March 2009

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Daniel Wiesen and Jason Shafrin ask you to participate in an economic survey.  By completing the survey, you will help advance the science of economics.  Further, if you complete the survey by March 20, you will be made eligible to win a $25 gift card to Amazon.   To take the survey click on this link or paste the following text into your Internet browser: http://webex.bonneconlab.uni-bonn.de/Prud_Prev/1a_reg.php

The survey contains 50 questions and will take about 20-30 minutes to complete.  By participating in the survey, you will help Daniel and Jason complete their dissertation research.  

If you have any questions, please feel free to email either Daniel Wiesen (daniel.wiesen@uni-bonn.de) or Jason Shafrin (jshafrin@ucsd.edu).

In 2004, 29% of Medicare enrollees had Medigap coverage.  Are these policies priced efficiently?

An NBER paper by Maestas, Schroeder and Goldman (2009) argues that the answer is no.  

Prior to July 1992, Medigap was minimally regulated.  With the passage of the Omnibus Budget Reconciliation Act of 1990 (implemented in July 1992), Medigap plans were standardized.  Each plan fell into one of ten types–labelled plans A though J. Medigap plans are basically identical within each type.  Further, since Medicap is a reinsurer–Medicare provides primary coverage–medical care quality is identical across plans.  

Because of this homogeneity, one would expect to see small variations in Medigap plan prices.  Maestas, Schroeder and Goldman, however, find significant price variation persists.  One reason for this price variation is high search costs.  Average search costs in the Medigap market are $72.  Further, the authors conclude that:

…the extensive (and perhaps overwhelming) array of unique options available, the elevated incidence of cognitive limitations among older individuals, and the high costs associated with fixing ‘wrong’ choices, all lead to a setting in which ‘choice overload’ is likely to prevail.  To compensate, individuals turn to others whom they perceive to be experts:  insurance agents.  As we show, agents sell the vast majority of policies in the market but do not necessarily steer buyers to the best policies.

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Daniel Wiesen and Jason Shafrin ask you to participate in an economic survey.  By completing the survey, you will help advance the science of economics.  Further, if you complete the survey by March 20, you will be made eligible to win a $25 gift card to Amazon.   To take the survey click on this link or paste the following text into your Internet browser: http://webex.bonneconlab.uni-bonn.de/Prud_Prev/1a_reg.php

The survey contains 50 questions and will take about 20-30 minutes to complete.  By participating in the survey, you will help Daniel and Jason complete their dissertation research.  

If you have any questions, please feel free to email either Daniel Wiesen (daniel.wiesen@uni-bonn.de) or Jason Shafrin (jshafrin@ucsd.edu).

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Penelope Trunk doesn’t believe in grad school.

The Kaiser Family Foundation that says 59% of people think health reform would make the country better off and only 12% thought health reform would make the country worse off.  This seems like overwhelming support.  However, how only 38% of people thought health reform would make themselves and their family better off compared to 11% who think health reform would make them and their families worse off.   Forty-five percent of respondents thought that health reform would make no difference in their family’s overall welfare.

Will voters support “what is best for the country” or what is “best for themselves and their family”?  I would guess that most people would vote selfishly despite their health reform preference for the country as a whole.

Nevertheless, “a poll conducted by Time/CNN/Yankelovich in September 1993 — just before the Clinton health plan was formally introduced — found the public much more conflicted than today, with 20% saying they thought the plan would make them and their family better off, 21% saying they would be worse off, and 57% believing they would be unaffected.”

Looks like health reform is gaining public support slowly but surely.

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Does Social Security work?  By that, I mean does giving elderly individuals a government pension increase their level of income, the amount of goods the can consume, or even their happiness?

An NBER working paper by Baker, Gruber and Milligan (2009) tries to answer this question in the Canadian setting.

Background

Currently, Canadian income transfer programs to seniors make up 2.3% of GDP, but this figure is expect to rise to 3.2% of GDP by 2030.  Unlike Social Security in the U.S., the pay-as-you-go (PAYGO) component of the Canadian Social Security System if fairly small.  Further, population growth in Canada is higher than in Europe making the old-age income transfer programs more solvent.

The Old Age Security (OAS) program is the oldest elderly income transfer program in Canada.  It was enacted in 1952.  Currently, “the monthly benefit paid to individuals who fully satisfied the residency requirement was $479.83.   This benefit is clawed back from higher income pensioners at a 15 percent rate, starting at incomes of $60,806 (2005).  Benefits are full indexed to the CPI and fully taxable under the Income Tax Act.”

The Guaranteed Income Supplement (GIS) is a means-tested income supplement for elderly individuals with low income.  Benefits are taxed back at a 50% rate.  The current enefit is between $370 and $570.  

The Canadian Pension Plan (CPP) and Quebec Pension Plan (QPP) are finance by contributions from employers and employees.  Individuals pay a 4.95% tax on earnings from $35,00 to $41,100 and benefits are based on a measure of average earnings over the individual’s working life.  Participants can claim benefits at age 60, but the benefit level is increased by 0.5% per month if the benefits are claimed at an older age.

Data

 The authors aim to investigate how changes in the programs described above affect the income, consumption and happiness level of individuals in different birth cohorts. These measures are taken from survey data from Statistics Canada.  Income data comes from the Survey of Consumer Finances (1971-1997) and the Survey of Labor and Income Dynamics (1998-2002).  Consumption data comes from the Family Expenditure Survey (1969-1996) and the Survey of Household Spending (1997-2002).  Happiness is measured by the General Social Survey.

  • For more details on the Canadian Social Security System, see my post from 4 July 2006.

Methodology

If there are time trends in elderly income and consumption, how does one identify the impact of the Canadian Social Security?  The authors use changes in Canadian Social Security legislation to identify this impact.  The regression methodology has 3 specifications:

  1. Regress actual retirement benefits on the dependent variables (income, consumption and happiness).
  2. Partial Simulation. In this approach, the authors hold constant the earnings, capital income, and family status of the individual, but allow the retirement age to vary.  Benefits are based on a fixed earnings histories across all birth cohorts, not actual earnings.
  3. Full Simulation.  In this case, earnings, capital income, family status, and retirement age are held constant and the authors calculate simulated benefits levels based on an average earnings histories and retirement ages across all cohorts.

Results

In general, the authors find that a higher Social Security benefit increases elderly income.  In the full simulation and when simulated benefits are used as an instrument for actual benefits, Social Security income benefits increase elderly income benefits dollar-for-dollar.  Further, elderly income poverty decreased significantly when more generous benefits were enacted; the authors claim that 96% of the reduction in elderly poverty is due to these added benefits.  However, in the partial simulation methodology, the authors find that a $1 increase in benefits leads to only a $0.55 cent increase in elderly income, thus indicating significant crowd-out.  

For consumption, the authors also find that more generous income benefits increase elderly consumption levels, but not dollar for dollar.  A $1 increase in benefits leads to a $0.66-$0.80 increase in consumption, thus indicating some crowd-out.  Unlike for the case of elderly income poverty, more generous Social Security benefits did not affect consumption poverty.  Thus, it may be the case that poor elderly individuals have other sources of consumption (e.g., purchase by family members, unreported income gifts from family members, unreported labor income) that may offset lower government supplied income benefits. 

“For the very happy question, we see no sign of a statistically significant relationship between benefits and being very happy.  On the other hand, there is some evidence of a decrease in reports of being unhappy or very unhappy with higher benefits in the reduced form results, but not in the IV results.”

Healthcare Economist’s Take

This paper indicates that more generous income benefits do increase income and consumption for the elderly.  Social Security benefits create more crowd-out in the case of consumption than income.  It is likely that consumption is a better indicator of well-being, especially since elderly savings is very low (i.e., the elderly are generally spending down their assets than building them up).  While income poverty declined due to these income benefits, consumption poverty did not.  Overall, I would say that these program do help increase elderly well-being, but likely not dollar for dollar.  As the authors note, this paper only looks at the benefits of Social Security without taking into account the costs of raising a significant amount of revenue to pay for these government program.

I will not comment on the happiness measure.  Although many people may think it is the government’s job to make individuals happier, I believe that happiness is determined on an individual level and often based on things the government can’t control (e.g., do you get along with your spouse, has their been a death in the family).  Further, happiness is often measured by comparing your emotional feelings against some status quo.  Thus, a poor family would be very happy to have their income increased to $80,000, but a millionaire would be very disappointed.  

I think this paper makes an important contribution showing that government old age income benefits do increase income and consumption, even if there is some crowd out on the consumption side.  The question for me is less whether or not there should be some government benefit, but more about how generous it should be and whether it should serve only the poor or all elderly.

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Healthcare Europa reports that despite being in a public healthcare system, many physicians receive informal payments to supplement their income.

“The top doctors, the ones in managerial positions in hospitals, make 5-10 times their monthly salaries of Euros 1,000 to Euros 2,000 from informal payments. They will also take bribes on any new equipment or facilities – 10% is the going rate.”

From conversations with some Chinese friends, I have heard that in China, it is also common for patients to pay physicians informally in exchange for quicker service or access to better physicians.  If these payments are unreported, this may underestimate the true cost of running a public health insurance system.

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In the Netherlands, the Health Insurance Act of 2006 mandates that all individuals have health insurance.  Health insurance is provided by the private sector and these private health insurers can charge any premium they please.  The government does provide some risk-adjusted payment to the insurance companies.  This means that the state gives insurance company more money if they take on sicker individuals.  Further, the state subsidies the cost of health insurance premiums for poor individuals.   Insurers are driving down prices by setting up their own pharmacies and primary care centers, and beginning to create preferred provider organizations.

In an earlier post, I wrote that the Dutch system could be a viable health reform option in the U.S.  A recent editorial in Health Economics, however, argues that the Dutch health reform is not complete.   Although there individuals have free choice between insurer they choose, insurers ability to negotiate prices with providers is severely limited.  For instance,

  • “in the hospital sector, most prices are still derived from a fixed global budget and are the same for all insurers.”
  • Insurers are responsible for the cost of building new facilities.  Only after they receive government approval will they be reimbursed for construction costs.  This creates significant uncertainty as to the cost effectiveness of plan hospital facility expansions.
  • Preferred-provider structures are still in a basic state because of much uncertainty as to provider quality.  However,there has been some progress in terms of quality measurement.  ”The Health Care Inspectorate (IGZ) started to develop a basic set of hospital performance indicators about quality (including structure, process and outcome indicators), safety, efficiency and accessibility, in cooperation with the hospitals and medical specialists…the Netherlands Health Insurers Association since 2006 annually publishes a guide with hospital performance indicators.”
  • Another reason for the limited use of preferred-provider contracts is consumer and provider backlash.  Both groups are weary of limitations to patient choice of provider.
  • Another impediment to reform is that most of the insurers hospital costs are eventually reimbursed by the government.  Although this protect insurers from catastrophic losses for a few very sick patients, insurers’ competitive advantage should be in measuring risk.  Further, if insurers are not on the hook for the downstream hospital costs, it gives them less of an incentive to improve the quality of care and reduce hospitalizations.

There are some positive developments.  The Dutch government began using Diagnosis Treatment Combinations (DTC) to pay insurers for patient hospitalizations.   This payment system–similar to the DRG system used in the U.S.–replaced per diem rates and gives an incentive to insurers to decrease the number of days an individual is hospitalized.

The Dutch health care reforms have made significant progress towards moving the country towards a “managed competition” model.  Despite the positive effects of many reforms, there remains significant room for improvement.

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