Essays on Health Insurance and Annuities

TitleEssays on Health Insurance and Annuities
Publication TypeThesis
Year of Publication2015
AuthorsShepard, M
UniversityHarvard University
CityCambridge, MA
KeywordsMedicare/Medicaid/Health Insurance, Methodology, Net Worth and Assets, Public Policy, Retirement Planning and Satisfaction, Social Security

Insurance creates an important source of economic well-being by providing for beneficiaries in times of need. But because a variety of forces may inhibit the proper functioning of insurance markets, governments are deeply involved through regulation, subsidies, and direct provision of insurance. This dissertation studies insurance demand, supply, and the role of policy in two types of markets of direct interest to policymakers: health insurance and annuities. I highlight the importance of both traditional market failures (adverse selection and moral hazard) and less standard factors like limited competition (market power) and puzzlingly low insurance demand to influence insurance market outcomes. In the first chapter, I study how health insurers compete in individual insurance markets like those established in the Affordable Care Act. I focus on the role of an increasingly important benefit: plans' networks of covered medical providers. Using data from Massachusetts' pioneer insurance exchange, I show evidence of substantial adverse selection against plans covering the most expensive and prestigious academic hospitals. Individuals loyal to the prestigious hospitals both select plans covering them and are more likely to use these hospitals' high-price care. Standard risk adjustment does not capture their higher costs driven by preferences for using high-price providers. To study the welfare implications of network-based selection, I estimate a structural model of hospital and insurance markets and use the model to simulate insurer competition on premiums and hospital coverage in an insurance exchange. I find that with fixed hospital prices, adverse selection leads all plans to exclude the prestigious hospitals. Modified risk adjustment or subsidies can preserve coverage, benefitting those who value the hospitals most but raising costs enough to offset these gains. I conclude that adverse selection encourages plans to limit networks and star academic hospitals to lower prices, with the welfare implications depending on whether those high prices fund socially valuable services. Chapter 2 also studies health insurance exchanges and the competitive effect of a policy design choice: how the level of subsidies is determined. In the Affordable Care Act exchanges and other programs, subsidies depend on prices set by insurers – as prices rise, so do subsidies. I show that these "price-linked" subsidies incentivize higher prices, with a magnitude that depends on how much insurance demand rises when the price of uninsurance (the mandate penalty) increases. To estimate this effect, I use two natural experiments in the Massachusetts subsidized insurance exchange. In both cases, I find that a $1 increase in the relative monthly mandate penalty increases plan demand by about 1%. Using this estimate, my model implies a sizable distortion of $48 per month (about 12%). This distortion has implications for the tradeoffs between price-linked and exogenous subsidies in many public insurance programs. I discuss an alternate policy that would eliminate the distortion while maintaining many of the benefits of price-linked subsidies. Chapter 3 studies demand for annuities – insurance products that protect retirees against outliving their assets. Standard life cycle theory predicts that individuals facing uncertain mortality will annuitize all or most of their retirement wealth. Researchers seeking to explain why retirees rarely purchase annuities have focused on imperfections in commercial annuities – including actuarially unfair pricing, lack of bequest protection, and illiquidity in the case of risky events like medical shocks. I study the annuity choice implicit in the timing of Social Security claiming and show that none of these can explain why most retirees claim benefits as early as possible, effectively choosing the minimum annuity. Most early claimers in the Health and Retirement Study had sufficient liquidity to delay Social Security longer than they actually did and could have increased lifetime consumption by delaying. Because the marginal annuity obtained through delay is better than actuarially fair, standard bequest motives cannot explain the puzzle. Nor can the risk of out-of-pocket nursing home costs, since these are concentrated at older ages past the break-even point for delayed claiming. Social Security claiming patterns, therefore, add to the evidence that behavioral explanations may be needed to explain the annuity puzzle.

Endnote Keywords

early claiming

Short TitleEssays on Health Insurance and Annuities
Citation Key6092