TY - JOUR
T1 - Distinguishing moral hazard from access for high-cost healthcare under insurance
AU - Robertson, Christopher T.
AU - Yuan, Andy
AU - Zhang, Wendan
AU - Joiner, Keith
N1 - Funding Information:
The authors gratefully acknowledge the funding support from the Center for Management Innovations in Healthcare at the Eller College of Management, from the Rogers College of Law, and from the College of Medicine, all at the University of Arizona. The authors appreciate the research assistance of Ellen Stark. The project benefitted from review of preliminary drafts of the protocol and/or manuscript by John Nyman, Gautam Gowrisankaran, William Sage, Victor Laurion, Jamie Robertson, Jim Greiner, Tara Sklar, Simone Sepe, Anna Rita Bennato, Govind Persad, and anonymous peer reviewers. The project benefitted from feedback at University of Arizona?s QuantLaw and University of Arizona?s Interdisciplinary Experimental Readings Group, University of Minnesota?s Symposium on Drug Prices, the American Association of Law Schools Insurance Law Section, the Philosophy, Politics, and Economics Program at University of Pennsylvania, and the Conference on Empirical Legal Studies. Fig 1 is also forthcoming as part of a book published by Harvard University Press.
PY - 2020/4
Y1 - 2020/4
N2 - Context Health policy has long been preoccupied with the problem that health insurance stimulates spending (“moral hazard”). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States. Methods We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions. Findings Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable. Conclusions For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.
AB - Context Health policy has long been preoccupied with the problem that health insurance stimulates spending (“moral hazard”). However, much health spending is costly healthcare that uninsured individuals could not otherwise access. Field studies comparing those with more or less insurance cannot disaggregate moral hazard versus access. Moreover, studies of patients consuming routine low-dollar healthcare are not informative for the high-dollar healthcare that drives most of aggregate healthcare spending in the United States. Methods We test indemnities as an alternative theory-driven counterfactual. Such conditional cash transfers would maintain an opportunity cost for patients, unlike standard insurance, but also guarantee access to the care. Since indemnities do not exist in U.S. healthcare, we fielded two blinded vignette-based survey experiments with 3,000 respondents, randomized to eight clinical vignettes and three insurance types. Our replication uses a population that is weighted to national demographics on three dimensions. Findings Most or all of the spending due to insurance would occur even under an indemnity. The waste attributable to moral hazard is undetectable. Conclusions For high-cost care, policymakers should be more concerned about the foregone efficient spending for those lacking full insurance, rather than the wasteful spending that occurs with full insurance.
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U2 - 10.1371/journal.pone.0231768
DO - 10.1371/journal.pone.0231768
M3 - Article
C2 - 32302322
AN - SCOPUS:85083499796
VL - 15
JO - PLoS One
JF - PLoS One
SN - 1932-6203
IS - 4
M1 - e0231768
ER -