Nonparametric bounds on the effect of deductibles in health care insurance on doctor visits - Swiss evidence

We evaluate the effect of the size of deductibles in the basic health insurance in Switzerland on the probability of a doctor visit. We employ nonparametric bounding techniques to minimise statistical assumptions. In order to tighten the bounds we consider two further assumptions: mean independence of an instrument and monotone treatment response. Under these two assumption we are able to bound the causal effect of high deductibles compared to low deductibles below zero. We conclude that the difference in health care utilisation is partly due to a reduction of moral hazard effects.     

The effect of income-based mandates on the demand for private hospital insurance and its dynamics

We examine the effect of an income-based mandate on the demand for private hospital insurance and its dynamics in Australia. The mandate, known as the Medicare Levy Surcharge (MLS), is a levy on taxable income that applies to high-income individuals who choose not to buy private hospital insurance. Our identification strategy exploits changes in MLS liability arising from both year-to-year income fluctuations, and a reform where income thresholds were increased significantly. Using data from the Household, Income and Labour Dynamics in Australia longitudinal survey, we estimate dynamic panel data models that account for persistence in the decision to purchase insurance stemming from unobserved heterogeneity and state dependence. Our results indicate that being subject to the MLS penalty in a given year increases the probability of purchasing private hospital insurance by between 2 to 3 percent in that year. If subject to the penalty permanently, this probability grows further over the following years, reaching 13 percent after a decade. We also find evidence of a marked asymmetric effect of the MLS, where the effect of the penalty is about twice as large for individuals becoming liable compared with those going from being liable to not being liable. Our results further show that the mandate has a larger effect on individuals who are younger.     

Subsidies and the demand for individual health insurance in California

OBJECTIVE: To estimate the effect of changes in premiums for individual insurance on decisions to purchase individual insurance and how this price response varies among subgroups of the population. DATA SOURCE: Survey responses from the Current Population Survey (http://www.bls.census.gov/cps/cpsmain.htm), the Survey of Income and Program Participation (http://www.sipp.census.gov/sipp), the National Health Interview Survey (http://www.cdc.gov/nchs/nhis.htm), and data about premiums and plans offered in the individual insurance market in California, 1996-2001. STUDY DESIGN: A logit model was used to estimate the decisions to purchase individual insurance by families without access to group insurance. This was modeled as a function of premiums, controlling for family characteristics and other characteristics of the market. A multinomial model was used to estimate the choice between group coverage, individual coverage, and remaining uninsured for workers offered group coverage as a function of premiums for individual insurance and out-of-pocket costs of group coverage. PRINCIPAL FINDINGS: The elasticity of demand for individual insurance by those without access to group insurance is about -.2 to -.4, as has been found in earlier studies. However, there are substantial differences in price responses among subgroups with low-income, young, and self-employed families showing the greatest response. Among workers offered group insurance, a decrease in individual premiums has very small effects on the choice to purchase individual coverage versus group coverage. CONCLUSIONS: Subsidy programs may make insurance more affordable for some families, but even sizeable subsidies are unlikely to solve the problem of the uninsured. We do not find evidence that subsidies to individual insurance will produce an unraveling of the employer-based health insurance system.     

Extending social health insurance to the informal sector in Kenya. An assessment of factors affecting demand

This paper contributes to analysing and understanding the demand for (social) health insurance of informal sector workers in Kenya by assessing their perceptions and knowledge of and concerns regarding health insurance and the Kenyan National Hospital Insurance Fund (NHIF). It serves to explore how informal sector workers could be integrated into the NHIF. To collect data, focus group discussions were held with organized groups of informal sector workers of different types across the country, backed up by a self-administered questionnaire completed by heads of NHIF area branch offices. It was found that the most critical barrier to NHIF enrollment is the lack of knowledge of informal sector workers about the NHIF, its enrollment option and procedures for informal sector workers. Inability to pay is a critical factor for some, but people were, in principle, interested in health insurance, and thus willing to pay for it. In sum, the mix of demand-side determinants for enrolling in the NHIF is not as complex as expected. This is good news, as these demand-side determinants can be addressed with a well-designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates.     

Crowd-in: the effect of private health insurance markets on the demand for Medicaid

OBJECTIVE: To investigate the effects of local labor market conditions and the availability of employer-sponsored health insurance on exits from the Medicaid program. DATA SOURCE: Data for this project come from a unique administrative database containing a 2 percent sample of all cases on California's Medicaid program in 1987 and a 2 percent sample of all new cases starting each year between 1987 and 1995. STUDY DESIGN: The results are estimated using a discrete duration model where the monthly exit probability is a function of demographic characteristics, local labor market variables, the probability of having employer-sponsored insurance, and fixed year and county effects. PRINCIPAL FINDINGS: Improvements in labor market opportunities (i.e., employment growth, wage growth, and increases in the availability of employer-sponsored health insurance) promote exits off the Medicaid program. A 2.5 percentage point increase in the availability of employer-sponsored insurance leads to a 6 percent increase in the probability that a completed spell lasts no more than 2 years. It would take a 2 percentage point decrease in unemployment rates or a 10 percent increase in average quarterly earnings to yield an equivalent increase in the likelihood of exiting Medicaid within 2 years. These effects are robust to the inclusion of county-level fixed effects and time effects. CONCLUSIONS: Medicaid expenditures and caseloads are sensitive to local economic fluctuations and secular trends in the availability of health insurance. Continued decreases in employer-based health insurance coverage will greatly increase the demand for public insurance coverage and the financial pressures on state governments.     

Family formation and the demand for health insurance

We study how demand for health insurance responds to family formation using a unique panel of young Australian women. Our data allow us to simultaneously control for the influence of state dependence and unobserved heterogeneity and detailed information on children and child aspirations. We find evidence that women purchase insurance in preparation for pregnancy but then transition out of insurance once they have finished family building. Children have a large, negative impact on demand for insurance, although this effect is smaller for those on higher incomes. We also find that state dependence has a large impact on insurance demand. Our results are robust to a variety of alternative modelling strategies.     

Progressive segmented health insurance: Colombian health reform and access to health services

Equal access for poor populations to health services is a comprehensive objective for any health reform. The Colombian health reform addressed this issue through a segmented progressive social health insurance approach. The strategy was to assure universal coverage expanding the population covered through payroll linked insurance, and implementing a subsidized insurance program for the poorest populations, those not affiliated through formal employment. A prospective study was performed to follow-up health service utilization and out-of-pocket expenses using a cohort design. It was representative of four Colombian cities (Cendex Health Services Use and Expenditure Study, 2001). A four part econometric model was applied. The model related medical service utilization and medication with different socioeconomic, geographic, and risk associated variables. Results showed that subsidized health insurance improves health service utilization and reduces the financial burden for the poorest, as compared to those non-insured. Other social health insurance schemes preserved high utilization with variable out-of-pocket expenditures. Family and age conditions have significant effect on medical service utilization. Geographic variables play a significant role in hospital inpatient service utilization. Both, geographic and income variables also have significant impact on out-of-pocket expenses. Projected utilization rates and a simulation favor a dual policy for two-stage income segmented insurance to progress towards the universal insurance goal.     

安徽省肥西农村地区卫生服务需求调查分析

目的 了解安徽省农村卫生服务需求及卫生服务利用情况。方法 采用整群随机抽样方法，抽取3077人进行问卷调查；用两周患病率和慢性病患病率两项指标评价卫生服务需求情况。结果 总两周患病率为94．37‰，男性两周患病率为91．13‰．女性两周患病率为98．00‰，男、女间差异无显性．其趋势与全国趋势相一致。两周患病率前5位依次为呼吸系统、消化系统、循环系统、血液系统及肌肉骨骼系统和结缔组织疾病，5大系统合计占疾病总数的90．52％。慢性病患病前5位依次是：慢性胃肠炎、类风湿性关节炎、慢性支气管炎、高血压、贫血。在性别上慢性病患病率女性高于男性，但差异无显性。随着年龄的增加慢性病患病率明显增加，由0～4a组的l0．02‰增加到65a以上组的343．82‰。本次调查发现盲或半盲慢性病患病率最高，不同化程度慢性病患病率差异有显性，大专及以上患病率较低。结论 政府和卫生主管部门应根据本地具体情况采取相应的卫生政策和办医形式，以满足农民高的卫生服务需求量。     

Unobserved heterogeneity and censoring in the demand for health care

In this paper we estimate a demand for private medical services equation based on the tradition of Grossman′s model of demand for health using data for a panel of Spanish households. The econometric specification accounts for the censored nature of the data, which arises from no participation and infrequency of purchases, and the existence of unobserved heterogeneity, which arises from the non-observability of health states. Our evidence suggests that ignoring these features can have a significant impact on the size, sign and significance of the model estimates. The estimates for the participation and consumption processes also suggest that the deduction of expenditures on health care currently applicable in the Spanish tax system are positively associated to income and fertility. © 1998 John Wiley & Sons, Ltd.     

Measuring the effects of reducing subsidies for private insurance on public expenditure for health care

This paper investigates the effects of reducing subsidies for private health insurance on public sector expenditure for hospital care. An econometric framework using simultaneous equation models is developed to analyse the interrelated decisions on the intensity and type of health care use and private insurance. The framework is applied to the context of the mixed public–private system in Australia. The simulation projections show that reducing premium subsidies is expected to generate net cost savings. This arises because the cost savings achieved from reducing subsidies are larger than the potential increase in public expenditure on hospital care.     

Demand for voluntary health insurance in developing countries: the case of Vietnam's school-age children and adolescent student health insurance program

Many developing countries are trying to expand health insurance to achieve universal coverage, yet enrolling informal sector workers and the rural population remains a challenge. A good knowledge of factors driving demand for health insurance among these groups is therefore important. The current study contributes to this body of knowledge by analyzing demand for school-age children and adolescent student (aged 6-20) health insurance, a major voluntary health insurance scheme in Vietnam. Data were drawn form the Vietnam National Health Survey (2001-2002). We found that demand increases significantly with the expected benefits of insurance as measured by proximity to and quality of a tertiary hospital. There is a strong socio-economic gradient both at the household and commune levels, with wealthier, more educated households in better-off communes significantly more likely to purchase insurance for their children. No clear evidence of adverse selection is observed whether health status is assessed objectively or subjectively. Finally, while female heads of household are generally more prone to purchase health insurance for their children, households prioritize young children, male children, and those children with more schooling in their purchase decision. Findings emphasize the need to understand the effects of both health system factors and intra-household dynamics in resource allocation to explain the demand for health insurance in developing countries.     

农民工医疗保险制度政策适应性研究——基于需求和制度运行环境的视角

自2003年以来,各地相继出台了农民工医疗保险制度的相关政策,并逐步形成了具有各地特色的农民工医保模式。但是实际参保率依然低下,政策适应性较差。本文从医疗保障需求和制度运行环境两方面来分析农民工医保制度政策的适应性。     

医疗保险道德风险的控制机制--市场供求关系的视角分析

医疗保险中防范道德风险的发生，必须建立起有效的控制机制。在医疗保险市场中，存在医方、患方和保方三个主体，三方可以形成不同的供求关系，相互联系和控制。三方的互相牵制同时也就控制了道德风险的发生。     

卫生应急管理教学案例需求调查分析

目的了解卫生应急管理教学案例的需求现状,为案例采编提供依据。方法采用问卷调查法,了解卫生应急管理案例教学亲历者对案例的需求情况。结果被调查者中,认为目前案例不能满足需要的占64．3％,认为案例具有代表性、针对性、相关性、真实性、时效性、信息详细特点的分别占85．7％、84．9％、88．0％、52．9％、41．4％、44．0％,对纯文本、图画语音、角色扮演等案例编写形式的需求程度分别占12．5％、66．4％、72．7％,对短篇、中篇、长篇等案例篇幅的需求程度分别占49．8％、44．1％、2．7％;对传染病、群体不明原因疾病、中毒、自然灾害、事故灾难、社会安全、核事故、其他内容等案例内容的需求程度分别占86．9％、84．9％、66．4％、56．O％、41．7％、35．1％、23．6％、42．1％。结论目前卫生应急管理教学案例还不能培训与教学需要。在案例编写中,应当突出案例的代表性、针对性、相关性、真实性等特点,采用图画语音等创新形式,长短适中,加快对突发公共卫生事件相关内容的案例开发。     

Tax incentives and the demand for private health insurance

We analyze the effect of an individual insurance mandate (Medicare Levy Surcharge) on the demand for private health insurance (PHI) in Australia. With administrative income tax return data, we show that the mandate has several distinct effects on taxpayers’ behavior. First, despite the large tax penalty for not having PHI coverage relative to the cost of the cheapest eligible insurance policy, compliance with mandate is relatively low: the proportion of the population with PHI coverage increases by 6.5 percentage points (15.6%) at the income threshold where the tax penalty starts to apply. This effect is most pronounced for young taxpayers, while the middle aged seem to be least responsive to this specific tax incentive. Second, the discontinuous increase in the average tax rate at the income threshold created by the policy generates a strong incentive for tax avoidance which manifests itself through bunching in the taxable income distribution below the threshold. Finally, after imposing some plausible assumptions, we extrapolate the effect of the policy to other income levels and show that this policy has not had a significant impact on the overall demand for private health insurance in Australia.     

EXTENSIONS OF HURDLE MODELS FOR OVERDISPERSED COUNT DATA

Hurdle models are frequently used to model count data. Recent developments in the count data literature make it possible to relax commonly imposed assumptions of these models. On the basis of these findings, two extensions of hurdle models that make popular specifications more flexible are developed. Both extensions nest the models that have been used so far, so they can be tested by appropriate parametric restrictions. An example from health economics illustrates the relevance of both model extensions. Copyright © 2012 John Wiley & Sons, Ltd.     

新疆农村居民卫生服务需求与利用状况调查

目的：了解新疆农村居民卫生服务需求利用现状,为制定农村卫生服务策略与计划提供依据。方法：采用随机整群抽样,抽取新疆新源县阿热勒托别镇、呼图壁县方草湖镇、霍城县芦草沟乡、哈密市天山乡4个乡镇的各100名农村居民,由调查员入户对农村居民卫生服务需求与利用现状等进行问卷调查。结果：调查地区农村居民新农合参合率99．5％,两周患病率15．62％,半年内高血压、糖尿病患病率分别为6．31％和1．33％。两周未就诊但自己买药者34．04％。32．6％的高血压患者和36．8％的糖尿病患者在村卫生室有健康档案。结论：新疆农村居民的卫生服务需要量大,但利用率较低,利用主要在村级医疗机构。应继续贯彻、完善新农合制度,加强农村基层医疗卫生机构能力建设与管理,开展健康教育,进一步提高农村基层医疗服务利用率。     

据管理方意向分析医改对职工卫生服务需求行为的影响

通过分析医保管理机构管理者和医疗机构医保管理者对医改前后职工卫生需求行为的变化及其相关影响因素显示,现行的医保政策有利于控制医疗费用的过快增长,医改政策实施后,职工的卫生服务需求行为趋向合理化,但对供方行没有显著影响,从而影响了需方行为和费用控制效果,管理方不规范操作作对职工卫生服务需求行为也有显著影响。