bluuebunny/crossref_metadata_2025 huggingface dataset:
A Health Insurance Tax Credit for Uninsured Workers
Authors: Zelenak Lawrence
Published: August 2011

This paper describes a new system of tax credits to help low-income workers pay for health insurance. The system would be designed to subsidize health insurance coverage for workers who are currently uninsured, or who pay high premiums for nongroup insurance. Anyone age 19 or older who is not covered by Medicaid, Medicare, or employer-sponsored health insurance would be eligible for a health insurance tax credit (HITC), administered through the Internal Revenue Service. The base amount of the proposed credit would be $2,000 per year for each covered individual, but this amount would be adjusted for the individual's age and sex, according to the effect of age and sex on the cost of insurance coverage. The base amount of the credit would be reduced by $150 for every $1,000 by which a person's income exceeded 200% of the federal poverty level, thus limiting HITC eligibility to lower-income workers. To encourage participation in the credit program, most of the credit would be available through an advance payment system, with final reconciliation after year's end.
Increasing Health Insurance Coverage through an Extended Federal Employees Health Benefits Program
Authors: Fuchs Beth C.
Published: August 2011

The Federal Employees Health Benefits Program (FEHBP) could be combined with health insurance tax credits to extend coverage to the uninsured. An extended FEHBP, or “E-FEHBP,” would be open to all individuals who were not covered through work or public programs and who also were eligible for the tax credits on the basis of income. E-FEHBP also would be open to employees of very small firms, regardless of their eligibility for tax credits. Most plans available to FEHBP participants would be required to offer enrollment to E-FEHBP participants, although premiums would be rated separately. High-risk individuals would be diverted to a separate high-risk pool, the cost of which would be subsidized by the federal government. E-FEHBP would be administered by the states, or if a state declined, by an entity that contracted with the Office of Personnel Management. While E-FEHBP would provide group insurance to people who otherwise could not get it, premiums could exceed the tax-credit amount and some people still might find the coverage unaffordable.
A Federal Tax Credit to Encourage Employers to Offer Health Coverage
Authors: Meyer Jack A. , Wicks Elliot K.
Published: August 2011

Many firms that employ low-wage workers cannot afford to offer an employee health plan, and many of the uninsured work for such firms. This article makes the case for an employer tax credit, administered by the Internal Revenue Service, as a way to extend health coverage to uninsured workers and their families. The permanent, fixed-dollar, refundable credit would be available to all low-wage employers (those with average wages of $10 per hour and less), including those already offering coverage. The credit would be graduated depending on average wage: the maximum credit would equal 50% of the cost of a standard benefit package; the minimum would equal 30% of the package. It also would vary by family size and could be used to cover part-time and temporary workers. Participating employers would be required to pay at least 50% of the health insurance premium, proof of which would be shown on firms' tax returns. The paper provides justification for this approach. It closes with a discussion of strengths and weaknesses of this approach and alternative design features.
Transitional Subsidies for Health Insurance Coverage
Authors: Gruber Jonathan
Published: August 2011

Losing or leaving a job often means losing health insurance. Of all those who have lost private insurance and become uninsured, one-third have either left or lost a job in the recent past. Continuation of coverage subsidies under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 mitigate only slightly this problem due to the high costs of the group coverage that must be purchased. This paper discusses a proposal to build on the successes of COBRA to extend insurance to this important population. The key components are: a doubling of the length of COBRA entitlement to 36 months; eligibility for workers in all firms, not just those with more than 20 employees, but with a waiting period of one to two years; the establishment of a new COBRA-LOAN program that would offer government loans to help enrollees pay the cost of COBRA while they searched for new opportunities; and forgiveness of repayments after the entitlement period for those with low incomes.
Health Plans and Selection: Formal Risk Adjustment vs. Market Design and Contracts
Authors: Frank Richard G. , Rosenthal Meredith B.
Published: August 2011

In this paper, we explore the demand for risk adjustment by health plans that contract with private employers by considering the conditions under which plans might value risk adjustment. Three factors reduce the value of risk adjustment from the plans' point of view. First, only a relatively small segment of privately insured Americans face a choice of competing health plans. Second, health plans share much of their insurance risk with payers, providers, and reinsurers. Third, de facto experience rating that occurs during the premium negotiation process and management of coverage appear to substitute for risk adjustment. While the current environment has not generated much demand for risk adjustment, we reflect on its future potential.
Low-Wage Workers and Health Insurance Coverage: Can Policymakers Target Them through Their Employers?
Authors: Long Stephen H. , Marquis M. Susan
Published: August 2011

Many policy initiatives to increase health insurance coverage would subsidize employers to offer coverage or subsidize employees to participate in their employers' health plans. Using data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey, we contrast “low-wage employers” with all other employers. Employees in low-wage businesses have significantly worse access to employment-based insurance than other employees do; they are less likely to work for an employer that offers insurance, less likely to be eligible if working in a business that offers insurance, and less likely to be enrolled if eligible. Low-wage employers contribute lower shares of premiums and offer less generous benefits than other employers do. Policies that would target subsidies to selected employers to increase insurance offers to low-wage workers are difficult to design, however, because several commonly mentioned employer characteristics (including firm size) are found to be poor indicators of low-wage worker concentration. Programs that would set minimum standards for employer plans to be eligible for “buy-ins” need to base these standards on the less generous terms offered by low-wage employers in order to effectively reach low-wage workers and their dependents.
Is Healthy Competition Healthy? New Evidence of the Impact of Hospital Competition
Authors: Gift Thomas L. , Arnould Richard , DeBrock Larry
Published: August 2011

Competition among hospitals is commonly regarded as inefficient due to the medical arms race phenomenon, but most evidence for this hypothesis predates the Medicare prospective payment system and preferred provider legislation. Recent studies indicate hospital competition reduces costs and prices, but nearly all such research has focused on California. We add to the body of literature that analyzes the effects of competition in hospital markets. Using data from the state of Washington, we show that hospitals assume more risk in competitive markets by being more likely to accept prospective payment arrangements with insurers. If the arrangement is retrospective, the hospital is more likely to offer a discount as the number of competing hospitals increases. Both findings indicate that competitive forces operate the same in hospital markets as in most others: as the number of competitors increases, prices decrease and market power shifts from the suppliers to purchasers. The medical arms race hypothesis that favors more concentrated hospital markets no longer appears to be valid.
Use of Resident-Origin Data to Define Nursing Home Market Boundaries
Authors: Zwanziger Jack , Mukamel Dana B. , Indridason Indridi
Published: August 2011

Previous studies of nursing home markets have assumed that a nursing home's market is coincident with the boundaries of the county in which it is located. We test this assumption by using the zip code of residence for Medicare beneficiaries admitted into a nursing home in New York state in the periods 1992–93 and 1996–97. We find that nursing homes located in urban areas have markets that are a fraction of the size of the county in which they are located. We calculate the Herfindahl-Hirschman Index (HHI) to measure the competitiveness of each nursing home's market. This shows that nursing home markets tend to be more concentrated than those that result from assuming countywide markets. These results suggest that studies of nursing home markets should not use counties as markets.
Using Survey Measures to Assess Risk Selection among Medicare Managed Care Plans
Authors: Zaslavsky Alan M. , Buntin Melinda J. Beeuwkes
Published: August 2011

This paper quantifies risk selection among competing Medicare managed care plans, using beneficiary survey data from the Consumer Assessments of Health Plans Survey®. Selection, measured by variation in plan-level prevalence of health conditions and predicted costs, was substantial. A plan with moderate (one standard deviation) adverse selection would have predicted costs 11.6% above an average plan. Only a small part of this variation was explained by the geographical differences in the prevalence of health conditions among or within Metropolitan Statistical Areas, indicating that the selection was driven by plan attributes. Plans serving members with greater health needs have the potential to establish programs to serve these sick members well, yet this places plans at financial risk. Hence, improved risk adjustment for chronic conditions may be warranted. Moreover, survey measures have the potential to measure the prevalence of such conditions reliably and consistently across plans.
Predicting the Use of Outpatient Mental Health Services: Do Modeling Approaches Make a Difference?
Authors: Bao Yuhua
Published: August 2011

Studies attempting to project the impact of providing health coverage to the uninsured population have demonstrated considerable variation in the estimated costs of mental health care. Different modeling approaches to project health care use and costs have been shown to address some data characteristics well, but not all of them. Using data from Health Care for Communities, a recent national household survey, this paper attempts to estimate and predict the use of mental health outpatient services if insurance coverage were extended to the uninsured. The study employs two-part models, with the second part based on an ordinary least squares (OLS) approach and a generalized linear model (GLM), and a zero-inflated negative binomial model (ZINB). Estimates and predictions are not sensitive to the modeling approaches chosen, although the ZINB model outperforms the two-part models in terms of out-of-sample prediction.
Physician Fees and Managed Care Plans
Authors: Zwanziger Jack
Published: August 2011

One of the objectives of managed care organizations (MCOs) has been to reduce the rate of growth of health care expenditures, including that of physician fees. Yet, due to a lack of data, no one has been able to determine whether MCOs have been successful in encouraging the growth of price competition in the market for physician services in order to slow the growth in physician fees. This study uses a unique, national-level data set to determine what factors influenced the physician fees that MCOs negotiated during the 1990–92 period. The most influential characteristics were physician supply and managed care penetration, which suggest that the introduction of competition into the health care market was an effective force in reducing physician fees.
Has Medicaid Managed Care Affected Beneficiary Access and Use?
Authors: Zuckerman Stephen , Brennan Niall , Yemane Alshadye
Published: August 2011

This paper uses data from the 1997 National Survey of America's Families to examine the effects of the various forms of mandatory Medicaid managed care on access and use among beneficiaries not receiving Supplemental Security Income or Medicare benefits. The results show that mandatory health maintenance organization (HMO) programs have had a positive impact on both children and adults, particularly when compared to Medicaid fee-for-service plans. We observed less dependence on emergency rooms as a usual source of care, a greater probability of visiting a doctor and, for children, greater use of preventive care. In contrast, mandatory primary care case management plans (PCCM) provided some benefits to children, but appeared to have very little impact on adult Medicaid beneficiaries. Mandatory programs that use both HMOs and PCCM produced mixed results. With the exception of mandatory HMO programs, discrepancies in access and use continue to exist between Medicaid managed care enrollees and low-income privately insured people.
The Economic Implications of Case-Mix Medicaid Reimbursement for Nursing Home Care
Authors: Grabowski David C.
Published: August 2011

In recent years, there has been large growth in the nursing home industry in the use of case-mix adjusted Medicaid payment systems that employ resident characteristics to predict the relative use of resources in setting payment levels. Little attention has been paid to the access and quality incentives that these systems provide in the presence of excess demand conditions due to certificate-of-need (CON) and construction moratoria. Using 1991 to 1998 panel data for all certified U.S. nursing homes, a fixed-effects model indicates that adoption of a case-mix payment system led to increased access for more dependent residents, but the effect was modified in excess demand markets. Quality remained relatively stable with the introduction of case-mix reimbursement, regardless of the presence of excess demand conditions. These results suggest that CON and construction moratoria are still important barriers within the nursing home market, and recent quality assurance activities related to the introduction of case-mix payment systems may have been effective.
Testing the Effect of Quality Reports on the Health Plan Choices of Medicare Beneficiaries
Authors: Uhrig Jennifer D. , Short Pamela Farley
Published: August 2011

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.
Measuring Community Benefits Provided by Nonprofit and For-Profit HMOs
Authors: Schlesinger Mark , Mitchell Shannon , Gray Bradford
Published: August 2011

Despite the dramatic shift from nonprofit to for-profit ownership in the managed care industry, little is known about the implications for health plans' relations with the communities in which they operate. This paper provides the first comprehensive comparison of the community benefit activities of nonprofit and for-profit health maintenance organizations (HMOs). We develop a conceptual framework for identifying these activities and provide evidence from a nationally representative survey of plans fielded in 1999. We find that nonprofit plans exceed their for-profit counterparts on some, but not all, aspects of community benefit activity. The most consistent ownership-related differences involve redistributive programs (subsidized services and general philanthropy), commitments to medical research, and services that benefit the entire local population, beyond the plan's enrollees. Other forms of community benefits show mixed or modest differences between nonprofit and for-profit plans. Unexpectedly, for-profit plans actually appear more active in helping consumers deal with information asymmetries. The paper concludes with a discussion of implications for policy and future research.
Demand for a Medicare Prescription Drug Benefit: Exploring Consumer Preferences under a Managed Competition Framework
Authors: Cline Richard R. , Mott David A.
Published: August 2011

Several proposals for adding a prescription drug benefit to the Medicare program rely on consumer choice and market forces to promote efficiency. However, little information exists regarding: 1) the extent of price sensitivity for such plans among Medicare beneficiaries, or 2) the extent to which drug-only insurance plans using various cost-control mechanisms might experience adverse selection. Using data from a survey of elderly Wisconsin residents regarding their likely choices from a menu of hypothetical drug plans, we show that respondents are likely to be price sensitive with respect to both premiums and out-of-pocket costs but that selection problems may arise in these markets. Outside intervention may be necessary to ensure the feasibility of a market-based approach to a Medicare drug benefit.
Changes in Hospital Performance after Ownership Conversions
Authors: Shen Yu-Chu
Published: August 2011

This paper examines the effects of ownership conversions on hospital performance between 1987 and 1998 in areas of financial performance, staffing, capacity, and unprofitable care. Conversions to government and for-profit ownership both increased the profit margin: the former due to rising revenue, and the latter due to reduced operating costs and rising revenue. Hospitals that converted to for-profit ownership had the greatest reduction in staffing relative to other converted hospitals. There was little change in bed capacity after conversion to for-profit status, but some reductions in bed capacity after conversion to government or nonprofit status. No conversion of any kind led to a reduced amount of unprofitable care, but conversion to private ownership (nonprofit and for-profit) increased the probability of trauma center closures.
The Effect of Parents' Insurance Coverage on Access to Care for Low-Income Children
Authors: Davidoff Amy , Dubay Lisa , Kenney Genevieve , Yemane Alshadye
Published: August 2011

This study examines the effects of having an uninsured parent on access to health care for low-income children. Using data from the 1999 National Survey of America's Families, we find that having an uninsured parent decreases the likelihood that a child will have any medical provider visit by 6.5 percentage points, and decreases the likelihood of a well-child visit by 6.7 percentage points. Estimates for low-income children who have insurance but have an uninsured parent indicate a 4.1 percentage-point reduction in the probability of having any medical provider visit, and a similar 4.2 percentage-point reduction in the probability of having a well-child visit relative to those with insured parents. The effects of having an uninsured parent are smaller in magnitude than the effects of a child being uninsured. Efforts to increase insurance coverage of parents, either by extending eligibility for public insurance or through other policy interventions, will have positive spillover effects on access to care for children. Although the magnitude of these effects is small relative to the direct effect of providing insurance to either the child or parent, they should be considered in analyses of costs and benefits of proposed policies.
Is Health Care Spending Higher under Medicaid or Private Insurance?
Authors: Hadley Jack , Holahan John
Published: August 2011

This paper addresses the question of whether Medicaid is in fact a high-cost program after adjusting for the health of the people it covers. We compare and simulate annual per capita medical spending for lower-income people (families with incomes under 200% of poverty) covered for a full year by either Medicaid or private insurance. We first show that low-income privately insured enrollees and Medicaid enrollees have very different socioeconomic and health characteristics. We then present simulated comparisons based on multivariate statistical models that estimate the effects of private and Medicaid coverage on the likelihood of using services, and the level of expenditures, given any use, holding constant demographic, economic, and health status characteristics. The simulations demonstrate that if people with Medicaid coverage—with their health status, disability, and chronic conditions—were given private coverage, they would cost considerably more than they do today. Conversely, if the privately insured were given Medicaid coverage, spending would be lower. We find no evidence that spending differences between Medicaid and private coverage for low-income people are due to lower service use by Medicaid beneficiaries. We conclude that most of the difference in expenditures is due to differences in provider payment rates.
HIV Patients in the HCUP Database: A Study of Hospital Utilization and Costs
Authors: Hellinger Fred J.
Published: August 2011

This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina), and examines the cost of hospital care for HIV patients in six of these states (California, Colorado, Kansas, New Jersey, New York, and South Carolina). The eight states in the sample account for more than 52% of all persons living with AIDS in the United States; the six states account for 39%. The unit of observation in both studies is a hospital admission by a patient with HIV. Hospital data were obtained from the Healthcare Cost and Utilization Project (HCUP), State Inpatient Database (SID), which is maintained by the Agency for Healthcare Research and Quality (AHRQ). The HCUP contains hospital discharge data and is a federal/state/industry partnership to build a multistate health care data system. Using multivariate analytic techniques and data from 2000, results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.
Malpractice Experience and the Incidence of Cesarean Delivery: A Physician-Level Longitudinal Analysis
Authors: Grant Darren , McInnes Melayne Morgan
Published: August 2011

This study examines the influence of malpractice claims on the practice behavior of a panel of obstetricians in Florida during the period 1992–1995 to determine whether physicians respond to malpractice events by performing more cesareans, consistent with the notion that cesarean sections are employed as “defensive medicine.” Findings indicate that clinical events resulting in claims that lead to substantial indemnity payments have a significant, modest effect on physician practice behavior: physicians experiencing those claims increase their risk-adjusted cesarean rates by about one percentage point. Malpractice experience does not appear to affect patient mix, but claims with large payouts may affect patient volume.
The Failed Conversion of CareFirst BlueCross BlueShield to For-Profit Status: Part 2, Lessons Learned
Authors: McPherson Bruce
Published: August 2011

This article presents lessons for other states and all types of nonprofit health care organizations from the failure by nonprofit CareFirst Blue Cross Blue Shield to convert to for-profit status and be sold to the publicly traded Wellpoint Health Networks, Inc. The lessons relate only in part to conversions. More broadly they concern any kind of strategic decision making by nonprofit health care boards of directors and their executives that substantially affects the public interest. This article is a companion to one by this same author published in the Fall 2004 issue of Inquiry. That article chronicled the events and political environment surrounding the conversion proposal, the review process and decision, and the aftermath of actions and reactions by various parties, including state legislation to clarify CareFirst's mission and to reform its board.
The Balanced Budget Act of 1997 and U.S. Hospital Operations
Authors: Bazzoli Gloria J. , Lindrooth Richard C. , Hasnain-Wynia Romana , Needleman Jack
Published: August 2011

The Balanced Budget Act (BBA) of 1997 initiated several changes to Medicare payment policy in an effort to slow the growth of hospital Medicare payments and ensure the future of the Medicare Hospital Insurance Trust Fund. Although subsequent federal legislation relaxed some original proposals, restored funds were limited and directed to specific types of hospitals. In addition, these Medicare policy changes came at a time when hospitals faced private sector payment constraints. This paper assesses the short-term effects of the BBA on operations of nonprofit hospitals in the United States and compares these effects to those observed in the early 1980s during implementation of the Medicare prospective payment system (PPS). We found that some operational changes instituted by hospitals facing financial pressures from the BBA were similar to those observed for hospitals that faced pressure from Medicare PPS, including efforts to contain Medicare cost growth, to expand outpatient service provision, and to contain hospital staffing. However, during PPS implementation hospitals experienced declining inpatient use and growing profit margins, whereas post-BBA hospitals experienced growing inpatient use and declining margins.
Quality Report Cards, Selection of Cardiac Surgeons, and Racial Disparities: A Study of the Publication of the New York State Cardiac Surgery Reports
Authors: Mukamel Dana B. , Weimer David L. , Zwanziger Jack , Gorthy Shih-Fang Huang , Mushlin Alvin I.
Published: August 2011

Quality report cards have become common in many health care markets. This study evaluates their effectiveness by examining the impact of the New York State (NYS) Cardiac Surgery Reports on selection of cardiac surgeons. The analyses compares selection of surgeons in 1991 (pre-report publication) and 1992 (post-report publication). We find that the information about a surgeon's quality published in the reports influences selection directly and diminishes the importance of surgeon experience and price as signals for quality. Furthermore, selection of surgeons for black patients is as sensitive to the published information as is the selection for white patients.
Electronic Prescribing and HIPAA Privacy Regulation
Authors: Greenberg Michael D. , Ridgely M. Susan , Bell Douglas S.
Published: August 2011

Electronic prescribing offers the prospect of safer medication management, but fulfillment of that promise depends on ready access to personal health information from many sources, thus raising new concerns about information privacy and security. Federal privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) limit the sharing of health information by providers, and particularly may discourage information sharing over distributed computer networks. This analysis finds that although HIPAA has only a limited effect on current e-prescribing practices, future electronic prescribing systems will likely fall short of their potential benefits, absent policy refinements designed to encourage clinically appropriate, networked sharing of patient health information.
How Much Can Really Be Saved by Rolling Back SCHIP? The Net Cost of Public Health Insurance for Children
Authors: Selden Thomas M. , Hudson Julie L.
Published: August 2011

A growing body of research demonstrates the many benefits of expanded public coverage for children. Expansions in Medicaid and the State Children's Health Insurance Program (SCHIP) have helped to increase insurance coverage, increase access to care, and reduce the financial burdens facing low-income families. Less attention has been focused on the cost of expanding public coverage. We argue that budgetary data may exaggerate the net costs of these expansions because many of the highest-cost children would have received publicly funded care even if the expansions had not taken place. Using data from the 2000 Medical Expenditure Panel Survey, we simulate the net cost of SCHIP, finding that the true cost of this program–both to states and to the federal government–is substantially less than average spending per enrollee would suggest. Our results strengthen the benefit-cost argument against implementing rollbacks in SCHIP.
Responsible Health Insurance Revisited: Pouring Liberal Wine into a Conservative Bottle
Authors: Seidman Laurence
Published: August 2011

In 1991, an article appeared proposing a plan for “Responsible National Health Insurance” (RHI) that contained three crucial elements supported by economists affiliated with two conservative policy institutions (the American Enterprise Institute and the Heritage Foundation). The central purpose of this article is to revisit RHI in light of developments over the past decade, and to make the case that liberals, rather than reject RHI, now should support it, provided conservatives agree to sufficient funding. In this article, I recommend “pouring liberal wine into this conservative bottle.”
Has Price Competition Changed Hospital Revenues and Expenses in New York?
Authors: Zwanziger Jack , Mooney Cathleen
Published: August 2011

This study analyzes the factors that influenced hospital expenses and revenues prior to and following the enactment of the New York State Health Care Reform Act of 1996 (HCRA)—the period from 1994–1999. HCRA was expected to encourage price competition which in turn was anticipated to lower hospital revenues and expenses. We measured the differential effects on hospital revenues and expenses in markets with varying degrees of competition. We also measured the relationship between hospital revenues and expenses and the increased concentration resulting from the formation of local hospital systems. We found that revenues and expenses both grew more slowly for hospitals located in more competitive markets; hospital systems that increased concentration tended to have higher revenues. In the short run at least, price competition induced by HCRA did constrain both hospital expense and revenue growth, although the increase in hospital mergers countered this trend.
Is the Individual Market More Than a Bridge Market? An Analysis of Disenrollment Decisions
Authors: Marquis M. Susan , Buntin Melinda Beeuwkes , Escarce José J. , Kapur Kanika , Louis Thomas A.
Published: August 2011

The individual insurance market is perceived by many to provide primarily transition coverage, but there is limited research about how long people stay in this market and what affects their disenrollment decisions. We examine these issues using administrative records and survey data for those enrolled in the individual market in California. We conclude that there is less turnover in this market than is commonly believed. We find that economic factors and coverage characteristics are important in the decision to disenroll, but that perceptions about insurance and the health care system also affect this decision.
New Cardiovascular Drugs: Patterns of Use and Association with Non-Drug Health Expenditures
Authors: Miller G. Edward , Moeller John F. , Stafford Randall S.
Published: August 2011

The potential role of new drugs in reducing expenditures for non-drug health services has received considerable attention in recent policy debates. We estimate expenditure models to determine whether the use of newer drugs to treat cardiovascular conditions is associated with lower (or higher) non-drug expenditures for these conditions. We fail to substantiate the findings of previous research that newer drugs are associated with reductions in non-drug expenditures. We find, however, that increases in the number of drugs used, or the mix of drugs of different ages, are associated with increased non-drug expenditures and find that the number or mix of drugs used are important confounders in the estimated association between drug age and non-drug expenditures.
The Implications of Unmet Need for Future Health Care Use: Findings for a Sample of Disabled Medicaid Beneficiaries in New York
Authors: Long Sharon K. , King Jennifer , Coughlin Teresa A.
Published: August 2011

Using survey data linked with Medicaid claims data, this study examines the consequences of unmet need for future health care use for a sample of disabled Medicaid beneficiaries in Westchester County, New York. Among other things, we find that individuals reporting unmet need in 1999 were more likely to use emergency room and hospital care in 2000 than those not reporting unmet need. Addressing the barriers to care that underlie unmet need could generate cost savings to Medicaid and provide better health outcomes for program beneficiaries.
Toward Universal Coverage in Massachusetts
Authors: Blumberg Linda J. , Holahan John , Weil Alan , Clemans-Cope Lisa , Buettgens Matthew , Blavin Fredric , Zuckerman Stephen
Published: August 2011

This paper presents several options designed to help the Commonwealth of Massachusetts move to universal health insurance coverage. The alternatives all build upon a common base that includes an expansion of the Medicaid program, income-related tax credits, a purchasing pool, and government-sponsored reinsurance. These measures in themselves would not yield universal coverage, nor would an employer mandate by itself. We show that an individual mandate, and an employer mandate combined with an individual mandate, both would yield universal coverage with a relatively small increase in government costs relative to state gross domestic product and current health spending. The cost of an employer mandate—with a “pay or play” design—is sensitive to the payroll tax rate and base, the number and kind of exemptions, and whether workers whose employers “pay” receive discounts when they purchase health insurance. The development of these alternatives and their analyses contributed to the eventual health care compromise that emerged in Massachusetts in April 2006.
Effects of Public Premiums on Children's Health Insurance Coverage: Evidence from 1999 to 2003
Authors: Kenney Genevieve , Hadley Jack , Blavin Fredric
Published: August 2011

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured. The results indicate that public premiums have larger effects when applied to lower-income families.
The Effect of Managed Care on Hospitals' Provision of Uncompensated Care
Authors: McKay Niccie L. , Meng Xiaoxian
Published: August 2011

This study examines the effect of managed care on hospitals' provision of uncompensated care, using a new measure of managed care that is hospital-specific, rather than measured for the area as a whole, and which includes payment by preferred provider organizations (PPOs) as well as by health maintenance organizations (HMOs). Based on data for Florida hospitals in the period 1998–2002, the results indicate that a higher percentage of private managed care patient-days was associated with a decrease in uncompensated care as a percentage of total operating expenses, holding net profit margin and other factors constant. The results suggest that spillover effects on uncompensated care should be taken into account when considering increases in managed care payment.
Was Part D a Giveaway to the Pharmaceutical Industry?
Authors: Newhouse Joseph P. , Seiguer Erica , Frank Richard G.
Published: August 2011

The Medicare Modernization Act (MMA) prohibited the government from negotiating drug prices, a feature that the act's critics characterize as a giveaway to the drug industry. Instead of the government negotiating to keep prices down, the act relies on competition among drug companies to obtain business from private insurers; yet, competition cannot be effective when there are no close clinical substitutes. In the past few years, the rate of introduction of first-in-class drugs has been low; if this continues, the prohibition on negotiation may be only a minor problem. However, if the prior rate of introduction resumes, the government may find itself with unacceptable expenditure levels.
Hospital Ownership and Financial Performance: What Explains the Different Findings in the Empirical Literature?
Authors: Shen Yu-Chu , Eggleston Karen , Lau Joseph , Schmid Christopher H.
Published: August 2011

This study applies meta-analytic methods to conduct a quantitative review of the empirical literature on hospital ownership since 1990. We examine four financial outcomes across 40 studies: cost, revenue, profit margin, and efficiency. We find that variation in the magnitudes of ownership effects can be explained by a study's research focus and methodology. Studies using empirical methods that control for few confounding factors tend to find larger differences between for-profit and not-for-profit hospitals than studies that control for a wider range of confounding factors. Functional form and sample size also matter. Failure to apply log transformation to highly skewed expenditure data yields misleadingly large estimated differences between for-profits and not-for-profits. Studies with fewer than 200 observations also produce larger point estimates and wide confidence intervals.
Public Reporting and Pay-for-Performance: Safety-Net Hospital Executives' Concerns and Policy Suggestions
Authors: Goldman L. Elizabeth , Henderson Stuart , Dohan Daniel P. , Talavera Jason A. , Dudley R. Adams
Published: August 2011

Safety-net hospitals (SNHs) may gain little financial benefit from the rapidly spreading adoption of public reporting and pay-for-performance, but may feel compelled to participate (and bear the costs of data collection) to meet public expectations of transparency and accountability. To better understand the concerns that SNH administrators have regarding public reporting and pay-for-performance, we interviewed 37 executives at randomly selected California SNHs. The main concerns noted by SNH executives were that human and financial resource constraints made it difficult for SNHs to accurately measure their performance. Additionally, some executives felt that market-driven public reporting and pay-for-performance may focus on clinical areas and incentive structures that may not be high-priority clinical areas for SNHs. Executives at SNHs suggested several policy responses to these concerns—such as offering training programs for SNH data collectors—that could be relatively inexpensive and might improve the cost-benefit ratio of public reporting and pay-for-performance programs.
Free-Standing Ambulatory Surgery Centers and Hospital Surgery Volume
Authors: Bian John , Morrisey Michael A.
Published: August 2011

This paper examines the association of free-standing ambulatory surgery centers (ASCs) with hospital surgery volume, using data from the 2002 Medicare Online Survey Certification and Reporting System and the American Hospital Association Annual Surveys of Hospitals. From 1993 to 2001, the number of ASCs per 100,000 population in metropolitan statistical areas (MSAs) increased by 150%. During the same period, hospital outpatient surgeries increased 28%, while inpatient surgeries decreased by 4.5%. MSA and year fixed-effects regression analyses suggest that an increase of one ASC per 100,000 people was associated with a 4.3% reduction in hospital outpatient surgical volume, but was not associated with inpatient surgical volume.
Socioeconomic Disparities in Medical Provider Visits among Medicare Managed Care Enrollees
Authors: Rogowski Jeannette , Freedman Vicki A. , Wickstrom Steve L. , Adams John , Escarce José J.
Published: August 2011

This study examined socioeconomic disparities in medical provider visits for elderly people enrolled in two Medicare managed care plans. Controlling for health and demographic differences, elderly people of lower income had fewer primary care visits and those with lower education had fewer specialist visits. The number of emergency room visits was not significantly related to socioeconomic status (SES). People of low SES reported having more financial barriers to receiving care and greater difficulties navigating the managed care system than people of high SES. Further, elderly people of low SES had different degrees of belief in the efficacy of the medical system and of lifetime experiences with a usual source of medical care prior to Medicare, both of which were associated with differential use of medical providers.
Health Insurance and Labor Markets: Concepts, Open Questions, and Data Needs
Authors: Garrett Bowen , Chernew Michael
Published: August 2011

This paper reviews the recent economic research on the relationship between health insurance and labor markets in the United States, with an emphasis on research that has emerged since existing major reviews and the aim of identifying the types of data that are needed for this research to progress. We focus on the conceptual and empirical challenges that researchers face in studying these relationships, the data that have allowed this research to proceed, policy-relevant questions that need further study, and the types of data that would help in obtaining better answers to these questions.
Retail Pharmacy Market Structure and Performance
Authors: Brooks John M. , Doucette William R. , Wan Shaowei , Klepser Donald G.
Published: August 2011

Substantial variation has been observed in the use of prescription drugs from retail pharmacies, the level of services provided by retail pharmacies, and the prices paid for prescriptions from retail pharmacies. It is not clear whether local area retail pharmacy market structures affect these pharmacy outcomes. The goal of this paper is to discuss the potential research avenues to address these issues. The discussion provides: 1) background on the retail pharmacy and its place within the pharmaceutical supply chain; 2) a discussion of the data that are available to address these issues and the measures that can be developed from these data; and 3) a review of existing research findings and gaps in knowledge.
Health Insurance and Access to Care among Welfare Leavers
Authors: Danziger Sheldon , Davis Matthew M. , Orzol Sean , Pollack Harold A.
Published: August 2011

This analysis explores the effects of the 1996 welfare reform on health insurance coverage and access to care among former recipients of cash aid. Using panel data from the Women's Employment Study, which conducted five interviews between 1997 and 2003 in one Michigan county, we find that 25% of welfare leavers lacked health insurance coverage in fall 2003. Uninsured adults were significantly more likely than others to report that they could not afford a medical or dental visit during the year prior to the 2003 interview. Fixed-effect logistic regression analysis indicates that women who had been off the welfare rolls for at least 12 months (the duration of transitional Medicaid) were significantly more likely to be uninsured than women who had made more recent welfare exits, and were significantly more likely to report financial obstacles to the receipt of medical and dental care.
How Do System-Affiliated Hospitals Fare in Providing Community Benefit?
Authors: Alexander Jeffrey A. , Young Gary J. , Weiner Bryan J. , Hearld Larry R.
Published: August 2011

The shift from local, community-based organizations to more complex delivery systems raises questions about the community orientation and accountability of health systems and their affiliates. This study examines whether hospitals affiliated with health care systems are more or less likely to engage in practices that reflect responsibility to their local communities by providing benefits in the form of uncompensated care, community engagement, Medicaid caseload, and accessible pricing policies. Using audited state data and other sources, we performed a longitudinal analysis on a pooled cross-sectional data file for the years 1989–2003 for all hospitals in Texas, California, and Florida. Results indicate that when compared to independent hospitals, system affiliation is associated with less community benefit. However, the level of community benefit varies depending on the type of community benefit examined and the structural characteristics of the system with which a hospital is affiliated. Results further suggest that the level and type of community benefit is conditioned by the market under which system-affiliated hospitals operate.
The Relationship between Medicare's Process of Care Quality Measures and Mortality
Authors: Ryan Andrew M. , Burgess James F. , Tompkins Christopher P. , Wallack Stanley S.
Published: August 2011

Using Medicare inpatient claims and Hospital Compare process of care quality data from the period 2004–2006, we estimate two model specifications to test for the presence of correlational and causal relationships between hospital process of care performance measures and risk-adjusted (RA) 30-day mortality for heart attack, heart failure, and pneumonia. Our analysis indicates that while Hospital Compare process performance measures are correlated with 30-day mortality for each diagnosis, after we account for unobserved heterogeneity, process of care performance is no longer associated with mortality for any diagnosis. This suggests that the relationship between hospital-level process of care performance and mortality is not causal. Implications for pay-for-performance are discussed.
Changes in Medicaid Physician Fees and Patterns of Ambulatory Care
Authors: Decker Sandra L.
Published: August 2011

Controlling for state fixed effects and other factors, this paper estimates the effect of the generosity of Medicaid physician payment levels on the volume and site of ambulatory care received by Medicaid patients compared to privately insured patients. Results indicate that cuts in Medicaid physician fees lead to statistically significant reductions in the number of visits for Medicaid patients compared to privately insured patients. Cuts in fees also lead to a statistically significant shift away from physician offices and toward hospital emergency departments and especially outpatient departments. Primary diagnoses for which site of care shifts are most pronounced include hypertension, asthma, urinary tract infections, and diabetes.
Private Long-Term Care Insurance and State Tax Incentives
Authors: Stevenson David G. , Frank Richard G. , Tau Jocelyn
Published: August 2011

To increase the role of private insurance in financing long-term care, tax incentives for long-term care insurance have been implemented at both the federal and state levels. To date, there has been surprisingly little study of these initiatives. Using a panel of national data, we find that market take-up for long-term care insurance increased over the last decade, but state tax incentives were responsible for only a small portion of this growth. Ultimately, the modest ability of state tax incentives to lower premiums implies that they should be viewed as a small piece of the long-term care financing puzzle.