برآورد ارزش گذاری حاشیه ای کارگران از مزایای درمانی کارفرما: آیا کارگران بیمه، بیمه سلامت بیشتر یا دستمزدهای بالاتر را ترجیح می دهند؟

In recent years the cost of health insurance has been increasing much faster than wages. In the face of these rising costs, many employers will have to make difficult decisions about whether to cut back health benefits or to compensate workers with lower wages or lower wage growth. In this paper, we ask the question, “Which do workers value more—one additional dollar's worth of health benefits or one more dollar in their pockets? ” Using a new approach to obtaining estimates of insured workers’ marginal valuation of health benefits this paper estimates how much, on average, employees value the marginal dollar paid by employers for their workers’ health insurance. We find that insured workers value the marginal health premium dollar at significantly less than the marginal wage dollar. However, workers value insurance generosity very highly. The marginal dollar spent on health insurance that adds an additional dollar's worth of observable dimensions of plan generosity, such as lower deductibles or coverage of additional services, is valued at significantly more than one dollar.

Dramatic changes in the U.S. health insurance market over the last two decades have had an enormous impact on our system of employer-provided health insurance. Employers have confronted soaring health insurance costs, a significant increase in the variety of health plans available, and substantial changes to public insurance programs. Of all of these changes, the increases in the cost of health insurance are certainly at or near the top of the list of health insurance worries. The New York Times (August 19, 2004) cites the “relentless rise in the cost of employee health insurance” and quotes experts who blame health insurance cost growth for the lack of job growth (Porter, 2004). In an Issue Brief, the Center for Studying Health System Change highlights employers’ pessimism about acceptable responses to the upward trend in insurance costs: “most employers see no viable alternatives on the horizon” (Regopoulos et al., 2004). Employers and policymakers face some difficult tradeoffs as they seek the optimal response with respect to health insurance offerings in this new health insurance environment, especially given the expectation of continued cost growth substantially greater than inflation. In the face of these rising costs, many employers will have to make difficult decisions about whether to cut back health benefits or to compensate workers with lower wages or lower wage growth. Policymakers may consider options such as mandated employer-provided coverage or minimum coverage levels for those offered insurance. As employers and policymakers confront these difficult choices, they need estimates of how much workers value an additional dollar in health benefits as compared to an additional dollar in wages. Which do workers value more—one additional dollar's worth of health benefits or one additional dollar in their pockets? Using a new approach to obtaining estimates of insured workers’ marginal valuation of health benefits, this paper estimates how much, on average, employees value the dollars employers pay for their workers’ health insurance. However, health insurance premiums vary for a number of reasons, not all of which may be expected to generate value to a worker. Premiums reflect not only the generosity of the coverage but also factors such as administrative costs, competition, and risk selection. There is no reason to expect that workers value premium dollars spent on these other items. In the second part of the paper, we distinguish between worker valuation of premium dollars that reflect insurance generosity and premium dollars that reflect these other factors. We find that insured workers value the marginal health premium dollar at significantly less than the marginal wage dollar. However, workers value insurance generosity very highly. The marginal dollar spent on health insurance that adds an additional dollar's worth of observable dimensions of plan generosity, such as lower deductibles or coverage of additional services, is valued at significantly more than one dollar.

We use worker choices among alternative health plans to identify worker preferences for health benefits versus wage dollars. Results suggest that insured families value health insurance benefits substantially more than singles but that neither group is willing to trade off one dollar of wages for an additional dollar of health insurance, especially once the tax advantage of the health insurance spending is taken into account. Given the structure of premiums, including the pricing of risk, administrative costs, and differences in competition, insured workers would, on average, prefer one more dollar in their pockets than one additional dollar of health insurance benefits. In considering the implications of these results, it is critical, however, to keep in mind that these results do not speak to the value of providing access to group health insurance for those workers not offered employer health insurance. The results are specific to insured workers and the value of increasing health insurance benefits for those insured by employer plans. When we use predicted premium as a measure of health insurance generosity, we find dramatically different results. Workers value an additional dollar of health insurance generosity, as we define it, at significantly more than one dollar. They do value and are willing to pay for additional health insurance if the dollars are spent on increasing observable benefits. Workers do not value residual premium dollars which are not associated with generosity but which may incorporate factors such as administrative costs, competition effects, and the effects of risk selection. It is clear from this evidence that workers respond very differently to premium increases that increase generosity as compared to those that do not and suggests that premium increases that generate value to workers must be evaluated very differently from premium increases that do not. This finding has some important implications for policy analysis. For example, the results confirm the importance of the Chernew et al. (2004) observation that the interpretation of estimated elasticities depends on whether the premiums vary due to “factors that generate value to consumers” or other factors that affect premiums. We must be clear both about whether the estimates were obtained using premium variation that reflects variation in generosity or other factors and whether the situation to which we want to apply the estimates reflects changes in premiums due to changes in generosity or not. Similarly, we must conduct analyses of the welfare implications of rising premiums with the source of those rising premiums in mind. The results also suggest some key points that employers and policymakers working on benefits design should keep in mind. The efficiency and implications of pricing strategies such as defined contributions or consumer-driven care options must be evaluated in light of this evidence that workers value an additional value of health insurance generosity very highly but residual dollars not at all. For example, the effects of making workers more price sensitive through pricing strategies such as defined contributions will depend on whether the premium differences workers face are due to differences in generosity across plans or not.