NATIONAL HEALTH CARE AND QUALITY OF SERVICE: LESSONS FROM MEDICAID

Much recent public debate centers around failures in the U.S. health care system. Studies indicate that as many as 33 million Americans are without health insurance, while health care expenditures continue to out-strip GNP growth. Numerous proposals for national health insurance have surfaced in response to these apparent shortcomings. The various proposed health insurance structures are not always based upon careful economic evaluation of incentive schemes and of the full range of potential effects. This paper examines results of recent Medicaid system studies so as to shed light upon the outcomes one can expect from national health insurance plans possessing similar incentive structures. The results here have potentially useful policy implications.     

NEW FORMS OF PROVIDER IN THE ENGLISH NATIONAL HEALTH SERVICE

ABSTRACT 1 : A wide ranging set of reforms is being introduced into the English National Health Service (NHS). They are designed to increase the market‐like behaviour of providers of care with a view to improving efficiency, quality and responsiveness of services. This paper is concerned with one aspect of those reforms: namely the policy to increase the diversity of types of providers of care to NHS patients. In this context, increasing diversity means that providers will not all be standard publicly owned NHS organizations. They can be publicly owned but autonomous, or independent (both in for‐profit and not for profit). The paper discusses the wide range of organizational forms available, analyzing their governance structures It then discusses the small amount of evidence currently available about the performance of diverse providers of health care.     

SERVICE PRODUCTION IN HISTORICAL NATIONAL ACCOUNTS

Constant price calculation of service production is a problematic issue in contemporary national accounts, and it is far more so in historical series. The indicator method has been suggested as one way of coming to terms with volume calculations. This method is scrutinized, and it is claimed that it does not represent the solution for historical matters. Instead, various techniques have to be used for various parts of the total. The methods of deflating service production in five countries' historical national accounts as well as the consequences of using different methods are compared. Most often, existing series are not compatible with those for goods production, which of course has repercussions on attempts to study e.g. productivity. It is concluded that much work has to be done to improve the methodology and to arrive at a common international framework for historical national accounts.     

HOUSEHOLD PRODUCTION AND NATIONAL PRODUCTION: AN IMPROVEMENT OF THE RECORD

1 By no means is the home based production of housewives the only or even the most important aspect of nonmarket production. The entire question of work vs. leisure, and the distinction between leisure and nonmarket oriented production, are currently under intensive scrutiny. See for instance the work of Nordhaus and Tobin [7, especially appendix section A.3], Gronau [2] and items cited in Gronau. The omission from the national income accounts of work performed at home by males, non-married females, and “working wives” is extremely important. This paper is concerned only with married females because (1) they are the subject of what must be one of the oldest jokes in the subject of social accounting, and (2) the relationship of production by housewives to total production has changed in the past ten years or so, and that deserves some attention even if it is not the most important thing which has been happening with respect to the GNP.
Specifically, we will present estimates of the value of home based nonmarket production by housewives. These estimates will then be used to supplement various national product aggregates in order to calculate more accurate growth rates for the U.S. economy. We find that the value of nonmarket production by married women during the 1960's has averaged approximately thirty percent of the GNP and close to 40 percent of the national income. The inclusion of the nonmarket work of housewives in GNP would reduce the measured rate of growth of real GNP per potential worker by about ten percent, the exact amount depending on how the value of nonmarket work is estimated. Our estimates indicate a reduction in the absolute rate of growth of almost 0.25 percent.     

A NEW METHOD OF ASSESSMENT OF THE INSURANCE SERVICE PRODUCTION

The French national accounts applied the insurance production assessment method recommended by the European system of accounts (ESA), for the years 1970 to 1985, in a particularly turbulent economic and financial environment. A better understanding of the sector was thereby obtained, but the problems set by the very "technical" production assessment method were thus brought to light. These problems are still not solved by the present accounting system, since, to summarize matters, it hides the importance of the sector's "financial" activity, whereas in fact the income drawn from this activity contributes to a high extent to the global balance of insurance operations. This is of course related to the reasons why in certain countries insurance companies are considered more as savings collecting and investment institutions rather than risk transformers.
This report sheds light on the significance of the present premiums, indemnities and reserves recording method and then presents the new method chosen by the french accounts to assess production; finally it analyses the remaining difficulties relating mainly to capital gains.     

SELECTED PROBLEMS OF WELFARE AND PRODUCTION IN THE NATIONAL ACCOUNTS

A number of rather traditional problems relating to the estimation of the national accounts have been raised in the recent literature. This paper examines five of these problems from the point of view of a government statistician working within certain time and resource constraints. Credibility, comprehensibility, theoretical validity, cost and analytical usefulness are the criteria which should aid in deciding how to treat such matters as the extension of the boundaries of economic production, proposed changes in the categorization of both final and intermediate expenses, the treatment of "total" welfare and estimation relating to the so-called underground economy.     

PROPOSALS FOR A HOMOGENEOUS TREATMENT OF HEALTH EXPENDITURES IN THE NATIONAL ACCOUNTS*

International comparisons always raise difficult problems, more especially when they deal with services which are jointly financed by households and government in varying shares with varying procedures in each country. This is obvious in the case of health where the area itself, the principles of economic analysis and the UN method of National Accounting appear to be either vague or unwieldy. Before any proposal it is necessary to review what is involved in the concept of service and the possibility of delimiting the health field inside which economic measures are feasible. Then using the SNA concept and with the help of six interdependent tables we propose two aggregates: the National Medical Consumption and the Current National Expenditure on health. The detailed and harmonized breakdowns of these global results make it possible to compare the structures of values, prices and quantities on an international base.     

A RE-EXAMINATION OF PRODUCTION FUNCTIONS AND EFFICIENCY ESTIMATES FOR THE NATIONAL BASKETBALL ASSOCIATION

This paper seeks to re‐examine the issue of estimating team efficiency for sports teams via an application of data from the National Basketball Association. This paper argues that the inputs the coaches allocate are the players the team employs. Therefore, this paper employs a measure of playing talent in modeling team production. Unlike previous studies, which only employed one measure of playing talent, we employ measures of guards, small forwards and big men in a study of basketball. This paper also argues that the time‐varying stochastic frontier models with the identical temporal pattern assumption such as Lee and Schmidt and Battese and Coelli cannot be used in the analysis of team efficiency in sports. The evidence we present shows by hypothesis test that this argument holds.     

THE IMPORTANCE OF COMMITTEE ASSIGNMENT: HEALTH CARE INDUSTRY POLITICAL ACTION COMMITTEE CONTRIBUTIONS AND THE HOUSE OF REPRESENTATIVES

This paper examines the relationship between political action committee (PAC) contributions from four sectors of the health care industry and committee membership in the House of Representatives over three election cycles, 1998–2002. The hypothesis tested is that members of the House who serve on committees with oversight responsibility for the health care industry are more likely to receive contributions from health care industry PACs than members of the House who do not serve on these committees. We find mixed support for the hypothesis. (JEL D72, HI0, I10)     

MEDICAID AND THE LABOR SUPPLY OF SINGLE MOTHERS: IMPLICATIONS FOR HEALTH CARE REFORM

The Medicaid expansions and health insurance subsidies of the Affordable Care Act (ACA) change work incentives for single mothers. To evaluate the employment effects of these policies ex ante, I estimate a model of labor supply and health insurance choice exploiting variation in pre‐ACA Medicaid policies. Simulations show that single mothers increase their labor supply at the extensive and intensive margin by 12% and 7%, respectively, uninsurance rates decline by up to 40%, and an average family's welfare improves by 1,600 dollars per year. Health insurance subsidies and not Medicaid expansions mostly drive these effects.     

GROWTH OF U.S. HEALTH CARE SPENDING

The share of output allocated to health care has more than doubled since 1960. This paper models the growth in this ratio and finds that the increase in the elderly population whose medical spending is heavily subsidized is a key factor behind this growth. Technological change is a symptom of the medical market structure rather than a cause of medical spending growth. The econometric model in the analysis here is based on a micro model composed of two groups. The first group is a healthier group that makes income transfers in order to finance the sicker group's health insurance premiums. In this model, a technical constraint places an upper bound on the healing ability of the medical good. This upper bound changes through an unobservable endogenous process. Estimating the health care model involves using estimation techniques that bypass the need to make any a priori assumptions about the functional form of the regressions or about the distribution of the residuals. The results suggest that technical change cannot indefinitely induce health care spending growth if no subsidies exist that provide full health care coverage with premiums fully paid by the subsidy. If subsidies provide full coverage and pay the entire premium, then new technical discoveries can induce constantly expanding medical expenditures.     

INTERNATIONAL AVERAGE PRICES AND COMPARISONS OF NATIONAL AGGREGATE PRODUCTION OF AGRICULTURE

"The whole question of making inter-spatial comparisons between countries is a most complicated and hazardous business" (Mr. Campion); international comparisons of a particular value aggregate between countries present a difficult problem connected with the conversion of national value aggregates into a comparable magnitude. This paper presents an alternative approach in that an internationally comparable value aggregate for each country is prepared by the international average prices of commodities which are determined simultaneously with the partial exchange rates of national currencies to a standard currency. The calculated partial exchange rates are so defined as to reflect the purchasing power of national currencies in respect of the group of commodities selected. Consequently, the resulting value aggregate for international comparison has a quantity dimension, eliminating the effect due to the different purchasing power of national currencies in which original prices are quoted. The other methods of international comparison so far being used by other research workers, such as C. Clerk and M. Gilbert and his associates, are examined in the light of the properties of the present method and the crucial differences are delineated. Using the method proposed, an international comparison is made of the aggregate value of agricultural products for 11 selected countries in the world, with sub-divisions into two regions.     

FORECASTING THE DEMAND FOR HEALTH CARE IN OECD NATIONS AND CHINA

This article argues that the nations of the Organisation for Economic Co-operation and Development (OECD) are facing a potential disaster: intergenerational conflicts between the large number of workers approaching retirement at an earlier age than ever before in history and the smaller number entering the labor market. These nations are confronted with the choice of whether to default on commitments to pensions and health care, to reduce benefits, or to increase the taxes borne by younger workers. The author argues that this new intergenerational conflict is the result of technophysio evolution , a synergism between technological and physiological improvements that has produced a form of human evolution that is biological but not genetic, rapid, culturally transmitted, and not necessarily stable. The author goes on to argue that an important aspect of technophysio evolution has been a change in the structure of consumption and in the division of discretionary time between work and leisure. The ongoing debate over whether or not the rapid advances in biotechnology will spare OECD nations' health systems from a financial crisis is addressed. Finally, the implications this argument has for forecasting China's future health care costs are discussed.     

INDIRECT PRICING THEORY OF THE FIRM: A GENERAL-EQUILIBRIUM ANALYSIS INVOLVING PRODUCTION TECHNOLOGY AND MANAGEMENT SERVICE

Abstract.  This paper develops a general-equilibrium model that involves production technology and management service to study the emergence of firms from the perspective of saving transaction costs. Inframarginal analysis is used to formalize Coase and Cheung's theory of the firm and to generalize Yang and Ng's indirect pricing theory of the firm. Not only the emergence of firms, their growth and contraction, but also the relevant conditions for the existence of technology entrepreneurs and professional management are also investigated.     

IS THERE A ‘SECESSION OF THE WEALTHY’? PRIVATE HEALTH INSURANCE UPTAKE AND NATIONAL HEALTH SYSTEM SUPPORT

The purchase of private health insurance (PHI) as a means to partially supplement the National Health System (NHS) coverage is often regarded as a potential signal for a declining support for the NHS. Exploiting the fact that PHI is typically purchased by the most affluent, in this paper we test the so called ‘secession of the wealthy’ hypothesis whereby the likelihood of expressing ‘lack of support for the NHS’ increases with having supplementary PHI. Using empirical data from Catalonia, we draw upon an empirical strategy that circumvents an obvious simultaneity problem by estimating both a recursive bivariate probit as well as an IV probit. After controlling for insurance premium, household income and other socio‐demographic determinants, we find that the purchase of PHI reduces the propensity of individuals to support the NHS. We also find evidence that PHI is a luxury good and sensitive to fiscal incentives.