New Releases by Jonathan Gruber

One popular option for health care reform in the U.S. is to make particular groups, such as children, eligible for public health insurance coverage. A key question in assessing the cost of this option is the extent to which public eligibility will crowd out the private insurance coverage of these groups. We estimate the extent of crowdout arising from the dramatic expansions of the Medicaid program during the 1987-1992 period. Over this time period, Medicaid eligibility for children increased by 50 percent and eligibility for pregnant women doubled. We estimate that between 50 percent and 75 percent of the increase in Medicaid coverage was associated with a reduction in private insurance coverage. This occurred largely because employees took up employer-based insurance less frequently, although employers may have encouraged them to do so by contributing less for insurance. There is some evidence that workers dropped coverage for their family and switched into individual policies.

The poor health status of children in the U.S. relative to other industrialized nations has motivated recent efforts to extend insurance coverage to underprivileged children. There is little past evidence that extending eligibility for public insurance to previously ineligible groups will increase health status or even utilization of medical resources. Using data from the Current Population Survey, the National Health Interview Survey, and state-level data on child mortality, we examine the utilization and health effects of eligibility for public insurance. Our models are identified by the recent expansions of the Medicaid program to low income children. We find that these expansions roughly doubled the fraction of children eligible for Medicaid between 1984 and 1992; by 1992, almost 1/3 of all children were eligible. But takeup of these expansions was much less than full even among otherwise uninsured children. Despite this takeup problem, we find that eligibility for Medicaid significantly increased the utilization of medical care along a number of dimensions. Medicaid eligibility was associated with large increases in care delivered in physician''s offices, although there was some increase in care in hospital settings as well. While there was no effect of eligibility on parentally-assessed subjective health measures, we do find notable reductions in child mortality. Finally, we find that rising Medicaid eligibility is associated with reductions in racial disparities in the number of visits and in child disparities in the site at which care is delivered.

Low rates of health insurance coverage among the non-employed have motivated consideration of policies to subsidize the purchase of insurance for those who are without a job. But there is little evidence on the extent to which coverage differentials between the employed and the non-employed reflect the effects of job loss or merely different underlying tastes for insurance. If the latter, subsidies may not be successful in increasing the rate of insurance coverage among the non-employed. Furthermore, subsidies which lower the costs of non-employment may increase both the incidence and duration of joblessness. We provide new evidence on these issues by analyzing longitudinal data on 25-54 year-old men over the 1983-1989 period. We have four findings of interest. First, even after modelling differences in underlying tastes for insurance, the likelihood of insurance coverage drops by roughly 20 percentage points following job separation. Second, limited subsidization of the cost of insurance through state laws mandating continued access to employer-provided health insurance for the non-employed increases the likelihood of having insurance while without a job by 6.7 percent. Third, these mandates also increase the number of individuals with spells of non-employment and the total amount of time spent jobless. Finally, at least some of this increased non-employment appears to be spent in productive job search as the availability of continuation coverage is related to significant wage gains among those who separate from their jobs.

This paper investigates the current tax subsidy to employer- provided health insurance, and presents new evidence on the economic effects of various tax reforms. It argues that previous analyses have overstated the tax subsidy to employer-provided insurance by neglecting the substantial and growing importance of after-tax employee payments for employer-provided insurance, as well as the tax subsidy for extreme medical expenses, which discourages insurance purchase. Even after considering these factors, however, the net tax subsidy to employer-provided insurance is substantial, with tax factors generating an average reduction of approximately thirty percent in the price of this insurance. Reducing the tax subsidy, either by capping the value of employer-provided health insurance that could be excluded from taxation, or eliminating the exclusion entirely, would have substantial effects on the level of employer- provided insurance and on tax revenues.

A key question for health care reform in the U.S. is whether expanded health insurance eligibility will lead to improvements in health outcomes. We address this question in the context of dramatic expansions in the Medicaid eligibility for pregnant women that took place during the 1980s. We build a detailed simulation model of each state''s Medicaid policy during the 1979-1990 period, and use this model to estimate 1) the effect of changes in the rules on the eligibility of pregnant women for Medicaid, and 2) the effect of Medicaid eligibility changes on birth outcomes in aggregate Vital Statistics data. We have three main findings. First, the expansions did dramatically increase the Medicaid eligibility of pregnant women, but did so at quite differential rates across the states. Second, the expansions lowered the incidence of infant mortality and low birthweight; we estimate that the 20 percentage point increase in eligibility among 15-44 year old women was associated with a decrease in infant mortality of 7%. Third, earlier, targeted changes in Medicaid eligibility, such as through relaxations of the family structure requirements from the AFDC program, had much larger effects on birth outcomes than broader expansions of eligibility to all women with somewhat higher income levels. We suggest that the source of this difference was the much lower takeup of Medicaid coverage by individuals who became eligible under the broader expansions. We find that the targeted expansions, which raised Medicaid expenditures by $1.7 million per infant life saved, were in line with conventional.

While efforts to improve the health of the uninsured have focused on demand side policies such as increasing insurance coverage, supply side changes may be equally important. Yet there is little direct evidence on the effect of policies designed to increase the supply of Medicaid services to the poor. We provide such evidence by examining the relationship between infant mortality and the ratio of Medicaid fees to private fees for obstetrician/gynecologists. We build a state and year specific index of the fee ratio for 1979-1992, a period of substantial variation in relative Medicaid fees. We find that increases in fee ratios are associated with significant declines in the infant mortality rate. We also find that higher fees raise payments made to physicians and clinics under the Medicaid program, but reduce payments to hospitals. Finally, we compare the cost effectiveness of reducing infant mortality by increasing fee ratios to the efficacy of reducing mortality by expanding the Medicaid eligibility of pregnant women. Although our results are sensitive to the time period used, we conclude that raising fee ratios is at least as cost effective as increasing eligibility.

The ''induced demand'' model states that in the face of negative income shocks physicians may exploit their agency relationship with patients by providing excessive care in order to maintain their incomes. We test this model by exploiting an exogenous change in the financial environment facing obstetrician/gynecologists during the 1970s: declining fertility in the U.S. We argue that the 13.5% fall in fertility over the 1970-1982 period increased the income pressure on ob/gyns, and led them to substitute from normal childbirth towards a more highly reimbursed alternative, cesarean delivery. Using a nationally representative micro-data set for this period, we show that there is a strong correlation between within state declines in fertility and within state increases in cesarean utilization. This correlation is robust to consideration of a variety of alternative hypotheses, and appears to be symmetric with respect to periods of fertility decline and fertility increase.

Disability Insurance (DI), which provides income support to disabled workers, has been criticized for inducing a large fall in the labor force participation rate of older workers. We study the effects of one policy response designed to address this moral hazard problem: raising the rate at which DI claims are denied. Initial DI applications are decided at the state level, and, in response to a funding crisis for the DI program in the late 1970s, the states raised their rejection rates for first time applicants by 30% on average. The extent of this rise, however, varied substantially across states. We use this variation to estimate a significant reduction in labor force non-participation among older workers in response to denial rate rises. A 10% increase in denial rates led to a 2.7% fall in non- participation among 45-64 year old males; between 1/2 and 2/3 of this effect is a true reduction in labor force leaving, with the remainder accounted for by the return to work of denied applicants. We find some support for the notion that increases in denial rates effectively target their incentive effects to more able individuals; the fall in labor force non-participation was much stronger among more able workers, according to an anthropometric measure of disability.

The link between health insurance and the workplace in the U.S. has led to concern over the possibility of insurance-induced reductions in job mobility or ''job-lock". Designing health insurance reforms which retain employer-based insurance coverage but mitigate the extent of job-lock requires an understanding of the policy dimensions to which job-lock is most receptive. We study a policy of limited insurance portability which has been adopted by a number of states and the federal government over the last 20 years. These "continuation of coverage'' mandates grant individuals the right to continue purchasing health insurance through their former employers for some period of time after leaving their jobs. We find that the passage of these mandates caused a significant increase in the job mobility of prime age male workers. This suggests that a sizeable share of job-lock arises from short run concerns over portability rather than from long run problems

The Tax Reform Act of 1986 introduced a new tax subsidy for health insurance purchases by self-employed persons. This paper analyzes the changing patterns of insurance demand before and after this reform to generate new estimates of how the after tax price of insurance affects the discrete choice of whether to buy insurance. We employ both traditional regression models for insurance demand, in which after-tax price of insurance is an explanatory variable. as well as nonparametric tests that compare changes in insurance purchases by self-employed individuals with the coincident changes for other groups. Our analysis suggests that I one percent increase in the cost of insurance coverage reduces the probability that a self-employed household will be insured by as much as 1.8 percentage points.

Although the vast majority of working individuals aged 55-64 receive health insurance coverage through their employment, many of these individuals face the prospect of losing such coverage should they retire before becoming eligible for guaranteed public coverage through Medicare at age 65. Because the expected medical expenses of this group are large and uncertain, the availability of health insurance coverage after retirement could be a key factor in the retirement decision of older workers. We examine the effect of health insurance on retirement by looking at variation in state and federal ''continuation of coverage'' mandates, laws which allow individuals to continue purchasing health insurance through a previous employer for a specified number of months after leaving the firm. By allowing individuals to maintain their employer-provided health insurance after retirement, these laws decrease the cost of early retirement for those who do not have other retiree health insurance available. Using data on 55-64 year old men from the Current Population Survey, we find that one year of continuation benefits increases the probability of being retired by 1 percentage point; this represents a 5.4 percent increase in the baseline probability of being retired for this group. We also find that continuation mandates increase the likelihood of being insured after retirement.

One popular explanation for this low rate of employee coverage is the presence of numerous state regulations which mandate that group health insurance plans must include certain benefits. By raising the minimum costs of providing any health insurance coverage, these mandated benefits make it impossible for firms which would have desired to offer minimal health insurance at a low cost to do so. I use data on insurance coverage among employees in small firms to investigate whether this problem is an important cause of employee non-insurance. I find that mandates have little effect on the rate of insurance coverage; this finding is robust to a variety of specifications of the regulations. I also find that this lack of an effect may be because mandates are not binding, since most firms appear to offer these benefits even in the absence of regulation.

Workers'' compensation insurance provides cash payments and medical benefits to workers who incur a work-related injury or illness. Many features of the workers'' compensation program parallel features of proposed mandated employer-paid health insurance plans. This paper empirically examines the incidence of the workers'' compensation program to infer the likely consequences of mandated health insurance proposals. In certain industries, such as trucking and carpentry, workers'' compensation insurance costs are quite large, and vary tremendously within states over time, and across states at a moment in time. This variation is used to identify the incidence of the program. Empirical analysis of two data sets suggest that changes in employers'' costs of workers'' compensation insurance are largely shifted to employees in the form of lower wages. In addition, higher insurance costs are found to have a negative but statistically insignificant effect on employment. The implied elasticity of labor demand from our results is about -.50.