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We study long-run selection and treatment effects of a health insurancesubsidy in Ghana, where mandates are not enforceable. We randomly providedifferent levels of subsidy (1/3, 2/3, and full), with follow-up surveys sevenmonths and three years after the initial intervention. We find that a one-timesubsidy promotes and sustains insurance enrollment for all treatment groups,but long-run health care service utilization increases only for the partialsubsidy groups. We find evidence that selection explains this pattern: thosewho were enrolled due to the subsidy, especially the partial subsidy, are moreill and have greater health care utilization.

Long-run Consequences of Health Insurance Promotion When Mandates are Not Enforceable: Evidence from a Field Experiment in Ghana