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Do Insurers Risk-Select Against Each Other? Evidence from Medicaid and Implications for Health Reform

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  • Ilyana Kuziemko
  • Katherine Meckel
  • Maya Rossin-Slater
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    Abstract

    Increasingly in U.S. public insurance programs, the state finances and regulates competing, capitated private health plans but does not itself directly insure beneficiaries through a public fee-for-service (FFS) plan. We develop a simple model of risk-selection in such settings. Capitation incentivizes insurers to retain low-cost clients and thus improve their care relative to high-cost clients, who they prefer would switch to a competitor. We test this prediction using county transitions from FFS Medicaid to capitated Medicaid managed care (MMC) for pregnant women and infants. We first document the large health disparities and corresponding cost differences between blacks and Hispanics (who make up the large majority of Medicaid enrollees in our data), with black births costing nearly double that of Hispanics. Consistent with the model, black-Hispanic infant health disparities widen under MMC (e.g., the black-Hispanic mortality gap grows by 42 percent) and black mothers' pre-natal care worsens relative to that of Hispanics. Remarkably, black birth rates fall (and abortions rise) significantly after MMC—consistent with mothers reacting to poor care by reducing fertility or plans discouraging births from high-cost groups. Implications for the ACA exchanges are discussed

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    Bibliographic Info

    Paper provided by National Bureau of Economic Research, Inc in its series NBER Working Papers with number 19198.

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    Date of creation: Jul 2013
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    Handle: RePEc:nbr:nberwo:19198

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    References

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    1. Batata, Amber, 2004. "The effect of HMOs on fee-for-service health care expenditures: evidence from medicare revisited," Journal of Health Economics, Elsevier, vol. 23(5), pages 951-963, September.
    2. Borghans, Lex & Gielen, Anne C. & Luttmer, Erzo F.P., 2010. "Social Support Substitution and the Earnings Rebound: Evidence from a Regression Discontinuity in Disability Insurance Reform," IZA Discussion Papers 5412, Institute for the Study of Labor (IZA).
    3. Grossman, Michael, 1972. "On the Concept of Health Capital and the Demand for Health," Journal of Political Economy, University of Chicago Press, vol. 80(2), pages 223-55, March-Apr.
    4. Bauhoff, Sebastian, 2012. "Do health plans risk-select? An audit study on Germany's Social Health Insurance," Journal of Public Economics, Elsevier, vol. 96(9-10), pages 750-759.
    5. Melissa S. Kearney & Phillip B. Levine, 2009. "Subsidized Contraception, Fertility, and Sexual Behavior," The Review of Economics and Statistics, MIT Press, vol. 91(1), pages 137-151, February.
    6. Mark Duggan, 2002. "Does Contracting Out Increase the Efficiency of Government Programs? Evidence from Medicaid HMOs," NBER Working Papers 9091, National Bureau of Economic Research, Inc.
    7. Leonard M. Lopoo & Kerri M. Raissian, 2012. "Natalist Policies in the United States," Journal of Policy Analysis and Management, John Wiley & Sons, Ltd., vol. 31(4), pages 905-946, 09.
    8. Silverman, Elaine & Skinner, Jonathan, 2004. "Medicare upcoding and hospital ownership," Journal of Health Economics, Elsevier, vol. 23(2), pages 369-389, March.
    9. Oliver Hart & Andrei Shleifer & Robert Vishny, 1996. "The Proper Scope of Government: Theory and an Application to Prisons," Harvard Institute of Economic Research Working Papers 1778, Harvard - Institute of Economic Research.
    10. Joseph P. Newhouse, 1996. "Reimbursing Health Plans and Health Providers: Efficiency in Production versus Selection," Journal of Economic Literature, American Economic Association, vol. 34(3), pages 1236-1263, September.
    11. Leemore Dafny & Katherine Ho & Mauricio Varela, 2010. "Let them Have Choice: Gains from Shifting Away from Employer-Sponsored Health Insurance and Toward an Individual Exchange," NBER Working Papers 15687, National Bureau of Economic Research, Inc.
    12. Thomas G. McGuire & Jacob Glazer, 2000. "Optimal Risk Adjustment in Markets with Adverse Selection: An Application to Managed Care," American Economic Review, American Economic Association, vol. 90(4), pages 1055-1071, September.
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    1. #HEJC papers for August 2013
      by academichealtheconomists in The Academic Health Economists' Blog on 2013-07-31 23:00:48

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