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The impact of insurer competition on welfare, negotiated provider prices, and premiums in the U.S. private health care industry is theoretically ambiguous. Reduced competition may increase the premiums charged by insurers and their payments made to hospitals. However, it may also strengthen insurers' bargaining leverage when negotiating with hospitals, thereby generating offsetting cost decreases. To understand and measure this trade-off, we estimate a model of employer-insurer and hospitalinsurer bargaining over premiums and reimbursements, household demand for insurance, and individual demand for hospitals using detailed California admissions, claims, and enrollment data. We simulate the removal of both large and small insurers from consumers' choice sets. Although consumer welfare decreases and premiums typically increase, we find that premiums can fall upon the removal of a small insurer if an employer imposes effective premium constraints through negotiations with the remaining insurers. We also document substantial heterogeneity in hospital price adjustments upon the removal of an insurer, with renegotiated price increases and decreases of as much as 10% across markets.

We compare health care spending in public and private Medicare using newly available claims data from Medicare Advantage (MA) insurers. MA insurer revenues are 30 percent higher than their health care spending. Adjusting for enrollee mix, health care spending per enrollee in MA is 9 to 30 percent lower than in Traditional Medicare (TM), depending on the way we define “comparable” enrollees. Spending differences primarily reflect differences in health care utilization, with similar reductions for “high-value” and “low-value” care, rather than health care prices. We present evidence consistent with MA plans encouraging substitution to less expensive care and engaging in utilization management.

We use administrative data from the Internal Revenue Service to examine long-term impacts of childhood Medicaid eligibility expansions on outcomes in adulthood at each age from 19 to 28. Greater Medicaid eligibility increases college enrolment and decreases fertility, especially through age 21. Starting at age 23, females have higher contemporaneous wage income, although male increases are imprecise. Together, both genders have lower mortality. These adults collect less from the earned income tax credit and pay more in taxes. Cumulatively from ages 19 to 28, at a 3% discount rate, the federal government recoups 58 cents of each dollar of its “investment” in childhood Medicaid.

The South African national department of the health system is piloting the National Health Insurance (NHI). This is in preparation for the overhaul of healthcare services so that they are efficient and equitable to all citizens immaterial of their socio-economic status. This article aims to evaluate healthcare providers' perceptions of improved service delivery by the government’s health department during the first piloting phases of the NHI. The context of the study is a health district center in a rural area of KwaZulu-Natal province in South Africa. The article is interdisciplinary in that it interrogates governance issues in the health sector. A quantitative research methodology was utilized to collect data from 30 participants who were the center’s staff. The findings indicate that the significant areas of concern are lack of improvement in response rate to emergencies, ambulances, provision of resources, and specialized staff. The implication is that the government’s health department working with provincial departments, still has major healthcare reforms to address if the NHI program contributes effectively to healthcare service delivery.

The Affordable Care Act (ACA) includes several provisions designed to expand health insurance coverage that also alter the tie between employment and health insurance. In this paper, we exploit variation across geographic areas in the potential impact of the ACA to estimate its effect on health insurance and labor market outcomes in its first four years. Our findings indicate that approximately 70 percent of the increase in health insurance coverage since 2013 is due to the ACA. We also find that these increases in health insurance coverage did not result in statistically significant changes in labor market outcomes.

Is the difficulty of purchasing health insurance as an individual or small business a major barrier to entrepreneurship in the USA? I answer this question by taking advantage of the natural experiment provided by the Affordable Care Act's dependent coverage mandate, which allowed many 19-25 year olds to acquire health insurance independently of their employment. Using a difference-in-difference strategy, I find that the dependent coverage mandate did not increase self-employment among young adults overall, but increased self-employment among disabled young adults by 19-23%.

This paper studies regulated health insurance markets known as exchanges, motivated by the increasingly important role they play in both public and private insurance provision. We develop a framework that combines data on health outcomes and insurance plan choices for a population of insured individuals with a model of a competitive insurance exchange to predict outcomes under different exchange designs. We apply this framework to examine the effects of regulations that govern insurers' ability to use health status information in pricing. We investigate the welfare implications of these regulations with an emphasis on two potential sources of inefficiency: (i) adverse selection and (ii) premium reclassification risk. We find substantial adverse selection leading to full unraveling of our simulated exchange, even when age can be priced. While the welfare cost of adverse selection is substantial when health status cannot be priced, that of reclassification risk is five times larger when insurers can price based on some health status information. We investigate several extensions including (i) contract design regulation, (ii) self-insurance through saving and borrowing, and (iii) insurer risk adjustment transfers.

In 2023 total health care spending in the US totaled approximately $4.7 trillion and represented 18 percent of GDP. In an attempt to reduce these expenditures, the Affordable Care Act (ACA) drastically reformed the operation and structure of health care and health insurance. We explore the effect the ACA had on health insurer liquidity by exploiting state-by-state variation and providing evidence that the ACA led health insurers to significantly adjust cash holdings. We find that for the 2010 to 2018 time period, health insurer cash as a proportion of assets increased by 40 percent and growth in cash was significantly greater than that of other types of insurers, but that specific ACA provisions had differing effects — Medicaid expansion, loss ratio regulation, and exchange participation were associated with reduced cash. Far from changing cash reserves for no reason, our empirical evidence suggests that health insurers altered cash as a precautionary strategic response to uncertainty created by the ACA.

We study the effect of public health insurance on labor supply by exploiting a large public health insurance disenrollment. In 2005, approximately 170,000 Tennessee residents abruptly lost Medicaid coverage. Using both across- and within-state variation in exposure to the disenrollment, we estimate large increases in labor supply, primarily along the extensive margin. The increased employment is concentrated among individuals working at least 20 hours a week and receiving private, employer-provided health insurance. We explore the dynamic effects of the disenrollment and find an immediate increase in job search behavior and a steady rise in both employment and health insurance coverage following the disenrollment. Our results are consistent with a significant degree of ‘‘employment lock’’—workers who are employed primarily to secure private health insurance coverage.