《健康经济学》课件Chapter18

TheAmericanmodelUnlikeeveryotherdevelopedcountry,theUnitedStateslacksuniversalguaranteedinsuranceforallcitizens.Nevertheless,mostAmericansfindinsurancecoveragethroughoneofthesethreeavenues:employer-basedinsurance,MedicareandMedicaid.ThismixofprivateandpublicinsuranceisahallmarkoftheAmericanmodel.TheAmericanmodelMajorcharacteristics:

Privatehealthinsurancemarkets:Thenon-elderlyandnon-poorseekinsuranceontheprivatemarket,whichiscenteredaroundemployer-basedhealthinsurancepools.Partialuniversalhealthinsurance:Subsidizeduniversalhealthinsuranceisprovidedtotwovulnerablesubpopulations:theelderly(throughMedicare)andthepoor(throughMedicaid).

Privatehealthcareprovision:

Mosthospitalsanddoctor’sclinicsareprivate.Whilethereissomeantitrustregulation,therearefewlegalrestrictionsonwheredoctorscanpracticeandhospitalscanopen.Therearealsonodirectpricecontrolsenforcedbythegovernment.TheAmericanmodelTheAmericanmodelreflectsapoliticalpreferenceforlibertyandfreechoice.Patients(usually)havefreechoiceof:DoctorHospitalInsuranceplanDoctors(usually)havefreechoiceof:PricestochargeWheretopracticeWhomtotreatCh18|TheAmericanmodelEMPLOYER-SPONSOREDHEALTHINSURANCEEmployer-sponsoredhealthinsuranceMostinsurednon-elderlyAmericansreceivecoveragethroughemployer-sponsoredplans.Thisinsuranceisnot“free”,sinceitisactuallypartoftheworker’stotalcompensationpackage.Thecostofpremiumsaretakenoutoftheworker’swages.Thefactthatthecostsofinsuranceeffectivelycomeoutoftheworker’swagesisknownaswagepass-through.Soforthesametypeofjobandskill-level,jobswithoutemployer-sponsoredinsuranceplansmayofferhigherwagesthanjobswiththem.Employer-sponsoredhealthinsuranceEmployer-sponsoredinsurancecombatsadverseselectionbyprovidingareasonforemployeestopooltogether.However,notallmembersofanemployer-sponsoredplanaretogetherinasinglepool.Example:Considerafirmwithfouremployees,twoofwhomareyoungandtwoofwhomareold.Theyoungeremployeeshavelowerexpectedhealthcarecoststhantheoldertwo.Therefore,thisfirmwouldlikelyusewagepass-throughto“charge”olderemployeesmorefortheirhealthinsurance(throughforgonewages).Meanwhile,theyoungerworkerspayless,sotheyarelesstemptedtoleaveforotherfirms.DifferentialwagepassthroughDifferentialwagepass-throughcanoccurwheneveremployerscanobserveelevatedhealthrisksamongtheiremployees.Technically,passinglowerwagesthroughtosickerworkersisillegalintheUS,butwagediscriminationisdifficulttodetect,andthereisevidencethatpeoplewhohavehigherexpectedmedicalexpendituresdoearnless.DifferentialwagepassthroughExamplesMaternitybenefits:Womenofchildbearingagesawtheirsalariesfallrelativetobothmenandolderwomenintheyearsfollowingthepassageofa1976lawmandatingmaternitycarecoverageforemployer-sponsoredinsuranceplans.Obesity:injobswithemployer-sponsoredhealthinsurance,theobeseearnmuchlessthantheirthincoworkers.Injobswithnoinsurance,theobeseandthinearnaboutthesamewage.Firm-specifichumancapitalWhydon’ttheseemployerpoolshaveadverseselectionproblems?Ifhealthyworkerscouldfinddesirablenewjobselsewherewheretheydonotsubsidizeunhealthycolleagues,thentheyhaveeveryincentivetoleavetheircurrentjobs.Sowhydohealthyemployeesstayintheirjobs,evenwhentheyaresubsidizingtheirunhealthyco-workers?Firm-specifichumancapitalFirm-specifichumancapital:knowledgeandexperiencegainedfromworkingataparticularfirmthatishighlyrelevanttherebutirrelevantatothercompanies.Workerswithfirm-specifichumancapitalcanbemuchmoreproductiveattheirfirmthananywhereelse.Theaccumulationoffirm-specifichumancapitalcanmeanthatanemployeewhoisinvaluabletoonefirmwouldbejustmediocreatanotherfirm.Ifso,wagestheworkerearnsinhercurrentjobwouldexceedwhatshecouldearnatanothercompany.JoblockSoemployer-sponsoredhealthinsurancecombatsadverseselection,butitcanalsohinderjobmobility.Theconfluenceofemployer-sponsoredhealthinsurance,wage-passthrough,andstickywagesisknownasjob-lock.Throughjoblock,employer-sponsoredhealthinsurancedistortslabormarketsandcanreducesocialwelfare.JoblockExample:Consideranemployeewhoisboundtoawheelchairbymultiplesclerosis(MS).Despitehishigherhealthcarecosts,hiswageshavenotbeencutbecauseof“wagepass-through”sincehisdiagnosis(hiscompanywouldhavebeensued).Supposethisemployeewouldbeabetterfitforanewjobopportunityelsewhere.However,hispotentialnewemployer,observinghiswheelchair,lowershisofferedwagetocompensateforananticipatedriseinhealthcarepremiums.Thislowerofferdeterstheworkerfromswitchingjobs,andhestays–unhappilyandinefficiently–athiscurrentone.JoblockThisworkerwouldbemoreproductiveatanewjob,soitwouldbesociallyefficientforhimtoswitch.Butjoblockdiscourageshimfromdoingso.Whilejob-lockreducesvoluntaryemployeeturnoverrateby25%,thetotalcostofjoblockintheU.S.ismodest,lessthan0.1%ofGDP.Thesociallossfromjoblockmaybethismodestbecauseofpoliciesaimedatmitigatingtheharmcausedbyjoblock.Example:TheCOBRAActof1985Ch18|TheAmericanmodelTHEMANAGEDCAREALTERNATIVEThefee-for-servicemodelInthemiddleofthe20thcenturyandintothe1980s,theU.S.privateinsurancemarketwasdominatedbyindemnityinsurance.Thistypeofinsuranceisalsoknownasfee-for-service(FFS)becausecustomersreceivehealthcare,andthentheinsurancecompanypaysthedoctororhospitalafeeforeachservicerendered.Coverageforspecifictreatmentswasrarelydenied,evencostlyonesthatprovidedminimalbenefits.Thefee-for-servicemodeldidlittletocontainmoralhazard,andprovidedampleincentiveforphysician-induceddemand.ThestoryofKaiserPermanenteTheKaisermanagedcareplanbeganasacommunalinsurancepoolforworkersinCaliforniashipyardsduringWorldWarII.HenryKaiserrealizeditwouldbecheapertoprovidemedicalcareforhisemployeesdirectly,ratherthanpayingforitatoutsidehospitals.InthedecadesafterKaiserPermanentewasfounded,moreinsurersbeganofferingmanagedcareplans.Customersandpolicymakersaliketooknoticeoftheirapparentcostsavings.Whatismanagedcare?Managedcare:aphilosophyofhealthinsurancethatemploystacticsintendedtoreducemoralhazard,physician-induceddemand,andpremiums.Thesetacticsinclude:gatekeeping–patientscanonlyvisitspecialistsorsurgeonsafterreceivingapprovalfromaprimarycaredoctor.coveragenetworksandverticalintegration–patientscanonlyreceivecarefromaspecifiedlistofproviders.monitoring–doctorsandhospitalsaremonitoredforcostsandhealthoutcomes.salariesandfixedpayments–theinsurerpaysafixedamountforcare;notfee-for-service.denialsofcoverage–caremaynotbecoveredifitisnotcost-effective.TheriseofmanagedcareA1973federallawestablishedthetermhealthmaintenanceorganization(HMO)todenotevertically-integratedmanagedcareorganizationslikeKaiserPermanente.Anothertypeofmanagedcareoptionisthepreferredproviderorganization(PPO).APPOisalessrestrictiveversionofanHMOthatdoesnotintegrateinsurerandprovider.U.S.consumersandemployershavegraduallymigratedfromexpensivefee-for-serviceinsurerstowardcheapermanagedcareHMOsandPPOsDoesmanagedcarework?GottfriedandSloan(2002)findthatthereisnosystematicdifferenceinhealthoutcomesbetweenmanagedcareorganizationsandfee-for-serviceplans.Althoughoutcomesareworseforvulnerablepopulations(poor,sick,disabled)Managedcareorganizationsdokeepcostslower.Ingeneral,managedcarepatientsarehospitalizedlessoftenandundergofewerexpensivetests.ThereisalsoevidencethatmanagedcarehasslowedtheproliferationofexpensivetechnologieslikeMRImachines.Doesmanagedcarework?Oneimportantcaveatisthatmanagedcareplanstendtoattracthealthiercustomersduetoadverseselection.Ifthisisthecase,managedcaremightbereducingcostssimplybecausetheircustomersarehealthier.Aninterestingsidenoteisthatacademicresearcherswhostudymanagedcareprofessionallyarelesslikelytopersonallyenrollinmanagedcareplansthemselves.Ch18|TheAmericanmodelMEDICARETheUSMedicareprogramMedicareisagovernmentinsuranceprogramthatprovidesinsurancecoverageto48millionelderlyanddisabledpeople(asof2012).TheMedicareprogramconsistsoffourparts:PartApaysforenrollees’hospitalcare.PartBpaysforoutpatientcareandphysicianservices.PartCprovidesanoptionforMedicareenrolleestoreceivetheirhealthinsurancefromaprivateplan,ratherthanthroughPlansAandB.PartDpaysforenrollees’prescriptiondrugs.TheUSMedicareprogramAllAmericancitizensover65yearsofage,andseverelydisabledAmericanswhohavebeenoutofworkfortwoyears,areeligibletoenroll.Medicareisexpensivebecauseitcoverspopulationsthatarelesshealthythanthegeneralpopulation,whichtendtodemandlotsofmedicalcare.Italsoreimbursesforanyprocedurethatisshowntobemedicallyeffective,irrespectiveofcost.Finally,itsetspremiumsfarbelowanactuariallyfairlevel.Thismeansitneedslargeoutsidesourcesoffunding(taxesontheyoung).CostcontrolinMedicareMedicareincludesseveralmechanismsdesignedtomitigatemoralhazardandcontrolcosts.InbothMedicarePartsAandB,patientsfacecost-sharingrequirements,includingdeductiblesandcopaymentsforoutpatientvisitsandhospitalstayslongerthan60days.However,mostMedicareenrolleesalsopurchaseprivatesupplementalinsurance,calledMedigapplans,whichpayforenrollees’deductiblesandcopayments,andtherebyundercutsthemoralhazardmitigationeffectsofcost-sharing.CostcontrolinMedicareAmoresignificantcostcontrolmechanismistheDiagnosisRelatedGroup(DRG)system.Underthissystem,Medicarepaysafixedamounttohospitalsbaseduponthediagnosisthepatienthaswhenadmittedtothehospital,ratherthanonhislengthofstayortheextentofcaregiven.TheDRGsystemofhospitalpaymenttransfersriskfromthegovernmenttohospitalsandeliminatesincentivesforhospitalstoprovideunnecessarilyexpensivecaretopatients.ProspectivepaymentsCost-effectivenessanalysisFinally,thereisamajorcostcontroltoolthatMedicareisprohibitedfromusing:cost-effectivenessanalysis.Anytreatmentthatisproveneffectiveinscientificstudies–regardlessofcost–iscoveredbyMedicare.ItseemslikelythatMedicarecouldreapsubstantialbudgetarysavingsfromCEA,butsofartherehasbeenlittlepoliticalwilltointroduceCEAintoMedicare’scoveragedeterminations.Ch18|TheAmericanmodelMEDICAIDMedicaidMedicaidisapublicinsuranceprogramthatprovideshighlysubsidizedinsurancecoveragetolow-incomefamilieswhohavenoinsurance.UnlikeMedicare,whichisrunbytheU.S.federalgovernmentandadministereduniformlyacrossthecountry,Medicaidisrunjointlybythefederalandstategovernments.Stategovernmentshavewidelatitudetosetbudgets,determineeligibilityrulesanddecidehowgeneroustheirlocalMedicaidprogramis.Asaconsequence,Medicaidcoverageandgenerositycanvarysubstantiallyfromstatetostate.MedicaidIn2009,Medicaidcovered62.5millionpeople–aboutafifthoftheU.S.population–anditsexpensestotaledabout$400billionnationwide.LowincomealonedoesnotqualifyoneforMedicaidinmoststates.Variousotherfactorsincludingmartialstatus,numberofchildren,pregnancy,disability,healthandimmigrationstatuscanaffecteligibility.Ingeneral,able-bodiedindividualswithoutchildrenarenoteligibleforcoverage,nomatterhowlowtheirincomes.CostcontrolinMedicaidCost-sharingburdensforMedicaidenrolleesaretypicallyverylow,soMedicaidprogramsmustcontaincostsandcurbmoralhazardwithacombinationofeligibilityandcoveragerestrictions.OnewaythatstatescontrolMedicaidexpendituresisbysettingreimbursementratesatalowlevel.AdoctortreatingaMedicaidpatientreceivesonlyafractionofthepaymentshewouldgetforseeingasimilar,butprivately-insured,patient.Asaresult,Medicaidpatientscanhavetroublefindingaregularsourceofcare,asmanydoctorschoosenottoacceptMedicaidpatients.CostcontrolinMedicaidStatesalsocontrolcostsbyrestrictingthesetofprescriptiondrugsavailabletoMedicaidenrollees,andbysettingreimbursementratesatalowlevel.Thelistofdrugsavailableoftenexcludesexpensivebrandeddrugswhengenericalternativesareavailable.Somestateshavealsoexperimentedwithotherformsofcostcontainment,includingexplicitcost-effectiveanalysis.WorkdisincentiveeffectsofMedicaidWhileMedicaidcertainlyimproveshealthequity,italsoreduceseconomicefficiency.Medicaideligibilityrulescreateadisincentivetoworkashardaspossible,becauserisingincomescanmeandisqualificationfromMedicaid.Ch18|TheAmericanmodelUNINSURANCEUninsuranceAsof2012thereare50-60millionpeopleintheU.S.whoarenotcoveredbyanyhealthinsuranceprogram,andaretermeduninsured.Theuninsuredcanpayformedicalcareout-of-pocket,buttheyfacetheriskofcatastrophichealthbillsandoftenendupdeferringcareuntilitbecomesanemergency.ThepersistenceofuninsurancehasbeenakeydriverofhealthpolicyreformintheU.S.Whydon’tBeveridgeandBismarcksystemshavethisproblem?Ch18|TheAmericanmodel2010HEALTHREFORM2010healthreformInMarch2010,theUScongresspassedthePatientProtectionandAffordableCareAct(PPACA),colloquiallyknownas“Obamacare.”Mostpartsofthelawareslatedtogointoeffectin2014.Thelawhasthousands