经济学（微观）（英文版原书第7版）课件 第7章　医疗保健经济学

EconomicsSeventhEditionChapter7TheEconomicsofHealthCareCopyright©2019,2017,2015PearsonEducation,Inc.AllRightsReserved.ChapterOutline7.1

TheImprovingHealthofPeopleintheUnitedStates7.2

HealthCarearoundtheWorld7.3

InformationProblemsandExternalitiesintheMarketforHealthCare7.4

TheDebateoverHealthCarePolicyintheUnitedStates7.1TheImprovingHealthofPeopleintheUnitedStatesUsedatatodiscusstrendsinU.S.healthovertime.HealthcareexpenditureintheUnitedStatesishigherthananywhereelseintheworld.Whyisthisthecase?Ideas:HighqualityofhealthcareSystemofpaymentforhealthcareHigherdemandforhealthcareInthischapter,wewilladdresssomeoftheelementsofhealthcarethatmakeitarichfieldofstudyforeconomists.Healthcare:Goodsandservices,suchasprescriptiondrugs,consultationswithadoctor,andsurgeries,thatareintendedtomaintainorimproveaperson’shealth.Table7.1HealthintheUnitedStates,1850and2015Variable18502016Lifeexpectancyatbirth38.3years78.8yearsAverageheight(adultmales)5’7”5’9.3”Infantmortality(deathofachildaged1yearorless)228.9per1,000livebirths5.8per1,000livebirthsThelastcoupleofcenturieshavebroughtincredibleadvancesinhealthoutcomesforAmericans.Explanations:ImprovementsinnutritionPublichealthmovement(latenineteenth,earlytwentiethcentury)Improvementsinsanitation,fooddistribution,etc.FeedbackfrombetterhealthtohigherincomestobetterhealthFigure7.1TheImprovingHealthoftheU.S.Population(1of2)Themostdramaticgainsinhealthhaveoccurredinthetwentiethcentury.(Mostly)steadyincreasesinlifeexpectancy.Correspondingdecreasesinthedeathrate(adjustedforlifeexpectancy).Figure7.1TheImprovingHealthoftheU.S.Population(2of2)Medicaladvancesinpreventionandtreatmentarereducingthedeathrate.Noticeinparticularthefallinthedeathratefromcardiovasculardisease.Howeverdeathsduetosomeobesity-relatedillnesseshaverisen.7.2HealthCarearoundtheWorldComparethehealthcaresystemsandhealthcareoutcomesintheUnitedStatesandothercountries.ThereareimportantdifferencesbetweenthehealthcaresystemsoftheUnitedStatesandthoseofothercountries,bothintermsofwhoprovidesthehealthcare,andwhopaysforthehealthcare.MosthealthcareintheUnitedStatesisprovidedbyprivatefirms,andpaidforthroughhealthinsurance.Healthinsurance:Acontractunderwhichabuyeragreestomakepayments,orpremiums,inexchangefortheprovider’sagreeingtopaysomeorallofthebuyer’smedicalbills.Insurancepaymentscantaketheformoffee-for-service,wheredoctorsandhospitalsreceiveapaymentforeachservicetheyprovide;orHealthMaintenanceOrganizations(HMOs),wheredoctorsreceiveaflatfeeperpatient.Figure7.2SourcesofHealthInsuranceintheUnitedStates,2014In2016,about49percentofpeoplereceivedhealthinsurancethroughtheiremployer,andabout35percentofpeoplereceiveditthroughgovernmentprograms.Somepeoplehavemultiplesourcesofhealthinsurance.About9percentofAmericanshadnohealthinsurancein2016.WhyAreSoManyAmericansUninsured?TheproportionofAmericanswithouthealthinsuranceislowernowthaninrecentyears,partlybecauseoftheAffordableCareAct(2010).Thislawenactedsubsidiesforlower-incomepeople,andintroducedpenaltiesfornothavinghealthinsurance.Howevermanypeoplestilldonothavehealthinsurance,typicallybecausethey:Believetheycannotaffordit,orBelieveitisunnecessarybecausetheyarehealthy.ApplytheConcept:TheIncreasingImportanceofHealthCareintheU.S.EconomyInmoststates,thehealthcareindustryisnowtheindustrywiththemostworkers.TheBLSforecaststhat13ofthe20fastest-growingoccupationsoverthenext10yearswillbeinhealthcare.HealthCareSystemsinComparisonCountriesCanada: Single-payerhealthcaresystem:thegovernmentprovideshealthinsurancetoallresidents,fundedthroughtaxes.Privatecompaniesprovidethecare.Individualspaynothingout-of-pocketforservices.Japan: Universalhealthinsurance:everyresidentisrequiredtoenrollinanonprofithealthinsurancesociety,orenrollinthenationalgovernment’sprogram.Individualshavesubstantialcopayments.UK: Socializedmedicine:ahealthcaresystemunderwhichthegovernmentownsmostofthehospitalsandemploysmostofthedoctors.Some(>10percent)peoplesupplementwithprivatehealthinsurance.Figure7.3LevelsofIncomeperPersonandSpendingperPersononHealthCareHealthcareisanormalgood;higherincomeleadstohigherexpenditureonhealthcare.ButtheUnitedStatesspendsagreaterproportionofincomeperpersononhealthcarethanothercountries.Table7.2HealthOutcomesinHigh-IncomeCountriesHealthCareOutcomeUnitedStatesCanadaJapanUnitedKingdomOECDAverageLifeExpectancyBlankBlankBlankBlankBlankLifeexpectancyatbirth78.8years81.0years83.7years81.4years80.6yearsMalelifeexpectancyatage6518.0years18.8years19.3years18.8years17.9yearsFemalelifeexpectancyatage6520.4years21.7years24.2years20.9years21.3yearsInfantmortality(deathsper1,000livebirths)6.04.92.13.94.0HealthProblemsObesity(percentageofthepopulationwithBMI>30)38.2%28.0%3.9%25.6%22.3%DiagnosticEquipmentMRIunitsper1,000,000population38.18.951.76.115.7CTscannersper1,000,000population41.014.7107.18.026.4CancerDeathsfromcancerper100,000population189.5207.5179.0221.9202.1Riskofdyingofcancerbeforeage7511.2%10.8%9.3%11.3%11.5%Mortalityratioforcancer33.3%34.9%43.2%40.3%40.4%Comparing(2012-14)dataacrosscountries,itappearsthatAmericagetsabaddealforitshighexpenditure.ProblemsinComparingacrossCountriesHowevercomparingacrosscountriesisoftendifficult,andpotentiallymisleading:Dataproblems:Countriesmaynotcollectdatainthesameway.Problemswithmeasuringhealthcaredelivery:Qualityofcareishardtomeasure.Lifestylechoices:Obesityanddiabetes,forexample,mayhavemoretodowiththechoicesofconsumersthantheeffectivenessofhealthcare.Problemswithdeterminingconsumerpreferences:Disconnectbetweenpricespeoplepayandservicesreceived.7.3InformationProblemsandExternalitiesintheMarketforHealthCareDefineinformationproblemsandexternalitiesandexplainhowtheyaffectthemarketforhealthcare.Thehealthcaremarketischaracterizedbyasymmetricinformation:asituationinwhichonepartytoaneconomictransactionhaslessinformationthantheotherparty.Thiscanleadtomarketfailure,theinabilityofthemarkettomaximizeeconomicwell-being.Twomainformsofasymmetricinformation:AdverseselectionMoralhazardAdverseSelectionSupposeyouarelookingtobuyausedcar.Ifsomeoneofferstosellyouausedcar,wouldyoubelieve:Thecarishighquality,andthesellerjusthappenstowanttosellit;orThecarislowquality(a“lemon”),andtheselleristryingtounloadtheirproblemsonyou.Ifyouofferamoderateprice,thenonlypeoplewithlow-qualitycarswillselltoyou.Sowithoutfurtherinformation,youdon’twanttobuyacarfromanyonewhoiswillingtosellacartoyou!Idon’twanttobelongtoanyclubthatwillacceptpeoplelikemeasamember. -GrouchoMarxAdverseSelectionintheHealthInsuranceMarketHealthinsurancesuffersfromasimilar“adverseselection”problem:Adverseselection:Thesituationinwhichonepartytoatransactiontakesadvantageofknowingmorethantheotherpartytothetransaction.Thepeoplewhowanthealthinsurancearetheoneswhoarelikelytouseit.Sothepremiumsneedtobehightocovertheexpectedcosts.Butnowpeoplewithonlymoderateneedsmayfindhealthinsurancetooexpensive,causingthemtodropout,etc.Thisproblemislessenedifpeopleareveryrisk-averse:wantingtoavoidrisk.CopingwithAdverseSelectionHealthinsurancecompanieshavetriedtolessentheimpactofadverseselectionbyexcludingpre-existingconditions.Itisanormative(valuejudgment)questionwhetherthegainsforsocietythroughavoidingadverseselectionoutweighthecoststosocietythroughreductionsinhealthinsurancecoverage.Analternativewayaroundtheadverseselectionproblemistomandatethatindividualscarryinsurance.Example:moststatesrequireautomobileaccidentinsurance.2010PatientProtectionandAffordableCareAct(ACA)bothintroducedanindividualmandatetobuyhealthinsurance,andrestrictedexclusionsofpre-existingconditions.MoralHazardinHealthInsurance—PatientsMoralhazardreferstoactionspeopletakeafterenteringintoatransaction,thatmaketheotherpartytothetransactionworseoff.Example:Peoplewithcarinsurancemightdrivelesscarefully,knowingtheyarefinanciallyprotectediftheycrash.Peoplemightusemorehealthcarewhentheydon’thavetopayforitsfullcost:GoingtothedoctorunnecessarilyEngaginginriskybehaviorAcceptingexcessivetreatmentoptionsSuchactionswouldincreasethecostofhealthcaretosociety,perhapswithoutprovidingsubstantialbenefits.MoralHazardinHealthInsurance—DoctorsThefinancialstructureofinsurancecontractsmaymakedoctorschangetheirbehavioralso:OrderingunnecessarytestsandproceduresSincepatientspaylittleout-of-pocketfortheadditionalcare,theyarelikelytoagreetoextratreatmentThisillustratestheprincipal-agentproblem:aproblemcausedbyagentspursuingtheirowninterestsratherthantheinterestsoftheprincipalswhohiredthem.Theinsurancecompanymustdelegatedecision-makingpowertothedoctor,whomaynothavethesameinterestsasthecompany.DoDoctorsSuccumbtoMoralHazard?Whilethenumberofmedicalprocedureshasbeenincreasing,doctorstendtoclaimthattheydonotorderextratestsandproceduresforfinancialgain,buteither:Outofgenuineconcernfortheirpatients,orAsdefensivemedicine,inordertoavoidmalpracticelawsuits.CopingwithMoralHazardinHealthCareThekeytodealingwithmoralhazardistotrytomakesurepeopledon’tchangetheirbehaviortoomuch.Patients:Deductibles(patientpaysfirst$Xoftreatmentcost)Coinsurance(patientpaysYpercentoftreatmentcost)Doctors:StandardizedpaymentsforparticularillnessesSuchmethodsreducebutdonoteliminatemoralhazardproblems.ExternalitiesintheMarketforHealthCareRecallthatanexternalcostorbenefitwillresultinmarketfailure,because(fromsociety’sperspective)the“wrong”quantitywillbeconsumed.Positiveexternalities:VaccinationsreducechanceofothersgettingsickHealthypopulationgoodforemployers(fewersickdays)Negativeexternalities:Poorhealthchoices(likeobesity,smoking)arepaidforbyothers(higherpremiums,taxes)Figure7.4TheEffectofaPositiveExternalityontheMarketforVaccinationsInthefigure,weassumepeoplepaythefullpriceofvaccinationsPMarket.Vaccinationshavepositiveexternalities,sothemarginalsocialbenefitcurveD2ishigherthanthemarginalprivatebenefitcurveD1.ConsumerswillpurchaseQMarketvaccinations—toofew,resultinginadeadweightloss.Inpractice,subsidizedvaccinationsreducethisexternalityproblemShouldtheGovernmentRuntheHealthCareSystem?Ifhealthcarewereapublicgood,thatwouldbeastrongargumentforgovernmentinvolvement.IshealthcareNon-rivalinconsumption?Non-excludable?Neitheroftheseseemlikely,sohealthcareseemstobeaprivategood.Howevertheexternalitiesandinformationasymmetriesmaygenerateenoughmarketfailuretopromptgovernmentinvolvement.Overall,thegovernment’sroleinhealthcareiscontroversial.7.4TheDebateoverHealthCarePolicyintheUnitedStatesExplainthemajorissuesinvolvedinthedebateoverhealthcarepolicyintheUnitedStates.ThePatientProtectionandAffordableCareAct(ACA)waspassedbyCongressin2010butremainscontroversial.TheUnitedStatesspendsmoreperpersononhealthcarethananyothercountry,withoutgettingbetteroutcomes.Andthiscostappearstocontinuetorise.Whatshouldbedoneaboutthis?Wewillexplorethistopicinthissection.Figure7.5SpendingonHealthCarearoundtheWorld(1of2)ExpenditureonhealthcareintheUnitedStates,asapercentageofnationalincome,hasbeenrising.Itisprojectedtocontinuetorise.Figure7.5SpendingonHealthCarearoundtheWorld(2of2)Thefigureshowshealthcarespendingperperson,1980–2015.GrowthinhealthcarespendinghasbeenfasterintheU.S.thaninotherhigh-incomecountries.Figure7.6TheDecliningShareofU.S.Out-of-PocketHealthCareSpendingAtthesametime,Americansarepayingasmallerandsmallerproportionofhealthcarecostsout-of-pocket.Americanswouldlikelynotchoosethesamelevelofhealthcareexpenditureiftheyhadtopayahigherout-of-pocketshare.Combinedwithrisinghealthcarecosts,thispresentsproblemsforgovernmentbudgets.ApplytheConcept:AreU.S.FirmsHandicappedbyPayingforHealthInsurance?U.S.firmsfrequentlypayfortheiremployees’healthinsurance,unlikeinmostothercountries.Thisappearstoputthematacompetitivedisadvantage.Example:Pay$50,000salaryplus$10,000healthinsurance.Butifthegovernmentprovidedhealthcare,itwouldlikelybepaidforviapayrolltaxes;sothetotalcompensationpaidbyfirmswouldlikelynotchangemuch.Example:Pay$50,000salaryplus$10,000“healthcaretax”.WhyAreHealthCareCostsRisingSoFast?Paperwork?Whilepaperworkissignificant,it’snotincreasingfastenoughtoexplaintheriseinspending.Malpracticelawsuits?Significantcost(CongressionalBudgetOfficesays1percent,economistsestimateasmuchas7percentoftotalhealthcarecost).Butagain,notrisingfastenoughtoexplainchanges.Uninsuredpatients?Increaseincostsof1–4percentduetogettingtreatmentin“wrongplaces”(emergencyroomvs.doctor’soffice).Stillnotrisingenoughtoexplainchanges.Primaryreason#1:HealthCareSector“CostDisease”Serviceproviders(likehealthcareproviders)havenotseenhugeproductivitygainslikeinmanufacturing.LaborproductivityinhealthcarehasrisenlessthanhalfasmuchasintheeconomyasawholeButinordertokeepworkers,wageshaveriseninservicesectoralso.Includinghealthcare,ofcourse.Thisisknownastheservicesector“costdisease”.Figure7.7ReasonsforRisingFederalSpendingonMedicareandMedicaidPrimaryreason#2istheagingpopulation.Olderpeoplerequiremorehealthcare,andasmedicaladvanceskeeppeoplealivelongerandbirthratesslow,theproportionofelderlypeoplewillrise.However,asthegraphfromtheCBOshows,theeffectoftheagingpopulationshouldnotbeoverstated.Figure7.8TheEffectoftheThird-PartyPayerSystemontheDemandforMedicalServicesPrimaryreason#3isthedistortedeconomicincentivesinheathcarearisingfrominsurance.Thedisconnectbetweenserviceandpaymentmeansconsumershavelittlereasontoacceptfewerservicesforlowercost.Theoverconsumptionofhealthcare(relativetoefficientlevels)createsadeadweightloss.TheContinuingDebateoverHealthCarePolicyExtendinghealthcarecoveragetobemoreuniversalhasbeenattemptedandrejectedseveraltimes:1945:PresidentHarryTrumanproposednationalhealthinsurance.1993:PresidentBillClintonproposedauniversalpublic/privateplan.Eachtime,Congressdeclinedtoenacttheplans.ThePatientProtectionandAffordableCareAct(2010)In2009,PresidentBarackObamaproposedsignificanthealthcarereformintheformoftheACA;inMarch2010,Congressapprovedthelegislation.Scheduledtobefullyimplementedby2019,PPACAincludes:IndividualmandatetoobtainhealthinsuranceStatehealthinsurancemarketplacestoincreaseaccesstopoliciesEmployermandateformostfirmstoprovidehealthinsuranceRegulationofhealthinsurancealteringhowhealthinsurancecompaniescanactExpansionofMedicaideligibilityandMedicarecostcontrolsIncreasedtaxesonhigh-incomeindividuals,high-costinsuranceplans,andsomehealthcarerelatedindustriesDebateovertheACAPresidentTrumptookofficein2017,vowingto“repealandreplace”theACA.DebateremainsoverwhethertheAC