1. Lecture 7 Health Insurance: Part 1

2. What is Insurance Meant to insure us against random uncertainty. Club of 100 members. On average, each year one member gets sick, it costs $20,000. It is random who gets sick. This is a lot of money for one person to pay.

3. What is Insurance Instead, they insure each other and each pay $200 a year. They pay this to avoid the risk of uncertainty that they will have to pay 20,000. Money put in bank to get interest, and pay out when someone gets sick. Aim of insurance is to reduce the variability in one’s income by pooling risks with a large number of people.

4. What is Insurance Outlays for health may be variable for one person, they are fairly predictable for the group. Health insurance would not be necessary if everyone had average needs. But we do not it is variable. Insurance makes it possible to obtain health care without going Bankrupt (new cancer drug $100,000 a year).

5. What is Insurance Desirable characteristics for insurance: 1. The number of insured should be large, and they should be independently exposed to potential risk. 2. Losses covered should be definite in time, place, and amount. 3. The chance of loss should be measurable. 4. The loss should be accidental from view point of person who is insured.

6. Concentration of Personal Health Expenditures, in US in 2002 AllTop 1% Middle 75% Bottom 15% Persons (000s) 285,0002,850213,75042,750 Health Exp. ($ millions) 1,545,9004,36,400455,7007,730 Per Person5,427153,1262,135184 Source: Getzen T. “Health Economics: Fundamentals and Flow of Funds”,

7. Terminology Loading Fee: general costs associated with the insurance company doing business, such as sales, advertising, or profit. Premium: When people buy insurance policies, they typically pay a given premium for a given amount of coverage should the event occur.

8. History of Private Health Insurance in US Modern private health insurance started in 1929.  Baylor University in Dallas began accepting premiums from local school teachers to cover any medical services provided at the University hospital. During great depression of 1930s other hospitals followed. American Hospital Association created and organized several plans, Blue Cross, and gave subscribers free choice of hospitals within a city.  Premiums determined by community ratings.

9. History of Private Health Insurance Hospital insurance market expanded during WWII  Gov’t imposed price and wage controls to curb inflation.  Only way employers could attract new workers was with fringe benefits. So offered private health insurance.  These fringe benefits were not reported to IRS (tax- exempt)  IRS eventually asked them to be included in wage bill  Workers expressed alarm and congress passed the health insurance could remain tax exempt.

10. Actuarially Fair Gamble and Risk Aversion Consider the gambling game:  Zan and Forest flip a coin.  If it comes up heads, Zan wins a dollar and Forest nothing.  If it comes up tails, Forest wills a dollar and Zan nothing.  How much should they each be willing to pay to play this game? Expected Return for Zan: P(head)*$1 + P(tails)*0=.5 (50 cents).  Willing to pay 50 cents

11. Demand for Private Health Insurance Expected Value: E[income if heads]=PrbH*$1+PrbT*0=.5 Actuarially fair gamble: is one in which the amount you pay for the gamble is equal to the expected value of the gamble. You paid a 50 cents to play, and the expected value of the game was 50 cents.

12. Demand for Private Health Insurance If price of gamble (amount pay to play game) is equal to the expected return, then the gamble is actuarially fair. In health, if expected benefit payment is equal to premiums, the insurance policy is actuarially fair. Now suppose the gamble was instead for $5,000, would you want to play the game?  If not you are defined as being risk averse, because you do not want to take the actuarially fair gamble.

13. Demand for Private Health Insurance See notes from black board Factors affecting demand for health insurance: 1. Loading fee 2. Probability of illness 3. Magnitude of loss relative to income 4. Degree of risk aversion

14. Moral Hazard What are the effects of the new price system (with insurance) on demand for insurance. Buying insurance lowers the price per unit of health care service at time it is bought. Person with health insurance is more likely to go to the doctor for a small problem than someone without health insurance

15. Moral Hazard Moral Hazard: refers to the increased usage of services when the pooling of risks lead to decreased marginal costs for services. (i.e the price is reduced). It is also used to refer to how one changes behavior when they are insured.  We may take more risks, which could have health care implications when insured rather than not insured. Learning snow boarding (lot of people break their arms). May not learn if don’t have health insurance.

16. Moral Hazard Quantity Price PoPo Price with insurance QoQo Q1Q1 “Moral Hazard” increase in consumption due to insurance P1P1 Price without insurance

17. Moral Hazard Quantity Price QoQo Q1Q1 D1 D2 Q2Q2 Moral Hazard: decreases when the price becomes more elastic. (i.e. for those goods you want no matter the price. Price without insurance PoPo Price with insurance P1P1

18. Moral Hazard For services that are not very price sensitive, insurance will not cause them to purchase more services.  E.g. purchase of insulin for diabetics. For those that are price sensitive (cosmetic surgery – not from accidents), insurance may encourage one to buy more.

19. Moral Hazard Hypothesize about services covered by insurance: services for hospitals and surgery (not cosmetic) more likely to be insured than nursing home care, physical therapy, mental health care, dentistry. Exchange has to make both groups better off, moral hazard reduces the value of transacting.

20. Adverse Selection This theoretical idea comes from Arrow’s 1963 article. Risk pooling works because everyone in the group is at risk and therefore has an interest in making sure that solid insurance benefits are provided. Suppose the risk was not random, you knew you had a higher chance of lung cancer because smoked all your life.  make sure you had health coverage and may be willing to pay more for it.

21. Adverse Selection Or suppose you never smoked, eat well, do exercise, so think there is a low chance of getting lung cancer.  You would not want to pay a lot for health insurance for lung cancer. If the high risks are something the insurance company can observe in advance, they can adjust premiums up or down to account for varying risk.  e.g pricing by age is common $300 a month for <=35 and $650 for 51-60 year olds.

22. Adverse Selection Adverse selection occurs when some factors are known to the insured (i.e you) by not to the insurer.  i.e. there is asymmetric information

23. Adverse Selection Example: suppose have n people all with the same demographic characteristics.  Each person knows what they will probably have to pay So know where they are on the horizontal axis of the next graph.  Insurance company knows distribution of health expenditures by person but not which person pays what.  People know exactly what they will have to pay.  How much should insurance company charge?

24. Adverse Selection 1M3/4M01/4M1/2M 1/n Probability Health Expenditures ($) People know how much they have to pay

25. Adverse Selection  Suppose set price of insurance at $0 Everyone will sign up. Insurance company expects to pay out $1/2M so would be losing money,

26. Adverse Selection  So suppose try to set the price of insurance at $1/2M Those who know their expenditures are less than 1/2M will choose to self-insure and will not sign up for the program. Once they leave the market, the expected amount insurance company will have to pay is $3/4M, so premium will need to be this much. But then others will drop out of the market. In fact, if adverse selection is very bad, there may be no health insurance offered!

27. Adverse Selection This is why insurers try to mitigate the problem of adverse selection:  Some do it in devious ways like putting on office on the second floor in a building with no elevator.  Premiums are often based on pre-existing conditions, age, employment status, occupation.

28. Adverse Selection Alternatively, there are: Group or Community Ratings: Premiums are based on the average characteristics of a group or community rather than your individual characteristics. Old and young in a group pay the same amount. Those with and without chronic conditions pay the same amount Problems for companies in US: Compare Google to Ford  Google is full of young workers – so insurance premiums and what the company has to pay might be quite low.  Ford has older workers – so their insurance premiums and what the company might pay will be quite high.  Google is probably happier than Ford with group ratings used by private health care.  Universal health care your `group’ will be much bigger.

29. Problems with Health Insurance Mkt (Cutler, 1994) He argues: 1. Health system fails to provide full coverage or finance this coverage appropriately.  Due to moral hazard cover catastrophic risks, but not lower-risk.  Due to adverse selection, do not want to insure pre- existing conditions.  80% of conventional insurance plans set a max. lifetime payment (250,000 – 1 million)  Concludes that many individuals are not covered for large financial risk.

30. Problems with Health Insurance Mkt (Cutler, 1994) 2. Insurance is over “experience rated”  3 types of health care costs. Those individuals can control (smoking) Costs that are not controllable but predictably related to characteristics of the group (age). Costs which are truly random factors (for unforeseen diseases or accidents).  He suggests that individual costs should be experience rated to ensure people face the true cost of their habits

31. Problems with Health Insurance Market (Cutler, 1994)  For predictable but uncontrollable costs it is essentially a distributional issue (should the young subsidize the old)  For random costs, it is natural to pool costs. For individual or employees of small firms their premiums are large and variable often making them unsustainable. He argues for community ratings- charge everyone the same rate based on age or location. But the bigger the pool of people the better, so why stop at community?