Three essays on the economics of health insurance [electronic resource]

This dissertation explores the functioning of the non-group health insurance market under various regulatory regimes. The first chapter estimates the relationship between health status and product choice in this market prior to the Affordable Care Act (ACA). I use insurers' decisions of whether to approve or reject applications for health insurance to identify this relationship. These decisions are based upon a comprehensive health history that the consumer must disclose to the insurer upon applying. I assume that the insurer uses this health history, as well as the financial characteristics of the product that was applied for, to estimate the expected cost of insuring the consumer, approving whenever this cost exceeds the product's premium. This assumption allows me to estimate how insurers' forecasts of applicants' costs differ depending on the type of product chosen in a discrete choice framework. I estimate that demanders of high deductible coverage are much costlier to insure than others. Additional analysis reveals that these consumers are likely to be impoverished, suggesting that cash constraints and/or price sensitivity may explain their preference for minimal coverage. The second chapter is co-authored with Pietro Tebaldi, and estimates the impact of age-based pricing restrictions in the post-reform market. The ACA fixes the ratio between health insurance premiums charged to consumers of different ages, which generates a relationship between the fraction of relatively old consumers in a geographic market and the prices faced by young consumers in that market. We show that this relationship is present in the prices faced by consumers on the ACA exchanges, but was not present in the pre-ACA market. We take this as evidence that the relationship between price and population age observed in the ACA data is indeed attributable to this regulation. We then use this variation, combined with a model of insurer price-setting, to back out the age-specific prices that would prevail if the regulation of interest were eliminated. We estimate that this regulation substantially raises premiums for younger buyers while reducing them for older buyers, and therefore alters the allocation of coverage to consumers of different ages. Because the value of the subsidies that the federal government provides is directly tied to premiums, this regulation has also had a substantial impact on the federal budget, decreasing subsidy outlays by approximately $2.3 billion. The final chapter is co-authored with Michael Dickstein, Mark Duggan, and Pieto Tebaldi, and explores another aspect of the ACA's pricing restrictions. Individual states have discretion in how they define coverage regions, within which insurers must charge the same premium to buyers of the same age, family structure, and smoking status. We exploit variation in these definitions to investigate whether the size of the coverage region affects outcomes in the ACA marketplaces. We find large consequences for small and rural markets. When states combine small counties with neighboring urban areas into a single region, the included rural markets see .6 to .8 more active insurers, on average, and savings in annual premiums of between

Keywords: Economics.
Advisor: Bresnahan Timothy F. primary advisor. Thesis advisor
Duggan Mark
Einav Liran advisor. Thesis advisor