Understanding the Impact of Health Reform on the States: Expansion of Coverage through Medicaid and Exchanges

The Affordable Care Act (ACA) expands Medicaid coverage and creates subsidized state health insurance exchanges. The implementation of the ACA will impact the states and consequently the state residents differently. We discuss the factors contributing to the variation in uninsured rates and the Medicaid population, and we predict that these underlying economic, demographic factors and state policies will continue to affect health insurance coverage. Using data from the March 2010 Current Population Survey (CPS), we examine health care coverage at the state level prior to the ACA and forecast the percentage of state residents eligible for expanded Medicaid and the exchanges. Our results suggest the percentage of state population eligible for expanded Medicaid and subsidized exchanges will vary considerably, especially for adults. Further, we show that current state Medicaid eligibility rules, the percentage of employers offering health insurance and poverty rates will continue to shape the variation in projected health insurance coverage across the states. Finally, we discuss the potential impact of the Supreme Court decision that allowed states to opt‐out of Medicaid expansion.     

Wages,Health Insurance and Pension Plans: The Relationship Between Employee Compensation and Small Business Owner Income

Small business owners claim that their ability to provide higher wages and more frequent employee health insurance and pension benefits is severely constrained by the profitability of their firms. This paper examines the proposition that employee wage levels, provision of employee health insurance, and sponsorship of an employee pension plan are associated with small business owner income. A large trade-association survey supplies the data for the inquiry. Regression analysis (OLS and logistic) demonstrates that all three forms of employee compensation are tied to business owner income. Further, the business owner income variable "washes out" the generally accepted relationship between size of business and wages, though not the relationships between size of the business and the presence of health insurance nor between the size of business and the presence of pension benefits. The regressions also indicate that unit costs of health insurance and pension benefits are higher for those employing 10 or fewer and 20 or fewer respectively compared the other small businesses.     

Union-nonunion compensation differentials across plant sizes: Evidence from CPS 1983

Previous empirical work on the relationship between plant size and union-nonunion differentials has focused either on wages (Podgursky, 1986) or benefits (Bramley, Wunnava, and Robinson, 1989; Freeman, 1981). This note extends this research by simultaneously focusing on both wages and benefits. There are several arguments that can be made in explaining union-nonunion differentials across plant sizes: (1) union threat effects, (2) efficiency wage effects, and (3) wage dispersion effects. Our study focuses on measuring the union-nonunion differential in total compensation. For this end, estimates of total compensation are obtained using Mellow's suggestion (1982) for combining hourly wage information with qualitative data on pensions and health insurance, and Ross's imputations (1989) for holidays and vacations benefits. Our results, based on the May 1983 CPS supplemented by BLS data on pensions, health insurance, holidays, and vacation benefits indicate significant union-nonunion total compensation differentials exist only for workers in establishments with less than 500 workers. These results are consistent with Podgursky's wage differential findings.     

Wages,Health Insurance Benefits,and Worker Sorting Under Asymmetric Information

Abstract

Employer-sponsored health insurance is the single largest source of health insurance in the USA. In this paper, we explore a model that treats a firm as a de facto insurance company. More specifically, we model a firm as both a producer of goods for an output market and a health insurance company for their employees. The model accounts for the joint provision of wages and health insurance, including the possibility of asymmetric information in employee health status. With this structure, a firm can choose to pay their workers in some combination of cash wages and health insurance. We characterize optimal employment contracts and show that the Rothschild–Stiglitz model results under asymmetric information extend to employer provided insurance. We also find that employment-based insurance offers pooling options that are typically not available when insurance is sold as a standalone product, suggesting a stability to employer-based insurance that is not dependent on the tax system.     

Improving Incentives in Health Care Spending

Although U.S. economic growth is likely to continue to be robust, the growth of private and public spending on health care presents long-run public policy challenges. To meet these challenges health care resources must be used more efficiently. Currently, there are few incentives to put health care dollars to the highest value use. This is true in both public and private spending. An important element of the problem lies in the tax-preferred treatment given to employer-provided insurance but not to out-of-pocket spending. The resulting bias towards first-dollar insurance coverage means that consumers are insulated from the real costs of the health care that they consume and have little reason to evaluate whether the benefits are greater than those costs. Moreover, they seldom have sufficient price and quality information to make informed decisions. Health Savings Accounts (HSAs) are a promising way to remove the tax-penalty for enrolling in catastrophic insurance and paying for routine care out of pocket. Given the information that they need, consumers would then have more choices and more control, strengthening their role in reducing waste, improving efficiency, and promoting competition. Coupled with other policies, HSAs can be a critical component in moving toward an efficient and equitable health care system. JEL Classification I11     

中国非寿险业发展的路径依赖问题研究

中国非寿险业已经走过了20多年的改革发展历程,虽然从规模上得到了长足的发展,却并未取得预期的经济绩效,而是陷入了大面积亏损的"闭锁"状态。为此,本文结合中国本土实际,运用有关制度变迁理论的重要思想方法,从经济学角度对中国非寿险业发展的路径依赖问题提供了理论解释,并提出了相应的政策建议。从长期、动态的观点来看,中国非寿险业发展要摆脱低效率的"闭锁"状态,应该由监管部门对发展中的利益进行协调,引入内部规则和外部规则,引导非寿险公司通过平等、有序、动态的市场博弈进入一种新的发展路径,从而实现对目前发展路径的替代。     

Making Health Care More Affordable Through Health Insurance Finance Reform

The way that we finance health insurance today is both unfair and inefficient. The tax code subsidizes the most expensive employment-based policies while penalizing those who buy insurance on their own or choose more basic policies. By reforming this system, we can both make health care more affordable for millions of people and get higher-value care for the money that we spend. These reforms should be coupled with policies to ensure that basic private insurance is affordable for everyone, including those with chronic health conditions or low income, and to ensure that patients and physicians have the tools that they need to make well-informed decisions. JEL Classification I11     

Impact of Financial Education Mandates on Younger Consumers' Use of Alternative Financial Services

Over one‐quarter of American adults used credit‐based alternative financial services (AFS) in the past five years, which carry a typical APR of 300%. Young adults are especially more likely to use AFS yet are also more likely to be exposed to personal finance education in schools. In this study, I use data from pooled 2012 and 2015 waves of National Financial Capability Study to examine whether state‐mandated financial education impacts young adults' use of AFS. I find that financial education mandates significantly reduced the likelihood and frequency of payday borrowing in particular. Additionally, I show that exposure to required personal finance courses could affect payday borrowing through increased financial literacy and improved financial planning practices. These findings suggest that policymakers and other stakeholders need to understand the full benefits of financial education when making cost–benefit analysis comparisons as to whether or not to implement.     

The Affordable Care Act,the Medicaid Coverage Gap,and Hispanic Consumers: A Phenomenology of Obamacare

The historic health care reform of the Patient Protection and Affordable Care Act, commonly referred to as Obamacare, enabled more than 20 million Americans to gain health insurance and access to health care. However, the original mandate requiring states to expand Medicaid was ruled as optional in 2012 by the Supreme Court. Focusing on Hispanic consumers residing in a state that opted out of the Medicaid expansion, this study reports on the consumer experience of Obamacare. Findings show that study participants are in an unfavorable situational context, better understood when the cultural context is considered, and cultural resistance recognized. The findings also show that participants are confused, discouraged, and fearful of the continued unaffordability of health insurance and the lawful need to enroll or be penalized. For these participants, affordable health insurance has not been realized and this research gives an insight on those individuals falling through the cracks.     

Public health insurance,individual health,and entry into self-employment

We investigate the impact of a differential treatment of paid employees versus self-employed workers in a public health insurance system on the entry rate into self-employment. Health insurance systems that distinguish between the two sectors of employment create incentives or disincentives to start a business for different individuals. We estimate a discrete time hazard rate model of entry into self-employment based on representative household panel data for Germany, which include individual health information. The results indicate that an increase in the health insurance cost differential between self-employed workers and paid employees by €10 per month decreases the probability of entry into self-employment by 1.7% of the annual entry rate. This shows that entrepreneurship lock, which an emerging literature describes for the system of employer-provided health insurance in the USA, can also occur in a public health insurance system. Therefore, entrepreneurial activity should be taken into account when discussing potential health-care reforms.     

永久性最低提取利益保证变额年金的公平保证费用定价

近年来,我国的人口老龄化趋势严重,截止到2012年底,年龄超过60岁的人口已达1.94亿,占总人口的14.3%,预计在2013年突破2亿。因此,老年人口的养老问题日益受到社会关注。在养老工具里面,相对于具有较低稳定收益的传统养老保险和没有最低保证的投连险,投资人(或投保人)更愿意选择具有最低利益保证的变额年金保险。在转移长寿风险的同时,投资人(或投保人)既有最低利益保证,又有可能获得更高的投资收益。因此有最低利益保证的变额年金未来会是年金保险的主流产品。本文对此进行探讨,为国内保险公司设计开发此类产品提供理论指导和参考。     

Health insurance provision and labor contracts for small firms

Healthcare reform in the USA requires all Americans to buy health insurance and businesses above a certain size to offer healthcare coverage to their employees by 2014. Understanding why some entrepreneurs do not provide employer-based health insurance is important and might help to solve future health insurance problems. Using two unique features which have not yet been discussed in the literature, namely, efficiency–wage theory and a compensation package of monetary wage and health insurance coverage, we provide here a theoretical foundation to why small firms are less likely to offer health insurance and are more likely to have employees with only a weak preference for acquiring health insurance. To reach the goal of health insurance coverage for all, one feasible solution is to allow small firms or individuals to pool together and pay a lower insurance premium.     

Dualit?t aus gesetzlicher und privater Krankenversicherung überholt?

The present division between statutory and private health insurance in Germany (GKV and PKV) is hard to justify. If it is the goal to include the whole population in the GKV eventually, one author states that the only legal way is to change its financing from wage-based contributions to a per-capita amount, which would generally reduce incentives to join the PKV. Possible reform alternatives for the financing of health insurance are analysed by another article according to the following principal questions: Are they able to raise sufficient funds and allocate them efficiently? How does that affect employment and distributive justice? These questions can be used to benchmark various insurance models, i.e. citizens insurance, citizens private insurance and premium models. Another article focuses on a non-profit private legal framework, e.g. a co-operative or a limited society.     

The welfare state after the great recession

The economic crisis has given rise to significant challenges to the welfare state. Given that welfare expenses account for a large proportion of all state spending in the member countries of the European Union, reducing government spending means cutting welfare measures. Yet social protection, in particular unemployment insurance benefits and minimum income support, has significantly softened the impact of the crisis for millions of individuals. The global recession calls into question the financial viability of current programmes, and the crisis is being used by some as an opportunity to roll back the welfare state permanently. The present Forum discusses challenges to and opportunities for the welfare state after the crisis.     

John E. Murray. Origins of American Health Insurance: A History of Industrial Sickness Funds

John E. Murray's Origins of American Health Insurance concernsa little-known precursor to commercial health insurance, the"industrial sickness funds" of the book's subtitle. This well-researchedbook makes a compelling case for the importance of these fundsin shaping the American health insurance system as we know it.Murray argues that the success of sickness funds during theearly twentieth century helps to explain why European-styleuniversal health insurance does not exist in the United States. In 1915, industrial sickness funds     

To Your Health: Health Insurance,Self‐Employment Exit,and Older Entrepreneurs

Drawing on a sample of 5,238 individuals in the Health and Retirement Study, we examined the relationship between having one's own health insurance and exit from self‐employment to employment. Our results indicate that individuals who have health insurance are less likely to exit self‐employment. When self‐employed individuals have their own health insurance, males, relative to females, are more likely to exit self‐employment. Additionally, when self‐employed individuals have their own health insurance, those who do not have health problems that limit work are more likely to exit. We discuss the implications that these findings have on the literature and policymakers.     

Health insurance coverage during the COVID-19 pandemic: The role of Medicaid expansion

Using data from the US Census Bureau's Household Pulse Survey, we analyzed the likelihood of loss of health insurance and enrollment into new health coverage during the early months of the COVID-19 pandemic. Loss of employment was associated with a significant increase in the likelihood of loss of health insurance and, specifically, an increase in the likelihood of employer-sponsored health insurance. However, individuals in Medicaid expansion states experienced a lower likelihood of loss of health insurance compared with individuals in nonexpansion states. At the same time, there was a statistically significant increase in Medicaid enrollment in expansion states, by 3.2 percentage points. Reemployment or acquiring employment was associated with a gain in health insurance coverage. During an economic downturn, eligibility, and coverage gaps leave many without affordable coverage options, and the pandemic will likely bring renewed attention to gaps in Medicaid coverage in nonexpansion states.     

Health Insurance,Job Lock,and the Supply of Self‐Employment

Unlike most wage earners, self‐employed Americans have limited access to health insurance and face higher costs. Thus, social commentators and policymakers argue that many potential entrepreneurs are “locked” into their current jobs for fear of losing their health coverage even though they could be more productive in self‐employment. Using a large data set for the period 2000–2008, we find the availability of employer‐provided health insurance to be negatively correlated to the likelihood of self‐employment in the long run, but the effect to be mediated by individual and family health status. However, we find employer‐provided health insurance to have no significant effect on the probability of switching in the short run. Finally, we find differences in the magnitude of the effects between our samples of husbands and wives.     

Activity-based Costing (ABC) and the Life Insurance Industry

This paper describes the concept of activity-based costing (ABC) and examines its relevance to the life insurance industry. The paper contends that the high overheads and diversified product lines of many life insurance companies makes them appropriate environments within which to apply ABC. It is considered that ABC can provide at least three important benefits to a life insurance company, namely: more accurate cost information, closer insights into the costs of production and better information concerning the strategic consequences of business decisions. These attributes can help a life insurance company to achieve important business objectives, such as the management of expenses and the continuous improvement in the quality of its products and services. However; the transition to ABC is not easy and it cannot be seen as a panacea for all corporate woes. Nevertheless, the paper concludes that with sound project management, an ABC system can provide life insurance companies with much better information for activity management and the achievement of longer term strategic goals.     

Measuring physician contribution to the healthcare safety net

There are an estimated 46 million Americans without health insurance and an even larger number for whom health insurance does not cover all needed medical services. These individuals and families have to rely more and more on government programs and physicians’ willingness to provide uncompensated services, most often described by providers as charity care. Previous studies have shown a downward trend in the percent of physicians willing or able to provide charity care. We extend this research by examining the results of the Medical Group Management Association's Cost Survey of Medical Group Practices for 2005, 2006, and 2007. It is important to examine the uncompensated care reported by medical groups because groups have policies that may govern how much, if any, charity care their physicians provide. This survey data shows that, overall, the number of medical practices providing charity care continues to decline. The results and analysis of the survey data indicate that uncompensated (charity) care is being offered by less than half of medical practices, and at less than 2% of total gross charges. We examined the results by potential explanatory variables: population density, practice size, physician practice specialty, practice ownership structure, payer mix, and practice financial performance. Results were consistent across all categories; charity care is declining. These results have major policy implications for both the federal government and all state governments, especially in light of the current recession and proposed healthcare reform legislation.