universal coverage with supply side reform the impact on medical expenditure risk and utilization in thailand abstract we estimate the impact on out of pocket oop medical expenditure of a major reform in thailand that greatly extended health insurance coverage to achieve universality while implementing supply side measures intended to deliver cost effective care from an increased but modest public health budget difference in differences comparison of groups to whom coverage was extended or deepened with those whose coverage did not change indicates that the reform reduced oop expenditure by 28 on average and by 42 at the 95th percentile of the conditional distribution simulations suggest that exposure to medical expenditure risk was reduced by three fifths on average generating a social welfare gain equivalent to 80 200 of the approximate deadweight loss from financing the reform estimated effects on health care access suggest that the policy managed to reduce households medical expenses while also raising their utilization of both inpatient and ambulatory care

effects of universal health insurance on health care utilization and supply side responses evidence from japan abstract we investigate the effects of a massive expansion in health insurance coverage on health care utilization and supply side responses by focusing on universal health insurance introduced in japan in 1961 there are two major findings first health care utilization measured in terms of admissions inpatient days and outpatient visits to hospitals increased significantly second we also find a supply response but the size of the supply response differs across service types while the number of beds increases effects on the number of medical institutions physicians and nurses are either negligible or inconclusive our results suggest that countries planning a large expansion in health insurance coverage would need to generate sufficient financial resources to cover the surge in health care expenditures both in the short and long run our results also indicate that any slowdown in the supply side response may constrain the ability of the health care system to meet increased demand

financial risk protection from social health insurance this paper estimates the impact of social health insurance on financial risk by utilizing data from a natural experiment created by the phased roll out of a social health insurance program for the poor in india we estimate the distributional impact of insurance on of out of pocket costs and incorporate these results with a stylized expected utility model to compute associated welfare effects we adjust the standard model accounting for conditions of developing countries by incorporating consumption floors informal borrowing and asset selling which allow us to separate the value of financial risk reduction from consumption smoothing and asset protection results show that insurance reduces out of pocket costs particularly in higher quantiles of the distribution we find reductions in the frequency and amount of money borrowed for health reasons finally we find that the value of financial risk reduction outweighs total per household costs of the insurance program by two to five times

why is there no cannery in cannery row exploring a behavioral simulation model of population extinction available ecological models of organizations do not provide satisfactory explanation for population extinction in this article we search for a minimal set of assumptions needed to expand the range of dynamic behaviors of the ecological model of density dependence to admit extinction while preserving its original insight the revised version of the model builds on two core assumptions the first is that organizational populations are linked to their environments through feedback processes of resource generation and consumption as a consequence the carrying capacity for an organizational population changes systematically with its density the second assumption is that organizational vital rates respond with delay to changes in the level of available resources as a consequence organizational founding and mortality rates are affected by expectations that decision makers form about the future state of their environment using computer simulation we test these assumptions and show that the relative speed at which processes of resource regeneration and consumption happen and the speed at which expectations about future levels of resources are revised jointly determine a wide range of evolutionary trajectories that admit population extinction as one distinct possibility the model is validated using multivariate sensitivity analysis techniques we discuss the implications of our findings in the broader context of the current debate on the implications of selective sampling in the study of organizational populations copyright 2012 the author 2011 published by oxford university press on behalf of associazione icc all rights reserved oxford university press

on the distribution and dynamics of health care costs using data from the health and retirement survey and the assets and health dynamics of the oldest old survey we estimate the stochastic process that determines both the distribution and dynamics of health care costs we find that the data generating process for log health costs is well represented as the sum of a white noise process and a highly persistent ar 1 process we also find that the innovations to this process can be modelled with a normal distribution that has been adjusted to capture the risk of catastrophic health care costs simulating this model we find that in any given year 0 1 of households receive a health cost shock with a present value of at least 125 000 copyright 2004 john wiley sons ltd

what mean impacts miss distributional effects of welfare reform experiments labor supply theory predicts systematic heterogeneity in the impact of recent welfare reforms on earnings transfers and income yet most welfare reform research focuses on mean impacts we investigate the importance of heterogeneity using random assignment data from connecticut s jobs first waiver which features key elements of post 1996 welfare programs estimated quantile treatment effects exhibit the substantial heterogeneity predicted by labor supply theory thus mean impacts miss a great deal looking separately at samples of dropouts and other women does not improve the performance of mean impacts we conclude that welfare reform s effects are likely both more varied and more extensive than has been recognized

the incidence of medicare abstract the medicare program transfers nearly 300 billion annually from taxpayers to beneficiaries this paper considers the incidence of such transfers in the context of a life cycle model with uncertainty about future health care expenditures we find the distributional consequences of the medicare program are roughly neutral in dollar terms households living in high income neighborhoods pay more in taxes but they also receive more in benefits these dollar flows however ignore the insurance value of the medicare system given the incomplete insurance coverage of lower income elderly households prior to the medicare program the money metric benefits to lower income groups exceed the dollar flows suggesting that medicare redistributes more than a simple accounting exercise would suggest

can targeted transfers improve birth outcomes evidence from the introduction of the wic program abstract the goal of federal food and nutrition programs in the united states is to improve the nutritional well being and health of low income families a large body of literature evaluates the extent to which the supplemental program for women infants and children wic has accomplished this goal but most studies have been based on research designs that compare program participants to non participants if selection into these programs is non random then such comparisons will lead to biased estimates of the program s true effects in this study we use the rollout of the wic program across counties to estimate the impact of the program on infant health we find that the implementation of wic led to an increase in average birth weight and a decrease in the fraction of births that are classified as low birth weight we find no evidence that these estimates are driven by changes in fertility or selection into live births our preferred estimates suggest that wic initiation raised average birth weight by 2 g or by 7 g among infants born to mothers with low education levels these translate into estimated birth weight increases among participating mothers of approximately 18 to 29 g estimated treatments on the treated impacts among infants born to participating mothers with low education are of similar magnitude

the effect of patient cost sharing on utilization health and risk protection abstract this paper exploits a sharp reduction in patient cost sharing at age 70 in japan using a regression discontinuity design to examine its effect on utilization health and financial risk arising from out of pocket expenditures due to the national policy cost sharing is 60 80 percent lower at age 70 than at age 69 i find that both outpatient and inpatient care are price sensitive among the elderly while i find little impact on mortality and other health outcomes the results show that reduced cost sharing is associated with lower out of pocket expenditures especially at the right tail of the distribution jel g22 i11 i12 i13 i18 j14

life cycle responses to health insurance status this paper studies the lifetime effects of exogenous changes in health insurance coverage e g medicare ppaca termination of employer provided plans on the dynamic optimal allocation consumption leisure health expenditures status health and wealth and welfare we solve simulate and structurally estimate a parsimonious life cycle model with endogenous exposure to morbidity and mortality risks and exogenous health insurance by varying coverage we identify the marginal effects of insurance when young and or when old on allocations statuses and welfare our results highlight positive effects of insurance on health wealth and welfare as well as mid life substitution away from healthy leisure in favor of more health expenses caused by peaking wages and accelerating health issues

estimating the tradeoff between risk protection and moral hazard with a nonlinear budget set model of health insurance insurance induces a tradeoff between the welfare gains from risk protection and the welfare losses from moral hazard empirical work traditionally estimates each side of the tradeoff separately potentially yielding mutually inconsistent results i develop a nonlinear budget set model of health insurance that allows for both simultaneously nonlinearities in the budget set arise from deductibles coinsurance rates and stoplosses that alter moral hazard as well as risk protection i illustrate the properties of my model by estimating it using data on employer sponsored health insurance from a large firm

the insurance value of medical innovation abstract economists think of medical innovation as a valuable but risky good producing health benefits but increasing financial risk for consumers and healthcare payers this perspective overlooks how innovation can lower physical risks borne by healthy patients facing the prospect of future disease we present an alternative framework that accounts for all these sources of value and links them to the value of healthcare insurance we show that any innovation worth buying reduces overall risk and generates positive insurance value on its own we conduct a stylized numerical exercise to assess the potential empirical significance of our insights our calculations suggest that conventional methods meaningfully understate the value of historical health gains and disproportionately undervalue treatments for the most severe illnesses where physical risk to consumers is the costliest these calculations also suggest that the value of physical insurance from new technologies may exceed the financial spending risk that they pose

signalling and the pricing of new issues this paper develops a signalling model with two signals two attributes and a continuum of signal levels and attribute types to explain new issue underpricing both the fraction of the new issue retained by the issuer and its offering price convey to investors the unobservable intrinsic value of the firm and the variance of its cash flows many of the model s comparative statics results are novel empirically testable and consistent with the existing empirical evidence on new issues in particular the degree of underpricing which can be inferred from observable variables is positively related to the firm s post issue share price

the value of medicaid interpreting results from the oregon health insurance experiment we develop frameworks for welfare analysis of medicaid and apply them to the oregon health insurance experiment across different approaches we estimate low income uninsured adults willingness to

informality and the expansion of social protection programs evidence from mexico many countries are moving from employer based to universal health coverage which can generate crowd out in mexico seguro popular provides public health coverage to the uninsured using the gradual roll out of the system at the municipality level we estimate that seguro popular had no effect on informality in the overall population informality did increase by 1 7 for less educated workers but the wage gains for workers who switch between the formal and the informal sector were not significantly affected this suggests that marginal workers do not choose between formal and informal jobs on the basis of health insurance coverage

the risk and duration of catastrophic health care expenditures the authors measure the time series property of catastrophic medical costs facing the elderly using information on medical deductions from a panel of tax returns during the period of analysis 1968 73 taxpayers could deduct medical expenses above 3 percent of income they correct for the resulting censoring bias using multivariate tobit estimated with a variant of the smoothed simulated maximum likelihood method the estimated coefficients imply a 1 00 increase in out of pocket medical spending is associated with 2 65 in future out of pocket spending copyright 1994 by mit press

catastrophic medical expenditure risk we propose a measure of household exposure to particularly onerous medical expenses the measure can be decomposed into the probability that medical expenditure exceeds a threshold the loss due to predictably low consumption of other goods if it does and the further loss arising from the volatility of medical expenses above the threshold depending on the choice of threshold the measure is consistent with a model of reference dependent utility with loss aversion unlike the risk premium the measure is only sensitive to particularly high expenses and can identify households that expect to incur such expenses and would benefit from subsidised but not actuarially fair insurance an empirical illustration using data from seven asian countries demonstrates the importance of taking account of informal insurance and reveals clear differences in catastrophic medical expenditure risk across and within countries in general risk is higher among poorer rural and chronically ill populations

losing public health insurance tenncare reform and personal financial distress abstract a primary goal of health insurance is smoothing the financial risk associated with health shocks we estimate the effect of exposure to health insurance reform on individual level financial well being utilizing a plausibly exogenous shock to health insurance status resulting from a sudden disenrollment from tennessee s medicaid program in 2005 we find that the reform resulted in a 2 78 point decline in credit risk score for an individual in the median county in tennessee this study is the first examining the impact of losing any form of public assistance on personal financial well being and our results inform ongoing discussions around medicaid reform

health insurance and the labor supply decisions of older workers evidence from a u s department of veterans affairs expansion this paper exploits a major mid 1990s expansion in the u s department of veterans affairs health care system to provide evidence on the labor market effects of expanding health insurance availability using data from the current population survey we employ a difference in differences strategy to compare the labor market behavior of older veterans and non veterans before and after the va health benefits expansion to test the impact of public health insurance on labor supply we find that older workers are significantly more likely to decrease work both on the extensive and intensive margins after receiving access to non employer based insurance workers with some college education or a college degree are more likely to transition into self employment a result consistent with job lock effects however less educated workers are more likely to leave self employment a result suggesting that the positive income effect from receiving public insurance dominates the job lock effect for these workers some relatively disadvantaged sub populations may also increase their labor supply after gaining greater access to public insurance consistent with complementary positive health effects of health care access or decreased work disincentives for these groups we conclude that this reform has affected employment and retirement decisions and suggest that future moves toward universal coverage or expansions of medicare are likely to have significant labor market effects

the impact of health insurance on stockholding a regression discontinuity approach economic theory predicts that a reduction in background risk should induce financial risk taking particularly for individuals with low stock market participation costs hence health insurance coverage could affect financial risk taking by offsetting health related background risk we use a regression discontinuity design to examine whether medicare eligibility at age 65 increases stockholding in the us and find that it does so for those with college education but not for their less educated counterparts who face higher stock market participation costs our results are unlikely due to the reduction of medical expenses associated with medicare coverage because the latter does not affect bondholding

health insurance and mortality experimental evidence from taxpayer outreach we evaluate a randomized pilot study in which the irs sent informational letters to 3 9 million taxpayers who paid a tax penalty for lacking health insurance coverage under the affordable care act drawing on administrative data we study the effect of the intervention on taxpayers subsequent health insurance enrollment and mortality we find the intervention led to increased coverage in the two years following treatment and that this additional coverage reduced mortality among middle aged adults over the same time period our results provide the first experimental evidence that health insurance reduces mortality

the credit consequences of unpaid medical bills abstract this paper quantifies the costs of leaving medical bills unpaid and what these costs imply for the value of health insurance to beneficiaries we argue that a large fraction of unpaid medical bills is sent to third party collections and reported to credit bureaus with detrimental effects on patients credit outcomes combining a large panel of credit records with data on credit offers we find that the aca medicaid expansion reduced newly reported medical collections by 5 89 billion and led to better terms of credit we find that the financial benefits of medicaid at least double when including this indirect credit channel

the oregon health insurance experiment evidence from the first year in 2008 a group of uninsured low income adults in oregon was selected by lottery to be given the chance to apply for medicaid this lottery provides an opportunity to gauge the effects of expanding access to public health insurance on the health care use financial strain and health of low income adults using a randomized controlled design in the year after random assignment the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected we find that in this first year the treatment group had substantively and statistically significantly higher health care utilization including primary and preventive care as well as hospitalizations lower out of pocket medical expenditures and medical debt including fewer bills sent to collection and better self reported physical and mental health than the control group

medicaid insurance in old age the old age provisions of the medicaid program were designed to insure retirees against medical expenses we estimate a structural model of savings and medical spending and use it to compute the distribution of lifetime medicaid transfers and medicaid valuations across currently single retirees compensating variation calculations indicate that current retirees value medicaid insurance at more than its actuarial cost but that most would value an expansion of the current medicaid program at less than its cost these findings suggest that for current single retirees the medicaid program may be of the approximately right size

long run impacts of childhood access to the safety net a growing economics literature establishes a causal link between in utero shocks and health and human capital in adulthood most studies rely on extreme negative shocks such as famine and pandemics we are the first to examine the impact of a positive and policy driven change in economic resources available in utero and during childhood in particular we focus on the introduction of a key element of the u s safety net the food stamp program which was rolled out across counties in the u s between 1961 and 1975 we use the panel study of income dynamics to assemble unique data linking family background and county of residence in early childhood to adult health and economic outcomes the identification comes from variation across counties and over birth cohorts in availability of the food stamp program our findings indicate that the food stamp program has effects decades after initial exposure specifically access to food stamps in childhood leads to a significant reduction in the incidence of metabolic syndrome obesity high blood pressure and diabetes and for women an increase in economic self sufficiency overall our results suggest substantial internal and external benefits of the safety net that have not previously been quantified

the aggregate effects of health insurance evidence from the introduction of medicare this paper investigates the effects of market wide changes in health insurance by examining the single largest change in health insurance coverage in american history the introduction of medicare in 1965 i estimate that the impact of medicare on hospital spending is over six times larger than what the evidence from individual level changes in health insurance would have predicted this disproportionately larger effect may arise if market wide changes in demand alter the incentives of hospitals to incur the fixed costs of entering the market or of adopting new practice styles i present some evidence of these types of effects a back of the envelope calculation based on the estimated impact of medicare suggests that the overall spread of health insurance between 1950 and 1990 may be able to explain about half of the increase in real per capita health spending over this time period

what did medicare do the initial impact of medicare on mortality and out of pocket medical spending abstract we study the impact of the introduction of one of the major pillars of the social insurance system in the united states the introduction of medicare in 1965 our results suggest that in its first 10 years the establishment of universal health insurance for the elderly had no discernible impact on elderly mortality however we find a substantial reduction in the elderly s exposure to out of pocket medical expenditure risk specifically we estimate that the introduction of medicare was associated with a 40 decline in out of pocket spending for the top quartile of the out of pocket spending distribution a stylized expected utility framework suggests that the welfare gains from such reductions in risk exposure alone may be sufficient to cover almost two fifths of the costs of medicare these findings underscore the importance of considering the direct insurance benefits from public health insurance programs in addition to any indirect benefits from an effect on health

the effect of medicare part d on pharmaceutical prices and utilization prescription drug expenditures represent the most rapidly growing component of health care spending increasing from 5 percent of health care spending in 1980 to more than 10 percent by 2005 centers for medicare and medicaid services cms 2007a further almost 60 percent of all prescriptions in the united states are filled for beneficiaries of medicare medicaid and other government programs rapid innovation in new pharmaceuticals has contributed substantially to quality of life and longevity in the us frank lichtenberg 1996 these facts combined indicate that government procurement schemes are critical both in determining government expenditure on pharmaceuticals and in stimulating innovation of new treatments in this paper we show that the institutions and mechanisms used by the government to pur chase prescription drugs can strongly affect market outcomes by institutions we have in mind large buyer groups structured incentives for patients to consume certain products and the devel opment and use of formularies a formulary is a mechanism that allows a buyer to identify a therapeutically similar treatment as a viable substitute for a patented treatment and to create price competition due to the ability to substitute away from the more expensive product when bargaining with the seller of a patented product the ability to shift demand to a substitute drug is a powerful negotiating tool our paper provides evidence for what we consider a surprising outcome in the case of the new prescription drug program for medicare enrollees moving consumers from cash paying status to membership in an insured group lowers optimal prices for branded prescription drugs below what they otherwise would be this is surprising because the standard effect of insurance is to create inelastic demand and therefore elicit higher prices from a seller with market power duggan and scott morton 2006 however the insurers that we study bundle insurance with a formulary and other mechanisms to create elastic demand an individual consumer typically does not know which drugs are acceptable therapeutic substitutes the consumer s physician typi cally has poor knowledge of prices especially negotiated prices and any one consumer is too small a share of demand to negotiate with a pharmaceutical company a prescription drug plan can potentially surmount all three hurdles our evidence leads us to conclude that the formulary and other mechanisms perform the spe cial role of allowing buyers to move market share among drugs with patent protection thereby raising cross price elasticities and lowering purchase prices or reducing price increases for branded drugs this result contrasts with the common intuition that an uninsured consumer

the interaction of public and private insurance medicaid and the long term care insurance market a long tradition in public finance examines how public programs can crowd out private activ ity in areas as diverse as education savings and insurance among others these studies typi cally focus on aggregate economic implications particularly for government expenditures and national savings in this paper we demonstrate that crowd out can also have an important effect on individual welfare specifically we show that the provision of even very incomplete public insurance can crowd out more comprehensive private policies by imposing a large implicit tax on private insurance benefits thus potentially increasing overall risk exposure for individuals we examine the interaction of public and private insurance for one of the largest uninsured financial risks facing the elderly in the united states long term care expenditures at 135 bil lion in 2004 long term care expenditures represented over 8 5 percent of total health expendi tures or all ages or roughly 1 2 percent of gdp moreover real long term care expenditures are projected to triple over the next 35 years due to rising medical costs and the aging of the baby boomers only 10 percent of the elderly however have any private long term care insurance and one third of expenditures are paid for out of pocket congressional budget office cbo 1999 cbo 2004 brown and finkelstein 2007 one potential explanation for the small size of the private market is that the public insurance provided by medicaid may crowd out demand for private insurance medicaid was designed to provide long term care insurance for the poor elderly mark v pauly 1989 1990 has established the qualitative result that as an incomplete but publicly funded source of long term care insur ance medicaid has the potential to reduce substantially demand for private long term care insur ance even among the nonpoor our work builds on this insight by quantifying the magnitude of medicaid s crowd out effect and the incomplete nature of medicaid coverage we also illustrate the mechanism behind medicaid s crowd out effect and are therefore able to assess the likely impact of alternative policies on private insurance demand we develop a utility based model of a 65 year old risk averse individual who chooses an opti mal intertemporal consumption path in the presence of uncertainty about long term care expen ditures we calibrate the model using data on the distribution of long term care expenditure risk common state medicaid rules and the prices and coverage of typical private long term care insurance policies

new evidence on the money s worth of individual annuities this paper presents new information on the expected present discounted value of payouts on individual life annuities the annuity we examine is the single premium immediate life annuity an insurance product that pays out a nominal level sum as long as the covered person lives in exchange for an initial lump sum premium this annuity offers protection against the risk of someone outliving his saving given uncertainty about longevity for reasonable estimates of behavioral parameters we calculate that individual annuities are currently priced so that retirees without bequest motives should find these policies of substantial value in configuring their portfolios to smooth retirement consumption we also find that the expected present discounted value of payouts relative to the initial cost of the annuity has increased over the last decade these findings bear on the policy debate regarding the role of individual choice and self reliance in retirement planning this abstract was borrowed from another version of this item

the effect of health insurance on home payment delinquency evidence from aca marketplace subsidies abstract we use administrative tax data and survey responses to quantify the effect of subsidized health insurance on rent and mortgage delinquency we employ a regression discontinuity rd design exploiting the income threshold for receiving marketplace subsidies in states that did not expand medicaid under the affordable care act among households targeted by the policy eligibility for subsidies is associated with a roughly 25 decline in the delinquency rate and reduced exposure to out of pocket medical expenditure risk iv treatment effects are significant indicating that the decline in the delinquency rate is related to participation in health insurance we show that under plausible assumptions the social benefits implied by our rd estimates in terms of fewer evictions and foreclosures are substantial

does medicare benefit the poor abstract measuring the progressivity of age targeted government programs is difficult because no single data set measures income and benefit use throughout life previous research using zip code as a proxy for lifetime income has found that medicare benefits flow primarily to the most economically advantaged groups and that the financial returns to medicare are often higher for the rich than the poor however our analysis produces the starkly opposed result that medicare is an extraordinarily progressive public program in dollar terms or welfare terms these new results owe themselves to our measurement of socioeconomic status as an individual s education rather than the geographically aggregated measures of income used by previous research we argue that individual education has important practical and conceptual advantages over geographically aggregated measures of income our results suggest the crucial importance of accurate poverty measurement in evaluating the progressivity of complex government programs like medicare or social security

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

estimating health demand for an aging population a flexible and robust bayesian joint model in this paper we analyse two frequently used measures of the demand for health care namely hospital visits and out of pocket health care expenditure which have been analysed separately in the existing literature given that these two measures of healthcare demand are highly likely to be closely correlated we propose a framework to jointly model hospital visits and out of pocket medical expenditure furthermore the joint framework allows for the presence of non linear effects of covariates using splines to capture the effects of aging on healthcare demand sample heterogeneity is modelled robustly with the random effects following dirichlet process priors with explicit cross part correlation the findings of our empirical analysis of the u s health and retirement survey indicate that the demand for healthcare varies with age and gender and exhibits significant cross part correlation that provides a rich understanding of how aging affects health care demand which is of particular policy relevance in the context of an aging population

the impact of nearly universal insurance coverage on health care utilization evidence from medicare the onset of medicare eligibility at age 65 leads to sharp changes in the health insurance coverage of the u s population these changes lead to increases in the use of medical services with a pattern of gains across socioeconomic groups that varies by type of service while routine doctor visits increase more for groups that previously lacked insurance hospital admissions for relatively expensive procedures like bypass surgery and joint replacement increase more for previously insured groups that are more likely to have supplementary coverage after 65 reflecting the relative generosity of their combined insurance package under medicare