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In a recent paper, professor John Nyman revisits an issue that has been central to much of the literature in health economics in recent years, namely the trade-off between the gains from insurance, on the one hand, and the efficiency losses from the moral hazard effect that arises as a result of the implicit subsidy to health services utilization under conventional insurance plans, on the other. The result, according to Nyman, has been a tendency in the health policy debate to put too much emphasis on insurance plan features such as consumer cost and provisions to control utilization in managed-care plans. One of the principal points in Nyman's paper is that the conventional approach underestimates the gains from insurance because it fails to take into account what can be termed the "affordability" effect: that certain interventions are so costly that, in the absence of insurance, the individual would have to go without them, even if they potentially would have very large health benefits.

In this paper, I estimate the impact of city-level public health regulations in the market for cow's milk on the mortality of infants and young children between 1900 and 1920. I find that the introduction of city-level dairy farm inspections reduced mortality from Diarrhea & Enteritis for one-year-old children by 1.3 annual deaths per thousand, a 14 percent effect relative to the baseline rate for this cause and a 3 percent effect relative to the baseline rate for all causes for this age group. Back-of-the-envelope calculations reveal that the benefits from these regulations exceeded costs by at least a factor of two., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Seasonal infectious diseases can cause demand and supply pressures that reduce the ability of healthcare systems to provide high-quality care. This may generate negative spillover effects on the health outcomes of patients seeking medical help for unrelated reasons. Separating these indirect burdens from the direct consequences for infected patients is usually impossible due to a lack of suitable data and an absence of population testing. However, this paper finds robust empirical evidence of excess mortality among non-COVID-19 patients in an integrated public healthcare system: the English National Health Service (NHS). Analysing the forecast error in the NHS' model for predicted mortality, we find at least one additional excess death among patients who sought medical help for reasons unrelated to COVID-19 for every 42 COVID-19-related deaths in the population. We identify COVID-19 pressures as a key driver of non-COVID-19 excess mortality in NHS hospitals during the pandemic, and characterize the hospital populations and medical conditions that were disproportionately affected. Our findings have substantive relevance in shaping our understanding of the wider burden of COVID-19, and other seasonal diseases more generally, and can contribute to debates on optimal public health policy. [ABSTRACT FROM AUTHOR]

This paper empirically examines the consumer welfare implications of changes in government policies related to patent protection and compulsory licensing in the Indian market for oral anti-diabetic (OAD) medicines. In contrast to previous studies on the impact of pharmaceutical patents in India, we observe, and estimate the welfare effects accruing from differential pricing and voluntary licensing strategies of patent-holding innovator firms. Three novel molecules belonging to the dipeptidyl peptidase-4 (DPP-4) inhibitor class of OADs have been launched in India by the patent holders, at lower prices than those prevailing in the developed countries. Using aggregate market transaction data, we structurally estimate demand and supply and use the parameter estimates in our model to simulate consumer welfare under various counterfactual scenarios. Our results suggest that the introduction of DPP-4 inhibitors generated a consumer surplus gain of around 7.6 cents per day for a typical DPP-4 inhibitor user under the existing differential pricing and voluntary licensing strategies. If the innovators decide to price at developed-country levels, this surplus is eliminated almost entirely. The issuance of compulsory licensing does not always improve consumer welfare because if innovators defer or delay the introduction of new drugs in response, the loss in consumer welfare could be substantial., (Copyright © 2015 Elsevier B.V. All rights reserved.)

This paper is the first to apply prospect theory to societal health-related decision making. In particular, we allow for utility curvature, equity weighting, sign-dependence, and loss aversion in choices concerning quality of life of other people. We find substantial inequity aversion, both for gains and losses, which can be attributed to both diminishing marginal utility and differential weighting of better-off and worse-off. There are also clear framing effects, which violate expected utility. Moreover, we observe loss aversion, indicating that subjects give more weight to one group's loss than another group's gain of the same absolute magnitude. We also elicited some information on the effect of the age of the studied group. The amount of inequity aversion is to some extent influenced by the age of the considered patients. In particular, more inequity aversion is observed for gains of older people than gains of younger people., (Copyright © 2015 Elsevier B.V. All rights reserved.)

This paper studies the cross-border health and productivity effects of alcohol taxes. We estimate the effect of a large cut in the Finnish alcohol tax on mortality, alcohol-related illnesses and work absenteeism in Sweden. This tax cut led to large differences in the prices of alcoholic beverages between these two countries and to a considerable increase in cross-border shopping. The effect is identified using differences-in-differences strategy where changes in these outcomes in regions near the Finnish border are compared to changes in other parts of northern Sweden. We use register data where micro level data on deaths, hospitalisations and absenteeism is merged to population-wide micro data on demographics and labour market outcomes. Our results show that the Finnish tax cut did not have any clear effect on mortality or alcohol-related hospitalisations in Sweden. However, we find that workplace absenteeism increased by 9% for males and by 15% for females near the Finnish border as a result of the tax cut., (Copyright © 2014 Elsevier B.V. All rights reserved.)

This paper studies the role of Medicare's premium policy in sorting beneficiaries between traditional Medicare (TM) and managed care plans in the Medicare advantage (MA) program. Beneficiaries vary in their demand for care. TM fully accommodates demand but creates a moral hazard inefficiency. MA rations care but disregards some elements of the demand. We describe an efficient assignment of beneficiaries to these two options, and argue that efficiency requires an MA program oriented to serve the large middle part of the distribution of demand: the "middle class." Current Medicare policy of a "single premium" for MA plans cannot achieve efficient sorting. We characterize the demand-based premium policy that can implement the efficient assignment of enrollees to plans. If only a single premium is feasible, the second-best policy involves too many of the low-demand individuals in MA and a too low level of services relative to the first best. We identify approaches to using premium policy to revitalize MA and improve the efficiency of Medicare., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Abstract: This paper estimates the impact of informal caregiving on self-reported well-being. It uses a sample of 23,285 respondents of the first eleven waves of the Household, Income and Labour Dynamics in Australia (HILDA). We apply a relatively new analytical method that enables us to estimate fixed effects ordered logit to analyse subjective well-being. The econometric estimates show that providing informal care has a negative effect on subjective well-being. The empirical evidence of our paper could be helpful to inform policy makers to better understand the impact of caregiving and design the appropriate long term care policies and support services. [Copyright &y& Elsevier]

The person tradeoff (PTO) is commonly used in health economic applications. However, to date it has no theoretical basis. The purpose of this paper is to provide this basis from a set of assumptions that together justify the most common applications of the PTO method. Our analysis identifies the central assumptions in PTO measurements. We test these assumptions in an experiment, but find only limited support for the validity of the PTO.

This paper seeks to determine the macro-economic impacts of changes in health care provision. The resource allocation issues have been explored in theory, by applying the Rybczynski theorem, and empirically, using a computable general equilibrium (CGE) model for the UK with a detailed health component. From the theory, changes in non-health outputs are shown to depend on factor-bias and scale effects, the net effects generally being indeterminate. From the applied model, a rise in the National Health Service (NHS) budget is shown to yield overall welfare gains, which fall by two-thirds assuming health care-specific factors. A nominally equivalent migration policy yields even higher welfare gains.

The evaluation of health care programmes is commonly approached with stated preference methods such as contingent valuation or discrete choice experiments. These methods provide useful information for policy decisions involving health regulations and infrastructures for health care. However, econometric modelling of these data usually relies on a number of maintained assumptions, such as the use of the compensatory or random utility maximization rule. On the other hand, health policy issues can raise emotional concerns among individuals, which might induce other types of choice behaviour. In this paper we consider potential deviations from the general compensatory rule, and how these deviations might be explained by the emotional state of the subject. We utilized a mixture econometric model which allows for various potential decisions rules within the sample, such as the complete ignorance, conjunctive rule and satisfactory rules. The results show that deviations from the full linear compensatory decision rule are predominant, but they are significantly less observed for those subjects with a medium emotional state about the issue of caring for the health state of the elderly. The implication is that the emotional impact of health policy issues should be taken into account when making assumptions of individual choice behaviour in health valuation methods.

Few cost-effectiveness analysis (CEA) models have accounted for geographic variation in input parameters. This paper describes a deterministic discrete-time multi-state model to estimate the cost-effectiveness of vector control policies for Chagas disease, where implementation varies according to village characteristics. The model outputs include the total number of new infections, disability adjusted life years (DALYs) incurred, costs of associated healthcare, and total costs of the Ministry of Health's control policy for house surveillance and spraying. Incremental net benefits were estimated to determine Colombian villages in which it is cost-effective to implement the control policy. The robustness of these conclusions was evaluated by deterministic sensitivity analyses. The model should help provide a decision-support system to compare control policies and to allocate resources geographically.

Abstract: Internationally, there is wide cross-country heterogeneity in government responses to dual practice in the health sector. This paper provides a uniform theoretical framework to analyze and compare some of the most common regulations. We focus on three interventions: banning dual practice, offering rewarding contracts to public physicians, and limiting dual practice (including both limits to private earnings of dual providers and limits to involvement in private activities). An ancillary objective of the paper is to investigate whether regulations that are optimal for developed countries are adequate for developing countries as well. Our results offer theoretical support for the desirability of different regulations in different economic environments. [Copyright &y& Elsevier]

This paper addresses two issues. The first is how health inequalities can be measured in such a way as to take into account policymakers' attitudes towards inequality. The Gini coefficient and the related concentration index embody one particular set of value judgements. By generalising these indices, alternative sets of value judgements can be reflected. The other issue addressed is how information on health inequality can be used together with information on the mean of the relevant distribution to obtain an overall measure of health "achievement".

This paper investigates the effects of introducing external medical review for disability insurance (DI) in a system relying on treating physician testimony for eligibility determination. Using a unique policy change and administrative data from Switzerland, I show that medical review reduces DI incidence by 23%. Incidence reductions are closely tied to difficult-to-diagnose conditions, suggesting inaccurate assessments by treating physicians. Due to a partial benefit system, reductions in full benefit awards are partly offset by increases in partial benefits. More intense screening also increases labor market participation. Existing benefit recipients are downgraded and lose part of their benefit income when scheduled medical reviews occur. Back-of-the-envelope calculations indicate that external medical review is highly cost-effective. Under additional assumptions, the results provide a lower bound of the effect on the false positive award error rate. [ABSTRACT FROM AUTHOR]

Abstract: New regulation of health insurance markets creates multiple levels of health plans, with designations like “Gold” and “Silver.” The underlying rationale for the heavy-metal approach to insurance regulation is that heterogeneity in demand for health care is not only due to health status (sick demand more than the healthy) but also to other, “taste” related factors (rich demand more than the poor). This paper models managed competition with demand heterogeneity to consider plan payment and enrollee premium policies in relation to efficiency (net consumer benefit) and fairness (the European concept of “solidarity”). Specifically, this paper studies how to implement a “Silver” and “Gold” health plan efficiently and fairly in a managed competition context. We show that there are sharp tradeoffs between efficiency and fairness. When health plans cannot or may not (because of regulation) base premiums on any factors affecting demand, enrollees do not choose the efficient plan. When taste (e.g., income) can be used as a basis of payment, a simple tax can achieve both efficiency and fairness. When only health status (and not taste) can be used as a basis of payment, health status-based taxes and subsidies are required and efficiency can only be achieved with a modified version of fairness we refer to as “weak solidarity.” An overriding conclusion is that the regulation of premiums for both the basic and the higher level plans is necessary for efficiency. [Copyright &y& Elsevier]

Abstract: Many governments have health programs focused on improving health among the poor and these have an impact on out-of-pocket health payments made by individuals. Therefore, one of the objectives of these programs is to reach the poorest and reduce their out-of-pocket expenditure. In this paper we propose the distributional poverty impact approach to measure the poverty impact of out-of-pocket health payments of different health financing policies. This approach is comparable to the impoverishment methodology proposed by that compares poverty indices before and after out-of-pocket health payments. In order to escape the specification of a particular poverty index, we use the marginal dominance approach that uses non-intersecting curves and can rank poverty reducing health financing policies. We present an empirical application of the out-of-pocket health payments for an innovative social financing policy implemented in Mexico named Seguro Popular. The paper finds evidence that Seguro Popular program has a better distributional poverty impact when families face illness when compared to other poverty reducing policies. The empirical dominance approach uses data from Mexico in 2006 and considers international poverty standards of $2 per person per day. [Copyright &y& Elsevier]

The OECD countries finance their health care through a mixture of taxes, social insurance contributions, private insurance premiums and out-of-pocket payments. The various payment sources have very different implications for both vertical and horizontal equity and on redistributive effect which is a function of both. This paper presents results on the income redistribution consequences of the health care financing mixes adopted in twelve OECD countries by decomposing the overall income redistributive effect into a progressivity, horizontal inequity and reranking component. The general finding of this study is that the vertical effect is much more important than horizontal inequity and reranking in determining the overall redistributive effect but that their relative importance varies by source of payment. Public finance sources tend to have small positive redistributive effects and less differential treatment while private financing sources generally have (larger) negative redistributive effects which are to a substantial degree caused by differential treatment.

This paper presents further international comparisons of progressivity of health care financing systems. The paper builds on the work of Wagstaff et al. [Wagstaff, A., van Doorslaer E., et al., 1992. Equity in the finance of health care: some international comparisons, Journal of Health Economics 11, pp. 361-387] but extends it in a number of directions: we modify the methodology used there and achieve a higher degree of cross-country comparability in variable definitions; we update and extend the cross-section of countries; and we present evidence on trends in financing mixes and progressivity.

Managed health care plans and providers in the US and elsewhere sell their services to multiple payers. For example, the three largest groups of purchasers from health plans in the US are employers, Medicaid plans, and Medicare, with the first two accounting for over 90% of the total enrollees. In the case of hospitals, Medicare is the largest buyer, but it alone only accounts for 40% of the total payments. While payers have different objectives and use different contracting practices, the plans and providers set some elements of the quality in common for all payers. In this paper, we study the interactions between a public payer, modeled on Medicare, which sets a price and takes any willing provider, a private payer, which limits providers and pays a price on the basis of quality, and a provider/plan, in the presence of shared elements of quality. The provider compromises in response to divergent incentives from payers. The private sector dilutes Medicare payment initiatives, and may, under some circumstances, repair Medicare payment policy mistakes. If Medicare behaves strategically in the presence of private payers, it can free-ride on the private payer and set its prices too low. Our paper has many testable implications, including a new hypothesis for why Medicare has failed to gain acceptance of health plans in the US. [Copyright &y& Elsevier]

This paper develops a conceptual framework in which preferences about the distribution of future health gains depend on differences in four 'health streams'. These are as follows: (1) the amount of health to be gained; (2) the no-treatment profiles; (3) the amount of health experienced thus far: and (4) the amount of health gained previously as a result of public health interventions. This classification puts the well-established concerns for severity (stream 2) and age weights (stream 3) into a more complete analytical framework. Stream 4 has not been discussed to date and the paper suggests some moral arguments about the distributive relevance of this stream of health. [ABSTRACT FROM AUTHOR]

This paper discusses health economics as a behavioral science and as input into health policy and health services research. I illustrate the dual role with data on publications and citations of two leading health economics journals and three leading American health economists. Five important and relatively new topics in economics are commended to health economists who focus on economics as a behavioral science. This is followed by suggestions for health economists in their role of providing input to health policy and health services research. I discuss the strengths and weaknesses of economics, the role of values, and the potential for interdisciplinary and multidisciplinary research. The fourth section presents reasons why I believe the strong demand for health economics will continue, and the paper concludes with a sermon addressed primarily to recent entrants to the field. [ABSTRACT FROM AUTHOR]

This paper seeks to understand the impact of the Medicare Rural Hospital Flexibility (Flex) Program on hospital choice and consumer welfare for rural residents. The Flex Program created a new class of hospital, the Critical Access Hospital (CAH), which receives more generous Medicare reimbursements in return for limits on capacity and length of stay. We find that conversion to CAH status resulted in a 4.7 percent drop in inpatient admissions to participating hospitals, almost all of which was driven by factors other than capacity constraints. The Flex Program increased consumer welfare if it prevented the exit of at least 6.5 percent of randomly selected converting hospitals. [ABSTRACT FROM AUTHOR]

Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and subsidizes MA plans based on a "benchmark" for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Many analysts recommend equalizing Medicare's subsidy across the options - referred to in policy circles as a "level playing field." This paper studies the normative question of how to set the level of the benchmark, applying the versatile model developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic. [ABSTRACT FROM AUTHOR]

Conventional wisdom suggests that if private health insurance plans compete alongside a public option, they may endanger the latter's financial stability by cream-skimming good risks. This paper argues that two factors may contribute to the extent of cream-skimming: (i) degree of horizontal differentiation between public and private options when preferences are heterogeneous; (ii) whether contract design encourages choice of private insurance before information about risk is revealed. I explore the role of these factors empirically within the unique institutional setting of the German health insurance system. Using a fuzzy regression discontinuity design to disentangle adverse selection and moral hazard, I find no compelling support for extensive cream-skimming of public option by private insurers despite their ability to fully underwrite risk. A model of demand for private insurance supports the idea that heterogeneity in non-pecuniary preferences and long-term structure of private insurance contracts may be muting cream-skimming in this setting. [ABSTRACT FROM AUTHOR]

While health care policies are frequently signed into law well before they are implemented, such lags are ignored in most empirical work. This paper demonstrates the importance of implementation lags in the context of Medicare Part D, the prescription drug benefit that took effect two years after it was signed into law. Exploiting the differential responses of chronic and acute drugs to anticipated future prices, I show that individuals reduced drug utilization for chronic but not acute drugs in anticipation of Part D's implementation. Accounting for this anticipatory response substantially reduces the estimated total treatment effect of Part D. [ABSTRACT FROM AUTHOR]

This paper investigates the average effects of firm-provided workplace health promotion measures on labour market outcomes of the firms' employees. Exploiting linked employer-employee panel data that consist of rich survey-based and administrative information on firms, workers and regions, we apply a flexible propensity score matching approach that controls for selection on observables and time-constant unobserved factors. While the effects of analysing sickness absenteeism appear to be rather limited, our results suggest that health circles/courses increase tenure and job stability across various age groups. A key finding is that health circles/courses strengthen the labour force attachment of elderly employees (51-60), implying potential cost savings for public transfer schemes such as unemployment insurance or early retirement schemes. [ABSTRACT FROM AUTHOR]

Health care financing and funding are usually analyzed in isolation. This paper combines the corresponding strands of the literature and thereby advances our understanding of the important interaction between them. We investigate the impact of three modes of health care financing, namely, optimal income taxation, proportional income taxation, and insurance premiums, on optimal provider payment and on the political implementability of optimal policies under majority voting. Considering a standard multi-task agency framework we show that optimal health care policies will generally differ across financing regimes when the health authority has redistributive concerns. We show that health care financing also has a bearing on the political implementability of optimal health care policies. Our results demonstrate that an isolated analysis of (optimal) provider payment rests on very strong assumptions regarding both the financing of health care and the redistributive preferences of the health authority. [ABSTRACT FROM AUTHOR]

More and more states have passed laws that allow individuals to use marijuana for medical purposes. There is an ongoing, heated policy debate over whether these laws have increased marijuana use among non-patients. In this paper, I address that question empirically by studying marijuana possession arrests in cities from 1988 to 2008. I estimate fixed effects models with city-specific time trends that can condition on unobserved heterogeneities across cities in both their levels and trends. I find that these laws increase marijuana arrests among adult males by about 15–20%. These results are further validated by findings from data on treatment admissions to rehabilitation facilities: marijuana treatments among adult males increased by 10–20% after the passage of medical marijuana laws. [ABSTRACT FROM AUTHOR]

Abstract: In this paper we estimate the causal effects on child mortality from moving into less distressed neighborhood environments. We match mortality data covering the period from 1997 to 2009 with information on every child in public housing that applied for a housing voucher in Chicago in 1997 (N =11,680). Families were randomly assigned to the voucher wait list, and only some families were offered vouchers. The odds ratio for the effects of being offered a housing voucher on overall mortality rates is equal to 1.13 for all children (95% CI 0.73–1.70), 1.34 for boys (95% CI 0.85–2.05) and 0.21 for girls (95% CI 0.01–1.04). [Copyright &y& Elsevier]

Abstract: How does increasing access to treatment affect the demand for preventive testing? In this paper we present results from a field experiment in Nigeria in which we offered cervical cancer screening to women at randomly chosen prices. To test our hypothesis, we also offered women a lottery where the payoff was a subsidy towards the cost of cervical cancer treatment (conditional upon a diagnosis of cervical cancer). We find that women randomly selected to receive the conditional cancer treatment subsidy were about 4 percentage points more likely to take up screening than those in the control group. We also show that reducing the price of screening by 10 cents increased take-up by about 1 percentage point. These results offer compelling evidence that the optimal set of subsidies to increase take-up of preventive testing in developing countries, must include subsidies towards treatment costs (in addition to price subsidies). [Copyright &y& Elsevier]

Abstract: In this paper, we examine the effects of recent parental Medicaid eligibility expansions on Medicaid participation and private insurance coverage. We present a new approach for estimating these policy effects that explicitly models the particular policy instrument over which legislators have control–income eligibility thresholds. Our approach circumvents estimation problems stemming from misclassification or measurement error. Moreover, it allows us to assess how the policy effects may vary at different initial threshold levels. Using data from the Survey of Income and Program Participation, we find three main results. First, the eligibility expansions result in significant increases in Medicaid participation; a “typical” expansion increases Medicaid participation by about four percent of baseline coverage rates. Second, the participation effect is larger for lower initial thresholds and the effect decreases as Medicaid thresholds increase. Third, we find no statistically significant evidence of crowd out regardless of initial threshold level. [Copyright &y& Elsevier]

Abstract: This paper examines the effect of income inequality on health for a group of particularly disadvantaged individuals: refugees. Our analysis draws on longitudinal hospitalization records coupled with a settlement policy where Swedish authorities assigned newly arrived refugees to their first area of residence. The policy was implemented in a way that provides a source of plausibly random variation in initial location. The results reveal no statistically significant effect of income inequality on the risk of being hospitalized. This finding holds also for most population subgroups and when separating between different types of diagnoses. Our estimates are precise enough to rule out large effects of income inequality on health. [Copyright &y& Elsevier]

Abstract: have analyzed the price adjustment policy of a payer implementing a Prospective Payment System in the hospital sector in the presence of exogenous cost differences when no lump-sum transfers are allowed. They focus on deriving conditions for the price adjustment being positive. In this paper, using a result of Miraldo et al., we emphasize whether the price adjustment is larger or smaller than the marginal cost. We show how the discrimination operates against either the low-cost or the high-cost hospitals according to the value of the elasticity of the additional marginal cost with respect to the quantity of services. [Copyright &y& Elsevier]

Abstract: This paper utilizes longitudinal data on varicella (chickenpox) immunizations in order to estimate the causal effects of state-level school-entry and daycare-entry immunization mandates within the United States. We find significant causal effects of mandates upon vaccination rates among preschool children aged 19–35 months; these effects appear in the year of mandate adoption, peak two years after adoption, and show a minimal difference from the aggregate trend about six years after adoption. For a mandate enacted in 2000, the model and estimates imply that roughly 20% of the short-run increase in state-level immunization rates was caused by the mandate introduction. We find no evidence of differential effects for different socioeconomic groups. Combined with previous cost–benefit analyses of the varicella vaccine, the estimates suggest that state-level mandates have been effective from an economic standpoint. [Copyright &y& Elsevier]

Abstract: In this paper, we investigate the impact of attending school on body weight and obesity using a regression-discontinuity design. As is the case with academic outcomes, school exposure is related to unobserved determinants of weight outcomes because some families choose to have their child start school late (or early). If one does not account for this endogeneity, it appears that an additional year of school exposure results in a greater BMI and a higher probability of being overweight or obese. When we compare the weight outcomes of similar age children with one versus two years of school exposure due to regulations on school starting age, the significant positive effects disappear, and most point estimates become negative, but insignificant. However, additional school exposure appears to improve weight outcomes of children for whom the transition to elementary school represents a more dramatic change in environment (those who spent less time in childcare prior to kindergarten). [Copyright &y& Elsevier]

Abstract: The World Health Report 2000 proposed three fundamental goals for health systems encompassing population health, health care finance and health systems responsiveness. The goals incorporate both an efficiency and equity dimension. While inequalities in population health and health care finance have motivated two important strands of research, inequalities in responsiveness have received less attention in health economics. This paper examines inequality and polarisation in responsiveness, bridging this gap in the literature and contributing towards an integrated analysis of health systems performance. It uses data from the World Health Survey to measure and compare inequalities in responsiveness across 25 European countries. In order to respect the inherently ordinal nature of the responsiveness data, median-based measures of inequality and polarisation are employed. The results suggest that, in the face of wide differences in the health systems analysed, there exists large variability in inequality in responsiveness across countries. [Copyright &y& Elsevier]

Abstract: This paper empirically evaluates whether government ideology and electoral motives influenced the growth of public health expenditures in 18 OECD countries over the 1971–2004 period. The results suggest that incumbents behaved opportunistically and increased the growth of public health expenditures in election years. Government ideology did not have an influence. These findings indicate (1) the importance of public health in policy debates before elections and (2) the political pressure towards re-organizing public health policy platforms especially in times of demographic change. [Copyright &y& Elsevier]

Abstract: The impact of informal care responsibilities on the willingness and ability of caregivers to undertake paid employment has been the subject of a number of studies. In contrast, the effect of employment status on willingness to undertake informal care has been less well explored. This paper concentrates on this less-studied direction of causality using the data provided by 15 waves of the British Household Panel Survey. We find that employment participation and earnings both impact negatively on willingness to supply informal care. This evidence has implications for health and social care policy since informal care has been shown to be a significant substitute for formal long-term care. [Copyright &y& Elsevier]

We use a “natural experiment”, the fiscal adjustment of Italy in the 1990s to meet the Maastricht criteria, to test a simple model of soft budget constraint that closely resembles the intergovernmental relationships in the Italian public health care sector. We show that the link between the ex-ante financing by the Central government and the health expenditure by regions was stronger when regional expectations of future bailing outs were presumably lower. Confirming previous research, we also prove that more fiscally autonomous regions were more financially responsible and that a political “alignment” effect was present, with “friendly” regional governments controlling more expenditure than unfriendly ones. Our results suggest that, at least in Italy, bailing out expectations by regions may be the missing variable emphasised by [Culyer A.J., 1988. Health care expenditures in Canada: Myth and reality. Canadian Tax Papers, 82] for empirical models explaining health expenditure. Our results also raise some worries about the outcome of the current decentralization process in Europe. [Copyright &y& Elsevier]

Abstract: Global ratings, such as those based on consumer satisfaction, are a commonly used form of report on the performance of health plans and providers. A simple averaging of the global rating by plan members leads to a problem: it gives a plan greater incentives to improve services used by low-cost members than services used by high-cost members. This paper presents a formal model of consumer formation of global ratings and the incentives these rating convey to plans. We use this model to characterize weights on consumer respondents to correct the incentive problem. We implement our proposed solution using data from the Consumer Assessments of Health Care Providers and Systems (CAHPS) and the Medicare Current Beneficiary Survey (MCBS). Our correction is low-cost, easily implemented on an on-going basis, and insensitive to assumptions about why health plans care about quality ratings. [Copyright &y& Elsevier]

Abstract: Beginning in the late 1980s, states and the federal government restricted the ability of physicians to “balance bill” Medicare beneficiaries for charges in excess of the copayment and reimbursement amounts approved by Medicare. In this paper, I provide empirical evidence that this policy change resulted in a 9% reduction in out-of-pocket medical expenditures by elderly households. In spite of the change in marginal reimbursement to physicians, however, I find little evidence that the restrictions affected patterns of care. Thus, this restriction on the prices charged by physicians amounted to a transfer from affected physicians to affected patients. [Copyright &y& Elsevier]

Abstract: This paper re-examines the relation between the predictability of health care spending and incentives due to adverse selection. Within an explicit model of health plan decisions about service levels, we show that predictability (how well spending on certain services can be anticipated), predictiveness (how well the predicted levels of certain services contemporaneously co-vary with total health care spending), and demand responsiveness all matter for adverse selection incentives. The product of terms involving these three measures of predictability, predictiveness, and demand responsiveness define an empirical index of the direction and magnitude of selection incentives. We quantify the relative magnitude of adverse selection incentives bearing on various types of health care services in Medicare. Our results are consistent with other research on service-level selection. The index of incentives can readily be applied to data from other payers. [Copyright &y& Elsevier]

Abstract: Quality reports about health plans and providers are becoming more prevalent in health care markets. This paper casts the decision about what information to report to consumers about health plans as a policy decision. In a market with adverse selection, complete information about quality leads to inefficient outcomes. In a Rothschild–Stiglitz model, we show that averaging quality information into a summary report can enforce pooling in health insurance, and by choice of the right weights in the averaged report, a payer or regulator can induce first-best quality choices. The optimal quality report is as powerful as optimal risk adjustment in correcting adverse selection inefficiencies. [Copyright &y& Elsevier]