Betting against pandemics: Ethical implications of the "COVID Claimania" in Taiwan, 2020-2022.

Among measures tackling the impacts of the COVID-19 pandemic, the selling of private insurance policies covering individual infection is overlooked by the ethics literature. To record the "COVID Claimania" in Taiwan and to assess its ethical implications, we collected 38 policies from 10 insurers sold between January 2020 and May 2022 and found that their risk calculation of the COVID-19 prevalence ranged from 0.5% to 11.08%. In reality, the prevalence by the end of 2022 was 37% in Taiwan. Selling private insurance policies is ethically problematic in three ways. First, it represents the insurance industry's irresponsible risk-taking profit-seeking behaviors. Second, it would jeopardize the effectiveness of the disease-prevention measures by inducing uncontrollable moral hazards. Third, it would expose the insurance companies to unbearable financial risks and cause substantial negative external impacts. The government should intervene in the private insurance market in preparation for future public health emergencies.

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study.

BACKGROUND: To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions. OBJECTIVE: We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions. DESIGN, SETTING, PARTICIPANTS: We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011. MAIN MEASURES: Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality. KEY RESULTS: Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7 %) and out-of-pocket costs (11.6 %) together explained nearly three times as much as quality ratings (13.6 %), but brand market share explained the most variation (35.3 %). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from $4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95 %CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95 %CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65 years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans. CONCLUSIONS: While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.

The development of the life insurance market and bank stability in developing countries.

This study investigates the relationship between the development of the life insurance market and bank stability within the context of developing countries. We used data from 2012 to 2020 across 108 developing countries and applied econometric techniques, including fixed-effect and system generalized method of moments (GMM) methods, to test the relationship between the life insurance market size, life insurance market growth, and bank stability at the country level. Our results indicate a positive relationship between life insurance market size and bank stability, i.e., a large life insurance market can help increase bank stability in developing countries. However, these countries should refrain from developing their life insurance markets too quickly; according to our empirical results, there is an inverted U-shaped relationship between life insurance market growth and bank stability. In the context of the growing life insurance market in developing countries as well as the increasing cooperation between banks and insurance companies towards expanding the life insurance market in these countries, our research provides important policy implications for ensuring the stability for financial markets in general.

Assessing the role of the insurance market and renewable energy in the load capacity factor of OECD countries.

In the empirical literature, few studies assessed the influence of the insurance market on carbon emissions. However, the effects of insurance markets on the load capacity factor (LCF) have been ignored. In this regard, the objective of the current work is to assess the potential impact of the insurance market on environmental sustainability in 27 OECD countries from 1990 to 2018 based on the LCF, which implies the strength of a state to enhance the population based on the current lifestyle. The present work employed the novel Method of Moments Quantile Regression (MMQR). This model is the prime and correct technique to better understand the association between the insurance market and the LCF across heterogeneous quantiles and to yield more robust empirical outcomes. The MMQR findings indicate a negative interaction between the insurance market and the LCF. In other words, the insurance sector has a powerful influence on economic activities and investments, such that insurance activities lead to an increase in the level of energy utilization, and thus have a negative influence on ecological sustainability. In contrast, the findings illustrate a positive and considerable association between renewable energy consumption and LCF. Based on the overall outcomes, it is suggested that OECD countries should focus on policies that encourage the use of renewable energy rather than incentivizing the insurance market. OECD country governments should also support green insurance activities to minimize the environmental damage of the insurance market.

Financial resilience of insurance network during Covid-19 pandemic.

We provide a novel approach for analysing the financial resilience of the insurance sector during coronavirus pandemic. To this end, we build temporal directed and weighted networks where the weights on the arcs take into account the tail dependence between couple of firms. To assess the resilience of the network, we provide a new global indicator, aimed at capturing the impact on the clustering coefficient of a shock affecting in turn each firm and diffusing in the network via shortest paths. A local measure of resilience is also provided by quantifying the contribution of each firm to the global indicator. In this way, we are able to detect most critical firms in the system. A numerical application has been developed in order to test the proposed approach. The results show that the proposed resilience measure appears able to detect main periods of financial crises. The first wave of COVID-19 pandemic results as a extreme phenomenon in the market and the lowest resilience is associated to the period in which COVID-19 has been declared pandemic.

Regulating Opioid Supply Through Insurance Coverage.

Responding to an opioid crisis in Canada, policy makers have implemented supply-side interventions seldom used in the US, regulating insurance reimbursement to discourage the prescribing of specified opioids. Using national databases of all opioids dispensed through provincial pharmaceutical programs and of opioid hospitalizations from January 2006 through March 2017, we found that requiring physicians to obtain prior authorization for patients to receive reimbursement for OxyContin prescriptions substantially reduced OxyContin fills, particularly among opioid-naive patients; it also reduced overall opioid prescriptions, suggesting limited substitution. "Grandfathering" OxyNeo (an abuse-resistant OxyContin variant), allowing previous OxyContin patients to obtain OxyNeo, increased OxyNeo fills but had no detectable effect on total opioid prescriptions, which points to substantial opioid substitution among chronic users of prescription opioids. We found no effects of regulatory changes on opioid-related hospitalizations. These results suggest that restrictions on pharmaceutical formularies can reduce fills of targeted opioids with the additional benefit of altering treatment of opioid-naive and other patients differently. Canadian policy makers may wish to extend such regulations to more provincial formularies and private insurers, and policy makers in the US and elsewhere could fruitfully follow suit.

Same Game, Different Names: Cream-Skimming in the Post-ACA Individual Health Insurance Market.

One of the Affordable Care Act's (ACA) signature reforms was creating centralized Health Insurance Marketplaces to offer comprehensive coverage in the form of comprehensive insurance complying with the ACA's coverage standards. Yet, even after the ACA's implementation, millions of people were covered through noncompliant plans, primarily in the form of continued enrollment in "grandmothered" and "grandfathered" plans that predated ACA's full implementation and were allowed under federal and state regulations. Newly proposed and enacted federal legislation may grow the noncompliant segment in future years, and the employment losses of 2020 may grow reliance on individual market coverage further. These factors make it important to understand how the noncompliant segment affects the compliant segment, including the Marketplaces. We show, first, that the noncompliant segment of the individual insurance market substantially outperformed the compliant segment, charging lower premiums but with vastly lower costs, suggesting that insurers have a strong incentive to enter the noncompliant segment. We show, next, that state's decisions to allow grandmothered plans is associated with stronger financial performance of the noncompliant market, but weaker performance of the compliant segment, as noncompliant plans attract lower-cost enrollees. This finding indicates important linkages between the noncompliant and compliant segments and highlights the role state policy can play in the individual insurance market. Taken together, our results point to substantial cream-skimming, with noncompliant plans enrolling the healthiest enrollees, resulting in higher average claims cost in the compliant segment.

Federalism And The ACA: Lessons For The 2020 Health Policy Debate.

Establishing a balance of power between states and the federal government has defined the American Republic since its inception. This conflict has played out in sharp relief with the implementation of the Affordable Care Act. This article describes the interplay between state and federal governments in the implementation of the act in three areas: the expansion of eligibility for Medicaid, implementation of the insurance Marketplaces, and regulation of insurers. The experience shows that states are intimately involved in health care and that useful policy and fiscal advantages can result from that involvement. However, strong national standards are critical to preventing partisan politics from trumping the health policy process.

Estimated Costs of a Reinsurance Program to Stabilize the Individual Health Insurance Market: National- and State-Level Estimates.

Reinsurance, an insurance product designed to protect health insurers against the financial risk of covering high-cost enrollees, has attracted bipartisan policy interest as a mechanism to stabilize individual health insurance markets. Three states-Alaska, Minnesota, and Oregon-have implemented state-based reinsurance programs under the Affordable Care Act's 1332 State Innovation Waivers, and reinsurance waivers have been approved though not yet enacted in Maine, Maryland, New Jersey, and Wisconsin. In this article, we estimate the costs of implementing national and state-based reinsurance programs using health spending data from the 2007-2016 Medical Expenditure Panel Survey and state demographic and health insurance coverage data from the 2015-2017 Current Population Survey Annual Social and Economic Supplement. We project that a reinsurance program with an 80% payment rate for expenditures between $40,000 and $250,000 would cost $30.1 billion from 2020-2022. We observed considerable variation in reinsurance programs and estimated costs between the 4 states we examined: California, Florida, Illinois, and Texas. Our projections provide updated estimates of the costs of implementing federal reinsurance programs for the individual health insurance market.

Financial liability for environmental damage: insurance market in Italy, focus on Veneto region experience.

Making good environmental damage caused by industrial accidents and restoring impaired ecosystems may be associated with high costs. The European Environmental Liability Directive requires that environmental damage is prevented or remediated and confers financial liability on operators responsible for the activities that caused the damage. The directive encourages adoption of financial risk instruments for environmental liability, ensuring that operators stand up for their responsibilities. We analyse the risk financing instruments for environmental liability in Italy, with emphasis on waste treatment and disposal plant management in Venice Metropolitan City, where financial guarantees and environmental insurance are mandatory. The regional legislation obliges operators of waste treatment plants to seek financial protection through financial guarantees and environmental insurance. We have conducted online survey and in-depth interviews with both suppliers and users of financial protection instruments. On national level, the relatively high environmental consciousness is countered by a low perception of risk and subsequently very low penetration of financial security instruments. Among the identified barriers, we have singled out a limited knowledge of cumulative and long-lasting impacts of industrial activities on environment and ecosystems. Financial and insurance are well developed, but a deep support for specific risk identification and coverage lacks. A closer cooperation between public and private sector can be an opportunity to foster the adoption of these instruments and to improve the coverage of public costs for environmental restoration, due to unattended liability.

Diminishing Insurance Choices In The Affordable Care Act Marketplaces: A County-Based Analysis.

While the Affordable Care Act has expanded health insurance to millions of Americans through the expansion of eligibility for Medicaid and the health insurance Marketplaces, concerns about Marketplace stability persist-given increasing premiums and multiple insurers exiting selected markets. Yet there has been little investigation of what factors underlie this pattern. We assessed the county-level prevalence of limited insurer participation (defined as having two or fewer distinct participating insurers) in Marketplaces in the period 2014-18. Overall, in 2015 and 2016 rates of insurer participation were largely stable, and approximately 80 percent of counties (containing 93 percent of US residents) had at least three Marketplace insurers. However, these proportions declined sharply starting in 2017, falling to 36 percent of counties and 60 percent of the population in 2018. We also examined county-level factors associated with limited insurer competition and found that it occurred disproportionately in rural counties, those with higher mortality rates, and those where insurers had lower medical loss ratios (that is, potentially higher profit margins), as well as in states where Republicans controlled the executive and legislative branches of government. Decreased competition was less common in states with higher proportions of residents who were Hispanic or ages 45-64 and states that chose to expand Medicaid.

Scope Of Primary Care Physicians' Participation In The Health Insurance Marketplaces.

Millions of Americans have purchased health insurance through the Marketplaces, but their access to care is not well understood. Using an audit study, we compared the scope of primary care physicians' participation in Marketplace plans to that in other insurance types in 2016. Across ten diverse states, rates of participation in Marketplace plans were higher than those in Medicaid, but lower than those in employer-sponsored insurance.

Consolidation Trends In California's Health Care System: Impacts On ACA Premiums And Outpatient Visit Prices.

California has heavily concentrated hospital, physician, and health insurance markets, but their current structure and functioning is not well understood. We assessed consolidation trends and performed an analysis of "hot spots"-markets that potentially warrant concern and scrutiny by regulators in terms of both horizontal concentration (such as hospital-hospital mergers) and vertical integration (hospitals' acquisition of physician practices). In 2016, seven counties were high on all six measures used in our hot-spot analysis (four horizontal concentration and two vertical integration measures), and five counties were high on five. The percentage of physicians in practices owned by a hospital increased from about 25 percent in 2010 to more than 40 percent in 2016. The estimated impact of the increase in vertical integration from 2013 to 2016 in highly concentrated hospital markets was found to be associated with a 12 percent increase in Marketplace premiums. For physician outpatient services, the increase in vertical integration was also associated with a 9 percent increase in specialist prices and a 5 percent increase in primary care prices. Legislative proposals, actions by the state's attorney general, and other regulatory changes are suggested.

The Complexity Of Billing And Paying For Physician Care.

The administrative costs of providing health insurance in the US are very high, but their determinants are poorly understood. We advance the nascent literature in this field by developing new measures of billing complexity for physician care across insurers and over time, and by estimating them using a large sample of detailed insurance "remittance data" for the period 2013-15. We found dramatic variation across different types of insurance. Fee-for-service Medicaid is the most challenging type of insurer to bill, with a claim denial rate that is 17.8 percentage points higher than that for fee-for-service Medicare. The denial rate for Medicaid managed care was 6 percentage points higher than that for fee-for-service Medicare, while the rate for private insurance appeared similar to that of Medicare Advantage. Based on conservative assumptions, we estimated that the health care sector deals with $11 billion in challenged revenue annually, but this number could be as high as $54 billion. These costs have significant implications for analyses of health insurance reforms.

Effects Of The ACA's Health Insurance Marketplaces On The Previously Uninsured: A Quasi-Experimental Analysis.

Descriptive studies have suggested that the Affordable Care Act's (ACA's) health insurance Marketplaces improved access to care. However, no evidence from quasi-experimental studies is available to support these findings. We used longitudinal survey data to compare previously uninsured adults with incomes that made them eligible for subsidized Marketplace coverage (138-400 percent of the federal poverty level) to those who had employer-sponsored insurance before the ACA with incomes in the same range. Among the previously uninsured group, the ACA led to a significant decline in the uninsurance rate, decreased barriers to medical care, increased the use of outpatient services and prescription drugs, and increased diagnoses of hypertension, compared to a control group with stable employer-sponsored insurance. Changes were largest among previously uninsured people with incomes of 138-250 percent of poverty, who were eligible for the ACA's cost-sharing reductions. Our quasi-experimental approach provides rigorous new evidence that the ACA's Marketplaces led to improvements in several important health care outcomes, particularly among low-income adults.

Despite Coverage Gains, One-Third Of People In Small-Firm Low-Income Families Were Uninsured In 2014-15.

Obtaining health insurance coverage has historically been challenging for workers at small firms and the self-employed. Using data from the Medical Expenditure Panel Survey, we found that the overall uninsurance rate for these workers and their families declined by 5 percentage points over the past decade, but one-third of those with lower incomes remained uninsured in 2014-15.

Medical Loss Ratios For California's Dental Insurance Plans: Assessing Consumer Value And Policy Solutions.

As a consumer protection, the Affordable Care Act (ACA) requires that large-group health plans spend at least 85 percent of all premium dollars on health services and quality improvement activities-thus giving the plans a medical loss ratio (MLR) of 85 percent. Small-group and individual plans must have an MLR of at least 80 percent. The ACA did not set minimum MLRs for dental plans. California passed a law in 2014 requiring dental plans to report MLRs but stopped short of setting minimum thresholds. We analyzed dental plans' MLRs reported in California for 2014 and 2015. The average MLR, weighted by covered lives, was 76 percent, with wide variation across product types and sizes. Few products sold by dental plans met the MLR thresholds set by the ACA, but many did meet or exceed other proposed thresholds. While millions of Californians were in large-group plans that achieved high MLRs, millions more were in other plans with relatively low MLRs. A legislatively mandated MLR would provide a standardized financial tool and potentially ensure value for dental insurance products. Given the multiplicity of dental products and the varying numbers of covered lives in those products, setting MLR thresholds poses a challenge for stakeholders.

New Risk-Adjustment Policies Reduce But Do Not Eliminate Special Enrollment Period Underpayment.

Millions of uninsured Americans do not sign up for available coverage despite job loss or other factors that would make them eligible for special enrollment periods (SEPs). Such periods let people enroll in nongroup insurance outside the usual open enrollment period for Marketplace coverage. Concerned that risk adjustment results in underpayment for the health risks associated with SEP enrollees, carriers rarely market their products to consumers eligible for SEPs, and many do not pay agents and brokers to enroll such consumers. To address the apparent underpayments, federal officials added enrollment duration factors that, starting in 2017, increased risk scores for SEP enrollees and other part-year members. Using individual-market claims data for 2015 from two large carriers, we found that risk adjustment did, in fact, undercompensate plans for part-year members. However, underpayment was much larger for SEP enrollees than for part-year members who joined during open enrollment periods. Short-term, urgent health problems appeared to drive enrollment more for SEP enrollees than for part-year members who signed up during open enrollment. We also found that the federal government's enrollment duration factors will remedy underpayment for part-year members whose coverage begins during open enrollment but leave carriers significantly underpaid for SEP enrollees. For carriers to recruit rather than avoid SEP enrollees, further increases to risk adjustment for such enrollees are likely needed.

ACA Marketplace Premiums Grew More Rapidly In Areas With Monopoly Insurers Than In Areas With More Competition.

Premiums have increased rapidly in the two most recent years of the health insurance Marketplaces, with notable variation across state rating areas. Some experts have speculated that these increases are due to greater enrollment among sicker patients, the expiration of market stabilization policies, or the federal government's discontinuation of funding for cost-sharing subsidies. However, these factors do not explain why some rating areas have experienced rapid premium growth, while others have experienced more modest increases. I used a comprehensive database of information about premiums and market characteristics for rating areas in states with federally facilitated Marketplaces to demonstrate that higher premiums are associated with local health insurance monopolies. In 2018, Marketplace premiums were 50 percent ($180) higher, on average, in rating areas with monopolist insurers, compared to those with more than two insurers. This was driven by large premium increases for the monopolist insurers' lowest-cost plans. Understanding how insurer competition has affected enrollment, costs, and quality will help guide future individual-market reforms.

Per Visit Emergency Department Expenditures By Insurance Type, 1996-2015.

Between 1996 and 2015, mean annual increases in per visit emergency department (ED) expenditures were significantly greater for private insurance than Medicare, Medicaid, and no insurance, with no corresponding difference in ED charges. Expenditures as a proportion of charges decreased for all insurers over time. Private insurance had the highest expenditure-to-charge ratio in each year.