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

economic and other determinants of infant and child mortality in small developing countries the case of central america and the caribbean inter country differences in infant and child mortality are explained by looking at demographic economic health and educational factors a model is presented in which the infant mortality rate the child mortality rate and the birth rate are endogenous the model is tested using cross national multiple regression analysis and simulations the presence of simultaneity is confirmed introducing non economic factors transforms the character of the relationship between exogenous and endogenous variables from a diminishing returns to an increasing returns one the role played by public expenditure in education vaccination coverage low birth weight female schooling number of nurses access to safe water or malnutrition can be assessed as well as that played by structural adjustment variables such as the inflation rate or the external debt to gnp ratio infant and child mortality can be diminished everywhere in the region with relatively small amounts of expenditure disappointing outcomes in som

income inequality and health lessons from a refugee residential assignment program this paper examines the effect of income inequality on health for a group of particularly disadvantaged individuals refugees our analysis draws on longitudinal hospitalization records coupled with a settlement policy where swedish authorities assigned newly arrived refugees to their first area of residence the policy was implemented in a way that provides a source of plausibly random variation in initial location the results reveal no statistically significant effect of income inequality on the risk of being hospitalized this finding holds also for most population subgroups and when separating between different types of diagnoses our estimates are precise enough to rule out large effects of income inequality on health

evolution of the infant health production function michael grossman s seminal publication on the demand for health and health production grossman 1972 has spawned a substantial body of research focusing on the production of infant health this article provides a systematic review of the published literature to date on infant health production and how it has evolved over the past 3 4 decades as data have become more available computing has improved and econometric methods have become more sophisticated while empirical research in most fields has expanded in corresponding ways the infant health production research has become an important part of the broader and inherently multidisciplinary literature on intergenerational health the strongest and most robust findings are that policies matter for infant health particularly those affecting access to health care and that prenatal smoking and other chemical exposures substantially compromise infant health promising directions for future research include elucidating relevant pathways reconciling the largely inconsistent estimated effects of nutrition and education and exploring the roles of preconceptional and lifetime health care paternal factors social support housing complementarity and substitutability of inputs factors that modify effects of inputs and evolving medical technologies

the medicaid notch labor supply and welfare participation evidence from eligibility expansions i assess the impact of losing public health insurance on labor market decisions of women by examining a series of medicaid eligibility expansions targeted toward young children these targeted expansions severed the historical tie between afdc and medicaid eligibility the reforms allowed a mother s earnings to increase without losing public health insurance for her young children increasing the income limit for medicaid resulted in a decrease in afdc participation and an increase in labor force participation among these women the effects were large for ever married women and negligible for never married women

behavioral modes for a firm facing an uncertain supply or demand curve this paper contains a theoretical analys is of the behavior of a firmfacing a stochastic supply and demand curve certai n behavioral modes can be ranked under weaker conditions than in corresponding s tudies on stochastic demand for other comparisons the authors derive sufficien t conditions for one mode to dominate another earlier results indicate that a f irm which faces demand uncertainty prefers price variability to quantity variabi lity it is shown by a counter example that the price variability preference which is troublesome for proponents of temporary fixed price equilibrium models is a consequence of restrictive stochastic specification copyright 1987 by the editors of the scandinavian journal of economics

information asymmetry and traceability incentives for food safety abstract we define traceability by its precision that is the probability of finding the source of a problem we consider a downstream food processor firm principal that sets traceability precision and contingent payments so to induce homogeneous upstream suppliers agents to exert the principal s preferred level of food safety effort we focus on cases in which food safety crises originate from defects in raw material provided by upstream firms to analytically show that high precision can substitute for high intensive contingent payments and vice versa and thus traceability is not an unequivocal signal for safer food contrary to previous results in the literature we also show that government regulation based on mandatory traceability with sanctions may not necessarily lead to safer food while increasing the food processor s costs finally we use our analytical results to give managerial feedbacks for firms adopting and considering traceability

income inequality and health status in the united states evidence from the current population survey several recent studies have identified an association between income inequality and aggregate health outcomes this has been taken to be evidence that inequality is detrimental to individual health we use data from the 1995 99 march current population survey to examine the effect of income inequality on individual health status for both the general population and those individuals in poverty we find no consistent association between income inequality and individual health status our results contradict recent claims that the psychosocial effects of income inequality have dramatic consequences for individual health outcomes

the costs of low birth weight birth weight has emerged as the leading indicator of infant health and welfare and the central focus of infant health policy this is because low birth weight lbw infants experience severe health and developmental difficulties that can impose enormous costs on society but would the prevention of lbw generate equally sizable cost savings and health improvements estimates of the return to lbwprevention from cross sectional associations may be biased by omitted variables that cannot be influenced by policy such as genetic factors to address this we compare the hospital costs health at birth and infant mortality rates between heavier and lighter infants from all twin pairs born in the united states we also examine the effect of maternal smoking during pregnancy the leading risk factor for lbw in the united states on health among singleton births after controlling for detailed background characteristics both analyses imply substantially smaller effects of lbw than previously thought suggesting two possibilities 1 existing estimates overstate the true costs and consequences of lbw by at least a factor of four and by as much as a factor of 20 or 2 different lbw preventing interventions have different health and cost consequences implying that policy efforts that presume a single return to reducing lbw will necessarily be suboptimal

consumer willingness to pay to reduce the probability of retail foodborne pathogen contamination abstract the us department of agriculture applies a cost of illness approach to value reductions in morbidity which may understate the projected benefits from proposed food safety improvements by ignoring costs such as pain suffering and worry we use a national survey with a hypothetical food choice experiment to estimate a more comprehensive measure of consumer willingness to pay for food safety improvements our approach differs from previous evaluations of food safety improvements because we 1 provide the respondent with information about the promised change in the probability of pathogen contamination in retail food packages rather than changes in the probability of becoming ill 2 elicit changes in respondents subjective probability of becoming ill and 3 elicit predicted changes in the quantity demanded for products that have enhanced food safety properties we estimate the consumer s choice between a safety enhanced and an existing product the change in subjective probability of contracting foodborne illness associated with the enhanced product and the change in demand for the enhanced product in a manner that recognizes the correlation among unobserved elements the aggregated results suggest benefit estimates that are significantly larger than previous estimates for similar improvements

the choice of a liability regime when there is a regulatory gatekeeper consider a firm planning a project that poses a risk of environmental spillovers such a firm might be deterred by the threat of legal liability or restrained by gatekeeper regulation if regulators would be perfect gatekeepers then negligence based liability combined with regulation is more efficient that strict liability with or without regulation however if the regulator has incomplete information then any of a variety of regimes could be the most efficient harsher regimes regulation rather than laissez faire and strict liability rather than negligence are more appropriate for larger risks the choice of a liability regime is more complicated however if regulators are biased if they are biased against projects then negligence plus regulation is less likely to be the most efficient regime if regulators are biased toward projects then it is possible that apparently soft liability regimes are more desirable when risk is high

on the effectiveness of liability rules when agents are not identical this paper is about accidents involving two risk neutral parties both parties engage in actions that are profitable but affect the magnitude of possible bilateral accidents we analyse how the action choices can be decentralized by liability rules that assign the accident costs to the two parties if we allow for punitive damages we can implement the first best actions by a liability rule even if agents are not identical under this liability rule some individuals may be in expectation better off in the event of an accident than in the event of no accident we provide conditions under which this problem does not arise

infant mortality relative income and public policy do health outcomes depend on relative income as well as on an individual s absolute level of income we use infant mortality as a health status indicator and find a significant and positive link between infant mortality and income inequality using cross national data for 93 countries holding constant the income of each of the three poorest quintiles of a country s population we find that an increase in the income of the upper 20 of the income distribution is associated with higher not the lower infant mortality our results are robust and not just caused by the concave relationship between income and health the estimates imply a decrease in infant mortality by 1 5 for a one percentage point decrease in the income share of the richest quintile the overall results are sensitive to public policy public health care expenditure educational outcomes and access to basic sanitation and safe water can explain the inequality health relationship thus our findings support the hypothesis of public disinves

socioeconomic status and child health why is the relationship stronger for older children case lubotsky and paxson 2001 show that the well known relationship between socio economic status ses and health exists in childhood and grows more pronounced with age however in cross sectional data it is difficult to distinguish between two possible explanations the first is that low ses children are less able to respond to a given health shock the second is that low ses children experience more shocks we show using panel data on canadian children that 1 the gradient we estimate in the cross section is very similar to that estimated previously using u s children 2 both high and low ses children recover from past health shocks to about the same degree and 3 that the relationship between ses and health grows stronger over time mainly because low ses children receive more negative health shocks in addition we examine the effect of health shocks on math and reading scores we find that health shocks affect test scores and future health in very similar ways our results suggest that public policy aimed at reducing ses related health differentials in children should focus on reducing the incidence of health shocks as well as on reducing disparities in access to palliative care

hyteresis in import prices the beachhead effect this paper shows that temporary real exchange rate fluctuations can have persistent hysteretic effects on trade specifically when market entry costs are sunk sufficiently large exchange rate shocks alter domestic market structure and thereby induce hysteresis this simple result has strong implications for exchange rate theory t rade policy and estimation of trade equations empirical evidence su ggests that the recent dollar overvaluation induced hysteresis in u s import prices namely the aggregate pass through equation of exchange rates to import prices shifted in the 1980s the shift s nature and timing is broadly consistent with the hysteresis hypothesis copyright 1988 by american economic association

striking at the roots of crime the impact of welfare spending on crime during the great depression abstractduring the great depression contemporaries worried that people hit by hard times would resort to crime president franklin roosevelt argued that the massive government relief efforts struck at the roots of crime by providing subsistence income to needy families after constructing a panel data set for 81 large american cities for the years 1930 40 we estimate the effect of relief spending by all levels of government on crime rates the analysis suggests that a 10 percent increase in relief spending during the 1930s reduced property crime by roughly 1 5 percent by limiting the amount of relief recipients free time work relief may have been more effective than direct relief in reducing crime more generally our results indicate that social insurance which tends to be understudied in economic analyses of crime should be more explicitly and more carefully incorporated into the analysis of temporal and spatial variations in criminal activity

recent trends in insured and uninsured unemployment is there an explanation this paper explores the recent decline in the fraction of unemployed workers who receive unemployment insurance benefits using march current population surveys we compare the fraction who are potentially eligible for benefits with the fraction who receive them the decline in insured unemployment is almost entirely due to a decline in the early 1980s in the takeup rate for benefits we analyze the determinants of the takeup rate using both aggregated state level data and micro data at least half the decline is due to an increasing share of unemployment in states with lower takeup rates

effects of income inequality on population health new evidence from the european community household panel this study provides new evidence in order to explore the relationship between income inequality and health in the european union countries using new data from the european community household panel echp a variety of different specifications were tried using diverse dependent variables such as life expectancy at birth and child mortality the results show new support to the influence of income inequality on health indicators using aggregate data and panel techniques

dumping at less than marginal cost abstract the traditional analysis of dumping in an export market treats the term merely as a synonym for price discrimination in an international context crucially it does not predict that goods will be sold overseas at price less than marginal cost this paper explores the possibility that dumping can occur in the more obvious lay sense of selling at less than marginal cost it suggests three reasons why this may occur in circumstances of uncertainty pursuance of managerial goals and strategic entry deterrence in the first of these the traditional prediction of reduced surplus for domestic consumers is no longer assured

the relationship between waste paper and other inputs in the swedish paper industry a number of life cycle assessment studies havecompared the environmental impacts of materialrecycling and incineration of waste paper theyhave shown that in most cases a recyclingscenario results in lower total energy use butgreater use of fossil fuels if waste paper andfossil fuels are complements parts of theenvironmental argument for recycling isabolished this paper estimates a cost functionfor the swedish paper industry if the costshares are co integrated an error correctionmodel will be used to model the dynamics short and long run elasticities are thencalculated to address the relationship betweenwaste paper and the other inputs capital labor purchased pulp fiber fossil fuels andelectricity contrary to the life cycleassessment studies the results show that wastepaper and fossil fuels are substitutes andthat waste paper and electricity arecomplements

ex post liability for harm vs ex ante safety regulation substitutes or complements this paper concerns the regulation of hazardous economic activities economists have generally viewed ex ante regulations safety standards pigouvian fees that regulate an activity before an accident occurs as substitutes for ex post policies exposure to tort liability for correcting extemalities this paper shows that where there is uncertainty there are inefficiencies associated with the exclusive use of negligence liability and that ex ante regulation can correct the inefficiencies in such a case it is efficient to set the safety standard below the level of precaution that would be called for if the standard were used alone jel 619

cyclical dumping and correlated business cycles in imperfect markets empirical applications to the canadian pulp and paper industry this paper deals with theoretical and empirical aspects of firm behaviour under imperfect competition and uncertainty it contains an analysis of the behaviour of a firm facing a stochastic demand

optimal sharing of foodborne illness prevention between consumers and industry the effect of regulation and liability consumers and the food industry can both prevent foodborne illness two questions are explored what is the socially optimal level of preventative effort by each and can tort and regulatory instruments induce such behavior analysis is complicated by two aspects of food safety technology one party s effort can affect the marginal effectiveness of the other party s effort and damage functions can be nonconvex previous analysis of accidents under torts and regulation fails to consider these generalizations indeed results concerning the ability of tort and regulatory instruments to induce first best and second best behavior often contradict previous results in the literature

socio economic status and child health does public health insurance narrow the drawing on evidence from the u s this paper examines the effects of public health insurance on children recent expansions of american public health insurance programs to previously ineligible children have created a great deal of variation that can be used to identify their effects results indicate that providing public insurance to poor children narrows socio economic gaps in utilization and health among children however inefficiencies and inequities in the allocation of health care remain which suggests that universality and outreach programs are also important components of the public health systems common in europe

no such thing as a free safe lunch the cost of food safety regulation in the meat industry this study develops theoretical and econometric cost function models for the meat industry to test the hypothesis of safety exogeneity i e that product safety does not affect productive efficiency using plant level data from the census of manufactures this hypothesis is rejected estimates of the impacts of food safety regulation on variable cost of production in the beef pork and poultry industries show that the efficiency costs of food safety regulations could plausibly exceed benefits estimated by the u s department of agriculture costs of regulation per pound of meat are found to be size neutral for all but the smallest plants copyright 2000 oxford university press

the injustice of inequality in many countries the operation of legal political and regulatory institutions is subverted by the wealthy and the politically powerful for their own benefit this subversion takes the form of corruption intimidation and other forms of influence we present a model of such institutional subversion focusing specifically on courts and of the effects of inequality in economic and political resources on the magnitude of subversion we then use the model to analyze the consequences of institutional subversion for the law and order environment in the country as well as for capital accumulation and growth we illustrate the model with historical evidence from gilded age united states and the transition economies of the 1990s we also present some cross country evidence consistent with the basic prediction of the model

estimating a household production function heterogeneity the demand for health inputs and their effects on birth weight the household production literature emphasizes that technical or biological processes condition input selection by households in their production activities along with prices and income exogenous variations in health to the extent that they are perceived by individuals heterogeneity lead to correlations between inputs and health outcomes that cannot be used to derive causal conclusions therefore estimates of health technology must be obtained from a behavioral model in which health inputs are themselves choices consistent estimates are reported of the effect of endogenous inputs such as medical care smoking and fertility on birth weight and fetal growth in the presence of health heterogeneity

food safety and product liability abstract this paper focuses on the u s product liability system for food poisoning cases and makes six key points first current legal incentives to produce safer food are weak though slightly stronger in outbreak situations and in markets where foodborne illness can be more easily traced to individual firms far less than 0 01 of cases are litigated and even fewer are paid compensation second even if potential plaintiffs can overcome the high information and transaction costs necessary to file lawsuits monetary compensation provides only weak incentives to pursue litigation firms paid compensation in 56 of the 294 cases examined in this study and the median compensation was only 2 000 before legal fees third indirect incentives for firms may be important and deserve more research for example firms may be influenced by costly settlements and decisions against other firms in the same industry fourth confidential settlements health insurance and product liability insurance distort legal incentives to produce safer food fifth the ambiguity about whether microbial contamination is natural or an adulterant hinders the legal system from effectively dealing with food safety issues sixth a brief comparison of the incentives from u s and english legal systems suggests that more research is needed to understand the strengths weaknesses and relative impact of each country s legal system on the incentives to produce safer food

income distribution and infant mortality comparing two countries in which the poor have equal real incomes the one in which the rich are wealthier is likely to have a higher infant mortality rate this anomalous result does not appear to spring from measurement error in estimating the income of the poor and the association between high infant mortality and income inequality is still present after controlling for other factors such as education medical personnel and fertility the positive association of infant mortality and the income of the rich suggests that measured real incomes may be a poor measure of social welfare this paper considers and tests several possible explanations such as the provision of medical services the degree of urbanization the extent of female literacy and differences in the composition of births among different income groups none of these factors adequately accounts for the positive association between the incomes of the rich and infant mortality the geographical scope is worldwide excerpt

product and occupational liability i ncreased liability for risks posed by jobs and products has transformed the cost structure of these markets premiums for general liability insurance which provides protection for injuries and property damage to others mushroomed from 6 5 billion in 1984 to 19 4 billion in 1986 the increase in workers compensation premiums has been slightly less dramatic rising from 11 3 billion in 1978 to 26 1 billion in 1988 in each case these costs are in addition to any legal fees and self insurance costs incurred by the firm insurance information institute 1990 moreover although these institutions have separate functions product liability remedies are for product related injuries and workers compensation is for job injuries their responsibilities have begun to overlap increasingly as workers file product claims for job injuries against the producers of products used in the workplace such as the asbestos manufacturer liability costs used to be an incidental expense now they are a factor of substantial economic consequence some markets such as pharmaceuticals and private aircraft have been hit particularly hard liability costs now account for 17 percent of the fares paid by riders on the philadelphia mass transit system and from 15 25 percent of the purchase price of a new ladder in addition as insurance coverage decreased some products have simply disappeared such as certain amusement park rides and diving boards at many motel swimming pools

product liability research and development and innovation product liability ideally should promote efficient levels of product safety but misdirected liability efforts may depress beneficial innovations this paper examines these competing effects of liability costs on product r d intensity and new product introductions by manufacturing firms at low to moderate levels of expected liability costs there is a positive effect of liability costs on product innovation at very high levels of liability costs the effect is negative at the sample mean liability costs increase r d intensity by 15 percent the greater linkage of these effects to product r d rather than process r d is consistent with the increased prominence of the design defect doctrine

the lulling effect the impact of child resistant packaging on aspirin and analgesic ingestions in 1972 the food and drug administration imposed a protective bottlecap requirement on aspirin and other selected drugs this regulation epitomizes the technological approach to social regulation the strategy for reducing children s poisoning risks was to design caps that would make opening containers of hazardous substances more difficult this engineering approach will be effective provided that children s exposure to hazardous products does not increase if however parents leave protective caps off bottles because they are difficult to open or increase children s access to these bottles because they are supposedly child proof the regulation may not have a beneficial effect indeed in this case there was no significant impact of the regulation on aspirin poisoning rates but there has been an alarming upward shift in the trend of analgesic ingestion rates since 1972 the source of this pattern appears to be attributable to a general reduction in parental caution with respect to such medicines which has had an adverse spillover effect on unregulated products the economic mechanisms involved can be best understood by considering the nature of individuals response to regulatory protection

infant and child mortality in developing countries analysing the data for robust determinants is development best achieved by going for growth or does specific attention need to be paid to directly improving human welfare in contrast to the human development reports of the undp the world bank has stressed the growth approach recent work has reinforced this position by arguing that health spending is extremely ineffective in reducing infant or child mortality which is mainly explained by a country s income per capita this article contests this position through testing the robustness of determinants of infant and child mortality we have estimated over 420 000 equations which show that while income per capita is a robust determinant of infant and child mortality so are indicators of health education and gender inequality some health spending such as immunisation is thus shown to be cost effective way of saving lives our results are consistent with the view that much health spending in developing countries may be poorly targeted or otherwise ineffective but do not support the position t

food safety regulation an overview of contemporary issues abstract this article discusses a number of issues that are influencing the evolution of food safety regulation in developed and to a lesser extent developing countries whilst not definitive it aims to highlight those factors which are considered crucial to an understanding of contemporary food safety controls in both the public and private spheres these issues include criteria applied to assess the need justification for food safety regulation relationships between public and private food safety control systems alternative forms that public food safety regulation can take strategic responses to food safety regulation and the trade implications of national food safety controls the article serves as an introduction to these issues which are discussed at greater length in the other papers that make up this special issue of food policy

the welfare impact of food pathogen vaccines abstract vaccines against several common foodborne pathogens are being developed and could substantially alter the policy tools available to address foodborne illness however little analysis is available to suggest how social welfare would be affected by consumer and industry responses to these new vaccines to address this void we use stated preference data to estimate consumer willingness to pay wtp for food safety vaccines and then simulate the welfare impacts of subsidizing consumer purchases of the vaccine given two different industry responses maintaining current levels of food safety vigilance and reducing food safety vigilance due to a moral hazard response that undermines consumer confidence in food safety to obtain consumer preferences for the vaccine we simultaneously estimate a three equation model that recognizes the recursive nature of responses to questions probing respondents willingness to purchase vaccines and perceptions of the probability and severity of possible foodborne illness incidents and the joint distribution of unobservable components our simulations show large consumer wtp if vaccines are relatively inexpensive while the presence of moral hazard increases respondents willingness to pay and voluntary uptake of vaccine

product liability and regulation establishing the appropriate institutional division of labor society has several institutional mechanisms that promote the control of product health and safety risks and compensation of the income losses that these risks generated for risks traded in the market economic forces at work foster each of these objectives social insurance programs such as worker s compensation promote the compensation objective directly and influence safety incentives through the meritrating procedure two additional institutional mechanisms which are the focus of this paper are tort liability and regulation each of these institutions has assumed a more active role in the last two decades and has been the focus of considerable academic and policy debate what is most noteworthy about these discussions is that both policymakers and economic analysts generally view each institution as the only societal response to the risk in the field of legal scholarship this narrow approach has been termed the tortcentric perspective by richard stewart 1987a b such a piecemeal approach may be necessary in some cases as an analytic convenience but it neglects potentially important interactions of the two systems in this paper i explore the nature of the institutional interactions in section i and examine the appropriate institutional design in section ii the general conclusion is that risk regulation should play a dominant role in augmenting market incentives for risk reduction and that the scope of product liability remedies should be scaled back to reflect its subsidiary role

the effects of public health spending on self assessed health status an ordered probit model this paper explores the relationship between public health expenditure and self assessed health status medical resources are imputed according to where individuals reside the analysis draws upon data from the 1993 national health survey controlling for a number of individual characteristics which also determine health status the estimations indicate that increases in public health expenditure significantly improve both physiological and physical health the results remain consistent when the model is reestimated and the change in the probability at the mean of the independent variable is calculated

health insurance eligibility utilization of medical care and child health two economists applied data from the current population survey and the national health interview survey and state level data on child mortality to a simulation model of utilization of medical care that varies only with the states legislative environment to examine the utilization of medical care and health effects of medicaid eligibility on low income children the models took into consideration the recent expansions of medicaid to low income children 38 of those ineligible for medicaid in 1984 who became eligible due to changes during 1984 1992 were uninsured between 1984 and 1992 expansions of the medicaid program increased the proportion of children eligible for medicaid almost two fold 16 1 vs 31 2 yet coverage rates were always lower than eligibility rates 13 2 vs 16 1 in 1984 and 20 3 vs 31 2 in 1992 and the increase in coverage rates was only about 50 of the increase in eligibility rates during 1984 1992 the probability that a child was eligible for medicaid increased the probability of health insurance coverage by 29 77 when the model considered bias in variables e g a recession in a state the take up rate was only 22 73 nevertheless medicaid markedly increased use of medical care for example eligibility for medicaid increased the likelihood of making a visit to a physicians office in the last two weeks by about 50 it also increased the probability of a child visiting the hospital suggesting inefficiency in the way that providers deliver care to medicaid enrollees medicaid eligibility had a significant effect on reducing child mortality the 15 1 percentage point increase in eligibility during 1984 1992 reduced child mortality by 4 5 when the researchers examined parent assessed subjective health measures medicaid eligibility had no effect on child health medicaid eligibility reduced race and education based disparities in the number of visits and racial differences in mortality yet it may actually intensify current disparities in health care delivery site