Abstract Blomqvist and Johansson (1996) criticize my results regarding Besley's ( Besley, 198... more Abstract Blomqvist and Johansson (1996) criticize my results regarding Besley's ( Besley, 1989 ) analysis of public catastrophic coverage. They concede that my analysis was correct under the assumptions I made, but they argue that a more general model than Besley or I used might yield different results. Unfortunately, Blomqvist and Johansson's analysis of the more general case is flawed. Whereas they claim to have provided a more general argument against the sort of public intervention Besley proposed, they have unwittingly discovered an example in which his original conjecture holds.
... Intemational Bank for Reconstruction and Development (World Bank) IDC Indian Dairy Corporatio... more ... Intemational Bank for Reconstruction and Development (World Bank) IDC Indian Dairy Corporation IEFR Intemational Emergency Food Reserve ILO Intemational Labour Organisation (of the United Nations) INTERFAIS Intemational System of Information on Food Aid (of WFP ...
The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adul... more The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adults eligible for Medicaid. Starting in 2014, states can elect to cover individuals and families with modified adjusted gross incomes below a threshold of 133 percent of federal poverty guidelines, with a 5 percent income disregard. We used simulation methods and data from the Medical Expenditure Panel Survey to compare nondisabled adults enrolled in Medicaid prior to the ACA with two other groups: adults who were eligible for Medicaid but not enrolled in it, and adults who were in the income range for the ACA's Medicaid expansion and thus newly eligible for coverage. Although differences in health across the groups were not large, both the newly eligible and those eligible before the ACA but not enrolled were healthier on several measures than pre-ACA enrollees. Twenty-five states have opted not to use the ACA to expand Medicaid eligibility. If these states reverse their decisions, their Medicaid programs might not enroll a population that is sicker than their pre-ACA enrollees. By expanding Medicaid eligibility, states could provide coverage to millions of healthier adults as well as to millions who have chronic conditions and who need care.
Objectives. We examined prereform patterns in insurance coverage, access to care, and preventive ... more Objectives. We examined prereform patterns in insurance coverage, access to care, and preventive services use by race/ethnicity in adults targeted by the coverage expansions of the Patient Protection and Affordable Care Act (ACA).Methods. We used pre-ACA household data from the Medical Expenditure Panel Survey to identify groups targeted by the coverage provisions of the Act (Medicaid expansions and subsidized Marketplace coverage). We examined racial/ethnic differences in coverage, access to care, and preventive service use, across and within ACA relevant subgroups from 2005 to 2010. The study took place at the Agency for Healthcare Research and Quality in Rockville, Maryland.Results. Minorities were disproportionately represented among those targeted by the coverage provisions of the ACA. Targeted groups had lower rates of coverage, access to care, and preventive services use, and racial/ethnic disparities were, in some cases, widest within these targeted groups.Conclusions. Our findings highlighted the opportunity of the ACA to not only to improve coverage, access, and use for all racial/ethnic groups, but also to narrow racial/ethnic disparities in these outcomes. Our results might have particular importance for states that are deciding whether to implement the ACA Medicaid expansions.
Veteran access to care is an important policy issue that has not previously been examined with po... more Veteran access to care is an important policy issue that has not previously been examined with population-based survey data. This study compares access to care for nonelderly adult Veterans versus comparable non-Veterans, overall and within subgroups defined by simulated eligibility for health care from the Veterans Health Administration and by insurance status. We use household survey data from the Medical Expenditure Panel Survey from 2006 to 2011. We use iterative proportional fitting to standardize (control for) differences in age, sex, income, medical conditions, disability, Census region, and Metropolitan Statistical Area. Nonelderly Veterans and comparable non-Veterans. For medical, dental, and prescription medicine treatments, we use 4 access measures: delaying care, inability to obtain care, perceiving delay as a big problem, and perceiving inability to obtain care as a big problem. We also examine having a usual source of care. Frequencies of access barriers are similar for nonelderly Veterans and comparable non-Veterans for dental and prescription medicine treatments. For medical treatment, we find that Veterans eligible for VA health care and Veterans with VA use who are uninsured report fewer access problems than the comparable non-Veteran populations for 2 measures: inability to obtain care and reporting inability to obtain care as a big problem. Our results show that uninsured Veterans, the most policy-relevant group, have better access to care than comparable non-Veterans. Our results highlight the importance of adjusting Veteran and non-Veteran comparisons to account for the higher than average health care needs of Veterans.
Objective: To determine the impact of parity in mental health benefits on the marginal prices tha... more Objective: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. Data sources/data collection: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. Study design: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. Principal findings: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. Conclusions: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population.
This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of e... more This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of equilibrium in the market for employment-related health insurance. We examine coverage generosity, premiums, and insurance benefits net of expenditures on premiums, showing that despite a degree of market segmentation, there was a substantial amount of pooling of heterogeneous risks in 1987 among households with employment-related coverage. Our results are largely invariant to (i) firm size and (ii) whether or not employers offer a choice among plans. Our results suggest the need for caution concerning incremental reforms that would weaken the link between employment and insurance without substituting alternative institutions for the pooling of risks.
Abstract Blomqvist and Johansson (1996) criticize my results regarding Besley's ( Besley, 198... more Abstract Blomqvist and Johansson (1996) criticize my results regarding Besley's ( Besley, 1989 ) analysis of public catastrophic coverage. They concede that my analysis was correct under the assumptions I made, but they argue that a more general model than Besley or I used might yield different results. Unfortunately, Blomqvist and Johansson's analysis of the more general case is flawed. Whereas they claim to have provided a more general argument against the sort of public intervention Besley proposed, they have unwittingly discovered an example in which his original conjecture holds.
... Intemational Bank for Reconstruction and Development (World Bank) IDC Indian Dairy Corporatio... more ... Intemational Bank for Reconstruction and Development (World Bank) IDC Indian Dairy Corporation IEFR Intemational Emergency Food Reserve ILO Intemational Labour Organisation (of the United Nations) INTERFAIS Intemational System of Information on Food Aid (of WFP ...
The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adul... more The Affordable Care Act (ACA) has dramatically increased the number of low-income nonelderly adults eligible for Medicaid. Starting in 2014, states can elect to cover individuals and families with modified adjusted gross incomes below a threshold of 133 percent of federal poverty guidelines, with a 5 percent income disregard. We used simulation methods and data from the Medical Expenditure Panel Survey to compare nondisabled adults enrolled in Medicaid prior to the ACA with two other groups: adults who were eligible for Medicaid but not enrolled in it, and adults who were in the income range for the ACA's Medicaid expansion and thus newly eligible for coverage. Although differences in health across the groups were not large, both the newly eligible and those eligible before the ACA but not enrolled were healthier on several measures than pre-ACA enrollees. Twenty-five states have opted not to use the ACA to expand Medicaid eligibility. If these states reverse their decisions, their Medicaid programs might not enroll a population that is sicker than their pre-ACA enrollees. By expanding Medicaid eligibility, states could provide coverage to millions of healthier adults as well as to millions who have chronic conditions and who need care.
Objectives. We examined prereform patterns in insurance coverage, access to care, and preventive ... more Objectives. We examined prereform patterns in insurance coverage, access to care, and preventive services use by race/ethnicity in adults targeted by the coverage expansions of the Patient Protection and Affordable Care Act (ACA).Methods. We used pre-ACA household data from the Medical Expenditure Panel Survey to identify groups targeted by the coverage provisions of the Act (Medicaid expansions and subsidized Marketplace coverage). We examined racial/ethnic differences in coverage, access to care, and preventive service use, across and within ACA relevant subgroups from 2005 to 2010. The study took place at the Agency for Healthcare Research and Quality in Rockville, Maryland.Results. Minorities were disproportionately represented among those targeted by the coverage provisions of the ACA. Targeted groups had lower rates of coverage, access to care, and preventive services use, and racial/ethnic disparities were, in some cases, widest within these targeted groups.Conclusions. Our findings highlighted the opportunity of the ACA to not only to improve coverage, access, and use for all racial/ethnic groups, but also to narrow racial/ethnic disparities in these outcomes. Our results might have particular importance for states that are deciding whether to implement the ACA Medicaid expansions.
Veteran access to care is an important policy issue that has not previously been examined with po... more Veteran access to care is an important policy issue that has not previously been examined with population-based survey data. This study compares access to care for nonelderly adult Veterans versus comparable non-Veterans, overall and within subgroups defined by simulated eligibility for health care from the Veterans Health Administration and by insurance status. We use household survey data from the Medical Expenditure Panel Survey from 2006 to 2011. We use iterative proportional fitting to standardize (control for) differences in age, sex, income, medical conditions, disability, Census region, and Metropolitan Statistical Area. Nonelderly Veterans and comparable non-Veterans. For medical, dental, and prescription medicine treatments, we use 4 access measures: delaying care, inability to obtain care, perceiving delay as a big problem, and perceiving inability to obtain care as a big problem. We also examine having a usual source of care. Frequencies of access barriers are similar for nonelderly Veterans and comparable non-Veterans for dental and prescription medicine treatments. For medical treatment, we find that Veterans eligible for VA health care and Veterans with VA use who are uninsured report fewer access problems than the comparable non-Veteran populations for 2 measures: inability to obtain care and reporting inability to obtain care as a big problem. Our results show that uninsured Veterans, the most policy-relevant group, have better access to care than comparable non-Veterans. Our results highlight the importance of adjusting Veteran and non-Veteran comparisons to account for the higher than average health care needs of Veterans.
Objective: To determine the impact of parity in mental health benefits on the marginal prices tha... more Objective: To determine the impact of parity in mental health benefits on the marginal prices that consumers face for mental health treatment. Data sources/data collection: We used detailed information on health plan benefits for a nationally representative sample of the privately insured population under age 65 taken from the 1987 National Medical Expenditure Survey (Edwards and Berlin 1989). The survey was carefully aged and reweighted to represent 1995 population and coverage characteristics. Study design: We computed marginal out-of-pocket costs from the cost-sharing benefits described by policy booklets under current coverage and under parity for various mental health treatment expenditure levels using the MEDSIM health care microsimulation model developed by researchers at the Agency for Healthcare Research and Quality. Descriptive analyses and two-limit Tobit regression models are used to examine how insurance generosity varies across individuals by demographic and socioeconomic characteristics. Our analyses are limited to a description of how parity would change the marginal incentives faced by consumers under their existing plan's cost-sharing arrangements for mental and physical health care. We do not attempt to simulate how parity might affect the level of benefits, including whether benefits are offered at all, or the level of managed care that affects the actual benefits that plan members receive. Rather, we focus only on the nominal benefits described in their policy booklets. Principal findings: Our results show that as of 1995 parity coverage would substantially reduce the share of mental health expenditures that consumers would pay at the margin under their existing plan's cost-sharing provisions, with larger changes for outpatient care than for inpatient care. Because current mental health coverage generally becomes less generous as expenditures rise, while coverage for other medical care becomes more generous (due to stop-loss provisions), the difference in incentives between current mental health coverage and the assumed parity coverage widens as total expenditure grows. We also find that the impact of parity on marginal incentives would vary greatly across the privately insured population. Conclusions: Based on the large variation in the impact of parity on marginal incentives across the population under current plan cost-sharing arrangements, changes in the demand for mental health treatment will likely also vary across the population.
This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of e... more This paper uses data from the 1987 National Medical Expenditure Survey to examine the nature of equilibrium in the market for employment-related health insurance. We examine coverage generosity, premiums, and insurance benefits net of expenditures on premiums, showing that despite a degree of market segmentation, there was a substantial amount of pooling of heterogeneous risks in 1987 among households with employment-related coverage. Our results are largely invariant to (i) firm size and (ii) whether or not employers offer a choice among plans. Our results suggest the need for caution concerning incremental reforms that would weaken the link between employment and insurance without substituting alternative institutions for the pooling of risks.
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Papers by Thomas Selden