Health, Private and Public Insurance, G 15, 16. U.S. Health care > 16% of GDP (7% in 1970), 8% in U.K. and Sweden, 11% in Switzerland.

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1 Health, Private and Public Insurance, G 15, 16 U.S. Health care > 16% of GDP (7% in 1970), 8% in U.K. and Sweden, 11% in Switzerland. 60% have private ins. as primary ins. Insured pay about 20% out of pocket. 90% of privately insured through employer: Group averaging reduces adverse selection. Tax subsidy: ins value not taxable income. Job-lock. Cuts mobility 25%? (COBRA effect) Public Ins: Medicare to elderly, Medicaid to poor, Tricare/Champva to military, veterans, families 18% uninsured: 92% below median income, 70% in households with fully employed head 22% children. Cheap hospitalization for 80%. Externalities: Empathy, Communicable disease, Inefficient care, e.g., emergency room use.

2 Ins. cuts price, raises quantity of care demanded. (This is not hidden action moral hazard.) RAND Health Ins Exper: 0.2 demand elasticity Is Feldstein s Major Risk Ins optimal? Combines incentives with consumption smoothing. Problem: Early care reduces catastrophic costs. Why subsidize care? Externalities above; selfcontrol problem: save too little for emergency. Avoid choice between money and care. Compensation scheme affects provider choices. Retrospective reimbursement: why cut cost? Preferred Provider (PPO) cuts cost via mkt power. HMOs (health maintenance organizations) like PPO + prospective reimbursement; 1980 below 5% of insured, now above 75%.

3 HMO contracting power reduced cost inflation in early 90s, now same cost inflation as in traditional insurance programs. HMOs cost 80% as much as traditional ins plans. Part cream skimming: attract healthy clients; part lower hospitalization rate. Public Insurance Medicaid for low income single parents, kids, low income pregnant women. Limited service, low reimbursement; many providers don t accept Medicaid. Effect on # insured? Not all eligible enroll. Crowd-out: switch from private to public ins. Demand rise when # providers limited? 25% take-up rate among eligible % of public ins rise replaces private ins.

4 Large effects on infant mortality and birth weights. Currie-Gruber: $1M/infant life (cheap). Prenatal nutrition, care even more cost effective. Debate: costs of low birth weight (twin studies). Medicaid for nursing home care lowers saving? Medicare (1965) insurance for 65+ and disabled. 35 million enrolled. $260 B, 2.5% of GDP. Reasons: Adverse selection, transaction costs (both high for aged?) Min. coverage for all: high deductible, copay. 50% have additional private insurance. Hospital Ins. (HI) financed by 2.9% payroll tax on all earnings (half by worker). Supplemental Medical (SMI) or Choice financed by premium (25%) and general funds (75%).

5 Fee-for-service vs. Capitation (fee for patient). For service incentive for too much service. Capitation incentive for less quality reform prospective pay (capitation). Big drop in service and cost growth for 5 yrs. Since then, DRG (diagnosis group) creep. HMOs paid 95% of cost of non HMO recipients. Raised total cost since HMO patients healthier. Supplementary ins raises demand, Medicare cost. Prescription ins: first $250, 75% of next $2250, 95% of cost above $5100. Purely political? Inefficiency: price MC. Bargaining ruled out. Medicare in first 10 yrs had little longevity effect Pre 65, uninsured hospitalized for critical illness. Costs rising at about same rate everywhere. Why? Aging population, not so important (Newhouse J Econ Perspectives 1992)

6 Income growth. Newhouse: accounts for less than 10% of cost growth. Medical schools control supply of doctors. More doctors per capita in region more treatment, not better outcomes. Technology. Newhouse: over 50%. Insurance speeds use of new technology. Medicare examples, Finkelstein NBER Distinguish average and marginal costs. HI funded only to 2022? Proposed Reforms: Price controls (market power on both sides); Hospice; only catastrophic coverage (Feldstein). Gov provision? Veterans Admin costs 20% less, with lower inflation. Improved health from rising health costs? Rise in life expectancy, but same as in Canada. Better exercise, diet, environment as good?

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