Date of Award
Doctor of Philosophy (PhD)
Mark G. Duggan
This dissertation focuses on topics in health economics and public finance. I deal with questions that have importance for health policy, and that are simultaneously of general economic interest; in particular, I consider the efficiency impact of privatization, the effects of competition in health care markets, and the effects of incomplete contracting and imperfect competition on rates of pass-through to consumers and governments.
In Chapter One, I examine the extent to which contracting out by governments yields efficiency improvements, by looking to Medicaid contracting in New York State. To identify the efficiency impact of private, relative to public Medicaid, I exploit involuntary switching between the two; primarily, I leverage age-based rules forcing individuals to switch from private to public Medicaid at 65. I also leverage unique administrative data, which longitudinally tracks individual utilization across the public and private Medicaid settings. I find evidence that private Medicaid yields efficiency improvements, but find no evidence that these improvements are passed on to either governments or patients. Instead, I find that pass-through is substantially limited by incomplete contracting, with plans shifting costs to medical services that remain under government provision.
In Chapter Two, I examine the effects of cost-sharing among a previously understudied population-those dually enrolled in Medicaid and Medicare. I leverage an exogenous court ruling that resulted in loss of Medicaid coverage in Tennessee, among 25,000 individuals who had previously been dually-enrolled. This disenrollment resulted in an increase in average cost-sharing rates, from around 0% to around 20%. I find that this cost-sharing increase resulted in a utilization reduction of about 30%, implying an arc-elasticity in spending of about -.2.
In Chapter Three, with Mark Duggan and Amanda Starc, we examine how contracts are affected by their generosity, by looking to the Medicare Advantage program. In doing so, we exploit a substantial policy-induced increase in MA reimbursement in metropolitan areas with a population of 250,000 or more relative to MSAs below this threshold. Our findings also reveal that about one-eighth of the additional reimbursement is passed through to consumers in the form of better coverage.
Vabson, Boris, "Essays in Health Economics and Public Finance" (2014). Publicly Accessible Penn Dissertations. 2071.