Article

Myths And Misconceptions About US Health Insurance

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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.

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... Another issue raised by Baicker and Chandra (2008) is who pays for health insurance. They argue that the misconception that employers pay for benefits out of a pool of profits stems from the view that we can get employers to shoulder the cost of providing health insurance (Baicker and Chandra, 2008). ...
... Another issue raised by Baicker and Chandra (2008) is who pays for health insurance. They argue that the misconception that employers pay for benefits out of a pool of profits stems from the view that we can get employers to shoulder the cost of providing health insurance (Baicker and Chandra, 2008). In reality, no matter how much a company profits, benefits are paid for out of workers' wages. ...
... Concluding, Baicker and Chandra (2008) believe the solution lies in a comprehensive healthcare reform proposal that aims at extending insurance protections and improving the value of care by those who are insured. Fuchs and Emanuel (2005) explain the many difficulties and obstacles of healthcare reform, varying from satisfaction of status quo and differing opinions on healthcare reform. ...
... Often, these patients eventually require ER or hospital care which may have been prevented with earlier utilization. 1 These utilization examples demonstrate how improper health care use contributes to an inefficient, costly system. Similar to utilization, preventive care can be provider-side or patient-side. ...
... Addressing preventive care brings up another efficiency issue: numerous studies show that the majority of preventive care measures spend more than they save. 1 The proposed solution to this is to promote and fund comparative based research. Recent legislation has set aside funds for this purpose, but comparative cost assessment is not a part of funding specifics. ...
Article
The American health care system is currently facing numerous changes. It is recognized that we can no longer sustain current costs nor projected health care spending. Thus, we must address health care inefficiencies and spending to improve overall efficiency as a means to lower costs. Three primary areas where increased efficiency may potentially lower costs involve delivery and integration of healthcare, the patient/physician relationship, and reevaluation of fields intimately related to health care. Recognizing and addressing these concerns will obviously have implications on policy development. It is hoped that resultant policy changes allow us to develop a more efficient and sustainable health care system that provides the highest level of health care value to the country overall.
... Most economists would agree that social insurance is in place either when the benefits are directly provided by the government using tax revenues or when beneficiaries receive tax-funded subsidies. Most economists would also agree that heavy state regulation of private insurers alone À for example, through an individual mandate, guaranteed issue, or community-rated premiums À would not be sufficient to label the insurance scheme as social insurance (Baicker & Chandra, 2008). ...
... 26,38 Access to health care does not mean access to quality of care. 20,39 It may be that deficiencies in quality in this sample produced need for more health care use. However, quality was likely variable across the many providers represented in the population studied and, as such, would not account for findings regarding any one or small group of children. ...
Article
The purpose of this study was to describe the demographic characteristics of low-income parents who perceive financial burden in managing their child’s asthma and related associations with their children’s asthma outcomes and clinical characteristics. We hypothesized that (1) identifiable differences between parents who do and do not report burden; (2) regardless of access to care, asthma outcomes would be worse for children whose parents perceive financial burden in obtaining care for their child’s condition. Baseline data from a randomized trial evaluating the effect of a school-based asthma intervention were analyzed for this research. Eight hundred thirty-five parents were interviewed by telephone regarding their child’s asthma management. Associations between demographic and clinical factors and perception of financial burden were examined using bivariate analysis. Multivariate regression analyses were used to examine associations between perceptions of financial burden and asthma outcomes, including emergency department visits, hospitalizations, and missed school days. Perceived financial burden was evident in 10 % (n = 79) of parents. Female heads of household (χ 2 (3) = 7.41; p < 0.05), those at the lowest income levels (χ 2 (3) = 12.14; p < 0.01), and those whose child’s asthma was poorly controlled (χ 2 (2) = 49.42; p < 0.001) were most likely to perceive financial burden. In models controlling for level of asthma control, income, and having a usual source of asthma care, parents who perceived financial burden were more likely to have children who had at least one emergency department visit (OR = 1.95; 95 % CI = 1.15 to 3.29), hospitalization (OR = 3.99; 95 % CI = 2.03 to 7.82), or missed school days due to asthma (OR = 3.26; 95 % CI = 1.60 to 6.67) in the previous year. Our results supported our hypotheses. Among low-income parents of children with asthma, the majority do not perceive financial burden to obtaining care. However, among parents that do perceive burden, urgent care use and missed school days due to asthma for their child were significantly higher, regardless of family income and having a usual source of asthma care. Mothers and grandmothers heading families and those caring for children with uncontrolled asthma were most likely to report burden. These findings have implications for clinical practice in that health care providers may be able to take simple actions to determine patients’ financial-related perceptions, correct misconceptions, and help patients consider their full range of options to manage their child’s asthma.
... An important prediction underpinning the altruism model for intergenerational transfers is that if a recipient's income 10 A more nuanced social protection categorization (ADB, 2003) encompasses four activities: active labor market policies, social insurance programs, social assistance and welfare service programs, and area-based schemes to address community vulnerability. 11 We use the definition of social insurance based on Nelson (2004), Baicker and Chandra (2008), Chetty and Finkelstein (2013), and Ziebarth (2018). 12 Programs exclusively means-tested programs are excluded from this group. ...
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In this paper, we critically survey the recent empirical literature on crowd-out effects in response to public policies, specifically in the context of LMICs. We review and synthesize patterns from the behavioral response to various types of social protection programs. Furthermore, we specifically examine for heterogeneous treatment effects by important socioeconomic characteristics.
... For instance, low quality of care can lead to low patient satisfaction which would instigate client-migration to private sector and subsequently an increase in out-of-pocket payment [4]. Studies have also shown that expanding coverage does not necessarily mean access to quality healthcare services [5][6][7]. In other words, the questions on quality of care in LMICs are still unanswered even with the directed efforts to achieve universal coverage. ...
Article
Objective: Quality of care may help explain the high burden of disease in maternal, newborn and child health in low- and middle-income countries even as access to care is improved. We explored the determinants of quality of antenatal care (ANC) in sub-Saharan Africa (SSA). Design: Cross-sectional study. Multilevel Generalized Linear Latent Mixed-Effect models with logit link function were employed to obtain the adjusted odds ratios (AORs) and 95% confidence interval (CI). Setting: We used Service Provision Assessment data from six countries in SSA, including Kenya, Malawi, Namibia, Rwanda, Tanzania and Uganda. Participants: Seven thousand, five hundred and seventy seven observed antenatal clients across the six countries. Main outcome measures: Quality of ANC services, measured using indexes of quality of clinical care and quality of information provided. Results: Providers in facilities that had ANC guideline (AOR = 1.26; 95% CI, 1.08-1.48), were well-equipped (AOR = 1.65; 95% CI, 1.41-1.92), were classified as upper level facility (AOR = 1.32; 95% CI, 1.05-1.66), had central electricity supply (AOR = 2.19; 95% CI, 1.81-2.65), and piped water (AOR = 1.30; 95% CI, 1.09-1.55) were more likely to provide optimal quality of clinical care. Moreover, those having ANC guideline (AOR = 1.81; 95% CI, 1.43-2.28) and central electricity supply (AOR = 2.67; 95% CI, 2.01-3.44) were more likely to provide optimal information as well. Provider's qualification and experience were also important in information provision and clinical care independently. Conclusion: The lack of some very basic facility equipment and amenities compromised quality of care in sub-Saharan countries. Policy actions and investment on facility and providers will enable provision of quality services necessary to improve maternal, newborn and child health in SSA.
... Most economists would agree that social insurance is in place when the benefits are either directly provided by the government using tax revenues, or when beneficiaries receive tax-funded subsidies. Most economists would also agree that heavy state regulation of private insurers alone-for example, through an individual mandate, guaranteed issue or community-rated premiums-would not be sufficient to label the insurance scheme as social insurance ( Baicker and Chandra 2008). ...
Chapter
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This chapter reviews the existing empirical evidence on how social insurance affects health. Social insurance encompasses programs primarily designed to insure against health risks, such as health insurance, sick leave insurance, accident insurance, long-term care insurance, and disability insurance as well as other programs, such as unemployment insurance, pension insurance, and country-specific social insurance programs. These insurance systems exist in almost all developed countries around the world. This chapter discusses the state-of-the art evidence on each of these social insurance systems, briefly reviews the empirical methods for identifying causal effects, and examines possible limitations to these methods. The findings reveal robust and rich evidence on first-stage behavioral responses (“moral hazard”) to changes in insurance coverage. Surprisingly, evidence on how changes in coverage impact beneficiaries’ health is scant and inconclusive. This lack of identified causal health effects is directly related to limitations on how human health is typically measured, limitations on the empirical approaches, and a paucity of administrative panel data spanning long-time horizons. Future research must be conducted to fill these gaps. Of particular importance is evidence on how these social insurance systems interact and affect human health over the life cycle.
... Businesses might in turn pass these savings back to workers in the form of higher wages. 12 Such an approach could insure more people than the ACA at no additional cost to the federal government. 13 Such a large-scale change, however, could disrupt the employer insurance market and cause some firms to drop coverage. ...
Article
The Affordable Care Act's "Cadillac tax" will apply a 40 percent excise tax on total employer health insurance premiums in excess of $10,200 for single coverage and $27,500 for family coverage, starting in 2018. Employer spending on premiums is currently excluded from income and payroll taxes. Economists argue that this encourages overconsumption of health care, favors high-income workers, and reduces federal revenue. This issue brief suggests that the Cadillac tax is a "blunt instrument" for addressing these concerns because it will affect workers on a rolling timetable, does relatively little to address the regressive nature of the current exclusion, and may penalize firms and workers for cost variation that is outside their control. Replacing the current exclusion with tax credits for employer coverage that scale inversely with income might allow for regional adjustments in health care costs and eliminate aspects of the tax exclusion that favor high-income over low-income workers.
... They believe that a war, depression, or major civil unrest could be necessary to precipitate reform, or alternatively a confluence of developments such as the business community deciding they no longer want to pay for health insurance, state budget crises related to Medicaid or a financial crisis on the federal level with Medicare. Baicker and Chandra (2008) address popular myths related to health insurance reform from an economics perspective. Confusing health, health care and health insurance is often at the center of these myths. ...
Article
Graduation date: 2010 Several states, including Oregon, Massachusetts and California, have been the focus of major health reform efforts in recent years. Oregon utilized a citizen-led commission to generate policy recommendations that led to the enactment of health reform legislation in 2009. This commission helped to create momentum and provide political cover for legislators to act, but other factors were also important. The results of Oregon’s reform process were significant compared with other state efforts.
... 18 Insurers should consider value-based insurance designs that subsidize high-value chronic care while increasing cost sharing for elective services without proven benefit. 19 n Study limitations. Several limitations should be considered in interpreting our findings. ...
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... From an economic standpoint, it can be argued that fringe benefits are indistinguishable from wages, and thus "paid" entirely by workers and not by employers at all.(Baicker and Chandra, 2008) True as this might be in an absolute sense, it is not how the question is perceived by firms or how it is generally discussed at the political level. In the remainder of this essay, thus, I will adopt the generally-held layperson's point of view that employment-linked insurance is an additional component of labor cost. ...
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This paper investigates the effects of market-wide changes in health insurance by examining the single largest change in health insurance coverage in American history: the introduction of Medicare in 1965. I estimate that the impact of Medicare on hospital spending is over six times larger than what the evidence from individual-level changes in health insurance would have predicted. This disproportionately larger effect may arise if market-wide changes in demand alter the incentives of hospitals to incur the fixed costs of entering the market or of adopting new practice styles. I present some evidence of these types of effects. A back of the envelope calculation based on the estimated impact of Medicare suggests that the overall spread of health insurance between 1950 and 1990 may be able to explain about half of the increase in real per capita health spending over this time period. Copyright by the President and Fellows of Harvard College and the Massachusetts Institute of Technology.
Article
People uninsured for any part of 2008 spend about $30 billion out of pocket and receive approximately $56 billion in uncompensated care while uninsured. Government programs finance about 75 percent of uncompensated care. If all uninsured people were fully covered, their medical spending would increase by $122.6 billion. The increase represents 5 percent of current national health spending and 0.8 percent of gross domestic product. However, it is neither the cost of a specific plan nor necessarily the same as the government's costs, which could be higher, depending on plans' financing structures and the extent of crowd-out.
Article
America's pluralistic health care system has been subjected to increasing criticism because it is very costly to administer particularly when matched with comparable expenses in the health care systems of other industrialized nations. The focus of such cross-national comparisons has been Canada, which administers a universal health insurance plan that is considerably less expensive than the private/public melange that makes up America's approach, although there is no agreement on the differential. Three papers in the Spring 1992 volume of Health Affairs addressed the relative administrative costs of the two systems; that debate continues in the Letters section of this volume. While the debate over administrative costs has continued-gaining far more attention, interestingly, than the other ninety cents or so of every health care dollar spent in the United States-some of the conclusions reached by analysts have been influenced as much by ideology as by analysis. Much less attention has focused on the question: Just what are the expenses that people group so casually under "administrative costs," and what are the implications of reducing or redistributing them in some fashion? To address these questions more thoroughly, The Robert Wood Johnson Foundation convened a conference in February 1992. This paper by Ken Thorpe, which reflects original work of an outstanding nature, was presented at that meeting. Here Thorpe presents a typology of administrative costs throughout thc health system and discusses the impact of costs in various sectors on systemwide spending. Such a typology is important, he writes, because "reductions in administrative expenses (assuming one could find them and transfer them) could be used to finance benefits for thc uninsured." Thorpe, who holds a doctorate in public policy (RAND Graduate Institute), is on the faculty of the University of North Carolina at Chapel Hill, Department of Health Policy and Administration.
Article
In this issue of the Journal, Fries et al.1 offer an attractive alternative to health care cost-control proposals such as managed competition, global budgets, rationing, and the like. On behalf of the Health Project Consortium, they propose that wider use of preventive care, broadly defined, would control growth in medical expenditures and make Americans healthier at the same time. Fries et al. are not the first to suggest that prevention saves money -- the idea has enduring appeal. Cost-effectiveness studies, however, provide little evidence of savings. At the same time, the expectation that preventive care will save money may hold . . .
Article
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.
Article
We have little systematic information about the extent to which standard processes involved in health care--a key element of quality--are delivered in the United States. We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence. The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.
Article
Since 1986, Woolhandler and Himmelstein, alone or with others, have written a series of articles that follow a simple template.1–5 In them, the authors measure the administrative costs of the U.S. and Canadian health care systems, subtract the second from the first, and note the difference. This issue of the Journal contains another article in the series.6 The authors report that the difference between the United States and Canada in outlays for health care administration seems to be increasing. Others have provided alternative estimates of administrative costs in the United States and elsewhere.7–9 This literature has been motivated, . . .
Article
Few U.S. hospitals have implemented computerized physician order entry (CPOE) in spite of its effectiveness at preventing serious medication errors. We interviewed senior management at twenty-six hospitals to identify ways to overcome barriers to adopting and implementing CPOE. Within the hospital, strong leadership and high-quality technology were critical. Hospitals that placed a high priority on patient safety could more easily justify the cost of CPOE. Outside the hospital, financial incentives and public pressures encouraged CPOE adoption. Dissemination of data standards would accelerate the maturation of vendors and lower CPOE costs. These findings highlight several policy levers to speed the adoption of this important patient safety technology.
Article
Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries. We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements. After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more. A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.
Article
This paper compares the long-term (1970-2002) rates of real growth in health spending per capita in the United States and a group of high-income countries in the Organization for Economic Cooperation and Development (OECD). Real health spending growth is decomposed into population aging, overall economic growth, and excess growth. Although rates of aging and overall economic growth were similar, annual excess growth was much higher in the United States (2.0 percent) versus the OECD countries studied (1.1 percent). That difference, which is of an economically important magnitude, suggests that country-specific institutional factors might contribute to long-term health spending trends.
Article
When everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both under- and overuse. Unlike most current health plan designs, Value-Based Insurance Design (VBID) explicitly acknowledges and responds to patient heterogeneity. It encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost. This paper makes the case for VBID and outlines current VBID initiatives in the private sector as well as barriers to further adoption.
Article
Previously uninsured adults who enroll in the Medicare program at the age of 65 years may have greater morbidity, requiring more intensive and costlier care over subsequent years, than they would if they had been previously insured. We used longitudinal data from the nationally representative Health and Retirement Study to assess self-reported health care use and expenditures from 1992 through 2004 among 5158 adults who were privately insured or uninsured before Medicare coverage began at the age of 65 years. We used propensity-score methods to compare health care use and expenditures for previously insured and uninsured beneficiaries who were similar across numerous characteristics at 59 to 60 years of age and adjusted for differences in supplemental and prescription-drug coverage after 65 years of age. Among 2951 adults with hypertension, diabetes, heart disease, or stroke diagnosed before 65 years of age, previously uninsured adults who acquired Medicare coverage at the age of 65 reported significantly greater increases in the numbers of doctor visits (P<0.001) and hospitalizations (P=0.001) and in total medical expenditures (P=0.02) than did previously insured adults. Significant differential increases were not evident among the 2207 adults without these conditions (P>0.12 for all comparisons). In analyses adjusted for supplemental and prescription-drug coverage, previously uninsured adults with these conditions reported more doctor visits (13% relative difference, P=0.04), more hospitalizations (20% relative difference, P=0.04), and higher total medical expenditures (51% relative difference, P=0.09) from ages 65 to 72 years than did previously insured adults. The costs of expanding health insurance coverage for uninsured adults before they reach the age of 65 years may be partially offset by subsequent reductions in health care use and spending for these adults after the age of 65, particularly if they have cardiovascular disease or diabetes before the age of 65 years.
Article
Consumer-directed health care is a potentially promising tool for moving toward more efficient use of health care resources. Tax policy has long been biased against health plans with significant patient cost sharing. Tax advantages created by health savings accounts (HSAs) began to change that, and proposed tax reforms could go even further. We assess various critiques of these plans, focusing on why they benefit not just the healthy and wealthy. Lower costs and more efficient health spending would help all patients and reduce uninsurance. Potential negative distributional effects are important but can be remedied more efficiently without distorting insurance design.
Article
This paper assesses the impact of employer-provided health insurance on job mobility by exploring the extent to which workers are 'locked' into their jobs because preexisting conditions exclusions make it expensive for individuals with medical problems to relinquish their current health insurance. I estimate the degree of job-lock by comparing the difference in the turnover rates of those with high and low medical expenses for those with and without employer-provided health insurance. Using data from the 1987 National Medical Expenditure Survey, I estimate that job-lock reduces the voluntary turnover rate of those with employer-provided health insurance by 25 percent, from 16 percent to 12 percent per year.
Article
This paper recognizes that compensating differentials are a function of the income tax rate, using this observation to introduce a methodology for estimating compensating differentials with a specific application to the value of a statistical life (VSL). When taxes change, the pre-tax wages of risky jobs should shift relative to the pre-tax wages of safe jobs in a manner proportional to the VSL. This approach controls for fixed effects without using industry-specific changes in risk as a source of identification. The strategy yields VSL estimates between $50 million and $75 million, an order of magnitude higher than the previous literature.
Article
Employer health insurance mandates form the basis of many health care reform proposals. Proponents make the case that they will increase insurance, while opponents raise the concern that low-wage workers will see offsetting reductions in their wages and that in the presence of minimum wage laws some of the lowest wage workers will become unemployed. We construct an estimate of the number of workers whose wages are so close to the minimum wage that they cannot be lowered to absorb the cost of health insurance, using detailed data on wages, health insurance, and demographics from the Current Population Survey. We find that 33 percent of uninsured workers earn within $3 of the minimum wage, putting them at risk of unemployment if their employers were required to offer insurance. Assuming an elasticity of employment with respect to minimum wage increase of -0.10, we estimate that 0.2 percent of all full-time workers and 1.4 percent of uninsured full-time workers would lose their jobs because of a health insurance mandate. Workers who would lose their jobs are disproportionately likely to be high school dropouts, minority, and female. This risk of unemployment should be a crucial component in the evaluation of both the effectiveness and distributional implications of these policies relative to alternatives such as tax credits, Medicaid expansions, and individual mandates, and their broader effects on the well-being of low-wage workers.
Article
We study the impact of the introduction of one of the major pillars of the social insurance system in the United States: the introduction of Medicare in 1965. Our results suggest that, in its first 10Â years, the establishment of universal health insurance for the elderly had no discernible impact on elderly mortality. However, we find a substantial reduction in the elderly's exposure to out of pocket medical expenditure risk. Specifically, we estimate that the introduction of Medicare was associated with a 40% decline in out of pocket spending for the top quartile of the out of pocket spending distribution. A stylized expected utility framework suggests that the welfare gains from such reductions in risk exposure alone may be sufficient to cover almost two-fifths of the costs of Medicare. These findings underscore the importance of considering the direct insurance benefits from public health insurance programs, in addition to any indirect benefits from an effect on health.
Article
Discusses some of the "new' development indicators being promoted by the UNDP, in particular the human development index. Argues that the notion of economic growth as the sole measure of development was never really accepted, either among economists or policymakers. -M.Amos
Use of Health Services by Previously Uninsured Medicare BeneficiariesPubMed: 17625126] Hadley J, et al. Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs
  • Jm Mcwilliams
McWilliams JM, et al. Use of Health Services by Previously Uninsured Medicare Beneficiaries. New England Journal of Medicine. 2007; 357(2):143–153. [PubMed: 17625126] Hadley J, et al. Covering the Uninsured in 2008: Current Costs, Sources of Payment, and Incremental Costs. Health Affairs. 2008; 27(4):w399–w415. (published online 25 August 2008; 10.1377/hlthaff.27.4.w399). [PubMed: 18725375]
Improving Incentives in Health Care Spending: Properly Designed Health Spending Accounts Can Be a Major Step Lowering the Barriers to Consumer-Directed Health Care: Responding to ConcernsPubMed: 17848443] Baicker and Chandra Page 10 Health Aff (Millwood) Author manuscript
  • K Baicker
  • K Baicker
  • Dow
  • J Wolfson
Baicker K. Improving Incentives in Health Care Spending: Properly Designed Health Spending Accounts Can Be a Major Step. Business Economics. 2006; 41(2):21–25.Baicker K, Dow WH, Wolfson J. Lowering the Barriers to Consumer-Directed Health Care: Responding to Concerns. Health Affairs. 2007; 26(5):1328–1332. [PubMed: 17848443] Baicker and Chandra Page 10 Health Aff (Millwood). Author manuscript; available in PMC 2009 February 24. NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
The Incidence of Employer-Provided Insurance: Lessons from Workers' Insurance. Tax Policy and the EconomyGruber J. The Incidence of Mandated Maternity Benefits
  • J Gruber
  • A Krueger
Gruber J, Krueger A. The Incidence of Employer-Provided Insurance: Lessons from Workers' Insurance. Tax Policy and the Economy. 1991; 5:111-143.Gruber J. The Incidence of Mandated Maternity Benefits. American Economic Review. 1994; 84(3):622-641. [PubMed: 10134748]
The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care [PubMed: 12585825] Fisher ES, et al. The Implications of Regional Variation in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care
  • Es Fisher
Fisher ES, et al. The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care. Annals of Internal Medicine. 2003; 138(4):273-287. [PubMed: 12585825] Fisher ES, et al. The Implications of Regional Variation in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care. Annals of Internal Medicine. 2003; 138(4):288-298. [PubMed: 12585826]
The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care The Implications of Regional Variation in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care
  • E S Fisher
E.S. Fisher et al., " The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care, " Annals of Internal Medicine 138, no. 4 (2003): 273–287; and E.S. Fisher et al., " The Implications of Regional Variation in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care, " Annals of Internal Medicine 138, no. 4 (2003): 288–298.
Improving Incentives in Health Care Spending: Properly Designed Health Spending Accounts Can Be a Major Step Lowering the Barriers to Consumer-Directed Health Care: Responding to Concerns
  • K Baicker
  • K Baicker
  • W H Dow
  • J Wolfson
K. Baicker, " Improving Incentives in Health Care Spending: Properly Designed Health Spending Accounts Can Be a Major Step, " Business Economics 41, no. 2 (2006): 21–25; and K. Baicker, W.H. Dow, and J. Wolfson, " Lowering the Barriers to Consumer-Directed Health Care: Responding to Concerns, " Health Affairs 26, no. 5 (2007): 1328–1332.
New America Foundation Working Paper Washington: NAF; 2008. Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms
  • L Nichols
  • S Axeen
Nichols, L.; Axeen, S. New America Foundation Working Paper. Washington: NAF; 2008. Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms.