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Risk selection and heterogeneous preferences in health insurance markets with a public option

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  • Polyakova, Maria

Abstract

Conventional wisdom suggests that if private health insurance plans compete alongside a public option, they may endanger the latter's financial stability by cream-skimming good risks. This paper argues that two factors may contribute to the extent of cream-skimming: (i) degree of horizontal differentiation between public and private options when preferences are heterogeneous; (ii) whether contract design encourages choice of private insurance before information about risk is revealed. I explore the role of these factors empirically within the unique institutional setting of the German health insurance system. Using a fuzzy regression discontinuity design to disentangle adverse selection and moral hazard, I find no compelling support for extensive cream-skimming of public option by private insurers despite their ability to fully underwrite risk. A model of demand for private insurance supports the idea that heterogeneity in non-pecuniary preferences and long-term structure of private insurance contracts may be muting cream-skimming in this setting.

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  • Polyakova, Maria, 2016. "Risk selection and heterogeneous preferences in health insurance markets with a public option," Journal of Health Economics, Elsevier, vol. 49(C), pages 153-168.
    • Handle: RePEc:eee:jhecon:v:49:y:2016:i:c:p:153-168
    DOI: 10.1016/j.jhealeco.2016.06.012
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    Cited by:

    1. Pilny, Adam & Wübker, Ansgar & Ziebarth, Nicolas R., 2017. "Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany," Journal of Health Economics, Elsevier, vol. 56(C), pages 330-351.
    2. Christian Bührer & Stefan Fetzer & Christian Hagist, 2018. "Adverse Selection in the German Health Insurance System – The Case of Civil Servants," WHU Working Paper Series - Economics Group 18-06, WHU - Otto Beisheim School of Management.
    3. Gabriela Mihaela Muresan & Codruta Mare & Dan Tudor Lazar & Sorin Paul Lazar, 2023. "Can Health Insurance Improve the Happiness of the Romanian People?," The AMFITEATRU ECONOMIC journal, Academy of Economic Studies - Bucharest, Romania, vol. 25(64), pages 903-903, August.
    4. Juan Pablo Atal & Hanming Fang & Martin Karlsson & Nicolas R. Ziebarth, 2020. "Long-Term Health Insurance: Theory Meets Evidence," PIER Working Paper Archive 20-009, Penn Institute for Economic Research, Department of Economics, University of Pennsylvania.
    5. Huang, Shan & Salm, Martin, 2020. "The effect of a ban on gender-based pricing on risk selection in the German health insurance market," EconStor Open Access Articles and Book Chapters, ZBW - Leibniz Information Centre for Economics, vol. 29(1), pages 3-17.
    6. Shan Huang & Martin Salm, 2020. "The effect of a ban on gender‐based pricing on risk selection in the German health insurance market," Health Economics, John Wiley & Sons, Ltd., vol. 29(1), pages 3-17, January.
    7. Bührer, Christian & Fetzer, Stefan & Hagist, Christian, 2020. "Adverse selection in the German Health Insurance System – the case of civil servants," Health Policy, Elsevier, vol. 124(8), pages 888-894.
    8. Kanika Kapur, 2020. "Private Health Insurance in Ireland: Trends and Determinants," The Economic and Social Review, Economic and Social Studies, vol. 51(1), pages 63-92.
    9. Thomas Neusius, 2021. "Inhomogenous risk exposure in dual insurance system: selection effects in Germany’s long-term care plans," SN Business & Economics, Springer, vol. 1(1), pages 1-24, January.
    10. William Nganje & Kwame Asiam Addey, 2019. "Health Uninsurance in rural America: a partial equilibrium analysis," Health Economics Review, Springer, vol. 9(1), pages 1-15, December.
    11. Marika Cabral & Colleen Carey & Jinyeong Son, 2023. "Partial Outsourcing of Public Programs: Evidence on Determinants of Choice in Medicare," NBER Working Papers 31141, National Bureau of Economic Research, Inc.
    12. Juan Pablo Atal & Hanming Fang & Martin Karlsson & Nicolas R. Ziebarth, 2020. "German Long-Term Health Insurance: Theory Meets Evidence," NBER Working Papers 26870, National Bureau of Economic Research, Inc.
    13. Oyvat, Cem, 2020. "The role of global finance in the provisioning of social infrastructure and the welfare state," Greenwich Papers in Political Economy 26750, University of Greenwich, Greenwich Political Economy Research Centre.
    14. Dauth, Christine, 2021. "The effects of private versus public health insurance on health and labor market outcomes," IAB-Discussion Paper 202103, Institut für Arbeitsmarkt- und Berufsforschung (IAB), Nürnberg [Institute for Employment Research, Nuremberg, Germany].

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    More about this item

    Keywords

    Health insurance; Public option; Adverse selection; Individual mandate; German insurance;
    All these keywords.

    JEL classification:

    • D12 - Microeconomics - - Household Behavior - - - Consumer Economics: Empirical Analysis
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health
    • G22 - Financial Economics - - Financial Institutions and Services - - - Insurance; Insurance Companies; Actuarial Studies
    • H44 - Public Economics - - Publicly Provided Goods - - - Publicly Provided Goods: Mixed Markets

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