An empirical examination of risk equalisation in a regulated community rated health insurance market

Despite universal access entitlements to the public healthcare system in Ireland, over half the population is covered by voluntary private health insurance. The market operates on the basis of community rating, open enrolment and lifetime cover. A set of minimum benefits also exists, and two risk equalisation schemes have been put in place but neither was implemented. These schemes have proved highly controversial. To date, the debate has primarily consisted of qualitative arguments. This study adds a quantitative element by analysing a number of pertinent issues. A model of a community rated insurance market is developed, which shows that community rating can only be maintained in a competitive market if all insurers in the market have the same risk profile as the market overall. This has relevance to the Irish market in the aftermath of a Supreme Court decision to set aside risk equalisation. Two reasons why insurers’ risk profiles might differ are adverse selection and risk selection. Evidence is found of the existence of both forms of selection in the Irish market. A move from single rate community rating to lifetime community rating in Australia had significant consequences for take-up rates and the age profile of the insured population. A similar move has been proposed in Ireland. It is found that, although this might improve the stability of community rating in the short term, it would not negate the need for risk equalisation. If community rating were to collapse then risk rating might result. A comparison of the Irish, Australian and UK health insurance markets suggests that community rating encourages higher take-up among older consumers than risk rating. Analysis of Irish hospital discharge figures suggests that this yields significant savings for the Irish public healthcare system. This thesis has implications for government policy towards private health insurance in Ireland.

Risk management and the potential of cattle insurance in Tigray, Northern Ethiopia

This study explores the role of livestock insurance to complement existing risk management strategies adopted by smallholder farmers. Using survey data, first, it provides insights into farmers’ risk perception of livestock farming, in terms of likelihood and severity of risk, attitude to risk and their determinants. Second, it examines farmers’ risk management strategies and their determinants. Third, it investigates farmers’ potential engagement with a hypothetical cattle insurance decision and their intensity of participation. Factor analysis is used to analyse risk sources and risk management, multiple regressions are used to identify the determinants; a Heckman model was used to investigate cattle insurance participation and intensity of participation. The findings show different groups of farmers display different risk attitude in their decision-making related to livestock farming. Production risk (especially livestock diseases) was perceived as the most likely and severe source of risk. Disease control was perceived as the best strategy to manage risk overall. Disease control and feed management were important strategies to mitigate the production risks. Disease control and participation on safety net program were found to be important to counter households’ financial risks. With regard to the hypothetical cattle insurance scheme, 94.38% of households were interested to participate in cattle insurance. Of those households that accepted cattle insurance, 77.38% of the households were willing to pay the benchmark annual premium of 4% of the animal value while for the remaining households this was not affordable. The average number of cattle that farmers were willing to insure was 2.71 at this benchmark. Results revealed that income (log income) and education levels influenced positively and significantly farmers’ participation in cattle insurance and the number of cattle to insure. The findings prompt policy makers to consider livestock insurance as a complement to existing risk management strategies to reduce poverty in the long-run.

Private health care coverage and increased risk of obstetric intervention

Background: When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Methods: Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. Results: 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Conclusions: Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.

Public evaluations of novel food technologies: a qualitative citizen-scientist deliberative discourse approach

This qualitative research expands understanding of how information about a range of Novel Food Technologies (NFTs) is used and assimilated, and the implications of this on the evolution of attitudes and acceptance. This work enhances theoretical and applied understanding of citizens’ evaluative processes around these technologies. The approach applied involved observations of interactive exchanges between citizens and information providers (i.e. food scientists), during which they discussed a specific technology. This flexible, yet structured, approach revealed how individuals construct meaning around information about specific NFTs. A rich dataset of 42 ‘deliberate discourse’ and 42 postdiscourse transcripts was collected. Data analysis encompassed three stages: an initial descriptive account of the complete dataset based on the top-down bottom-up (TDBU) model of attitude formation, followed by inductive and deductive thematic analysis across the selected technology groups. The hybrid thematic analysis undertaken identified a Conceptual Model, which represents a holistic perspective on the influences and associated features directing ‘sense-making’ and ultimate evaluations around the technology clusters. How individuals make sense of these technologies is shaped by: their beliefs, values and personal characteristics; their perceptions of power and control over the application of the technology; and, the assumed relevance of the technology and its applications within different contexts. These influences form the frame for the creation of sense-making around the technologies. Internal negotiations between these influences are evident and evaluations are based on the relative importance of each influence to the individual, which tend to contribute to attitude ambivalence and instability. The findings indicate the processes of forming and changing attitudes towards these technologies are: complex; dependent on characteristics of the individual, technology, application and product; and, impacted by the nature and forms of information provided. Challenges are faced in engaging with the public about these technologies, as levels of knowledge, understanding and interest vary.