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ABSTRACT: In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides an opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.
Quarterly Journal of Economics 08/2012; 127(3):1057-1106. · 5.92 Impact Factor
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ABSTRACT: The United States is in the throes of the most serious recession in postwar history. Despite improving employment numbers, the official unemployment rate still exceeded 8% in June 2012. Amid this malaise, the health care sector is one of the few areas of steady growth.(1) It may seem natural to think that if this sector is one of the bright spots in the economy, public policies should aim to foster continued growth in health care employment. Indeed, hospitals and other health care organizations point to the size of their payrolls as evidence that they play an important role in economic . . .
New England Journal of Medicine 06/2012; 366(26):2433-5. · 53.30 Impact Factor
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NBER Book Chapters. 12/2011;
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ABSTRACT: There is growing concern over the rising share of the US economy devoted to health care spending. Fueled in part by demographic transitions, unchecked increases in entitlement spending will necessitate some combination of substantial tax increases, elimination of other public spending, or unsustainable public debt. This massive increase in health spending might be warranted if each dollar devoted to the health care sector yielded real health benefits, but this does not seem to be the case. Although we have seen remarkable gains in life expectancy and functioning over the past several decades, there is substantial variation in the health benefits associated with different types of spending. Some treatments, such as aspirin, beta blockers, and flu shots, produce a large health benefit per dollar spent. Other more expensive treatments, such as stents for cardiovascular disease, are high value for some patients but poor value for others. Finally, a large and expanding set of treatments, such as proton-beam th...
08/2011; 4:33-56.
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ABSTRACT: In 2008, Oregon used a lottery to allocate a limited number of Medicaid spots for low-income adults to people on the waiting list. The resulting natural experiment permits assessment of the effects of Medicaid coverage on health and use of health care services.
New England Journal of Medicine 08/2011; 365(8):683-5. · 53.30 Impact Factor
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New England Journal of Medicine 07/2011; 365(4):e7. · 53.30 Impact Factor
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ABSTRACT: In 2008, a group of uninsured low-income adults in Oregon was selected by lottery to be given the chance to apply for Medicaid. This lottery provides a unique opportunity to gauge the effects of expanding access to public health insurance on the health care use, financial strain, and health of low-income adults using a randomized controlled design. In the year after random assignment, the treatment group selected by the lottery was about 25 percentage points more likely to have insurance than the control group that was not selected. We find that in this first year, the treatment group had substantively and statistically significantly higher health care utilization (including primary and preventive care as well as hospitalizations), lower out-of-pocket medical expenditures and medical debt (including fewer bills sent to collection), and better self-reported physical and mental health than the control group.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.
Public Health Law & Policy eJournal. 07/2011;
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ABSTRACT: The fraction of GDP devoted to health care in the United States is the highest in the world and rising rapidly. Recent economic studies have highlighted the growing value of health improvements, but less attention has been paid to the efficiency costs of tax-financed spending to pay for such improvements. This paper uses a life cycle model of labor supply, saving, and longevity improvement to measure the balanced-budget impact of continued growth in the Medicare and Medicaid programs. The model predicts that top marginal tax rates could rise to 70 percent by 2060, depending on the progressivity of future tax changes. The deadweight loss of the tax system is greater when the financing is more progressive. If the share of taxes paid by high-income taxpayers remains the same, the efficiency cost of raising the revenue needed to finance the additional health spending is $1.48 per dollar of revenue collected, and GDP declines (relative to trend) by 11 percent. A proportional payroll tax has a lower efficiency cost (41 cents per dollar of revenue averaged over all tax hikes, a 5 percent drop in GDP) but more than doubles the share of the tax burden borne by lower income taxpayers. Empirical support for the model comes from analysis of OECD country data showing that countries facing higher tax burdens in 1979 experienced slower health care spending growth in subsequent decades. The rising burden imposed by the public financing of health care expenditures may therefore serve as a brake on health care spending growth.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.
Tax Law: Tax Law & Policy eJournal. 02/2011;
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ABSTRACT: In this paper, we explore the role patient incentives play in slowing healthcare spending growth. Evidence suggests that while patients do indeed respond to financial incentives, cost-sharing does not uniformly improve value; rather, cost-sharing provisions must be deliberately structured and targeted to reduce care of low marginal value. Other mechanisms may be helpful in targeting particular populations or types of utilization. The spillover effects between privately insured and publicly insured populations as well as market imperfections suggest a potential role for public policy in promoting insurance design that slows spending growth while increasing the health that each dollar buys.
Journal of Economic Perspectives 01/2011; 25(2):47-68. · 4.21 Impact Factor
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ABSTRACT: The recently enacted Patient Protection and Affordable Care Act includes a major expansion of Medicaid to low-income adults in 2014. This paper describes the Oregon Health Study, a randomized controlled trial that will be able to shed some light on the likely effects of such expansions. In 2008, Oregon randomly drew names from a waiting list for its previously closed public insurance program. Our analysis of enrollment into this program found that people who signed up for the waiting list and enrolled in the Oregon Medicaid program were likely to have worse health than those who did not. However, actual enrollment was fairly low, partly because many applicants did not meet eligibility standards.
Health Affairs 08/2010; 29(8):1498-506. · 4.31 Impact Factor
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New England Journal of Medicine 03/2010; 362(13):1166-8. · 53.30 Impact Factor
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ABSTRACT: Government-sponsored reinsurance for individuals with high health costs is a commonly proposed strategy to improve access and affordability in the individual and small-group health insurance markets. While reinsurance may have some benefits, other schemes may be more effective at accomplishing the same goals at lower cost. Reinsurance can be seen as a crude special case of risk-adjusted insurance subsidies. This paper estimates the effect of different reinsurance schemes on insurance premiums and insurers’ disincentives to enroll potentially high-cost individuals. We find that reinsurance is relatively ineffective at reducing cream-skimming incentives and argue that more sophisticated risk-adjustment schemes are more effective, particularly under community rating with guaranteed issue. Although in the past risk adjustment had been considered too complex to implement in practice, recent experience suggests that it is now feasible, and we argue that incorporation of risk adjustment would strengthen current health insurance reform efforts.
Forum for Health Economics & Policy 01/2010; 13(2):7-7.
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New England Journal of Medicine 12/2009; 362(2):95-7. · 53.30 Impact Factor
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ABSTRACT: Insurance market reforms face the key challenge of addressing the threat that risk selection poses to the availability, of stable, high-value insurance policies that provide long-term risk protection. Many of the strategies in use today fail to address this breakdown in risk pooling, and some even exacerbate it. Flexible risk adjustment schemes are a promising avenue for promoting market stability and limiting insurer cream-skimming, potentially providing greater benefits at lower cost. Reforms intended to increase insurance coverage and the value of care delivered will be much more effective if implemented in conjunction with policies that address these fundamental selection issues.
Inquiry: a journal of medical care organization, provision and financing 02/2009; 46(2):215-28. · 0.83 Impact Factor
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ABSTRACT: In his papers, Richard Cooper finds positive associations between health care quality and both specialist and generalist physicians, but he misinterprets his results. Instead of undermining the findings of our study, which found higher quality in areas with more generalists relative to specialists, his results bolster ours: they suggest that the effect of generalists on quality is ten times larger than that of specialists. Furthermore, his rejection of multiple regression in favor of exclusive reliance on isolated correlations precludes him from gauging the relative contributions of specialists, generalists, and other factors. Unfortunately, these deficiencies mean that we can learn little from Cooper's analyses.
Health Affairs 01/2009; 28(1):w116-8. · 4.31 Impact Factor
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ABSTRACT: Several myths about health insurance interfere with the diagnosis of problems in the current system and impede the development of productive reforms. Although many are built on a kernel of truth, complicated issues are often simplified to the point of being false or misleading. Several stem from the conflation of health, health care, and health insurance, while others attempt to use economic arguments to justify normative preferences. We apply a combination of economic principles and lessons from empirical research to examine the policy problems that underlie the myths and focus attention on addressing these fundamental challenges.
Health Affairs 11/2008; 27(6):w533-43. · 4.31 Impact Factor
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ABSTRACT: We estimate the effect of rising health insurance premiums on wages, employment, and the distribution of part-time and full-time work using variation in medical malpractice payments driven by the recent "medical malpractice crisis." We estimate that a 10% increase in health insurance premiums reduces the aggregate probability of being employed by 1.2 percentage points, reduces hours worked by 2.4%, and increases the likelihood that a worker is employed only part time by 1.9 percentage points. For workers covered by employer provided health insurance, this increase in premiums results in an offsetting decrease in wages of 2.3%.
Journal of Labor Economics 02/2006; 24(3):609-634. · 1.64 Impact Factor
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ABSTRACT: There is a great deal of public debate about potential reforms of the malpractice system. A closer look at available data suggests that some of the rhetoric surrounding this debate may be misleading. First, increases in malpractice payments do not seem to be the driving force behind increases in premiums. Second, increases in malpractice costs do not seem to affect the overall size of the physician workforce, although they may affect some subsets of the physician population more severely. Third, we find evidence that the strongest effect of greater malpractice pressure is in increased use of imaging services, with somewhat smaller effects on the use of other discretionary, generally low-risk services such as physician visits and consultations, use of diagnostic tests, and minor procedures. We find little evidence of increased utilization of major surgical procedures.
Torts & Products Liability Law eJournal. 10/2005;
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American Economic Review 02/2005; 95(2):214-218. · 2.69 Impact Factor
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ABSTRACT: In its study of racial and ethnic disparities in health care, the Institute of Medicine (IOM) concluded that there were large and significant disparities in the quality and quantity of health care received by minority groups in the United States. This article shows that where a patient lives can itself have a large impact on the level and quality of health care the patient receives. Since black or Hispanic populations tend to live in different areas from non-Hispanic white populations, location matters in the measurement and interpretation of health (and health care) disparities. There is wide variation in racial disparities across geographic lines: some areas have substantial disparities, while others have equal treatment. Furthermore, there is no consistent pattern of disparities: some areas may have a wide disparity in one treatment but no disparity in another. The problem of differences in quality of care across regions, as opposed to racial disparities in care, should remain the target of policy makers, as reducing quality disparities would play a major role in improving the health care received by all Americans and by minority Americans in particular.
Perspectives in biology and medicine 02/2005; 48(1 Suppl):S42-53. · 1.34 Impact Factor
