بیمه ملی سلامت و صرفه جویی پیشگیرانه: شواهدی از تایوان
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|24322||2003||22 صفحه PDF||سفارش دهید||9115 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Journal of Public Economics, Volume 87, Issues 9–10, September 2003, Pages 1873-1894
By reducing uncertainty about future medical expenses, comprehensive health insurance can reduce households’ precautionary saving. We examine this effect using Taiwan micro-data spanning the 1995 introduction of National Health Insurance. The effects of National Health Insurance are identified using employment-based variation in prior insurance coverage. Replacement of the households’ prior insurance coverage with National Health Insurance is exogenous to the household, so our estimates are not subject to selection bias. Compared with the preceding government insurance programs, National Health Insurance reduced saving by an average of 8.6–13.7% with the largest effects for households with the smallest saving.
The possibility of economic adversity leads households to save more and consume less than they would otherwise. Because health expenditures can be large relative to income, persistent and generally increase with age, they make a significant contribution to a households’ uncertainty about its future economic circumstances.1 The introduction of comprehensive health insurance, by reducing uncertainty about the magnitude of future out-of-pocket health expenditures, can substantially reduce the demand for precautionary saving and so increase current consumption. We investigate this effect by studying the 1995 introduction of National Health Insurance (NHI) in Taiwan. Numerous theoretical studies have examined the precautionary-saving motive when future income or expenses are uncertain (see e.g. Leland, 1968, Sandmo, 1970, Drèze and Modigliani, 1972, Skinner, 1988, Zeldes, 1989a, Zeldes, 1989b, Kimball, 1990, Caballero, 1990, Caballero, 1991 and Deaton, 1991). Most empirical studies have focused on uncertain future income and provide mixed evidence of precautionary saving. There have been few empirical studies testing the impact of social health insurance on saving behavior. We use a natural experiment associated with the creation of NHI to examine the effect of reduction in uncertainty about future medical expenses on household saving and consumption behaviors. Before the implementation of NHI, health insurance in Taiwan had been provided through employment-based government programs.2 A majority of the working population had almost complete coverage under Labor Insurance or Government Employees’ Insurance. Two major differences between these government-sponsored policies enable us to exploit the variation with respect to uncertain health expenditures to identify the effect of NHI on saving. NHI covers workers after retirement and family members. Prior to NHI, only government employees received these benefits. As a result, the introduction of comprehensive coverage under NHI had a smaller effect on government-employed than on other households. We estimate the effect of NHI on precautionary saving using a ‘difference-in-differences’ approach. We compare the change in saving for a treatment group with the change in saving for a control group. The change in saving for the control group accounts for any systematic structural change while the experimental group’s change reflects both the systematic structural change and the impact of the policy intervention. Prior to NHI, a household could obtain health insurance for all household members if either the husband or wife worked in the government sector. Accordingly, we define treatment and control groups based on the husband’s and wife’s joint employment status. Our data are from the Survey of Family Income and Expenditure, a nationally representative survey that collects detailed information on household income and consumption expenditures as well as demographic and employment status for each household member.3 The characteristics of health-insurance programs in Taiwan and these data allow us to improve previous studies in three aspects. First, our estimates are not subject to selection bias, since National Health Insurance covers everyone and was inaugurated by the Taiwan government. Second, NHI is not an asset-based, means-tested program. Thus, the empirical analysis offers a direct test of the impact of NHI on precautionary saving, without an additional negative effect arising from means testing. Third, we are able to exploit variation across different insurance policies before the implementation of NHI to identify the effect of NHI on saving and consumption behaviors. Our empirical results support the premise that the precautionary motive is an important determinant of household saving and consumption behaviors. We find that government provision of universal health insurance can cause a considerable reduction in private saving: Compared with the preceding Labor Insurance, implementation of National Health Insurance lowers average saving by 8.6–13.7% and raises average consumption expenditures by 2.9–3.6%. The effect on saving is strongest for households with the smallest saving, which is consistent with the hypothesis that prudence (the sensitivity of precautionary saving to risk) declines with wealth (Kimball, 1990). The paper proceeds as follows. Section 2 provides some background on health insurance in Taiwan and a brief review of the related literature. Section 3 outlines a theoretical framework. Section 4 presents the data. Section 5 describes the empirical strategy and empirical specification. Section 6 reports the estimation results and Section 7 concludes.
نتیجه گیری انگلیسی
The introduction of social health insurance can substantially reduce uncertainty about out-of-pocket health expenditures, and thus reduce households’ precautionary-saving motive. Examination of the effect of National Health Insurance on Taiwanese households’ saving and consumption behaviors suggests that households significantly reduced their saving and increased their consumption when the comprehensive health insurance became available. These results are robust to a variety of specifications. Contrary to Starr-McCluer’s (1996) finding that health insurance is positively related to wealth, our study offers a more direct test of the impact of health insurance on saving that is not subject to selection bias. By exploiting the fact that government and non-government employed households received different insurance packages before NHI, our approach controls for idiosyncratic shocks and identifies the effects of NHI on households’ saving and consumption. Our empirical results are consistent with recent studies that have found that coverage by other social programs, such as disability insurance (Kantor and Fishback, 1996), unemployment insurance (Engen and Gruber, 2001) and Medicaid (Gruber and Yelowitz, 1999), are negatively associated with saving. Unlike these studies, we examine health insurance, which is more likely to affect precautionary saving throughout the population. We find that NHI has a larger impact on precautionary saving for households at the bottom of the saving distribution than for those at the top. This result supports the assumption of decreasing absolute prudence and is consistent with the theoretical argument of Kimball (1990) and the empirical result of Guiso et al. (1992). It further suggests that NHI yields a larger welfare improvement, through consumption smoothing, for households with smaller saving. Our evidence supports the contention that precautionary motives are an important determinant of saving. This study provides some explanation for two consumption puzzles mentioned by Zeldes (1989b): the excess sensitivity of consumption to anticipated income fluctuations (people ‘save too much’) and the steep consumption path in the presence of a low or negative real interest rate (people ‘consume too little’). Financial risk and the level of health expenditure affect saving and consumption decisions, as suggested by Kotlikoff (1989), Palumbo (1999) and Hubbard et al. (1995). Our findings suggest that the introduction and expansion of social health insurance will contribute significantly to the decline in private saving. Moreover, even if eligibility for the insurance policy is not means tested, it may still have a larger impact on households at the bottom than the top of the saving distribution.