The Effects of Offering Health Plan Choice within Employment-Based Purchasing Groups

Over the last two decades, employers have increasingly offered workers a choice of health plans. The availability of choice has the potentially beneficial effects of lowering the cost and increasing the quality of health care through greater competition among health plans for enrollees as well as allowing consumers to enroll in the type of coverage that most closely matches their preferences. On the other hand, concerns about the potential for adverse selection within employment-based purchasing in response to the availability of choice exist. In this paper, I examine the effects of offering choice in employment-based purchasing groups on access to and the cost of employer-sponsored coverage. I find that greater availability of choice was associated with a reduction in the premium of employer-sponsored coverage and an increase in the proportion of workers covered by the plans offered by employers. However, most of the premium reductions were due to a shift from family to single coverage within employment-based purchasing groups and a reduction in the generosity of the plans in which employees were enrolled. The results are not consistent with the availability of choice leading to lower premiums through greater competition among plans for workers.

Mandated Health Insurance Benefits and the Utilization and Outcomes of Infertility Treatments

During the last two decades, the treatment of infertility has improved dramatically. These treatments, however, are expensive and rarely covered by insurance, leading many states to adopt regulations mandating that health insurers cover them. In this paper, we explore the effects of benefit mandates on the utilization and outcomes of infertility treatments. We find that use of infertility treatments is significantly greater in states adopting comprehensive versions of these mandates. While greater utilization had little impact on the number of deliveries, mandated coverage was associated with a relatively large increase in the probability of a multiple birth. For relatively low fertility patients who responded to the expanded insurance coverage, treatment was often unsuccessful and did not result in a live birth. For relatively high fertility patients, in contrast, treatment often led to a multiple, rather than a singleton, birth. We also find evidence that the beneficial effects on the intensive treatment margin that have been proposed in other studies are relatively small. We conclude that, while benefit mandates potentially solve a problem of adverse selection in this market, these benefits must be weighed against the costs of the significant moral hazard in utilization they induce.

Is Health Insurance Affordable for the Uninsured?

In this paper, we investigate the meaning of affordability' in the context of health insurance. Assessing the relationship between the affordability of coverage and the large number of uninsured in the U.S. is important for understanding the barriers to purchasing coverage for the uninsured and evaluating the role of policy in reducing this number. We propose several definitions of affordability and examine the implications of alternative definitions on estimates of the proportion of currently uninsured who are unable to afford coverage. We find that, depending on the definition, health insurance was affordable to between one-quarter and three-quarters of the uninsured in 2000.

Health Risk, Income, and Employment-Based Health Insurance

While many believe that an individual’s health plays an important role in both their willingness and ability to obtain health insurance in the employment-based setting, relatively little agreement exists on the extent to which health status affects coverage rates, particularly for those with lower incomes. In this paper, we examine the relationship between health risk and the purchase of group health insurance and whether that relationship differs by a person’s income and whether they obtain coverage in the small, medium, or large group market. Using the panel component of the 1996-2002 Medical Expenditure Panel Survey (MEPS), we find that health risk is positively associated with private health insurance across the different markets, and that this positive relationship is stronger for low and middle income people, particularly in the large group market. Our results are consistent with the existence of adverse selection in the group market in the form of low rates of coverage among low risks due to an absence of risk rating of premiums. We conclude that pooled premiums for low risks, particularly those with low incomes, may represent a more important financial barrier to coverage in voluntary group insurance than high premiums for high risks.

The Magnitude and Nature of Risk Selection in Employer-Sponsored Health Plans

Most existing studies of risk selection in the employer-sponsored health insurance market are case studies of a single employer or of an employer coalition in a single market. We examine risk selection in the employer-sponsored market by applying a switcher' methodology to a national, panel data set of enrollees in employer-sponsored health plans. We find that people who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in the non-HMO plan, and that this relatively low use persists once they enroll in an HMO. Furthermore, people who switch from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than those who remained in an HMO plan. HMOs would most likely continue to experience favorable risk selection if employers adjusted health plan payments based on enrollees' gender and age because the selection appears to occur based on enrollee characteristics that are difficult to observe such as preferences for medical care and health status.

Consumer Demand for Health Information on the Internet

The challenges consumers face in acquiring and using information are a defining feature of health care markets. In this paper, we examine demand for health information on the Internet. We find that individuals in poor health are more likely than those in better health to use the Internet to search for health information and to communicate with others about health and health care. We also find that individuals facing a higher price to obtain information from health care professionals are more likely to turn to the Internet for health information. Our findings indicate that demand for consumer health information depends on the expected benefits of information and the price of information substitutes.

Is Health Insurance Affordable for the Uninsured?

In this paper, we investigate the meaning of “affordability” in the context of health insurance. Assessing the relationship between the affordability of coverage and the large number of uninsured in the U.S. is important for understanding the barriers to purchasing coverage and evaluating the role of policy in reducing the number of uninsured. We propose several definitions of affordability and examine the implications of alternative definitions for estimates of the proportion of uninsured who are unable to afford coverage. We find that, depending on the definition, health insurance was affordable to between one-quarter and three-quarters of the uninsured in the United States in 2000

Pricing and Welfare in Health Plan Choice

Prices in government and employer-sponsored health insurance markets only partially reflect insurers' expected costs of coverage for different enrollees. This can create inefficient distortions when consumers self-select into plans. We develop a simple model to study this problem and estimate it using new data on small employers. In the markets we observe, the welfare loss compared to the feasible efficient benchmark is around 2-11% of coverage costs. Three-quarters of this is due to restrictions on risk-rating employee contributions; the rest is due to inefficient contribution choices. Despite the inefficiency, we find substantial benefits from plan choice relative to single-insurer options.