1. Insurance and Health Care Health care normally considered a good that is different from most others Consumption of health care by many individuals is only occasional but may be extremely expensive Concept of consumer choice on whether to acquire health care is less relevant in life/death circumstances Health care also may have substantial positive externalities

2. Insurance and Health Care Why does insurance in some form finance health care consumption for most people in advanced countries? –Insurance lowers risk –Allows the insured not to suffer large variation in consumption year to year (consumption smoothing)

3. Breakdown of Insurance Coverage The proportions with private and government insurance add to more than 85% because some people have both Insurance Status in 2004Percent of US population With Health Insurance84.3% Private Insurance 68.1% Employer Based 59.8% Purchased Individually 9.3% Government Provided Insurance 27.2% Without Health Insurance15.7%

4. Private Insurance Two fundamental problems with private health insurance –Moral hazard reflects the change in behavior in people brought about by being insured –Adverse Selection reflects the additional cost to insurers brought about by the non-random self-selection of people into the pool of the insured

5. Private Insurance How do Insurance Companies deal with Moral Hazard? Insurance lowers the marginal cost of the decision to consume health care inducing moral hazard Most private health plans include a yearly deductible the consumer pays before any payments are made by the insurance company (with exceptions) deductible Many programs also include coinsurance or copayment schedules in which the insured pays part of health costs beyond deductiblecoinsurance copayment

6. With no insurance, equilibrium is at point e with a 1000 doctor visits per time period With insurance covering 80% of costs, quantity demanded doubles from 1000 to 2000 visits If health insurance covered 100% the quantity demanded would be 2250 visits Market for non-emergency health care Number of visits Price (per visit) S 1000 500 100 D 20002250 e

7. Adverse Selection Adverse selection causes non-group based insurance to be very expensive Example of 1000 individuals in market for insurance Suppose per capita health care expenditure is known to be $5000/year If the insurance company offers a policy for $5000/year, self selection will cause policy to unravel Company would respond by screening out those applicants the company anticipates would be costly to coverscreening out those applicants

8. Adverse Selection The Adverse Selection problem is solved if the company could insure all 1000 individuals at once The premiums collected from healthy would subsidize the care of those that are not healthy Group insurance through employers represent over 85% of private insurance in the US

9. The Uninsured Roughly 47 million Americans lack health insurance Represents 18% of the non-elderly population They are virtually all under the age 65; the elderly are universally covered by Medicare They are typically not among the poorest residents, because the poorest are covered by Medicaid

10. Uninsured by Age (as of 2008) Age Percent uninsured Under 18 years9.9 18 to 24 years28.6 25 to 34 years26.5 35 to 44 years19.4 45 to 64 years14.4 65 years and older1.7

11. Uninsured by Family Income (as of 2008) Income percent uninsured less than $25,000 24.5 $25,000 to $49,999 21.4 $50,000 to $74,999 14 $75,000+ 8.2

12. Health Care Health care resources are scarce. Those resources must be rationed. Why should non-market, collective decisions allocate health care? 1.Positive Externalities of health care (examples) 2.Private market for health insurance breaks down 3.Many people don’t support idea that scarce health care resources allocated solely on the basis of willingness (or ability) to pay

13. Health Care The uninsured are subject to market conditions for health care US fares poorly among wealthier nations in terms of deaths from treatable diseasesdeaths from treatable diseases This is due partially to many people without insurance not seeking timely health care for problems

14. International Comparison Characteristics of Health Care System in France 1.Insurance coverage is universal and obtained through employer 2.Employer (and employee) pay premium to one of fourteen regulated non-profit insurance funds that cover different segments of population 3.It’s illegal not to participate in your designated fund - government pays premium for unemployed

15. Characteristics of Health Care System in France Insurance funds not allowed to deny coverage to anyone who falls under their purview The funds are not allowed to challenge any bill sent by a doctor for service performed The French are allowed to go to any doctor in the country

16. Characteristics of Health Care System in France Cost control: government negotiates on behalf of insurance funds on prices of medical procedures with doctors’ unions Through carte vitale there is little paperwork Cost of procedures are in many cases a quarter of the cost in US

17. Health Care Costs The high cost of health care makes it difficult for those without insurance to acquire it The US will spend $8,160 on health care per resident in 2009 Country Percent of GDP in Health Care in 2006 US15.3 Switzerland11.3 France11 UK8.4

18. Health Care Costs Why does the US pay so much for health care? 1.Public policy encourages very generous group insurance plans through employers Employee/Employer must pay taxes on every dollar earned in wages but do not pay taxes on the dollar value of health insurance offered by employers; there is no cap on this tax subsidy 98% of firms with more than 200 employees and 76% of firms with 10-24 employees offer insurance

19. Health Care Costs 2.Private insurance firms earn profits not by negotiating down the price of medical services, but through selection of consumers 3.Medicare, the largest insurer in the US, pays less per medical procedure, but rarely questions any procedure

20. Health Care Costs 4.The use of expensive technology is used in the US as a marketing tool for insured patients A.CT ScanCT Scan B.Magnetic Resonance Imaging machine (MRI) Diagnostic technology that can create images within the entire human body Each machine cost between 1 million and 2.5 million dollars There are between 7,000 and 10,000 MRI machines in the US As of 2007, Canada had 222

21. Proposed Health Care Reform Goal of reform 1.Make health insurance coverage universal 2.Slow the increasing cost of health care

22. Proposed Health Care Reform Major features A.Expand medicaid to reach the uninsured whose family incomes are further above poverty line B.Large employers that do not offer health insurance to employees would have to pay an extra fee per employee

23. Proposed Health Care Reform C.Mandate that everyone must obtain insurance coverage - define what insurance coverage means - lack of proof of coverage would result in a fine levied through income tax system - waivers would be granted in some cases D.Subsidies to individuals for the purchase of insurance would be provided for families earning up to $80,000

24. Proposed Health Care Reform E.Insurance companies will no longer be allowed to use an applicant’s existing health condition in deciding on insuring the person F.The pricing practice of insurance companies would be restricted: Insurance companies could no longer set premiums for individual cases based on expected cost Companies allowed to set single premium for broadly defined categories of customers

25. Proposed Health Care Reform G.Federal Government provides funding to set up a separate Public Option for health insurance 1. After the startup, the Public Option would be a non-profit insurance company financed (theoretically) solely by the premiums of those it insures 2. The option would be open only to individuals otherwise without insurance