The Geneva Papers, 2008, 33, (627644)

r 2008 The International Association for the Study of Insurance Economics 1018-5895/08
www.palgrave-journals.com/gpp

Health Insurance and Lifestyle Choices: Identifying

Ex Ante Moral Hazard in the US Market
Anderson E. Stanciole
Department of Economics and Related Studies, University of York, Heslington, York YO10 5DD, UK.
E-mail: [email protected]

There is extensive debate in the literature about the practical significance of ex ante moral
hazard in health insurance markets. This paper uses data from the U.S. Panel Study
of Income Dynamics (19992003) to estimate a structural model of individual choice of
insurance coverage and four lifestyle decisions: heavy smoking, heavy drinking, lack of
exercise and obesity. The results show that health insurance has significant incentive effects
on lifestyle choices, increasing the propensity to heavy smoking, lack of exercise and
obesity and decreasing the propensity to heavy drinking. There is also significant
correlation between the errors of each equation. The results might have implications for the
design of health financing policies.
The Geneva Papers (2008) 33, 627644. doi:10.1057/gpp.2008.27

Keywords: ex ante moral hazard; health insurance; lifestyle choices; maximum simulated
likelihood

Introduction
Moral hazard is an important concept in health economics that refers to the incentive
for individuals that are covered by health insurance to change their behaviour in ways
that increase the risk of loss for the insurer. According to Zweifel and Manning,1 it is
possible to distinguish two types of moral hazard behaviour in health insurance
markets. First, under ex ante moral hazard, the risk of loss increases before a medical
event as individuals behave in more risky ways, therefore making the loss event more
likely to occur. Second, under ex post moral hazard, the individual utilisation of health
care services increases after the event as a result of more intensive use of medical
resources.
Ehrlich and Becker2 were among the first to propose a model describing the complex
relationship between health insurance and preventive activities. While some kinds of
preventive actions are complementary to market insurance, others can be shown to be
substitutes. In some circumstances, health insurance coverage may imply that
individuals become less concerned about their future health. This might affect the
demand for preventive health services and individual lifestyle choices that influence
future health.

1
Zweifel and Manning (2000).
2
Ehrlich and Becker (1972).
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628

Until recently, there has been a widespread view in the literature that, although
a theoretical possibility, ex ante moral hazard has possibly limited practical con-
sequences for health insurance markets. Some authors3 have suggested that the welfare
loss from ex ante moral hazard is probably small because health insurance offers
incomplete coverage. Although the monetary component is covered, there are still
significant utility losses in terms of pain and suffering, which reduce individual
incentives to engage in harmful activities.4 In other words, risk aversion contributes to
make indeterminate the effect of insurance coverage on preventive activities.5
In the empirical literature, several studies support the view that ex ante moral
hazard has limited importance for health insurance markets. Kenkel6 studied the
influence of private insurance on the demand for preventive health care (breast exams
and pap tests), finding important life cycle and schooling effects. Kenkel7 finds that the
use of preventive services decreases with age, which suggests an adaptation to a
shortening payoff period to investment in prevention. Increasing coverage for curative
services also increases the demand for preventive care because the out-of-pocket cost is
reduced.8 This suggests that the two types of care are complements and may serve as
substitutes for a patients own preventive effort.
Courbage and Coulon9 investigate how private health insurance affects the demand
for preventive care (insured) and individual behaviours (non-insured) in the U.K.
Health insurance coverage might increase the demand for insured preventive services
simply because the direct cost for the patient is reduced. However, it is unlikely to
increase non-insured activities. Therefore, the fact that preventive care is insured while
preventive activities are not insured helps to disentangle the ex ante and ex post moral
hazard effects. Their results, based on univariate probit regressions that control
unobservable characteristics using an instrumental variables strategy, suggest that
private health insurance increases the probability of exercising and undergoing breast
screening and reduces the probability of smoking. The authors argue that this might be
due to the fact that insurance makes individuals more concerned about the risks they
are facing.
In recent years, new studies have provided additional evidence on the existence of
ex ante moral hazard. Dave and Kaestner10 have explored the effect of health
insurance on health behaviours in the U.S., arguing that there is a direct (ex ante moral
hazard) and indirect effect. The indirect effect works through increased contact with
health professionals, which might improve health information and reduce the
probability of illness.

3
For example, Kenkel (2000) and Zweifel and Manning (2000).
4
A similar argument should also apply to workers compensation. The possibility of serious health
consequences should make it unlikely that more generous benefits induce workers to become more
reckless. However, several studies have documented this effect.
5
Zweifel and Manning (2000).
6
Kenkel (1994).
7
Ibid.
8
See also Courbage and Coulon (2004) and Pagan et al. (2007).
9
Courbage and Coulon (2004).
10
Dave and Kaestner (2006).
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
629
11
Focusing on the effect of health knowledge on health behaviour, Kenkel also
tests the hypothesis that increased contact with health professionals granted by
health insurance might improve health knowledge and decrease the propensity to
engage in harmful health-related behaviours. The results show that health knowledge
decreases smoking and heavy drinking, and increases exercise, but there is still a
significant influence of schooling. This suggests the existence of unobservable
factors that affect both schooling and health-related behaviour. Similarly, Zweifel
and Manning12 comment on the likely endogeneity between insurance coverage and
wage income.
A major point in Dave and Kaestners13 study is to consider the exogenous change
in insurance status that takes place as people above 65 years old become automatically
eligible for Medicare in the U.S. This allows the identification of the ex ante moral
hazard since insurance coverage is independent from health-related behaviour.
Likewise, Bhattacharya and Sood14 research the relation between insurance and
obesity. They show that, when premiums are not risk rated for obesity, there is a
significant negative externality on non-obese enrollees, which appears because obese
enrollees have higher expected medical expenditures.
Another important question relates to the relationship between health risk and
insurance demand. Some studies15 find evidence of a positive relationship between
health risk and insurance demand, which is consistent with the existence of adverse
selection in the insurance market. Likewise, Courbage and Rey16 argue that the fear of
sickness exerts a positive influence on the level of effort to prevent the occurrence
of sickness. However, other empirical evidence suggests the opposite, that health risk
is negatively associated with insurance coverage. For example, Finkelstein and
McGarry17 find that individuals who invest more on prevention and therefore have
lower risk, also spend more on insurance. This might be explained by other
unobserved characteristics that are positively related to coverage and negatively
related to risk occurrence,18 for instance, if those who purchase health insurance are
more risk-averse. This also provides some support for the idea of propitious selection,
which according to Thomas19 is the idea that purchasing more insurance is
sometimes associated with lower risk, not higher risk.20
Recent studies21 show that lifestyle choices are an important determinant of
individual health. Habits like smoking or excess drinking have harmful effects on
health status and increase the probability of disease and premature death. As a

11
Kenkel (1991).
12
Zweifel and Manning (2000).
13
Dave and Kaestner (2006).
14
Bhattacharya and Sood (2006).
15
For example, Cardon and Hendel (2001) and Bundorf et al. (2005).
16
Courbage and Rey (2006).
17
Finkelstein and McGarry (2003).
18
Ibid.
19
Thomas (2007).
20
See also Pauly and Held (1990), Hemenway (1990, 1992), Chiappori and Salanie (2000), de Meza and
Webb (2001) and de Donder and Hindriks (2006).
21
For example, Contoyannis and Jones (2004) and Balia and Jones (2005).
The Geneva Papers on Risk and Insurance Issues and Practice
630

result, health care expenses are also adversely affected, imposing external costs on
society.
Manning et al.22 have shown that, apart from the internal costs imposed on the
individual and the family, over the lifetime each smoker creates an external cost of 15
cents per pack of cigarettes in terms of increased medical expenses and fire damage,
and of lower income taxation.23 Some studies suggest that, due to lower life
expectancy, smokers on average can expect to make positive net contributions to
Social Security. Even after controlling for this, Sloan et al.24 estimate the lifetime total
social cost of smoking at $106,000 for a woman and $220,000 for a man. The study by
Bhattacharya and Sood25 cited above estimates that uniform insurance premiums
impose an externality of $150 per capita per year on non-obese enrollees resulting from
increased health expenditures incurred by obese enrollees.
To date most empirical papers have tended to focus on the demand for preventive
services or diagnostic tests.26 By focusing on the effect of health insurance on lifestyle
choices this study fills an important gap, which has implications for the design of
both private plans and public systems of social security.27 In particular, to the extent
that health insurance coverage induces greater engagement in harmful lifestyle
choices, the results suggest that health insurance plans might consider introducing
incentives to reduce the possible impact in terms of higher expected costs. This might
include, for example, the introduction of risk-rated premiums whereby individual
contributions are adjusted according to whether or not the patient engages in harmful
activities.
Since this paper focuses on the U.S. institutional background as an illustration for
the issue of ex ante moral hazard in health insurance markets, a few words about the
American health insurance system are in order. The health insurance coverage system
for the adult working-age population in the U.S. is based on a combination of
different programmes. The Kaiser Family Foundation28 estimates that of the total
260 million U.S. non-elderly population in 2006, 61 per cent were covered by
employer-sponsored insurance, 5 per cent by private non-group plans, 16 per cent
by Medicaid and other public programmes and 18 per cent were uninsured. In
addition, the federal and state governments provide specific coverage programmes for
the elderly (Medicare, which automatically covers all persons above 65 years) and for
vulnerable populations (Medicaid, which provides coverage for low-income families
and other groups). As a general rule, health insurance coverage is not mandatory in
most states.
This paper is organised as follows. The following section describes the data set used
for this study, the waves of 1999, 2001 and 2003 of the Panel Study of Income
Dynamics (PSID). The econometric strategy and the estimated models are discussed in

22
Manning et al. (1991).
23
In 1986 U.S. dollars. For comparison, the price of a pack of cigarettes was about US$1.
24
Sloan et al. (2004).
25
Bhattacharya and Sood (2006).
26
For example, Kenkel (1994).
27
Courbage and Coulon (2004).
28
Kaiser Family Foundation (2006).
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
631

the subsequent section. The penultimate section then presents the results and the final
section concludes.

Data
The data used in this paper comes from the PSID. The PSID is a nationally
representative longitudinal study of nearly 8,000 U.S. families, which has been
following the same families and individuals since 1968. We analyse the waves of 1999,
2001 and 2003, which contain the information relative to lifestyle choices, health
insurance status and other indicators of health status that are relevant for this analysis.
We use a balanced sample of 5,126 individuals. The sample includes only the heads of
each household, which are all adult individuals (17 years and above).
Our main dependent variable (insured ) is a binary indicator equal to one if the
individual is covered by health insurance and zero otherwise. This variable is allowed
to change over time. Due to data limitations in the PSID survey it is not possible to
identify the type of insurance plan that the individual has, whether employer-
sponsored, private or publicly provided such as Medicare/Medicaid. Moreover, we
have no information about the amount of premiums and other co-payments that the
individual eventually pays in connection with the insurance coverage. On average 93
per cent of individuals in the sample are covered by health insurance.
Table 1 provides some descriptive statistics separating the sample into insured and
uninsured individuals. We notice several differences between the two sub-samples. The
uninsured sample can be considered more socio-economically deprived in many
aspects. For instance, the average family income is less than half that of the insured
sample (US$25,858 vs. US$62,609), and the average schooling is also lower. While
in the insured sample 20 per cent of the individuals have only primary education
and 48 per cent have college education, in the uninsured the proportions are
practically inversed (44 and 21 per cent, respectively). The unemployment rate is
markedly higher in the uninsured sample (14 per cent vs. 5 per cent in the insured
sample), but the proportion of retired people is lower (10 per cent vs. 18 per cent).
Finally, the combined proportion of African-American and Hispanic individuals
is almost double among the uninsured compared to the insured (57 per cent vs.
32 per cent).
Let us focus on the observed prevalence of the lifestyle choices. In almost all cases,
the uninsured tend to lead a less health-conscious lifestyle. They tend to smoke more
(5 per cent of heavy smokers compared to 3 per cent in the uninsured sample), drink
more alcohol (8 per cent vs. 4 per cent of heavy drinkers) and to be more sedentary
(16 per cent vs. 11 per cent). With respect to the prevalence of obesity, however, the
two groups fare very similarly (25 per cent vs. 26 per cent).
For almost all health condition indicators the insured group reports higher
prevalence rates, both for lifestyle-related (stroke, high blood pressure, diabetes,
cancer, heart attack and coronary heart disease) and unrelated conditions (arthritis
and loss of mental ability). The proportion of individuals with fair or poor
self-assessed health is higher among the uninsured. As the measure of health status
is self-assessed, this might be related to differences between the two groups on
 632
The Geneva Papers on Risk and Insurance Issues and Practice
Table 1 Variable definitions and descriptive statistics (mean and standard deviation)

Variable Definition Sample

Full Insured Uninsured

insured 1 if covered by health insurance, 0 otherwise 0.93 (0.26)

heavy smoker 1 if smokes 20+ cigarettes per day, 0 otherwise 0.03 (0.18) 0.03 (0.17) 0.05 (0.21)
heavy drinker 1 if has three or more drinks per day, 0 otherwise 0.04 (0.2) 0.04 (0.2) 0.08 (0.27)
sedentary 1 if never engages light physical activity, 0 otherwise 0.12 (0.32) 0.11 (0.32) 0.16 (0.37)
obese 1 if body mass index equal or above 30, 0 otherwise 0.26 (0.44) 0.26 (0.44) 0.25 (0.43)
bad 1 if self assessed health is fair/poor, 0 if good/very good/excellent 0.16 (0.36) 0.15 (0.36) 0.19 (0.4)
stroke 1 if ever diagnosed stroke, 0 otherwise 0.03 (0.17) 0.03 (0.17) 0.02 (0.12)
high BP 1 if ever diagnosed high blood pressure, 0 otherwise 0.26 (0.44) 0.26 (0.44) 0.21 (0.41)
diabetes 1 if ever diagnosed diabetes, 0 otherwise 0.08 (0.28) 0.08 (0.28) 0.06 (0.24)
cancer 1 if ever diagnosed cancer, 0 otherwise 0.04 (0.2) 0.04 (0.2) 0.02 (0.15)
lung disease 1 if ever diagnosed lung disease, 0 otherwise 0.04 (0.19) 0.04 (0.19) 0.04 (0.21)
heart attack 1 if ever diagnosed heart attack, 0 otherwise 0.04 (0.21) 0.05 (0.21) 0.02 (0.15)
heart disease 1 if ever diagnosed coronary heart disease, 0 otherwise 0.07 (0.25) 0.07 (0.26) 0.03 (0.17)
emotional 1 if ever diagnosed emotional problems, 0 otherwise 0.05 (0.23) 0.05 (0.23) 0.05 (0.21)
arthritis 1 if ever diagnosed arthritis or rheumatism, 0 otherwise 0.18 (0.39) 0.19 (0.39) 0.12 (0.33)
mental loss 1 if ever diagnosed loss of mental ability, 0 otherwise 0.02 (0.14) 0.02 (0.14) 0.01 (0.1)
score Sum of emotional, arthritis and mental loss 0.25 (0.51) 0.26 (0.52) 0.18 (0.43)
income Total annual family income 59,976 (79,241) 62,568 (81,291) 25,858 (26,403)
male 1 if male, 0 if female 0.74 (0.44) 0.74 (0.44) 0.7 (0.46)
age Age in years 46.77 (15.18) 47.14 (15.29) 41.82 (12.71)
married 1 if married, 0 otherwise 0.57 (0.5) 0.59 (0.49) 0.31 (0.46)
kids No. of children in the household 0.91 (1.19) 0.93 (1.19) 0.7 (1.16)
primary 1 if primary education, 0 otherwise 0.21 (0.41) 0.2 (0.4) 0.44 (0.5)
high school 1 if high school education, 0 otherwise 0.33 (0.47) 0.33 (0.47) 0.35 (0.48)
college 1 if college education, 0 otherwise 0.46 (0.5) 0.48 (0.5) 0.21 (0.41)
Table 1 (continued)

Variable Definition Sample

Full Insured Uninsured

white 1 if white ethnicity, 0 otherwise 0.63 (0.48) 0.64 (0.48) 0.4 (0.49)
black 1 if black ethnicity, 0 otherwise 0.29 (0.46) 0.28 (0.45) 0.42 (0.49)
hispanic 1 if Hispanic ethnicity, 0 otherwise 0.05 (0.21) 0.04 (0.19) 0.14 (0.35)
other race 1 if other ethnicity, 0 otherwise 0.03 (0.18) 0.04 (0.18) 0.03 (0.17)
employed 1 if currently working, 0 otherwise 0.74 (0.44) 0.74 (0.44) 0.72 (0.45)
housekeeper 1 if currently keeping house, 0 otherwise 0.03 (0.17) 0.03 (0.17) 0.03 (0.17)
student 1 if student, 0 otherwise 0.01 (0.09) 0.01 (0.09) 0.01 (0.11)
unemployed 1 if unemployed or looking for work, 0 otherwise 0.05 (0.22) 0.05 (0.21) 0.14 (0.35)
retired 1 if retired or disabled, 0 otherwise 0.17 (0.38) 0.18 (0.38) 0.1 (0.29)
northeast 1 if lives in Northeast region, 0 otherwise 0.15 (0.36) 0.15 (0.36) 0.09 (0.29)
north central 1 if lives in North Central region, 0 otherwise 0.25 (0.44) 0.26 (0.44) 0.21 (0.41)
south 1 if lives in South region, 0 otherwise 0.41 (0.49) 0.4 (0.49) 0.48 (0.5)
west 1 if lives in West region, 0 otherwise 0.19 (0.39) 0.18 (0.39) 0.21 (0.41)
alaska 1 if lives in Alaska or Hawaii, 0 otherwise 0 (0.06) 0 (0.06) 0 (0.04)
metropolitan 1 if lives in metropolitan area, 0 otherwise 0.72 (0.45) 0.72 (0.45) 0.69 (0.46)
urban 1 if lives in urban area, 0 otherwise 0.25 (0.43) 0.25 (0.43) 0.27 (0.44)
rural 1 if lives in rural area, 0 otherwise 0.03 (0.16) 0.03 (0.16) 0.04 (0.2)
wave1 1 if year 1999, 0 otherwise 0.33 (0.47) 0.33 (0.47) 0.36 (0.48)
wave2 1 if year 2001, 0 otherwise 0.33 (0.47) 0.33 (0.47) 0.33 (0.47)

Health Insurance and Lifestyle Choices

wave3 1 if year 2003, 0 otherwise 0.33 (0.47) 0.34 (0.47) 0.31 (0.46)

Anderson E. Stanciole
633
The Geneva Papers on Risk and Insurance Issues and Practice
634

individual perception about what constitutes bad health. However, as the health
conditions depend on medical diagnosis, this might also be explained by lower access
to medical care among the uninsured.

Econometric model
Our primary interest is to determine the effect of health insurance coverage on the
individual propensity to particular lifestyle choices. A natural way to obtain this is to
estimate reduced form equations for the lifestyle choices, including health insurance as
an explanatory variable. This is essentially the approach implemented by Kenkel29 and
Courbage and Coulon.30
However, the decision to purchase health insurance coverage is intrinsically
correlated with lifestyle decisions. In general, we might expect the existence of
observable and unobservable individual attributes that influence both health insurance
coverage and the choice of lifestyle. Observable characteristics such as age play an
important role in shaping these correlated decisions. For the analyst, however, the
question is that other unobservable attributes might have the same effect. For
instance, it is possible that unobservable attributes such as risk aversion might increase
the motivation to obtain health insurance coverage and reduce the willingness to
engage in harmful activities. If ignored, this unobservable characteristic might lead
to biased estimates.
Several strategies can be used to control such unobservable characteristics. For
instance, Courbage and Coulon31 use instrumental variables as one method for
controlling the unobservable heterogeneity that jointly determine health insurance and
health behaviour. Another possible method to control unobserved heterogeneity is to
consider an exogenous change in insurance status, and to evaluate how this change
might affect the moral hazard variable. Dave and Kaestner32 explore the exogenous
variation in health insurance as a result of obtaining Medicare coverage at age 65.
They find limited evidence that obtaining health insurance reduces prevention and
increases unhealthy behaviours among elderly people.
Our approach to identifying the effect of health insurance on lifestyle choices is to
estimate a system of equations based on the multivariate probit model.33 The
multivariate probit is a 5-equation recursive model, with a structural equation for
health insurance coverage and reduced form equations for each of our four lifestyle
choices: heavy smoking, heavy drinking, lack of exercise and obesity. Health insurance
is included as explanatory variable in the reduced form equations for lifestyle and
the residuals in each equation are allowed to be freely correlated.
Let yiI denote a dummy variable for health insurance status. Also let YLil {yi1, yi2,
yi3, yi4} denote a vector of four dummies representing the lifestyle choices of heavy

29
Kenkel (1994).
30
Courbage and Coulon (2004).
31
Ibid.
32
Dave and Kaestner (2006).
33
See Wilde (2000), Cappelari and Jenkins (2003) and Train (2003).
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
635

smoking, heavy drinking, lack of exercise and obesity. The multivariate probit model
can be formalised as:

yiI bI0 xiI eiI ;

yil gl yiI bl0 xil eil ; l 1; :::; 4;
  1
1 if y1I;l 40
yiI ;l
0 otherwise:

2 3 02 3 2 31
e1I 0 1
6 e11 7 B6 0 7 6 r1I 1 7C
6 7 d B6 7 6 7C
6 e12 7 ! N B6 0 7; 6 r2I r21 1 7C 2
6 7 B6 7 6 7C
4 e13 5 @4 0 5 4 r3I r31 r32 1 5A
e14 0 r4I r41 r42 r43 1

Estimating univariate probit regressions for the lifestyle choices implicitly ignores
the unobserved heterogeneity and assumes that the error terms are uncorrelated (rjk0
for all jak). Therefore, the estimates for the effect of insurance on lifestyle choices are
biased.
There are, however, some practical difficulties associated with the estimation of
multivariate probit. In particular, the log-likelihood function is of the form:

X
N
L log F5 yiI ; yi1 ; :::; y14 ; xiI ; xi1 ; :::; xi4 ; 3
i1

where F5 is the 5-dimensional multivariate standard normal distribution. Therefore,

the estimation of the multivariate probit requires the evaluation of a 5-dimensional
integral over the distribution of the correlated errors. This integral does not have a
closed form solution. Moreover, the elevated number of dimensions implies that
traditional methods such as the Gauss-Hermite quadrature cannot be applied.
Our approach to circumvent this problem consists of approximating the log-
likelihood function using Maximum Simulated Likelihood. This approach is based on
the fact that a multivariate normal distribution function can be expressed as the
product of sequentially conditioned univariate normal distribution functions, which
can be easily and accurately evaluated.34 In practical terms, the joint distribution of
errors is decomposed into independent univariate normal distributions using the
Cholesky decomposition. This is achieved by drawing repeated random samples from
the error distribution.
There has been considerable argument in the literature about the identification
of this model. In this aspect we follow Wilde35 who has shown that the only

34
Cappelari and Jenkins (2003, p. 280).
35
Wilde (2000).
The Geneva Papers on Risk and Insurance Issues and Practice
636

condition for identification of the multivariate probit is that there be sufficient

variation in the data, while exclusion restrictions are not necessary. Rashad and
Kaestner36 use a comparable strategy to identify the causal effect of substance
abuse on adolescent sexual activity by controlling for unobserved factors using
bivariate probit regressions. Moreover, similarly to Adda and Lechene,37 we construct
an indicator of the individual underlying health. This indicator (variable score) is
based on the indicators for arthritis, emotional problems and loss of mental ability.
These conditions are supposedly unrelated to the lifestyle choices but give an
indication of the individual underlying health. Therefore, they are expected to
influence the demand for health insurance, but not the lifestyle choices, acting as an
additional exclusion restriction.

Results
In addition to the multivariate probit, we have also estimated univariate and bivariate
probit regressions. The univariate probit results are interesting to compare with
previous studies that have used the same method.
The bivariate probit has a similar structure to the multivariate probit but takes only
two equations at a time. That is, we estimate four specifications for the bivariate
probit, focusing on health insurance and one of the lifestyle choices at each time. The
bivariate probit evaluates a bi-dimensional integral with closed form solution over
the distribution of residuals. Therefore, the regressions are estimated without resorting
to simulation and can serve as a good benchmark to compare the estimates from the
multivariate probit.

Effect of control variables

Results including estimated coefficients for the univariate, bivariate and multivariate
probit models are presented in Tables 2, 3 and 4 respectively. The values shown in the
tables represent estimated coefficients. Let us first consider the effect of control
variables. Some patterns of effects of control variables are consistently estimated in all
three groups of models.
The constructed indicator of underlying health stock exerts positive effect on the
propensity to insure, which might be interpreted as a sign of adverse selection. With
respect to other health indicators, bad health has no effect on health insurance,
perhaps because any correlation is already being captured by the variable score, but is
positively associated with heavy smoking, lack of exercise and obesity. In some cases
diagnosed health conditions affect the propensity to lifestyle choices. However, this
might be due to reverse causality implying that the effects should be interpreted as
simple correlations without any causal connotation. Generally we find that diabetes is
negatively associated with the propensity to heavy drinking, but positively associated

36
Rashad and Kaestner (2004).
37
Adda and Lechene (2004).
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
637

Table 2 Univariate probit regressions

Explanatory Dependent variables

variables
insured heavy smoker heavy drinker sedentary obese

insured 0.08 (0.11) 0.19* (0.078) 0.12* (0.06) 0.13* (0.06)

score 0.22*** (0.049)
bad 0.09 (0.061) 0.37*** (0.074) 0.03 (0.069) 0.48*** (0.043) 0.23*** (0.044)
ln income 0.44*** (0.028) 0.05 (0.035) 0.01 (0.034) 0.086*** (0.021) 0.053** (0.02)
male 0.41*** (0.065) 0.58*** (0.11) 0.82*** (0.083) 0.13* (0.053) 0.14** (0.055)
age 3140 0.06 (0.067) 0.25* (0.1) 0.08 (0.078) 0.16** (0.057) 0.11* (0.054)
age 4150 0.06 (0.07) 0.37*** (0.1) 0.18* (0.076) 0.26*** (0.057) 0.02 (0.056)
age 5164 0.03 (0.083) 0.34** (0.11) 0.12 (0.087) 0.23*** (0.065) 0.15* (0.063)
age 65 above 0.75*** (0.12) 0.58*** (0.17) 0.1 (0.12) 0.32*** (0.079) 0.51*** (0.084)
married 0.4*** (0.06) 0.27*** (0.081) 0.31*** (0.063) 0.08 (0.05) 0.09 (0.05)
kids 0.17*** (0.025) 0.01 (0.03) 0.01 (0.025) 0.035* (0.015) 0 (0.016)
stroke 0.15 (0.15) 0.09 (0.18) 0.01 (0.13) 0.28*** (0.083) 0.27** (0.095)
high BP 0.04 (0.056) 0.01 (0.066) 0.1 (0.058) 0.02 (0.04) 0.53*** (0.039)
diabetes 0.09 (0.091) 0.19 (0.12) 0.23* (0.1) 0.05 (0.056) 0.54*** (0.058)
cancer 0.16 (0.12) 0.06 (0.2) 0.06 (0.14) 0.1 (0.074) 0.01 (0.085)
lung disease 0.03 (0.1) 0.45*** (0.1) 0.21 (0.11) 0.21** (0.071) 0.01 (0.074)
heart attack 0.08 (0.13) 0.04 (0.16) 0.22 (0.13) 0.06 (0.077) 0.06 (0.084)
heart disease 0.15 (0.11) 0.07 (0.12) 0.02 (0.099) 0.04 (0.062) 0.09 (0.064)
high school 0.29*** (0.057) 0.26*** (0.077) 0.13* (0.067) 0.11* (0.044) 0.02 (0.049)
college 0.61*** (0.062) 0.72*** (0.09) 0.28*** (0.075) 0.3*** (0.047) 0.04 (0.051)
white 0.44*** (0.078) 1.3*** (0.23) 0.24* (0.1) 0.29*** (0.065) 0.04 (0.072)
black 0.36*** (0.083) 0.4 (0.25) 0.26* (0.11) 0.12 (0.069) 0.29*** (0.076)
housekeeper 0.26* (0.13) 0.6* (0.27) 0.23 (0.16) 0.14 (0.089) 0.05 (0.092)
student 0.1 (0.18) 0.11 (0.3) 0.05 (0.25) 0.11 (0.19) 0.48** (0.18)
unemployed 0.09 (0.075) 0.08 (0.11) 0.21* (0.087) 0.04 (0.066) 0.05 (0.059)
retired 0.3** (0.092) 0.01 (0.11) 0.02 (0.091) 0.14* (0.058) 0.01 (0.059)
north central 0.09 (0.082) 0.07 (0.095) 0.03 (0.081) 0.15** (0.056) 0.08 (0.058)
south 0.19* (0.078) 0.05 (0.093) 0.08 (0.078) 0.06 (0.052) 0.07 (0.056)
west 0.2* (0.087) 0.29* (0.12) 0.11 (0.088) 0.13* (0.062) 0.08 (0.063)
alaska 0.13 (0.46) 0.11 (0.49) 0 (0.37) 0.02 (0.27) 0.43 (0.37)
urban 0.03 (0.054) 0.07 (0.068) 0.02 (0.058) 0.05 (0.04) 0.04 (0.041)
rural 0.37** (0.12) 0.07 (0.15) 0.02 (0.15) 0.07 (0.1) 0.17 (0.097)
wave2 0.03 (0.039) 0.13*** (0.037) 0.05 (0.039) 0.01 (0.033) 0.039* (0.019)
wave3 0 (0.042) 0.18*** (0.042) 0.06 (0.042) 0.04 (0.034) 0.1*** (0.021)
_cons 3.7*** (0.29) 2.4*** (0.4) 2.1*** (0.35) 0.15 (0.22) 0.4 (0.22)
Pseudo R2 0.22 0.16 0.06 0.11 0.073
N 14,557 14,517 14,540 14,515 14,344
N clusters 5,481 5,478 5,480 5,481 5,456

Notes: *po0.1; **po0.05; ***po0.01. Cluster-robust standard errors in parentheses.

with the propensity to obesity. Similarly, high blood pressure has a positive association
with obesity. There is also positive association of lung disease with heavy smoking and
lack of exercise.
With respect to demographic indicators, males are more likely than females to be
heavy drinkers and heavy smokers but less likely to be insured and obese. The effect of
The Geneva Papers on Risk and Insurance Issues and Practice
638

Table 3 Bivariate probit regressions

Explanatory Dependent variables

variables
insured a heavy smoker heavy drinker sedentary obese

insured 1.1*** (0.25) 0.66* (0.26) 0.72*** (0.2) 0.65** (0.23)

score 0.24*** (0.048)
bad 0.1 (0.06) 0.33*** (0.073) 0.03 (0.068) 0.47*** (0.043) 0.22*** (0.043)
ln income 0.43*** (0.028) 0.18*** (0.047) 0.02 (0.036) 0.15*** (0.028) 0.089*** (0.026)
male 0.4*** (0.065) 0.66*** (0.093) 0.77*** (0.086) 0.04 (0.059) 0.1 (0.059)
age 3140 0.04 (0.067) 0.23* (0.092) 0.07 (0.078) 0.16** (0.056) 0.12* (0.054)
age 4150 0.05 (0.07) 0.34*** (0.093) 0.17* (0.076) 0.26*** (0.056) 0.01 (0.056)
age 5164 0.03 (0.083) 0.28** (0.1) 0.12 (0.086) 0.21** (0.065) 0.15* (0.063)
age 65 above 0.75*** (0.12) 0.71*** (0.15) 0.08 (0.12) 0.22** (0.083) 0.54*** (0.085)
married 0.41*** (0.06) 0.35*** (0.077) 0.28*** (0.064) 0.01 (0.054) 0.06 (0.052)
kids 0.17*** (0.025) 0.05 (0.03) 0 (0.025) 0.01 (0.017) 0.01 (0.017)
stroke 0.15 (0.15) 0.12 (0.17) 0 (0.13) 0.26** (0.084) 0.28** (0.095)
high BP 0.03 (0.055) 0.01 (0.06) 0.1 (0.057) 0.01 (0.039) 0.52*** (0.039)
diabetes 0.1 (0.09) 0.18 (0.1) 0.22* (0.1) 0.03 (0.055) 0.53*** (0.058)
cancer 0.15 (0.12) 0 (0.18) 0.07 (0.13) 0.12 (0.073) 0.02 (0.084)
lung disease 0.06 (0.1) 0.39*** (0.096) 0.22 (0.11) 0.21** (0.069) 0.01 (0.074)
heart attack 0.1 (0.13) 0.05 (0.14) 0.22 (0.13) 0.06 (0.077) 0.06 (0.084)
heart disease 0.16 (0.11) 0.1 (0.11) 0.02 (0.098) 0.03 (0.061) 0.08 (0.064)
high school 0.28*** (0.056) 0.32*** (0.07) 0.11 (0.068) 0.15*** (0.045) 0.01 (0.051)
college 0.6*** (0.061) 0.79*** (0.08) 0.26*** (0.076) 0.36*** (0.049) 0.07 (0.053)
white 0.46*** (0.077) 0.87*** (0.26) 0.27** (0.1) 0.35*** (0.066) 0 (0.073)
black 0.37*** (0.082) 0.19 (0.21) 0.28* (0.11) 0.18* (0.069) 0.26*** (0.077)
housekeeper 0.25* (0.12) 0.59* (0.23) 0.24 (0.15) 0.09 (0.088) 0.07 (0.092)
student 0.11 (0.18) 0.11 (0.25) 0.06 (0.24) 0.13 (0.19) 0.48** (0.17)
unemployed 0.1 (0.074) 0.11 (0.098) 0.19* (0.088) 0 (0.064) 0.03 (0.058)
retired 0.29** (0.089) 0.12 (0.1) 0.04 (0.091) 0.08 (0.059) 0.02 (0.06)
north central 0.07 (0.081) 0.09 (0.087) 0.03 (0.08) 0.14* (0.056) 0.08 (0.058)
south 0.18* (0.077) 0.09 (0.087) 0.08 (0.077) 0.07 (0.051) 0.06 (0.056)
west 0.18* (0.087) 0.19 (0.12) 0.11 (0.088) 0.11 (0.062) 0.08 (0.063)
alaska 0.05 (0.41) 0.15 (0.46) 0.01 (0.37) 0.04 (0.26) 0.45 (0.36)
urban 0.03 (0.054) 0.05 (0.062) 0.03 (0.057) 0.04 (0.039) 0.04 (0.041)
Rural 0.36** (0.13) 0.17 (0.14) 0 (0.15) 0.01 (0.1) 0.19* (0.096)
wave2 0.04 (0.039) 0.1** (0.036) 0.05 (0.039) 0.01 (0.033) 0.041* (0.019)
wave3 0 (0.042) 0.16*** (0.04) 0.06 (0.042) 0.04 (0.034) 0.1*** (0.021)
_cons 3.6*** (0.29) 1.6** (0.55) 2*** (0.34) 0.07 (0.23) 0.44* (0.22)
r 0.73*** (0.3) 0.25** (0.129) 0.48*** (0.139) 0.29** (0.129)
N 14,517 14,517 14,540 14,515 14,344
N cluster 5,478 5,478 5,480 5,481 5,456
a
Estimates from bivariate probit regression for insurance coverage and heavy smoking.
Notes: *po0.1; **po0.05; ***po0.01. Cluster-robust standard errors in parentheses.

age is a bit contradictory. Compared to adults below 30 years old, those between
41 and 64 years can be considered to engage relatively more in unhealthy lifestyles.
Those above 65 years, however, are more likely to be sedentary but less likely to be
heavy smokers and obese. This might be explained by survival effects suggesting that
individuals with unhealthy lifestyle are less likely to reach old age. The group above 65
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
639

Table 4 Multivariate probit regressions

Explanatory Dependent variables

variables
insured heavy smoker heavy drinker sedentary obese

insured 0.64** (0.222) 0.38* (0.191) 0.54** (0.171) 0.49*** (0.148)

score 0.27*** (0.044)
bad 0.12* (0.054) 0.37*** (0.063) 0.03 (0.06) 0.47*** (0.039) 0.23*** (0.036)
ln income 0.44*** (0.023) 0.11** (0.039) 0 (0.029) 0.14*** (0.025) 0.077*** (0.02)
male 0.39*** (0.051) 0.63*** (0.078) 0.8*** (0.07) 0.06 (0.05) 0.11** (0.04)
age 3140 0.04 (0.057) 0.24** (0.078) 0.08 (0.067) 0.16** (0.055) 0.11** (0.041)
age 4150 0.06 (0.057) 0.36*** (0.076) 0.17** (0.065) 0.27*** (0.054) 0.02 (0.041)
age 5164 0.03 (0.067) 0.31*** (0.085) 0.14 (0.074) 0.22*** (0.061) 0.15** (0.046)
age 65 above 0.78*** (0.106) 0.65*** (0.133) 0.08 (0.102) 0.24** (0.076) 0.53*** (0.062)
married 0.41*** (0.049) 0.31*** (0.059) 0.3*** (0.051) 0.02 (0.046) 0.07 (0.037)
kids 0.17*** (0.019) 0.03 (0.024) 0.01 (0.019) 0.02 (0.015) 0 (0.012)
stroke 0.09 (0.137) 0.09 (0.147) 0.01 (0.125) 0.28*** (0.072) 0.29*** (0.073)
high BP 0.02 (0.049) 0.01 (0.055) 0.1* (0.047) 0.02 (0.035) 0.53*** (0.029)
diabetes 0.1 (0.077) 0.19* (0.093) 0.27** (0.084) 0.03 (0.05) 0.52*** (0.043)
cancer 0.16 (0.112) 0.03 (0.134) 0.06 (0.113) 0.13 (0.066) 0.02 (0.062)
lung disease 0.07 (0.092) 0.41*** (0.091) 0.22* (0.092) 0.22*** (0.063) 0 (0.06)
heart attack 0.07 (0.114) 0.04 (0.117) 0.22 (0.115) 0.06 (0.067) 0.06 (0.061)
heart disease 0.15 (0.101) 0.1 (0.102) 0.03 (0.089) 0.04 (0.057) 0.08 (0.051)
high school 0.28*** (0.046) 0.29*** (0.057) 0.12* (0.053) 0.14*** (0.039) 0 (0.034)
college 0.6*** (0.051) 0.76*** (0.064) 0.26*** (0.055) 0.35*** (0.042) 0.06 (0.036)
white 0.42*** (0.066) 1.1*** (0.191) 0.28** (0.09) 0.32*** (0.058) 0.01 (0.051)
black 0.35*** (0.07) 0.28 (0.19) 0.29** (0.095) 0.14* (0.06) 0.27*** (0.054)
housekeeper 0.22 (0.114) 0.59* (0.278) 0.21 (0.14) 0.13 (0.082) 0.08 (0.077)
student 0.11 (0.182) 0.07 (0.315) 0.04 (0.243) 0.1 (0.188) 0.48** (0.161)
unemployed 0.09 (0.067) 0.1 (0.096) 0.2* (0.079) 0.01 (0.065) 0.04 (0.054)
retired 0.3*** (0.075) 0.04 (0.084) 0.04 (0.073) 0.09 (0.053) 0.01 (0.046)
north central 0.04 (0.069) 0.09 (0.069) 0.05 (0.061) 0.15** (0.05) 0.082* (0.039)
south 0.15* (0.065) 0.07 (0.069) 0.1 (0.059) 0.06 (0.046) 0.07 (0.037)
west 0.16* (0.072) 0.24** (0.088) 0.12 (0.069) 0.12* (0.054) 0.08 (0.043)
alaska 0.12 (0.412) 0.12 (0.342) 0.02 (0.288) 0.06 (0.265) 0.45 (0.231)
urban 0.05 (0.044) 0.08 (0.049) 0.04 (0.045) 0.05 (0.034) 0.04 (0.028)
rural 0.35*** (0.098) 0.15 (0.111) 0.01 (0.114) 0.03 (0.093) 0.19** (0.071)
wave2 0.03 (0.046) 0.12* (0.053) 0.05 (0.049) 0.02 (0.037) 0.04 (0.03)
wave3 0.00 (0.047) 0.18** (0.054) 0.04 (0.049) 0.04 (0.037) 0.1*** (0.03)
_cons 3.8*** (0.246) 2.2*** (0.393) 0.2*** (0.277) 0.13 (0.212) 0.43* (0.178)
N 14,260 14,260 14,260 14,260 14,260
Draws 130 130 130 130 130

Notes: *po0.1; **po0.05; ***po0.01. Standard errors in parentheses.

years has a higher propensity to be covered by health insurance reflecting the fact that
all individuals in this group are automatically eligible for Medicare. There are few
differences between geographical regions but in general it is possible to say that
individuals from North, Central and West lead healthier lifestyle, and those from rural
areas have lower probability to insurance. We also notice a tendency for reducing
heavy smoking and increasing obesity prevalence over time.
The Geneva Papers on Risk and Insurance Issues and Practice
640

Socioeconomic status is important to explain many lifestyle choices. Higher income

and education decrease the likelihood to be a heavy smoker, heavy drinker38 and
sedentary but increases the propensity to health insurance. White people are more
heavy smokers and heavy drinkers but less sedentary than other ethnicities. The
propensity to obesity is clearly higher among African-Americans. Students have a
lower propensity to obesity perhaps due to an association with age and the
unemployed are more likely to be heavy drinkers. Again, the retired are more likely
to be insured due to automatic Medicare coverage above 65 years.

The effect of insurance on lifestyle choices

Let us now focus on the effect of insurance coverage on the lifestyle choices. Table 2
shows the estimated coefficients from the univariate probit regressions. The univariate
probit is estimated separate and independently and each column corresponds to a
different regression. According to this model, insurance coverage has no effect on the
propensity to be a heavy smoker, decreases the probability of being a heavy drinker or
sedentary and is associated with an increase in the probability of obesity. Only the
latter can interpreted as evidence of ex ante moral hazard.
Based on similar results, previous published studies have argued that health
insurance does not have an incentive effect in terms of inducing ex ante moral
hazard. For example, using an instrumental variable approach, Courbage and
Coulon39 find that health insurance significantly decreases the probability of smoking
and increases the probability of practicing a sport and of undergoing breast screening.
The bivariate and multivariate probit models further extend the relevance of
unobservable attributes in influencing both stages of individual decision. This
framework explicitly recognises that the choice of insurance coverage is related to
the choices about lifestyle.
Table 3 presents the bivariate probit estimates, where lifestyle choices are modelled
as joint decisions with insurance coverage, allowing for unspecified correlation
between the residuals. In the table, lifestyle equations (columns 25) are, one at a time,
jointly estimated with the insurance coverage.40
In effect, the bivariate probit coefficients for insurance coverage are very different
from those for the univariate probit. If we assume the bivariate estimates, the effect of
insurance on the propensity to heavy drinking remains negative and significant.
However, now insurance coverage exerts positive and significant effects on the
probability of being a heavy smoker, sedentary and/or obese. This is very distinct from
the results of the univariate analysis. This also suggests the existence of ex ante moral

38
Kenkel (1991) finds that schooling has a positive effect on the total number of drinks. This might be
explained either because the stigma of alcohol consumption varies across socioeconomic groups or
because better-educated individuals are more aware of the beneficial effects of moderate alcohol
consumption.
39
Courbage and Coulon (2004).
40
Table 3 reports the insurance equation estimated together with heavy smoking. The results of the
insurance equation with the other lifestyle choices are very similar and are available on request.
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
641

hazard in the sense that insured individuals are more likely to be heavy smokers,
sedentary and obese.
It is instructive to analyse more closely the correlations between the residuals in the
insurance and lifestyle equations (r). This gives an estimate of the correlation between
unobservable factors that influence both decisions. For instance, we notice a negative
correlation between residuals in the heavy smoking and insurance equations. This
suggests the existence of unobservable elements which, if they increase the propensity
to insure, decrease the propensity to heavy smoking and vice-versa. For example, it
might be the case that more risk-averse people (unobservable characteristic) are more
likely to purchase health insurance and less likely to be heavy smokers, for fear of the
adverse consequences of smoking.41 The univariate probit model ignores this channel
of correlation, and consequently yields a negative (and incidentally not significant)
estimate of the effect of insurance on heavy smoking. The univariate estimate is,
nonetheless, biased.
Similarly, the residuals of the insurance equation are also negatively correlated with
the residuals of the lack of exercise and obesity equations. Consequently, the
univariate probit coefficient of the effect of insurance is negative for lack of exercise
and downward biased for obesity.
With respect to heavy drinking, the correlation between residuals is positive,
suggesting that unobservable characteristics increase the probability of both insurance
coverage and heavy drinking. Therefore, both the univariate and the bivariate probit
models estimate negative effects of insurance on heavy drinking, suggesting the
absence of ex ante moral hazard in this dimension.
The multivariate probit extends the notion of controlling for unobservable
heterogeneity by estimating the correlation of the residuals between all the equations
in the recursive system. The five equations are estimated simultaneously and the
residuals are allowed to be freely correlated. Estimation is based on the simulation of
the multivariate normal distribution of the residuals. We set the number of draws
of the simulation to 130, which is approximately equal to the square root of our
pooled sample size of 14,000 individuals.42
The results of the multivariate probit can be considered qualitatively similar to
the bivariate probit estimates. This is a good robustness indicator since the bivariate
probit does not rely on simulation to be estimated. According to the multivariate
probit, health insurance increases the propensity to heavy smoking, lack of
exercise and obesity, and decreases the propensity to heavy drinking. This suggests
the existence of ex ante moral hazard, at least for the first three lifestyle choices.
Table 5 shows the correlation between residuals in all five equations. The first
column gives the correlation of residuals in the insurance equation with those in the
other four equations, suggesting a similar pattern as the bivariate probit regressions.
Unobservable attributes of the insurance decision are negatively correlated to those
that influence heavy smoking, lack of exercise and obesity.

41
See Kenkel (1994, p. 320, footnote).
42
See Cappelari and Jenkins (2003).
The Geneva Papers on Risk and Insurance Issues and Practice
642

Table 5 Correlation between residuals from multivariate probit regressions

Insured Heavy smoker Heavy drinker Sedentary

Heavy smoker 0.41*** (0.128)

Heavy drinker 0.09 (0.095) 0.33*** (0.038)
Sedentary 0.37*** (0.095) 0.19*** (0.040) 0.07** (0.032)
Obese 0.2** (0.078) 0.04 (0.035) 0.06** (0.027) 0.09*** (0.021)

Notes: *po0.1; **po0.05; ***po0.01. Standard errors in parentheses.

Moreover, we notice significant correlation between residuals in the lifestyle

equations. We find specifically that unobservable determinants of heavy smoking,
heavy drinking and lack of exercise are all positively correlated. Similarly, there
is positive association between unobservable determinants of obesity and lack of
exercise. This suggests some degree of complementarity between these lifestyle choices.
On the other hand, there is significant negative association between unobservable
determinants of heavy drinking and obesity, suggesting these choices might be
considered substitutes.

Conclusion
In this paper, we have used data from the 1999, 2001 and 2003 waves of the PSID to
explore the effect of health insurance coverage on lifestyle choices. We estimated a
structural model of the individual choice of insurance and of four lifestyle-related
decisions: heavy smoking, heavy drinking, lack of exercise and obesity.
The underlying correlation between insurance and lifestyle choices is modelled using
a multivariate probit. This structural approach assumes that insurance coverage and
the four lifestyle choices are sequential and interdependent decisions. Most previous
studies ignore this feature and consequently find that health insurance is not an
important determinant of lifestyle choices.
The results show that health insurance has significant incentive effects on lifestyle
choices, increasing the propensity to heavy smoking, lack of exercise and obesity and
decreasing the propensity to heavy drinking. There is also significant correlation
between the residuals of each equation. The pattern of correlation suggests that heavy
smoking and heavy drinking, and obesity and lack of exercise may be considered
complementary lifestyle choices, while heavy drinking and obesity may be considered
substitutes.
The results suggest that unobserved heterogeneity plays an important role in the
sequential determination of insurance and lifestyle. There is evidence to suggest the
existence of ex ante moral hazard in the choice of heavy smoking, lack of exercise and
obesity. The results might also have implications for the design of health financing
policies. In particular, to the extent that health insurance coverage induces greater
engagement in harmful lifestyle choices, the results suggest that health insurance plans
might consider introducing incentives to reduce the possible impact in terms of higher
expected costs. This might include, for example, the introduction of risk-rated
 Anderson E. Stanciole
Health Insurance and Lifestyle Choices
643

premiums whereby individual contributions are adjusted according to whether or not

the patient engages in harmful activities.
Incomplete data limit the interpretation of some of the results. For instance, it was
not possible to control some characteristics of the insurance plan, such as premium
payments, level of coverage and co-payments and to distinguish the type of health
insurance coverage, whether public (Medicare/Medicaid), employer-sponsored or
individual. However, sensitivity analysis, which restricts the sample to individuals
below 65 years old (ineligible to Medicare), suggests that the results are very robust
(full results available on request). Our measure of heavy drinking also deserves
additional attention, since it is not clear how to compare different individuals in this
aspect.
Among the possible extensions, it would be interesting to explore the economic costs
associated with this ex ante moral hazard effect. In particular, it would be useful to
estimate the additional costs in terms of extra medical care use and health
expenditures. Also if it were possible to control health plan characteristics, we would
like to simulate the potential to use risk-rated premiums and co-payments in order to
induce the adoption of healthier lifestyles.

Acknowledgements
I thank Philippe Van Kerm, Elanor Colleoni, Monica Szeles and other workshop participants at CEPS/
INSTEAD Luxembourg in March 2007, the editor and three anonymous referees for helpful comments on
the paper. This research was co-funded by the Coordenacao de Aperfeicoamento de Pessoal de N vel
Superior of the Ministry of Education of Brazil (Grant no. 1474022) and the European Commission under
the 6th Framework Programmes Research Infrastructures Action (Trans-national access contract RITA
026040) hosted by IRISS-C/I at CEPS/INSTEAD in Luxembourg.

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About the Author

Anderson E. Stanciole is a health economist with experience in health systems financing
in international organisations. He received a B.A. (1998) and a M.A. (2002) in
Economics from the Universidade de Sao Paulo, Brazil and a Ph.D. (2007) in Health
Economics from the University of York, U.K.
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