公共政策的经济分析Chap10课件

Chapter10–SocialInsuranceII:HealthCare1What’sSpecialAboutHealthCare?HealthcarecostsarelargeandgrowingfastNumberofreasonswhyFirstWelfareTheoremmaybeviolatedPoorinformation(physicianinduceddemand)AdverseselectionandmoralhazardDiseaseexternalities2What’sSpecialAboutHealthCare?Inthecontextofhealthcare,moralhazardcanbeanalyzedinaconventionalsupply-and-demandframework.Healthinsurancechangesthepriceofhealthcare,andcreatesdeadweightloss.3Figure10.14What’sSpecialAboutHealthCare?Withoutinsurance,consumeM0ofhealthcareservices.Insuranceinthisexamplelowersthepriceofservicesto20%ofactualprice.Withinsurance,consumeM1ofhealthcareservices.Deadweightlossequalsabh.5What’sSpecialAboutHealthCare?Assumedthatdemandforhealthcaredownwardsloping(e.g.,healthcareuseiselasticwithrespecttotheprice).Assumedcoinsurancerateof20%--theamounttheinsuredpersonpaysoutofpocket.Socialexperimentsfindthattheelasticityofdemandforhealthcareis-0.20.6TheU.S.HealthCareMarketPatchworkofpublicandprivateinsurance.13.2%ofGDPSpendingonhospitalsis32%ofcostsSpendingonphysicianservicesis22%7TheU.S.HealthCareMarket:PrivateInsuranceVirtuallyall(93%)ofprivateinsuranceforthenon-elderlyisprovidedthroughtheemployer.By-productofwage&pricecontrolsduringWorldWarIITaxprovisionssubsidizeemployercontributionsGroupmarketislessexpensivethanindividualmarket8TheU.S.HealthCareMarket:PrivateInsuranceLinktoemploymentpotentiallyleadsto“joblock”Whenyouleaveyourjob,youalsoloseyourhealthinsuranceMaybedifficulttogetnewinsuranceifyouhavea“pre-existing”conditionKennedy-KassenbaumActmandatedthatemployersmustincludeanewemployeewhopreviouslyhadhealthinsurance,eveniftheyhavepre-existingcondition.9TheU.S.HealthCareMarket:PrivateInsuranceGroupmarketPossiblethatworkerswithinafirmarefairlyheterogeneous,soadverseselectionislessofaconcernOntheotherhand,employeesnotrandomlyassignedAnemployermayshift-compensationtowardwages,orshiftemployee’sontospouse’splanbyofferingalessgenerouspackageofbenefits.Moreproblematicatsmallerfirms.10TheU.S.HealthCareMarket:PrivateInsuranceCost-basedreimbursement/Fee-for-serviceInsurancepoliciesthatprovidepaymentstohealthcareprovidersbasedonactualcostsoftreatingpatientLittleincentivetoeconomizeonmethodsfordeliveringhealthcaresincefullyreimbursed11TheU.S.HealthCareMarket:PrivateInsuranceManagedCareFocusonsupply-side(healthcareprovider-side)ofmarketratherthanonthedemandsize.Oftenpatientsfaceverylittlecostsharing(pricesclosetozero)Quantityconstraints(suchasseeinga“gatekeeper”primarycarephysicianbeforeseeingaspecialist).Capitationbasedreimbursement–providersreceivedfixed,lumpsumperpatient,regardlessofactualutilization.12TheU.S.HealthCareMarket:PrivateInsuranceManagedCare,continuedHealthMaintenanceOrganizations(HMOs)–agroupofphysiciansworkonlyforaparticularplanandpatientscanonlyseedoctorswithinthatplanPreferredProviderOrganizations(PPOs)–agroupofphysiciansacceptlowerfeesforaccesstopatientnetwork;patientscangooutofthenetworkatgreatercost.13TheRoleofGovernmentMedicareImplicitsubsidyforemployerhealthinsuranceMedicaid14TheRoleofGovernment:MedicareEnactedin1965,provideshealthinsurancecoveragetovirtuallyallelderlyindividualsandsomedisabled.$254billionin2002Adverseselectionproblemslikelytobelargestfortheelderly15TheRoleofGovernment:MedicareApproximately40millionenrolleesNotmeans-testedProgramdividedintothreeparts:PartA:Hospitalinsurance(HI)PartB:Supplementarymedicalinsurance(SMI)–optional,but99%ofelderlytakeitupPartC:Medicare+Choice–optional,amanagedcarearrangementwhereelderlygetcertainadditionalbenefitslikeprescriptiondrugcoverageandhaverestrictedchoiceofproviders16TheRoleofGovernment:MedicareMedicaredoesnotcover:Long-terminstitutionalserviceslikenursinghomesPrescriptiondrugs,thoughnewlegislationwaspassedin2003thatwillphase-incoverageMedicarebeneficiariesspent$87billiononoutpatientprescriptiondrugsin200217TheRoleofGovernment:MedicareMedicarefinancingpaidforbypayrolltaxoncurrentworkersUncapped,totals2.9%splitevenlybetweenemployerandemployee18TheRoleofGovernment:MedicareMedicarefinancingpaidforbypayrolltaxoncurrentworkersUncapped,totals2.9%splitevenlybetweenemployerandemployeeMedicareoutlayshavegrowndramaticallyovertime–raisesconcernsaboutitssolvency19Table10.120TheRoleofGovernment:ControllingthecostsofMedicareIncreasingburdenoncurrentbeneficiariesPricecontrolsComplicatedtoadministerMayleadtoaccessproblemsAfterMedicarereducedreimbursementby5.4%in2002,asubstantialnumberofmedicalpracticesstoppedtakingMedicarepatients21TheRoleofGovernment:ControllingthecostsofMedicareManagedcareOnly15%ofMedicareelderlychoosemanagedcarearrangementsAnumberofHMOshavebackedoutofprovidingserviceHospiceandhomehealthcareEnd-of-lifeexpendituresare27%ofMedicarecosts.Maybelessexpensivetoprovidehomehealthcareratherthanexpensivein-patientproceduresHasnotslowedthegrowthinMedicarecosts22TheRoleofGovernment:ControllingthecostsofMedicareMedicalSavingsAccounts(MSAs)Consumershaveveryweakincentivestocontrolcosts,themoralhazardissueMSAsareineffectacatastrophicinsurancepolicy–providespaymentsforveryexpensiveillnesses,butnottheday-to-dayhealthcareneedsMoneyinMSAsthatisnotusedcanbeusedfornon-medicalpurposesLeadstoadverseselection,wherethelow-risksoptintoMSAs.23TheRoleofGovernment:

ImplicitSubsidyforHealthInsuranceEmployercontributionsforhealthcareplansarenotsubjecttotaxationIfemployerincreaseswagesby$2000,employeeonlykeeps(1-t)x$2000,wheret=marginaltaxrateIfemployerprovideshealthinsuranceworth$2000,taxbilldoesnotincreaseProvidesincentivetosubstituteawayfromwagesandtowardsfringebenefitslikehealthinsurance.24TheRoleofGovernment:

ImplicitSubsidyforHealthInsuranceBecauseofsubsidy:Morefirmsprovideemployer-providedhealthinsuranceFirmsprovidemoregeneroushealthinsurance25TheTwinIssues:AccessandCostAccesstohealthcare83%ofnon-elderlyhavesomeformofhealthcare17%ofnon-elderly(41millionpeople)areuninsuredUninsuredarediversegroupMostareemployedLessthanhalfarepoorAbsenceofhealthinsurancedifferentfromabsenceofhealthcare26TheTwinIssues:AccessandCostCostsTable10.2showstherapidgrowthinhealthcareovertimeTable10.3andFigure10.2showthattheU.S.hasmuchhigherlevelsofhealthcareexpenditurethanotherdevelopedcountries,buttherateofgrowthisnotoutofline27Table10.228Table10.329Figure10.230TheTwinIssues:AccessandCostWhyarecostsgrowing?The“Graying”ofAmerica–olderpopulationsrequiremorehealthcareIncomegrowth–healthcareisanormalgoodThirdpartypayments–insurancecoveragemayhavechangedImprovementsinquality–treatmentsareverydifferent(better&moreexpensive)thaninpreviousdecade31NewDirectionsforGovernment’sRoleinHealthCareIndividualmandatesStatesforcetheirresidentstopurchaseautomobileinsurance,sowhynothealthinsurance?HeritageFoundation’splanwouldhaveanindividualmandate,replacetheimplicittaxsubsidytoemployer-providedhealthinsurancewithvouchers,andkeepMedicareandMedicaidintact.32NewDirectionsforGovernment’sRoleinHealthCareIndividualmandatesAnalogywithautomobileinsuranceistenuous.Automobileaccidentsclearlycausefiscalexternalities–damagestoothervehicles,passengers,andproperty.Theconsequencesofgettingsickarelargelyinternalized.Statesremovethehighestrisks(e.g.thosewhohavedrunkdrivingconvictionsandthoseunderage16,etc.)fromtheinsurancepoolbyrestrictingtheirabilitytodrive.Thehighhealthrisksarenotremovedinanyway.33NewDirectionsforGovernment’sRoleinHealthCareIndividualmandatesEnforcementofmandateisunclearWhathappensifsomeonedidnotpurchaseinsurance?Ifsomeonechoosesnottodriveorownanautomobile,thereisnomandatethattheybuyinsurance.34NewDirectionsforGovernment’sRoleinHealthCareSinglePayerOneproviderofhealthinsurance,fundedbytaxcollections.Eliminatesadverseselectionproblem,andisusedinmanydevelopedcountries.AnaloginU.S.wouldbetoextend