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Insurance Health Impacts on Health and Non-Medical Consumption in a Developing Country

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  • Health Insurance Impacts on Health and
    Nonmedical Consumption in a Developing Country
    Adam Wagstaff
    Development Research Group and East Asia Human Development Unit
    The World Bank, Washington DC, USA
    Menno Pradhan
    Indonesia Resident Mission
    The World Bank, Jakarta, Indonesia
    World Bank Policy Research Working Paper 3563, April 2005
    The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange
    of ideas about development issues. An objective of the series is to get the findings out quickly, even if the
    presentations are less than fully polished. The papers carry the names of the authors and should be cited
    accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors.
    They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they
    represent. Policy Research Working Papers are available online at http://econ.worldbank.org.
    Corresponding author and contact details: Adam Wagstaff, The World Bank, 1818 H Street NW, Washington,
    D.C. 20433, USA. Tel. (202) 473-0566. Fax (202)-522-1153. Email: awagstaff@worldbank.org.
    Acknowledgements: We are grateful for comments on an earlier version to Martin Ravallion and to participants
    at the International Health Economics Association Meeting in San Francisco in 2003, and faculty and students at
    Tinbergen University.
    WPS3563
  • ii
    Summary
    We examine the effects of the introduction of Vietnam’s health insurance (VHI) program on health outcomes, health
    care utilization, and nonmedical household consumption. The use of panel data collected before and after the
    insurance program’s introduction allows us to eliminate any confounding effects due to selection on time-invariant
    unobservables, and our coupling of propensity score matching with a double-difference estimator allows us to reduce
    the risk of biases due to inappropriate specification of the outcome regression model. Our results suggest that
    Vietnam’s health insurance program impacted favorably on height-for-age and weight-for-age of young school
    children, and on body mass index among adults. Our results suggest that among young children, VHI increases use
    of primary care facilities, and leads to a substitution away from the use of pharmacists as a source of advice and
    non-prescribed medicines toward the use of them as a supplier of medicines prescribed by a health professional.
    Among older children and adults, VHI results in a marked increase in the use of hospital inpatient and outpatient
    departments. Our results also suggest that VHI causes a reduction in annual out-of-pocket expenditures on health,
    and an increase in nonmedical household consumption, including food consumption but mostly non-food
    consumption. Our estimate of the VHI-induced reduction in out-of-pocket health spending is considerably smaller
    than our estimate of the VHI-induced increase in nonmedical consumption, which is consistent with the idea that
    households hold back their household consumption considerably if, through lack of health insurance, they are
    exposed to the risk of large out-of-pocket expenditures. This is especially plausible in a country where at the time
    (1993), a single visit to a public hospital cost on average the equivalent of 20% of a person’s annual non-food
    consumption.
    Keywords: Health insurance; impact evaluation.
    JEL codes: I1, O1
  • 1
    I. INTRODUCTION
    Policy toward health insurance requires striking a balance between the benefits insurance
    brings and the costs and inefficiencies involved (cf. e.g. Arrow 1963, Feldstein 1973, Manning
    and Marquis 1996). Until recently, most of the empirical literature on health insurance was
    focused on the latter, and in particular on the market inefficiencies arising from information
    asymmetries between the insured and insurer, especially the issue of moral hazard. Recently, the
    literature has shifted focus somewhat toward the benefits of health insurance, and has had some
    second thoughts about the methods used hitherto to investigate moral hazard.
    Several recent studies investigate the benefits of health insurance in terms of improved
    health outcomes.
    1
    These include three recent studies of the expansion of Medicaid in the US,
    exploiting for identification purposes the fact that some states expanded eligibility more than
    others did and at different times (Currie and Gruber 1996b, Currie and Gruber 1996a, Currie and
    Gruber 1997). Currie and Gruber (1996a) find that Medicaid expansion significantly increased
    use of services among children and significantly reduced child mortality. Significant effects on
    low birthweight and infant mortality were found in another paper (Currie and Gruber 1996b),
    while in their third paper Currie and Gruber (1997) found that impacts on infant mortality were
    larger for mothers and infants living close to high-tech hospitals. Hanratty (1996) reports
    significant impacts on infant mortality of Canada’s health insurance program, the analysis again
    taking advantage of variations in the date of adoption of health insurance across geographic units
    (in this case provinces).
    In addition to the benefits in terms of better health, several other studies examine the
    issue of how far health insurance, through reducing uncertainty, enables households to reduce
    precautionary savings and labor supply. Gruber and Yelowitz (1999) find that Medicaid in the
    US led to a reduction in savings and an increase in consumption. Chou et al. (2003) find that the
    introduction of National Health Insurance (NHI) in Taiwan led to a reduction in precautionary
    savings and to an increase in consumption, while Chou and Staiger (2001) found Taiwan’s NHI
    led to a reduction in female labor force participation. The welfare implications of such findings
    are, of course, not straightforward: the case needs to be made—though it is surely a plausible
    one—that informal insurance devices, such as precautionary savings and diversification in
    household labor supply choices, are less efficient than formal health insurance.
    In a largely parallel literature, reservations have been expressed (cf. e.g. Cutler and
    Zeckhauser 2000, Vera-Hernandez 2003) about the tendency in the literature to equate moral
    hazard to the effect of insurance on medical care utilization.
    2
    Moral hazard, it noted, reflects an
    information asymmetry between the insured and insurer, and the fact that the parties cannot
    contract over an unobserved variable. To the extent that the insurer can infer the value of the
    unobservable variable from observable contractible variables, the problem of moral hazard
    diminishes, and at the limit disappears altogether. The degree to which this happens is
    independent of the elasticity of use with respect to insurance coverage. Indeed, the increased
    1
    See Levy and Meltzer (2001) for a very useful review of this literature.
    2
    Examples of recent studies in this genre include Waters (1999), Harmon and Nolan (2001), Sapelli and Vial (2003), Trujillo
    (2003), Jowett et al. (2003) and Savage and Wright (Jowett et al. 2003).

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Insurance Health Impacts on Health and Non-Medical Consumption in a Developing Country

Insurance Health Impacts on Health and Non-Medical Consumption in a Developing Country

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