Address correspondence to Avi Dor, Ph.D., John R. Mannix Medical Mutual Professor of Health Care Economics, Weatherhead School of Management, Case Western Reserve University, Peter B. Lewis Building, 11119 Bellflower Rd., Cleveland, OH 44128-7235. Joseph J. Sudano, Jr., Ph.D. Assistant Professor, is with the Department of Epidemiology and Biostatics and Center for Healthcare Research and Policy, Case Western Reserve University School of Medicine at the MetroHealth System, Cleveland, OH. David W. Baker, M.D. M.P.H., Chief, is with the Division of General Internal Medicine, Feinberg School of Medicine of Northwestern University, Chicago, IL.
The Effect of Private Insurance on the Health of Older, Working Age Adults: Evidence from the Health and Retirement Study
Article first published online: 21 FEB 2006
Health Services Research
Volume 41, Issue 3p1, pages 759–787, June 2006
How to Cite
Dor, A., Sudano, J. and Baker, D. W. (2006), The Effect of Private Insurance on the Health of Older, Working Age Adults: Evidence from the Health and Retirement Study. Health Services Research, 41: 759–787. doi: 10.1111/j.1475-6773.2006.00513.x
- Issue published online: 21 FEB 2006
- Article first published online: 21 FEB 2006
- health scores;
- health status;
- endogeneity bias;
- instrumental variables
Objective. Primarily, to determine if the presence of private insurance leads to improved health status, as measured by a survey-based health score. Secondarily, to explore sensitivity of estimates to adjustments for endogeneity. The study focuses on adults in late middle age who are nearing entry into Medicare.
Data Sources. The analysis file is drawn from the Health and Retirement Study, a national survey of relatively older adults in the labor force. The dependent variable, an index of 5 health outcome items, was obtained from the 1996 survey. Independent variables were obtained from the 1992 survey. State-level instrumental variables were obtained from the Area Resources File and the TAXSIM file. The final sample consists of 9,034 individuals of which 1,540 were uninsured.
Study Design. Estimation addresses endogeneity of the insurance participation decision in health score regressions. In addition to ordinary least squares (OLS), two models are tested: an instrumental variables (IV) model, and a model with endogenous treatment effects due to Heckman (1978). Insurance participation and health behaviors enter with a lag to allow their effects to dissipate over time. Separate regressions were run for groupings of chronic conditions.
Principal Findings. The OLS model results in statistically significant albeit small effects of insurance on the computed health score, but the results may be downward biased. Adjusting for endogeneity using state-level instrumental variables yields up to a six-fold increase in the insurance effect. Results are consistent across IV and treatment effects models, and for major groupings of medical conditions. The insurance effect appears to be in the range of about 2–11 percent. There appear to be no significant differences in the insurance effect for subgroups with and without major chronic conditions.
Conclusions. Extending insurance coverage to working age adults may result in improved health. By conjecture, policies aimed at expanding coverage to this population may lead to improved health at retirement and entry to Medicare, potentially leading to savings. However, further research is needed to determine whether similar results are found when alternative measures of overall health or health scores are used. Future research should also explore the use of alternative instrumental variables. Preliminary results provide no justification for targeting certain subgroups with susceptibility to certain chronic conditions rather than broad policy interventions.