estimates of the returns to quality and coauthorship in economic academia salaries of academic economists are studied to determine if individuals receive differential returns to publishing articles of varying quality and to coauthored versus single authored articles estimates based on detailed data and a flexible nonlinear least squares procedure indicate that substantial returns to quality exist and that an individual s return from a coauthored paper with n authors is approximately 1 n times that of a single authored paper

politics growth and inequality in rural china does it pay to join the party abstract economic reform is often constrained because rank and file bureaucrats responsible for implementation have vested interests that oppose change drawing on an unusual longitudinal survey data set for a representative rural county in northern china we show an alternative positive scenario consistent with the presence of an implicit performance based incentive contract that ties the household incomes of local officials to market liberalization increases in consumer demand and the provision of local public goods the mechanisms appear to be tolerated as the fruits of growth are shared fairly equitably thus allowing implementation of a politically and economically self reinforcing reform process

inequality and polarisation in health systems responsiveness a cross country analysis the world health report 2000 proposed three fundamental goals for health systems encompassing population health health care finance and health systems responsiveness the goals incorporate both an efficiency and equity dimension while inequalities in population health and health care finance have motivated two important strands of research inequalities in responsiveness have received less attention in health economics this paper examines inequality and polarisation in responsiveness bridging this gap in the literature and contributing towards an integrated analysis of health systems performance it uses data from the world health survey to measure and compare inequalities in responsiveness across 25 european countries in order to respect the inherently ordinal nature of the responsiveness data median based measures of inequality and polarisation are employed the results suggest that in the face of wide differences in the health systems analysed there exists large variability in inequality in responsiveness across countries

aging and productivity among economists economists productivity over their careers and as measured by publication in leading journals declines very sharply with age there is no difference by age in the probability that an article submitted to a leading journal will be accepted rates of declining productivity are no greater among the very top publishers than among others and the probability of acceptance is increasingly related to the author s quality rather than the author s age

obsolescence of knowledge and career publication profiles some evidence of differences among fields in costs of interrupted careers in recent years women have received about 45 percent of all baccalaureate degrees but only approximately 20 percent of all ph d s does this imply that academic careers as compared with careers of the wider market for college graduates are less conducive to dual career family objectives evidence suggesting the relative tradeoff of these objectives is shown by the fact that over the last thirty years the zero order correlation between average cohort fertility and the proportion of ph d recipients who are women is 0 939 a female recipient of a doctorate is twice as likely as a male recipient to have specialized in the humanities and only one third as likely to have specialized in a physical science field furthermore of those who receive a doctorate in physical science a male is 60 percent more likely than a female to pursue research as a primary work activity in the humanities on the other hand a woman is at least as likely as a man to have research as an initial postdoctoral work activity obviously many factors affect opportunities and resultant decisions to enter particular careers and to select specific occupational specialties this study considers only onethe rate of obsolescence or depreciation of knowledge as reflected in the age profile of cited works this measure of the obsolescence of knowledge refers to the rate of decay in the relative frequency at which citations are made to a particular vintage of research communications as the communications age in other words the usefulness of older published research papers as an input to current research depreciates over time the rate at which this depreciation occurs is interpreted as measuring the durability of a professor s accumulated stock of knowledge evidence presented in section ii indicates that the durability of knowledge varies considerably from discipline to discipline this information raises a number of questions concerning how the durability of knowledge influences career decisions one influence considered here is that of a temporary career interruption for example if a woman experiences a break in her academic career such as for the purpose of raising children she will incur an opportunity cost in the sense that her research knowledge will to some extent become obsolete consequently her accumulated stock of knowledge will decline relative to those professors who have continuous careers the relative cost imposed on a woman who pursues dual family career objectives is higher the less durable the jobrelated knowledge this difference in relative costs is expected to alter career incentives the results presented here suggest that women who pursue academic careers have responded to these incentives before discussing the evidence on female careers i consider a more general model in which a professor is assumed to have a continuous career profile this model which is more appropriately viewed as a male model of investment behavior is used to analyze how the durability of a professor s knowledge affects his research productivity over a career interestingly the evidence suggests that a professor s response to less durable knowledge is not to compact all learning early in his career but rather to smooth learning over the career perhaps the most assistant professor arizona state university i would like to thank an anonymous referee and many friends for helpful comments on earlier drafts i am especially indebted to finis welch for valuable suggestions throughout the development of this paper the views expressed are my own and i am responsible for any possible errors

great expectations the subjective well being of rural urban migrants in china summary this paper is among the first to link the literatures on migration and on subjective well being in developing countries it poses the question why do rural urban migrant households settled in urban china have an average happiness score lower than rural households three basic hypotheses are examined migrants had false expectations about their future urban conditions or about their future urban aspirations or about their future selves estimated happiness functions and decomposition analyses based on a 2002 national household survey indicate that certain features of migrant conditions make for unhappiness and that their high aspirations in relation to achievement influenced by their new reference groups also make for unhappiness although the possibility of selection bias among migrants cannot be ruled out it is apparently difficult for migrants to form unbiased expectations about life in a new and different world

are migrants more productive than stayers some evidence from a set of highly productive academic economists this article compares the average productivity of migrants who work in a country different from their country of origin and stayers whose entire academic career takes place in their country of origin in a set of 2 530 highly productive economists that work in 2007 in a selection of the top 81 economics departments worldwide the main findings are the following two first productivity comparisons depend on the cohort and the type of department for example in the top u s departments foreigners are more productive than stayers only among older individuals in the bottom u s departments this is the case for both cohorts while in the other countries the productivity of foreigners and stayers is indistinguishable for both cohorts second when we restrict our attention to an elite consisting of economists with above average productivity all productivity differences between migrants and stayers in the united states vanish as our analysis depends on observational data in which the migration decision is not exogenously identified our estimates have a descriptive rather than a causal interpretation however our results are very robust to the treatment of the elite the partition into several department categories and the definition of the cohorts and the productivity notion jel j61

equity in the finance of health care some international comparisons this paper presents the results of a ten country comparative study of health care financing systems and their progressivity characteristics it distinguishes between the tax financed systems of denmark portugal and the u k the social insurance systems of france the netherlands and spain and the predominantly private systems of switzerland and the u s it concludes that tax financed systems tend to be proportional or mildly progressive that social insurance systems are regressive and that private systems are even more regressive out of pocket payments are in most countries an especially regressive means of raising health care revenues

the impact of immigration on the human capital of natives implications of the quantity number and quality skill of immigration on the destination economy are analyzed including impacts on value added wages quasi rents rates of return and the skill distribution of the native labor force quantity quality trade offs are considered for both immigrant and native workers medium and long run labor supply responses by natives to immigrant induced changes in wage rates are shown to have second order effects which substantively affect the impacts of immigrants the impact of immigration policy depends on the quality as well as quantity of immigrants the time horizon and the speed of factor market adjustment

redistribution and government tactical behaviour an analysis of local public expenditure in china after the 1994 tax reform during the last few decades significant changes have affected chinese public finance in 1994 a major tax reform was undertaken and central local sharing arrangements were deeply modified the evolutions of regional public expenditure in the years following the reform deserve to be analysed the issue is relevant for two additional reasons first income inequality is becoming a relevant issue and it is therefore important to understand whether the chinese government is pursuing some kind of redistribution policy second an analysis of the local expenditure dynamics might provide some important information concerning the objectives and the behaviour of the chinese government the article considers a set of structural political and socio economic variables to analyse the determinants of local public expenditure in 30 chinese regions over the period 1995 2007 the results reveal that redistribution seems not to be a priority for the chinese government expenditure is higher in richer and more internationally open regions and the only redistribution evidence that emerges is related to urban rural disparities

consumption and happiness we examine the relationship between relative consumption and happiness using panel data for china an important developing country we find that consumption has a positive effect on happiness an

the politics of redistributive social insurance this paper analyses the political support for a social insurance that includes elements of redistribution when there exists an imperfect private insurance alternative individuals differ both in their income and risk the social insurance is compulsory and charges an income related contribution with pooling of risks the private insurance is voluntary and charges a contribution based on individual risks however due to the adverse selection problem private insurance companies provide only partial insurance adopting a non expected utility model we show that there is a general majority support for social insurance and that this support is increasing with risk aversion we also show that a mixed insurance is politically impossible regardless of the degree of redistribution of social insurance and the joint distribution of risk and income in the population lastly we analyse how the political support for social insurance is affected by any change in its redistributive component and the possibility of using genetic tests

who pays for health care in asia we estimate the distributional incidence of health care financing in 13 asian territories that account for 55 of the asian population in all territories higher income households contribute more to the financing of health care the better off contribute more as a proportion of ability to pay in most low and lower middle income territories health care financing is slightly regressive in three high income economies with universal social insurance direct taxation is the most progressive source of finance and is most so in poorer economies in universal systems social insurance is proportional to regressive in high income economies the out of pocket oop payments are proportional or regressive while in low income economies the better off spend relatively more oop but in most low middle income countries the better off not only pay more they also get more health care

the redistributive effect of health care finance in twelve oecd countries the oecd countries finance their health care through a mixture of taxes social insurance contributions private insurance premiums and out of pocket payments the various payment sources have very different implications for both vertical and horizontal equity and on redistributive effect which is a function of both this paper presents results on the income redistribution consequences of the health care financing mixes adopted in twelve oecd countries by decomposing the overall income redistributive effect into a progressivity horizontal inequity and reranking component the general finding of this study is that the vertical effect is much more important than horizontal inequity and reranking in determining the overall redistributive effect but that their relative importance varies by source of payment public finance sources tend to have small positive redistributive effects and less differential treatment while private financing sources generally have larger negative redistributive effects which are to a substantial degree caused by differential treatment

diverging patterns with endogenous labor migration abstract the standard neoclassical model cannot explain persistent migration flows and lack of cross country convergence when capital and labor are mobile here we present a model where both phenomena may take place assuming increasing returns and perfect capital mobility the driving forces behind labor migration are the size and the composition of the workforce the size of the workforce produces divergence a larger workforce in one country implies higher wages the wage gap induces in migration and this makes the wage gap even larger in this case migration is only beneficial for the labor importing country the evolution in the composition of the workforce due to migration may have opposite effects in one case in migration keeps the wage of skilled workers high enough to induce people to qualify for skilled jobs this improves the composition of labor in the receiving country only and it makes divergence a likely outcome in another case labor migration keeps the relative wage of unskilled workers in the rich country high enough to induce all migrants to take unskilled jobs and reduce the skilled to unskilled ratio in that country then migration is beneficial to the country which was first exporting labor

trade theory distribution of income and immigration this paper examines the impact of mass immigration utilizing the analytical framework of so called trade theory as such its emphasis is on general equilibrium effects and on the constraints imposed by the openness of the economy on such effects the analysis will center on the distributional impact of unskilled labor immigration excerpt

economic effects of immigrants on native and foreign born workers complementarity substitutability and other channels of influence the authors use standard metropolitan statistical area smsa data constructed from 1980 census microdata files and other sources to estimate a structural model of native foreign born labor demand and labor supply which distinguishes the effects upon real wages of each type of labor and on the employment of natives the authors specify econometrically estimate and simulate the structural model which incorporates not only a production structure channel through which immigrants influence area real wages and employment but also demand and native labor supply channels it is noted that while these are not the only channels through which immigrants may affect native workers the model nonetheless constitutes a step in the direction of a general equilibrium approach in the production structure channel immigrants and natives are found to be substitutes in production immigration lowers foreign born wage rates and leads to lower wages for natives the negative effects of the production channel usually are ameliorated through the demand channel further immigrants add to local demand through their earnings and potentially through non labor income while also lowering unit costs and local prices which enhances real incomes and potentially net exports and thus the demands for local output and area labor the author discusses findings of interest from the simulation results based upon an analysis of all areas

the economics of communist party membership the curious case of rising numbers and wage premium during china s transition abstract as the chinese communist party has loosened its grip in a more market oriented economy why have membership and the economic benefits of joining risen we use three national household surveys over 11 years to answer this question for wages in urban china individual demand for party membership is treated as an investment in political capital that brings monetary rewards in terms of a wage premium that has risen in recent years however this does not explain why the wage premium is higher for the personal characteristics that reduce the probability of membership rationing with a scarcity value for members with those characteristics provides an explanation

equity during an economic crisis financing of the argentine health system this article analyses the redistributive effect caused by health financing and the distribution of healthcare utilization in argentina before and during the severe 2001 2002 economic crisis both dramatically changed during this period the redistributive effect became much more positive and utilization shifted from pro poor to pro rich this clearly demonstrates that when utilization is contingent on financing changes can occur rapidly and that an integrated approach is required when monitoring equity from a policy perspective the argentine health system appears vulnerable to economic downturns mainly due to high reliance on out of pocket payments and the strong link between health insurance and employment

unfair inequalities in health and health care inequalities in health and health care are caused by different factors measuring unfair inequalities implies that a distinction is introduced between causal variables leading to ethically legitimate inequalities and causal variables leading to ethically illegitimate inequalities an example of the former could be life style choices an example of the latter is social background we show how to derive measures of unfair inequalities in health and in health care delivery from a structural model of health care and health production direct unfairness linked to the variations in medical expenditures and health in the hypothetical distribution in which all legitimate sources of variation are kept constant fairness gap linked to the differences between the actual distribution and the hypothetical distribution in which all illegitimate sources of variation have been removed these two approaches are related to the theory of fair allocation in general they lead to different results we propose to analyse the resulting distributions with the traditional apparatus of lorenz curves and inequality measures we compare our proposal to the more common approach using concentration curves and analyse the relationship with the methods of direct and indirect standardization we discuss how inequalities in health care can be integrated in an overall evaluation of social inequality

the distributional impact of health financing in europe a review this article summarises extends and updates previous empirical work on the distributional implications of alternative health care financing arrangements in a selection of european countries and the us on the one hand total health care payments are almost proportional to ability to pay in most countries this is predominantly driven by a high reliance on public financing on the other hand private payments out of pocket payments as well as private insurance premiums are highly regressive more extended reliance on private financing may therefore endanger the equitable nature of financing systems in addition private payments put a heavy burden on unfortunate households

redistribution effect and unequal income tax treatment decomposing the post tax gini coefficient across groups of pre tax equals reveals the separate contributions to the redistributive effect of an income tax of 1 the effective schedule the vertical effect 2 the unequal treatment of equals arising from departures from this effective schedule the horizontal effect and 3 the reranking of unequals as a result of such departures the reranking effect the methodology is applied to u k microdata throughout the period 1978 91 reranking understates the negative contribution to redistributive effect of unequal tax treatment by about one third and is far outweighed by the vertical effect copyright 1994 by royal economic society

statistical inference of progressivity dominance an application to health care financing distributions this paper employs a distribution free statistical test suitable for comparisons based on dependent samples to analyse changes in health care financing distributions on finnish data in distinction to the more general summary index approach used in most studies of progressivity measurement the difference between the lorenz curve of income inequality and the concentration curves of various taxes and payments is used to evaluate progressivity dominance and changes in progressivity sample weights are applied to account for the effect of sampling design and non response the analysis demonstrates that the dominance approach can be successfully applied to various types of distributional problems besides comparisons concerning differences in income distributions as an empirical application the paper presents estimation results for the progressivity of various health care financing sources using data from the 1987 and 1996 finnish health care surveys

happiness and job satisfaction in urban china a comparative study of two generations of migrants and urban locals this study investigates determinants of happiness and job satisfaction of urban locals first generation migrants and new generation migrants in china s urban workforce we present evidence to suggest that new generation migrants are less satisfied with their jobs and lives than first generation migrants despite having higher income this finding is consistent with aspirations rising faster than income in china s fast growing urban economy

life satisfaction in urban china components and determinants survey data from urban china in 2002 show levels of life satisfaction to be low but not exceptionally so by international comparison many of the determinants of life satisfaction in urban china appear comparable to those for people in other countries these include inter alia unemployment income marriage sex health and age communist party membership and political participation raise life satisfaction people appear fairly satisfied with economic growth and low inflation and this contributes to their overall life satisfaction there is dissatisfaction over pollution but this like job insecurity does not appear to impact on life satisfaction

assimilation changes in cohort quality and the earnings of immigrants this paper reexamines the empirical basis for two facts that seem to be found in most cross section studies of immigrant earnings 1 the earnings of immigrants grow rapidly as they assimilate into the united states and 2 this rapid growth leads to many immigrants overtaking the earnings of the natives within 10 15 years after immigration using the 1970 and 1980 u s censuses this paper studies the earnings growth experienced by specific immigrant cohorts during the period 1970 80 it is found that within cohort growth is significantly smaller than the growth predicted by cross section regressions for most immigrant groups this differential is consistent with the hypothesis that there has been a secular decline in the quality of immigrants admitted to the united states

the ramaswami proposition and the choice among labor capital and technology flows abstract this paper examines the choice between labor and capital flows in the context of a one good two country model where the two countries differ in their levels of disembodied technology in contrast to the ramaswami proposition it is shown that a country may prefer an optimal outflow of its abundant factor to an optimal inflow of its scarce factor it is also shown that for sufficiently small differences in technology the labor rich technology inferior country will benefit more from an optimal outflow of labor than from a gift of superior technology

the labor market skills of recent male immigrants evidence from the current population survey using data from special supplements to the current population survey cps the authors track the education and hourly earnings of recent male immigrants to the united states in terms of these measures of labor market skills the cps data suggest that immigrants who came in the late 1980s were more skilled than those who arrived earlier in the decade this pattern represents a break from the steady decline in immigrant skill levels observed in 1940 80 census data despite the encouraging trend over the 1980s however the average skills of recent immigrants remain low by historical standards

immigrant and emigrant earnings a longitudinal study this paper analyzes the relationship between earnings and the extent of assimilation cohort quality change and return migration experienced by the foreign born population the study uses the longitudinal data available in the survey of natural and social scientists and engineers the analysis reveals that there was a sizable decline in the skills of this population over the last two decades in addition the study shows that return migration is more likely among immigrants who did not perform well in the u s labor market

assessing equitable health financing for universal health coverage a case study of south africa abstractthis article argues that an assessment of progressivity over time can provide an indication of progress towards a more progressive or a less regressive health financing system and can be useful to policymakers it introduces a framework to characterize shifts in progressivity in health financing between two time periods using the popularly known kakwani index of progressivity and other associated indices it also decomposes the shifts in progressivity into the relative contributions of the changes in income distribution and the changes in the distribution of health payments further it proposes graphics that statistically analyses how the shifts in progressivity vary along the distribution of income a pro poor pro rich shift implies that the health financing mechanism is becoming more less progressive or less more regressive between two time periods a proportional shift means that progressivity is constant between the two periods this framework is applied to nationally represen

self selection and the earnings of immigrants this paper analyzes the way in which the earnings of the immigrant population may be expected to differ from the earnings of the native population because of the endogeneity of the decision to migrate the empirical study shows that differences in the u s earnings of immigrants with the same measured skills but from different home countries are attributable to variations in political and economic conditions in the countries of origin at the time of migration excerpt

a conceptual framework for community based health insurance in low income countries social capital and economic development summary the international policy model linking community based health insurance cbhi and universal coverage for health care in low income countries is implicitly determined by the development of mutual health insurance in 19th century europe and japan the economic and health system frameworks employed in cbhi policy have not sufficiently taken into account contextual considerations social capital theories could contribute to understanding why generally cbhi does not achieve significant and sustainable levels of population coverage a framework of social capital and economic development is used to organize and interpret existing evidence on cbhi this suggests that solidarity trust extra community networks vertical civil society links and state society relations affect the success of cbhi aligning schemes to social determinants of cbhi could result in structures that differ from those proposed by current analytic frameworks

factor rewards and the international migration of unskilled labor a model with capital mobility abstract conventional economic wisdom holds that the migration of unskilled labor from less developed countries to neighboring developed countries should be expected to narrow the wage gap between those countries and thereby reduce the incentive for further migration if capital is mobile internationally this reasoning may be inappropriate instead emigration of unskilled labor out of the less developed country provides an incentive for capital to leave the country too as a consequence wage rates move in the same direction in each country and the gap between wage rates across countries even may increase

equity in the finance of health care some further international comparisons this paper presents further international comparisons of progressivity of health care financing systems the paper builds on the work of wagstaff et al wagstaff a van doorslaer e et al 1992 equity in the finance of health care some international comparisons journal of health economics 11 pp 361 387 but extends it in a number of directions we modify the methodology used there and achieve a higher degree of cross country comparability in variable definitions we update and extend the cross section of countries and we present evidence on trends in financing mixes and progressivity

the use of transfer payments by immigrants this paper uses data from the 1976 survey of income and education to compare the receipt of transfers by families headed by male and female immigrants and those headed by native born americans the average level of transfers is found to be considerably higher among families headed by immigrants but this is almost entirely the result of the higher average age of family members among the immigrant group a reflection of the large inflows of immigrants into the u s during the pre 1924 period when age and other factors are held constant immigrant families are found to be considerably less likely to rely on welfare than native families and their receipts from social insurance programs are found to be only slightly higher

europe and central asia s great post communist social health insurance experiment aggregate impacts on health sector outcomes abstract the post communist transition to social health insurance in many of the central and eastern european and central asian countries provides a unique opportunity to try to answer some of the unresolved issues in the debate over the relative merits of social health insurance and tax financed health systems this paper employs regression based generalizations of the difference in differences method on panel data from 28 countries for the period 1990 2004 we find that controlling for any concurrent provider payment reforms adoption of social health insurance increased national health spending and hospital activity rates but did not lead to better health outcomes

productivity of highly skilled immigrants economists in the postwar period larry d singell jr prior work finds declining immigrant quality in the postwar period that is linked to source country and skill composition changes associated with the 1965 immigration act this paper uses a unique panel of foreign and native born american economic association members to show that the highly skilled experienced a similar shift away from european migrants toward those from asia however the findings do not indicate that this change in source country composition has been accompanied by a decline in quality rather the most recent cohorts of foreign born economists appear to be more productive than their native counterparts jel j61 i introduction this article is the first systematic analysis of the attributes and abilities of foreign born u s economists since a descriptive study of the brain drain by grubel and scott 1967 it also provides some of the first formal evidence for the largely theoretical proposition in earlier work by bhagwati and rodriquez 1975 that the united states draws the best skilled workers from abroad however recent immigration literature has not focused on the brain drain but has generated considerable debate concerning whether the 1965 immigration and nationality act has reduced the skill quality of u s immigrants in particular descriptive evidence in borjas 1987 and greenwood 1983 respectively indicates that the 1965 law shifted the composition of u s immigrants toward non european nations and increased the number of low skilled migrants to the united states our article extends this work by examining whether there has been a post 1965 change in the source country mix of ph d economists and whether such chan ges impact the productivity of the foreign born in comparison to their native counterparts most empirical studies of immigrant productivity have focused on earnings early cross sectional studies of immigrant earnings including chiswick 1978a concluded that the age earnings profile of immigrants is steeper than that of comparable native born workers and though initially lower crosses the native profile 10 to 15 years after immigration these results are consistent with the widely held belief that the immigration process self selects the highly motivated and industrious from their respective source countries thus immigrants although they initially enter the united states with relatively low levels of human capital eventually become more productive than their native counterparts more recent work by borjas 1985 1987 has contested these conclusions arguing that it is not possible to separately identify assimilation and cohort effects using a single cross sectional data set in particular the positive correlation between earnings and years since migration in cross sectional data may be due to immigrant assimilation or a cohort effect that arises from the declining skill quality of more recent immigrant groups borjas combines multiple cross sectional data sets to separately identify assimilation and cohort effects and finds evidence indicating that earlier cohorts of immigrants do relatively better than both natives and more recent immigrant cohorts suggesting a decline in immigrant quality although chiswick 1986 challenges the contention of declining immigrant quality and funkhouser and trejo 1995 find evidence that immigrant quality may have increased during the 1980s borjas 1995 contends that the empirical evidence consistently shows that immigrant quality has declined for most of the postwar period however the decline in immigrant quality has not necessarily been found within specific groups of immigrants in particular greenwood and mcdowell 1986 find that the change in skill quality is related to the shift in the source country composition of immigrants away from european nations toward those from asia and latin american after the 1965 immigration act thus explanations for the relatively poor performance of recent immigrants including those in lalonde and topel 1991 1992 and borjas 1992 focus on the post 1965 changes in the incentives to migrate to the united states that have increased the number of low skilled non european immigrants

progressivity horizontal inequality and reranking caused by health system financing a decomposition analysis for switzerland abstract this paper presents an application of the duclos et al duclos j y jalbert v araar a 2003 classical horizontal inequity and reranking an integrated approach research on economic inequality 10 65 100 decomposition to an analysis of the 1998 swiss health system financing we see that in addition to measuring horizontal inequality in the classical sense this decomposition is more efficient and flexible than earlier ones it is also pointed out that methods involving a nonparametric estimation lead to asymptotically biased vertical and horizontal effects a procedure to estimate this bias is given finally it is shown that despite a major reform health system financing is still very regressive and social health insurance is more regressive than direct financing