Contributions published at Applied Microeconomics (Peter Zweifel)

Häufig wird die Globalisierung und auch die Welthandelsorganisation WTO für den verstärkten Raubbau an der Umwelt verantwortlich gemacht. Eine wichtige Rolle beim Schutz der Umwelt spielen die Eigentumsrechte. Wie kann erreicht werden, dass der Eigentümer vom Schutz der Umwelt profitiert, die externen Kosten also internalisiert werden?

In der Volksabstimmung vom 11. März 2007 unterstützte eine grosse Mehrheit der Schweizer Stimmberechtigten einmal mehr den Wettbewerb in der sozialen Krankenversicherung. Die Diskussionen im Vorfeld des Urnengangs zeigten aber ebenso deutlich, dass die Risikoselektion auf wenig Verständnis stösst. Besonders stark wird – inzwischen auch von einer Mehrheit der Krankenversicherer selbst - das Aushöhlen der Einheitsprämie durch billige Tochterkassen kritisiert. Die wissenschaftliche Diskussion des letzten Jahrzehnts unterstreicht, dass der Anreiz zur Risikoselektion systembedingt ist. Solange die Einheitsprämie mit einer allzu groben Berechnung des Risikoausgleichs kombiniert wird, stellt die Risikoselektion die optimale Marktstrategie dar. Im Wettbewerb, wo jeder Versicherer gezwungen ist, seinen Kunden möglichst günstige Prämien zu offerieren, wächst daher der Druck, zum Mittel der Selektion zu greifen, auch wenn der Mehrheit der Versicherer bewusst ist, dass Risikoselektion in einer obligatorischen Sozialversicherung eine Verschwendung volkswirtschaftlicher Ressourcen darstellt. Zur Behebung des Problems haben die Schweizer Gesundheitsökonomen grundsätzlich zwei wissenschaftlich unbestrittene Lösungsvorschläge eingebracht: Der Wechsel von der Einheitsprämie zu risikogerechten Prämien oder eine morbiditätsorientierte Berechnung des Risikoausgleichs. Der erste Vorschlag fand in der Politik keinen Widerhall, während der zweite Vorschlag in den Revisionsvorschlag des Ständerats vom 8. März 2006 aufgenommen wurde. Nach Ansicht des Ständerats soll die Risikoausgleichsberechnung um das Kriterium „Spitalaufenthalt im Vorjahr“ ergänzt werden. In jüngster Zeit brachte Bundesrat Couchepin als Alternative zur Ständeratsposition die Idee eines Hochrisikopools in die Diskussion ein. In diesem Pool sollten die teuersten Versicherten zusammengefasst und in Rahmen eines staatlichen Disease Management-Programms betreut werden. Die vorliegende Arbeit untersucht, gestützt auf die Angaben von 180'000 Versicherten während eines Zeitraums von 8 Jahren, wie sich der Hochrisikopool auf den Anreiz zur Risikoselektion auswirkt. Der Befund ist eindeutig. Da nur wenige Versicherte für einen Hochrisikopool in Frage kommen, reduziert er die Prämienvorteile der Risikoselektion kaum und Risikoselektion bleibt für den einzelnen Versicherer die erfolgreichste Strategie. Zudem werden durch staatliche Disease-Management Programme die Möglichkeiten privatwirtschaftlicher Innovationen sowie die Wahlfreiheit gewisser Patienten eingeschränkt, was dem aktuell geäusserten Willen der stimmenden Bevölkerung nicht entspricht. Durch den ständerätlichen Revisionsvorschlag hingegen werden die Anreize zur Selektion signifikant reduziert, die Auswirkung der Selektion auf die Prämienvorteile abgedämpft und das (vom Gesetzgeber gewünschte) Kostensparen durch Managed Care zur gewinnbringenden Strategie im Markt gemacht. Die vorliegenden Resultate werden von der vergleichbaren Literatur gut gestützt. Sowohl betreffend der Effektivität des Ständeratsvorschlags als auch der relativen Wirkungslosigkeit des Hochrisikopools, gibt es unter den zahlreichen empirischen Analysen keine, die einen widersprechenden Befund liefern würde.

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There is growing interest in discrete-choice experiment (DCE) as a method to elicit consumers' preferences in the health care sector. Increasingly this method is used to determine willingness to pay (WTP) for health-related goods. However, its external validity in the health care domain has not been investigated until now. This paper examines the external validity of DCE concerning the reduction of a health risk. Convergent validity is examined by comparing the value of a statistical life with other preference elicitation techniques, such as revealed preference. Criterion validity is shown by comparing WTP values derived from stated choices in the experiment with those derived from actual choices made by the same individuals. Both tests provide strong evidence in favour of external validity of the DCE method.

The objective of this text is to develop the theory of social health insurance (SHI; the expression used especially in the United States is “public health insurance,” which will be viewed as one variant of SHI here). While a good deal is known about the demand and supply of private insurance, the theoretical basis of SHI is much more fragile. Specifically, on the demand side, what are the reasons for social (or public) health insurance to exist, even to dominate private health insurance in most developed countries? With regard to supply, what do we know about the objectives and constraints of SHI managers? Finally, economists can predict properties of the equilibrium characterizing private health insurance (PHI). However, what is the likely outcome (“performance”) of SHI? At the normative level, one may ask, Should the balance be shifted from SHI to PHI?

This chapter describes how economic theory (and experience) of the demand for insurance predicts that risk-averse individuals purchase coverage if available at so-called fair premiums, which amount to no more than the expected value of the loss to be covered. In the case of health, additional fi nancial means (provided by coverage) may be even more important when a person is ill than when he or she is healthy. If so, demand for health insurance, even in low-income countries, could be high. Every insurer needs to charge a “loading” for administrative expense, compensation for risk, and profi t (in the case of a public insurer, the loading amounts to the effi ciency loss caused by taxation needed to finance the insurer’s operations). Therefore, the behavior of health insurance suppliers becomes of crucial importance. The loading contained in their premiums (or contributions) is just one of several supply dimensions, which include comprehensiveness of benefits, amount of risk selection effort, degree of vertical integration with health services providers, and degree of seller concentration in the market. This chapter addresses these dimensions of supply and the powerful effect on them of moral hazard (the tendency of consumers to underinvest in prevention, choose the most intensive treatment alternative, and push for application of the latest medical technology). In the presence of marked moral hazard effects, health insurers are well advised to include only a few items in their benefi t list, because each of these items tends to increase in price, quantity, and hence expenditure. Moreover, premium regulation induces risk selection efforts. If allowed to charge contributions according to true risk, health insurers will set premiums such that high and low risks yield the same contribution margin on expectation. In that event, risk selection (“cream skimming”) is not worthwhile. These phenomena hold not only for private health insurance in low-income countries but also for community-based and public health insurance. Because little empirical data on the supply of health insurance exist, case studies, mainly of low-income countries, are used to illustrate theoretical predictions. On the whole, the limited empirical evidence suggests that the theory developed in this chapter may be suffi ciently descriptive to provide some guidelines for policy.

This paper revisits the debate on the red herring, viz. the claim that population ageing will not have a significant impact on health care expenditure (HCE). It decomposes HCE into seven components, includes both survivors and deceased individuals, and estimates a two-part model of the demand for health care services, using a large Swiss data set for 1999. It finds no or weak age effects on HCE for the components of HCE when proximity to death is controlled for, and points to differences between users and non-users of long-term care (LTC). For deceased non-users of LTC services, a falling age curve for all components of HCE except for inpatient care is observed, while survivors show a weak age effect in ambulatory and inpatient care once proximity to death is controlled for. As to surviving users of LTC services, their probability of incurring LTC expenses markedly increases in old age, while most of the components of their conditional HCE show a decreasing age profile. Thus, a school of red herrings can be claimed to exist-with the possible exception of LTC, where ageing might matter regardless of proximity to death.

DEUTSCH: Gesundheitsleistungen erinnern an eine Sisyphusarbeit. Um die Analogie zu begreifen, betrachte man eine Entscheidung, mehr Mittel für Gesundheit zur Verfügung zu stellen. Dies führt zu einer höheren Zahl von Überlebenden, die eine Mehrnachfrage nach Gesundheitsleistungen ausüben. Die Aufwendungen für die Gesundheit steigen, und der Kreis schließt sich. Die Zielsetzung dieses Beitrages besteht darin, frühere Untersuchungen zu verbessern, welche den Nachweis eines Sisyphus-Syndroms in den Industrieländern nicht erbringen konnten. Dieses Mal gibt es Hinweise auf ein solches Syndrom, das erst nach 10 Jahren seine Virulenz verliert. ENGLISH: Health care may be similar to the work Sisyphus, a Greek hero who was condemned by the Gods to push a big rock up a hill only to see it slip out of his hands before making it to the top. To see why there my be a Sisyphus syndrome in health, consider an initial decision to devote more resources to health. The likely consequence is an increased number of survivors, who exert political pressure in favor of even more health care. If they succeed, the cycle goes into its next round and might even prove explosive. Earlier research failed to identify this political feedback in industrial countries. Using improved model formulation, data, and econometric methodology, this contribution does find evidence suggesting the existence of a Sisyphus syndrome. However, the good news is that the cycle seems to be dampened rather than explosive.

The impact of aging on healthcare expenditure (HCE) has been at the center of a prolonged debate. This paper purports to shed light on several issues of this debate by presenting new evidence on the "red herring" hypothesis advanced by Zweifel, Felder and Meier (1999). This hypothesis amounts to distinguishing a mortality from a morbidity component in healthcare expenditure (HCE) and claiming that failure to make this distinction results in excessive estimates of future growth of HCE. A re-estimation based on a much larger data set is performed, using the refined econometric methodology. The main contribution is consistency, however. Rather than treating the mortality component as a residual in forecasting, its dynamics are analyzed in the same detail as that of the morbidity component when predicting the impact of population aging on the future growth of HCE. For the case of Switzerland, it finds this impact to be relatively small regardless of whether or not the mortality component is accounted for, thus qualifying the "red herring" hypothesis.

The impact of aging on healthcare expenditure (HCE) has been at the center of a prolonged debate. This paper purports to shed light on several issues. First, it presents new evidence on the relative importance of the two components of HCE that have been distinguished by Zweifel, Felder and Meier (1999), viz. the cost of morbidity and the cost of mortality (their "red herring" hypothesis claims that neglecting the mortality component results in excessive estimates of future growth of HCE). Second, it takes account of recent evidence suggesting that HCE does increase life expectancy, implying that time-to-death is an endogenous determinant of HCE. Third, it investigates the contribution of population aging to the future growth of HCE. For the case of Switzerland, it finds this contribution to be relatively small regardless of whether or not the cost of dying is accounted for, thus qualifying the "red herring" hypothesis.

This paper applies the five standard criteria for assessing the performance of an economy to one of its sectors, namely, the provision of health care. They are (1) matching of consumer preferences, (2) technical efficiency, (3) adaptive capacity, (4) dynamic efficiency, and (5) a distribution of income that provides incentives for producers to attain criteria (1) through (4). Being insurance-based, the Swiss healthcare system comprises three contractual relationships that can be judged in the light of these criteria. First, the relationship between consumers and health insurers satisfies criterion (1) to a high degree, not least thanks to the managed-care (MC) options that were introduced with the new law on health insurance (effective 1996). However, it fails with regard to (2) because cost reductions achieved by MC cannot be passed on to consumers but to a very limited degree. The relationship between health insurers and service providers, by way of contrast, does not fully satisfy any of the five criteria, mainly because health insurers continue to operate under an any-willing-provider clause for conventional fee-for-service care. This makes it difficult for them to find MC providers. Finally, the relationship between consumers and healthcare providers match consumer preferences well (criterion 1) but do not result in an income distribution in the healthcare sector that is conducive to the attainment of criteria (2) through (4). The total score for the Swiss healthcare system amounts to 13 points out of a maximum of 30, to which the relationship between insurers and providers contributes only 3 points. Therefore, performance could be improved by granting health insurers freedom to contract not only with domestic but also foreign healthcare providers offering a favorable benefit cost ratio.

Probleme der Finanzierung sind für die Marktdiffusion innovativer Energietechnologien ebenso wichtig wie ihre technischen Eigenschaften oder der erwartete Nutzen aus der Technologieanwendung. Welche Rolle spielt dabei die Eigentümerstruktur des Innovators? Welchen Einfluss hat die Finanzierungsform des Investitionsvorhabens—und damit das finanzielle Risiko—auf die Attraktivität einer Energieinvestition?

DEUTSCH: Dieser Beitrag setzt sich zum Ziel, zwei miteinander verbundene Fragen zu beantworten: 1. Was ist der Auftrag der Krankenversicherung? Oder in anderen Worten: Warum gibt es eine Nachfrage nach sozialer (bzw. staatlicher) Krankenversicherung? Ist sie der Grund dafu¨ r, dass in den meisten entwickelten La¨ndern die private Krankenversicherung ein Schattendasein fu¨hrt? 2. Wo liegen die Grenzen der Sozialen Krankenversicherung? Kann man sagen, es gebe ein Zuviel an Sozialer Krankenversicherung in mindestens einer der beiden Dimensionen? Sollte ihre Vorherrschaft zu Gunsten der privaten Krankenversicherung gebrochen werden? Ist das heutige Ausmaß der Deckung zu hoch? ENGLISH: This contribution seeks to answer two questions, (1) What are the reasons for a demand for social health insurance (SHI)?, and (2) What are the limits to the growth of SHI? A review of the reasons for the existence of SHI reveals that while economists have emphasized the possible contribution of SHI to efficiency, the available evidence points to public choice reasons, which also seem to explain better the growth of SHI. Indeed, since private insurance redistributes as well (albeit governed by chance), it is tempting for politicians to use SHI for systematic redistribution (the extent of which cannot easily be detected by net payers). Turning to the supply of SHI, two dimensions are studied in some detail, viz. efforts at product innovation and at risk selection. Competing suppliers of SHI, while hampered by risk adjustment which sanctions innovators for attracting the young, are predicted to invest in innovation. A monopolistic public SHI scheme, by way of contrast, does not need to select risks and, on the other hand, it is predicted to refrain from product innovation. This is but one limit to the growth of SHI; the ultimate one is citizens' lack of willingness to pay for its continuing expansion, about which some evidence for the case of Switzerland is presented.

This contribution starts out by noting a conflict of interest between consumers and insurers. Consumers face positive correlation in their assets (health, wealth, wisdom, i.e. skills), causing them to demand a great deal of insurance coverage. Insurers on the other hand eschew positively correlated risks. It can be shown that insurance contributes to a reduction of their asset volatility only if unexpected deviations of payments from expected value correlate negatively across lines of insurance. Analyzing deviations from trend in aggregate insurance payments, one finds the following for the United States and Switzerland. Private U.S. but not Swiss insurance has a hedging effect for consumers, while both social insurance schemes expose consumers to excess asset volatility. In the insurance systems of both countries, the private component fails to offset deviations in the social component (and vice versa). As to the supply of insurance, cointegration analysis indicates the absence of common trends. Therefore, insurance companies could offer combined policies to the benefit of consumers, hedging their underwriting risks both domestically and internationally.

Uniform, risk-independent insurance premiums are accepted as part of ‘managed competition’ in health care. However, they are not compatible with optimality of health insurance contracts in the presence of both ex ante and ex post moral hazard. They have adverse effects on insurer behaviour even if risk adjustment is taken into account. Risk-based premiums combined with means-tested, tax-financed transfers are advocated as an alternative.