An Equilibrium Model of Health Insurance Provision and Wage Determination

We investigate the effect of employer‐provided health insurance on job mobility rates and economic welfare using a search, matching, and bargaining framework. In our model, health insurance coverage decisions are made in a cooperative manner that recognizes the productivity effects of health insurance as well as its nonpecuniary value to the employee. The resulting equilibrium is one in which not all employment matches are covered by health insurance, wages at jobs providing health insurance are larger (in a stochastic sense) than those at jobs without health insurance, and workers at jobs with health insurance are less likely to leave those jobs, even after conditioning on the wage rate. We estimate the model using the 1996 panel of the Survey of Income and Program Participation, and find that the employer‐provided health insurance system does not lead to any serious inefficiencies in mobility decisions.     

Equitable Taxation and the Provision of Health Insurance Subsidies

Current U.S. income tax laws allow many taxpayers to exclude from taxable income part or all of the cost of acquiring health insurance through an employer‐sponsored benefit plan. This favorable tax treatment generally applies regardless of whether the employer or employee actually pays the health insurance premiums. We describe the effects of this tax policy on the U.S. tax system's horizontal and vertical equity. We also explain how taxpayers covered by employer‐sponsored plans are significantly subsidized by the government in acquiring health insurance, whereas taxpayers who acquire health insurance by other means or who are not covered by health insurance at all receive no such government assistance. We conclude that any prospective health‐care policy initiatives, including modifications to the 2010 health‐care reforms, should contemplate both the horizontal and vertical equity of the tax treatment of health insurance premiums.     

Health‐Care Reform and ESI: Reconsidering the Relationship Between Employment and Health Insurance

The health‐care reform promised by the Patient Protection and Affordable Care Act of March 2010 continues our dependence on a central feature of the American health‐care system: employer‐sponsored insurance (ESI). In this article I will criticize the assumptions regarding market and welfare concerns on which this dependence is based and argue that efforts to mandate ESI ignore both the dynamics of the employment relation and the nature of health‐care needs. A comparison between investing in employee education and investing in employee health will reveal the pragmatic challenges to ESI and the covert appeal to employer beneficence on which ESI rests. This paper argues that relying on ESI to guarantee appropriate care for a significant segment of the population is undesirable and unsustainable from both market and moral perspectives.     

Medicare's ESRD Program, Part 1: Dialysis.

The federal End State Renal Disease (ESRD) program was created by statute in 1972 as a general population entitlement to be administered by Medicare. The program extends all Medicare benefits to patients, regardless of age, who are diagnosed as having ESRD, as long as they are fully insured for old age and survivor insurance benefits (Social Security), are entitled to monthly insurance benefits under the Social Security Act, or are spouses or dependent children of individuals with the foregoing Social Security benefits. About 7 percent of all ESRD patients are excluded from this entitlement by these criteria. The two major therapies embraced by the ESRD program are renal dialysis and kidney transplantation. In this first part of a two-part article, dialysis is the focal point. Kidney transplants will be covered in the May-June issue of Physician Executive.     

DISTANCE TO RETIREMENT AND OLDER WORKERS‘ EMPLOYMENT: THE CASE FOR DELAYING THE RETIREMENT AGE

This paper presents empirical evidence and a theoretical foundation in favor of the view that the retirement age decision affects older workers' employment prior to retirement. To the extent that there are search frictions on the labor market, the return on jobs is determined by their expected duration: The time to retirement is then key to understanding older workers' employment. Countries with a retirement age of 60 are indeed characterized by lower employment rates for workers aged 55–59. Based on the French Labor Force Survey, we show that the likelihood of employment is significantly affected by the distance to retirement, in addition to age and other relevant variables. We then extend McCall's job search model by explicitly integrating life‐cycle features with the retirement decision. Using simulations, we show that the distance effect in interaction with the generosity of unemployment benefits and the depressed demand for older workers explains the low rate of employment just before the eligibility age for the Social Security pension. Finally, we show that implementing actuarially fair schemes not only extends the retirement age, but also encourages a more intensive job search by older unemployed workers. (JEL: J22, J26, H55)     

Unemployment Insurance and Entrepreneurship

Based on administrative registers from Norway, we examine how unemployment insurance (UI) and active labor market programs (ALMP) affect the transition rates from unemployment to regular employment and entrepreneurship, as well as subsequent earnings levels. We find that both the employment and entrepreneurship hazards rise sharply in response to UI sanctions and UI exhaustion. On average, transitions to entrepreneurship are more profitable than transitions to regular employment. While employment transitions are highly pro‐cyclical, entrepreneurship transitions are weakly counter‐cyclical. ALMPs targeted at entrepreneurship are rare in Norway, but the few start‐up subsidies that are provided are successful in terms of generating paid work.     

MANAGED COMPETITION IN HEALTH INSURANCE

Rising healthcare costs have sparked debate about the best way to provide high‐quality affordable health insurance. We discuss the potential for regulated insurance markets to outperform single‐payer public insurance. We use as an example the private Medicare plans that now provide insurance to almost a third of seniors in the United States. The evidence suggests that private plans can limit costs and potentially appeal to enrollees, and that well‐designed risk adjustment can mitigate market failures due to adverse selection. However, fostering competition between insurers, especially in smaller markets, is difficult. We discuss how future research might illuminate the relative advantages of public and private health insurance.     

Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk

This paper studies regulated health insurance markets known as exchanges, motivated by the increasingly important role they play in both public and private insurance provision. We develop a framework that combines data on health outcomes and insurance plan choices for a population of insured individuals with a model of a competitive insurance exchange to predict outcomes under different exchange designs. We apply this framework to examine the effects of regulations that govern insurers' ability to use health status information in pricing. We investigate the welfare implications of these regulations with an emphasis on two potential sources of inefficiency: (i) adverse selection and (ii) premium reclassification risk. We find substantial adverse selection leading to full unraveling of our simulated exchange, even when age can be priced. While the welfare cost of adverse selection is substantial when health status cannot be priced, that of reclassification risk is five times larger when insurers can price based on some health status information. We investigate several extensions including (i) contract design regulation, (ii) self‐insurance through saving and borrowing, and (iii) insurer risk adjustment transfers.     

Medical resource allocation: rationing and ethical considerations--Part I

The United States' system of high-quality but expensive and poorly distributed medical care is in trouble. Dramatic advances in medical knowledge and procedures, combined with soaring demands created by growing public awareness, the cost of private hospital and medical insurance, and Medicare and Medicaid, are burdening the medical care delivery systems. The costs of medical care have reached levels that can no longer be sustained. Government officials, insurance planners, labor leaders responsible for union health care benefits, and ordinary citizens are questioning whether it is acceptable to limit health care based on economic considerations. If health care is deemed a social good, the method of allocation must be addressed. Unless society decides that other priorities of the infrastructure are to be subjugated to health service delivery, difficult decisions will be forced upon us, consciously or by default. The discussion in this two-part article explores the ethical considerations of the more formalized approaches to resource allocation that presently exist in our society.     

Are People Willing to Buy Natural Disaster Insurance in China? Risk Awareness,Insurance Acceptance,and Willingness to Pay

After the Wenchuan earthquake (magnitude 7.9, May 12, 2008), intensive debates on how China should establish a natural disaster insurance system were initiated among researchers, policymakers, and insurance professionals. Our focus was the social aspects of disaster insurance, explored in China through a nationwide survey. Our questionnaires investigated people's risk awareness, insurance acceptance, their opinions on governmental measures for disaster management, and their willingness to pay for disaster house insurance. We analyzed the results at both regional and individual scales. We found that the integrated hazard index and respondents’ experience of insurance (considered objective factors), and their opinions on the importance of insurance and government responsibility (considered subjective factors) showed strong correlation with the regional overall acceptance of disaster insurance. An individual's decision to participate highly depended on his/her experience of both insurance and disaster and his/her opinion on the importance of insurance as a coping mechanism. Respondents from poverty‐stricken or less‐developed counties were not necessarily more reluctant to accept natural disaster insurance, though they exhibited relatively lower ability to afford insurance. In general, respondents had correct perceptions of natural disasters in their areas; however, people from regions with a greater multihazard threat showed less willingness to accept disaster insurance because they tended to expect the government to undertake to cover losses and considered insurance to be less important. People's willingness to pay for an assumed disaster house insurance was also investigated and analyzed. We consequently discuss the policy implications for developing a disaster insurance system in China.     

Will the Dismantlement of Early Retirement Schemes Increase Older Unemployment? A Competing‐risk Analysis for Belgium

On the basis of administrative data for Belgium, we estimate a competing‐risk model on transitions from employees aged 50 and older into unemployment, early and old‐age retirement while accounting for forward‐looking work disincentives. Our estimates are used to simulate a cut in early retirement benefits. Although this would enhance the financial sustainability of the social security system, our simulations predict a strong increase in unemployment among older blue‐collar workers in traditional industries. Members of private saving plans or occupational pension schemes and highly educated workers are predicted to move into the old‐age pension system.     

Cost shifting: the final straw in federalization of health care

While cost controls applied by Medicare and indemnity insurance programs initially helped curtail abusive medical billing practices, creative billing techniques have since resulted in runaway medical costs and rising insurance premiums. Employers have been forced to increase employee's contributions to health care by increasing deductibles, copayments, and coinsurance or by simply dropping health care benefits. If National Health Insurance comes to pass, and that is a cry now coming from major employers, it will be followed in time by federalization of all health care delivery systems, including Workers' Compensation. It is the providers who shift their fees into Workers' Compensation, which pays from the first dollar, who will cause the business community to petition Washington for relief. It will claim the need for cost controls in Workers' Compensation to keep American business competitive in world markets.     

Unemployment Insurance and Underemployment

Should unemployment insurance (UI) systems provide coverage for underemployed job seekers? Based on a statistical analysis of Norwegian unemployment spells, we conclude that the answer to this question is yes. Allowing insured job seekers to retain partial UI benefits during periods of insufficient part‐time work not only reduces UI expenditures during the part‐time work period, but it also unambiguously reduces the time until a regular self‐supporting job is found. Probable explanations are that even small temporary part‐time jobs provide access to useful vacancy information and that such jobs are used by employers as a screening device when hiring from the unemployment pool.     

Insurance,Public Assistance,and Household Flood Risk Reduction: A Comparative Study of Austria,England, and Romania

In light of increasing losses from floods, many researchers and policymakers are looking for ways to encourage flood risk reduction among communities, business, and households. In this study, we investigate risk‐reduction behavior at the household level in three European Union Member States with fundamentally different insurance and compensation schemes. We try to understand if and how insurance and public assistance influence private risk‐reduction behavior. Data were collected using a telephone survey (n = 1,849) of household decisionmakers in flood‐prone areas. We show that insurance overall is positively associated with private risk‐reduction behavior. Warranties, premium discounts, and information provision with respect to risk reduction may be an explanation for this positive relationship in the case of structural measures. Public incentives for risk‐reduction measures by means of financial and in‐kind support, and particularly through the provision of information, are also associated with enhancing risk reduction. In this study, public compensation is not negatively associated with private risk‐reduction behavior. This does not disprove such a relationship, but the negative effect may be mitigated by factors related to respondents' capacity to implement measures or social norms that were not included in the analysis. The data suggest that large‐scale flood protection infrastructure creates a sense of security that is associated with a lower level of preparedness. Across the board there is ample room to improve both public and private policies to provide effective incentives for household‐level risk reduction.     

Insurer Competition in Health Care Markets

The impact of insurer competition on welfare, negotiated provider prices, and premiums in the U.S. private health care industry is theoretically ambiguous. Reduced competition may increase the premiums charged by insurers and their payments made to hospitals. However, it may also strengthen insurers' bargaining leverage when negotiating with hospitals, thereby generating offsetting cost decreases. To understand and measure this trade‐off, we estimate a model of employer‐insurer and hospital‐insurer bargaining over premiums and reimbursements, household demand for insurance, and individual demand for hospitals using detailed California admissions, claims, and enrollment data. We simulate the removal of both large and small insurers from consumers' choice sets. Although consumer welfare decreases and premiums typically increase, we find that premiums can fall upon the removal of a small insurer if an employer imposes effective premium constraints through negotiations with the remaining insurers. We also document substantial heterogeneity in hospital price adjustments upon the removal of an insurer, with renegotiated price increases and decreases of as much as 10% across markets.     

保险需求悖论的解释——来自中国汽车险市场的实证研究

经典的保险需求模型认为绝对风险规避系数递减时保险是一个劣质品,也就是说保险需求会随着财富水平的上升而下降,但这一结论与许多现实的保险行为不符。本文从损失和财富的关系角度出发对经典模型进行了扩展,讨论了在损失随财富变化时的保险需求变化,对保险需求的悖论进行了解释。论文还采用国内汽车险市场的微观数据对拓展模型进行了实证研究,结果显示车险投保人的个人财富与其所选择的保险金额、投保比率以及索赔金额之间存在着显著的正相关关系,检验表明模型的假设和结论具有很好的解释现实的能力。     

Shadow Insurance

Life insurers use reinsurance to move liabilities from regulated and rated companies that sell policies to shadow reinsurers, which are less regulated and unrated off‐balance‐sheet entities within the same insurance group. U.S. life insurance and annuity liabilities ceded to shadow reinsurers grew from $11 billion in 2002 to $364 billion in 2012. Life insurers using shadow insurance, which capture half of the market share, ceded 25 cents of every dollar insured to shadow reinsurers in 2012, up from 2 cents in 2002. By relaxing capital requirements, shadow insurance could reduce the marginal cost of issuing policies and thereby improve retail market efficiency. However, shadow insurance could also reduce risk‐based capital and increase expected loss for the industry. We model and quantify these effects based on publicly available data and plausible assumptions.     

Policy tenure under the U.S. National Flood Insurance Program (NFIP)

In the United States, insurance against flood hazard (inland flooding or storm surge from hurricanes) has been provided mainly through the National Flood Insurance Program (NFIP) since 1968. The NFIP covers $1.23 trillion of assets today. This article provides the first analysis of flood insurance tenure ever undertaken: that is, the number of years that people keep their flood insurance policy before letting it lapse. Our analysis of the entire portfolio of the NFIP over the period 2001-2009 reveals that the median tenure of new policies during that time is between two and four years; it is also relatively stable over time and levels of flood hazard. Prior flood experience can affect tenure: people who have experienced small flood claims tend to hold onto their insurance longer; people who have experienced large flood claims tend to let their insurance lapse sooner. To overcome the policy and governance challenges posed by homeowners' inadequate insurance coverage, we discuss policy recommendations that include for banks and government-sponsored enterprises (GSEs) strengthening their requirements and the introduction of multiyear flood insurance contracts attached to the property, both of which are likely to provide more coverage stability and encourage investments in risk-reduction measures.     

Credential Effects and the Returns to Education in China

Using the China Household Income Project (CHIP) data for 1995 and 2002, we examine the returns to education in China, separating out credential effects from pure years‐of‐schooling effects. The results are broadly consistent with the implications of China moving towards a market‐oriented economy: increasing returns to education where both years of schooling and credentials from completing key phases are rewarded; a decline in the importance of credentials as firms have more discretion to select the best‐suited employees irrespective of their credentials; more emphasis on credentials in the state sector; less emphasis on credentials for long‐tenured employees for whom the employer has more opportunity to assess productivity without relying on credentials; and a greater importance of credentials for females for whom the value of such signals may be more important.