Doctors are not allowed to offer most services privately. The main role of health insurance in Canada is to cover prescription costs and dental care, which are not funded publicly. In most other countries, there is a mixture of public and private health care. The United Kingdom, for example, has a publicly funded health care system, but some individuals buy insurance to have access to a private system that operates side by side with the public system. (The main advantage of private health insurance is a reduction in waiting times for routine elective surgery.)
In 2010, President Obama signed into law the Patient Protection and Affordable Care Act in an attempt to reform health care in the United States and increase the number of people with medical coverage. The eligibility for Medicaid (a program for low income individuals) was expanded and subsidies were provided for low and middle income families to help them buy insurance. The act prevents health insurers from taking pre-existing medical conditions into account and requires employers to provide coverage to their employees or pay additional taxes. One difference between the United States and many other countries continues to be that health insurance is largely provided by the private rather than the public sector.
In health insurance, as in other forms of insurance, the policyholder makes regular premium payments and payouts are triggered by events. Examples of such events are the policyholder needing an examination by a doctor, the policyholder requiring treatment at a hospital, and the policyholder requiring prescription medication. Typically the premiums increase because of overall increases in the costs of providing health care. However, they usually cannot increase because the health of the policyholder deteriorates. It is interesting to compare health insurance with auto insurance and life insurance in this respect. An auto insurance premium can increase (and usually does) if the policyholder's driving record indicates that expected payouts have increased and if the costs of repairs to automobiles have increased. Life insurance premiums do not increase – even if the policyholder is diagnosed with a health problem that significantly reduces life expectancy. Health insurance premiums are like life insurance premiums in that changes to the insurance company's assessment of the risk of a payout do not lead to an increase in premiums. However, it is like auto insurance in that increases in the overall costs of meeting claims do lead to premium increases.
Of course, when a policy is first issued, an insurance company does its best to determine the risks it is taking on. In the case of life insurance, questions concerning the policyholder's health have to be answered, pre-existing medical conditions have to be declared, and physical examinations may be required. In the case of auto insurance, the policyholder's driving record is investigated. In both of these cases, insurance can be refused. In the case of health insurance, legislation sometimes determines the circumstances under which insurance can be refused. As indicated earlier, the Patient Protection and Affordable Health Care Act makes it very difficult for insurance companies in the United States to refuse applications because of pre-existing medical conditions.
Health insurance is often provided by the group health insurance plans of employers. These plans typically cover the employee and the employee's family. The cost of the health insurance is sometimes split between the employer and employee. The expenses that are covered vary from plan to plan. In the United States, most plans cover basic medical needs such as medical check-ups, physicals, treatments for common disorders, surgery, and hospital stays. Pregnancy costs may or may not be covered. Procedures such as cosmetic surgery are usually not covered.
3.7 MORAL HAZARD AND ADVERSE SELECTION
We now consider two key risks facing insurance companies: moral hazard and adverse selection.
Moral Hazard
Moral hazard is the risk that the existence of insurance will cause the policyholder to behave differently than he or she would without the insurance. This different behavior increases the risks and the expected payouts of the insurance company. Three examples of moral hazard are:
1. A car owner buys insurance to protect against the car being stolen. As a result of the insurance, he or she becomes less likely to lock the car.
2. An individual purchases health insurance. As a result of the existence of the policy, more health care is demanded than previously.
3. As a result of a government-sponsored deposit insurance plan, a bank takes more risks because it knows that it is less likely to lose depositors because of this strategy. (This was discussed in Section 2.3)
Moral hazard is not a big problem in life insurance. Insurance companies have traditionally dealt with moral hazard in property-casualty and health insurance in a number of ways. Typically there is a deductible. This means that the policyholder is responsible for bearing the first part of any loss. Sometimes there is a co-insurance provision in a policy. The insurance company then pays a predetermined percentage (less than 100 %) of losses in excess of the deductible. In addition there is nearly always a policy limit (i.e., an upper limit to the payout). The effect of these provisions is to align the interests of the policyholder more closely with those of the insurance company.
Adverse Selection
Adverse selection is the phrase used to describe the problems an insurance company has when it cannot distinguish between good and bad risks. It offers the same price to everyone and inadvertently attracts more of the bad risks. If an insurance company is not able to distinguish good drivers from bad drivers and offers the same auto insurance premium to both, it is likely to attract more bad drivers. If it is not able to distinguish healthy from unhealthy people and offers the same life insurance premiums to both, it is likely to attract more unhealthy people.
To lessen the impact of adverse selection, an insurance company tries to find out as much as possible about the policyholder before committing itself. Before offering life insurance, it often requires the policyholder to undergo a physical examination by an approved doctor. Before offering auto insurance to an individual, it will try to obtain as much information as possible about the individual's driving record. In the case of auto insurance, it will continue to collect information on the driver's risk (number of accidents, number of speeding tickets, etc.) and make year-to-year changes to the premium to reflect this.
Adverse selection can never be completely overcome. It is interesting that, in spite of the physical examinations that are required, individuals buying life insurance tend to die earlier than mortality tables would suggest. But individuals who purchase annuities tend to live longer than mortality tables would suggest.
3.8 REINSURANCE
Reinsurance is an important way in which an insurance company can protect itself against large losses by entering into contracts with another insurance company. For a fee, the second insurance company agrees to be responsible for some of the risks that have been insured by the first company. Reinsurance allows insurance companies to write more policies than they would otherwise be able to. Some of the counterparties in reinsurance contracts are other insurance companies or rich private individuals; others are companies that specialize in reinsurance such as Swiss Re and Warren Buffett's company, Berkshire Hathaway.
Reinsurance contracts can take a number of forms. Suppose that an insurance company has an exposure of $100 million to hurricanes in Florida and wants to limit this to $50 million. One alternative is to enter into annual reinsurance contracts that cover on a pro rata basis 50 % of its exposure. (The reinsurer would then probably receive 50 % of the premiums.) If hurricane claims in a particular year total $70 million, the costs to the insurance company would be only 0.5 × $70 or $35 million, and the reinsurance company would pay the other $35 million.
Another more popular alternative, involving lower reinsurance premiums, is to buy a series of reinsurance contracts covering what are known as excess cost layers. The first layer might provide indemnification for losses between $50 million and $60 million, the next layer might cover
