医疗保险支付方式的经济分析

本文在对医疗保险市场道德风险分析的基础上,运用经济学原理对医疗保险市场支付方式的作用机制进行了深入研究.结果表明,医疗保险支付方式不仅是一种医疗消耗的补偿手段,而且还是有效控制医疗费用,保障患者健康,正确引导供需双方行为,抑制道德风险的关键.因此,为了抑制供需双方的道德风险,控制医疗费用的不合理增长,医疗保险支付方式成为保险机构的首选工具.     

Social Insurance and Redistribution with Moral Hazard and Adverse Selection*

Rochet (1991) showed that with distortionary income taxes, social insurance is a desirable redistributive device when risk and ability are negatively correlated. This finding is re‐examined when ex post moral hazard and adverse selection are included, and under different informational assumptions. Individuals can take actions influencing the size of the loss in the event of accident (or ill health). Social insurance can be supplemented by private insurance, but private insurance markets are affected by both adverse selection and moral hazard. We study how equity and efficiency considerations should be traded off in choosing the optimal coverage of social insurance when those features are introduced. The case for social insurance is strongest when the government is well informed about household productivity.     

关于保险市场道德风险的微观经济学问题研究

保险市场是一个典型的信息不对称市场,主要表现为道德风险问题,这种对信息占有的不对称状况,很容易被保险市场参与者所利用,并导致保险市场运行的低效率。目前,中国保险市场上保险公司和投保人之间的道德风险问题表现得比较突出,已经成为制约保险业可持续发展的一个重要因素。本文从理论角度研究道德风险问题产生的机制,梳理信息不对称问题在理论上的解决方法,并从中得到保险市场应对道德风险问题的建议。     

Moral hazard,insurance claims,and repeated insurance contracts

Abstract The paper develops a simple model of repeated automobile insurance contracts, providing a framework for analyzing changes in aggregate insurance data in periods of changes that affect driver incentives. Experience rating of premiums gives drivers an incentive to exert effort to avoid accidents (ex ante moral hazard), and an incentive to hide accidents (ex post moral hazard). The empirical analysis, using data from the competitive insurance markets in Ontario and Alberta over a period of major legislative changes in Ontario, suggests that much of the recent decline in accidents in Ontario was due to an increased incentive to hide accidents.     

Health insurance subsidies and the expansion of an implicit marriage penalty: a regional comparison of various means-tested programmes

Any subsidy provision for healthcare premiums, including those embedded in Affordable Care Act (ACA), has the potential to result in some couples facing an implicit penalty when married relative to unmarried. To illustrate such consequences of means-tested subsidies of health insurance premiums, we construct hypothetical households earning different levels of income who are eligible for current subsidies in the USA. and compare the estimated implicit marriage penalty faced by these households to the one faced by low-income households who are eligible for various means-tested programmes (e.g. TANF, WIC, SNAP) for each of the 48 contiguous states. We find that, like very low-income households, marriage can potentially penalize couples who receive health insurance premium subsidies by decreasing their overall disposable income by as much as 14%. We find that the ACA increases the number of households subject to marriage penalties embedded in means-tested programmes for low-income couples. This distortion will exist for any future health insurance premium subsidies that are means tested at the household income level.     

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.     

社会医疗保障改革的福利效应:以中国城镇为例

This paper evaluates Chinese public health insurance reform enforced since 1998 in terms of its welfare effects. We evaluate China health insurance reform since 1998 using the China Health and Nutrition Surveys (CHNS) data with relevant econometric models. The results of empirical studies show that the public health insurance status has significant impact on medical service utilization and expenditure. The reform reduces the positive effect of public health insurance on medical service utilization, meaning the utilization gap is narrowed after the reform. However, the empirical studies find that the medical expenditure growth of the sample individuals in urban China has not been controlled after the Basic Medical Insurance (BMI) program even if a new co-payment is enforced. Two main reasons for this failure might be the rising cost of medical service and physician’s severe moral hazard, while both of them come from no managed care mechanism for medical service providers in China.      

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.     

When prices hardly matter: Incomplete insurance contracts and markets for repair goods

This paper looks at markets characterized by the fact that the demand side is insured. In these markets, a consumer purchases a good to compensate consequences of unfavorable events, such as an accident or an illness. Insurance policies in most lines of insurance base indemnity on the insured's actual expenses, i.e., the insured would be partially or completely reimbursed when purchasing certain goods. In this setting, we discuss the interaction between insurance and repair markets by focusing, on one hand, upon the development of prices and the structure of markets with insured consumers, and, on the other hand, the resulting backlash on optimal insurance contracting. We show that even in the absence of ex post moral hazard the extension of insurance coverage will lead to an increase in prices as well as to a socially undesirable increase in the number of repair service suppliers if repair markets are imperfect.     

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.     

The effects of government intervention on the market for corporate terrorism insurance

Nine OECD countries presently have national terrorism insurance programs based on some type of public–private risk sharing. While such arrangements have helped provide the necessary insurance capacity in the post-September 11, 2001 era, little is known about the effect of such governmental intervention on terrorism insurance markets. This paper focuses on the United States, where the Terrorism Risk Insurance Act of 2002 (TRIA) provides insurers with no cost federal reinsurance up to an industry-wide loss of $100 billion. We present an empirical analysis to compare how insurers' diversification behavior varies between property coverage (no governmental intervention) and terrorism coverage (with government intervention). We find evidence that insurers in the U.S. are much less diversified for terrorism coverage than they are for property lines of coverage. We interpret these findings as tentative evidence for moral hazard caused by the governmental intervention under TRIA.     

论作为保险人法定免责事由的故意犯罪认定立场

被保险人故意犯罪作为保险人的法定免责事由,其立法根据在于防止道德风险、维护社会公共秩序和善良风俗、避免保险制度被滥用。对作为保险人免责事由的故意犯罪认定与刑法保持一致之立场,既符合保险法与刑法各自的功能与立法目的,不违背保险法把被保险人故意犯罪作为保险人法定免责事由的立法根据,也是由保险法免责要件规范的不明确性决定的,同时也符合保险合同疑义利益解释规则的基本原理。     

Small firms,bigger changes: health insurance coverage take-up rates in small firms after the ACA

Measuring the impact of the Affordable Care Act of 2010 (ACA) on employer-sponsored health insurance is essential in an era of constant changes to health policy. Using data from the Kaiser Family Foundation Employer Survey, we focus on firms with fewer than 50 employees in order to isolate the effect of the ACA on small firms. We utilize a differences‐in‐differences approach with a time fixed effect structure to provide analysis for a treatment group of small firms and a control group of large firms. After excluding firms with grandfathered plans, we find that the ACA provisions reduced health insurance coverage take-up rates in small firms by 1.96 to 2.67 percentage points (compared to large firms).     

Private insurance subsidies and public health care markets: evidence from Canada

In this study I examine the effects of government subsidies to employer-provided health insurance on the decision to purchase insurance, and on utilization of publicly funded health services. Using unique variation in tax subsidies across Canadian provinces as an instrument, I estimate the effects of these subsidies on the demand for supplemental health insurance and their extended effects on the decision to use publicly-funded health services. My results show that government subsidies through tax exemptions have significant effects on the decision to purchase insurance. Furthermore, additional insurance policies lead to moral hazard in the use of publicly funded health services. JEL Classification: H2,H4, I1     

我国基本医疗保险制度的激励与监督机制——基于道德风险的分析

逐步在我国建立公平有效的基本医疗保障制度是当前医疗体制改革的首要目标.几年来,尽管我国在这方面取得了一定成绩,但为了防范广泛存在的道德风险,政府的不恰当措施却导致我国在医疗保险体制上出现了诸如门诊负担沉重、报销水平偏低、医疗成本控制过严和医疗保险基金挪用等严重问题.如何解决这些问题是本文研究的关键.我们从分析基本医疗保险的性质出发,集中论述了由共用资源和委托代理关系所引发的道德风险以及政府所面临的两难困境.最后,我们提出了相应的政策建议:政府应在放宽对参保人和医疗机构限制的基础上,通过构建合理的激励与监督机制来健全基本医疗保险体系.     

A dynamic analysis of the demand for health insurance and health care

We find that asymmetric information is important for the uptake of supplementary private health insurance and health care utilization. We use dynamic panel data models to investigate the sources of asymmetric information and distinguish short-run selection effects into insurance from long-run selection effects. Short-run selection effects (i.e. responses to shocks) are adverse, but small in size. Also long-run effects driven by differences in, for example, preferences and risk aversion, are small. But we find some evidence for multidimensional asymmetric information. For example, mental health causes advantageous selection. Estimates of health care utilization models suggest that moral hazard is not important.     

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.     

Converging trends in national health services and social health insurance systems

Despite the difficulties in comparing the problems and solutions in the European healthcare system reforms, this paper will emphasise that there are signs of convergence among them given the way that they respond to similar challenges. By observing recent developments in national health services and social health insurance systems the focus will be on common trends. They both appear to favour models of (i) greater decentralisation of responsibilities in managing insurance coverage, (ii) population-based mechanisms to finance providers and (iii) more extensive consumer choice and additional private finance.     

Risk adjustment and prevention

Abstract Widespread integration of market‐based incentives into healthcare systems calls for – and has elicited – increasing adoption of risk adjustment. By deterring selection, risk adjustment helps to assure fair and efficient payments among health insurers or capitated provider groups. However, since conventional risk adjustment allocates funds among regions or insurers according to current population health status, it does not reward – indeed, it penalizes – preventive efforts that improve population health. This prevention penalty of risk adjustment represents a hidden cost of unclear magnitude, undermining provider incentives for health promotion. We develop a theoretical model of selection and prevention demonstrating this problem with conventional risk adjustment and suggesting a simple alternative: risk adjustment should be linked to pay‐for‐performance for prevention.     

A Simple Model of Health Insurance Competition

This study investigates competition between health insurance companies under different financing regulations. We consider two alternatives advanced in recent German healthcare reform discussions: competition by contribution rates (health contributions) and by fees (health premia). We find that contribution rate competition yields lower company profits and higher consumer welfare than premia competition when switching between insurance companies is costly.