Health Policy Conference Examines the Uninsured

Summer 2003, Volume 25, Number 1

(From left) Jonathan Gruber, Robert LaLonde, and IPR's Bruce Meyer at the health conference

In 2002, 41 million Americans were without health insurance for the entire year. The ramifications of the uninsured for both government and individuals are considerable. To examine this issue in greater depth, Bruce Meyer, IPR faculty fellow and economist, assembled a group of top researchers in the field at the “Health Policy and the Underserved” conference held May 8-9 in Washington, D.C. It was hosted jointly by IPR and the Joint Center for Poverty Research.

Conference presenters spoke to issues that dominate current policy discussions, from the effects of no insurance on health, to immigrant health, to the rising number of workers who are choosing not to participate in employer-sponsored health care, to crowd-out effects of varying policies.

A much debated issue is that of “crowd-out”—the degree to which families substitute public programs for private in health care and health insurance. Meyer and Anthony Lo Sasso, an IPR faculty associate and research associate professor, find little evidence that hospitals and clinics that provide free care for the poor discourage them from purchasing insurance. “That we do not find strong evidence of crowd-out suggests that the effects may be small if present,” Meyer said. Other researchers found similarly small effects of crowd-out from Medicaid expansions and other policy changes, though a paper by George Borjas of Harvard found substantial crowd-out among immigrants.

Jonathan Gruber and Ebonya Washington with the Massachusetts Institute of Technology reported that the decline in insurance coverage has been driven almost exclusively by workers who are opting out of employer-sponsored health care—not because of reduced offering. In response, subsidies have been offered to employees to encourage them to sign up for coverage. This, however, “is truly a bad policy,” Gruber said. He and Washington found that subsidies induce employees to choose more expensive coverage and have only a small impact on how many uninsured individuals sign up for insurance.

Other efforts are more successful in insuring families. For those lacking jobs or access to employer-sponsored health care, Anna Aizer of Princeton University and Jeffrey Grogger of the University of California at Los Angeles studied Medicaid programs that have been expanded to cover more adults. They found that the expansions benefited adults as well as their children, and they modestly increased maternal and child coverage.

These expansions also improved the health services received by adults, according to Susan Busch and Noelia Duchovny of Yale University. Medicaid eligibility raised the probability that a parent gets a check-up and increased the likelihood that women receive preventive cancer screenings. In addition, the expansions appear to have made it more likely that an adult with children will not forgo medical care because of costs. “The increase in check-ups and screenings implies that the programs are having the desired effects,” Grogger said.

The potential importance of public policies affecting early childhood health is underscored by research on the long-run effects of improved infant health during the 1960s War on Poverty. Douglas Almond of the National Bureau of Economic Research and Kenneth Chay of the University of California at Berkeley found that the health of girls during infancy appears to be one of the most important determinants of subsequent maternal health. Moreover, inferior health among African-American infants appears to exert a persistent, negative effect on black maternal health, which in turn leads to poor birth outcomes in the subsequent generation.

Other topics covered in the conference included the effects of managed care, why people do not purchase health coverage, the nature of changes in employment and health insurance coverage, health insurance coverage choices by married couples, and the effects of changes in Medicaid coverage for immigrants. The issues facing policymakers and researchers working in the health policy field are complex and pressing. “By bringing together a diverse group of people working on these issues, we advanced our understanding of a wide range of policy issues,” Meyer said.

The papers presented at the conference are available at www.jcpr.org/conferences/oldconferences/health_policy.html