 dollars per year. Health insurance subsidies and not Medicaid expansions mostly drive these effects.     

A natural experiment of the effect of advertising on sales: the SASOL case

China's so-called ‘reform and opening up’ policy (Gai Ge Kai Fang), implemented nearly 30 years ago, has led to tremendous economic development. China's nominal Gross Domestic Product (GDP) was 3.25 trillion US dollars in 2007, making it the fourth largest economy in the world. At the same time, income inequality has become quite skewed in China, inviting considerable criticism. Moreover, the trend towards greater income inequality persists. Of particular public policy relevance is the effect of income inequality on health disparities in China, particularly for low-income households. This study addresses this issue using a longitudinal dataset from the China Health and Nutrition Survey (CHNS) over the period 1997 to 2006. Our central finding is that income inequality affects health differently by socioeconomic status: income inequality harms individual health among low income households by more than it does among high income households. More specifically, health is more adversely affected by greater income inequality for households with low incomes. China's central government is committed to making further investments in the health care system. As part of that effort, attention should be directed at low income households to reduce health inequality, possibly providing them with a health insurance safety net similar to Medicaid in USA.     

PORTFOLIO ALLOCATION IN THE FACE OF A MEANS‐TESTED PUBLIC PENSION

We investigate whether households adjust their asset portfolios just prior to retirement in ways that are consistent with maximizing eligibility for a means‐tested public pension. We utilize detailed micro data for a nationally‐representative sample of Australian households to estimate a system of asset equations which are constrained to add up to net worth. Our results provide little evidence that healthy households or couples are responding to the incentives embedded in the means tests determining pension eligibility by reallocating assets. While there are some differences in asset portfolios associated with having an income near the income threshold, being of pensionable age, and being in poor health, these differences are often only marginally significant and are not clearly consistent with the incentives inherent in the Australian age pension eligibility rules. Any behavioral response to the incentives inherent in the age‐pension means test appears to be predominately concentrated among single pensioners who are in poor health.     

The disappearing gay income penalty

Since 1995, labor economists have reported on the income disparities between individuals who engage in same-sex behavior and those that do not. Many of these papers report a significant wage penalty, while others find no effect, but few look at the trend over time. We find, using National Health and Examination Survey (NHANES) data from 1988 to 2007, that the income gap has reversed over time from a penalty to a premium.     

New Evidence on Gay and Lesbian Household Incomes

Using independent data from the Centers for Disease Control, the author tests a key assumption of previous research on gay and lesbian incomes: that same-sex unmarried partner households are, indeed, gay or lesbian. The author shows that this independent data suffers from less severe underreporting of same-sex unmarried partner households than the 1990 Decennial Census. Furthermore, individual level information on sexual behavior and family planning is used to show that these households exhibit sexual behavior that is systematically different from married and different-sex couples and that is consistent with a large body of public health and HIV literature on gay men and lesbians. Finally, the author replicates, confirms, and extends previously published Census-based results on the household income penalty faced by gay male couples, showing that these results are not an artifact of deficient data. He finds similar results for lesbian couples. (JEL J1 , J3 )     

An Analysis of a Rules-based Approach to Disciplining Export Credits in Agriculture

ABSTRACT

This paper examines the comparative static effects of rules-based disciplines for government supported export credit arrangements. The arrangements provide traders in the country offering the guarantees more favourable borrowing conditions. This may provide an advantage relative to rival exporters since the supported trader may offer better financial terms to importers. Rules that discipline implicit interest rate subsidies are appropriate when an importing country does not face liquidity constraints when borrowing. However, these rules may not be appropriate with liquidity constraints because of the potential for additionality and benefits for all exporting countries. Rules on benchmarks for insurance premiums are always appropriate because insurance subsidies unambiguously have the potential to distort markets.     

Migration Effects of Welfare Benefit Reform

This study tests for a migration response to the implementation of stricter rules for receiving welfare benefits (means-tested social assistance for individuals who lack sufficient work-related income), in the form of mandatory participation in activation programmes in Stockholm town districts. The results give no indications that activation programmes affect the moving choices of recipients of welfare benefits.