The Effects of Health Insurance and Self‐Insurance on Retirement Behavior

This paper provides an empirical analysis of the effects of employer‐provided health insurance, Medicare, and Social Security on retirement behavior. Using data from the Health and Retirement Study, we estimate a dynamic programming model of retirement that accounts for both saving and uncertain medical expenses. Our results suggest that Medicare is important for understanding retirement behavior, and that uncertainty and saving are both important for understanding the labor supply responses to Medicare. Half the value placed by a typical worker on his employer‐provided health insurance is the value of reduced medical expense risk. Raising the Medicare eligibility age from 65 to 67 leads individuals to work an additional 0.074 years over ages 60–69. In comparison, eliminating 2 years worth of Social Security benefits increases years of work by 0.076 years.     

Defining the health care product to ensure quality and manage costs

The frenzy of health care reform activity now led by the Clinton Administration's American Health Security Act of 1993 might end in the worst of all possible outcomes: a new government entitlement program financed by business and a global budget. Unbridled entitlement could drive utilization of benefits to the maximum and, with a budget cap, guarantee rationing. So far, the administration has talked about expanding access and controlling costs--not about the health care product. Given the threat that change poses for vested interests, time will undoubtedly lapse before final implementation of a new system. Unless physicians involved in health management seize the opportunity during this window of opportunity to help shape the future of health care delivery, the likelihood of preserving the U.S. health care delivery system as we know it will be dim indeed.     

Medical resource allocation: rationing and ethical considerations--Part I

The United States' system of high-quality but expensive and poorly distributed medical care is in trouble. Dramatic advances in medical knowledge and procedures, combined with soaring demands created by growing public awareness, the cost of private hospital and medical insurance, and Medicare and Medicaid, are burdening the medical care delivery systems. The costs of medical care have reached levels that can no longer be sustained. Government officials, insurance planners, labor leaders responsible for union health care benefits, and ordinary citizens are questioning whether it is acceptable to limit health care based on economic considerations. If health care is deemed a social good, the method of allocation must be addressed. Unless society decides that other priorities of the infrastructure are to be subjugated to health service delivery, difficult decisions will be forced upon us, consciously or by default. The discussion in this two-part article explores the ethical considerations of the more formalized approaches to resource allocation that presently exist in our society.     

Cost shifting: the final straw in federalization of health care

While cost controls applied by Medicare and indemnity insurance programs initially helped curtail abusive medical billing practices, creative billing techniques have since resulted in runaway medical costs and rising insurance premiums. Employers have been forced to increase employee's contributions to health care by increasing deductibles, copayments, and coinsurance or by simply dropping health care benefits. If National Health Insurance comes to pass, and that is a cry now coming from major employers, it will be followed in time by federalization of all health care delivery systems, including Workers' Compensation. It is the providers who shift their fees into Workers' Compensation, which pays from the first dollar, who will cause the business community to petition Washington for relief. It will claim the need for cost controls in Workers' Compensation to keep American business competitive in world markets.     

Measuring Pension‐benefit Expectations Probabilistically

Abstract. Research aiming to understand the impact of public and private pension plans on individual decision making has been hampered by a dearth of empirical evidence on benefit expectations. We review the occasional national surveys that have sought to measure pension‐benefit expectations and describe our recent efforts to improve the measurement of US Social Security benefit expectations by elicitation of probabilistic expectations about well‐defined outcomes. We document striking uncertainty and heterogeneity of beliefs about the long‐term existence of the Social Security system and about the level of benefits should the system survive. In so doing, we highlight the additional information that is extracted using our probabilistic elicitation method as opposed to more traditional methods that only seek point forecasts.     

Medicare's ESRD program, Part 2: Transplantation.

In Part 1 of this discussion (Long, H. "Medicare's ESRD Program, Part 1: Dialysis. "Physician Executive 15(2):24-26, March-April 1989), the focus was on the various forms of dialysis for patients with end stage renal disease (ESRD). In this article, we turn our attention to the alternative therapy-transplantation.     

The Influence of Unemployment Benefits on Unemployment Duration: Evidence from Spain

ABSTRACT: This paper analyses the duration of unemployment spells and the possible incidence of unemployment insurance on job search behaviour and voluntary duration of unemployment in Spain. To do so, a longitudinal data set containing information on unemployment recipients during the period 1987-93 is used. Hazard rates and survival profiles are constructed for the cohorts of unemployed workers entering the benefit system at different points in time, and a logit model of the probability of leaving the system before exhausting entitlement period is presented. The results do not support the view that the unemployed tend to intensify their job search when benefits are near exhaustion.     

Physician self-referral on the fast track

One of the most hotly debated areas of health care fraud and abuse has been the prohibition on physician self-referral. Now, this prohibition is limited to physicians referring patients to clinical laboratories in which they have an ownership interest and for which the services are reimbursed under the Medicare program. However, this law may be expanded to include other health care services to which physicians cannot refer, as well as to other federal programs and private payers. While Congress works toward this end, many state governments have already taken the lead in expanding the prohibition beyond clinical laboratories and the Medicare program. "Health Law" is a regular feature of Physician Executive contributed by Epstein, Becker, and Green. Mark Lutes of the firm's Washington, D.C., offices serves as editor of the column.     

DISTANCE TO RETIREMENT AND OLDER WORKERS‘ EMPLOYMENT: THE CASE FOR DELAYING THE RETIREMENT AGE

This paper presents empirical evidence and a theoretical foundation in favor of the view that the retirement age decision affects older workers' employment prior to retirement. To the extent that there are search frictions on the labor market, the return on jobs is determined by their expected duration: The time to retirement is then key to understanding older workers' employment. Countries with a retirement age of 60 are indeed characterized by lower employment rates for workers aged 55–59. Based on the French Labor Force Survey, we show that the likelihood of employment is significantly affected by the distance to retirement, in addition to age and other relevant variables. We then extend McCall's job search model by explicitly integrating life‐cycle features with the retirement decision. Using simulations, we show that the distance effect in interaction with the generosity of unemployment benefits and the depressed demand for older workers explains the low rate of employment just before the eligibility age for the Social Security pension. Finally, we show that implementing actuarially fair schemes not only extends the retirement age, but also encourages a more intensive job search by older unemployed workers. (JEL: J22, J26, H55)     

Operational research in social security

In this paper we describe the work of the Department of Health and Social Security Operational Research (OR) Unit in Social Security. This work started in 1972 and with one break of eighteen months still continues. One of the authors (AFH) led the OR team from the beginning until September 1979 and the other (MJP) was the customer for much of its work. We describe briefly the organisation of social security work, and go on to talk about some of the projects attempted by the OR team. We will not shrink from describing some of the successes but we will concentrate most attention on the things which did not achieve the expected results. Readers will make their own judgements about the extent to which the failures were due to circumstances or to inadequacies of the team, or its leader.     

强制性约束下企业信息安全投资与网络保险的最优决策分析

研究了强制性约束下企业信息安全投资和网络保险的最优决策问题,对比了可观测企业损失和不可观测企业损失两种情形下基于破产概率约束的最优安全投资和网络保险保费厘定。研究结果表明：在可观测损失和公平保费情况下,当最大化单个企业的期望效用时,存在最优安全投资额,并且政府补贴和强制性约束都可以激励企业增加安全投资;但是当最大化所有企业效用时,只有强制性约束才能增加企业安全投资使得总效用最大化,并且企业的最优安全投资与损失的可观测程度无关。在不可观测损失情况下,当最大化单个企业期望效用时,企业的安全投资增大,而最大化所有企业效用时,存在正网络外部性,即任何企业均不敢轻易的减少安全投资,即使同在一个网络中的其他企业减少了安全投资。此外,在破产概率约束下,随着保费的增加,当损失可观测时,企业的安全投资也增加,但期望效用减少了;而当损失不可观测时,企业的安全投资和期望效用均减少。本文所得结论对政府设定强制性标准,以及企业利用安全投资和网络保险进行信息安全风险控制具有较好的参考价值。     

The Unemployed Individual's Marginal Willingness to Pay for the Remaining Entitlement Period

Abstract. This paper introduces a method of estimating the unemployed individual's marginal willingness to pay for the remaining entitlement period by application of search theory. It is demonstrated that search theory implies that the unemployed individual's marginal willingness to pay for the remaining entitlement period must be less than the value of the unemployment benefit. When benefits expire, though, the willingness to pay for an additional period must be equal to the benefit received during that period. The empirical relevance of this method is shown by re‐interpreting the studies of Meyer (Econometrica 58: 757–782, 1990) and Katz and Meyer (Journal of Public Economics 41: 45–72, 1990).     

Medicare private contracting: increasing patient choice and access?

Congress modified the Medicare program through the Balanced Budget Act of 1997 to expand patient choices for payment to physicians and certain other practitioners by allowing private contracting. This represents a shift in policy that has broad consequences for health care financing and program integrity. The effect of private contracting on quality and access to care remains unknown. Quality and access should be the most important measures of its success or failure. Out of pocket costs to seniors and vulnerable patients must also be watched closely.     

考虑保险机构参与的重大工程风险管理激励模型

重大工程建设过程往往面临着巨大的风险暴露，保险是重要的风险处置手段，承接保险合同的保险机构和业主一起成为风险损失的承担主体。考虑到保险机构拥有极强参与现场风险管理的动能，本文基于委托代理理论构建了保险机构介入下业主与承包商的激励模型，分别讨论了共同代理和独家代理两种模式下各方的策略与收益。研究结果表明：共同代理模式下，保险机构实现了主动风险管理，业主和保险机构的收益均得以提高，业主愿意提供比独家代理模式更高的激励系数；承包商在共同代理模式下将采取更为积极的风险管理努力，同时其机会主义行为得到了抑制；业主的最优激励系数受项目特征、承包商自身因素以及外界环境的不确定性共同作用。     

Health care reform. Gridlock and pork?

Can Americans expect the same gridlock and pork between now and the 21st Century? What are the possible directions that the United States can move in regarding health care reform and the long-term financing of health entitlement programs? Here, the author offers a snapshot of current politics and some predictions for the next four years. And explores the question: Are Americans willing to make the necessary sacrifices for future generations to profit by the significant changes needed by entitlement and health reform, or will it be business as usual? America's centrist perspective was recently reinforced by the 1996 election, suggesting that no major innovations in entitlement or in the health system should be anticipated in the next four years.     

A Medicare reform primer

The use of the federal budget process to change Medicare policy is of importance to physician executives because of its impact on the health care delivery system. In particular, changes in Medicare policy, driven by the need to shore up the solvency of a politically popular program, will create changes for other public and private purchasers of health care. Reforming Medicare through the budget process is not new. Physician fees have been frozen, reduced, and selectively increased as a result. In 1983, the hospital reimbursement methodology was changed to prospective payment through this process. The budget process will continue to be used to make policy changes because of the large amount that Medicare occupies of the federal budget. Given the profound impact changes in Medicare can have in other health care sectors, the lack of consensus for a long-term solution would mean those in the health care arena will have to be prepared for significant annual policy changes through the reconciliation process.     

National health reform advocates retrench and prepare for Medicare

With the failure of President Truman's efforts to pass compulsory health insurance for all, national health reform (NHR) advocates began to redirect their political attention to a politically powerful group of Americans who were simultaneously vulnerable from a health care point of view--the elderly. This effort culminated in the passage of Medicare under President Johnson. This article will focus on antecedents to passage of Medicare that can be found in the Eisenhower and Kennedy administrations. It will also discuss other facets of health reform proposals from the Eisenhower administration. While most proposals never became law, the legislative intent of many of them--outlawing cancellation of policies, a minimum standard health benefit package, establishment of regional health authorities, preference for prepayment plans, and establishment of a reinsurance pool administered by the federal government--is currently under active discussion by the Clinton health reform task forces.