Health insurance coverage and the macroeconomy

Joint effects of Medicaid eligibility and fees on recession-linked declines in healthcare access and health status

Whether Medicaid can function as a safety net to offset health risks created by health insurance coverage losses due to job loss is conditional on (1) the eligibility guidelines shaping the pathway for households to access the program for temporary relief, and (2) Medicaid reimbursement policies affecting the value of the program for both the newly and previously enrolled. We find states with more expansive eligibility guidelines lowered the healthcare access and health risk of coverage loss associated with rising unemployment during the 2007-2009 Great Recession. Rises in cost-related barriers to care associated with unemployment were smallest in states with expansive eligibility guidelines and higher Medicaid-to-Medicare fee ratios. Similarly, states whose Medicaid programs had expansive eligibility guidelines and higher fees saw the smallest recession-linked declines in self-reported good health. Medicaid can work to stabilize access to health care during periods of joblessness. Our findings yield important insights into the alignment of at least two Medicaid policies (i.e., eligibility and payment) shaping Medicaid's viability as a safety net.

A Well-Designed Implement for Promoting Population Health and Property via Insurance

The frequency and intensity of catastrophes (including natural disasters and pandemics) rise and damage the population's health, life and property more seriously. In order to protect population health and wealth via full insurance indemnity, many countries set up a public catastrophe insurance scheme (PCIS) to maintain the function of catastrophe insurance markets. Little literature discusses the smart payment way of contributions charged by PCIS. This article design a model to describe the upward trend and cyclic frequency and intensity of catastrophic events. Such characteristics also promote the business cycle of the insurance industry. We analyze the changes in catastrophic insurer's capital structures under three cases of that the volume-based charges to the PCIS may come from equity holders or policyholders or both. PCIS may entail a shift of equity capital toward minimum solvency requirements, and then adverse incentives regarding insurer's security level arise. Various numerical experiments illustrate the changes in equity position, default probabilities, or expected policyholder deficits. The results show that the payment way of contributions should be designed carefully, not only with regard to PCIS's finance balance but also the resultant incentives and effects.

Integrated care models and behavioral health care utilization: Quasi-experimental evidence from Medicaid health homes

Integration of behavioral and general medical care can improve outcomes for individuals with behavioral health conditions-serious mental illness (SMI) and substance use disorder (SUD). However, behavioral health care has historically been segregated from general medical care in many countries. We provide the first population-level evidence on the effects of Medicaid health homes (HH) on behavioral health care service use. Medicaid, a public insurance program in the United States, HHs were created under the 2010 Affordable Care Act to coordinate behavioral and general medical care for enrollees with behavioral health conditions. As of 2016, 16 states had adopted an HH for enrollees with SMI and/or SUD. We use data from the National Survey on Drug Use and Health over the period 2010 to 2016 coupled with a two-way fixed-effects model to estimate HH effects on behavioral health care utilization. We find that HH adoption increases service use among enrollees, although mental health care treatment findings are sensitive to specification. Further, enrollee self-reported health improves post-HH.

Supply-side effects from public insurance expansions: Evidence from physician labor markets

Medicaid and the Child Health Insurance Programs (CHIP) are key sources of coverage for U.S. children. Established in 1997, CHIP allocated $40 billion of federal funds across the first 10 years but continued support required reauthorization. After 2 failed attempts in Congress, CHIP was finally reauthorized and significantly expanded in 2009. Although much is known about the demand-side policy effects, much less is understood about the policy's impact on providers. In this paper, we leverage a unique physician dataset to examine if and how pediatricians responded to the expansion of the public insurance program. We find that newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.

The Great Recession and Workers' Health Benefits

During a recession, cost-sharing of employer-sponsored health benefits could increase to reduce labor costs in the U.S. Using a variation in the severity of recession shocks across industries, I find evidence that the enrollment rate of high deductible health plans (HDHPs) among workers covered by employer-sponsored health benefits increased more among firms in industries that experienced severe recession shocks. As potential mechanisms, I study employer-side and worker-side mechanisms. I find that employers changed health benefit offerings to force or incentivize workers to enroll in HDHPs. But I find little evidence of an increase in workers' demand for HDHPs due to a reduction in income. These results suggest that the HDHP enrollment rate increased during the Great Recession, as employers tried to save costs of offering health benefits.

Graduating into a downturn: Are physicians recession proof?

An extensive literature documents immediate and persistent adverse labor market outcomes for individuals graduating into an economic downturn, but these effects are heterogeneous across sectors, occupations, and skill levels. In particular, the impact of recessions on the labor market outcomes for new physician graduates remains unknown. We leverage a unique dataset on New York physicians to analyze if and how the Great Recession impacted the labor market of physicians who have completed their residency and fellowship training and are seeking their first job. We find that these physicians do not delay labor market entry and their job searches and other employment outcomes are unaffected by the business cycle. The collage of evidence demonstrates that new graduates were largely unfazed by the recent downturn, which sharply contrasts with other highly educated, high remunerating occupations.

Decomposition of moral hazard

This study seeks to simulate the portion of moral hazard that is due to the income transfer contained in the coinsurance price reduction. Healthcare spending of uninsured individuals from the MEPS with a priority health condition is compared with the predicted counterfactual spending of those same individuals if they were insured with either (1) a conventional policy that paid off with a coinsurance rate or (2) a contingent claims policy that paid off by a lump sum payment upon becoming ill. The lump sum payment is set to be equal to the insurer's predicted spending under the coinsurance policy. The proportion of moral hazard that is efficient is calculated as the proportion of total moral hazard that is generated by this lump sum payment. We find that the efficient proportion of moral hazard varies from disease to disease, but is the highest for those with diabetes and cancer.

Health & access to care among working-age lower income adults in the Great Recession: Disparities across race and ethnicity and geospatial factors

In the United States (US) and elsewhere, residents of low resource areas face health-related disparities, and may experience different outcomes throughout times of severe economic flux. We aimed to identify individual (e.g. sociodemographic) and environmental (e.g. region, rurality) factors associated with self-reported health and forgone medical care due to the cost of treatment in the US across the Great Recession (2008-2009). We analyzed nationally representative data (2004-2010) using the Behavioral Risk Factor Surveillance System in the US. Individual and geospatial factors (rurality, census region) were used to identify differences in self-reported health and forgone medical care due to the cost. Adjusted-analyses taking into account individual and geospatial factors among those with incomes <$50,000 identified multiple differences across time, sex, education, disability, rurality and Census Region for health. Similar analyses for forgone medical care found that those in the Recovery and the Recession were more likely to report forgone care than before the Recession. Having insurance and/or being employed (versus unemployed) was a protective factor in terms of reporting fair/poor health and having to forgo health care due to cost. Policies affecting improvements in health and access for vulnerable populations (e.g., low-income minority adults) are critical. Monitoring trends related to Social Determinants of Health, including the relationship between health and place (e.g. Census region, rurality), is necessary in efforts targeted towards ameliorating disparities.

Economic conditions, illicit drug use, and substance use disorders in the United States

We provide the first analysis of the relationship between economic conditions and the use of illicit drugs other than marijuana. Drawing on US data from 2002 to 2015, we find mixed evidence on the cyclicality of illicit drug use. However, we find robust evidence that economic downturns lead to increases in the intensity of prescription pain reliever use as well as increases in clinically relevant substance use disorders involving opioids. These effects are concentrated among working-age white males with low educational attainment. We conclude that policymakers should consider devoting more, not fewer, resources to treating substance use disorders during economic downturns.

Effects of Public Premiums on Children's Health Insurance Coverage: Evidence from 1999 to 2003

This study uses 2000 to 2004 Current Population Survey data to examine the effects of public premiums on the insurance coverage of children whose family incomes are between 100% and 300% of the federal poverty level. The analysis employs multinomial logistic models that control for factors other than premium costs. While the magnitude of the estimated effects varies across models, the results consistently indicate that raising public premiums reduces enrollment in public programs, with some children who forgo public coverage having private coverage instead and others being uninsured. The results indicate that public premiums have larger effects when applied to lower-income families.

Effects of Premium Increases on Enrollment in SCHIP: Findings from Three States

This study examines the effects of new and higher premiums on SCHIP enrollment in Kansas, Kentucky, and New Hampshire—three states that implemented premium changes in 2003. We used state administrative enrollment records from 2001 to 2004–2005 to track changes in total caseloads, new enrollments, and disenrollment timing in premium-paying categories of SCHIP before and after the premium changes were implemented. Premium hikes were associated with lower caseloads in all three states and with earlier disenrollment in Kentucky and New Hampshire. Premium increases appeared to have greater disenrollment effects for lower-income children in New Hampshire and for nonwhite children in Kentucky.

Careful in the Crisis? Determinants of Older People's Informal Care Receipt in Crisis-Struck European Countries

Macroeconomic downturns can have an important impact on the receipt of informal and formal long-term care, because recessions increase the number of unemployed and affect net wealth. This paper investigates how the market for informal care changed during and after the Great Recession in Europe, with particular focus on the determinants of care receipt. We use data from the Survey of Health, Ageing and Retirement in Europe, which includes a rich set of variables covering waves before and after the Great Recession. We find evidence of an increase in the availability of informal care after the economic downturn when controlling for year and country fixed effects. This trend is mainly driven by changes in care provision of individuals not cohabiting with the care recipient. We also find evidence of several determinants of informal care receipt changing during the crisis - such as physical needs, personal wealth, and household structures. Copyright © 2016 John Wiley & Sons, Ltd.

The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011

OBJECTIVES

This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs.

METHODS

We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing.

RESULTS

A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%.

CONCLUSION

Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.

Physician responses to rising local unemployment rates: Healthcare provision to Medicare and privately insured patients

Prior studies suggest that hospital care is countercyclical among Medicare beneficiaries, and if anything, procyclical among the non-elderly. In this paper, we provide the first physician-level analysis of changes in healthcare provision to Medicare and privately insured patients across the business cycle. Using Florida discharge data aggregated to the physician level, we find that as county unemployment rates increase, physicians treat fewer privately insured patients in both inpatient and outpatient settings. In contrast, physicians who are more exposed to income losses during recessions provide more care to Medicare patients as the unemployment rate rises. Further analysis suggests that easing capacity constraints may contribute to this rise in Medicare volume; however, even in areas that are not capacity constrained, care provided to Medicare patients remains countercyclical among physicians with a large share of privately insured patients. This pattern is consistent with demand inducement in response to a negative income shock.

The impact of the macroeconomy on health insurance coverage: evidence from the Great Recession

This paper investigates the impact of the macroeconomy on the health insurance coverage of Americans using panel data from the Survey of Income and Program Participation for 2004-2010, a period that includes the Great Recession of 2007-2009. We find that a one percentage point increase in the state unemployment rate is associated with a 1.67 percentage point (2.12%) reduction in the probability that men have health insurance; this effect is strongest among college-educated, white, and older (50-64 years old) men. For women and children, health insurance coverage is not significantly correlated with the unemployment rate, which may be the result of public health insurance acting as a social safety net. Compared with the previous recession, the health insurance coverage of men is more sensitive to the unemployment rate, which may be due to the nature of the Great Recession.

Health Care Use, Out-of-Pocket Expenditure, and Macroeconomic Conditions during the Great Recession

We study how macroeconomic conditions during the Great Recession affected health care utilization and out-of-pocket expenditures of American households. We use two data sources: the Consumer Expenditure (CE) Survey and the Survey of Income and Program Participation (SIPP); each has its own advantages. The CE contains quarterly frequency variables, and the SIPP provides panel data at the individual level. Consistent evidence across the two datasets shows that utilization of routine medical care was counter-cyclical, whereas hospital care was pro-cyclical during the Great Recession. When we examine the pre-recession period, the relationship between macroeconomic conditions and health care use was either non-existent or in opposite directions, suggesting that this relationship may have been unique to the Great Recession.

Marital Disruption and Health Insurance

Despite the high levels of marital disruption in the United States and the fact that a significant portion of health insurance coverage for those less than age 65 is based on family membership, surprisingly little research is available on the consequences of marital disruption for the health insurance coverage of men, women, and children. We address this shortfall by examining patterns of coverage surrounding marital disruption for men, women, and children, further subset by educational level. Using the 1996, 2001, and 2004 panels of the Survey of Income and Program Participation (SIPP), we find large differences in health insurance coverage across marital status groups in the cross-section. In longitudinal analyses that focus on within-person change, we find small overall coverage changes but large changes in type of coverage following marital disruption. Both men and women show increases in private coverage in their own names, but offsetting decreases in dependent coverage tend to be larger. One surprising result is that dependent coverage for children also declines after marital dissolution, even though children are still likely to be eligible for that coverage. Children and (to a lesser extent) women show increases in public coverage around the time of divorce or separation. We also find that these patterns differ by education. The most vulnerable group appears to be lower-educated women with children because the increases in private, own-name, and public insurance are not large enough to offset the large decrease in dependent coverage. As the United States implements federal health reform, it is critical that we understand the ways in which life course events—specifically, marital disruption—shape the dynamic patterns of coverage.

The US healthcare workforce and the labor market effect on healthcare spending and health outcomes

The healthcare sector was one of the few sectors of the US economy that created new positions in spite of the recent economic downturn. Economic contractions are associated with worsening morbidity and mortality, declining private health insurance coverage, and budgetary pressure on public health programs. This study examines the causes of healthcare employment growth and workforce composition in the US and evaluates the labor market's impact on healthcare spending and health outcomes. Data are collected for 50 states and the District of Columbia from 1999-2009. Labor market and healthcare workforce data are obtained from the Bureau of Labor Statistics. Mortality and health status data are collected from the Centers for Disease Control and Prevention's Vital Statistics program and Behavioral Risk Factor Surveillance System. Healthcare spending data are derived from the Centers for Medicare and Medicaid Services. Dynamic panel data regression models, with instrumental variables, are used to examine the effect of the labor market on healthcare spending, morbidity, and mortality. Regression analysis is also performed to model the effects of healthcare spending on the healthcare workforce composition. All statistical tests are based on a two-sided [Formula: see text] significance of [Formula: see text] .05. Analyses are performed with STATA and SAS. The labor force participation rate shows a more robust effect on healthcare spending, morbidity, and mortality than the unemployment rate. Study results also show that declining labor force participation negatively impacts overall health status ([Formula: see text] .01), and mortality for males ([Formula: see text] .05) and females ([Formula: see text] .001), aged 16-64. Further, the Medicaid and Medicare spending share increases as labor force participation declines ([Formula: see text] .001); whereas, the private healthcare spending share decreases ([Formula: see text] .001). Public and private healthcare spending also has a differing effect on healthcare occupational employment per 100,000 people. Private healthcare spending positively impacts primary care physician employment ([Formula: see text] .001); whereas, Medicare spending drives up employment of physician assistants, registered nurses, and personal care attendants ([Formula: see text] .001). Medicaid and Medicare spending has a negative effect on surgeon employment ([Formula: see text] .05); the effect of private healthcare spending is positive but not statistically significant. Labor force participation, as opposed to unemployment, is a better proxy for measuring the effect of the economic environment on healthcare spending and health outcomes. Further, during economic contractions, Medicaid and Medicare's share of overall healthcare spending increases with meaningful effects on the configuration of state healthcare workforces and subsequently, provision of care for populations at-risk for worsening morbidity and mortality.

State unemployment in recessions during 1991-2009 was linked to faster growth in Medicare spending

During the US recession of 2007-09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991-2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.

Recessions and seniors' health, health behaviors, and healthcare use: analysis of the Medicare Current Beneficiary Survey

A number of studies report that U.S. state mortality rates, particularly for the elderly, decline during economic downturns. Further, several prior studies use microdata to show that as state unemployment rates rise, physical health improves, unhealthy behaviors decrease, and medical care use declines. We use data on elderly mortality rates and data from the Medicare Current Beneficiary Survey from a time period that encompasses the start of the Great Recession. We find that elderly mortality is countercyclical during most of the 1994-2008 period. Further, as unemployment rates rise, seniors report worse mental health and are no more likely to engage in healthier behaviors. We find suggestive evidence that inpatient utilization increases perhaps because of an increased physician willingness to accept Medicare patients. Our findings suggest that either elderly individuals respond differently to recessions than do working age adults, or that the relationship between unemployment and health has changed.

Does uninsurance affect the health outcomes of the insured? Evidence from heart attack patients in California

In this paper, I examine the impact of uninsured patients on the in-hospital mortality rate of insured heart attack patients. I employ panel data models using patient discharge and hospital financial data from California (1999-2006). My results indicate that uninsured patients have an economically significant effect that increases the mortality rate of insured heart attack patients. I show that these results are not driven by alternative explanations, including reverse causality, patient composition effects, sample selection or unobserved trends and that they are robust to a host of specification checks. The primary channel for the observed spillover effects is increased hospital uncompensated care costs. Although data limitations constrain my capacity to check how hospitals change their provision of care to insured heart attack patients in response to reduced revenues, the evidence I have suggests a modest increase in the quantity of cardiac services without a corresponding increase in hospital staff.

The effect of community uninsurance rates on access to health care

OBJECTIVE

To investigate the effect of local uninsurance rates on access to health care for the uninsured and insured and improve on recent studies by controlling for time-invariant differences across markets.

DATA SOURCES

Individual-level data from the 1996 and 2003 Community Tracking Study, and market-level data from other sources, including the Area Resource File and the Bureau of Primary Healthcare.

STUDY DESIGN

Market-level fixed effects models estimate the effect of changes in uninsurance rates within markets on access to care, measured by whether individuals report forgoing necessary care. Instrumental variables models are also estimated.

PRINCIPAL FINDINGS

Increases in the rate of uninsurance are associated with poorer access to necessary care among the uninsured. In contrast with recent evidence, increases in uninsurance had no effect on access to care among the insured. Instrumental variables results are similar, although not statistically significant.

CONCLUSIONS

Changes in rates of insurance coverage are likely to affect access to care for both previously and continuously uninsured. In contrast with earlier studies, there is no evidence of spillover effects on the insured, suggesting that such policy changes may have little effect on access for those who are already insured.

Public and Private Health Insurance Premiums: How Do They Affect the Health Insurance Status of Low-Income Adults? Childless

The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000–2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.

Employer-sponsored health insurance erosion continues in 2008 and is expected to worsen

Although employer-sponsored health insurance (ESI) is the primary source of health coverage in the United States, at 61.9 percent of the under-65 population, the rate of this coverage has decreased every year since 2000, when 68.3 percent had ESI. By 2008, the rate of ESI coverage had fallen 6.4 percentage points, and 5 million fewer people under the age of 65 had ESI in 2008 than in 2000. Because of these large declines in ESI, workers and their families have become uninsured at alarming rates; more than 7.5 million more Americans became uninsured after 2000. Uninsured workers are disproportionately young, Hispanic, lower educated, and lower income; however, workers across all socioeconomic groups have experienced declines in coverage since 2000. Children's coverage also fell 7.0 percentage points over the 2000s, and the gap in ESI access by income substantially widened over this period. The only reason the drop in ESI did not translate into a larger increase in the overall number of uninsured is that 3.4 million additional non-elderly people were covered by public insurance from 2007 to 2008. Because of the rise in unemployment between 2008 and 2010, the number without ESI and without any coverage at all is likely to swell in the coming years.

Hispanics and health insurance coverage: the rising disparity

BACKGROUND

Many reports have focused attention on the rising percentage of adults in the United States without health insurance. This hides the fact that the uninsured rate for non-Hispanic nonelderly adults has held fairly steady since 1983, while the rate for Hispanics has increased.

OBJECTIVES

To document the trends in the coverage rate by source of coverage for different population groups between 1983 and 2003 and suggest how changes in the composition of these groups have contributed to these trends.

RESEARCH DESIGN

We stack panels of the Survey of Income and Program Participation to create a nationally representative 20-year pooled cross-section of nonelderly adults. We calculate actual trends in insurance coverage as well as 2 hypothetical time series that disentangle the effect of the decreasing coverage rate for Hispanics from the growth of the Hispanic adult population.

RESULTS

Although the increase in uninsured rate is largest for Hispanic noncitizens, US-born Hispanics also have a significant upward trend, primarily driven by a decrease in private coverage, with little change in public coverage. Although the increase in the Hispanic population contributed to the increase in the number of uninsured adults, the widening coverage disparity was more important.

CONCLUSIONS

Hispanic nonelderly adults, both US-born and immigrants, have fallen behind non-Hispanic nonelderly adults in insurance coverage. Although combinations of economic growth and private and public insurance policy changes have maintained, and in some cases improved, overall coverage rates for non-Hispanics, these changes have not helped Hispanic adults, leading to increased disparities in coverage.

The effects of recent employment changes and premium increases on adults' insurance coverage

This study uses national survey data from 1997, 1999, and 2002 to estimate a statistical model of the relationships between employment loss, insurance costs, and insurance coverage of nonelderly adults. Simulations based on the model suggest that the large increase in private insurance premiums (about 33 percent in constant dollars) was responsible for 3.1 of the 3.4 percentage-point drop in private insurance coverage between 2000 and 2003. Employment loss has a substantial impact on the coverage of people who lose employment, but its impact on aggregate coverage is relatively small. Expanded public coverage absorbed only about one quarter of the loss of private coverage. Controlling insurance (and medical) cost inflation is critical to expanding insurance coverage, even after the employment rate recovers.