Less social health insurance, more private supplementary insurance? Empirical evidence from Germany

Based on individual level data from Germany, we analyze the effect of changes in the compulsory benefit package of the social health insurance on the demand for supplementary private insurance, employing a difference-in-differences approach. The focus is on the exclusion of dental prostheses from the benefit package in 1997 and its re-inclusion in 1999. Individuals born prior to 1979 serve as control group because only the young were affected by the reform. No significant effect on the demand for supplementary health insurance is found. Thus, the notion of clients making informed choices about their health insurances’ coverage is not supported.     

Arrow’s theorem of the deductible: Moral hazard and stop-loss in health insurance

The logic of Arrow’s theorem of the deductible, i.e. that it is optimal to focus insurance coverage on the states with largest expenditures, remains at work in a model with ex post moral hazard. The optimal insurance contract takes the form of a system of “implicit deductibles”, resulting in the same indemnities as a contract with full insurance above a variable deductible positively related to the elasticity of medical expenditures with respect to the insurance rate. In a model with a predefined ceiling on expenses, there is no reimbursement for expenses below the stop-loss amount. One motivation to have some insurance below the deductible arises if regular health care expenditures in a situation of standard health have a negative effect on the probability of getting into a state with large medical expenses.     

Competing allocation principles: time for compromise?

A small set of allocation principles is said to be behind several theories of distributive justice. However, disagreement about the appropriate relationship between these notions remains, so that compromises between principles may generate more agreement. Truncated utilitarianism is a prominent candidate. It demands maximising total wealth subject to a floor level of individual wealth for all people. Based on some well-known distributive notions, we developed a questionnaire setting and confronted student respondents with corresponding allocation problems, where an exogenously given poverty line served as a floor. However, support for allocations resulting from this specific interpretation of truncated utilitarianism remained rather low. This is surprising because the respective solution was close to an equal split of resources, and aspects of efficiency and responsibility were explicitly introduced to promote more general acceptance. We argue that people may either wish to see higher floor levels or are more inequality averse than probably expected. Moreover, high support for an unconditional consideration of the poverty line can be witnessed, even though aspects of responsibility, but not efficiency arguments, display an influence. In general, attitudes with respect to the equality?Cefficiency trade-off are found to remain heterogeneous, although different equality concerns are prominent. Furthermore, trade-offs are moderated by the responsibility principle.     

The new privatized market: A question of ideology or pragmatism within the Swedish addiction treatment system?

Given its traditions of universal welfarism and social democracy, Sweden had already scored unexpectedly high on New Public Management by the 1980s. Health and welfare services remain primarily tax‐funded, but the production of care is increasingly transferred to a competitive quasi‐market. To what extent can this development be understood in terms of right‐wing governments, and to what extent in terms of other, socioeconomic and pragmatic factors? We examined this question through official statistics on providers of institutional addiction care since 1976, and through the total expenditure and purchases by local‐level municipal social services of interventions for substance users in Sweden in 1999, 2004, 2009, and 2014. We have analyzed the distribution across public and private providers within the addiction treatment system, and whether national developments and local differences across the 290 municipalities—which bear the major treatment responsibility—can be understood in terms of local‐level political majority, population size, and local wealth. The share of purchased services has remained stable, but the treatment system shows increasing financial turnover and an increasing share of for‐profit providers among producers of purchased care, especially in outpatient treatment. While venture capital enterprises emerged as a new actor, non‐governmental organizations lost out in importance. Bourgeois government correlated with larger shares of purchasing and purchases from for‐profit providers. However, purchasing on a market dominated by for‐profit providers has also become the “new normal”, regardless of ideology, and recent years have shown a reversed effect of left‐wing municipalities purchasing more services than right‐wing governments. Pragmatic reasons also influence local‐level purchasing.     

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.     

Taking Care of Later Life: A Matter of Justice?

Correspondence to: Julia Johnson, Senior Lecturer, School of Health and Social Welfare, The Open University, Walton Hall, Milton Keynes MK7 6AA, UK. E-mail: j.s.johnson{at}open.ac.uk Summary This paper reviews current policies and practices regardingthe provision of long-term care for older people. In particularit focuses on three aspects which are central to social workand care management: current developments in residential andnursing home care; charging for care; and the shifting boundarybetween health and social care. It argues that, in all respects,these policies and the ways in which they are being implementedare incompatible with the notion of social justice. Over thelast fifty years, the older generation has invested heavilyin the welfare state and continues to make a significant contributionto it. The security and well-being of those in need of long-termcare is, however, being threatened by the marketization andcommodification of care provision.     

Does insurance fraud in automobile theft insurance fluctuate with the business cycle?

Financial institutions face various cyclical risks, but very few studies have analyzed the cyclicality of operational risk. External fraud is an important operational risk faced by insurers. In this research, we analyze the empirical relationship between insurance fraud and the business cycle and we concentrate our study on two insurance contracts that may create an incentive to defraud. We find that residual insurance fraud exists both in the contract with replacement cost endorsement and the contract with no-deductible endorsement in the Taiwan automobile theft insurance market. These results are consistent with previous literature on the relationship between fraud activity and non-optimal insurance contracting. We also show that the severity of insurance fraud is countercyclical. Fraud is stimulated during periods of recession and mitigated during periods of expansion. Although this last result seems intuitive, our contribution is the first to measure its significance.     

Too risk averse to purchase insurance?

This paper suggests a new explanation for the low level of annuitization, which is valid even if one assumes perfect markets. We show that, as soon there is a positive bequest motive, sufficiently risk averse individuals should not purchase annuities. A model calibration accounting for lifetime risk aversion generates a significantly smaller willingness-to-pay for annuities than the one generated by a standard time-additive model. Moreover, the calibration predicts that riskless savings finance one third of consumption, in line with empirical findings.     

A theory of justice?

This is a critical analysis of John Rawls's A Theory of Justice. Rawls offers a theoretical justification of social democratic principles of justice. He argues that they are the principles which rational men would choose, under defined constraints, in an original position of social contract. The author criticises Rawls's assumption that men of any background, of any socialisation, would choose these principles in the original position. He argues that the choice which Rawls imputes to his contractors reflects a specific socialisation — one dominant in Western democracies. The theory is useful because it systematises a particular sense of justice; it is in no sense however a universal theory.My warm thanks go to Jimmy Altham, Harry Bracken, Stefan Collini, Martin Hollis, Steven Lukes, Quentin Skinner and Denys Turner. Without their comments this paper would certainly have been a poorer effort. I am also grateful to Professor Rawls for a useful correspondence about his position.     

Responses to affirmative action: Is there a question order affect?

This paper analyzes the affect of question order on support for affirmative action. While the literature is replete with studies detailing the racial differences for support for affirmative action, there is a dearth of studies that analyze how probing, using open-ended questions, can influence individuals’ responses. Given this, we seek to analyze and explain how open-ended questions, related to affirmative action, might affect responses to close-ended questions as well as how their joint interaction help us to understand resonant attitudes. Using a split-ballot approach, we found that responses to the closedended question were significantly affected by the experimental design.     

Employment relations and dismissal regulations: Does employment legislation protect the health of workers?

Sociologists have long acknowledged that being in a precarious labour market position, whether employed or unemployed, can harm peoples' health. However, scholars have yet to fully investigate the possible contextual, institutional determinants of this relationship. Two institutions that were overlooked in previous empirical studies are the regulations that set minimum compensation for dismissal, severance payments, and entitlements to a period of notice before dismissal, notice periods. These institutions may be important for workers' health as they influence the degree of insecurity that workers are exposed to. Here, we test this hypothesis by examining whether longer notice periods and greater severance payments protect the health of labour market participants, both employed and unemployed. We constructed two cohorts of panel data before and during the European recession using data from 22 countries in the European Union Statistics on Income and Living Conditions (person years = 338,000). We find more generous severance payments significantly reduce the probability that labour market participants, especially the unemployed, will experience declines in self‐reported health, with a slightly weaker relationship for longer notice periods.     

Gender and health among older people: What is the role of social policies?

The study investigated how social policies moderate the association between gender and health among older people across European countries. The study is the first to take a comprehensive view on the role of social policies in connection with gender inequality in health among older Europeans. The association between gender and poor self‐rated health and limiting long‐standing illness was investigated in a multilevel framework. Cross‐level interaction effects showed that more generous minimum pensions, higher spending on eldercare and a higher degree of eldercare formalisation are associated with relatively better health among women, while more generous standard pensions are associated with relatively better health among men. The conclusion is that policies directed towards older people are not gender neutral; rather they are likely to affect men and women differently. By shaping the distribution of resources as well as of unpaid work, social policies can contribute to either strengthening or weakening the link between gender and health.     

One new policy: A variety of applications—The implementation processes of a new mental health policy in Sweden

The increase in mental ill health at a global level is widely acknowledged. This trend has led to the development of new policy frameworks that focus on public mental health. This study aimed to explore the implementation process regarding regional and local responses to national policy, proposing a substantially enhanced understanding of mental health within the Swedish welfare system. To explore the implementation process, a multiple case study was conducted using snowball sampling. In all, 18 key informants were interviewed. The results revealed that the informants adopted an experimental implementation process in which policy learning could take place. Contextual factors were essential for how a broad policy approach could be translated into practice. The broad policy not only made it possible for local needs to be addressed, but it also allowed for variations in focus position within the country as a whole. There seemed to be no consensus among the informants as to the origin or solution to the problem. Essentially, the question of whether public mental health issues should be dealt with at a structural or individual level remained unresolved. The Swedish case could be understood as an illustrative example of how one country attempts to handle a major problem despite insufficient information to direct the initiative towards a certain direction.     

Walking: A Gender Issue?

Gender has been neglected in models of the social determinants of health. We use walking as a case study to demonstrate how gender might be incorporated into multilevel social determinants of health frameworks to investigate health behaviours. We found that while men and women had some similar individual (e.g. confidence in doing regular physical activity) and environmental (e.g. presence of destinations) predictors of walking there were also gender differences in the associations found at both of these levels. For example, low levels of education were only associated with men's walking time while having people in the household who made walking easy or hard was only associated with women's walking time. Likewise, having a variety of places to walk to was important for women's walking but not men's. These results indicate that both universal and gender‐specific approaches to health education, health promotion and planning might be needed to improve walking levels.     

Coexisting principles and logics of elder care: Help to self‐help and consumer‐oriented service?

Healthy and active ageing has become an ideal in Western societies. In the Nordic countries, this ideal has been supported through a policy of help to self‐help in elder care since the 1980s. However, reforms inspired by New Public Management (NPM) have introduced a new policy principle of consumer‐oriented service that stresses the wishes and priorities of older people. We have studied how these two principles are applied by care workers in Denmark. Is one principle or logic replacing the other, or do they coexist? Do they create tensions between professional knowledge and the autonomy of older people? Using neo‐institutional theory and feminist care theory, we analysed the articulation of the two policy principles in interviews and their logics in observations in four local authorities. We conclude that help to self‐help is the dominant principle, that it is deeply entrenched in the identity of the professional care worker and that it coexists with consumer‐oriented service and without major tensions in the logics identified in their practices.     

Firm’s protection against disasters: are investment and insurance substitutes or complements?

Theory and Decision - We use a controlled laboratory experiment to study firm’s protection against potential technological damages. The probability of a catastrophic event is known, and the...     

How do Australian adult mental health clinicians manage the challenges of working with parental mental illness? A phenomenological study

Adult mental health clinicians face a range of challenges that hinder their use of family‐focused practices when working with consumers who are parents. The purpose of this study was (a) to examine clinicians' experiences when working with parents and (b) identify strategies they found to be effective when working with parents. Eleven Australian mental health clinicians were recruited who regularly worked with consumers who are parents. Semistructured interviews were conducted within a qualitative paradigm and analysed using interpretative phenomenological analysis. Themes were identified which related to (a) managing sensitive parenting conversations, (b) making decisions about child safety in unclear or unpredictable situations, and (c) working with child protection services. Participants had developed strategies for managing the challenges of the first two practice issues and suggested organizational changes that could facilitate collaboration with child protection services. The findings highlight that the challenges of working with parents with mental health issues cannot be addressed with a one‐size‐fits‐all approach. Initiatives to facilitate the effective support of parents and their children need to be informed by contextual factors, including clinical practice.