The political economy of public health expenditure and wait times in a public‐private mixed health care system

Abstract This paper investigates the determinants of public health expenditure in a public‐private mixed health care system, where a longer wait time for public care is the major difference between public and private sectors. Voter preferences for health care vary according to their age and by income, and public policy choices are part of a multi‐dimensional, competitive political equilibrium. We show how equilibrium public health expenditure and wait times depend on demographics and explain why they are independent of the distributions of income and political influence. We also show that population aging may not always lead to more public health expenditure.     

Infrastructure privatization and changes in corruption patterns: The roots of public discontent

This paper offers a theory of how the degree of corruption that prevails in a society responds to changes in the ownership structure of major public service providers. We show that there are cases in which privatization, even though it fosters investments in infrastructure, also opens the door to more corruption. The public dissatisfaction towards privatization is then crucially affected by the changes in the degree and pattern of corruption. Our model thus helps understand the seemingly paradoxical situation prevailing in Latin America, where most studies find that privatizations have been efficiency-enhancing and have fostered investments and, at the same time, popular dissatisfaction with the process is extremely high, especially among the middle class. We show that this line of explanation is consistent with the evidence from surveys in the region.     

The effects of upcoding,cream skimming and readmissions on the Italian hospitals efficiency: A population-based investigation

In this paper we analyze the effects of some distortions induced by the prospective payment system, i.e. upcoding, cream skimming and readmissions, on hospitals' technical efficiency. We estimate a production function using a population-based dataset composed by all active hospitals in an Italian region during the period 1998–2007. We show that cream skimming and upcoding have a negative impact on hospitals' technical efficiency, while readmissions have a positive effect. Moreover, the results indicate that private hospitals engage more in cream skimming than public and not-for-profit ones, while we observe no ownership differences regarding upcoding. Not-for-profit hospitals have the highest readmission index. Last, not-for-profit and public hospitals have the same efficiency levels, while private hospitals have the lowest technical efficiency.     

The role of networking in the competitiveness of firms

Two main forces characterise production systems today: on the one hand, the increasingly global nature of markets and economies has resulted in increasing competition and a new, more global division of labour. On the other, the greater complexity of technology makes innovation a key aspect in the competitiveness of manufacturing firms. The establishment of cooperative networks seems to be important in both processes. This paper aims to explore these aspects by analysing the competitiveness of firms in four different sectors of the manufacturing industry: food, chemicals, electronics and vehicles. Data have been obtained from a survey conducted specifically for this purpose at company level in Spain. Findings from the empirical analysis, based on the application of the Polytomous Logistic Universal Model (PLUM), confirm the positive effects that the ability to network has on company performance. In particular, among all the potential organisations that work as partners of the firms, the paper shows the importance of intra-firm cooperation, the user-producer relationships and the cooperation between competitors.     

A dynamic‐efficiency rationale for public investment in the health of the young

In this paper we assume away standard distributional and static‐efficiency arguments for public health and instead seek a dynamic efficiency rationale. We study a lifecycle model wherein young agents make health investments to reduce mortality risk. We identify a welfare rationale for public health under dynamic efficiency and exogenous mortality even when private and public investments are perfect substitutes. If health investment reduces mortality risk but individuals do not internalize its effect on the life‐annuity interest rate, the “Philipson‐Becker effect” emerges; when the young are net borrowers, this works together with dynamic efficiency to support a role for public health.     

Public procurement in times of crisis: The bundling decision reconsidered

The government wants two tasks to be performed. In each task, unobservable effort can be exerted by a wealth-constrained private contractor. If the government faces no binding budget constraints, it is optimal to bundle the tasks. The contractor in charge of both tasks then gets a bonus payment if and only if both tasks are successful. Yet, if the government has only a limited budget, it may be optimal to separate the tasks, so that there are two contractors each in charge of one task. In this case, high efforts in both tasks can be implemented with smaller bonus payments.     

Supply and quality choices in private child care markets: Evidence from São Paulo

Many developing countries have adopted the market approach for expanding the supply of child care, but little is known about the economic behavior of independent providers. Drawing on uniquely rich census data on child care providers from São Paulo, we document three main facts: (1) the stock of private suppliers is considerably larger in high-income city districts; (2) the quality of private provision – as measured by teachers' schooling, group size and equipment – is highly heterogeneous across space and increases systematically with local household income; and (3) a considerable share of centers operates below recommended (but not regulated) quality standards, especially in low-income districts. These findings are consistent with a model of endogenous entry and quality choices by heterogeneous providers. Market-driven heterogeneity in the quality of provision across space is an important consideration for the design of regulations in child care markets.     

Policy induced increases in private healthcare financing provide short-term relief of total healthcare expenditure growth: Evidence from OECD countries

Healthcare reforms have long been advocated as a cure to the increasing healthcare expenditures in advanced economies. Nevertheless, it has not been established whether a market solution via private financing, rather than public financing, curb aggregate healthcare expenditures. To our knowledge, this paper is the first that quantifies the impact of reforms that significantly increases (decreases) the private (public) share of healthcare financing on total healthcare expenditures relative to income in 20 OECD countries. Our reform measure is based on structural break testing of the private share of total expenditures, and verification using evidence of policy reforms. To quantify the effect of these reforms we apply Propensity Score Matching and Inverse Probability Weighted regression analysis. Over a 5-year evaluation period the reforms lead to an accumulated cost saving 0.45 percentage points of GDP. The yearly effects of the reforms are largest in the first years in the post-reform period and decreases in size as a function of time since the reform. Our findings suggest that the investigated healthcare reforms have a relatively short-lived effect on aggregate health spending relative to GDP. The findings are robust to various sensitivity tests.     

Monopoly pricing with negative network effects: The case of vaccines

We study the market for vaccinations considering income heterogeneity on the demand side and monopoly power on the supply side. A monopolist has an incentive to exploit the external effect of vaccinations and leave the poor susceptible in order to increase the willingness to pay the rich. Even the possibility of price discrimination does not remove this incentive. We demonstrate that the weaknesses of standard policy measures are mitigated when income heterogeneity is taken into account. This offers an efficiency based rationale for distribution oriented national or international public health interventions.     

Equity-regarding poverty measures: differences in needs and the role of equivalence scales

Abstract .  The paper investigates the definition of equity-regarding poverty measures when there are different household types in the population. It demonstrates the implications of a between-type regressive transfer principle for poverty measures, for the choice of poverty lines, and for the measurement of living standard. The role of equivalence scales, which are popular in empirical work on poverty measurement, is clarified.     

The marginal cost of public funds and tax reform in Africa

In this paper we propose estimates of the marginal cost of public funds (MCF) in 38 African countries. We develop a simple general equilibrium model that can handle taxes on five major tax classes, and can be calibrated with little more than national accounts data. A key feature of our model is the explicit recognition of the informal economy. Our base case estimate of the average MCF from marginal increases in all five tax instruments is 1.2. Focusing on the lowest cost tax instruments in each country, commonly the VAT but not always, the average MCF is 1.1. Finally extending the tax base to include sections of the informal economy by removing some tax exemptions offers the potential for a low MCF source of public funds, and a lowering of MCFs on other tax instruments.     

Childhood preventive care,adult healthcare and economic growth: The role of healthcare financing

We analyze the impact of healthcare financing on economic growth, focusing on the issue of the joint public–private financing of healthcare (co-payment). We use an overlapping-generations model with endogenous growth based on health human capital accumulation, where families pay for childhood preventive care and the government can either fully finance or co-finance adulthood curative care. From a growth maximizing perspective, distortionary taxes give an advantage to co-financing. Nevertheless, we prove that, if agents are assumed to be heterogeneous in preferences, full financing can become the best option.     

Savings from public procurement centralization in the healthcare system

We show that the introduction of the procurement centralization within the regional healthcare systems in Italy reduced per capita health expenditure approximatelyt by 2–8%, without affecting the level of health-related public services. Our results also indicate that the effect is persistent after six years, and is not influenced by the coexistence of other organizational models, such as amalgamation and hybrid systems. Finally, we document that the reduction in public expenditure is effective only in areas characterized by poor quality of institutions, indicating that procurement centralization might be an effective tool to reduce corruption-related inefficiencies in the health sector.     

The public and private provision of pure public goods and the distortionary effects of income taxation: a political economy approach

Abstract .  A pure public good is provided by the government and the voluntary contributions of two types of households. The government finances its contribution by means of income taxation. The latter has distortionary effects. A third type of household never makes contributions. We analyse the effects of changes in the income tax rate on (a) the provision of the public good, (b) the private contributions of the households, and (c) changes in the distribution of income and welfare between contributing and non-contributing households. We derive a simple and testable condition under which the lowering of the income tax entails a Pareto improvement.     

Public provision of health insurance and aggregate saving in an overlapping generations model with endogenous health risk: The South Korean case

This paper examines the effect of expanding public health insurance in South Korea on medical expenditures and aggregate saving using an overlapping generations model with endogenous health risk. South Korea had a substantial underinsured population, which is aging rapidly. Higher public health insurance benefits reduce individual medical expenditure and health risks but lead to a modest decline in individual and aggregate saving. Even after the expansion, the medical care coverage remains incomplete, and the elderly face a substantial risk of out-of-pocket medical expenditures.     

Reshaping the schooling system: The role of immigration

This paper studies how the schooling system may be impacted by the number and skill type of immigrants. When the number of low-skilled immigrants is large, the education regime tends to become segregated. Wealthy locals are more likely to choose private schools and vote for a lower tax rate to finance public education. In contrast, high-skilled immigrants tend to reinforce the public system. The optimal immigration policy is highly skill-biased. The admission of high-skilled immigrants expedites redistribution toward the less-skilled local households through both a stronger fiscal support for public education and a reduction in the skill wage premium.     

The influence of political fragmentation on public enterprises: Evidence from German municipalities

This study investigates the influence of politically fragmented municipal councils on the investment behaviour of municipally owned public enterprises. We argue that common public choice theories can also be applied to public enterprises. For our observation period (2002–2014), we use a data set encompassing 8,685 municipally owned enterprises subject to commercial accounting located in 3,237 municipalities drawn from all 13 German federal area states. On average, our results point to a negative effect of fragmentation on investment per capita, supporting a war of attrition or veto player approach. Effects are heterogeneous among different sectors, possibly due to higher visibility to voters. Thus, veto players might actively try to block prestigious and publicly perceivable investment projects to hinder their opponents. Political budget cycles additionally influence this effect for some sectors. However, testing non-linearities reveal that the common-pool hypothesis cannot be completely ruled out.     

Domestic and international research joint ventures: The effect of collusion

We analyze the effect of research joint ventures (RJVs) on consumer welfare in an international context when collusion can occur. Our results suggest that antitrust authorities should distinguish between domestic and international RJVs and be more benevolent with international RJVs.     

Institutions,quality competition and public service provision: The case of public education

This paper contributes to the literature on integovernmental competition in two ways. First, the institutional setting within which public services are delivered is analyzed with respect to the impact on the quality of services provided. Previous studies have measured competition only in terms of governmental structure, ignoring the issue of service quality and the potential for differentiating local governmental jurisdictions along quality dimensions. Second, the outcome of competition is defined in terms of service quality. Previous studies generally have measured the outcome of competition by examining the fiscal effects of fragmentation and accountability through service costs or tax revenue impacts. School districts were used to empirically test quality competition. Student academic performance was modeled as a function of control variables and the degree of competition from neighboring school districts. Academic performance in public schools was positively associated with the performance of neighboring districts, although the effect was small. These findings, however, suggest that strategies to strengthen interjurisdictional competition may be useful in enhancing public service quality.