Jonathan Gruber

Does Public Insurance Crowd out Private Insurance

One popular option for health care reform in the U.S. is to make particular groups, such as children, eligible for public health insurance coverage. A key question in assessing the cost of this option is the extent to which public eligibility will crowd out the private insurance coverage of these groups. We estimate the extent of crowdout arising from the dramatic expansions of the Medicaid program during the 1987-1992 period. Over this time period, Medicaid eligibility for children increased by 50 percent and eligibility for pregnant women doubled. We estimate that between 50 percent and 75 percent of the increase in Medicaid coverage was associated with a reduction in private insurance coverage. This occurred largely because employees took up employer-based insurance less frequently, although employers may have encouraged them to do so by contributing less for insurance. There is some evidence that workers dropped coverage for their family and switched into individual policies.

Health Insurance Eligibility, Utilization of Medical Care, and Child Health

The poor health status of children in the U.S. relative to other industrialized nations has motivated recent efforts to extend insurance coverage to underprivileged children. There is little past evidence that extending eligibility for public insurance to previously ineligible groups will increase health status or even utilization of medical resources. Using data from the Current Population Survey, the National Health Interview Survey, and state-level data on child mortality, we examine the utilization and health effects of eligibility for public insurance. Our models are identified by the recent expansions of the Medicaid program to low income children. We find that these expansions roughly doubled the fraction of children eligible for Medicaid between 1984 and 1992; by 1992, almost 1/3 of all children were eligible. But takeup of these expansions was much less than full even among otherwise uninsured children. Despite this takeup problem, we find that eligibility for Medicaid significantly increased the utilization of medical care along a number of dimensions. Medicaid eligibility was associated with large increases in care delivered in physicians offices, although there was some increase in care in hospital settings as well. While there was no effect of eligibility on parentally-assessed subjective health measures, we do find notable reductions in child mortality. Finally, we find that rising Medicaid eligibility is associated with reductions in racial disparities in the number of visits and in child disparities in the site at which care is delivered.

Insuring Consumption Against Illness

One of the most sizable and least predictable shocks to economic opportunities in developing countries is major illness. We investigate the extent to which families are able to insure consumption against major illness using a unique panel data set from Indonesia that combines excellent measures of health status with consumption information. We find that there are significant economic costs associated with major illness, and that there is very imperfect insurance of consumption over illness episodes. These estimates suggest that public disability insurance or subsidies for medical care may improve welfare by providing consumption insurance.

Saving Babies: The Efficacy and Cost of Recent Changes in the Medicaid Eligibility of Pregnant Women

A key question for health care reform in the United States is whether expanded health insurance eligibility will lead to improvements in health outcomes. We address this question in the context of the dramatic changes in Medicaid eligibility for pregnant women that took place between 1979 and 1992. We build a detailed simulation model of each states Medicaid policy during this era and use this model to estimate (1) the effect of changes in the rules on the fraction of women eligible for Medicaid coverage in the event of pregnancy and (2) the effect of Medicaid eligibility changes on birth outcomes in aggregate Vital Statistics data. We have three main findings. First, the changes did dramatically increase the Medicaid eligibility of pregnant women, but did so at quite differential rates across the states. Second, the changes lowered the incidence of infant mortality and low birth weight; we estimate that the 30-percentage-point increase in eligibility among 15-44-year-old women was associated with a decrease in infant mortality of 8.5 percent. Third, earlier, targeted changes in Medicaid eligibility, which were restricted to specific low-income groups, had much larger effects on birth out-comes than broader expansions of eligibility to women with higher income levels. We suggest that the source of this difference is the much lower take-up of Medicaid coverage by individuals who became eligible under the broader eligibility changes. Even the targeted changes cost the Medicaid program

The Incidence of Payroll Taxation: Evidence from Chile

840,000 per infant life saved, however, raising important issues of cost effectiveness.

Is Making Divorce Easier Bad for Children? The Long Run Implications of Unilateral Divorce

I provide new evidence on the incidence of payroll taxation by examining the experience of Chile before and after the privatization of its Social Security system. This policy change led to a sharp exogenous reduction in the payroll tax burden on Chilean firms; on average, payroll tax rates fell by 25% over 6 years. Using data from a census of manufacturing firms, I estimate that the incidence of payroll taxation is fully on wages, with no effect on employment. This finding is robust to a variety of empirical approaches to the problem of measurement error in firm‐level measures of taxes/worker.

Crowd-out 10 years later: Have recent public insurance expansions crowded out private health insurance?

I assess the long‐run implications for children of growing up in a unilateral divorce environment, which increases the ease of divorce by not requiring the explicit consent of both partners. Using 40 years of census data to exploit the variation across states and over time in changes in divorce regulation, I confirm that unilateral divorce regulations do significantly increase the incidence of divorce. Adults who were exposed to unilateral divorce regulations as children are less well educated, have lower family incomes, marry earlier but separate more often, and have higher odds of adult suicide.

Physician Fees and Procedure Intensity: the Case of Cesarean Delivery

Ten years ago, Cutler and Gruber [Cutler, D., Gruber, J., 1996. Does public health insurance crowdout private insurance? Quarterly Journal of Economics 111, 391-430] suggested that crowd-out might be quite large, but much subsequent research has questioned this conclusion. Our results using improved data and methods clearly show that crowd-out is still significant in the 1996-2002 period. This finding emerges most strongly when we consider family level measures of public insurance eligibility. We also find that recent anti-crowd-out provisions in public expansions may have had the opposite effect, lowering take-up by the uninsured faster than they lower crowd-out of private insurance.

Abortion Legalization and Child Living Circumstances: Who is the “Marginal Child”?

While there is a large literature investigating the response of treatment intensity to Medicare reimbursement differentials, there is much less work on this question for the Medicaid program. The answers for Medicare may not apply in the Medicaid context, since a smaller share of a physicians patients will be Medicaid insured, so that income effects from fee changes may be dominated by substitution effects. We investigate the effect of Medicaid fee differentials on the use of cesarean delivery over the period 1988-1992. We find, in contrast to the backward-bending supply curve implied by the Medicare literature, that larger fee differentials between cesarean and normal childbirth for the Medicaid program leads to higher cesarean delivery rates. In particular, we find that the lower fee differentials between cesarean and normal childbirth under the Medicaid program than under private insurance can explain between one half and three-quarters of the difference between Medicaid and private cesarean delivery rates. Our results suggest that Medicaid reimbursement reductions can cause real reductions in the intensity with which Medicaid patients are treated.

FUTURE SOCIAL SECURITY ENTITLEMENTS AND THE RETIREMENT DECISION

We examine the impact of increased abortion availability on the average living standards of children through a selection effect. Would the marginal child who was not born have grown up in different circumstances than the average child? We use variation in the timing of abortion legalization across states to answer this question. Cohorts born after legalized abortion experienced a significant reduction in a number of adverse outcomes. We find that the marginal child would have been 40–60 percent more likely to live in a single-parent family, to live in poverty, to receive welfare, and to die as an infant.