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Selection in Health Insurance Markets and Its Policy Remedies

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  • Michael Geruso
  • Timothy J. Layton

Abstract

Selection (adverse or advantageous) is the central problem that inhibits the smooth, efficient functioning of competitive health insurance markets. Even—and perhaps especially—when consumers are well-informed decision makers and insurance markets are highly competitive and offer choice, such markets may function inefficiently due to risk selection. Selection can cause markets to unravel with skyrocketing premiums and can cause consumers to be under- or overinsured. In its simplest form, adverse selection arises due to the tendency of those who expect to incur high health care costs in the future to be the most motivated purchasers. The costlier enrollees are more likely to become insured rather than to remain uninsured, and conditional on having health insurance, the costlier enrollees sort themselves to the more generous plans in the choice set. These dual problems represent the primary concerns for policymakers designing regulations for health insurance markets. In this essay, we review the theory and evidence concerning selection in competitive health insurance markets and discuss the common policy tools used to address the problems it creates. We emphasize the two markets that seem especially likely to be targets of reform in the short and medium term: Medicare Advantage (the private plan option available under Medicare) and the state-level individual insurance markets.

Suggested Citation

  • Michael Geruso & Timothy J. Layton, 2017. "Selection in Health Insurance Markets and Its Policy Remedies," Journal of Economic Perspectives, American Economic Association, vol. 31(4), pages 23-50, Fall.
    • Handle: RePEc:aea:jecper:v:31:y:2017:i:4:p:23-50
    Note: DOI: 10.1257/jep.31.4.23
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    2. Gemmo, Irina & Kubitza, Christian & Rothschild, Casey, 2020. "Constrained efficient equilibria in selection markets with continuous types," Journal of Public Economics, Elsevier, vol. 190(C).
    3. Kreider, Amanda R. & Layton, Timothy J. & Shepard, Mark & Wallace, Jacob, 2024. "Adverse selection and network design under regulated plan prices: Evidence from Medicaid," Journal of Health Economics, Elsevier, vol. 97(C).
    4. Richard Domurat & Isaac Menashe & Wesley Yin, 2019. "The Role of Behavioral Frictions in Health Insurance Marketplace Enrollment and Risk: Evidence from a Field Experiment," NBER Working Papers 26153, National Bureau of Economic Research, Inc.
    5. Remmerswaal, Minke & Boone, Jan & Douven, Rudy, 2023. "Minimum generosity levels in a competitive health insurance market," Journal of Health Economics, Elsevier, vol. 90(C).
    6. Martin Gaynor & Kate Ho & Robert J. Town, 2015. "The Industrial Organization of Health-Care Markets," Journal of Economic Literature, American Economic Association, vol. 53(2), pages 235-284, June.
    7. Layton, Timothy J. & McGuire, Thomas G. & van Kleef, Richard C., 2018. "Deriving risk adjustment payment weights to maximize efficiency of health insurance markets," Journal of Health Economics, Elsevier, vol. 61(C), pages 93-110.
    8. Anna Jędrzychowska, 2022. "A Bridge Life Insurance for Households—Diagnosis and Motives," Risks, MDPI, vol. 10(4), pages 1-21, April.
    9. Moiz Bhai & Danny Hughes, 2024. "Estimating Self-Selection in Medicare Advantage," Working Papers 2024-009, Human Capital and Economic Opportunity Working Group.
    10. Minke Remmerswaal & Jan Boone & Rudy Douven, 2019. "Selection and moral hazard effects in healthcare," CPB Discussion Paper 393, CPB Netherlands Bureau for Economic Policy Analysis.
    11. Shuli Brammli-Greenberg & Jacob Glazer & Ruth Waitzberg, 2019. "Modest risk-sharing significantly reduces health plans’ incentives for service distortion," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 20(9), pages 1359-1374, December.
    12. Keaton S. Miller & Amil Petrin & Robert Town & Michael Chernew, 2019. "Optimal Managed Competition Subsidies," NBER Working Papers 25616, National Bureau of Economic Research, Inc.
    13. Nathalie Fombaron & Georges Dionne & Wanda Mimra, 2023. "Adverse Sélection in Insurance," Post-Print hal-04416340, HAL.
    14. Olivier Darmouni & Dan Zeltzer, 2022. "Horizon effects and adverse selection in health insurance markets," Canadian Journal of Economics/Revue canadienne d'économique, John Wiley & Sons, vol. 55(2), pages 800-827, May.
    15. Timothy J. Layton & Nicole Maestas & Daniel Prinz & Boris Vabson, 2019. "Private vs. Public Provision of Social Insurance: Evidence from Medicaid," NBER Working Papers 26042, National Bureau of Economic Research, Inc.
    16. Casey Rothschild, 2024. "Welfare analysis in insurance markets," The Geneva Risk and Insurance Review, Palgrave Macmillan;International Association for the Study of Insurance Economics (The Geneva Association), vol. 49(1), pages 36-58, March.
    17. Damon Jones & David Molitor & Julian Reif, 2019. "What do Workplace Wellness Programs do? Evidence from the Illinois Workplace Wellness Study," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 134(4), pages 1747-1791.
    18. Roy McGee, 2023. "Adverse Selection Among Early Adopters and Unraveling Innovation," University of Western Ontario, Centre for Human Capital and Productivity (CHCP) Working Papers 2022302, University of Western Ontario, Centre for Human Capital and Productivity (CHCP).
    19. Daniel Garcia & Roee Teper & Matan Tsur, 2018. "Information Design in Insurance Markets: Selling Peaches in a Market for Lemons," CESifo Working Paper Series 6853, CESifo.
    20. Jing Jian Xiao & Chunsheng Tao, 2020. "Consumer finance/household finance: the definition and scope," China Finance Review International, Emerald Group Publishing Limited, vol. 11(1), pages 1-25, June.
    21. Minke Remmerswaal & Jan Boone & Rudy Douven, 2019. "Selection and moral hazard effects in healthcare," CPB Discussion Paper 393.rdf, CPB Netherlands Bureau for Economic Policy Analysis.

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    More about this item

    JEL classification:

    • D82 - Microeconomics - - Information, Knowledge, and Uncertainty - - - Asymmetric and Private Information; Mechanism Design
    • G22 - Financial Economics - - Financial Institutions and Services - - - Insurance; Insurance Companies; Actuarial Studies
    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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