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Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges

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  • Michael Geruso
  • Timothy Layton
  • Daniel Prinz

Abstract

We study insurers' use of prescription drug formularies to screen consumers in the ACA Health Insurance exchanges. We begin by showing that exchange risk adjustment and reinsurance succeed in neutralizing selection incentives for most, but not all, consumer types. A minority of consumers, identifiable by demand for particular classes of prescription drugs, are predictably unprofitable. We then show that contract features relating to these drugs are distorted in a manner consistent with multidimensional screening. The empirical findings support a long theoretical literature examining how insurance contracts offered in equilibrium can fail to optimally trade off risk protection and moral hazard.

Suggested Citation

  • Michael Geruso & Timothy Layton & Daniel Prinz, 2019. "Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges," American Economic Journal: Economic Policy, American Economic Association, vol. 11(2), pages 64-107, May.
  • Handle: RePEc:aea:aejpol:v:11:y:2019:i:2:p:64-107
    Note: DOI: 10.1257/pol.20170014
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    References listed on IDEAS

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    1. Glazer Jacob & Huskamp Haiden A. & McGuire Thomas G., 2012. "A Prescription for Drug Formulary Evaluation: An Application of Price Indexes," Forum for Health Economics & Policy, De Gruyter, vol. 15(2), pages 1-26, March.
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    8. Michael Geruso & Timothy Layton, 2020. "Upcoding: Evidence from Medicare on Squishy Risk Adjustment," Journal of Political Economy, University of Chicago Press, vol. 128(3), pages 984-1026.
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    11. Marika Cabral & Michael Geruso & Neale Mahoney, 2018. "Do Larger Health Insurance Subsidies Benefit Patients or Producers? Evidence from Medicare Advantage," American Economic Review, American Economic Association, vol. 108(8), pages 2048-2087, August.
    12. Martin Andersen, 2017. "Constraints on Formulary Design Under the Affordable Care Act," Health Economics, John Wiley & Sons, Ltd., vol. 26(12), pages 160-178, December.
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    Citations

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    Cited by:

    1. Joseph P. Newhouse & Mary Beth Landrum & Mary Price & J. Michael McWilliams & John Hsu & Thomas G. McGuire, 2019. "The Comparative Advantage of Medicare Advantage," American Journal of Health Economics, University of Chicago Press, vol. 5(2), pages 281-301, Spring.
    2. Michele Fioretti & Hongming Wang, 2019. "Subsidizing Inequality: Performance Pay and Risk Selection in Medicare," Sciences Po Economics Discussion Papers 2019-15, Sciences Po Departement of Economics.
    3. Jonathan Gruber, 2017. "Delivering Public Health Insurance through Private Plan Choice in the United States," Journal of Economic Perspectives, American Economic Association, vol. 31(4), pages 3-22, Fall.
    4. Daniel W. Sacks & Khoa Vu & Tsan-Yao Huang & Pinar Karaca-Mandic, 2017. "How do insurance firms respond to financial risk sharing regulations? Evidence from the Affordable Care Act," NBER Working Papers 24129, National Bureau of Economic Research, Inc.
    5. Bijlsma, Michiel & Boone, Jan & Zwart, Gijsbert, 2017. "The complementarity between risk adjustment and community rating: Distorting market outcomes to facilitate redistribution," Journal of Public Economics, Elsevier, vol. 155(C), pages 21-37.
    6. Michael Geruso & Timothy J. Layton, 2017. "Selection in Health Insurance Markets and Its Policy Remedies," Journal of Economic Perspectives, American Economic Association, vol. 31(4), pages 23-50, Fall.
    7. Geruso, Michael & Layton, Timothy J. & McCormack, Grace & Shepard, Mark, 2019. "The Two Margin Problem in Insurance Markets," Working Paper Series rwp19-035, Harvard University, John F. Kennedy School of Government.
    8. Keith M. Marzilli Ericson & Kimberley H. Geissler & Benjamin Lubin, 2018. "The Impact of Partial-Year Enrollment on the Accuracy of Risk-Adjustment Systems: A Framework and Evidence," American Journal of Health Economics, MIT Press, vol. 4(4), pages 454-478, Fall.
    9. David Dranove & Christopher Ody & Amanda Starc, 2021. "A Dose of Managed Care: Controlling Drug Spending in Medicaid," American Economic Journal: Applied Economics, American Economic Association, vol. 13(1), pages 170-197, January.
    10. A. A. Withagen-Koster & R. C. Kleef & F. Eijkenaar, 2020. "Incorporating self-reported health measures in risk equalization through constrained regression," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 21(4), pages 513-528, June.
    11. Maria Polyakova & Stephen P. Ryan, 2019. "Subsidy Targeting with Market Power," NBER Working Papers 26367, National Bureau of Economic Research, Inc.
    12. Jason Abaluck & Mauricio M. Caceres Bravo & Peter Hull & Amanda Starc, 2020. "Mortality Effects and Choice Across Private Health Insurance Plans," NBER Working Papers 27578, National Bureau of Economic Research, Inc.
    13. Thomas G. McGuire & Anna L. Zink & Sherri Rose, 2020. "Simplifying and Improving the Performance of Risk Adjustment Systems," NBER Working Papers 26736, National Bureau of Economic Research, Inc.
    14. Savannah L. Bergquist & Timothy J. Layton & Thomas G. McGuire & Sherri Rose, 2018. "Intervening on the Data to Improve the Performance of Health Plan Payment Methods," NBER Working Papers 24491, National Bureau of Economic Research, Inc.
    15. Timothy Layton & Ellen J. Montz & Mark Shepard, 2017. "Health Plan Payment in U.S. Marketplaces: Regulated Competition with a Weak Mandate," NBER Working Papers 23444, National Bureau of Economic Research, Inc.
    16. Anna Zink & Sherri Rose, 2020. "Fair regression for health care spending," Biometrics, The International Biometric Society, vol. 76(3), pages 973-982, September.
    17. Lieber, Ethan M.J., 2018. "Does health insurance coverage fall when nonprofit insurers become for-profits?," Journal of Health Economics, Elsevier, vol. 57(C), pages 75-88.
    18. Bergquist, Savannah L. & Layton, Timothy J. & McGuire, Thomas G. & Rose, Sherri, 2019. "Data transformations to improve the performance of health plan payment methods," Journal of Health Economics, Elsevier, vol. 66(C), pages 195-207.

    More about this item

    JEL classification:

    • D82 - Microeconomics - - Information, Knowledge, and Uncertainty - - - Asymmetric and Private Information; Mechanism Design
    • G22 - Financial Economics - - Financial Institutions and Services - - - Insurance; Insurance Companies; Actuarial Studies
    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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