Nyman John A
University of Minnesota, USA.
J Health Polit Policy Law. 2007 Oct;32(5):759-83. doi: 10.1215/03616878-2007-029.
Much American health policy over the past thirty-five years has focused on reducing the additional health care that is consumed when a person becomes insured, that is, reducing moral hazard. According to conventional theory, all of moral hazard represents a welfare loss to society because its cost exceeds its value. Empirical support for this theory has been provided by the RAND Health Insurance Experiment, which found that moral hazard--even moral hazard in the form of effective and appropriate hospital procedures--could be reduced substantially using cost-sharing policies with little or no measurable effect on health. This article critically analyzes these two cornerstones of American health policy. It holds that a large portion of moral hazard actually represents health care that ill consumers would not otherwise have access to without the income that is transferred to them through insurance. This portion of moral hazard is efficient and generates a welfare gain. Further, it holds that the RAND experiment's finding (that health care could be reduced substantially with little or no effect on health) may actually be caused by the large number of participants who voluntarily dropped out of the cost-sharing arms of the experiment. Indeed, almost all of the reduction in hospital use in the cost-sharing plans could be attributed to this voluntary attrition. If so, the RAND finding that cost sharing could reduce health care utilization, especially utilization in the form of effective and appropriate hospital procedures, with no appreciable effect on health is spurious. The article concludes by observing that the preoccupation with moral hazard is misplaced and has worked to obscure policies that would better reduce health care expenditures. It has also led us away from policies that would extend insurance coverage to the uninsured.
在过去35年里，美国的许多卫生政策都聚焦于减少人们参保后额外消费的医疗保健服务，即减少道德风险。根据传统理论，所有的道德风险都代表着社会福利损失，因为其成本超过了价值。兰德健康保险实验为这一理论提供了实证支持，该实验发现，通过成本分摊政策，道德风险——甚至是以有效且适当的医院诊疗程序形式存在的道德风险——可以大幅降低，而对健康几乎没有可衡量的影响。本文对美国卫生政策的这两大基石进行了批判性分析。文章认为，很大一部分道德风险实际上代表的是患病消费者在没有通过保险转移给他们的收入的情况下原本无法获得的医疗保健服务。这部分道德风险是有效率的，并产生了福利收益。此外，文章认为，兰德实验的发现（即可以大幅减少医疗保健服务而对健康几乎没有影响）可能实际上是由大量自愿退出实验成本分摊组的参与者导致的。事实上，成本分摊计划中医院使用量的几乎所有减少都可归因于这种自愿退出。如果是这样，兰德关于成本分摊可以减少医疗保健利用率，尤其是以有效且适当的医院诊疗程序形式存在的利用率，而对健康没有明显影响的发现就是虚假的。文章最后指出，对道德风险的过度关注是错误的，它掩盖了那些能更好地降低医疗保健支出的政策。它还使我们偏离了将保险覆盖范围扩大到未参保者的政策。
