Information Asymmetries and Risk Management in Healthcare Markets: The U.S. Affordable Care Act in Retrospect

This article critically examines the pertinent issues in ex ante and ex post moral hazard in healthcare markets, with the U.S. Affordable Care Act (ACA) as its focal point of inquiry. First, it compares the various types of information asymmetries resulting from the production, allocation, and utilization of health insurance. Second, it reviews the literature on adverse selection, moral hazard, and risk mitigation against which salient ACA reforms are analyzed. In contrasting conventional moral hazard from an alternative theory of welfare maximization, it suggests that healthcare (over)utilization cannot necessarily be considered wasteful, even if it ends up costing insurers more on a short-term basis. Costs and savings attributable to healthcare spending under the ACA will vary between the consumer, insurer, and regulator-subsidizer. Despite the ambiguities surrounding definitions of “health,” the challenge of containing inefficient moral hazard, and encouraging its desirable counterpart, lies in the tradeoffs that arise between consumer access to affordable and quality healthcare and the market competitiveness of health insurers. The new Trump administration will have to address these tradeoffs in repealing and replacing the ACA, particularly in light of escalating insurance premiums and deductibles, narrower provider networks, and technical implementation issues.     

DO HEALTH INSURERS CONTRACT THE BEST PROVIDERS? PROVIDER NETWORKS,QUALITY, AND COSTS

We provide a modeling framework to analyze selective contracting in the health‐care sector. Two health‐care providers differ in quality and costs. When buying health insurance, consumers observe neither provider quality nor costs. We derive an equilibrium where health insurers signal provider quality through their choice of provider network. Selective contracting focuses on low‐cost providers. Contracting both providers signals high quality. Market power reduces the scope for signaling, thereby leading to lower quality and inefficiency.     

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.     

“Interest Rate Trap”, or Why Does the Central Bank Keep the Policy Rate Too Low for Too Long?

In this paper, we provide a framework for modeling one risk‐taking channel of monetary policy, the mechanism whereby financial intermediaries' incentives for liquidity transformation are affected by the central bank's reaction to a financial crisis. The anticipation of the central bank's reaction to liquidity stress gives banks incentives to invest in excessive liquidity transformation, triggering an “interest rate trap” – the economy will remain stuck in a long‐lasting period of suboptimal, low interest rate equilibrium. We demonstrate that interest rate policy as a financial stabilizer is dynamically inconsistent, and the constrained efficient outcome can be implemented by imposing ex ante liquidity requirements.     

Investment risk taking by institutional investors

According to theory, institutional investors face both risk-management and risk-shifting incentives. This article assesses the relevance of these conflicting incentives for Dutch pension funds and insurance firms over the period 1995 to 2009. Using a unique and extended data set, we observe a significant positive relationship between capital and asset risk for insurers, indicating that risk-management incentives dominate in the Dutch insurance industry. Risk-shifting incentives, however, also seem relevant, as stock insurers take more investment risk than their mutual peers. For Dutch pension funds, we conclude that overall neither risk-shifting nor risk-management incentives seem to dominate. Interestingly, we find that professional group pension funds take significantly less investment risk than other types of pension funds. This finding is in line with expectations, as in professional group pension funds potential incentive conflicts between pension fund participants and the employer are effectively internalized.     

WHY REWARDS ARE BETTER THAN SANCTIONS

Sanctions are said to fail because of the “rally‐round‐the‐flag effect”. This is the main reason why many advocate the use of positive incentives as a viable alternative. Not only do rewards provoke no defensive reaction, but they may elicit a rally in support of compliance – a “fifth‐column effect.” Yet, positive incentives are vulnerable to extortion – doing wrong in the hope of obtaining larger rewards. As a result, many conjecture that sanction threats and promises of reward are most efficient when used simultaneously. We put this conjecture to a test, staging a formal confrontation of the two forms of incentives. Our model pits a sanctioner and a target in a game allowing for the possibility of rally‐round‐the‐flag, fifth‐column, and extortion effects. The game yields unambiguous results: under no circumstances should a sanctioner prefer sanction threats to reward promises. This result holds despite the risk of extortion, a risk that proves to be less of a drawback than the rally round the flag.     

Employment Protection Versus Flexicurity: On Technology Adoption in Unionised Firms*

We analyse how different labour‐market institutions – employment protection versus ‘flexicurity’– affect technology adoption in unionised firms. We consider trade unions’ incentives to oppose or endorse labour‐saving technology and firms’ incentives to invest in such technology. Increased flexicurity – interpreted as less employment protection and a higher reservation wage for workers – unambiguously increases firms’ incentives for technology adoption. If unions have some direct influence on technology, a higher reservation wage also makes unions more willing to accept technological change. Less employment protection has the opposite effect, as this increases the downside (job losses) of labour‐saving technology.     

EQUITY-SENSITIVE INDICATORS OF LIVING STANDARDS WITH AN APPLICATION TO NORTHERN IRELAND

The level of a region's achievement with respect to a particular outcome is usually measured by the mean value of that outcome. This, however, ignores the fact that the distribution of that outcome, between population or geographical subgroups in that region, may be unequal: in order to reflect this inequality, ‘equity‐sensitive’ indicators make a downward adjustment to the mean value of the outcome. This paper extends the notion of ‘equity‐sensitive’ indicators which take cognisance of inter‐group inequality, to ‘equity‐sensitive’ indicators which paid heed to intra‐group inequality. It constructs – using data from a Northern Ireland survey into poverty and social exclusion conducted in 2002/2003 –‘equity‐sensitive indicators’ of living standards in Northern Ireland. These take account of both the average level of the standard of living and also inequality in these levels between groups, and between persons in these groups.     

中国居民医疗保险购买行为研究-基于商业健康保险的角度

本文通过健康保险市场供需双方行为分析,构建居民医疗保险购买行为模型,利用中国健康与营养调查数据(2000—2006),运用部分观测的二元Probit估计方法(Bivariate Probit with partial observability),从实证的角度分析商业健康保险市场中供需双方各自的风险选择行为,以及城乡地区居民对商业健康保险的潜在需求行为及其宏微观影响因素。本文发现:(1)城乡居民都存在显著的逆向选择行为;(2)城乡社会医疗保障对居民商业健康保险需求行为有显著的促进作用;(3)影响居民商业健康保险行为的其他因素还包括,个人的风险偏好和经济购买力。     

GENETIC ENDOWMENTS, PARENTAL AND CHILD HEALTH IN RURAL ETHIOPIA

The determinants of long‐term child health in Ethiopia – as measured by height‐for‐age z‐scores – are examined controlling for community, household and individual level heterogeneity. The influence of parental health and the role of genetics are analysed. The height of parents is highly significant but no significant correlation with per capita expenditures is found. Food prices, birth order, sex and age of children, number of siblings of the mother, years of marriage and altitude are important determinants. Deprivations in later years are more important than during pre‐ or neo‐natal periods. Genetic inheritance seems to explain the correlations between child and parental health.     

The NIRCU and the Phillips curve: an approach based on micro data

Abstract In this paper we propose a straightforward method to derive a non‐inflationary rate of capacity utilization (NIRCU) based on micro data. We condition the current capacity utilization of firms on their current and planned price adjustments. The non‐inflationary capacity utilization rate is then defined as the rate where a firm feels no price adjustment pressure. One of the main advantages is that this methodology uses structural aspects and does not make it necessary to operate with – often rather arbitrary – statistical filters. We show that our aggregate NIRCU performs remarkably well as an indicator of inflationary pressure in a Phillips curve estimation.     

ACQUISITION OF INFORMATION TO DIVERSIFY CONTRACTUAL RISK*

Are hedging transactions that diversify a manager’s compensation risk detrimental to incentives, or can they improve contracting efficiency? If hedging provides efficiency benefits, should the manager or the firm undertake it? In our model, both the firm and the manager can trade financial portfolios to diversify the manager’s compensation risk. Prior to the portfolio selection, the parties need to acquire information on how different financial portfolios fit their diversification purposes. We illustrate that financial portfolios correlated with firm‐specific risk improve contracting efficiency. For equal information costs, it is optimal for the firm to undertake the hedging on the manager’s behalf.     

INFORMATION,RISK SHARING,AND INCENTIVES IN AGENCY PROBLEMS

This article studies the use of information for incentives and risk sharing in agency problems. When the principal is risk neutral or the outcome is contractible, risk sharing is unnecessary or dealt with by a contract on the outcome, so information systems are used for incentives only. When the outcome is noncontractible, a risk‐averse principal relies on imperfect information for both incentives and risk sharing. Under the first‐order approach, this article relaxes Gjesdal's criterion for ranking information systems and finds conditions justifying the first‐order approach when the principal is risk averse and the outcome is noncontractible.     

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.     

UNEMPLOYMENT POLICIES IN AN ECONOMY WITH ADVERSE SELECTION

This paper studies the effects of unemployment policies in a simple static general equilibrium model with adverse selection in the labour market. Firms offer a contract that induces the self‐selection of workers. In equilibrium, all unskilled workers are screened out and some skilled workers are rationed out. It is shown that the provision of unemployment insurance raises involuntary unemployment by encouraging adverse selection, while unemployment assistance – or subsidy to unemployment – reduces involuntary unemployment. A simple efficiency wage model is also presented to show that either of the two policies reduces employment by taxing effort and subsidizing shirking. The key is whether the social role of unemployment is a sorting device or a worker discipline device.     

AN EMPIRICAL STUDY ON HEALTH IN TAIWAN AND ITS LONG‐TERM ADJUSTMENT*

This paper investigates the dynamic change of the population health status in Taiwan. Specifically, it provides insight into the empirical determinants of health production function and explores the nature of the long‐term adjustment in health performance. For these purposes, panel data are used incorporating dynamic effects as well as controls for unobservable area‐specific effect and area‐invariant time effect. The findings are consistent with the earlier research in terms of the determinants of the health production function. The result of the present paper suggests that after decades of improvement in health care, people in Taiwan have lower age‐adjusted mortality rates. Also, the decreases in mortality rates follow a rapid pace of long‐term adjustment implying that health‐care policy that focuses on the provision of medical care services substantially benefits the nation's health.     

Solving the global warming problem: beyond markets,simple mechanisms may help!

This paper discusses the feasibility and performances of simple mechanisms to implement international environmental agreements in the multilateral externalities context of global warming. Asymmetric information and voluntary participation by sovereign and heterogeneous countries are key constraints on the design of those agreements. Mechanisms must prevent two sorts of free‐riding problems – free riding in effort provision and free riding in participation. As markets might fail to solve simultaneously those two problems, we construct instead a simple menu of options that trades off the provision of incentives for participating countries and the provision of incentives to participate. With such a mechanism, all countries voluntarily contribute to a fund, although at different intensities, but only the most efficient ones effectively reduce their pollution below its ‘business as usual’ level.     

Forming and Dissolving Partnerships in Cooperative Game Situations

A group of players in a cooperative game are partners (e.g., as in the form of a union or a joint ownership) if the prospects for cooperation are restricted such that cooperation with players outside the partnership requires the accept of all the partners. The formation of such partnerships through binding agreements may change the game implying that players could have incentives to manipulate a game by forming or dissolving partnerships. The present paper seeks to explore the existence of allocation rules that are immune to this type of manipulation. An allocation rule that distributes the worth of the grand coalition among players is called partnership formation‐proof if it ensures that it is never jointly profitable for any group of players to form a partnership and partnership dissolution‐proof if no group can ever profit from dissolving a partnership. The paper provides results on the existence of such allocation rules for general classes of games as well as more specific results concerning well‐known allocation rules.     

COSTLY AGEING OR COSTLY DEATHS? UNDERSTANDING HEALTH CARE EXPENDITURE USING AUSTRALIAN MEDICARE PAYMENTS DATA*

In health economics and health care planning, the observation that age cohorts are generally positively correlated with per capita health expenditures is often cited as evidence that population ageing is the main driver of health care costs. Several recent studies, however, challenge this view. Zweifel et al. (1999 ) and Felder et al. (2000 ), for example, find that individuals incur the highest health care costs around the time before their death. Thus, they argue, it is proximity to death rather than ageing that is driving health care costs. This paper examines the issue by estimating a two‐equation exact aggregation demand model using Australian Medicare payments data over an eight‐year period (1994–2001). The results suggest that once proximity to death is accounted for, population ageing has either a negligible or even negative effect on health care demand.     

Unionization,international integration,and selection

Abstract We study how unionization affects competitive selection between heterogeneous firms when wage negotiations can occur at the firm or at the profit‐centre level. With productivity specific wages, an increase in union power has: (i) a selection‐softening; (ii) a counter‐competitive; (iii) a wage‐inequality; and (iv) a variety effect. In a two‐country asymmetric setting, stronger unions soften competition for domestic firms and toughen it for exporters. With profit‐centre bargaining, we show how trade liberalization can affect wage inequality among identical workers both across firms (via its effects on competitive selection) and within firms (via wage discrimination across destination markets).