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Little is known about how the coronavirus disease 2019 (COVID-19) pandemic affected influenza vaccine utilization and disparities. We sought to estimate changes in the likelihood of receiving an influenza vaccine across different demographic subgroups during the COVID-19 pandemic.In this cohort study, we analyzed influenza vaccine uptake from 2019 to 2020 using Optum commercial insurance claims data. Eligible individuals were aged 18 or above in 2018 and continuously enrolled from 08/01/2018 through 12/31/2020. Multivariable logistic regressions were fitted for the individual-level influenza vaccine uptake. Adjusting for demographic factors and medical histories, we estimated probabilities of receiving influenza vaccines before and after the COVID-19 pandemic across demographic subgroups.From August to December 2019, unadjusted influenza vaccination rate was 42.3%, while in the same period of 2020, the vaccination rate increased to 45.9%. Females had a higher vaccination rate in 2019 (OR: 1.16, 95% CI 1.15-1.16), but the increase was larger for males. Blacks and Hispanics had lower vaccination rates relative to whites in both flu seasons. Hispanics showed a greater increase in vaccination rate, increasing by 7.8 percentage points (p .001) compared to 4.4 (p .001) for whites. The vaccination rate for Blacks increased by 5.2 percentage points (p .001). All income groups experienced vaccination improvements, but poorer individuals had lower vaccination rates in both seasons. The most profound disparities occurred when educational cohort were considered. The vaccination rate increased among college-educated enrollees by 8.8 percentage points (p .001) during the pandemic compared to an increase of 2.8 percentage points (p .001) for enrollees with less than a 12th grade education. Past influenza infections or vaccination increased the likelihood of vaccination (p .001).The COVID-19 pandemic was associated with increased influenza vaccine utilization. Disparities persisted but narrowed with respect to gender and race but worsened with respect to income and educational attainment.

To evaluate the impact of Facebook's vaccine misinformation policy in March 2019 on user endorsements of vaccine content on its platform.We identified 172 anti- and pro-vaccine Facebook Pages and collected posts from these Pages six months before and after the policy. Using interrupted time series regression models, we evaluated the policy impact on user endorsements (i.e., likes) of anti- and pro-vaccine posts on Facebook.The number of likes for posts on anti-vaccine Pages had decreased after the policy implementation (policy = 153.2, p 0.05; policy*day = -0.838, p 0.05; marginal effect at the mean = -22.74, p 0.01; marginal effect at the median = -24.56, p 0.01). When the number of subscribers was considered, the policy effect on the number of likes for anti-vaccine posts was much smaller, but still statistically significant (policy = 4.849, p 0.05; policy*day = -0.027, p 0.05; marginal effect at the mean = -0.742, p 0.01; marginal effect at the median = -0.800, p 0.01). There was no policy effect observed for posts on pro-vaccine Pages.Our analysis suggested that Facebook's March 2019 vaccine misinformation policy moderately impacted the number of endorsements of anti-vaccine content on its platform. Social media companies can take measures to limit the popularity of anti-vaccine content by reducing their reach and visibility. Future research efforts should focus on evaluating additional policies and examining policies across platforms.

A potential solution to the deceased donor organ shortage is to expand donor acceptability criteria. The procurement cost implications of using nonstandard donors is unknown. Using 5 years of US organ procurement organization (OPO) data, we built a cost function model to make cost projections: the total cost was the dependent variable; production outputs, including the number of donors and organs procured, were the independent variables. In the model, procuring one kidney or procuring both kidneys from double/en bloc transplantation from a single-organ donor resulted in a marginal cost of $55 k (95% confidence interval [CI] $28 k, $99 k) per kidney, and procuring only the liver from a single-organ donor results in a marginal cost of $41 k (95% CI $12 k, $69 k) per liver. Procuring two kidneys for two candidates from a donor lowered the marginal cost to $36 k (95% CI $22 k, $66 k) per kidney, and procuring two kidneys and a liver lowers the marginal cost to $24 k (95% CI $17 k, $45 k) per organ. Economies of scale were observed, where high OPO volume was correlated with lower costs. Despite higher cost per organ than for standard donors, kidney transplantation from nonstandard donors remained cost-effective based on contemporary US data.

Background Quantifying health care quality has long presented a challenge to identifying the relationship between provider level quality and cost. However, growing focus on quality improvement has led to greater interest in organizational performance, prompting payers to collect various indicators of quality that can be combined at the provider level. Objective To explore the relationship between quality and average cost of medical visits provided in US Community Health Centers (CHCs) using composite measures of quality. Research design Using the Uniform Data System collected by the Bureau of Primary Care, we constructed composite measures by combining 9 process and 2 outcome indicators of primary care quality provided in 1331 US CHCs during 2015-2018. We explored different weighting schemes and different combinations of individual quality indicators constructed at the intermediate domain levels of chronic condition control, screening, and medication management. We used generalized linear modeling to regress average cost of a medical visit on composite quality measures, controlling for patient and health center factors. We examined the sensitivity of results to different weighting schemes and to combining individual quality indicators at the overall level compared with the intermediate domain level. Results Both overall and domain level composites performed well in the estimations. Average cost of a medical visit was negatively associated with quality, although the magnitude of the effect varied across weighting schemes. Conclusion Efforts toward improvement of primary health care quality delivered in CHCs need not involve greater cost.

Hospitals have increasingly relied on nurse assistants to support nurses in the provision of patient care, yet knowledge about their contributions to the patient experience in U.S. hospitals is limited. We address this issue by exploring the impact of nurse assistants and registered nurses on an array of patient satisfaction measures from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems. Using linked data for 2,807 hospitals from 2008 to 2016, we employ a production function approach to estimate and plot marginal impact curves for both nurse assistants and registered nurses. We find that although registered nurses are more impactful, nurse assistants are the more underdeployed staffing category. We also find that after meeting certain thresholds for minimal hours, nurse assistants have a comparative advantage in improving patient satisfaction scores in the housekeeping and patient support domain. Given their lower labor costs, further employment of nurse assistants may be warranted.

A policy concern is that the initiation of Hospital Compare (HC) reporting in Medicare provided leverage to insurers in price negotiations for lowering private sector prices without regard to hospital performance. Using the sequential Nash bargaining framework we provide economic intuition to the contrary: while average hospital prices decline under quality disclosures, hospitals with above‐average quality are able to exert a stronger bargaining position, consequently capturing prices above the market rate. To explore this issue empirically we estimate variants of difference‐in‐difference models, examining the effects of the three main scores (heart attack, heart failure, and combined mortalities) on transaction prices of related hospital procedures. States which had similar mandated reporting systems in place before the initiation of HC form the control group. Analyzing claims data of privately insured patients, we find that HC exerted downward pressure on prices. However, hospitals rated “above‐average” captured higher prices, thereby offsetting the overall policy effect fully or partially. Leads and lags analysis lends further support for our difference‐in‐difference approach. We find that highly ranked hospitals received a quality premium of 8–14%, comparable to price effects found in other health care markets. We conclude that HC was effective at constraining prices without penalizing high performers.

While recent policy reforms aim to improve access to kidney transplantation for patients with end-stage kidney disease, the cost implications of kidney waiting list expansion are not well understood. The Organ Acquisition Cost Center (OACC) is the mechanism by which Medicare reimburses kidney transplantation programs, at cost, for costs attributable to kidney transplantation evaluation and waiting list management, but these costs have not been well described to date.To describe temporal trends in mean OACC costs per kidney transplantation and to identify factors most associated with cost.This economic evaluation included all kidney transplantation waiting list candidates and recipients in the United States from 2012 to 2017. A population-based study of cost center reports was conducted using data from all Center of MedicareMedicaid-certified transplantation hospitals. Data analysis was conducted from June to August 2021.Year, local price index, transplantation and waiting list volume of transplantation program, and comorbidity burden.Mean OACC costs per kidney transplantation.In 1335 hospital-years from 2012 through 2017, Medicare's share of OACC costs increased from $0.95 billion in 2012 to $1.32 billion in 2017 (3.7% of total Medicare End-Stage Renal Disease program expenditure). Median (IQR) OACC costs per transplantation increased from $81 000 ($66 000 to $103 000) in 2012 to $100 000 ($82 000 to $125 000) in 2017. Kidney organ procurement costs contributed to 36% of mean OACC costs per transplantation throughout the study period. During the study period, transplantation hospitals experienced increases in kidney waiting list volume, kidney waiting list active volume, kidney transplantation volume, and comorbidity burden. For a median-sized transplantation program, mean OACC costs per transplantation decreased with more transplants (-$3500 [95% CI, -$4300 to -$2700] per 10 transplants; P .001) and increased with year ($4400 [95% CI, $3500 to $5300] per year; P .001), local price index ($1900 [95% CI, $200 to $3700] per 10-point increase; P = .03), patients listed active on the waiting list ($3100 [95% CI, $1700 to $4600] per 100 patients; P .001), and patients on the waiting list with high comorbidities ($1500 [9% CI, $600 to $2500] per 1% increase in proportion of waitlisted patients with the highest comorbidity score; P = .002).In this study, OACC costs increased at 4% per year from 2012 to 2017 and were not solely attributable to the cost of organ procurement. Expanding the waiting list will likely contribute to further increases in the mean OACC costs per transplantation and substantially increase Medicare liability.

OBJECTIVE: To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. DATA SOURCES: We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county‐level characteristics from the Census Bureau. Our final dataset included 5841 center‐year observations. STUDY DESIGN: We used difference‐in‐differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state‐specific trend models, and placebo law tests as robustness checks. DATA COLLECTION METHODS: Not applicable. PRINCIPAL FINDINGS: On the revenue side, we found a $2.08 million relative increase (p = 0.002) in Medicaid revenues, offset by a $0.44 million decrease (p = 0.015) in total grants among community health centers in expansion states compared with centers in non‐expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p = 0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p

Immunization can lead to moral hazard by reducing the cost of risky behaviors and reducing preventive efforts. In this study, we examine the effect of HPV (human papillomavirus) vaccination on participation in the Pap test, which is a diagnostic screening test to detect HPV and non-HPV-related cancerous processes. The HPV vaccination is explicitly recommended for women up to age 26 years who were not previously vaccinated. Pap tests are strongly recommended for women between 21 and 65 years old even after having the HPV vaccine. To study the effect of HPV vaccination on Pap test uptake, we construct a fuzzy regression discontinuity design, centered on the vaccination threshold age. The results suggest that moral hazard was not the dominant effect. The estimates show that women who have been vaccinated, if anything, are actually more likely to have a Pap test, possibly due to increased awareness of its benefits at the time of vaccination.

We present an incremental cost-effectiveness analysis of an evidence-based childhood asthma intervention (Community Healthcare for Asthma Management and Prevention of Symptoms [CHAMPS]) to usual management of childhood asthma in community health centers. Data used in the analysis include household surveys, Medicaid insurance claims, and community health center expenditure reports. We combined our incremental cost-effectiveness analysis with a difference-in-differences multivariate regression framework. We found that CHAMPS reduced symptom days by 29.75 days per child-year and was cost-effective (incremental cost-effectiveness ratio: $28.76 per symptom-free days). Most of the benefits were due to reductions in direct medical costs. Indirect benefits from increased household productivity were relatively small.

Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results.To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time.Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204).HRS participants who were also enrolled in Medicare.Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes.The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059).Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

Multimorbidity affects the majority of elderly adults and is associated with higher health costs and utilization, but how specific patterns of morbidity influence resource use is less understood.The objective was to identify specific combinations of chronic conditions, functional limitations, and geriatric syndromes associated with direct medical costs and inpatient utilization.Retrospective cohort study using the Health and Retirement Study (2008-2010) linked to Medicare claims. Analysis used machine-learning techniques: classification and regression trees and random forest.A population-based sample of 5771 Medicare-enrolled adults aged 65 and older in the United States.Main covariates: self-reported chronic conditions (measured as none, mild, or severe), geriatric syndromes, and functional limitations. Secondary covariates: demographic, social, economic, behavioral, and health status measures.Medicare expenditures in the top quartile and inpatient utilization.Median annual expenditures were $4354, and 41% were hospitalized within 2 years. The tree model shows some notable combinations: 64% of those with self-rated poor health plus activities of daily living and instrumental activities of daily living disabilities had expenditures in the top quartile. Inpatient utilization was highest (70%) in those aged 77-83 with mild to severe heart disease plus mild to severe diabetes. Functional limitations were more important than many chronic diseases in explaining resource use.The multimorbid population is heterogeneous and there is considerable variation in how specific combinations of morbidity influence resource use. Modeling the conjoint effects of chronic conditions, functional limitations, and geriatric syndromes can advance understanding of groups at greatest risk and inform targeted tailored interventions aimed at cost containment.

Defensive medicine, broadly defined as medical practices that protect physicians from malpractice lawsuits without providing benefits to patients, can lead to wasteful use of health care resources and higher cost. Although physicians cite malpractice liability as an important factor driving their decisions to order imaging tests, little research has been done to examine the systematic impact of liability pressure on overall imaging. The authors examined the extent to which radiography use is influenced by malpractice liability pressure among office-based physicians.Using National Ambulatory Medical Care Survey data from 1999 to 2010, the authors used multivariate difference-in-difference logistic regression to examine the effects of different types of state tort reforms on the probability of radiography orders by primary care physicians (PCPs) and specialists.The probability that a PCP ordered radiography decreased when states enacted permanent caps on noneconomic damages (-1.0%, P .01), periodic payment reforms (-1.6%, P.05), and the total number of tort reforms (-0.5%, P.05). Specialist physicians were responsive to two reforms: caps on punitive damages (-6.1%, P.01) and the total number of medical tort laws (-1.2%, P .01). The passage of new indirect reforms was found to reduce radiography orders for PCPs (-1.8%, P.05), and the repeal of indirect reforms was found to increase radiography orders for specialists (+3.4%, P.01).State tort reform seems to reduce physicians' ordering of radiography. This analysis also suggests that reforms that make it harder to sue physicians have a stronger impact than reforms that directly reduce physicians' malpractice claim payments.

Objective: To understand the correlates of COVID-19 vaccine hesitancy in the American public and the reasons why individuals intend to refuse a COVID-19 vaccine. Rationale: Recent polls suggest that a significant share of the American public is reluctant to receive an impending COVID-19 vaccine. However, far less is known about which Americans are most likely to refuse the vaccine and their reasons for reluctance. Understanding these issues is critical to developing effective health communications to improve COVID-19 vaccination and end the pandemic. Method: We rely on a demographically representative survey of 5,009 American adults collected from May 28-June 8, 2020. We analyze the influence of demographic factors, political ideology, and COVID-19 experiences on COVID-19 vaccine hesitancy. Results: 31.1% of Americans do not intend to pursue getting vaccinated when a COVID-19 vaccine becomes available. The likelihood of refusal is higher for Blacks, women, and conservatives. People who are more concerned about COVID-19 were less likely to refuse the vaccine. Positive views of vaccination in general (vaccines are safe, effective, and important) were also negatively associated with vaccine refusal intention. The two most cited reasons for refusal are concerns about vaccine safety, and effectiveness. Reasons for reluctance vary across sub-populations. Women were most likely to be hesitant based on concerns about safety and efficacy. Blacks were more likely to be hesitant than Whites because of concerns about safety and efficacy, because they lack needed financial resources or health insurance, and because already had COVID-19. Conclusion: Large proportions of the American public do not intend to pursue a vaccine against COVID-19 once it becomes available, reducing its potential impact. Blacks are particularly likely to be hesitant, exacerbating existing disparities in COVID-19 outcomes.

Objective: This study explores the price implications of hospital systems by analyzing the association of system characteristics with selected cardiac surgery pricing. Data Source: Using a large private insurance claim database, the authors identified 11 282 coronary artery bypass graft (CABG) cases and 49 866 percutaneous coronary intervention (PCI) cases from 2002 to 2007. Study Design: We conducted a retrospective observational study using generalized linear models. Principal Findings: We found that the CABG and PCI prices in centralized health and physician insurance systems were significantly lower than the prices in stand-alone hospitals by 4.4% and 6.4%, respectively. In addition, the CABG and PCI prices in independent health systems were significantly lower than in stand-alone hospitals, by 15.4% and 14.5%, respectively. Conclusion: The current antitrust guidelines tend to focus on the market share of merging parties and pay less attention to the characteristics of merging parties. The results of this study suggest that antitrust analysis could be more effective by considering characteristics of hospital systems.

Background In an effort to increase price transparency, the Centers for Medicare and Medicaid Services (CMS) began reporting charges for Medicare inpatients treated in ∼3400 hospitals online in 2013. As of 2019, CMS began to require hospitals themselves to publicize a more comprehensive list of their underlying procedure charges. Objective The objective of this study was to assess the responses of hospitals to broad-scale public reporting of their charges for inpatient services. Research design We used descriptive analysis to examine the trend in CMS charge data for high charge hospitals before and after the 2013 intervention. We also applied difference-in-differences analysis to comprehensive inpatient charge data from New York and Florida for the years 2011-2016, defining the reported high-volume diagnosis-related groups (DRGs) as the intervention group. Results At the national level, the CMS charge data showed relatively lower growth in high charge hospitals following the intervention. From the state data, we found that after 3 years, the growth in charges for reported DRGs in New York hospitals was 4%-9% lower than for unreported diagnosis-related groups. In Florida, it was 2%-8% lower. Conclusion Public reports of hospital inpatient charges by DRG appear to influence subsequent charges, slowing their growth.

Nonmedical exemptions are widely shown to be associated with outbreaks of vaccine-preventable disease. In response to a recent measles outbreak in 2015, California acted to increase immunization coverage by removing all nonmedical exemptions effective in 2016. Employing a unique dataset of county-level vaccination and exemption rates at Kindergarten entry, we exploit the recent policy change in California to estimate the impact of the repeal of nonmedical exemptions on immunization coverage for school-mandated vaccines. Relative to a diverse group of control states, our findings indicate that vaccination coverage increased for all required vaccines following the repeal, ranging from 2.5% for MMR to 5% for Polio. We also find a significant 3.4 percentage-point decline in nonmedical exemptions, accompanied by a 2.1 percentage-point increase in medical exemptions in counties that previously had high rates of nonmedical waivers. Our findings indicate that the repeal of nonmedical exemptions in California was only partially effective in improving vaccination coverage, and may have led parents to substitute between medical and nonmedical exemptions, leading to a net decline in total exemptions of just 1 percentage-point.

With millions of confirmed coronavirus (COVID-19) cases and hundreds of thousands of deaths, the United States (U.S.) continues to battle the public health crisis arising from the pandemic spread of the SARS-CoV-2 virus (COVID-19 Dashboard, 2020). COVID-19 has emerged as an American health disparity, with racial and ethnic minorities exhibiting the highest burden of illness and deaths in the U.S. due to COVID-19 (Wortham et al., 2020). According to the Centers for Disease Control and Prevention (CDC), Black and Hispanic persons are 4.7 and 4.6 times more likely, respectively, to be hospitalized for COVID-19 compared to Whites (CDC, 2020). The global pandemic has also imposed significant economic and social costs for individuals, institutions, businesses, and communities. Here too, minorities have borne a disproportionally high share of the economic and social cost of the pandemic (CDC, 2020). A COVID-19 vaccine will be vital to producing an immune response that slows the pandemic. Depending on its efficacy, modeling studies indicate we could need up to 70% of the American population vaccinated against COVID-19 to effectively interrupt virus transmission (Bartsch et al., 2020). Critically, the decision to fast track a COVID-19 vaccine has raised concern among the public that vaccine development is being rushed. Surveys assessing the share of Americans willing to get vaccinated against COVID-19 place estimates of intention to refuse vaccination between 25 and 50% (The Associated Press, 2020). If that proportion of the public opts out of vaccinating, then vaccination rates may be inadequate to produce herd immunity to the virus. Vaccine hesitancy, “defined as the decision to delay vaccination or the refusal to vaccinate despite available vaccination services,” is growing increasingly common in the U.S. public (Callaghan et al., 2019). It has been observed for vaccination against influenza (Nyhan and Reifler 2015), human papillomavirus (Fowler and Gollust 2015), and pneumococcal vaccines (Glanz et al., 2011; Gatwood et al., 2020). Critically, however, we see intention to vaccinate against COVID-19 as similar but conceptually distinct from traditional vaccine hesitancy. Whereas traditional hesitancy occurs in circumstances where vaccine safety is established and the vaccine is already widely available, that is not yet the case with COVID-19 vaccination. Improving intention to vaccinate against COVID-19 to slow the pandemic will require targeted health communication strategies that effectively reach the subpopulations most likely to refuse COVID-19 vaccination and that ameliorate the primary concerns of individuals reluctant to vaccinate using scientific evidence (Goldstein et al., 2015). Consequently, an important first step in this process is to identify who in the American public is least likely to pursue an eventual COVID-19 vaccine and their reasons for not pursuing vaccination. Our efforts to start this process are, necessarily, an exploratory exercise. The uncertain nature of the COVID-19 pandemic, coupled with the unprecedented pace at which vaccines are being developed, makes it difficult to say with certainty whether previous research on the reasons for vaccine refusal may extend to this particular vaccine. Consequently, our work aims to provide a pluralistic overview of the public opinion landscape surrounding COVID-19 vaccination that considers many potential correlates and justifications for intended vaccine refusal. Of course, while we are open to the possibility that insights from past research may not apply to this particular vaccine, previous work nevertheless does suggest several areas in which we might expect to observe important differences in vaccination intentions. For example, it is critical to examine the possibility of racial differences in COVID-19 vaccine refusal, as previous research suggests that racial minority groups are less likely to be vaccinated against some vaccine-preventable diseases. For example, Black and Hispanic adults are less likely to receive annual influenza vaccinations (CDC 2019; “Immunizations and African Americans,” 2018). Moreover, concerning this particular vaccine, anti-vaccine advocacy groups have made a concerted effort to target Black Americans with anti-COVID-19 vaccine messaging. Specifically, the Children's Health Defense – a prominent anti-vaccine advocacy group – has suggested that a COVID-19 vaccine could fit in with a pattern of ‘historical lapses in public health ethics’ and has attempted to tie the COVID-19 vaccine with past medical abuses against Blacks in the U.S. (Children’s Health Defense, 2020). These anti-vaccination messages have invoked the Tuskegee Syphilis Study, in which the United States Public Health Service studied untreated syphilis in Black men who were never told about the purpose of the study, were led to believe they were simply receiving free health care from the federal government, and were never provided penicillin to treat the disease (Brandt 1978). To the extent that anti-vaccine advocacy groups are successful in framing COVID-19 vaccination in terms of past medical abuses against minority groups, it could decrease the likelihood that racial minorities will pursue COVID-19 vaccination, particularly in light of recent findings emphasizing the implications of peripheral trauma (Alsan et al., 2020). Additionally, while past research has presented a mixed pattern of results concerning the possibility that women are less likely than men to vaccinate, we nevertheless recognize that women make 80% of health care decisions for families and are more likely to be deeply concerned about vaccination issues, especially for children (Matoff-Stepp et al., 2014; Pew Research Center, 2017). Given this increased burden for health care decisions and concern about vaccination, women may pay particularly close attention to information concerning the safety and efficacy of a COVID-19 vaccine. Finally, we think it is important to consider the possibility of partisan asymmetries in vaccination intentions. Prior research suggests that conservatives are less likely to trust medical and scientific experts (e.g., Motta 2018), and – perhaps consequently – are more likely to think that vaccines are unsafe (Joslyn and Sylvester 2019; Baumgaertner et al., 2018). Conservatives are also less likely to believe that the COVID-19 pandemic poses a serious public health threat (Tyson 2020), potentially due to messaging from President Trump suggesting otherwise (Summers 2020), which could undermine the perceived necessity of vaccinating.

BACKGROUND Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation. METHODS Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing. RESULTS For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA. CONCLUSIONS The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585–1589. © 2017 American Cancer Society.

In order to better understand what threatens vulnerable populations’ access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic’s financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.

Previous research has found that Hospital Compare, Medicare's public reporting initiative, has had little impact on patient outcomes. However, little is known about the initiative's impact on hospital prices, which may be significant because private insurers are generally well positioned to respond to quality information when negotiating prices with hospitals. We estimated difference-in-differences models of the effects of Hospital Compare quality reporting on transaction prices for two major cardiac procedures, coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). States that had mandated their own public reporting systems before the implementation of Hospital Compare formed the control group. We found that prices for these procedures continued to increase overall after the initiation of Hospital Compare quality scores, but the rate of increase was significantly lower in states with no quality reporting metrics of their own before Hospital Compare, when compared to the control states (annual rates of increase of 4.4 percent versus 8.7 percent for PCI, and 3.9 percent versus 10.6 percent for CABG, adjusted for overall inflation). This finding implies that Hospital Compare provided leverage to purchasers in moderating price increases, while adding competitive pressures on hospitals. Providing accurate quality information on both hospitals and health plans could benefit consumers.

Regulatory entry barriers to hospital service markets, namely Certificate of Need (CON) regulations, are enforced in many US states. Policy makers in other states are considering reinstating CON policies in tandem with service expansions mandated under the Affordable Care Act. Although previous studies examined the volume effects of CON, demand responses to actual entry into local hospital markets are not well understood. In this paper, we empirically examine the demand-augmenting, demand-redistribution, and risk-allocation effects of hospital entry by studying the cardiac revascularization markets in Pennsylvania, a state in which dynamic market entry occurred after repeal of CON in 1996. Results from interrupted time-series analyses indicate demand-augmenting effects for coronary artery bypass graft (CABG) and business-stealing effects for percutaneous coronary intervention (PCI) procedures: high entrant market share mitigated the declining incidence of CABG, but it had no significant effect on the rising trend in PCI use, among patients with coronary artery disease. We further find evidence that entry by new cardiac surgery centers tended to sort high-severity patients into the more invasive CABG procedure and low-severity patients into the less invasive PCI procedures. These findings underscore the importance of considering market-level strategic responses by hospitals when regulatory barriers are rescinded. Copyright © 2014 John Wiley & Sons, Ltd.

Previous research found that the initiation of Hospital Compare (HC) quality reporting had little impact on patient outcomes. However little is known about its impact on hospital prices, which may be significant since insurers are positioned to respond to quality information when engaging hospitals in price negotiations. To explore this issue we estimate variants of difference-in-difference models allowing HC impacts to vary by levels of quality scores. We separately examine the effects of the three main scores (heart attack, heart failure, and combined mortalities) on transaction prices of two related cardiac procedures: bypass surgery and angioplasty. States which had mandated reporting systems preceding HC form the control group. Analyzing claims data of privately insured patients, we find that HC exerted downward pressure on prices, which we attribute to competitive pressures. However, hospitals ranked “above average” captured higher prices, thereby offsetting the overall policy effect. We conclude that HC was effective at constraining prices without penalizing high performers.

Out-of-pocket expenditures are thought to be an important barrier to the receipt of cancer preventive services, especially for those of a lower socioeconomic status (SES). The Affordable Care Act (ACA) eliminated out-of-pocket expenditures for recommended services, including mammography and colonoscopy. The objective of this study was to determine changes in the uptake of mammography and colonoscopy among fee-for-service Medicare beneficiaries before and after ACA implementation.Using Medicare claims data, this study identified women who were 70 years old or older and had not undergone mammography in the previous 2 years and men and women who were 70 years old or older, were at increased risk for colorectal cancer, and had not undergone colonoscopy in the past 5 years. The receipt of procedures in the 2-year period before the ACA's implementation (2009-2010) and after its implementation (2011 to September 2012) was also identified. Multivariate generalized estimating equation models were used to determine the independent association and county-level quartile of median income and education with the receipt of testing.For mammography, a lower SES quartile was associated with less uptake, but the post-ACA disparities were smaller than those in the pre-ACA period. In addition, mammography rates increased from the pre-ACA period to the post-ACA period in all SES quartiles. For colonoscopy, in both the pre- and post-ACA periods, there was an association between uptake and educational level and, to some extent, income. However, there were no appreciable changes in colonoscopy and SES after implementation of the ACA.The removal of out-of-pocket expenditures may overcome a barrier to the receipt of recommended preventive services, but for colonoscopy, other procedural factors may remain as deterrents. Cancer 2017;123:1585-1589. © 2017 American Cancer Society.

Introduction: The Department of Health and Human Services’ 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults. Objectives: To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50–64 and ≥65 years of age, respectively). Design: A cross-sectional study of the 2010 Health and Retirement Study (HRS; n=17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries ( n=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status. Results: No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50–64 years, 26.7% of the participants presented with ≥10 CCMM, but incurred 48% of the expenditure. In those aged ≥65 years, these percentages were 16.9% and 34.4%, respectively. Conclusion: Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.

BACKGROUND: This study examined effects of health maintenance organization (HMO) penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer. METHODS: The MarketScan Database (data from 2002-2007) was used to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n ¼ 1035 and n ¼ 6389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, the Herfindahl-Hirschman index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy. RESULTS: Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.9% increase in the likelihood of undergoing laparoscopic colectomy (adjusted odds ratio ¼ 1.109; 95% confidence interval [CI] ¼ 1.062, 1.158) and a 10% increase in HHI resulting in 6.6% lower likelihood (adjusted odds ratio ¼ 0.936; 95% CI ¼ 0.880, 0.996). Price models indicated that the price of laparoscopy was 7.6% lower than that of open surgery (transformed coefficient ¼ 0.927; 95% CI ¼ 0.895, 0.960). A 10% increase in HMO penetration was associated with 1.6% lower price (transformed coefficient ¼ 0.985; 95% CI ¼ 0.977, 0.992), whereas a 10% increase in HHI was associated with 1.6% higher price (transformed coefficient ¼ 1.016; 95% CI ¼ 1.006, 1.027; P < .001 for all comparisons). CONCLUSIONS: Laparoscopy was significantly associated with lower hospital prices. Moreover, laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption. Cancer 2012;118:5741-8. V C 2012 American Cancer Society.

This study assesses the potential cost savings associated with the use of community health centers, based on econometric analyses of the 2006 Medical Expenditure Panel Survey. After controlling for health status, health insurance coverage, income, age, and other factors, this study finds that patients who receive a majority of their ambulatory care at community health centers have significantly lower annual overall medical expenditures (24%) and ambulatory expenditures (25%) than those who do not. These results are consistent with other studies indicating that, by providing good quality primary care, community health centers can reduce the utilization of other medical services.

Insurance for prescription drugs is characterized by two types of cost-sharing: flat copayments and variable coinsurance. We develop a theoretical model to show that refill purchases of preventive drugs (compliance) are lower under coinsurance due to the consumer's exposure to variation in drug prices. Coinsurance creates countervailing incentives. Consumers who never comply under flat copayments might find it optimal to comply if they drew a relatively low price under coinsurance. In contrast, consumers who always comply under flat copayments might stop complying if they drew a relatively high price under coinsurance. Our theory shows the second effect dominates under certain distributional assumptions about health states. Empirically, we derive comparable models for compliance behavior in the two regimes. Using claims data from eight large firms, we focus our analysis on diabetes, a common chronic condition that leads to severe complications when not continuously treated with medications. Propensity score methods are used to create matched samples for the two insurance regimes. We find that when coinsurance and flat copayments have the same expected out-of-pocket of $9, at least 34% of patients under copayments would fully comply and refill their medication over the next 90 days, compared to only 24% under coinsurance. Similarly, under copayments, moving from the 25th percentile to the 75th percentile of cost sharing results in a significantly lower shift into the non-compliance state compared with coinsurance. Thus, the empirical results confirm the main theoretical predictions. This research is a substantial revision and extension of our earlier 2004 NBER working paper no. 10738.

IMPORTANCE: Physicians often report practicing defensive medicine to reduce malpractice risk, including performing expensive but marginally beneficial tests and procedures. Although there is little evidence that malpractice reform affects overall health care spending, it may influence physician behavior for specific conditions involving clinical uncertainty. OBJECTIVE: To examine whether reducing malpractice risk is associated with clinical decisions involving coronary artery disease testing and treatment. DESIGN, SETTING, AND PARTICIPANTS: Difference-in-differences design, comparing physician-specific changes in coronary artery disease testing and treatment in 9 new-cap states that adopted damage caps between 2003 and 2005 with 20 states without caps. We used the 5% national Medicare fee-for-service random sample between 1999 and 2013. Physicians (n = 75 801; 36 647 in new-cap states) who ordered or performed 2 or more coronary angiographies. Data were analyzed from June 2015 to January 2018. MAIN OUTCOMES AND MEASURES: Changes in ischemic evaluation rates for possible coronary artery disease, type of initial evaluation (stress testing or coronary angiography), progression from stress test to angiography, and progression from ischemic evaluation to revascularization (percutaneous coronary intervention or coronary artery bypass grafting). RESULTS: We studied 36 647 physicians in new-cap states and 39 154 physicians in no-cap states. New-cap states had younger populations, more minorities, lower per-capita incomes, fewer physicians per capita, and lower managed care penetration. Following cap adoption, new-cap physicians reduced invasive testing (angiography) as a first diagnostic test compared with control physicians (relative change, −24%; 95% CI, −40% to −7%; P = .005) with an offsetting increase in noninvasive stress testing (7.8%; 95% CI, −3.6% to 19.3%; P = .17), and referred fewer patients for angiography following stress testing (−21%; 95% CI, −40% to −2%; P = .03). New-cap physicians also reduced revascularization rates after ischemic evaluation (−23%; 95% CI, −40% to −4%; P = .02; driven by fewer percutaneous coronary interventions). Changes in overall ischemic evaluation rates were similar for new-cap and control physicians (−0.05%; 95% CI, −8.0% to 7.9%; P = .98). CONCLUSIONS AND RELEVANCE: Physicians substantially altered their approach to coronary artery disease testing and follow-up after initial ischemic evaluations following adoption of damage caps. They performed a similar number of ischemic evaluations but conducted fewer initial left heart catheterizations, referred fewer stress-tested patients for left heart catheterizations, and referred fewer patients for revascularization. These findings suggest that physicians tolerate greater clinical uncertainty in coronary artery disease testing and treatment if they face lower malpractice risk.

This paper examines the extent to which hospitals that are under external contract management engage in service duplication, as well as the degree to which the various services they offer contribute to or detract from community access. The study incorporates all USA hospitals using data from the American Hospital Association Annual Survey Database, supplemented by county level measures obtained from the area resource file (ARF). Using data on the 3794 hospitals classified as acute care facilities in 2002, we performed a set of logistic regressions that analyzed whether a hospital offered each of 74 distinct services. For each service (regression), key independent variables measured the number of other hospitals in the local market area that also offered the service. Local area market definitions are the areas circumscribed by the hospital within distances of 10 and 20 miles. Results suggest that contract-managed (CM) hospitals display a more competitive pattern (service duplication) than hospitals in general, but CM hospitals that are the sole provider of services locally are less likely to offer services than traditionally managed sole hospital providers. Contract management does not appear to offer any particular advantages in improving access to hospital services.

Specialized managerial expertise, coupled with the threat of non-renewal should improve efficiency in firms that opt for contract management arrangements. To examine this we apply a generalized version of tests for expense preference behavior to U.S. hospitals in the 1990s. Extending prior literature, we create a quasi-experimental design for a comparison of adopters and non-adopters of contracts using propensity score methods. We generate the distribution of ‘expense preference’ parameters for all contract adopters in both the pre- and post-adoption states, and for a matched control group of non-adopters over the same period. Our results show that contract adoption leads to reduced expense preference behavior, but that this result depends critically on the input being examined.

End-stage renal disease (ESRD) is a debilitating, costly, and increasingly common condition. Little is known about how different financing approaches affect ESRD outcomes and delivery of care. This paper presents results from a comparative review of 12 countries with alternative models of incentives and benefits, collected under the International Study of Health Care Organization and Financing, a substudy within the Dialysis Outcomes and Practice Patterns Study. Variation in spending per ESRD patient is relatively small, but correlated with overall per capita health care spending. Remaining differences in costs and outcomes do not seem strongly linked to differences in incentives.

BACKGROUND The Affordable Care Act (ACA) removed copayments for screening mammography and colonoscopy in Medicare beneficiaries, but its clinical impact is unknown. METHODS Using a 5% random sample of Medicare claims from 2009 through 2012 in individuals age 70 years or older who were due for screening, we examined claims for screening mammography and screening or surveillance colonoscopy for two years prior to ACA (2009-2010) and two years post-ACA (2011-2012). Receipt of the procedures at the patient level was compared across years using generalized estimating equations. Statistical tests were two-sided. RESULTS Compared with 2009, we found an increase in mammography uptake during the ACA coverage period, with multivariable odds ratios (MOR) of 1.22 (95% confidence interval [CI] = 1.20 to 1.25, P < .001) for 2011 and 1.17 (95% CI = 1.15 to 1.20, P < .001) for 2012 and less change in 2010 (OR = 1.03, 95% CI = 1.01 to 1.05, P = .01). In contrast to mammography, uptake of screening or surveillance colonoscopy decreased in 2012 (MOR = 0.95, 95% CI = 0.92 to 0.98, P = .002) compared with 2009, with no change in 2010 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .47) or 2011 (MOR = 1.01, 95% CI = 0.99 to 1.04, P = .34). Other factors associated with procedure receipt included younger age and prior preventive health visits. In an analysis restricted to patients age 70 to 74 years, colonoscopy use increased slightly in 2011 but was unchanged in 2012, and the findings by year for mammography were consistent with the main analysis. CONCLUSIONS Following ACA implementation with concomitant reduction in out-of-pocket expenditures, there was a statistically significant increment in mammography uptake but not colonoscopy. This suggests that affordability is a necessary but not sufficient facilitator of preventive services.

In order to better understand what threatens vulnerable populations’ access to primary care, it is important to understand the factors associated with closing safety-net clinics. This paper examines how a clinic’s financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers (FQHCs) and non-FQHCs generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety-net clinics.

Background Routine HIV testing is an essential approach to identifying undiagnosed infections, linking people to care and treatment, and preventing new infections. In Washington, DC, where HIV prevalence is 2.4%, a combination of routine and targeted testing approaches has been implemented since 2006. Methods We sought to evaluate the cost effectiveness of the District of Columbia (DC) Department of Health’s routine and targeted HIV testing implementation strategies. We collected HIV testing data from 3 types of DC Department of Health-funded testing sites (clinics, hospitals, and community-based organizations); collected testing and labor costs; and calculated effectiveness measures including cost per new diagnosis and cost per averted transmission. Results Compared to routine testing, targeted testing resulted in higher positivity rates (1.33% vs. 0.44%). Routine testing averted 34.30 transmissions per year compared to targeted testing at 17.78. The cost per new diagnosis was lower for targeted testing ($2,467 vs. $7,753 per new diagnosis) as was the cost per transmission averted ($33,160 vs. $104,205). When stratified by testing site, both testing approaches were most cost effective in averting new transmissions when conducted by community based organizations ($25,037 routine; $33,123 targeted) compared to hospitals or clinics. Conclusions While routine testing identified more newly diagnosed infections and averted more infections than targeted testing, targeted testing is more cost effective per diagnosis and per transmission averted overall. Given the high HIV prevalence in DC, the DC Department of Health’s implementation strategy should continue to encourage routine testing implementation with emphasis on a combined testing strategy among community-based organizations.

Colorectal cancer (CRC), a highly prevalent condition and a leading cancer-related cause of death in the elderly (Jemal et al. 2005), is potentially curable when detected early (Smith, Cokkinides, and Eyre 2005). In addition, when surgery for CRC is of an emergency and/or palliative nature, it is associated with a substantially elevated risk of mortality (McArdle and Hole 2004), especially in the frail elderly (Koperna, Kisser, and Schulz 1997). Consequently, the benefits of screening may not necessarily be limited to those who are healthy, but are likely to extend to older individuals, and to those with compromised health as well (Clark et al. 2004). The U.S. Preventive Services Task Force (USPSTF) recommends fecal occult blood test (FOBT) to be performed on an annual basis, and flexible sigmoidoscopy (FLEX) and colonoscopy at 10-year intervals (The U.S. Preventive Services Task Force 2005). It further recommends initiating CRC screening at 50 years of age in men and women at average risk for CRC, and earlier in individuals at higher risk for the disease, although there is no consensus on the age at which CRC screening should be discontinued. Despite the higher yield of CRC screening in older individuals, its benefits may be considered limited because of competing causes of death. Given the changing demographics, however, and the increasingly greater representation of healthier individuals in the older age groups, there may be less of a tendency to set an age limit beyond which CRC screening is no longer recommended. Also, because of the greater morbidity and mortality in patients presenting with emergency CRC resection, generally resulting from screening failure, the recommendation and practice of CRC screening in the context of age and the presence of comorbid conditions are likely to be reconsidered. Dually eligible Medicare–Medicaid beneficiaries (hereafter referred to as “duals”) represent the oldest, poorest, and frailest of the elderly population (The Henry J. Kaiser Family Foundation 2004; Murray and Shatto 1998). For example, whereas 73 percent of duals have annual incomes of $10,000 or less, only 12 percent of nonduals may be identified with such income levels. Similarly, duals are considerably more likely than nonduals to rate their health as poor or fair (52 versus 26 percent, respectively), to present significant limitations in activities of daily living (over 30 versus 11 percent), or to reside in nursing homes (19 versus 3 percent; The Henry J. Kaiser Family Foundation 2005). On the other hand, the above statistics imply that nearly 50 percent rate their health as good, very good, or excellent; two thirds report no limitations in their activities of daily living; and 80 percent are community-dwelling—suggesting that a sizable proportion of duals may in fact benefit from preventive care. Also, while most duals have low incomes, enrollment in Medicaid is likely to give them considerable leverage to access health services that they could not afford otherwise. The above descriptions attest to the complexity of issues in studying the health care needs of duals as a subgroup of Medicare beneficiaries at large, and illustrate the diversity in this population, especially relative to their health and functional status. In comparing the use of cancer screening between duals and nonduals, several factors need to be accounted for in formulating research hypotheses. First, considering differentials in health status between duals and nonduals, we can posit that because of competing priorities in addressing the complex health care needs in a sizable proportion of duals, management of acute and/or chronic ailments—rather than prevention—becomes the focus of care—hence the lower likelihood of undergoing cancer screening tests. Second, from the perspective of income, we postulate, based on previous studies, that lower income—and potentially lower educational attainment—is associated with underuse of preventive services (Katz and Hofer 1994; Katz, Zemencuk, and Hofer 2000), even if enrollment in Medicaid is conducive to greater access to health care. We therefore hypothesize that duals would experience a significantly lower rate of cancer screening than their nondual counterparts. The present study examines the use of CRC screening services among Medicare beneficiaries by dual Medicare–Medicaid enrollment status, an attribute largely understudied in the disparities literature. More specifically, we compare receipt of CRC screening by duals and nonduals 65 years of age or older, after adjusting for individual-level characteristics. Given the previously documented associations between county-level socioeconomic and health systems attributes with the use of CRC screening (Koroukian et al. 2005), relevant contextual variables are also accounted for in the analysis.

According to the U.S. Census Bureau, 45 million Americans were without health insurance in 2003 and their numbers continues to grow. Health benefits in the U.S. remain heavily employer-based with about 60 percent of all insured individuals being enrolled through employer-sponsored plans. While the indigent can often qualify for public assistance programs such as Medicaid, many participants in the labor force may not have adequate access to coverage through their employer. Although it is possible to purchase individual plans privately, these may only be available at prohibitively high rates compared with the group rates available through large employers. As a consequence, 16 percent of full-time workers are uninsured (Fronstin 2003). Not surprisingly, much of the policy discussion focuses on ways of expanding coverage to all workers. In 2005, Congress enacted Health Savings Accounts to allow small employers and their employees to purchase high deductible insurance plans at low premiums. During the last presidential election campaign the Bush administration proposed a tax credit of up to $1,000 to help low income workers purchase insurance and health savings accounts, while the Kerry–Edwards campaign favored expanding employer-based coverage by allowing private buy-ins through the health insurance program for Federal government employees or through Medicare. The potential impact of health insurance of the health of the population is one important issue that underlies the policy debate. Evidence to this effect may provide further support in favor of policies designed to expand health insurance coverage, irrespective of the policy mechanism ultimately chosen. In a recent review of the literature, Hadley (2003) found broad evidence of positive impacts in studies based on observational data. The magnitude of these effects, however, varied with the type of population sampled, type of illness and the particular measure of health outcomes chosen and thus merits further investigation. Most of the previous research focused on mortality as the outcome measure, rather than actual measures of health status. Moreover Hadley notes the paucity of research that adjusts for endogeneity of insurance participation in health equations, suggesting that previous studies may have underestimated the insurance effect (p. 43). In this paper, we attempt to fill both of these gaps. First, we employ a composite health score as our outcome measure, rather than the more commonly used mortality probabilty (e.g., Franks, Clancy, and Gold 1993; Sorlie et al. 1994). Second, we attempt to adjust for potential endogeneity. Our identification approach is similar to that of Goldman et al. (2001), who focused on the effect of Medicaid on declines in mortality probabilities for HIV-positive individuals. However, given our interest in employment related insurance we focus on working-age adults. While our findings are in agreement with Goldman et al. in that both studies yield greater insurance effects after adjusting for endogeneity, we are also careful to point out difficulties in statistical identification inherent in such models and we note the possible range of estimates for the insurance effect. With this caveat noted, our results provide deeper evidence that expanding insurance will have direct benefits in terms of improved health outcomes. The rest of the paper proceeds as follows: the second section summarizes the relevant literature on health scores, and on the effect of insurance on outcomes. The third section presents the methodological approach and estimation framework. The fourth section presents data and variable definitions. The fifth section presents results from the insurance participation equation and the health status equation for the full sample and a summary of number of tests for endogeneity bias. The sixth section replicates this analysis for subsets of survey respondents based on groupings of chronic conditions. This was done in order to test whether insurance effects are repeated across various settings in which symptoms of the underlying medical condition may not be equally observable to the individual. Finally, implications and limitations of the results are discussed in the last section.

Pricing methodologies in Medicare vary from one component of the system to another, often leading to conflicting incentives. Failure to recognize linkages may result in inefficient allocation of resources and higher overall costs. To motivate the analysis, I derive pricing rules for a welfare-maximizing regulator. I show that while optimal inpatient payments are standard Ramsey prices, optimal outpatient payments must incorporate net loss due to unnecessary hospitalizations, as well as supply elasticities. Ignoring this leads the myopic regulator to underprovide preventive services. The dialysis program is a useful case for empirical investigation, since payments for maintenance care are more rigidly determined than payments for related hospital care. Given constant prices, empirical analysis focuses on the effect of dialysis intensity on hospital use. Results indicate that greater dialysis intensity reduces hospital use, even at levels considered more than “adequate”. A simple cost-benefit calculation suggests that for every dollar of additional spending on outpatient intensity, about $2 in hospital expenditures can be saved. This suggests that the current pricing structure within aspects of the Medicare program is inefficient, underscoring the problem of regulatory myopia.