Publication Date



Upjohn Institute working paper ; 21-357




Arrow (1963) hypothesized that demand-side moral hazard induced by health insurance leads to supply-side expansions in healthcare markets. Capturing these effects empirically has been challenging, as non-marginal insurance expansions are rare and detailed data on healthcare labor and capital is sparse. We combine administrative labor market data with the geographic variation in the rollout of a universal insurance program—the introduction of long-term care (LTC) insurance in Germany in 1995—to document a substantial expansion of the inpatient LTC labor market in response to insurance expansion. A 10 percentage point expansion in the share of insured elderly leads to 0.05 (7%) more inpatient LTC firms and four (13%) more workers per 1,000 elderly in Germany. Wages did not rise, but the quality of newly hired workers declined. We find suggestive evidence of a reduction in old-age mortality. Using a machine learning algorithm, we characterize counterfactual labor market biographies of potential inpatient LTC hires, finding that the reform moved workers into LTC jobs from unemployment and out of the labor force rather than from other sectors of the economy. We estimate that employing these additional workers in LTC is socially efficient if patients value the care provided by these workers at least at 25% of the market price for care. We show conceptually that, in the spirit of Harberger (1971), in a second-best equilibrium in which supply-side labor markets do not clear at perfectly competitive wages, subsidies for healthcare consumption along with the associated demand-side moral hazard can be welfare-enhancing.

Issue Date

November 2021


Upjohn project #58156


Polyakova gratefully acknowledges grant support from the W.E. Upjohn Institute for Employment Research and from the National Institute on Aging (K01AAG05984301).

Subject Areas

LABOR MARKET ISSUES; Health insurance


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Hackmann, Martin, Joerg Heining, Roman Klimke, Maria Polyakova, and Holger Seibert. 2021. "General Equilibrium Effects of Insurance Expansions: Evidence from Long-Term Care Labor Markets." Upjohn Institute Working Paper 21-357. Kalamazoo, MI: W.E. Upjohn Institute for Employment Research.