"What was strange about Duggan’s discussion of adverse selection and
moral hazard is that he ignored his own discussion later in the chapter.
On adverse selection, for example, he laid out how asymmetric
information leads to adverse selection, writing:
Insurers cannot perfectly determine whether a potential purchaser is a large or small health risk. (p. 186.)
But then later, in discussing the House and Senate bills, he writes:
These
regulations would correct insurance market failures by preventing
health insurers from responding to adverse selection by raising rates
and denying coverages . . . . (p. 202)
Huh? Just 16
pages after laying out that the adverse selection problem occurs because
insurers can’t adjust rates to risk, he says that these regulations,
which he seems to think are good, will prevent insurers from adjusting rates to risk.
On moral hazard, Duggan writes:
A
second problem with health insurance is moral hazard: the tendency for
some people to use more health care because they are insulated from its
price. When individuals purchase insurance, they no longer pay the full
cost of their medical care. As a result, insurance may induce some
people to consume health care on which they place much less value than
the actual cost of this care or discourage patients and their doctors
from choosing the most efficient treatment. (p. 187)
But in a section titled, “Declining Coverage among Non-Elderly Adults,” Duggan writes:
The
generosity of private health insurance coverage has also been declining
in recent years. For example, from 2006 to 2009, the fraction of
covered workers enrolled in an employer-sponsored plan with a deductible
of $1,000 or greater for single coverage more than doubled, from 10 to
22 percent. The increase in deductibles was also striking among covered
workers with family coverage. For example, during this same three-year
period, the fraction of enrollees in preferred provider organizations
with a deductible of $2,000 or more increased from 8 to 17 percent.
Similar increases in cost-sharing were apparent for visits with primary
care physicians. The fraction of covered workers with a copayment of $25
or more for an office visit with a primary care physician increased
from 12 to 31 percent from 2004 to 2009. (p. 192)
If the goal
is to have people pay more attention to cost when buying health care, a
goal that the vast majority of health economists, whatever their
political stripe would share, this is good news. Yet Duggan seems to
lament it.
Along the way, though, Duggan does give little nuggets
that suggest that health insurance markets work better than he
originally claimed. For instance:
Forty-four states now permit
insurance companies to deny coverage, charge inflated premiums, or
refuse to cover whole categories of illnesses because of preexisting
medical conditions. (p. 188)
“Inflated” in the above quote
simply means high and, given the risk, it makes sense to charge high
rates. Here again Duggan undercuts his own “adverse selection” critique
of insurance markets.
What do the data tell us about insurance
companies rescinding coverage and refusing to pay claims if individuals
fail to list any medical conditions? Here’s what Duggan writes:
A
House committee investigation found that three large insurers rescinded
nearly 20,000 policies over a five-year period, saving these companies
$300 million that would otherwise have been paid out as claims (Waxman
and Barton 2009). (p. 188)
Now, 20,000 sounds like a large
number but remember that these are three large insurers who could
easily, among them, have one million policy holders. 20,000 over five
years is 4,000 a year. So taking the one-million assumption, which I
think is too low, one would conclude that 4/10 of a percent of insured
people every year lost their insurance in this way.
DRH note in 2026:
I probably way underestimated the number of policy holders that the
three large insurers insured. I bet that it was at least 10 million. So
4,000 people per year having their policies rescinded would constitute
1/25 of one percent. Should a huge intervention in the health market be
justified on the basis of a problem for 1/25 of 1 percent of insured
people.
Another nugget is his number on
uncompensated care, which he estimates at $56 billion in 2008. Given
that approximately 255 million had insurance at any given time that
year, this amounts to $220 per insured person. That’s large, but it’s
not huge. The Samaritan’s Dilemma, it appears, is smaller than many have
thought."