Consider it done? The likely efficacy of mandates for health insurance

Several health insurance reform plans, including the recently enacted Massachusetts plan, envision the use of individual or employer mandates to increase coverage rates. In this paper we summarize and analyze existing evidence on the effectiveness of mandates, drawing on evidence both from health insurance and from other arenas where mandates are often used. We find that mandates can, but do not always, increase participation in programs. The effectiveness of a mandate depends critically on the cost of compliance, the penalties for noncompliance, and the timely enforcement of compliance.     

Supplementary private health insurance: The impact of physician financial incentives on medical practice

In the French diagnosis-related group (DRG)-based payment system, both private and public hospitals are financed by a public single payer. Public hospitals are overcrowded and have no direct financial incentives to choose one procedure over another. If a patient has a strong preference, they can switch to a private hospital. In private hospitals, the preference does come into play, but the patient has to pay for the additional cost, for which they are reimbursed if they have supplementary private health insurance. Do financial incentives from the fees received by physicians for different procedures drive their behavior? Using French exhaustive data on delivery, we find that private hospitals perform significantly more cesarean deliveries than public hospitals. However, for patients without private health insurance, the two sectors differ much less in terms of cesareans rate. We determine the impact of the financial incentive for patients who can afford the additional cost. Affordability is mainly ensured by the reimbursement of costs by private health insurance. These findings can be interpreted as evidence that, in healthcare systems where a public single payer offers universal coverage, the presence of supplementary private insurance can contribute to creating incentives on the supply side and lead to practices and an allocation of resources that are not optimal from a social welfare perspective.     

Health insurance and ex ante moral hazard: evidence from Medicare

Basic economic theory suggests that health insurance coverage may cause a reduction in prevention activities, but empirical studies have yet to provide much evidence to support this prediction. However, in other insurance contexts that involve adverse health events, evidence of ex ante moral hazard is more consistent. In this paper, we extend the analysis of the effect of health insurance on health behaviors by allowing for the possibility that health insurance has a direct (ex ante moral hazard) and indirect effect on health behaviors. The indirect effect works through changes in health promotion information and the probability of illness that may be a byproduct of insurance-induced greater contact with medical professionals. We identify these two effects and in doing so identify the pure ex ante moral hazard effect. This study exploits the plausibly exogenous variation in health insurance as a result of obtaining Medicare coverage at age 65. We find evidence that obtaining health insurance reduces prevention and increases unhealthy behaviors among elderly men. We also find evidence that physician counseling is successful in changing health behaviors.     

Medicaid and crowding out of private insurance: a re-examination using firm level data

While previous research has identified a relationship between expanded Medicaid eligibility and falling private health insurance coverage, the exact mechanism by which this "crowding out" occurs is largely unexplained. We combine individual and firm-level data to investigate possible responses to the Medicaid expansions by firms and workers. We find no evidence that the expansions affected employer offers of insurance to workers. However, we find some evidence of an effect on the probability that a firm offers family coverage, and on the percentage of full-time workers accepting employer-sponsored coverage offered to them.     

Stability of children’s insurance coverage and implications for access to care: evidence from the Survey of Income and Program Participation

Even as the number of children with health insurance has increased, coverage transitions—movement into and out of coverage and between public and private insurance—have become more common. Using data from 1996 to 2005, we examine whether insurance instability has implications for access to primary care. Because unobserved factors related to parental behavior and child health may affect both the stability of coverage and utilization, we estimate the relationship between insurance and the probability that a child has at least one physician visit per year using a model that includes child fixed effects to account for unobserved heterogeneity. Although we find that unobserved heterogeneity is an important factor influencing cross-sectional correlations, conditioning on child fixed effects we find a statistically and economically significant relationship between insurance coverage stability and access to care. Children who have part-year public or private insurance are more likely to have at least one doctor’s visit than children who are uninsured for a full year, but less likely than children with full-year coverage. We find comparable effects for public and private insurance. Although cross-sectional analyses suggest that transitions directly between public and private insurance are associated with lower rates of utilization, the evidence of such an effect is much weaker when we condition on child fixed effects.     

Child outpatient mental health service use: why doesn't insurance matter?

BACKGROUND: Several recent studies of child outpatient mental health service use in the US have shown that having private insurance has no effect on the propensity to use services. Some studies also find that public coverage has no beneficial effect relative to no insurance. AIMS: This study explores several potential explanations, including inadequate measurement of mental health status, bandwagon effects, unobservable heterogeneity and public sector substitution for private services, for the lack of an effect of private insurance on service use. METHODS: We use secondary analysis of data from the three mainland US sites of NIMH's 1992 field trial of the Cooperative Agreement for Methodological Research for Multi-Site Surveys of Mental Disorders in Child and Adolescent Populations (MECA) Study. We examine whether or not a subject used any mental health service, school-based mental health services or outpatient mental health services, and the number of outpatient visits among users. We also examine use of general medical services as a check on our results. We conduct regression analysis; instrumental variables analysis, using instruments based on employment and parental history of mental health problems to identify insurance choice, and bivariate probit analysis to examine multiservice use. RESULTS: We find evidence that children with private health insurance have fewer observable (measured) mental health problems. They also appear to have a lower unobservable (latent) propensity to use mental health services than do children without coverage and those with Medicaid coverage. Unobserved differences in mental health status that relate to insurance choice are found to contribute to the absence of a positive effect for private insurance relative to no coverage in service use regressions. We find no evidence to suggest that differences in attitudes or differences in service availability in children's census tracts of residence explain the non-effect of insurance. Finally, we find that the lack of a difference is not a consequence of substitution of school-based for office-based services. School-based and office-based specialty mental health services are complements rather than substitutes. School-based services are used by the same children who use office-based services, even after controlling for mental health status. DISCUSSION: Our results are consistent with at least two explanations. First, limits on coverage under private insurance may discourage families who anticipate a need for child mental health services from purchasing such insurance. Second, publicly funded services may be readily available substitutes for private services, so that lack of insurance is not a barrier to adequate care. Despite the richness of data in the MECA dataset, cross-sectional data based on epidemiological surveys do not appear to be sufficient to fully understand the surprising result that insurance does not enable access to care. IMPLICATIONS FOR POLICY AND RESEARCH: Limits on coverage under private mental health insurance combined with a relatively extensive system of public mental health coverage have apparently generated a situation where there is no observed advantage to the marginal family of obtaining private mental health insurance coverage. Further research using longitudinal data is needed to better understand the nature of selection in the child mental health insurance market. Further research using better measures of the nature of treatment provided in different settings is needed to better understand how the private and public mental health systems operate.     

The spillover effects of health insurance benefit mandates on public insurance coverage: Evidence from veterans

This study examines how regulations in private health insurance markets affect coverage of public insurance. We focus on mental health parity laws, which mandate private health insurance to provide equal coverage for mental and physical health services. The implementation of mental health parity laws may improve a quality dimension of private health insurance but at increased costs. We graphically develop a conceptual framework and then empirically examine whether the regulations shift individuals from private to public insurance. We exploit state-by-year variation in policy implementation in 1999–2008 and focus on a sample of veterans, who have better access to public insurance than non-veterans. Using data from the Current Population Survey, we find that the parity laws reduce employer-sponsored insurance (ESI) coverage by 2.1% points. The drop in ESI is largely offset by enrollment gains in public insurance, namely through the Veterans Affairs (VA) benefit and Medicaid/Medicare programs.     

Use of Health Insurance Among Clients Seeking Contraceptive Services at Title X–Funded Facilities in 2016

CONTEXT

As federal initiatives aim to fundamentally alter or dismantle the Affordable Care Act (ACA), evidence regarding the use of insurance among clients obtaining contraceptive care at Title X–funded facilities under ACA guidelines is essential to understanding what is at stake.

METHODS

A nationally representative sample of 2,911 clients seeking contraceptive care at 43 Title X–funded sites in 2016 completed a survey assessing their characteristics and insurance coverage and use. Chi‐square tests for independence with adjustments for the sampling design were conducted to determine differences in insurance coverage and use across demographic characteristics and facility types.

RESULTS

Most clients (71%) had some form of public or private health insurance, and most of these (83%) planned to use it to pay for their services. Foreign‐born clients were less likely than U.S.‐born clients to have coverage (46% vs. 75%) and to use it (78% vs. 85%). Clients with private insurance were less likely than those with public insurance to plan to use their insurance (75% vs. 91%). More than one‐quarter of clients not planning to use existing insurance for services indicated that the reason was that someone might find out.

CONCLUSION

Coverage gaps persist among individuals seeking contraceptive care within the Title X network, despite evidence indicating increases in health insurance coverage among this population since implementation of the ACA. Future research should explore the impact of altering or eliminating the ACA both on the Title X provider network and on the individuals who rely on it.     

Moral hazard and the demand for health services: a matching estimator approach

We estimate the impact of extra health insurance coverage beyond a National Health System on the demand for several health services. Traditionally, the literature has tried to deal with the endogeneity of the private (extra) insurance decision by finding instrumental variables. Since a priori instrumental variables are hard to find we take a different approach. We focus on the most common health insurance plan in Portugal, ADSE, which is given to all civil servants and their dependents. We argue that this insurance is exogenous, i.e., not correlated with the beneficiaries' health status. This identifying assumption allows us to estimate the impact of having ADSE coverage on the demand for three different health services using a matching estimator technique. The health services used are number of visits, number of blood and urine tests, and the probability of visiting a dentist. Results show large positive effects of ADSE coverage for number of visits and tests among the young (18-30 years old) but only the latter is statistically significantly different from zero. The effects represent 21.8% and 30% of the average number of visits and tests for the young. On the contrary, we find no evidence of moral hazard on the probability of visiting a dentist.     

Does employer-provided health insurance constrain labor supply adjustments to health shocks? New evidence on women diagnosed with breast cancer

Employment-contingent health insurance may create incentives for ill workers to remain employed at a sufficient level (usually full-time) to maintain access to health insurance coverage. We study employed married women, comparing the labor supply responses to new breast cancer diagnoses of women dependent on their own employment for health insurance with the responses of women who are less dependent on their own employment for health insurance, because of actual or potential access to health insurance through their spouse's employer. We find evidence that women who depend on their own job for health insurance reduce their labor supply by less after a diagnosis of breast cancer. In the estimates that best control for unobservables associated with health insurance status, the hours reduction for women who continue to work is 8 to 11% smaller. Women's subjective responses to questions about working more to maintain health insurance are consistent with the conclusions from observed behavior.     

Colorectal Cancer Screening and State Health Insurance Mandates

Colorectal cancer (CRC) is the third most deadly cancer in the USA. CRC screening is the most effective way to prevent CRC death, but compliance with recommended screenings is very low. In this study, we investigate whether CRC screening behavior changed under state mandated private insurance coverage of CRC screening in a sample of insured adults from the 1997 to 2008 Behavioral Risk Factor Surveillance Survey (BRFSS). We present difference‐in‐difference‐in‐differences (DDD) estimates that compare insured individuals age 51 to 64 to Medicare age‐eligible individuals (ages 66 to 75) in mandate and non‐mandate states over time. Our DDD estimates suggest endoscopic screening among men increased by 2 to 3 percentage points under mandated coverage among 51 to 64 year olds relative to their Medicare age‐eligible counterparts. We find no clear evidence of changes in screening behavior among women. DD estimates suggest no evidence of a mandate effect on either type of CRC screening for men or women. Copyright © 2014 John Wiley & Sons, Ltd.     

The impact of benefits coverage expansion of social health insurance: Evidence from Korea

Despite mandatory social health insurance in Korea, the fraction of total healthcare spending paid out-of-pocket has been considerably high. In 2013, the Korean government expanded benefits coverage of social insurance for patients diagnosed with the costliest disease groups (cardiovascular and cerebrovascular diseases, cancer, and intractable diseases). We analyze individual longitudinal information from the 2010 to 2016 Korea Health Panel to estimate the impact of the policy change on healthcare spending, utilization, and enrollment in private supplemental health insurance. Impacts on other health-related and financial measures are additionally assessed to evaluate the effects in multiple dimensions. Our difference-in-differences approach with entropy balancing weights shows that the expansion of benefits coverage of public health insurance reduced out-of-pocket spending on health by 30% without accompanying increases in healthcare utilization. The impact was smaller for the individuals with high socioeconomic characteristics, who are more likely to use other costly services that remained unaffected by the policy. We do not find evidence that expanding social insurance benefits coverage changed the demand for supplemental private health insurance.     

Economic evaluation of options for measles vaccination strategy in a hypothetical Western European country

In this study an analysis was made of economic costs and medical effects (by cost-effectiveness and cost-benefit analysis) associated with measles vaccination in a hypothetical Western European country. We analysed ten vaccination options in terms of past and future vaccination coverage. We show that several of the proposed strategies for improving measles vaccination coverage are preferable to maintaining the existing policies, regardless of past coverage and the viewpoint of the analysis. For society, very high coverage (95%) two-dose vaccination is most optimal, irrespective of past vaccination coverage. The addition of a one-time campaign (to reduce susceptibility in (pre-)adolescent age groups) to such a high coverage two-dose vaccination programme is cost-saving to the health-care payer and to society when coverage in the past was low (< or = 70%). Even when coverage in the past was high (90%) for more than a decade, this 'maximum strategy' could be implemented at an acceptable cost to the health-care payer (incremental direct costs per discounted life-year gained < 30,000 Euros), and at net savings to society.     

Supplemental health insurance and equality of access in Belgium

The effects of supplemental health insurance on health-care consumption crucially depend on specific institutional features of the health-care system. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. Within this institutional background, we find only weak evidence of adverse selection in the coverage of supplemental health insurance. We find much stronger effects of socio-economic background. We estimate a bivariate probit model and cannot reject the assumption of exogeneity of insurance availability for the explanation of health-care use. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights per spell. We comment on the implications of our findings for equality of access to health care in Belgium. Copyright © 2009 John Wiley & Sons, Ltd.     

The effect of Health Savings Accounts on group health insurance coverage

This paper presents new empirical evidence on the impact of tax subsidies for Health Savings Accounts (HSAs) on group insurance coverage. HSAs are tax-free health care expenditure savings accounts. Coupled with high deductible health insurance plans (HDHPs), they together represent new health insurance options. The tax advantage of HSAs expands the group health insurance market by making health care more affordable. Using individual level data from the Current Population Survey and exploiting policy variation by state and year from 2004 to 2012, I find that HSA tax subsidies increase small-group coverage by a statistically significant 2.5 percentage points, although not coverage in larger firms. Moreover, if the tax price of HSA contribution decreases by 10 cents, small-group insurance coverage increases by almost 2 percentage points. I also find that for older workers or less-educated workers, HSA subsidies are associated with 2–3 percentage point increase in their group insurance coverage.     

Medicaid Expansion’s Impact on Emergency Department Use by State and Payer

ObjectivesThe Affordable Care Act’s Medicaid Expansion Program influences healthcare use by increasing insurance coverage. Of particular interest is how this will affect inefficient and expensive emergency department (ED) visits. We estimated the impact of the Medicaid expansion on ED use by states and payer (Medicaid, private insurance, and uninsured) 5 years after the implementation of the Medicaid expansion and illustrated the use of the generalized synthetic control method.MethodsIn this quasi-experiment study, we implemented the generalized synthetic control method to compare states with Medicaid expansion and states without Medicaid expansion. Data were from the Healthcare Cost Utilization Project Fast Stats, which cover >95% of all ED visits. We included states with complete data from 2010 to 2018.ResultsOverall, the Medicaid expansion increased Medicaid share of ED visits (average treatment effect on the treated [ATT] 11.39%; 95% confidence interval [CI] 8.76-14.02) and decreased private share of ED visits (ATT ?5.80%; 95% CI ?7.40 to ?4.12) and uninsured share of ED visits (ATT ?6.66%; 95% CI ?9.78 to ?3.55).ConclusionsMedicaid Expansion Program shifted ED payer mix to Medicaid ED visits from private insurance and uninsured ED visits for adults at age of 19 to 64 years, whereas its effect on total ED volume is mixed among states. States that experienced the largest increase in Medicaid enrollment seem to experience an increase in ED visits although such results did not reach statistical significance.     

The Effect of Medicare Eligibility on Spousal Insurance Coverage

A majority of married couples in the USA take advantage of the fact that employers often provide health insurance coverage to spouses. When older spouses become eligible for Medicare, however, many of them can no longer provide their younger spouses with coverage. In this paper, we study how spousal eligibility for Medicare affects the health insurance and health care access of younger spouses. We find that spousal eligibility for Medicare results in younger spouses no longer having employers pay for their insurance and being less likely to have employer‐sponsored coverage. Instead, younger spouses switch to privately purchased coverage, which tends to be worse than what they had before their spouses became eligible for Medicare. We also find suggestive evidence that younger spouses are less likely to use health care services after their older spouses become eligible for Medicare. Copyright © 2015 John Wiley & Sons, Ltd.     

Costs and effectiveness of alternative dog vaccination strategies to improve dog population coverage in rural and urban settings during a rabies outbreak

Dog-rabies elimination programs have typically relied upon parenteral vaccination at central-point locations; however, dog-ownership practices, accessibility to hard-to-reach sub-populations, resource limitations, and logistics may impact a country’s ability to reach the 70% coverage goal recommended by the World Organization for Animal Health (OIE) and World Health Organization (WHO). Here we report the cost-effectiveness of different dog-vaccination strategies during a dog-rabies outbreak in urban and peri-urban sections of Croix-des-Bouquets commune of the West Department, Haiti, in 2016. Three strategies, mobile static point (MSP), mobile static point with capture-vaccinate-release (MSP + CVR), and door-to-door vaccination with oral vaccination (DDV + ORV), were applied at five randomly assigned sites and assessed for free-roaming dog vaccination coverage and total population coverage. A total of 7065 dogs were vaccinated against rabies during the vaccination campaign. Overall, free-roaming dog vaccination coverage was estimated at 52% (47%-56%) for MSP, 53% (47%-60%) for DDV + ORV, and 65% (61%-69%) for MSP + CVR (differences with MSP and DDV + ORV significant at p < 0.01). Total dog vaccination coverage was 33% (95% CI: 26%-43%) for MSP, 49% (95% CI: 40%-61%) for MSP + CVR and 78% (77%-80%) for DDV + ORV (differences significant at p < 0.001). Overall, the least expensive campaign was MSP, with an estimated cost of about $2039 per day ($4078 total), and the most expensive was DDV + ORV with a cost of $3246 per day ($6492 total). Despite the relative high cost of an ORV bait, combining DDV and ORV was the most cost-effective strategy in our study ($1.97 per vaccinated dog), largely due to increased efficiency of the vaccinators to target less accessible dogs. Costs per vaccinated dog were $2.20 for MSP and $2.28 for MSP + CVR. We hope the results from this study will support the design and implementation of effective dog vaccination campaigns to achieve the goal of eliminating dog-mediated human rabies deaths by 2030.     

Is employer-based health insurance a barrier to entrepreneurship?

The focus on employer-provided health insurance in the United States may restrict business creation. We address the limited research on the topic of “entrepreneurship lock” by using recent panel data from matched Current Population Surveys. We use difference-in-difference models to estimate the interaction between having a spouse with employer-based health insurance and potential demand for health care. We find evidence of a larger negative effect of health insurance demand on business creation for those without spousal coverage than for those with spousal coverage. We also take a new approach in the literature to examine the question of whether employer-based health insurance discourages business creation by exploiting the discontinuity created at age 65 through the qualification for Medicare. Using a novel procedure of identifying age in months from matched monthly CPS data, we compare the probability of business ownership among male workers in the months just before turning age 65 and in the months just after turning age 65. We find that business ownership rates increase from just under age 65 to just over age 65, whereas we find no change in business ownership rates from just before to just after for other ages 55-75. We also do not find evidence from the previous literature and additional estimates that other confounding factors such as retirement, partial retirement, social security and pension eligibility are responsible for the increase in business ownership in the month individuals turn 65. Our estimates provide some evidence that “entrepreneurship lock” exists, which raises concerns that the bundling of health insurance and employment may create an inefficient level of business creation.