Adverse selection is NOT the problem

by on December 13, 2005 at 7:16 am in Economics | Permalink

The adverse selection story is a wonderful example of McCloskey’s argument that great rhetoric persuades even when it shouldn’t.  The market for lemons is simple enough for your friends to understand but profound enough for them to be impressed at your learning, so it’s a hard story not to tell!      

The facts of the matter, however, are that adverse selection is not an important part of the market for automobiles (trucks), or of auto, life insurance or health insurance (on the latter see below).

One reason adverse selection may not be that important in practice is because buyers and sellers use testing and certification to remove the most important information asymmetries.  You can buy a decent used car, for example just get it inspected or certified.  Only if such adjustments are illegal, or in some other way not allowed, will adverse selection become important.

Second, the asymmetry may run in favor of the sellers.  Do I really know more about my own life expectancy than an insurance firm that has access to sophisticated actuarial models?  And, assuming that I do have extra information is it all that important?  After all "the race is not to the
swift, nor the battle to the strong, neither yet bread to the wise… but
time and chance happen to them all."  Or, more prosaically, the signal is near irrelevant when the noise to signal ratio is high.
 

Third, propitious selection can be more important than adverse selection.  What sort of person buys a lot of life insurance?  Is it people who expect to die soon?  Or is it the sort of person who is so worried about not leaving their family in trouble that not only do they buy life insurance they also buckle their safety belt and eat healthy?  The price of life insurance falls the more you buy so evidently insurance companies believe it is the latter.

Everyone talks about adverse selection in the market for health insurance but in fact non-group policies in these markets are not relatively expensive and not hard to get.  The national average annual premium for reasonably generous coverage for a single person is just $2,268.

Sure, that’s a lot of money but the point is that it’s not a lot relative to what an employed person and their employer would pay for similar coverage in the group market.  There is no evidence for an adverse-selection death spiral in the market for health insurance.  That’s not surprising because non-group health insurance is medically underwitten (i.e. medical inspections just like car inspections).  Most people are accepted a few are not.  Only in states that require insurance companies to accept all or most buyers are rates high relative to the group market (rates in New Jersey, an outlier, are almost three times as high as the national average.)

There are problems in the health insurance market, including a lack of long term insurance, job lock and the inequity of affordability, but adverse selection is not one of them.

Thanks to Bryan Caplan, Robin Hanson, Tyler Cowen, Tim Harford, and Ray Lehmann for discussion.

Addendum: Comments are open.

1 alkali December 13, 2005 at 9:53 am

“There is no evidence for an adverse-selection death spiral in the market for health insurance. That’s not surprising because non-group health insurance is medically underwitten (i.e. medical inspections just like car inspections). Most people are accepted a few are not.”

I’m not really sure what you’re trying to show. It is correct that “adverse selection death spirals” are not a problem in the health insurance marketplace because, as you note, insurance companies carefully avoid insuring sick people to avoid going broke by paying their health care bills. But I don’t think that when people complain about the problem of “adverse selection” in the health insurance marketplace they are concerned with the welfare of the insurance companies; rather, they are worried about the sick people who can’t get coverage. I may be missing your point here so I’d appreciate any clarification you can offer.

2 Alex Tabarrok December 13, 2005 at 10:16 am

To answer alkali’s question I am mostly speaking to economists who use the adverse selection argument to suggest that there is in a technical sense a “market failure” in health insurance markets. It’s not a market failure, however, if bad cars don’t sell for much. Nor is it a market failure if people who are born with medical problems have to pay a lot for health insurance. These are issues of distribution not efficiency. Issues of distribution are important, but we need to correctly understand the problem we are dealing with to have an appropriate solution.

Peter, the national average premium for family coverage is $4,424 – again not expensive relative to what you would pay in the group market.

3 cb December 13, 2005 at 11:03 am

My gut reaction is your on crack. I have never heard of anybody at anytime ever say that individual coverage is close to the cost of group coverage. I’ve looked into individual coverage during a period of self-employment, the cost was factors more than the $50 I pay now (my company is cheap, so I assume they don’t pay more than 50, probably 0).

At any rate, if there was a problem, it wouldn’t be markets, which I think is your point. Health insurance is probably the most regulated industry in the economy.

4 dsquared December 13, 2005 at 11:25 am

[Everyone talks about adverse selection in the market for health insurance but in fact non-group policies in these markets are not relatively expensive and not hard to get. The national average annual premium for reasonably generous coverage for a single person is just $2,268.]

I have a real problem with people using statements about pricing as evidence one way or the other on adverse selection. It’s meaningless. If you can price for a risk, it’s not a case of asymmetric information. What we need to hear about is the excess or co-pay; how does this differ between pooled and individual policies? Also that average is a somewhat misleading number because it’s the average over underwritten policies in cases when the denials rate was as high as 20%. If you cut out 20% of cases, of course the average is going to be lower; we would need to know the cost of providing insurance to the cases that were not underwritten to get a meainingful measure because not insuring a medical risk doesn’t make it go away.

And Alex’s “Second” above is a really bad argument about adverse selection. The overall signal/noise ratio may be low, but it will be higher in some cases than others and the high cases are the ones that create the problem.

5 ed December 13, 2005 at 11:51 am

Alex’s point is a good one, but easy to misunderstand.

The main problem with the “health insurance” system is one of distribution,
not insurance. We want to be able to efficiently redistribute from healthy
people to sick people. Large group employer policies do this to some degree,
but in general the free market is not designed to provide redistribution.

Imagine we had technology to perfectly predict everyones future health. Then
there would be no hidden information, no risk, and no need for classic “insurance.”
But society would still want a way to give resources to the sick people.

I wish Alex would tell us his opinion on why New Jersey has so much higher rates than states without community rating.

6 John Thacker December 13, 2005 at 1:05 pm

I wish Alex would tell us his opinion on why New Jersey has so much higher rates than states without community rating.

Alex, the above quote points something out, albeit indirectly, adverse selection can be a problem when laws prohibit the market from working.

Take “community rating,” for example. Depending on how fully implemented the system is, community rating forces insurers to sell to all people for the same price, regardless of health condition and other factors. Surely adverse selection is a problem in this case. People have an enormous incentive to buy more health insurance as their health worsens, and the insurance companies cannot price people differently. Since the insurance companies price insurance the same for everyone, and people can buy insurance at any time, it’s always worth it for sick people to buy insurance, but not worth it for healthy people to subsidize the sick people. If you’re healthy, it makes sense to wait until you get sick.

Adverse selection definitely happens, but it happens most strongly in situations where various consumer protection laws prevent sellers from acting on publically available information but buyers obviously can. There are situations where regulated markets are worse than both freer markets or socialized ones.

7 Joseph Heath December 13, 2005 at 1:20 pm

Alex is right in diagnosing a common fallacy: the problem of adverse selection (i.e. the efficiency loss) in health insurance is that low-risk individuals get priced out of the market, not that high risks have to pay too much. Similarly, the problem in used cars is that people with good used cars hold on to them, rather than sell them, because they can’t get a good price.

However, it is not useful simply to point to insurance rates for individuals (vs. group rates) as evidence that there is no adverse selection problem. Far more telling is the fact that so many individuals (young and in relatively good health) don’t buy it, at the supposedly bargain price of $2,268. I don’t know much about their utility functions (and I suspect Alex doesn’t either), so my inclination is to regard this pattern of market preference as significant. The more plausible conclusion is that the group rate is too high for many as well, but individuals who get health insurance through their employer either have no choice but to participate, don’t see the true cost of their policies, can’t opt out with full reimbursement (esp. regarding tax treatment of the benefit), etc.

With this in mind, consider the following argument: The fact that any solution to the problem of the uninsured seems to involve massive cross-subsidization (as one finds in group plans) is itself an argument in favor of social insurance. At least then the cross-subsidization has a principled and consistent basis, rather than being ad hoc and morally arbitrary.

Finally, to get back to used cars for a second — there have been a number of major initiatives in the past few decades, by manufacturers, dealers, and in consumer protection law, aimed precisely at correcting adverse selection problems in this market. The practice of offering warranties on used cars, which many dealers now do, is an example of a relatively recent innovation, aimed at correcting these problems. Note also that the price of used cars has steadily risen in the past decade as well (at least where I live). So one must be cautious in saying adverse selection is “not the problem” in this market. It’s not the problem anymore, but only because the market has been tweaked and regulated in various ways to fix the problem. It would become the problem again very quickly if these kludges were removed. Furthermore, because the problems involve information asymmetries, things have the potential to change very quickly. The most recent problem I had with my car involved a software glitch. It was solved by bringing it into the dealer for a firmware upgrade. My suspicion is that these sorts of problems would probably go undetected in a traditional car inspection.

8 Philippe December 13, 2005 at 3:32 pm

Isn’t the fact that insurance companies (and credit institutions etc…) have put in place tools to reduce information asymetry a proof of the existence of the adverse selection?

These tools allow insurers or creditors the ability to better gage a person’s risk, and thus better price their offer. Its a cost the insurers have to bear because there is not much one can do to convincingly signal one’s true risk level. In addition, the incentives in this respect work against the insurer: the “inseree” will try to present the best profile possible.

9 Unknown December 13, 2005 at 4:48 pm

“I don’t understand how wanting to stay healthy is a “lifestyle” choice…”

Because hardly anyone does even the basic things that are generally considered to be the components of a healthy lifestyle. Such things include regular exercise, maintaining a healthy weight, eating mostly healthy food, and avoiding constant stress. A study I read at

http://www.healthfinder.gov/news/newsstory.asp?docID=525339

estimated only 3% of the US population practices such healthy habits routinely.

Wanting to stay healthy and actually doing what it takes are not the same thing.

10 elliottg December 13, 2005 at 5:18 pm

I hope you stay well unknown, but that, to me, sounds like pretty lousy coverage at a relatively high price and that’s without knowing your copays and drug coverage. Also, Iowa health costs are less than the national average so you benefit from that as well.

11 ellliottg December 13, 2005 at 5:32 pm

Remember, just because you gamble and win, doesn’t mean it was a good bet.

12 Unknown December 13, 2005 at 5:36 pm

Do you also understand that the $4800 a year (to continue my case) for coverage (individual coverage btw) that employers pay comes out of the employee’s compensation? The marginal difference between the cost of an HSA and the cost of standard big company insurance is wasted money that could be put to more productive use elsewhere.

13 David Y. December 13, 2005 at 9:28 pm

To me Alex’s argument fails. The low figure cited for individual insurance is for a LIMITED TIME, usually one year. After which you policy is reevaluated and your premiums skyrocket. This doesn’t happen in a large group policy where there is still always a certain percentage of healthy people to share the costs.

14 anon December 13, 2005 at 9:40 pm

Just a quick question. What is the definition of ‘no adverse selection’ used here? Is it that the market leads to the complete information allocation and prices? How does the evidence cited support that?

I thought we could have an equilibrium in a model with advsere selection where everyone is insured, but the allocation is not optimal: a pooling (or even partially pooling) equilibrium. How does the evidence cited rule that out?

15 Dottore December 14, 2005 at 6:26 am

Here’s my comment on your LIFE insurance statement. You say, in part, “not only do they buy life insurance they also buckle their safety belt and eat healthy? The price of life insurance falls the more you buy so evidently insurance companies believe it is the latter.”

Since life insurance payout, unlike that for health insurance, is an all-or-nothing deal, aren’t the life insurance risk managers looking mainly at the likelihood of your dying within a set period (during which they can invest your premiums), rather than just the dollar payout of your policy? If that’s true, then isn’t the declining price of additional insurance more a case of declining marginal cost (for the company) for each $X-thousand of coverage rather than a link between the total dollar value of your policy and your risk of dying during that period?

16 Alex Tabarrok December 14, 2005 at 10:29 am

anony-mouse is correct, I meant to say the signal is near irrelevant when the noise to signal ratio is high. For the record, I have corrected in the original post.

17 joshg December 14, 2005 at 11:50 am

So give him some of your money, odograph.

18 Robert A. Book December 14, 2005 at 12:28 pm

Alex,

I think one bit of evidence you cited against adverse selection is actually evidence that there is adverse selection:

“Only in states that require insurance companies to accept all or most buyers are rates high relative to the group market (rates in New Jersey, an outlier, are almost three times as high as the national average.)”

So in states that require insurance companies to sell to everyone at the same price, prices are higher. This would be true only if, in those markets, people buying individual health insurance were sicker than average. Unless you believe that states with those laws have populations three times as sick as the national average, this can come about only through healthy people dropping out of the market — that is, only through adverse selection.

In addition, Devon M. Herrick at NCPA found that “[A]lmost one-third of the uninsured now live in households with annual incomes above $50,000 and one in five live in households earning more than $75,000 annually.”

If individual health insurance is as affordable as you say, we can only conclude that these people believe they are healthy enough that health insurance is not worth the price. Assuming they are not extraordinarily risk-seeking (opposite of risk-averse), this means their lack of insurance is evidence of adverse selection.

The fact that there is no “adverse-selection death spiral” (outside of New Jersey and other states that essentially implement adverse selection by law) does not mean that there is no adverse selection — it just means there is an equilibrium in which some healthy risk-averse (but not sufficiently so) people find health insurance to be too actuarially unfair for them to buy it.

19 Unknown December 14, 2005 at 1:07 pm

In my personal case Benard, the individual coverage – after factoring in taxes – is substantially less expensive. This is in part because the premium is so much lower (, in part because my premium is tax deductible (I’m self-employed), and in part because I put tax-free dollars into an HSA account.

20 odograph December 14, 2005 at 1:24 pm

Can you save me a little time? Doesn’t 25% leave the other 75%? On the surface you are telling me that the “11 modifiable risk factors” cause a minority “of total medical care costs for these companies.”

21 odograph December 14, 2005 at 1:33 pm

Sorry to tripple post, but note that some of these 11 “modifiable” factors also have been shown to be at least in part “heritable.” Twin studies.

22 elliottg December 14, 2005 at 1:59 pm

Unknown,

First, I think you don’t have the full picture and are full of arrogance about your good health. I start with the assumption that the insurance companies only underwrite when they can make a profit. Without risk aversion, there is no market for insurance (although there is still a reason to provide social insurance). Secondly, I’ll observe that $400 per month for a 37 year-old male with no dependents in a group plan is outrageous. I’m not saying you’re wrong, I’m saying the HR manager who is paying that in Iowa needs to be fired or investigated for receiving kickbacks. Finally, your personal situation has nothing to do with the policy debate we are engaging in. A 37 year old single male who is not so risk-averse that he is willing to tolerate a 1 million lifetime cap and limited renewal options if the problem spans several years is not the target of any reasonable policy person. I suspect that you are most excited about the tax advantages of your HSA and would consider, if legally allowed, to dispense with insurance entirely if you could retain the HSA.

23 Unknown December 14, 2005 at 2:26 pm

Elliottq-

First, I think you don’t have the full picture

And I’ve never claimed to have it. My first post about my personal situation was prefaced with “for what it is worth† and I think the other comments were pretty well moderated, until you tossed in the non sequitir about betting.

and are full of arrogance about your good health.

Hardly. I’m grateful for it and I know genetics plays a role, but in a family with incidences of high blood pressure and cancer, I also know that my diligence in taking care of myself plays a role as well. I do exercise, eat well, and avoid stress to the best of my ability.

Secondly, I’ll observe that $400 per month for a 37 year-old male with no dependents in a group plan is outrageous.

But common. These were standard in every company I’ve worked for since 1993 – and they were in CA, MN, and IA. The reason I think it occurs is because of competition for employees. Maybe it’s different in other industries, but in mine – software – these sorts of plans are completely normal and expected by most.

Finally, your personal situation has nothing to do with the policy debate we are engaging in.

My info was offered to contrast the line of thinking that individual insurance is as expensive or more than group insurance. Clearly that is not universally true. I am hardly the only case.

I suspect that you are most excited about the tax advantages of your HSA and would consider, if legally allowed, to dispense with insurance entirely if you could retain the HSA.

You mean have an IRA or 401k? You are wrong. I hardly want to be accountable for tens of thousands or more in medical bills if something catastrophic happened out of my control. If we didn’t have insurance when my wife became sick and needed 100k in care we would be in trouble. But that’s what insurance is supposed to be for – massive and uncommon medical costs. What I don’t want to do, on the other hand, is subsidize the bad habits of others to the extent possible.

24 jadagul December 14, 2005 at 3:21 pm

Odograph: “Maybe you have a tendency toward cancer X when exposed to environment Y. Is it a “market sucess” if you are charged for that?”

I won’t say that it’s a good thing, but yes, it is a market success. If you and the insurance company both know that you’ll cost significantly more than average, your payments would also be significantly higher than average; otherwise it’s just the other people subsidizing you. We as a society may decide that we want to subsidize the unusually sick, but I don’t think that group insurance plans are the right way to do that.

25 odograph December 14, 2005 at 4:28 pm

Haven’t we already decided, and it’s just that our method (mandates upon insurance companies) is less than perfect?

I’m in California where there are both regulations to encourage insurance companies to cover everyone, and a Major Risk Medical Insurance Program to pick up people refused by private carriers. We also, in an attempt to reduce the ability of insurance companies to play the genetics angle, and restrict their ability to genetic screening.

It is all in all, neither fish nor fowl, it is an attempt to hammer the private system into a socialized medicine work-alike. It becomes an adversarial system between insurance and oversight. I actually am a fair free marketeer, but think I might dislike such intensively “managed” markets more than I would hate a straight public service to replace them.

26 david December 15, 2005 at 4:24 am

Wow, four grand sounds pretty good to me. I will pay more than $11,000 for health insurance next year for my family, and that’s a small group rate HMO with a $25 copay. That rate is up 6.5% from this year. At least everything else is cheap in New York and the taxes are low.

I’d be just slightly more worried about adverse selection in a free market in health insurance if we actually had a free market in health insurance. For example, it would be great if that nice insurance company in Iowa could legally offer me a policy.

Am I just blinded by frustration or is it folly to be discussing an industry so intensely regulated by states, distorted by the historic third-party purchase by employers, and skewed by historically lower pre-tax costs for C corporations, as if it’s some textbook example of market failure?

27 david December 15, 2005 at 3:21 pm

That’s a neat trick Tony. Set the initial conditions such that the insurance company can never be profitable. Maybe there are some other reasons health insurance is so expensive besides adverse selection:

1. No deductible. All expenses after a miniscule co-pay are covered. In essence your health plan is part insurance and part prepaid expenses, usually prepaid by someone else. Why not run to the doctor for every little sniffle? Talk about subsidizing other’s lifestyles. HSA’s may help eventually but, at least in my state, they are not yet a competitive product.

2. Zero competition. One way to maximize profits is to offer insurance to only the healthy; the other way is to spread the risk across many people as possible. To some that means a universal system. Why not try a national market in health insurance first? Why average costs over county-sized parcels (community rating) when there’s a whole wide world of conusmers out there? Let insurance providers compete nationally.

3. Values skewed by tax policy and third-party purchasing. Buy a non-group plan and not only do you pay a premium 30% higher than even a group of two, you pay with after-tax money. No wonder it’s corporations buying all the insurance. Employers get value out of each health insurance dollar that individual buyers don’t see. Health insurance has value as alternative untaxed compensation to attract and retain employees. Get employers out of the business of providing and paying for insurance, and let everyone (or no one) pay with pre-tax money.

28 UberIcarus December 20, 2005 at 5:29 am

I was of the oppinion that the primary cause of “market failure” in the case of provision of medical care was simply non-price factors of demand. Wouldn’t that be more important that the existance or non-existance of information asymetry? To put it another way:

Those who argue that its a distributional issue are correct, because even if the insurance providers did have perfect information in reguards to an individuals health, it would still be priced inefficiently in accordance to actual demand. (E.g., I want people I’ve never met to be vaccinated against communicable diseases even if they can’t afford the cost of the shot.)

However information asymetry does exist, but the analysis that certification and independant verification reduces the effect of a “market of lemons” is also correct. The primary basis of the successful utilization of these information correcting processes is the reputation and objectivity of the 3rd party however. If the system of trust breaks down between buyer, seller, and certifier, then a market of lemons prevails. Likewise, if for some reason the data-set involved in accurately forecasting information is simply too variable, the reliability of data-correction through 3rd party certification is increadibly suspect. The health of any given person is a good example of that. And in fact the asymetry is likely to favor neither the buyer nor seller, as its likely to simply put the market well under equilibrium. A particular individual may have knowledge his insurance company does not have, but the insurance company is likely to experience significant losses if it didn’t attempt to account for lack of particular knowledge. Ergo, you may also have knowledge of your own particular health which may be hard or impossible to prove to an insurer, that would qualify you for a much lower rate. However the insurer has to assume you may have knowledge that they don’t which would put you in a higher category.

Thus over-all demand is diminished due to pricing having to be somewhere above what a person might be on a completely “objective” scale of health, while at the same time those who do fit a perfectly objectively healthy archetype are overcharged.

29 icci harambre April 15, 2006 at 4:47 pm

Paris

Hover above Paris as you dine on a three-course dinner in the bustling first-floor restaurant of the Eiffel Tower. Then board a boat and cruise under the Seine’s illuminated bridges.

http://geocities.com/bblessme1st2/classic_blue.html

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