The Effects of Switching Health Insurance on Individual Health

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1 The Effects of Switching Health Insurance on Individual Health Jan Kleibrink 2,3 Thu-Van Nguyen 1,3 1 Duesseldorf Institute for Competition Economics 2 University Duisburg-Essen 3 CINCH - Health Economics Research Center June 30th 2014

2 Introduction Aim Two-tier system: statutory health insurance (SHI) vs. private health insurance (PHI) Existing literature focuses on effect of having PHI on health and health care utilization Long term effects - main channels: quality differences, selection Neglected: psychological effect of switching process itself (a) Investigate the effect of switching health insurance on individual health (b) Analyze effect at time of switch instead of comparing existing status (c) Disentangle psychological effects and quality differences between insurances The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 1 / 16

3 Related Literature Hullegie and Klein (2010): Jürges (2009): Riphahn et al. (2003): Jones et al. (2007): Positive effect of PHI insurance on med. care utilization and SAH PHI less likely to contact GP, # doctor visits larger No relationship betw. insurance type and hospital nights / doctor visits Holding PHI increases probability of use of specialists The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 2 / 16

4 Implications and Contribution Literature focuses on effects of already holding either PHI or SHI on health outcomes (stock of insurees) Additional effect due to the switch itself (flow of insurees) Previous results might be underestimated due to additional psychological effects of switching itself The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 3 / 16

5 Idea Analysis of inner-system switch: effect on health outcomes Similar benefit packages in SHI No analysis of inner-phi-switch because until 2009: no transferability of old-age-provisions Analysis of between-system switch: effect on health outcomes Comparison of (1) and (2) single out effects beyond quality differences The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 4 / 16

6 Idea Inner-SHI switch: IVs: premium & additional premium Between-system switch: effect on health outcomes RD: Eligibility to opt out of SHI only determined by income 1st stage: a) PHI it = β 0 + β 1inc difference it + β k inc thresholds kt, if PHI it 1 = 0 b) Robustness check: = β 0 + β 1inc difference it + β k inc thresholds kt 2nd stage: effect of switch on individual health (health worries, SAH, health satisfaction, hospital stays) switch SHI2PHI it The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 5 / 16

7 Main differences betw. PHI and SHI SHI PHI Premia Community-rated, Individual, Risk-based Income-related Reimbursement System In-kind Provision In-cash Provision Family Insurance Yes No Coverage Universal Individual Doctors Compensation Lower Higher The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 6 / 16

8 Income Thresholds year Compulsory Insurance Threshold Contribution Ceiling amt. per month amt. per year amt. per year ,83 e e e ,17 e e e ,00 e e e ,00 e e e ,50 e e e ,00 e e e ,50 e e e ,00 e e e ,50 e e e ,00 e e e ,50 e e e ,00 e e e ,50 e e e ,00 e e e ,50 e e e Contribution rate: 15.5% of gross income The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 7 / 16

9 Descriptives Table 1: Descriptive Statistics SHI Insurants Switchers SHI PHI Insurants Switchers SHI-PHI (No) Health Worries (0.64) (0.64) (0.58) (0.57) Dummy (No) Worries (0.48) (0.47) (0.49) (0.50) Health Satisfaction (1.93) (1.95) (1.79) (1.81) Self-assessed Health (0.82) (0.83) (0.78) (0.78) No Hosp Stays (5 Yrs.) (0.41) (0.42) (0.39) (0.39) Labor Income ( ) ( ) ( ) ( ) Male (0.50) (0.50) (0.45) (0.47) Age (8.14) (8.12) (7.37) (7.67) Married (0.47) (0.47) (0.48) (0.50) Children in HH (0.96) (0.96) (0.91) (0.93) In Education (0.19) (0.18) (0.22) (0.24) Yrs. of Education (2.44) (2.46) (2.89) (2.89) Fulltime (0.44) (0.44) (0.32) (0.30) East Germany (0.42) (0.42) (0.37) (0.39) N Note: Authors calculations based on the SOEP for the years Means of variables, standard deviations in parentheses. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 8 / 16

10 Models 1 Inner-system switch switch shi-shi it health it = β 0 + β 1 2 Between-system switch = α 0 + α 1 premium + α 2 add.premium + α 3 X it + ɛ it switch shi-shi it + β 2 health it 1 + β 3 X it + v it switch shi-phi it health it = δ 0 + δ 1 = γ 0 + γ 1 inc difference + γ k inc threshold k + ɛ it switch shi-phi it + δ 2 health it 1 + β 3 X it + v it The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 9 / 16

11 Results: switch within system Table 2: Linear FE Regressions (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Inner-SHI switch (0.020) (0.015) (0.053) (0.024) (0.010) SC Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes Years Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. p<0.01; p<0.5; p<0.1. Robust standard errors in parentheses. Table 3: IV Regressions (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Inner-SHI switch (0.433) (0.325) (1.239) (0.536) (0.218) SC Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes Years Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). Switching insurances ins instrumented with last year s insurance premium and an indicator for an add-on premium, which was introduced in For each dependent variable, a higher value indicates a better health state. p<0.01; p<0.5; p<0.1. Robust standard errors in parentheses. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 10 / 16

12 Results: switch between systems: 1st stage Table 4: First stage regressions: Effect of Thresholds on insurane status Private insurance Switch public private inc difference (0.006) (0.002) inc th (0.006) (0.002) inc th (0.006) (0.002) inc th (0.005) (0.002) inc th (0.006) (0.002) inc th (0.006) (0.002) inc th (0.006) (0.003) inc th (0.008) (0.003) inc th (0.008) (0.003) inc th (0.008) (0.003) inc th (0.008) (0.003) inc th (0.007) (0.003) inc th (0.007) (0.003) N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 11 / 16

13 2nd stage: switch between systems - OLS Table 5: OLS: effect of system switch on health, no covariates (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.066) (0.053) (0.220) (0.089) (0.045) N Table 6: OLS: effect of system switch on health, including covariates (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.041) (0.034) (0.117) (0.050) (0.015) SC Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 12 / 16

14 2nd stage: switch between systems - FE Table 7: Linear FE: effect of system switch on health (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.060) (0.050) (0.179) (0.077) (0.032) SC Yes Yes Yes Yes Yes Years Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 13 / 16

15 Summary of Results Inner-system switch: no effect of insurance switch on health Between-system switch: positive effect of switch on health in OLS models; no effect in FE models The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 14 / 16

16 Conclusion Switch itself does not have an impact on individual health Health effects can be explained by quality differences of the systems The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 15 / 16

17 Thanks for your attention! The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 16 / 16

18 Robustness Check: switch between systems - OLS Table 8: OLS: effect of system switch on health, no covariates (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.694) (0.562) (2.301) (0.954) (0.507) N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. Table 9: OLS: effect of system switch on health, including covariates (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.441) (0.379) (1.281) (0.564) (0.197) SC Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 16 / 16

19 Robustness Check: switch between systems - FE Table 10: Linear FE: effect of system switch on health (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.656) (0.539) (1.864) (0.809) (0.356) SC Yes Yes Yes Yes Yes Years Yes Yes Yes Yes Yes Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 16 / 16

20 Results 2nd stage; between-system switch; OLS incl. only lagged health variables Table 11: OLS: effect of system switch on health, including lagged health variables (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.037) (0.031) (0.107) (0.045) (0.013) Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 16 / 16

21 Robustness Check: 2nd stage; between-system switch; OLS incl. only lagged health variables Table 12: OLS: effect of system switch on health, including lagged health variables (No) Worries Dummy (No) Worries Health Sat. SAH No Hosp. 5 Yrs. Switch SHI to PHI (0.411) (0.355) (1.200) (0.522) (0.180) Lagged health Yes Yes Yes Yes Yes N Note: Authors calculations based on the SOEP ( ). For each dependent variable, a higher value indicates a better health state. (No) worries ranges from 1(highly worried about health) to 3(not worried about health). (Gross labor income - Income threshold) [ 1500; 2500]. p<0.01; p<0.5; p<0.1. Standard errors clustered on individual level. The Effects of Switching Health Insurance on Individual Health Thu-Van Nguyen 16 / 16

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