Universal mandatory health insurance in the Netherlands: a model for the United States?

Policy analysts consider the Netherlands health system a possible model for the United States. Since 2006 all Dutch citizens have to buy standardized individual health insurance coverage from a private insurer. Consumers have an annual choice among insurers, and insurers can selectively contract or integrate with health care providers. Subsidies make health insurance affordable for everyone. A Risk Equalization Fund compensates insurers for enrollees with predictably high medical expenses. The reform is a work in progress. So far the emphasis has been on the health insurance market. The challenge is now to successfully reform the market for the provision of health care.     

Purchasing cooperatives for small employers: performance and prospects

Health insurance purchasing cooperatives were established in the early to mid-1990s for the purpose of making health insurance more affordable and accessible for small employers. Extensive interviews at six cooperatives reveal that while some cooperatives enrolled large numbers of small employers, most have won only small market shares and a number have struggled for survival, not always successfully. They have allowed small employers to offer individual employees choice of health plans, but none has been able to sustain lower prices than are available in the conventional market. Among the important impediments to their success are limited support from health plans and conflicts over the role of insurance agents.     

Consumer information and biased selection in the demand for coverage supplementing Medicare.

This study examines how the relationship between health insurance knowledge and the health status of health insurance consumers influences their decisions to purchase insurance coverage. Data from the federal Medicare health insurance program for the elderly in the United States are used. The basic Medicare program provides a limited amount of coverage for health care services obtained from any provider in the private fee-for-service (FFS) market. Beneficiaries of this program may choose to supplement the basic coverage which they receive by two mechanisms: either they may purchase private insurance designed to fill some of the gaps left by the federal program ('Medigap' policies), thereby remaining in the FFS market and preserving their choice of provider, or they may enroll in health maintenance organizations (HMOs), thereby leaving the FFS market and agreeing to use only those providers affiliated with the HMO, and in return receiving broader coverage at little additional out-of-pocket cost. The study was made possible by a unique data set which combines measures of beneficiary knowledge of Medicare coverage with measures of perceived health status, socio-economic characteristics, and insurance coverage choices for a sample of Medicare beneficiaries who participated in an educational workshop about their insurance coverage options. These data were used to estimate a multinomial logistic model of the determinants of insurance choices, where the options included the two listed above and a basic Medicare option. The study explicitly recognizes the interaction between insurance information and health status in health plan choice. These results show that knowledge of coverage does have a differential impact on the decision to purchase health insurance depending on health status. With a high level of knowledge, sicker beneficiaries are less likely to have basic Medicare alone, compared with HMOs or Medigap policies, while healthier beneficiaries are less likely to be enrolled in HMOs, compared with Medigap policies. This finding has important implications for the use of health status measures to adjust capitated payment formulas when knowledgable consumers have the option to enroll in HMOs or remain in the FFS environment. In the absence of health status adjusters for the HMO capitation payments, high levels of coverage knowledge may exacerbate inherent selection bias among these coverage options by healthier and sicker consumers of health insurance.     

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.     

How Much Risk Pooling Is There in the Individual Insurance Market?

OBJECTIVE: To examine how much pooling of risks occurs among potential purchasers in the individual market, how much pooling occurs among those who purchase coverage, and whether there is greater pooling among longer-term enrollees. DATA SOURCES: The data are administrative records for enrollees in individual insurance plans in California in 2001, and from a survey of Californians enrolled in the individual insurance market and the uninsured. STUDY DESIGN: Logit models were estimated for 5 health outcome measures to compare the insured and uninsured after adjusting for other factors that affect insurance status and health. Multivariate models were also estimated to explore the relationship between health and three measures of pooling in the market: plan type, pricing tier, and the actuarially adjusted premium paid by the enrollee. PRINCIPAL FINDINGS: Those who purchase individual health insurance are in better health than those who remain uninsured. On the other hand, a large share of people with health problems does obtain individual insurance. The distribution of subscribers across plan type and pricing tier varies with their health status. Those in poor health are less likely to purchase low benefit plans. There is less separation of risks for those who become sick after enrollment based on the measure of pricing tier. The distribution of subscribers across plan type for those who have health problems at enrollment and those who become sick differs, but so does the distribution of those who become sick and those who remain healthy. CONCLUSIONS: Despite small differences among the healthy and sick, our results support the conclusion that there is considerable risk pooling in the individual market. To some extent, this pooling occurs because underwriting happens at the time people enroll and there is greater pooling among those who become sick than those who enroll sick. Our results however suggest that health savings accounts may further fragment the market.     

How risky is individual health insurance?

This paper describes the relationship between type of insurance coverage in one period and the likelihood of becoming uninsured in the next. We find that for people at the median health status, becoming uninsured is most likely for those with individual insurance, less likely for those with small-group insurance, and least likely for those with large-group insurance. However, for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance. We attribute these results to the offsetting effects of high loadings and guaranteed renewability in the individual market.     

Patterns of individual health insurance coverage, 1996-2000

Information about patterns of individual health insurance coverage is limited. Knowledge gaps include the extent to which individual insurance provides transitional versus long-term coverage, and participants' insurance status before and after being covered by an individual plan. In this study we use data from the 1996-2000 Survey of Income and Program Participation (SIPP) to examine how long the individually insured maintain their coverage; sources of coverage before and after enrolling in an individual health plan; and characteristics of those who rely on individual insurance coverage. Understanding the dynamics of this market will better inform federal and state insurance reform efforts.     

President Bush's comprehensive health reform program

To deal with the shortcomings of the current U.S. health care system, President Bush has proposed a comprehensive reform package that would offer tax credits and deductions to low- and middle-income Americans to purchase private insurance, reform small market insurance to ensure availability and portability of insurance, allow creation of Health Insurance Networks to allow small businesses and nonprofit organizations to pool their purchasing power, reduce administrative costs, and control the growth of government health programs. Combined, the proposals would build on the strengths of the present private/public system and preserve consumer choice and free market discipline.     

基于“三方四体”的健康保险系统运营的博弈分析

从商业健康保险相关理论入手,分析归纳各个主体行为。目的在于在此基础上建立博弈模型,重点对政府-健康保险公司和健康保险公司-健康服务提供者两个博弈模型进行分析;研究表明政府要介入到健康保险市场进行监管,主要是对健康保险公司进行监管;研究说明在整个市场中,健康保险公司和健康服务提供者的最佳选择就是合作,以达到"共赢";指出健康保险系统是一个有机整体,其正常有效运作管理要靠"三方四体"协同合作。     

Duplicate coverage and demand for health care. The case of Catalonia.

An individual has duplicate coverage when he enjoys a compulsory medical public insurance, and in addition he has purchased a private one. This paper studies the implications of duplicate coverage on both demand for visits to specialists and on the selection process of the private insurance market. Econometric models, estimated by the generalized method of moments, accommodate both the endogeneity of insurance choice decision and the non-negativity of the variable number of visits. The choice of instrumental variables is motivated within a theoretical model of demand for health care. The results shows that endogeneity is important for the subsample of heads of household, but not for the subsample of non-heads of household. For the subsample of non-heads of household, a positive effect of duplicate coverage on the number of visits to specialists is found. Health related variables, education and income are also important. Results are consistent with the idea that heads of household that buy private insurance are the ones with poor unobservable health conditions. It is argued that this last result is related to the existence of a compulsory public insurance.     

The effect of Health Savings Accounts on group health insurance coverage

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2–3 percentage point increase in their group insurance coverage.     

Risk pooling and regulation: policy and reality in today's individual health insurance market

Analysis of new data on the relationship between and premiums and coverage in the individual insurance market and health risk shows that actual premiums paid for individual insurance are much less than proportional to risk, and risk levels have a small effect on obtaining coverage. States limiting risk rating in individual insurance display lower premiums for high risks than other states, but such rate regulation leads to an increase in the total number of uninsured people. The effect on risk pooling is small because of the large amount of risk pooling in unregulated individual insurance.     

More than half of individual health plans offer coverage that falls short of what can be sold through exchanges as of 2014

The Affordable Care Act creates state-based health exchanges that will begin acting as a market place for health insurance plans and consumers in 2014. This paper compares the financial protection offered by today's group and individual plans with the standards that will apply to insurance sold in state-based exchanges. Some states may apply these standards to all health insurance sold within the state. More than half of Americans who had individual insurance in 2010 were enrolled in plans that would not qualify as providing essential coverage under the rules of the exchanges in 2014. These people were enrolled in plans with an actuarial value below 60 percent, which means that the plans covered less than that proportion of the enrollees' health expenses. Many of today's individual health plans are below the "bronze" level, the lowest level of plan that can be sold through exchanges. In contrast, most group plans in 2010 had an actuarial benefit of 80-89 percent and would qualify as highly rated "gold" plans in the exchanges. To sell to ten million new buyers on the exchanges, insurers will need to redesign benefit packages. Combined with a ban on medical underwriting, the individual insurance market in a post-health reform world will sharply contrast with the market of past decades.     

Workable competition in health care: prospects for the Dutch design.

Since 1989 a gradual restructuring of the Dutch health care system is taking place to realize a multiple choice social health insurance system with workable competition among insurers and among health care providers. This paper investigates whether the structural change will induce the intended competition. An examination of the characteristics of the market for health insurance, physician services and hospital services in the Netherlands points out that the scope for competition is limited. If competition is to work, rather extensive government regulation to monitor the conduct of both providers and insurers is needed. Without an effective antitrust policy a high degree of concentration and collusion is likely.     

Consumer-directed health plans: enrollee views, early employer experience

PURPOSE: Consumer-directed health plans (CDHPs) are a new health insurance product that is of growing interest to employers who are struggling to cope with rising health insurance premium costs and to consumers who are desiring more choice and engagement in their health care. This paper presents the results of a study of California consumer awareness of, and attitudes toward, CDHPs in the context of several national surveys and the experiences of some early-adopting employers. DESIGN AND METHODOLOGY: California Health Decisions conducted a telephone survey of 800 insured adult California residents in November 2002. PRINCIPAL FINDINGS: Few respondents had heard of CDHPs. They appealed more to younger, single, less educated, and healthier respondents and those who did not understand them well. The most attractive CDHP features were greater provider choice and health savings accounts' portability and flexibility. Concerns centered on personal financial exposure. CONCLUSION: While CDHPs' commercial market penetration is increasing, their greatest potential future contributions might be to reduce the number of uninsured Americans by offering an affordable health insurance product and to fund additional health services for retirees. As CDHPs further evolve, more consumer involvement in their refinement, implementation, and evaluation is essential.     

Have small-group health insurance purchasing alliances increased coverage?

We use data from 1993 and 1997 employer surveys to assess whether the three largest statewide small-group health insurance purchasing alliances--in California, Connecticut, and Florida--increased coverage in small business. They did not. Specifically, they did not reduce small-group market health insurance premiums, and they did not raise small-business health insurance offer rates. We explore and discuss some reasons why. Alliances do permit employers to offer much greater choice in the number and types of plans; employees are found to take advantage of this wider choice.     

The Affordable Care Act's insurance market regulations' effect on coverage

Much of the debate surrounding reform of the Patient Protection and Affordable Care Act (ACA) revolves around its insurance market regulation. This paper studies the impact on health insurance coverage of those provisions. Using data from the American Community Survey, years 2008–2015, I focus on individuals, ages 26 to 64, who are ineligible for the subsidies or Medicaid expansions included in the ACA to isolate the effect of its market regulation. To account for time trends, I utilize a differences‐in‐differences approach with a control group of residents of Massachusetts who were already subject to a similarly regulated health insurance market. I find that the ACA's regulations caused an increase of 0.95 percentage points in health insurance coverage for my sample in 2014. This increase was concentrated among younger individuals, suggesting that the law's regulations ameliorated adverse selection in the individual health insurance market.     

Should administrative costs in health insurance be included in the risk-equalization? An analysis of five countries

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers.

     

How small business health exchanges can offer value to their future customers--and why they must

The success of the Small Business Health Options Program (SHOP)-health insurance exchanges targeted at the small-group market and opening for business in January 2014-will depend in large part on persuading small employers and qualified health plans to participate. The most important objective will be offering employers lower-cost health plans than they have now. Other critical objectives will be offering small firms administrative efficiencies and access to choices among high-value plans that are not offered elsewhere. This article frames the challenges that exchanges will encounter in meeting these objectives. In particular, it discusses the advisability of small-business exchanges' offering an "employee choice" model (which the article describes in detail); of combining the small-business and individual exchanges to broaden product offerings and gain operational efficiencies; and of encouraging low-cost plans to enter the exchange market, perhaps by enabling Medicaid managed care plans to offer comparable commercial products, and in turn affording health plans access to a uniquely motivated market of small firms and their workers who want affordable coverage.