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.     

智利健康保险制度改革分析

本文介绍了智利健康保险制度改革后的基本框架，分析了其运行过程中出现的问题及原因，指出无论是从公平还是从效率的角度看，智利的模式都很难说是成功的。从全球范围来看，面对实践的挑战，健康保险的理论研究仍旧任重而道远。     

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     

我国商业健康保险发展的制度分析

我国商业健康保险的发展严重滞后于经济和社会发展的需要,医疗保障制度供求失衡为商业健康保险制度创新提供了动力机制。从商业健康保险制度创新所要求的制度环境看,在我国现阶段还存在诸多不利于商业健康保险制度创新的体制性和机制性障碍。应统筹考虑医疗社会保险和商业健康保险的协调发展,建立市场退出机制,促使保险企业成为合格的产品供给主体,加快保险消费文化与消费意识转型,引导消费者成为理性消费群体。     

Insurance of Household Risks and the Rebalancing of the Chinese Economy: Health Insurance,Health Expenses and Household Savings

This paper studies the effects of a public insurance system, the New Cooperative Medical Scheme (NCMS) on household savings in rural China. We develop a theoretical model in which we explain the impact of health insurance on savings through the impact of health insurance on out‐of‐pocket (OOP) health expense given the household level of wealth and seriousness of illness. We test the model empirically using data from the China Health and Nutrition Survey. We run endogenous and exogenous quantile regressions to evaluate the effects of NCMS participation on the distributions of household savings and OOP health expense. The impact of NCMS varies with the seriousness of illness. The NCMS induces an increase in OOP health expense for mild illness and, inversely, a decrease in health payments for more serious illnesses. The NCMS also leads to a higher incidence of catastrophic healthcare spending. The impact of the NCMS, given a certain state of illness, also varies with the household level of wealth. Poor households face health expense for both mild and serious illnesses. As the NCMS has opposite effects on the OOP expense for these two kinds of illness, we observe no effect on poor households’ precautionary savings. Because the decrease in OOP health expense for mild illness is larger for less poor households, the NCMS induces a decrease in their savings. For the most affluent households, the higher decrease in OOP spending on most moderate illness is dominated by a sharp increase in catastrophic expense, causing an increase in savings. To significantly reduce household savings and enhance household consumption, the NCMS has to offer better coverage against both serious and catastrophic health risks.     

农民的疾病风险与医疗保障:一个实证分析

农民的疾病风险与医疗保障是“三农”研究中一个不能回避的问题。在调查数据基础上，本文通过提出假设并建立回归模型进行检验的实证研究发现，在大多数农民已解决温饱的今天，疾病风险已是农民所面临的诸多现实威胁中最普遍的一种，对于身体状况不太好和家庭有惠重病成员的农民来说尤为如此。本研究认为，建立与完善农民的疾病医疗保障制度已是当务之急，应充分注重提高农村医疗的可及性，加快农村基层医疗体系建设，为农民提供方便、高质量的医疗服务。     

Analysing Systemic Risk in the Chinese Banking System

We examine systemic risk in the Chinese banking system by estimating the conditional value at risk (CoVaR), the marginal expected shortfall (MES), the systemic impact index (SII) and the vulnerability index (VI) for 16 listed banks in China for the 2007–2014 period. We find that these measures show different patterns, capturing different aspects of systemic risk of Chinese banks. However, rankings of banks based on these measures are significantly correlated. The time‐series results for the CoVaR and MES measures suggest that systemic risk in the Chinese banking system decreased after the global financial crisis but started rising in 2014.     

Adverse Selection in Health Insurance Markets: A Classroom Experiment

Adverse selection as it relates to health care policy will be a key economic issue in many upcoming elections. In this article, the author lays out a 30-minute classroom experiment designed for students to experience the kind of elevated prices and market collapse that can result from adverse selection in health insurance markets. The students should come away from the experiment understanding why adverse selection leads to high prices on good quality insurance and why it forces healthy individuals into low quality plans. Additionally, the experiment helps students think about the market characteristics that make health insurance particularly vulnerable to problems of asymmetric information. Finally, the experiment connects the adverse selection problem with key features of the 2010 Patient Protection and Affordable Care Act.     

发展中国家的社会医疗保险:一个持续的挑战

本文探讨了发展中国家推行社会医疗保险（简称SHI）的可行性。SHI的目的是为了保护所有人免遭疾病所致的财务风险。然而，由于在金融团结程度、医疗服务提供难题和管理能力欠缺等方面缺乏探讨与共识，因此SHI在执行时确有难度。实现医疗保险的全面覆盖可能需要花很长时间，但也可以加快进度。通过家庭解决金融保护问题，从政府和捐助者那里获得持续的金融支持，并使SHl分散地发展，就可以缩短实现医疗保险覆盖所有人所需的时间。     

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。     

Income and Health Concentration in Australia

This paper measures the concentration of ill-health among income groups in Australia using health survey data from 1989–90 ( Australian Bureau of Statistics 1991 ) and 1995 ( Australian Bureau of Statistics 1997 ), which contain responses on self-assessed health status and gross personal income. The technique of direct standardisation is used to control for the influence on health status of gender and age. Comparisons of the concentration of ill-health over time and between males and females and persons living in rural and urban areas are reported. For both surveys and all groups, we find that ill-health is concentrated among lower income groups. Concentration measures of ill-health are higher (in absolute terms) for men than for women. In all categories apart from women, the concentration measures fell between 1989–90 and 1995 surveys.     

Private Information in Life Insurance,Annuity, and Health Insurance Markets

Economic theory predicts that private information on risks in insurance markets leads to adverse selection. To counterbalance private information, insurers collect and use information on applicants to assess their risk and to calculate premiums in an underwriting process. Using data from the English Longitudinal Study of Ageing (ELSA), this paper documents that differences in the information used in underwriting across life insurance, annuity, and health insurance markets attenuate private information to different extents. The results are in line with – and might help to reconcile – the mixed empirical evidence on adverse selection across these markets.     

A Critique of the Private Health Insurance Regulations

The private health insurance sector is one of the most regulated sectors in Australia. The Private Health Insurance Incentives Scheme, along with community rating, is intended to make private insurance equitable, profitable and popular. We argue that the subsidy to health insurance ought to be a very effective tool for increasing insurance–but it was ineffective because community rating was ineffective. Using data from the Household Expenditure Survey we find that despite community rating rules which prohibit age‐adjusted premiums, young adults paid considerably less for their insurance than older adults. We conclude that insurers circumvented community rating through plan design, screening older consumers into more expensive plans. We also find that the penalty of 2 per cent per year for delaying insurance, introduced as part of the lifetime cover plan, is too low to be effective. We reflect on the New Zealand experience, where a completely deregulated insurance industry continues to be profitable and enjoys similar rates of coverage to those of Australia, and we ask whether Australia too could not benefit from complete deregulation.     

Health Insurance, Liquidity and Growth

Within the context of an endogenous growth model, it is shown that in the presence of health risks which influence household income, the introduction of a private insurance company increases the long-term economic growth rate. The introduction of such an institution has two effects on savings: a level effect and a composition effect. Although the presence of this risk-reducing institution induces a decrease in the level of total savings, as suggested in earlier papers, the rate of illiquid savings, which contribute to growth, increases.
JEL Classification E 1; G 2; O 1; O 4     

Correcting for transitory effects in RCTs: Evidence from the RAND Health Insurance Experiment

Temporary randomized controlled trials are susceptible to transitory effects that would not result from a permanent treatment. We find a large and statistically significant “deadline effect”—a surge in spending in the final treatment year—in the RAND Health Insurance Experiment, identified by random allocation to three- or five-year enrolment terms. Participants facing lower coinsurance rates show larger spending surges. Partialing out the price–deadline interaction reduces in magnitude estimates of the permanent price elasticity of drug spending (and in some specifications of outpatient and supplies spending). This implies higher optimal coinsurance rates and illustrates the importance of experimental design to identifying parameters of interest in randomized controlled trials.     

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.