THE EFFECTS OF YOUNG ADULT‐DEPENDENT COVERAGE AND CONTRACEPTION MANDATES ON YOUNG WOMEN

This research investigates two features of the Affordable Care Act that especially affect young adults, the young adult‐dependent coverage (YAD) mandate and the requirement to cover contraception (CM). Both mandates were first enacted at the state level but have been studied only in isolation. We estimate a wide range of models allowing these mandates to have joint effects on insurance coverage, health‐care access, health outcomes and fertility. We provide new evidence that helps settle the mixed findings from past state‐level YAD and CM research and suggests the two mandates may combine to improve the well‐being of young adults. (JEL I18, I12, H75)     

The effect of state health insurance benefit mandates on premiums and employee contributions

The average US state has 40 benefit mandates, laws requiring health insurance to cover particular conditions, treatments, providers or people. We investigate the extent to which these mandates increase the health insurance premiums paid by employers, and the extent to which these higher premiums are passed on to employees in the form of higher employee contributions. We use state-level data on premiums and employee contributions to health insurance from the insurance component of the 1996–2011 Medical Expenditure Panel Survey. Our main analysis is a fixed effects regression that controls for age, race, income, union membership and the presence of state mandate waivers. We find robust evidence that the average mandate increases premiums by approximately 0.6%, and that mandates lead to similar increases in employee contributions for single-coverage health insurance plans. Alternative specifications using an AR(1) error structure estimate a larger effect of mandates, while those using generalized estimating equations estimate smaller effects. We find that mandates requiring insurers to cover a specific benefit, as opposed to a specific type of provider or person, lead to the largest increases in employee contributions.     

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.     

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Microfinance and child mortality

Microfinance institutions (MFIs) offer targeted opportunities for the poor to generate additional income with a range of financial services including credit, insurance, savings accounts and money transfers. Aside from reducing poverty, microfinance can potentially improve health because it is the poor who are usually more constrained from health investments due to limited budgets. Furthermore, microfinancing specifically targets women, who are more likely to spend additional income on children’s well-being. Finally, several MFIs have also begun to offer health-related services, such as health education, health-care financing, clinical care, training community health workers, health micro-insurance and linkages to public and private health providers. Using a new data set, this article conducts the first multi-country study of the effect of microfinance on child mortality, the health outcome, which is most sensitive to the effects of absolute deprivation. Our findings confirm that an increase in the proportion of MFI clients in a country is significantly associated with lower under-five and infant mortality rates. We conclude that if MFIs’ educational and health services have indeed caused improvements in health outcomes at the community level, then it may be important for governments to complement these activities with similar campaigns, particularly in remote areas where MFI penetration is low.     

Efficiency of health care delivery systems: effects of health insurance coverage

Health insurance expansions may increase the demand for care-creating incentives for health systems to increase input consumption. The possibility remains that added capacity and personnel will have little effect on health outcomes, decreasing the technical efficiency of health care delivery systems. We estimate that a 1 percentage point increase in health insurance coverage decreases the technical efficiency of health care delivery by 1.3 percentage points, translating into approximately 50 billion dollars in additional health expenditures. This finding uncovers a previously unexplored consequence of changes in health insurance on the supply side of health care markets suggesting one avenue through which health care costs growth may occur.     

Does contracting out increase the efficiency of government programs? Evidence from Medicaid HMOs

State governments contract with health maintenance organizations (HMOs) to coordinate medical care for nearly 20 million Medicaid recipients. Identifying the causal effect of HMO enrollment on government spending and health care quality is difficult if, as is often the case, recipients have the option to enroll in a plan. To estimate the average effect of HMO enrollment, this paper exploits county-level mandates introduced during the last several years in the state of California that required most Medicaid recipients to enroll in a managed care plan. The empirical results demonstrate that the resulting switch from fee-for-service to managed care was associated with a substantial increase in government spending but no corresponding improvement in infant health outcomes. The findings cast doubt on the hypothesis that HMO contracting has reduced the strain on government budgets.     

The simplest, best cure for our health-care crisis

Could national health insurance (NHI) cap the explosive rise in medical costs and at the same time give everyone access to health care? More and more people believe so, and for the first time in 20 years NHI proposals are being taken seriously in Washington. But the author contends NHI proponents have misread the causes for America's health-care crisis, and have been misled in their search for a solution by the example of the Canadian health system. All we really need she says, is a home-grown reform that's surprisingly simple and remarkably inexpensive.     

URBANIZATION AND HEALTH CARE IN RURAL CHINA

Strong economic growth has led to remarkable urbanization in China. Using the China Health and Nutrition Survey, this study provides the first empirical evidence documenting the impact of urbanization on rural health care and insurance. The primary finding is that urbanization leads to a significant and equitable increase in insurance coverage, which in turn plays a critical role in access to care. In addition, adverse selection exists in the demand for insurance. Income is also a significant determinant of insurance coverage. This study concludes that urbanization can help make substantial changes in rural health care and insurance status.     

WHAT ARE EMPLOYERS DOING TO CREATE A COMPETITIVE MARKET FOR HEALTH CARE IN THE TWIN CITIES?

Employers' willingness to control costs is a critical aspect of pro-competition strategies for the health-care market. Here, we present some of the first quantitative evidence of what employers do to control health-care costs. Our sample is 44 large private and public employers in Minnesota.
We develop a theoretical model in which the employer chooses cost-control "innovations"—along with wages, fringe benefits, and labor-force size—to maximize profits. The role of innovations is to reduce unit costs of offering fringe benefits.
Our data are from a 1982 survey. Eighty percent of the surveyed employers, representing nearly 200,000 employees, responded. Most respondents offer both indemnity insurance plans and health-maintenance organizations (HMOs). Many firms and individual health-insurance plans conduct cost-control activities, but less than half of the firms which offer HMOs have adopted level-dollar premium contributions for their family health-insurance policies. Few plans have increased their coinsurance and deductible requirements in the past five years.
We use probit equations to estimate the probability that a firm or a health plan will adopt cost-control activities. Our analysis suggests that many firms may soon make major plan-design changes to control health-care costs, although they have not yet done so.     

The determinants of the demand for private health insurance under Medicare

Since the introduction of Medicare in 1984, the proportion of the Australian population with private health insurance has declined considerably. Insurance for health care consumption is compulsory for the public health sector but optional for the private health sector. In this paper, we explore a number of important issues in the demand for private health insurance in Australia. The socio-economic variables which influence demand are examined using a binary logit model. A number of simulations are performed to highlight the influence and relative importance of various characteristics such as age, income, health status and geographical location on demand. A number of important policy issues in the private health insurance market are highlighted. First, evidence is provided of adverse selection in the private health insurance pool, second, the notion of the wealthy uninsured is refuted, and finally it is confirmed that there are significant interstate differences in the demand for private health insurance.     

中国城镇社会医疗保障改革的理论探索

With its transition to a market-oriented economy, China has gone through significant changes in health care delivery and financing systems in the last three decades. Since 1998, a new public health insurance program for urban employees, called Basic Medical Insurance Program (BMI), has been established. One theme of this reform was to control medical service over-consumption with new cost containment methods. This paper attempts to evaluate the effects of the reformed public health insurance on health care utilization, with in-depth theoretical investigation. We formulate a health care demand model based on the structure of health care delivery and health insurance systems in China. It is assumed in the model that physicians have pure monopoly power in determining patients’ health care utilization. The major inference is that the insurance co-payment mechanism cannot reduce medical service over-utilization effectively without any efforts to control physicians’ behavior. Meanwhile, we use the calibrated simulation to demonstrate our hypothesis in the theoretical model. The main implication is that physicians’ incentive to over utilize medical services for their own benefits is significant and severe in China.      

The problem of the uninsured

The problem of the uninsured cannot be fully understood without considering the role of non-market alternatives to ‘market insurance’ called ‘self-insurance’ and ‘self-protection’ (SISP), including the public ‘health care safety-net’ system. We tackle the problem by formulating a ‘full-insurance’ paradigm that accounts for all four interacting insurance measures. We apply two versions of the full-insurance model to estimate, via calibrated simulations, the impacts of SISP on the fraction of uninsured, health spending, and health levels, and to assess how the mandated Affordable Care Act might affect these outcomes in comparison with the CBO projections in 2010. The results indicate that policy analyses which overlook the role of the real price of market insurance relative to the shadow prices of SISP in determining the decision to insure can grossly distort the capacity of mandated reforms like the ACA to insure the uninsured, contain overall health care costs, and improve health and welfare outcomes.     

The relationship between the markets for health insurance and medical malpractice insurance

This article evaluates the interdependence of medical malpractice insurance markets and health insurance markets. Prior research has addressed the performance of these markets, individually, without specifically quantifying the extent to which they are linked. Increasing levels of health insurance losses could increase the scale of potential malpractice claims, boosting medical malpractice losses, or could embody an improvement in medical care quality, which will reduce malpractice losses. Our results for a state panel data set from 2002 to 2009 demonstrate that health insurance losses are negatively related to medical malpractice insurance losses. An additional dollar of health insurance losses is associated with a $0.01–$0.05 reduction in medical malpractice losses. These findings have potentially important implications for assessments of the net cost of health insurance policies.     

The Impact of Maternity Minimum Stay Mandates on Hospitalizations: An Extension

Due to concerns about the health impacts of deliveries with short postpartum hospital stays, many states—and later the federal government—passed mandates regulating the minimum length of hospitalizations insurance policies had to cover. We use the Healthcare Cost and Utilization Project-National Inpatient Sample to analyze whether these mandates have differential impacts on various groups of patients. We find that mandates do have a differential impact based on race and hospital size. These differential effects, however, are not equally present in all analyzed discharge groups.     

The incidence of mandated maternity benefits

I consider the labor-market effects of mandates which raise the costs of employing a demographically identifiable group. The efficiency of these policies will be largely dependent on the extent to which their costs are shifted to group-specific wages. I study several state and federal mandates which stipulated that childbirth be covered comprehensively in health insurance plans, raising the relative cost of insuring women of childbearing age. I find substantial shifting of the costs of these mandates to the wages of the targeted group. Correspondingly, I find little effect on total labor input for that group.     

Public financing of health expenditures,insurance, and health outcomes

The effects of public financing of health expenditures, insurance coverage and other factors on health outcomes are examined within health production models estimated using 1960–1992 data across 20 OECD countries. Mortality rates are found to depend on the mix of health care expenditures and the type of health insurance coverage. Increases in the publicly financed share of health expenditures are associated with increases in mortality rates. Increases in inpatient and ambulatory insurance coverage are associated with reduced mortality. The effects of GDP, health expenditures and age structure on mortality are similar to those in previous studies. Tobacco use, alcohol use, fat consumption, female labour force participation, and education levels are also significantly related to overall mortality rates. Increases in income inequality are associated with lower mortality rates, suggesting that the negative relationship between inequality and health outcomes suggested by some previous studies does not remain when a more complete model is estimated. The result that increases in public financing increase mortality rates is robust to a number of changes in specifications and samples. Thus, as countries increase the level of their health expenditures, they may want to avoid increasing the proportion of their expenditures that are publicly financed.     

A dynamic analysis of the demand for health insurance and health care

We find that asymmetric information is important for the uptake of supplementary private health insurance and health care utilization. We use dynamic panel data models to investigate the sources of asymmetric information and distinguish short-run selection effects into insurance from long-run selection effects. Short-run selection effects (i.e. responses to shocks) are adverse, but small in size. Also long-run effects driven by differences in, for example, preferences and risk aversion, are small. But we find some evidence for multidimensional asymmetric information. For example, mental health causes advantageous selection. Estimates of health care utilization models suggest that moral hazard is not important.