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The Anatomy of Health Insurance
David Cutler
Richard Zeckhauser
Five Lessons on Health Insurance
Risk spreading v.s. incentives Integration of insurance and provision Competition and consumer identity Information and long-term insurance Health insurance and health
Why Health Insurance?
Medical expenditure is extreme volatile 1% use 25% exp 5% use 50% exp 20% use 75% exp
Difficult to self-insured because some people are sicker than others
Health insurance is relatively new (at the end of 19th century) since treatment was not very effective before
健康保險歷史回顧
我國社會醫療保險計畫之演進
1950 勞工保險開辦 1958 公務人員保險開辦 1985 農民保險開辦 1990 低收入戶保險開辦 1995 全民健康保險開辦
0
30
60
90
120
150
1960 1970 1980 1990 2000
per
cap
ita
GN
P in
US
$100
0
20
40
60
80
100
Co
vera
ge
rate
(%
)
per capita GNP Coverage Rate
Withdraw from UN
US De-Recognition
Democratic Progressive Party
Full Congress Election
President Election
Taiwan’s NHI
THE BIRTH OF TAIWAN’s NHI
NHI Law
OBJECTIVES OF TAIWAN’S NHI
Equal access to adequate health care Control health care costs at a reasonable level Promote the efficient use of health care resources
全民健保組織架構
全民健康保險基本架構
保險對象保險對象 醫事服務機構醫事服務機構
中央健康保險局中央健康保險局
繳保險費繳保險費
部分負擔部分負擔
醫療服務醫療服務
核付費用 核付費用 申請醫療費用申請醫療費用
發健保卡發健保卡
全民健保制度設計
公辦公營 單一保險人 全民納保 勞工雇主政府三方付費 部分負擔 法定給付範圍 ---正面表列與負面表列 財務平衡機制 ---量出為入、量入為出、法定調節
各年齡層醫療費用分布89年 7 月至 90年 6 月
0
10000
20000
30000
40000
50000
60000
70000
80000
女男
八十八年醫療費用保險對象使用情形
人 $ 人 $
8% 0 1% 24%
49% 7% 5% 48%
75% 21% 10% 60%
20% 75%
低使用者 高使用者
8%完全未使用, 49%使用 5,000元以下
低使用者 vs高使用者
保險的作用
1 個癌症病患 6 個健康的人 1 個洗腎病患 40 個健康的人 1 個血友病患 67 個健康的人
A Basic Economic ModelA Basic Economic Model
Health as a consumer durable good: Utility = U (X, Health)
X represents “other goods and services” H is a stock -- every action will affect health On its own or combined with other goods and
services, the stock of H generates a flow of services that yield satisfaction=utility
HEALTH OVER THE LIFE CYCLEHEALTH OVER THE LIFE CYCLE
TIME
HEALTH
BIRTH
Hmin
Appendicitis
Auto Crash
Cancer (radiation therapy)
Cancer complications
A Basic Economic Model A Basic Economic Model (cont.)(cont.)
Health=H(Profile, Medical Care, Lifestyle, Socioeconomic Status, Environment)
If an individual has a heart attack, then overall health decreases, regardless of the amount of medical care consumed The total product curve for medical care shifts
down
As a person ages, both health and the marginal product of medical care are likely to fall The total product curve shifts down and flattens
out
Insurance with Fixed Spending
One person: U(x, h) U’>0, U’’<0
One illness sick with probability p fixed treatment cost: m H(h, m)=H(1, m)=H(0,0)
Two states Sick (s): U(y-m, H(1,m)) Health (m): U(y, H(0,0))
Without insurance
With insurance
Fair insurance: π= pm
Comparing With and Without Insurance
Taking Taylor’s expansion, we have
aversionreiskabsoluteoftcoefficienU
U
mm
The insurance plan specifies the amount of money transferred to the bad state
Problem with Fixed Spending
Complete information All the sicknesses known All the treatment known No wasted resources in the policy
The insurance specifies the amount of money being transferred during the sickness (contingency plan)
The policy completely insures the health, but s it possible to insure someone’s health?
Moral Hazard Def : moral hazard refers the likely malfeasance of an
individual making purchases that are partly or fully paid for by others.
① Moral hazard conflicts with risk-spreading
Buy more than should if paid the full price.
② Moral hazard is a substitution effect, not income effect.
Insurance policy
( ( ( )), [ , ( )]) ( )
( ( )) self paid
( , ( )) health status
IV U y c m s H s m s f s ds
c m s
H s m s
First Best (s is observed)
For a given s:
( )
( ) ( , [ , ]) ( )
m H x
x x
H U E U x y pm
where
E U U y pm H s m f s ds
Second Best (s is not observed)
sUmcUH xhm )(
Adverse Selection
Adverse Selection
Begin with an example
Two types: High (H) , 50% Low (L) , 50%
Three insurances Generous (G) Moderate (M) Basic (B)
Efficient outcome H type chooses G plan L type chooses M plan An separating equilibrium
Once a separating equilibrium occurs, H type has incentives to join M plan Not efficient
Cross Subsidy Suppose we tax $1.25 for M plan to subsidy G plan H is better L is better too