اثر حق بیمه در تصمیم گیری برای شرکت در بیمه سلامتی و سایر مزایای جانبی ارائه شده توسط کارفرما: شواهد از یک آزمایش در دنیای واقعی

In this paper, we investigate the effect of the out-of-pocket premium on the decision to enroll in employer health insurance and other benefits plans including dental insurance, vision care, long-term care insurance, and wellness benefits. Previous estimates of the effects of premium on takeup of health insurance could be biased toward zero due to a correlation between premium and unobservable demand or plan quality. We solve this problem using data representing hypothetical choices by employees under three different price regimes, providing price variation uncorrelated with either individual-specific or plan-specific unobservables. We find that workers are insensitive to price in health insurance takeup. Workers show much greater price sensitivity to decisions about dental insurance, vision plans, long-term care insurance, and wellness benefits. We conclude that premium subsidies are unlikely to have a substantial impact on increasing insurance rates of workers already offered employer insurance.

More than 38 million Americans had no health insurance in 2000 according to the U.S. Census Bureau. Concern for the uninsured stems from many sources, ranging from negative health consequences of being uninsured, to the financial impact of lack of insurance, to the strain that uncompensated care due to lack of insurance puts on already burdened publicly-funded health facilities. Despite a growing awareness of the problem over the preceding decade and attention to the matter by policymakers all the way up to the White House, the number of uninsured Americans increased substantially between 1987 and 2000 (U.S. Census Bureau, 2001). In the U.S. most private insurance is employment-based. In 1996, 75% of workers were offered insurance through the workplace but 20% of those eligible for insurance from their employer did not take up that coverage (Cooper and Schone, 1997). Of workers who were uninsured in recent years, approximately 60% worked at firms that did not offer insurance, 20% were not eligible for offered employer insurance, and 20% did not take up the health insurance offered by the employer (2000 data from Cutler, 2002; 1999 data from Garrett et al., 2001). Efforts to increase the number of workers covered by employer-based insurance can therefore be directed in any or all of three ways: policies to increase the number of employers offering insurance, policies to encourage liberalized eligibility at firms already offering insurance, or policies designed to increase the number of eligible workers who take up the coverage offered by their employers. We focus here on the decision to enroll in offered employer health insurance. Not only do a substantial number of workers offered employer insurance decline the coverage, that number has been increasing in recent years (Cooper and Schone, 1997, Farber and Levy, 2000 and Cutler, 2002). The most common policy prescription for increasing takeup when insurance is offered is a premium subsidy. (see, for example, Glied, 2001). The question is whether or not this will work. How much would premium subsidies increase participation in employer health plans that are already being offered? And, more specifically, how large would such subsidies have to be to have a real impact on the number of workers who have no health insurance? The previous work most directly addressing these questions has found very small effects of premiums on takeup. These estimates imply that even subsidies as large as 50% would not induce most workers currently not enrolling in offered insurance to do so (Blumberg et al., 2002, Cutler, 2002 and Chernew et al., 1997). These studies are unable, however, to control completely for the correlation between premium and unobservable demand for insurance or plan quality that could bias the estimates. We estimate the price sensitivity of workers’ takeup decisions using a unique dataset in which the variation in workers’ out-of-pocket premiums is exogenous, allowing us to estimate price effects unbiased by a correlation of premium and unobservable demand or unobservable plan quality. The data represent hypothetical choices of whether or not to participate in fringe benefits such as employer-sponsored health insurance by employees at a single firm. The data were collected in an effort to revise the firm's benefits offerings to reflect more closely employee preferences. The same employees made choices from the same (quality-constant) menu of alternatives under three different price regimes, providing price variation uncorrelated with either individual-specific or plan-specific unobservables that could affect the takeup decision. We use these data to produce unbiased price elasticities. We are also able to estimate the effect of out-of-pocket prices on workers’ decisions to take up other offered employee benefits such as dental insurance, vision benefits, long-term care insurance, and wellness benefits. Our estimates are the first evidence on the price sensitivity of workers with respect to some of these other fringe benefits and, as such, should be of interest in understanding cafeteria-type benefit plans as well as fringe benefits more generally. We find that workers are much more price sensitive to the out-of-pocket premium for fringe benefits other than health insurance than they are to health insurance. In fact, the price elasticity of the takeup of health insurance is essentially zero in all of our models, providing support for previous work that has found very small effects. However, workers are clearly sensitive to the price they pay for other fringe benefits. Those negative and significant effects are quite robust to a variety of model specifications. The robust negative effects of price on the takeup of other benefits also helps to validate the survey procedure and thereby to lend support to our zero finding for the elasticity of health insurance.

Our findings from these unique data complement and confirm previous studies. We find, consistent with previous results, very small elasticities of takeup of health insurance with respect to the out-of-pocket premium. Most other analyses have suffered, however, from a possible bias due to price endogeneity that could cause workers to appear less price sensitive than they really are. We use data with exogenous price variation – prices are uncorrelated with worker demand and plan quality by construction – and still produce very low premium elasticities. We conclude that previous results are not merely a result of biases induced by price endogeneity but that employees who are already offered health insurance are, in fact, very insensitive to price in the takeup decision. The small price effects we find here are also consistent with previous work on the effect of subsidies to small employers not currently offering insurance. Thorpe et al. (1992) examine the effect of an experiment by New York state to provide 50% subsidies to small employers not currently offering health insurance to their employees. They find that these large subsidies did not induce a large proportion of eligible firms to begin offering insurance. We conclude that efforts to reduce the number of the uninsured via the employer-based system of health insurance will have to approach the problem broadly and creatively since it appears that a simple focus on health insurance subsidies will not provide the coveted silver bullet. Specifically, our work suggests that subsidies to employees in the range under consideration are unlikely to increase substantially the number of workers that voluntarily take up already offered employer coverage. Employers and policymakers should not, however, assume that the price insensitivity of workers in health insurance takeup should be extrapolated to takeup decisions of other fringe benefits. We find evidence that workers are much more price sensitive in decisions to enroll in dental insurance, vision coverage, long-term care insurance, and wellness benefits.