Health Insurance Theory: The Case of the Missing Welfare Gain. John A. Nyman University of Minnesota

Transcription

1 Health Insurance Theory: The Case of the Missing Welfare Gain John A. Nyman University of Minnesota February 11, 2005

2 Abstract An important source of value is missing from the conventional welfare analysis of moral hazard, namely, the effect of income transfers (from those who purchase insurance and remain healthy to those who become ill) on purchases of medical care. Income transfers are contained within the price reduction that is associated with standard health insurance. However, in contrast to the income effects contained within an exogenous price decrease, these income transfers act to shift out the demand for medical care. As a result, the consumer s willingness to pay for medical care increases and the resulting additional consumption is welfare increasing.

3 1. Introduction Consider Elizabeth. This year, Elizabeth becomes one of the 12 percent of women in the U.S. who is diagnosed with breast cancer sometime during their lifetime (American Cancer Society, 2003). Without health insurance, Elizabeth would purchase a $20,000 mastectomy, including chemotherapy, which is the care that she needs to rid her body of the cancer. Because a mastectomy is a disfiguring procedure, she would consider also purchasing a breast reconstruction procedure for an additional $20,000. Without insurance, however, she would choose not to do so because, even though she could raise the funds privately, the competing claims on her income and resources make this additional procedure too expensive. Fortunately, Elizabeth had purchased a contingent-claims insurance policy this year for $3,000 that paid her a cashier s check for $40,000 when she was diagnosed with breast cancer (an amount equal to the cost of the two $20,000 procedures). With the extra ($40,000 - $3,000 =) $37,000 in income, Elizabeth now chooses to purchase the additional $20,000 breast reconstruction. She is happy with her purchase because, although she could have spent the extra income on anything of her choosing, she obtained the highest utility by purchasing the additional medical care. The standard translation of a scenario like this into economic theory is that the demand for medical care has shifted out because of the increased income. As illustrated in Figure 1, without insurance, the ill consumer s demand curve is D u and she consumes M u of medical care because at M u, her willingness to pay equals the price, P. With the additional income from insurance, demand shifts out to D i and she consumes M i. Because the price of medical care is 1

4 assumed to be constant and equal the marginal cost of care, the consumer experiences a welfare gain from the additional medical care, that is, from the moral hazard. The moral hazard welfare gain is equal to the difference between the amount the insured consumer is now willingness to pay and what she must pay for the additional medical care, (M i - M u ), or area abc. And, because her income has increased, she is now willing to pay more for the original care as well. Area decb represents the entire welfare gain that is generated by the income transfer. Now, consider what would have happened if the private market only offered insurance that paid off by covering the cost of the medical care that Elizabeth chose to purchase. That is, what if the payments were made to the providers of the mastectomy, chemotherapy, and reconstruction surgery, instead of to Elizabeth? Furthermore, to hold things constant and provide the starkest contrast, what if Elizabeth s premium remained $3,000 and her voluntary behavior with this policy was the same as her behavior under the contingent-claims policy, and $40,000 in checks were simply written to the providers in payment for the same two $20,000 procedures? The conventional translation of this payoff mechanism and behavior is that it represents a reduction to zero of the price that the consumer faces for medical care and a movement along the pre-insurance Marshallian demand curve (Pauly, 1968; Feldstein, 1973). On Figure 1, the consumer again decides to purchase M i as a result of a movement along her original uninsured demand curve, D u, in response to the price decrease. By this simple change in the payoff mechanism, the original welfare gain from insurance vanishes and is replaced by a moral hazard welfare loss equal to area bcm i. This seeming loss is generated because the value of the additional care, area bm i M u, is assumed to be less than the cost of the additional care, area 2

5 bcm i M u, by area bcm i. This analysis and diagram appear in all health economics texts and teach that moral hazard unambiguously decreases welfare. Yet, the consumer s behavior has not changed at all. Returning to the specific case of Elizabeth, she would voluntarily pay the same $3,000 premium for both insurance contracts, she would receive the same $40,000 payoff if she became ill, and she would consume the same $20,000 worth of additional care, that is, she would exhibit the same moral hazard. Most importantly, she would be equally happy with her purchases under either insurance contract because they generate the same level of utility. Yet, under the economic analysis of the contingent-claims insurance, the consumer experiences a welfare gain, but under the conventional analysis of standard or price-payoff insurance, 1 the consumer experiences a welfare loss. That so much value can be lost simply by writing the check to the provider, instead of to the beneficiary, does not make sense. This implies a fundamental flaw in conventional insurance theory. 1 The term price-payoff refers to the standard insurance contract where the insurer pays for a portion of the insured patient s health care spending. The term is used to emphasize that even though the price of medical care has fallen for all insured consumers, it is primarily those consumers who become ill that benefit from this price reduction. For example, few healthy consumers would purchase a breast reconstruction procedure, coronary artery bypass graft procedure, or a liver transplant just because the price has fallen to zero. Thus, the price reduction is the vehicle by which the insurance payoff occurs. 3

6 This paper presents a new analysis of the welfare gain from moral hazard that is generated by price-payoff health insurance. 2 It makes the claim that, in contrast to the income effects generated by an exogenous price decrease, the income transfer effects generated by standard price-payoff insurance act to shift out the Marshallian demand for medical care. Thus, the moral hazard that is generated by insurance income effects is efficient and welfare increasing. While many studies of health insurance seek to determine optimal coinsurance rates, this analysis simply seeks to present the standard analysis of the decision to purchase health insurance at a given coinsurance rate. Modest as this goal might seem, the widespread acceptance of the conventional analysis creates an environment where any new analysis is fraught with opportunities for misinterpretation. Thus, adding an optimal insurance layer would simply increase these opportunities and complicate the analysis unnecessarily. In addition, the present approach is also more in keeping with the choice that consumers actually have. The analysis is based on the same underlying model that was used in Nyman (1999b, 2003) and Nyman and Maude-Griffin (2001) to show that the welfare loss from moral hazard is smaller than is assumed in the conventional model, 3 but proceeds beyond that analysis to develop the theory that a welfare gain exists within standard price-payoff moral hazard, and that this welfare gain is similar to the ex post welfare gain that would be generated by a contingent 2 Some have objected to the characterization of this theory as new, arguing that it has appeared already elsewhere. None of these critics, however, has been able to identify a specific previous citation. 3 These works also show that the decomposition required to determine the insurance welfare loss is different from the standard Hicksian decomposition of an exogenous price change. 4

7 claims policy with the same fair premium, payoff, and income transfer. It then shows how the welfare gain from price-payoff insurance is expressed in a price-quantity diagram that facilitates comparison with the famous diagram of the moral hazard welfare loss that was proposed by Pauly (1968) and Feldstein (1973), and that appears in every health economics textbook. In the next section, the basic mathematical model of the ex post consumption decision is presented, along with its translation into standard indifference curve and demand curve analyses for a series of four cases, distinguished by the nature of the preferences. This section is intended to show how different diseases and treatments would generate different consumer preferences, and how these preferences would in turn generate different welfare implications for health insurance. It is also intended to show how the conventional movement-along analysis is only a special case of this more general model. In the third section, this ex post consumption decision analysis is inserted into an expected utility model of the ex ante decision of whether or not to purchase a given price-payoff insurance contract. The ex ante decision is specified in its simplest form as a quid pro quo transaction: the consumer pays an actuarially fair premium if healthy in exchange for a transfer of income if ill, the transfer determined jointly by the coinsurance rate specified in the contract and the probability of becoming ill. This income transfer is accomplished through the price reduction described in the previous section. The paper concludes by suggesting the new theory s implications for public policy. It argues that the conventional analysis is responsible for a number of counterproductive policies. When the welfare gain from moral hazard is recognized and replaces that portion of moral hazard that was incorrectly deemed to generate welfare losses, the value of health insurance 5

8 increases dramatically. This reevaluation would lead to changes in prescriptions of the ideal price-payoff insurance contract and cost containment policies, and represents a strong justification for government intervention in the health insurance market. 6

9 2. The Ex Post Consumption Decision Basic model. This section describes the representative insured consumer s ex post consumption decision, that is, the decision that is conditional on illness having occurred. The ill consumer derives utility from consumption of medical care, M, and other goods and services, Y. For simplicity, assume that Y is the numeraire, denominated in dollars, and that the competitive market price of a unit of M is $1, its marginal cost. A single insurance contract is available that pays off by reducing the price of medical treatments for a specific disease from 1 to c, 0 c < 1, and every consumer who purchases insurance has the same probability, π, of becoming ill during the contract period. All these consumers have the same preferences and endowment, Y o. Without health insurance, the ill consumer faces the problem, max U s (M,Y) (1) s.t. Y o = M + Y, (2) where U s indicates utility when ill. The consumer solves this problem by consuming bundle (M u, Y u ), consistent with the first order conditions, U s M/U s Y = -1 and (3) Y o - M - Y = 0. (4) After substituting the optimal consumption into equation (2), the consumer s realized budget is Y o = M u + Y u. (5) If the consumer had purchased the price-payoff insurance that reduces the price from 1 to c, such that 0 c < 1, the consumer would solve, max U s (M,Y) (6) 7

10 s.t. Y o - R = cm + Y, (7) where R is the fair insurance premium, taken as a given. The consumer maximizes utility at (M ppi, Y ppi ) consistent with the first order conditions, U s M/U s Y = -c and (8) Y o - R - cm - Y = 0. (9) Before setting R, the insurer conducts an actuarial study to determine demand for medical care, M ppi, given R, c, and Y o, and sets the fair premium at R = π(1-c)m ppi. Substituting this back into equation (7) yields a realized budget of Y o - π(1-c)m ppi = cm ppi + Y ppi. (10) Adding (1-c)M ppi to both sides of equation (10) and rearranging terms shows that the consumer s budget constraint with price-payoff insurance is Y o + (1-π)(1-c)M ppi = M ppi + Y ppi, (11) where (1-π)(1-c)M ppi are transfers of income from those (1-π)/π consumers who purchase insurance but remain healthy. A comparison of equations (11) and (5) shows the effect of becoming insured on the income of the ill consumer. Without insurance, spending (M u + Y u ) by the ill consumer is constrained by Y o, her endowed income. With insurance, her spending (M ppi + Y ppi ) is constrained by Y o + (1-π)(1-c)M ppi, that is, by endowed income plus the income transfers from the healthy. These transfers exist because not all consumers become ill during the contract period. Equation (11) also shows that if everyone became ill during the contract period (that is, if π=1) and the insurer charged the fair premium, a reduction in the price of medical care from 1 to 8

11 c would generate no income transfers at all because each consumer would bear the entire cost of the insurer s payoff as part of her insurance premium. Thus, despite the price decrease, the consumer would be constrained to consume within her original budget constraint and endowed income, Y o. If the consumer had purchased a contingent-claims contract that cost the exact same premium, R, [that is, R = π(1-c)m ppi, with R is taken as a given] as under the price-payoff policy, and paid off with the same expenditure, only this time as a lump sum income payoff, I, [that is, I = (1-c)M ppi ] the consumer would face the problem, max U s (M,Y) (12) s.t. Y o - R + I = M + Y, (13) and solve it at (M cci, Y cci ), consistent with first order conditions, U s M/U s Y = -1 and (14) Y o - R + I - M - Y = 0. (15) Because the premiums and the payoffs are the same as under the price-payoff contract, the income transfers are also the same. That is, equation (13) can be written Y o - π(1-c)m ppi + (1-c)M ppi = M cci + Y cci, or (16) Y o + (1-π)(1-c)M ppi = M cci + Y cci, (17) and the left hand side, representing available income, is identical to the left hand side of equation (11). If the endowments, premiums, payoffs, and income transfers for these two types of contracts are the same, then whether M cci equals M ppi depends on the nature of preferences alone. Preferences for medical care. How to represent consumer preferences for medical care presents a challenge. In the introductory scenario, Elizabeth responds to the price reduction in 9

12 the exact same way that she responds to the income transfer. Thus, her preferences must reflect the fact that no substitution occurs at the margin (between medical care and other goods and services) when the price of medical care drops to zero. A lack of substitutability is typically modeled by assuming a utility function that generates angular indifference curves, reflecting the idea that, while still nominally convex, the level of convexity does not result in a noticeable change in behavior as relative prices change. This appears to be a reasonable assumption for many illnesses, especially those illnesses that require major medical procedures like mastectomies, breast reconstructions, coronary bypass operations, organ transplants, in short, those procedures that comprise the bulk of health care spending in the U.S. Angular preferences reflect the lumpiness of these procedures. For example, the patient in need of a coronary bypass procedure is willing to give up a very large amount of other goods and services in exchange for one medical procedure, but willing to give up very little for a second procedure if the first is successful. Moreover, the ill consumer often does not know enough to evaluate each component of the procedure to determine whether it is worth the value of other goods and services forgone to obtain it. As a result, for many expensive medical procedures, little substitution would occur at the margin as prices changed. Even though many, perhaps most, of the more expensive components of major medical procedures are not subject to consumer discretion at the margin, there may be some components for which the consumer is price-responsive. For example, the consumer who pays for care out of her income plus a lump sum insurance payoff may not choose to purchase any extra days in the hospital, while the consumer who faces a zero price may purchase an extra day or two. The physician, however, may act to limit this substitutability. That is, she may permit some 10

13 additional hospital days, but would probably limit the stay of the rare patient who simply likes the comfort and lifestyle associated with living in the hospital. This preference-constraining function of the physician is not unusual. The physician often acts to limit medical expenditures to those that can be justified medically and, in that way, to limit the substitutability of medical care for other goods and services. For example, the physician limits hospital admissions to those who are ill, so that people who travel cannot stay in a hospital instead of a hotel. Or, the physician limits the use of steroids to those who have legitimate medical needs, and does not permit body-builders to obtain them under insurance coverage. Thus, the physician often acts to constrain the preferences of the insured consumer, essentially reducing substitutability and making their indifference curves more angular. Most importantly, there is a self-limiting aspect to much of medical care. That is, because most medical procedures are associated with pain, time and travel costs, or risk of mortality or morbidity, they are not desired by those who are healthy. For example, a cancer patient would not want to undergo another chemotherapy session unnecessarily because of the pain and quality of life reductions associated with this form of medical care. If the additional chemotherapy is painful and has no medical value, the indifference curve for the consumption of additional chemotherapy would need to be upward sloping, indicating that the consumer would need to be paid in other goods and services to endure more of this treatment. Indifference curves that are u-shaped, perhaps approaching a v-shape, would describe the preferences for this medical care. A v-shaped curve would indicate that the consumer has a high willingness to pay for a certain effective level of medical care, but additional care that is medically unnecessary would be so painful that additional payments of other goods and services would be required to 11

14 keep the consumer at the same utility level. Indifference curves that approach a v-shape would also imply that the consumer is largely unresponsive to differences in relative prices, holding utility constant. In general, preferences will vary according to the illnesses and the medical procedures associated with the illnesses. Therefore, it would be impossible to specify a general utility function that would be applicable to all medical care, and that could in turn be used to calculate a generally applicable optimal coinsurance rate, as some have attempted (e.g., Feldstein, 1973; Manning and Marquis, 1996). Instead, for each illness, a consumer would have a unique set of preferences for medical care, based on the degree of substitutability between medical care and other goods and services, filtered through and at times constrained by the physician, who functions mainly, but not entirely, as the knowledgeable agent of the consumer. 4 In the next sections, it is shown how the welfare implications of moral hazard vary according to this substitutability and how these different cases would be represented in price-quantity space. Case 1: Negligible substitutability. The indifference curves in Figure 2 are based on the assumption that the degree of substitutability of medical care for other goods and services is negligible. If so, then it does not matter to the consumer whether the health insurance contract pays off by writing a cashier s check to the consumer for a lump sum amount I, equal to (1-4 It is well known that the agency function of the physician may also create a response to insurance on behalf of the interests of either the patient or the physician. Suffice it to say that the behavior of the physician-patient decision unit can reflect any of the responses to the price reduction and income transfers discussed in this paper. 12

15 c)m ppi dollars, or whether the contract pays off by reducing the price of medical care to c, so that the insurer spends (1-c)M ppi worth of the pooled premiums in purchasing the same procedures on the consumer s behalf. In either case, the consumer receives an income transfer equal to the payoff minus the premium, or (1-π)(1-c)M ppi dollars, and in either case, the consumer s ex post consumption bundle is exactly the same. Most importantly, the two contracts generate the same increase in utility, from U s u to U s i, so that the consumer is equally well-off. Because this consumer lacks the desire (or ability) to substitute medical care for other goods and services at the margin (but is responsive to income transfers), the demand curve diagrams for these two contracts must show the same welfare gain. This behavior would correctly be represented by points in price-quantity space (specifically, a shift from point A to points B and C in Figure 3a), but this is not entirely satisfactory because the intent of this analysis is to produce price-quantity diagrams that are comparable to those used by Pauly (1968) and Feldstein (1973). Thus, Figure 3a shows the stylized response to the income transfer under the contingent claims contract: additional medical care is demanded at every price. The consumer purchases M u without insurance and M cci with insurance, because of the transfer of (I - R) = (1-π)(1-c)M ppi worth of income to the ill consumer. The consumer experiences a welfare gain from moral hazard equal to ABC. Similarly, Figure 3b shows the response to the income transfer that is contained in the price-payoff contract. Because the ill consumer must pay only cm u for care that, if uninsured, would have cost her M u, her residual income after consuming M u of care has increased by (1- c)m u with this insurance (assuming the effect of the premium payment is negligible). Therefore, her willingness to pay for the original M u units of care has increased, as has her willingness to 13

16 pay for the next (M ppi - M u ) units of medical care. Once the effect of the income transfers has been accounted for, the consumer s demand curve is drawn so that reductions in price from the market price (or more precisely, the percentage decrease in the original price due to c, where c can only represent a price decrease) do not generate any substitution of medical care for other goods and services. Because M ppi and M cci are the same, moral hazard is also the same under both contracts, and the consumer experiences the same welfare gain from both, area ABC. That is, in both cases, the willingness to pay for the additional care, after the effect of the income transfer is accounted for, exceeds the cost of producing the additional care. 5 This analysis suggests that an income transfer is contained within the price reduction 5 Note that the consumer is also consuming the same amount of other goods and services, Y cci = Y ppi, with either insurance contract. With the contingent-claims contract, the consumer spends M cci = M ppi on medical care with Y o + (1 - π)(1 - c)m ppi in income, so that, Y cci = Y o + (1 - π)(1 - c)m ppi - M ppi. (18) Similarly, with the price-payoff contract, the consumer spends cm ppi of her endowed income, Y o, after she has purchased insurance for a premium of π(1 - c)m ppi, so has Y ppi = Y o - π(1 - c)m ppi - cm ppi. (19) Simultaneously adding and subtracting (1 - c)m ppi from the right-hand-side of equation (19) yields Y ppi = Y o + (1 - π)(1 - c)m ppi - M ppi, (20) which is identical to the right-hand-side of equation (18). Thus, the entire consumption bundle is the same under both insurance contracts, with these preferences. 14

17 mechanism of standard price-payoff insurance, the size of which depends on both the coinsurance rate and the probability of illness. This income transfer generates the same type of increase in medical care consumption that is, moral hazard and same welfare gain that would be generated by an income transfer from a similar contingent claims policy. If the consumer s preferences exhibit a negligible level of substitutability between medical care and other goods and services, holding utility constant, then the ex post moral hazard welfare gains from the two types of contracts would be identical, as the demand diagrams indicate. Unaffordable care. One sub-case that merits special attention is that of the consumer who becomes ill and does not have sufficient resources to purchase the current treatment of choice (Nyman, 1999a). For example, the current treatment of choice for many liver failure cases is a liver transplant, currently costing about $300,000. A consumer without insurance and only $100,000 in liquid assets would need to either save or borrow the difference. Because of the urgency of the need for treatment, saving $200,000 is often not feasible, and few lending institutions would be willing to make an uncollateralized $200,000 loan for this risky procedure. Thus, without insurance (and without charity or government safety nets) the consumer would not be able to purchase the liver transplant and, perhaps, receive only palliative care for the short period before death. With insurance, however, the consumer can take advantage of the approximately 1/75,000 probability of receiving a liver transplant in a given year to purchase insurance coverage for an actuarially fair premium of ($300,000/75,000 =) $4. Regardless of whether the insurer pays off by writing a check for $300,000 to the beneficiary, or the same amount to the surgeon and hospital, there is still a transfer of ($300,000 - $4 =) $299,996 in income from those 74,999 who purchase this coverage and remain healthy to the 1 (in 75,000) 15

18 who becomes ill. With this additional income, the consumer gains access to a liver transplant procedure under either type of policy and experiences the same increase in utility. This case is illustrated in Figure 4, which again assumes negligible substitutability, consistent with the stylized preferences for major procedures. Figure 4 shows the gain from moral hazard when the consumer faces a binding liquidity constraint in purchasing M i, compared with purchasing M u, the often palliative care that is affordable without insurance. In this case, (M i - M u ) again represents moral hazard and the demand analysis would correspond to Figures 3a and 3b, except that the welfare gain would be larger. This type of moral hazard is important because such procedures often save lives or substantially reduce morbidity, and as a consequence, they often represent procedures that are very valuable to consumers. Thus, for society, this moral hazard may have a large welfare impact through its effect on health (see Franks, Clancy and Gold, 1993; Currie and Gruber, 1996; Hanratty, 1996; and Lichtenberg, 2001). This moral hazard is also important because it represents a large portion of total health care spending. It is estimated that well over 30 percent of the health insurance premium of the typical purchaser of insurance in the U.S. is devoted to paying for care that is beyond that consumer s liquidity constraint (Nyman, 1999a). Case 2: Limited substitutability. For some diseases and treatments, consumers may exhibit utility functions that reflect a limited level of substitutability between medical care and other goods and services. For example, in the introductory example of the breast cancer, a different consumer (not Elizabeth) may exhibit some willingness to trade off other goods and services for medical care. That is, with a price-payoff policy, she might spend an extra night in the hospital, compared to her hospital stay under a comparable contingent-claims policy. 16

19 Figure 5 illustrates this case. Without insurance, the ill consumer purchases (M u, Y u ). With price-payoff insurance that pays off by reducing the proportion of the price paid from 1 to c, she purchases (M ppi, Y ppi ). Again the ill consumer is assumed to have paid a fair premium equal to π(1-c)m ppi dollars and to receive a payoff equal to (1-c)M ppi dollars spent on medical care by the insurer on her behalf, implying a net income transfer of (1-π)(1-c)M ppi, financed by those who remain healthy. If the consumer had instead purchased a contingent-claims insurance contract for the same fair premium, payoff level, and income transfer, only in this case, the payoff were made as a lump sum income payment, the consumer would consume at (M cci, Y cci ). In both cases, the consumer is paying the same fair premium for the same income transfer from the insurer, thus holding constant the exchange that represents the insurance contract. The contradictory welfare implications of moral hazard are perhaps more clearly illustrated by these preferences. The income transfer within both these types of insurance contracts generates an increase in consumption of medical care from M u to M cci. This increase in medical care, along with the increased consumption of other goods and services (from Y u to Y cci ), increases utility from U s u to U s cci. For the price-payoff contract, by having the same the premium, payoff, and income transfer as the contingent claims contract, but by paying off the contract with a price reduction to c, some additional medical care would be purchased: (M ppi - M cci ). This is because, with a price-payoff contract, this consumer s preferences are responsive to differences in relative prices. These additional purchases of medical care actually cost society (Y cci - Y ppi ) to produce, but because the willingness to pay is less than the resource cost for each of these additional units of medical care, their purchase would reduce the gain in utility from 17

20 (U s cci - U s u) to (U s ppi - U s u). 6 Figure 6a shows the corresponding demand curve analysis for the contingent-claims case, indicating that the insurance payoff generates a welfare gain from moral hazard equal to area ABC. This reflects the fact that the consumer s willingness-to-pay has increased with the additional income. For example, returning to Figure 5, the willingness to pay for unit M u of medical care without the income transfer from insurance is represented by the slope of the difference curve at point a. With the income transfer from insurance, the willingness to pay for M u has increased because the slope of the consumer s indifference curve at point b is greater, owing to the assumed (quasi-)convexity of preferences. Returning to price-quantity space (Figure 6a), this translates into a shifting out of the demand curve so that with insurance, 6 The income-transfer and pure-price effects of an insurance price reduction differ from the Hicksian income and substitution effects that are used to decompose an exogenous price decrease. In Nyman (1999c), although the new decomposition was presented in the paper that was originally submitted, the editors would permit publication only of a diagram representing the Hicksian decomposition. The suppression of my model has generated misunderstanding because it appears as if the insurance price decomposition is the same as that of an exogenous price decrease. With insurance, however, the price reduction requires an increasingly larger premium payment to obtain each lower coinsurance rate, and this has an increasingly larger effect on the quantity demanded. This produces a different decomposition than that of a exogenous price reduction where no payment is required to obtain a lower price (see Nyman, 1999b, 2003). Although they are both price reductions, they have different origins. 18

21 willingness to pay exceeds the price by some margin at M u. Indeed, with the additional income, willingness to pay exceeds the price for all medical care purchased up to unit M cci. Figure 6b shows the corresponding ex post demand curve diagram for price-payoff insurance, assuming that c = 0, compared with uninsured demand. The same increase in willingness to pay (as illustrated in Figure 5) occurs with price-payoff insurance between M u and M cci, and represents the welfare gain from purchasing additional health care with the additional income that is transferred from the healthy (Misham, 1981). The moral hazard that is generated by the income transfers in the price-payoff contract is exactly equal to the moral hazard that would occur with a contingent claims contract that transferred the same amount of income. This portion of moral hazard produces the same welfare gain, equal to area ABC. In addition, however, using a percentage, c, of the original price to pay off the contract generates additional moral hazard because of the consumer s willingness to substitute some medical care for other goods and services at the lower effective insurance price. The portion of moral hazard attributed to the pure price effect is (M ppi - M cci ), and the welfare loss is the difference between the marginal cost of producing this additional care and the willingness to pay for this care if the ill consumer must pay for any price reductions herself (for a formal derivation of this portion of the demand function, see Nyman, 1999b, 2003; Nyman and Maude-Griffin, 2001). The cost of this portion of moral hazard is area CFM ppi M cci in Figure 6b, the willingness to pay for this care is area CM ppi M cci, and the welfare loss is equal to area CFM ppi. The net moral hazard welfare effect is the gain, area ABC, minus the loss, area CFM ppi. As drawn, the gain exceeds the loss and this moral hazard is on net welfare increasing. To find the total utility gain from medical care purchased with insurance, the gain in willingness to pay for the original 19

22 uninsured M u must also be added. 7 Case 3: Total substitutability. Some health states may be such that the entire moral hazard is due to the willingness to substitute medical care for other goods and services, and nothing is due to income transfers. Cosmetic surgery, drugs to enhance sexual performance, and designer prescription sunglasses may represent this case. This case is illustrated in Figure 7. The consumer purchases (M u, Y u ) without insurance, and with price payoff insurance, purchases (M ppi, Y ppi ). With a contingent claims policy that contains the same income transfer, the consumer would consume at (M cci, Y cci ) such that M cci = M u. All the moral hazard would be due to the willingness to substitute medical care for other goods and services at the margin. 7 Some economists have claimed that only the pure-price portion is moral hazard, while the income-related portion is something else (Cutler and Zeckhauser, 2000). The term moral hazard, however, is not the province of economists. It is a term that was originally coined by insurers to refer to changes in the behavior of the purchasers of insurance as a result of becoming insured. Insurance companies generally considered moral hazard a problem because it often resulted in payoffs that were larger than expected when setting premiums, hence the pejorative name. Economists can legitimately analyze, categorize, and evaluate the behavior known as moral hazard, but because moral hazard has currency and meaning that is independent of its welfare consequences in economics, we should probably not try to redefine it. 20

23 Figure 8a shows the demand curve diagram for the contingent-claims case. Even though income has increased, demand with insurance does not respond to it, and there is no ex post moral hazard welfare gain due to income transfers. Figure 8b shows the demand curve diagram for the price-payoff insurance compared with the Marshallian demand, representing the observed relationship between the exogenously determined market price and quantity. These demand curves are drawn to diverge, so that at P=0, the quantity of medical care demanded with an exogenous decrease to 0, M P=0, exceeds the quantity demanded if the consumer were required to pay a premium out of endowed income to purchase a policy that reduced the price of medical care to 0 in the event of illness. That is, while the indifference curve analysis in Figure 7 shows no income effect at P=1, it is possible that at lower prices, income effects may occur. As the coinsurance rate, c, is reduced toward 0, the insurer must charge a larger premium, and income available to purchase medical care if ill diminishes, so Figure 8b is drawn to show that at these lower price levels, an income effect may exist. 8 If no income effect exists throughout the entire range, then the Marshallian demand and the insured demand coincide. This is the case represented by conventional theory (Pauly, 1968; Feldstein, 1973): the entire moral hazard from the observed demand generates a welfare loss. Case 4: Price-reductions with no income payoffs. While the total substitutability case assumes that no income transfer effect occurs because of the nature of preferences, a final case 8 For example, while the indirect costs of medical care (that is, the transportation and time costs) may not enter the decision when M u is purchased, they may have a greater influence on consumption as the price of medical care itself is reduced. 21

24 assumes that no income transfer effect occurs because there is no income transfer. That is, what if insurance were purchased for coverage of services, such as, annual checkups, annual screening, flu and other vaccinations, that were purchased annually by virtually everyone who is insured? If so, the probability of such expenditure would approach 1, and there would be no income transfer from insurance because the insurer s cost is paid for entirely in each consumer s premium. Thus, the insurance payoff simply cancels the fair premium payment, and the consumer s income and spending remains constant at the original level, Y o. Figure 9 shows the indifference curve analysis of this case, assuming preferences that reflect limited substitutability like those in Figure 5. With contingent-claims insurance, no shifting of the budget constraint occurs in the contract period because the income payoff equals the insurance premium. With price-payoff insurance, the consumer is constrained to simply purchase a lower price for medical care. The new optimum would occur at the intersection of the original budget constraint (reflecting no income transfers) and the consumer s income expansion path for P=c. Thus, depending on preferences, price-payoff insurance would either leave the consumer on her original indifference curve, or on a lower one, unambiguously reducing welfare. Figure 10a shows that with contingent-claims insurance, the demand for medical care would stay constant without an income transfer. Figure 10b shows that if the consumer alone must pay for the additional care received in response to the price change, price payoff insurance could only represent a welfare loss. Figure 10b also illustrates that the response to the price reduction in price-payoff insurance is different than the response to an exogenous reduction in the market price of medical care. This comparison shows that, if the consumer must pay the entire cost of the price 22

25 reduction, the consumer s behavior would exhibit a smaller moral hazard effect than conventional theory would lead one to believe, and result in a smaller welfare loss (area BFM ppi ). This case is shown to make the point that an insurance price decrease, without any income transfers, would reduce welfare. Thus, it suggests that the income transfer is central to understanding the demand for health insurance. This is important because conventional theory has often assumed that the effect of the premium on demand was small enough to be negligible, that we could ignore the effect of the premium on demand, and that the Marshallian demand curve would reflect behavior if insured (Pauly, 1968). This analysis shows that the premium is only one side of the relationship. The more important side is the income transfer. This transfer must be explicitly accounted for in order to understand the welfare implications insurance. If this income transfer does not exist, then there is no gain from purchasing insurance that pays off by reducing price. In summary, conventional insurance theory suggests that all moral hazard generates a welfare loss, and that the magnitude of this loss can be represented by Marshallian demand (Pauly, 1968; Feldstein, 1973). The theory presented here suggests that the conventional analysis of the moral hazard welfare loss is a special case of a more general response. Most of moral hazard either generates a welfare gain in its entirety or a combination of a gain and loss, and the magnitude of these losses is smaller than the loss that would be calculated from a Marshallian demand curve. Thus, conventional theory has not only overstated the welfare loss, but also understated the welfare gain from health insurance. 9 9 It should be noted that this analysis suggests that consumers are better off with contingent claims insurance than price payoff insurance, ceteris paribus. Contingent claims insurance is rarely sold in the U.S. because it is difficult to observe illness. As a result, it is 23

26 costly to monitor for fraud and even more costly to write the complex contracts that would accurately specify the various clinical conditions (diseases, complications, sequellae, courses of a disease, etc.) under which different payoffs would be made. Because of these transaction cost considerations, most health insurance contracts pay off by reducing price. 24

27 3. The Ex Ante Demand for Price-Payoff Health Insurance The conventional theory of the demand for health insurance is based on a model that generally does not recognize that the income transfers contained within price-payoff insurance can generate additional consumption of medical care, that is, moral hazard. The conventional ex ante choice model (the prototype is Friedman and Savage, 1948) suggests that the gain from insurance derives from consumers being able to substitute financial losses that are certain for uncertain ones of the same expected magnitude. (In optimal ex ante insurance models, the equivalent motivation is a smoothing of consumption of other goods and services across states of nature.) These single argument utility function models do not recognize that this payoff net of the premium represents an increase in income that can be spent on both (1) other goods and services and (2) medical care, much less that the consumer who receives this additional income when he becomes ill might spend a substantial portion of it on additional medical care. Thus, conventional theory assumes that all additional consumption of medical care that is generated by price-payoff insurance produces a welfare loss (Pauly, 1968) and this welfare loss is so substantial as to render fair price-payoff insurance welfare decreasing (Feldstein, 1973; Feldman and Dowd, 1991; Manning and Marquis, 1996). In contrast, the new theory suggests insurance is purchased in order to obtain an income transfer when ill, from those who purchase insurance and remain healthy (Nyman, 2003). With this additional income, consumers purchase more of medical care and other goods and services. The effect of the income transfer on consumption of medical care is efficient and is central to understanding the demand for price-payoff health insurance. 25

28 Ex ante, the consumer considers whether or not to purchase a specific price-payoff contract with a coinsurance rate equal to c. Thus, she compares expected utility without insurance, EU u = (1-π)U h (0, Y o ) + πu s (M u,y o - M u ), (21) with expected utility for a price-payoff insurance contract, EU i = (1-π)U h [0, Y o - R] + πu s [M ppi, Y ppi ] (22) = (1-π)U h [0, Y o - π(1-c)m ppi ] + πu s [M ppi, Y o + (1- π)(1-c)m ppi - M ppi ]. (23) U h is utility when healthy, where M is assumed to be 0, consistent with assumption that only those who are ill purchase medical care. For the healthy consumer without insurance, spending on other goods and services is constrained by endowed income, but for the healthy consumer with insurance, spending on other goods and services is constrained by endowed income after a fair premium is subtracted. Note that, although the first term on the right-hand-side of equation (23) shows the components, π(1-c)m ppi, of the actuarially fair premium, the actual premium, R, is ex ante taken as a given by the consumer, as in equation (22). It is only because of the actuarial study conducted by the insurer that we know that R is set to equal π(1-c)m ppi. The second term on the right-hand-side of equation (22) represents the ex post consumption decision with insurance, (M ppi, Y ppi ), that was derived in the previous section. In equation (23), Y ppi has been expanded to show the income transfer, (1-π)(1-c)M ppi. This insurance is purchased if (EU i - EU u ) > 0, or if EU i - EU u = (1-π)U h [0, Y o - π(1-c)m ppi ] + πu s [M ppi, Y o + (1-π)(1-c)M ppi - M ppi ] - (1-π)U h (0, Y o ) - πu s (M u,y o - M u ) (24) = (1-π){U h [0, Y o - π(1-c)m ppi ] - U h (0, Y o )} + 26

29 π{u s [M ppi, Y o + (1-π)(1-c)M ppi - M ppi ] - U s (M u,y o - M u )} > 0. (25) Thus, in considering the purchase of a given price-payoff insurance contract, the consumer weighs the effect of paying the premium when healthy on consumption of other goods and services (the first term on the right hand side of equation 25), against the effect of the income transfer when ill on consumption of both medical care and other goods and services (the second term). The expected premium payment, -(1-π)[π(1-c)M ppi ], equals the expected income transfer, π[(1-π)(1-c)m ppi ] and, as a result, the insurance premium is fair. The consumer purchases this price-payoff insurance contract when the expected utility gain that is generated by (the additional medical care and other goods and services purchased with) the income transfer when ill exceeds the expected utility lost from paying the premium when healthy. The assumption in this model that only those who are ill consume medical care is important because it bears on an early discussion of income effects in insurance (Pauly, 1983). Although a few obtain large increase in income from insurance, many others simply pay their premiums into the system, and these income changes essentially cancel each other out. If so, then the additional medical care caused by the income increases would be cancelled by a reduction in care caused by the premium payments, and no net income effects would occur. The present model, however, assumes that those who receive the additional income are ill, and those who only pay into the pool remain healthy. As a result, they have different propensities to spend their income on health care. For example, persons with severe angina and coronary heart disease would be more likely to purchase a coronary arterial bypass procedure with the additional income from insurance, but no healthy person would be less likely to purchase a coronary arterial bypass procedure because of having less income, as a result of 27

30 having paid an insurance premium. With or without paying the insurance premium, the healthy consumer would purchase the same number of bypass procedures: zero. Therefore, although the income gained by the few who become ill is cancelled by the income paid in by the many who remain healthy, these income changes would still generate an net increase in health care expenditures. This is true for the serious, expensive, often painful medical care that represents most of health care expenditures. Some of the moral hazard, however, may be generated by a pure price effect and this portion of moral hazard causes a reduction of utility, compared with moral hazard that is caused by the income transfer alone. Because of the important welfare benefit associated with gaining access to those expensive and effective medical services that would otherwise be beyond the consumer s liquidity constraint, the net welfare effect of moral hazard is likely to be positive. Indeed, the value of price-payoff health insurance under the new theory may be dominated by the one component that is completely missing from conventional theory: the welfare gain from the consumption of additional medical care that is generated by the income transfer. 4. Conclusions This paper has presented theory showing that a large source of value is missing from the conventional welfare analysis of price-payoff health insurance. Conventional theory has focused on the effect of the income payoff in generating additional purchases of other goods and services, and on the effect of the price reduction in generating additional purchases of medical care. The income transfer contained within the price reduction also generates additional 28

31 purchases of medical care, but this effect is completely missing from conventional theory. This is an important omission and one that changes the value of price-payoff insurance dramatically. Without recognition of this income transfer effect, the voluntary purchase of fair health insurance at traditional coverage parameters appears to reduce welfare (Feldstein, 1973; Feldman and Dowd, 1991; Manning and Marquis, 1996) because all the additional medical care purchased is assumed to be in response to the willingness to substitute medical care for other goods and services as relative prices change. As such, it could only mean that the additional care purchased with insurance is not worth the cost of producing it. With the recognition of the income transfer effect, however, not only is much of the welfare loss eliminated, but furthermore, it is replaced by a welfare gain. This welfare gain is due to the fact that with the additional income transfers, the consumer s willingness to pay increases and exceeds marginal cost for at least a portion of moral hazard. This gain is important because it is often derived from the purchase of those major medical procedures that would otherwise be beyond the consumer s liquidity constraint. There is evidence that, when the spurious losses are eliminated and true gains are recognized, (1) the value of moral hazard far exceeds the costs of producing it, (2) the welfare gain from moral hazard represents an important, if not the dominant reason, for purchasing health insurance, and (3) the voluntary purchase of (unsubsidized, fair) health insurance generally makes the consumer better off (Nyman, 2003). Recognition of the income transfer effect also dramatically changes the nature of costcontainment policy. Without this income transfer effect, public policy has been directed at reducing consumption of medical care at the margin in order to reduce costs. Over the last 35 years, economists have promoted cost-sharing and managed care as efficient cost-containment 29