Does It Matter if Your Health Insurer Is For Profit? Effects of Ownership on Premiums, Insurance Coverage, and Medical Spending

Leemore S. Dafny

Article | American Economic Journal: Economic Policy | February 2019

Does It Matter if Your Health Insurer Is For Profit? Effects of Ownership on Premiums, Insurance Coverage, and Medical Spending

Abstract

There is limited empirical evidence about the impact of for-profit health insurers on various outcomes. I study the effects of conversions to for-profit status by Blue Cross Blue Shield (BCBS) affiliates in 11 states, spanning 28 geographic markets. I find both the BCBS affiliate and its rivals increased premiums following conversions in markets where the converting affiliate had substantial market share. Medicaid enrollment rates also increased in these markets, a pattern consistent with "crowd in" of families who were formerly privately insured. The results suggest for-profit insurers are likelier than not-for-profit insurers to exercise market power when they possess it.

Keywords: health insurance; medical loss ratio; Blue Cross; Corporate Governance; Health; Insurance; For-Profit Firms; Insurance Industry; United States;

Format: Print

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Citation:

Dafny, Leemore S. "Does It Matter if Your Health Insurer Is For Profit? Effects of Ownership on Premiums, Insurance Coverage, and Medical Spending." American Economic Journal: Economic Policy 11, no. 1 (February 2019): 222–265.

In July 2017, CEO Kevin Tabb of Boston's Beth Israel Deaconess Medical Center announced his plan to consolidate 11 Massachusetts hospitals under a common management structure. These hospitals collectively generated $5 billion in patient revenue and 25% of privately-insured hospital stays in the state. The merger would create a credible competitor to Partners Healthcare, the state's dominant health care provider, but would potentially reduce competition and raise prices. State regulators were assessing the merger, and Tabb needed to argue its merits.

We consider the effect of mergers between firms whose products are not viewed as direct substitutes for the same good or service but are bundled by a common intermediary. Focusing on hospital mergers across distinct geographic markets, we show that such combinations can reduce competition among merging hospitals for inclusion in insurers' networks, leading to higher prices (or lower-quality care). Using data on hospital mergers from 1996 to 2012, we find support that this mechanism operates within state boundaries: cross-market, within-state hospital mergers yield price increases of 7%–9% for acquiring hospitals, whereas out-of-state acquisitions do not yield significant increases.

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Does It Matter if Your Health Insurer Is For Profit? Effects of Ownership on Premiums, Insurance Coverage, and Medical Spending

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