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.     

MEASURING THE IMPACT OF VALUING HEALTH INSURANCE ON LEVELS AND TRENDS IN INEQUALITY AND HOW THE AFFORDABLE CARE ACT OF 2010 COULD AFFECT THEM

A substantial part of the U.S. inequality literature focuses on yearly levels and trends in pre‐tax, post‐transfer cash income and its distribution over time and finds that median income appears to be stagnating, with income growth primarily coming at higher income levels. When we use data from the Current Population Survey for 1995–2008 and add the value of employer‐ and government‐provided health insurance coverage, not only does it increase the upward trend in the level of resources controlled by Americans, but also reduces the level of inequality in these resources and its upward trend. We then provide a highly stylized example of this broader income measure's value in capturing the impact of two key provisions of the Affordable Care Act of 2010—an expansion in Medicaid and the provision of subsidies to lower‐income families for purchasing private coverage on state‐run exchanges. Even though these incremental expansions build on existing systems of government‐provided health insurance, we find that the vast majority of the benefits would still accrue to the bottom three deciles of the income distribution when we include the value of employer‐ and government‐provided health insurance in our expanded yearly income measure. (JEL D31, H51, I14)     

Willingness‐to‐pay for parallel private health insurance: evidence from a laboratory experiment

Abstract Debate over the effects of public versus private health care finance persists in both academic and policy circles. This paper presents the results of a revealed preference laboratory experiment that tests how characteristics of the public health system affect a subject's willingness‐to‐pay (WTP) for parallel private health insurance. Consistent with the theoretical predictions of Cuff et al. (2010), subjects’ average WTP is lower and the size of the private insurance sector smaller when the public system allocates health care based on need rather than randomly and when the probability of receiving health care from the public system is high.     

Supplementary private health insurance and health care utilization of people aged 50+

Does supplementary private health insurance (PHI) coverage influence health care utilization in countries where the coverage ratio with public health insurance is high? I estimate this effect using the Survey of Health, Ageing and Retirement in Europe. Handling the potential endogeneity of supplementary insurance coverage and the large fraction of zero observations in the utilization models influences the empirical results. I show that the effect of PHI coverage on inpatient and outpatient care utilization is not trivial even in countries with generous public health funding. The main finding is that supplementary PHI coverage increases dental care utilization, but decreases the visits to general practitioners. Private insurance is estimated to have little and insignificant influence on the utilization of inpatient care and outpatient specialist care. The magnitude of the effect of supplementary PHI on health care utilization varies with the characteristics of the health care systems.     

The political economy of public health expenditure and wait times in a public‐private mixed health care system

Abstract This paper investigates the determinants of public health expenditure in a public‐private mixed health care system, where a longer wait time for public care is the major difference between public and private sectors. Voter preferences for health care vary according to their age and by income, and public policy choices are part of a multi‐dimensional, competitive political equilibrium. We show how equilibrium public health expenditure and wait times depend on demographics and explain why they are independent of the distributions of income and political influence. We also show that population aging may not always lead to more public health expenditure.     

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.     

Do Consumers Purchase Too Much Health Insurance? The Role of Market Power in Health‐Care Markets

Several authors have suggested that consumers purchase too much health insurance in private markets. We readdress this issue within a model that combines excess health‐care demand due to health insurance with market power due to monopolistic production of health‐care services. We evaluate the market equilibrium in terms of consumer welfare and social welfare. The consumer welfare criterion suggests that in the market equilibrium consumers in fact purchase too much health insurance coverage. The social welfare criterion, in contrast, suggests that because profits of the health‐care industry are properly accounted for, consumers should purchase more insurance coverage than they choose to do in the market equilibrium.     

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.     

On the determination of the US aggregate health care expenditure

Per capita real health care expenditure is examined against three major groups of explanatory variables: economic, demographic, and health stock, and it is found that the three groups of variables have an impact on real health care spending. Other subcategories, such as real private, and government health care, pharmaceutical, dental, home nursing, ambulatory, personal medical consumption, and in-patient expenditures have also been examined, and have been found to be affected by the explanatory variables. For several subcomponents there is evidence of supplier inducement. Of the demographic group of variables, the ageing population had an impact only on the per capita real overall, and private health care outlay, and pharmaceutical spending. Also, cointegrating relationships were found and consistent estimators of the elasticities found.     

MEASURING HEALTH INSURANCE BENEFITS: THE CASE OF PEOPLE WITH DISABILITIES

Since 2012, the Congressional Budget Office has included an estimate of the market value of government‐provided health insurance coverage in its measures of household income. We follow this practice for both public and private health insurance to capture the impact of greater access to government‐provided health insurance for working‐age people with disabilities, whose market value rose in 2010 dollars from $11.7 billion in 1980 to $114.3 billion in 2012. We then consider the more general implications of incorporating estimates of the market price of insurance, equivalent to that provided by the government, into policy analyses in a post‐Affordable Care Act world. (JEL D31, H24, I18, J31)     

THE ROLE OF RETIREE HEALTH INSURANCE IN THE EMPLOYMENT BEHAVIOR OF OLDER MEN*

Using data from the Health and Retirement Survey, we estimate preference and expectations parameters of a structural model of the employment and medical care decisions of older men in order to evaluate the role of health insurance. The budget constraint incorporates detailed cost‐sharing characteristics of private health insurance and Medicare as well as rules and requirements associated with Social Security and private pensions. Simulations imply that changes in health insurance, including access and restrictions to retiree health insurance and Medicare, have a modest impact on employment behavior among older males, with the greatest effect on men in bad health.     

The Use of Dental Services among Older Australians: Does Location Matter?

Based on the National Health Survey of 2005, this study examined the use of dental services among non‐institutionalised older Australians. The results of the regression revealed differences in the frequency of dental visits across the states. The greater the public dental health expenditure per capita in each state the more likely residents of that state were to have visited the dentist in the previous year. Older people residing outside major cities experienced the greatest disadvantage. In addition to the socioeconomic factors reported by studies, in Australia inequalities in access to dental health services was associated with urbanicity and Australian states.     

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)     

Delivering Public Health Care Services: Substitutes,Complements, or Both?

In this article we investigate how the availability of public health care providers increases (complement) or decreases (substitute) the likelihood of having public or private health insurance. The probability of each of three insurance alternatives (uninsured, Medicaid, private insurance) is modeled as a function of the availability of public programs in the respondents'community along with individual characteristics including family income, health status, and family structure. Using population-based estimates, public hospitals are associated with a crowd-out rate of 3.5 percent to 8.6 percent. Federally qualified health centers were associated with a net complementary effect (additional public insurance take-up) of 7.1 percent. (JEL I11 , I18 , I38 )     

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.     

Public financing of health expenditures,insurance, and health outcomes

The effects of public financing of health expenditures, insurance coverage and other factors on health outcomes are examined within health production models estimated using 1960–1992 data across 20 OECD countries. Mortality rates are found to depend on the mix of health care expenditures and the type of health insurance coverage. Increases in the publicly financed share of health expenditures are associated with increases in mortality rates. Increases in inpatient and ambulatory insurance coverage are associated with reduced mortality. The effects of GDP, health expenditures and age structure on mortality are similar to those in previous studies. Tobacco use, alcohol use, fat consumption, female labour force participation, and education levels are also significantly related to overall mortality rates. Increases in income inequality are associated with lower mortality rates, suggesting that the negative relationship between inequality and health outcomes suggested by some previous studies does not remain when a more complete model is estimated. The result that increases in public financing increase mortality rates is robust to a number of changes in specifications and samples. Thus, as countries increase the level of their health expenditures, they may want to avoid increasing the proportion of their expenditures that are publicly financed.     

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.     

Funding and Providing Aged Care: Lessons from the Last Decade

This article examines the future funding of aged care in the context of the Intergenerational Report. Noting the predicted substantial increases in aged‐care costs, it argues that the current funding of aged care, which imposes high and likely rising co‐contributions on care recipients, should be replaced with comprehensive aged‐care insurance. It also recommends improving the transparency of the Intergenerational Report and the sophistication of its sensitivity testing.     

THE GROWTH OF FAMILY EARNINGS INEQUALITY IN CANADA, 1980–2005

In this study we document recent trends in family earnings inequality using data from the Canadian Census and provide insight into the various factors that drive changes in the family earnings distribution. Over the period 1980–95 we observe substantial increases in family earnings inequality. In contrast, we find that some decrease in inequality occurred over the period 1995–2005 although the earnings of the richest 1 percent of families increased substantially. We use semi‐parametric decomposition methods to show that increases in the employment rates of men and women, increases in their educational attainment, and decreases in assortative mating tended to have equalizing effects on the family earnings distribution. We also show that increases in the returns to higher education and increases in the proportion of single individuals as well as lone‐parent families drove increases in family earnings inequality.     

Income-related inequalities of health and health care utilization

By utilizing the China Health and Nutrition Survey (CHNS) data, this paper examines the extent of deviations in terms of horizontal equity in the field of China’s health and medical community, i.e., that those in equal demand ought to be treated equally, and computes the contribution of income in health inequality and utilization inequality of health care. The main conclusions are: There is pro-rich inequality in health and utilization of health care; income contribution to inequality of health care utilization accounts for 0.13–0.2; insurance also enlarges the inequality of health care utilization; health inequality in rural area is larger than that of in urban area; and both rural and urban health inequality are increasing. From 1991 to 2006, income changes in urban districts and rural area account for 7.08% and 13.38% respectively of raising inequality of rural and urban health.