2015年10月2日星期五

艾米Finkelstein的采访:健康保险,不利选择等等

道格拉斯克莱门特有一个“采访艾米Finkelstein“在2015年9月期刊中该区域,这是由明尼阿波利斯联邦储备出版的。Finkelstein做了许多最突出的工作,看着保险和风险问题:特别是健康保险,也是长期护理保险,年金和其他人。她是一个理论考试器:也是一个经验研究员,致力于对先前接受的潜在理论似乎暗示的内容的敏锐认识。回到2012年,Finkelstein被授予着名的盛名约翰贝茨克拉克奖牌,每年为“美国经济学家根据第四岁的美国经济学家为经济思想和知识作出最大贡献”。在2012年秋季问题的j经济观点(我在田地中劳动为管理编辑器),Jonathan Levin和James Poterba提供Finkelstein早期职业的概述

例如,保险经济学的标准模型表明,谁知道他们更有可能获得保险支付(例如,更有可能生病)更有可能寻求慷慨的保险政策。保险卖方需要注意这种“不利选择”动态,因为它被称为,或者他们最终可以将他们的保险定价好像是普通人,然后以高于预期的支付比预期结束。但证据是否支持这个理论?Finkelstein指出,在许多研究中,那些获得保险的人往往不会最终收到更高的支付。可能的原因是有些人部分是非常安全的风险,因为它们是非常冒险的厌恶,因此他们更有可能购买保险,不太可能使用它。以下是Finkelstein的一些评论:

Suppose you have people—in health insurance we often refer to them as the “worried well”—who are healthy, so a low-risk type for an insurer, but also risk averse: They’re worried that if something happens, they want coverage. ... As a result, people who are low risk, but risk averse, will also demand insurance, just as high-risk people will. And it’s not obvious whether, on net, those with insurance will be higher risk than those without. ... We looked at long-term care insurance—which covers nursing homes—and rates of nursing home use. We found that individuals with long-term care insurance were not more likely to go into a nursing home than those without it, as standard adverse selection theory would predict. In fact, they often looked less likely to go into a nursing home. These results held even after controlling for what the insurance company likely knew about the individual, and priced insurance on. ... [O]our data gave us a way to detect private information: people’s self-reported beliefs about their chance of going into a nursing home. And we showed that people who think they have a higher chance of going into a nursing home are both more likely to buy long-term care insurance and more likely to go into a nursing home. ... That certainly sounds like the standard adverse selection models! ... Then we found some examples in the data that we broadly interpreted as proxies for preferences such as risk aversion, and we found that individuals who report being more likely to, for example, get flu shots, or more likely to wear seatbelts, were both more likely to buy long-term care insurance and less likely to subsequently go into a nursing home.
在另一个突出的工作中。Finkelstein和几位共同作者看着医疗保健成本的地理变异问题 - 即众所周知的事实,即某些城市地区和各国的医疗保健利用和支出比其他人的州更高。他们问这个问题:如果一个人从高利用率,高成本区域迁移到低成本,低利率区域,会发生什么?如果一个人认为,医疗保健决策是由患者期望的混合和当地医疗服务提供者认为是“最佳实践”的策略决定,可能会期望那些搬迁到逐渐趋向于其新地理模式的人的医疗保健地点。但这不是发生的事情。Finkelstein解释:
"We ... look at people who moved geographically across areas with different patterns of health care utilization (i.e., high-utilization versus low-utilization areas) and whether their health care utilization changed. Originally, we were very focused on this issue of habit formation, which would suggest a very specific conceptual model and econometric specification. ... So you would expect, in a model with habit formation, that maybe initially there wouldn’t be much change in your health care utilization. But over time—whether it’s because doctors would be urging you to do less or the people around you were like, “Why go to the doctor when you have a minor pain?”—you would gradually change your behavior toward the new norm.But that’s just not what we see at all. We have about 11 years of data on Medicare beneficiaries and about 500,000 of them who move across geographic areas. When they do, we see a clear, on-impact change: When you move from a high-spending to a low-spending place, or vice versa, you jump about 50 percent of the way to the spending patterns of the new place. But then your behavior doesn’t change any further. ... We estimate that about half of the geographic variation in health care utilization reflects something “fixed” about the patient that stays with them when they move, such as their health or their preferences for medical care. And about half of the geographic variation in health care utilization reflects something about the place, such as the beliefs and styles of the doctors there, or the availability of various medical technologies. This gives you a very different perspective on how to think about the geographic variation in health care spending than the prior conventional wisdom that most of the geographic variation in the health care system was due to the supply side—that is, something about the place rather than the patient.
在过去的几年里,Finkelstein的一些最突出的研究一直是对俄勒冈州的实验产生的数据的分析。回到2008年,俄勒冈州希望将医疗补助范围扩大到低收入人民,这些人不会有资格获得医疗补助。国家意识到它没有足够的钱来为每个人提供扩大的健康保险,所以它持有彩票。从学术研究的角度来看,这一决定是一个梦想成真,因为可以比较两个非常相似的群体的健康和生命结果 - 一个随机选择接受额外的健康保险和一个。Finkelstein和一支共同作者团队正在工作中。Finkelstein描述了他们的一些发现:
对于医疗保健,我们发现医疗补助更多的医疗保健用途:住院,医生访问,处方药和急诊室使用全部增加。一方面,这是经济学101.需求曲线坡度下降:当你制造更便宜的东西时,人们会买更多的东西。通过设计,健康保险的确实是较低的患者的医疗保健价格。......另一方面,有些结果令人惊讶的方式。对于医疗补助,特别是,有很多猜想,虽然一般而言,健康保险将增加医疗保健的使用,因为医疗补助国对提供商的薪酬率如此之低,所提供者不想治疗医疗补助患者。...我们的调查结果拒绝了这个观点。我们发现来自随机评估的令人信服的证据,即相对于没有保险,医疗补助将增加医疗保健的使用。另一个结果让一些发现令人惊讶的是使用急诊室。在政策界中曾担任过医疗问题的政策界可能会让他们走出急诊室......希望ER使用会下降来自博士访问是替代欧尔的替代,所以当医生也是免费的,你去看医生而不是急诊室。也许这就是这种情况(或者也许不是),但在网上,我们的结果表明可能存在的医生的任何替代,这些医生也不会被制作急诊室自由的直接影响。 On net, Medicaid increases use of the emergency room, at least in the first one to two years of coverage we are able to look at.
从该研究中出现了各种其他研究结果,正在进行中。在俄勒冈州的数据中,额外的健康保险减少了家庭的财务风险,也许不巧合,也导致了心理健康状况的改善(通过自我报告的心理健康和抑郁症的比例来衡量)。在物理健康的措施方面,Finkelstein报告,“我们没有发现我们研究的身体健康措施的统计学显着影响:血糖,胆固醇和血压。”

俄勒冈州医疗补助的扩张显然为以前没有保险的至少一些好处。但国家对个人有益于国的成本是多少?Finkelstein和一些共同作者试图模拟保险对接收它的保险。他们发现:
[o]你的中央估计是,每美元的政府支出的医疗补助价值约为20至40美分。......另一个关键发现是名义上“没有保险”并没有真正完全没有保险。我们发现,平均而言,未保险的人只需支付约20美分的美元医疗保健。这有两个重要的含义。首先,这是一大堆直接工作,以降低医疗补助的价值;他们已经有很大的隐性保险。......第二,至关重要的是,没有保险的事实是大量隐性保险也是一股力量,说明医疗补助的许多支出都没有直接向接受者进行;这将是一组人,因为想要一个更好的术语,我们称为“外国方”。他们是在美元支付其他80美分的人。


对于那些喜欢一些额外的Finkelstein的人,我发布了几次俄勒冈研究的结果,你可以在“健康保险的影响:俄勒冈州的随机证据“(2012年8月31日)和”为什么没有保险没有更多的急诊室访问“(2014年1月6日)。Finkelstein还在经济角度杂志上发表了几篇文章,一次就是”美国长期护理保险“(2011年11月22日)和另一个时间在一篇文章中,在2011年冬天的冬天埃基纳夫问题分析了一个“保险市场的选择:图片中的理论和经验。”