JAYANTA BHATTACHARYA, Stanford University - Center for Primary Care and Outcomes Research, National Bureau of Economic Research (NBER)
Email: jay@stanford.edu
M. KATE BUNDORF, Stanford University - Department of Health Research And Policy, National Bureau of Economic Research (NBER)
Email: bundorf@stanford.edu
NOEMI PACE, University College London
Email: n.pace@ucl.ac.uk
NEERAJ SOOD, RAND Corporation, National Bureau of Economic Research (NBER)
Email: sood@rand.org

The prevalence of obesity has been rising dramatically in the U.S., leading to poor health and rising health care expenditures. The role of policy in addressing rising rates of obesity, however, is controversial. Policy recommendations for interventions intended to influence body weight decisions often assume the obesity creates negative externalities for the non-obese. We build on earlier work demonstrating that this argument depends on two important assumptions: 1) that the obese do not pay for their higher medical expenditures through differential payments for health care and health insurance, and 2) that body weight decisions are responsive to the incidence of medical care costs associated with obesity. In this paper, we test the latter proposition – that body weight is influenced by insurance coverage - using two approaches. First, we use data from the Rand Health Insurance Experiment, in which people were randomly assigned to varying levels of health insurance, to examine the effect of generosity of insurance coverage on body weight along the intensive coverage margin. Second, we use instrumental variables methods to estimate the effect of type of insurance coverage (private, public and none) on body weight along the extensive margin. We explicitly address the discrete nature of the endogenous indicator of health insurance coverage by estimating a nonlinear instrumental variables model. We find weak evidence that more generous insurance coverage increases body mass index. We find stronger evidence that being insured increases body mass index and obesity.

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ELIZABETH PENDO, Saint Louis University - School of Law
Email: ependo@slu.edu

Although chronic illness is generally associated with the elderly or disabled, chronic conditions are widespread among working-age adults and pose significant challenges for employer-based health care plans. Indeed, a recent study found that the number of working-age adults with a major chronic condition has grown by 25 percent over the past 10 years, to a total of nearly 58 million in 2006. Chronic illness imposes significant costs on workers, employers, and the overall economy. This population accounts for three-quarters of all personal medical spending in the United States, and a Milken Institute study recently estimated that lost workdays and lower productivity as a result of the seven most common chronic diseases results in an annual loss of over $1 trillion dollars.

I am focusing on this significant and growing population as a challenge for employers and as a critical test case for current health care reform proposals. Many of the cost-control methods used by employer-based plans simply shift rather than lower health care costs. This disproportionately burdens people with chronic illnesses and creates long-term social and economic costs. The experiences and challenges of workers with chronic illness provide an opportunity to examine the larger framework of health care reform, not just the employer’s role in isolation, and they make clear that chronic illness is an issue that must be addressed by employers and policymakers.

PAUL FRONSTIN, Employee Benefit Research Institute (EBRI)
Email: FRONSTIN@EBRI.ORG

In general, Americans support concepts that are on the table for health reform. For instance, a majority either strongly or somewhat support health insurance market reform, the availability of a public plan option, mandates on employers and individuals, and expansion of public programs to cover more of the uninsured. When the implications of health reform are raised in public opinion polls, support for health reform drops. This paper examines public opinion by insurance status and health status, using data from the 2009 EBRI/Mathew Greenwald & Associates Health Confidence Survey. It finds that the uninsured are more likely than individuals with insurance coverage to be dissatisfied with the quality of health care received and they are less confident in various aspects of health care. The gap in satisfaction and confidence has also grown over time. Similar differences in satisfaction and confidence are found by health status. While these sharp differences in attitudes are not surprising, shoring up the system for the uninsured and individuals with chronic conditions means changing the health care system for everyone - notably for those with insurance coverage and in good health. Ultimately, will the needs of the few outweigh the satisfaction of the many?

PAUL FRONSTIN, Employee Benefit Research Institute (EBRI)
Email: FRONSTIN@EBRI.ORG

This paper examines the status of health insurance coverage in the United States. Based on EBRI estimates from the U.S. Census Bureau’s March 2009 Current Population Survey (CPS), it reflects 2008 data. It also discusses trends in coverage for the 1994-2008 period and highlights characteristics that typically indicate whether an individual is insured. The report focuses on the nonelderly population (under age 65) because this group can receive health insurance coverage from a number of different sources, and because Medicare covers nearly all individuals age 65 and older. The estimates presented in this report therefore differ from those published by the Census Bureau. As a result of this difference between EBRI and Census Bureau estimates, this report shows a higher percentage of uninsured in the United States. The percentage of the nonelderly population (under age 65) with health insurance coverage decreased to 82.6 percent in 2008. Increases in health insurance coverage have been recorded in only four years since 1994, when 36.5 million nonelderly individuals were uninsured; in 2008, the uninsured population was 45.7 million. Employment-based health benefits remain the most common form of health coverage in the United States. In 2008, 61.1 percent of the nonelderly population had employment-based health benefits, down from 68.4 percent in 2000. Between 1994 and 2000, the percentage of the nonelderly population with employment-based coverage expanded. This paper also discusses recent trends in health insurance coverage and some of their causes; the determinants of having employment-based health insurance coverage as well as other types of coverage; the uninsured population and the factors associated with being uninsured; and policy implications. The final section of the paper presents conclusions. Data sources are discussed in more detail in the appendix.

ROSEMARY HYSON, U.S. Census Bureau - Center for Economic Studies
Email: rosemary_hyson@baruch.cuny.edu
ALICE M. ZAWACKI, U.S. Census Bureau - Center for Economic Studies
Email: alice.m.zawacki@census.gov

Economic studies on health-related issues have the potential to benefit all Americans. The approaches for dealing with the growth of health care costs and health insurance coverage are ever changing and information is needed on their efficacy. Research on health-related topics has been conducted for about a decade at the Census Bureau’s Center for Economic Studies and the Research Data Centers. This paper begins by describing the confidential business and demographic Census Bureau data products used in this research. The discussion continues with summaries of nearly 30 papers, including how this work has benefited the Census Bureau and its research findings. Some focus on data linkages and assessing data quality, while others address important questions in the employer, public, and individual insurance markets. This research could not have been accomplished with public-use data. The newly available data from the Agency for Healthcare Research and Quality and National Center for Health Statistics, as well as additional Census Bureau data now available in the Research Data Centers are also discussed.

EDWARD A. ZELINSKY, Benjamin N. Cardozo School of Law
Email: ZELINSKY@PRODIGY.NET

?Whatever happens in Washington in the weeks and months ahead, the United States is fated for the indefinite future to conduct a prolonged and difficult national debate on health care. The reason for this protracted and arduous argument can be summarized in a single word: cost. Yet, paradoxically, the rhetoric of unspecified cost reduction is used to avoid the painful choices needed to prune health care outlays, choices which inevitably involve agonizing denials of medical services in a world of finite resources. Medical costs cannot be controlled without denying something to somebody. Yet, paradoxically the term “cost” is used in contemporary political discourse to avoid the difficult choices involved in such denials. It is easier to favor unspecified cost reductions, than to identify particular service denials which would actually reduce medical care expenditures. Elected officials are reluctant to deny medical services to cut costs, but health care costs cannot be meaningfully controlled without such service denials. Our employer-based system of medical care is a major reason we confront this difficult situation. Yet, again paradoxically, the employer-based system, though flawed, is the best tool available to us to control medical care costs since employers must respond to competitive pressures in the marketplace and thus are better positioned than is government to implement the painful service denials necessary to curb health care outlays. However, even under the best of circumstances, medical care costs are not a problem which will be solved but rather are a reality to be permanently and painfully managed and controlled.

MERVE CEBI, University of Massachusetts at Dartmouth
Email: mcebi@umassd.edu
STEPHEN WOODBURY, Michigan State University, W.E. Upjohn Institute for Employment Researach
Email: WOODBUR2@PILOT.MSU.EDU

The Omnibus Budget Reconciliation Act of 1990 introduced a refundable tax credit for low-income working families who purchased health insurance coverage for their children. This health insurance tax credit (HITC) existed during tax years 1991, 1992, and 1993, and was then rescinded. We use Current Population Survey data and a difference-in-differences approach to estimate the HITC’s effect on private health insurance coverage of low-earning single mothers. The findings suggest that during 1991-1993, the health insurance coverage of single mothers was about 6 percentage points higher than it would have been in the absence of the HITC.

HEATHER L. HARRELL, affiliation not provided to SSRN
Email: authorharrell@ssrn.com
MARK A. ROTHSTEIN, University of Louisville - Institute for Bioethics, Health Policy, and Law, University of Louisville - Louis D. Brandeis School of Law
Email: mark.rothstein@louisville.edu

We sought to examine the legal and ethical implications of workplace health risk reduction programs (HRRP's) using health risk assessments, individually focused risk reduction, and financial incentives to promote compliance. Methods: We conducted a literature review, analyzed relevant statutes and regulations, and considered the effects of these programs on employee health privacy. Results: A variety of laws regulate HRRP's, and there is little evidence that employer-sponsored HRRP's violate these provisions; infringement on individual health privacy is more difficult to assess. Conclusion: Although current laws permit a wide range of employer health promotion activities, HRRP's also may entail largely unquantifiable costs to employee privacy and related interests. (J Occup Environ Med. 2009; 51:951–957)

PAUL FRONSTIN, Employee Benefit Research Institute (EBRI)
Email: FRONSTIN@EBRI.ORG

This paper examines the relationship between health benefits and union status. Union workers are much more likely to have employment-based health benefits than nonunion workers. In September 2007, 82.7 percent of union workers were covered by health benefits through their own job, compared with 58.2 percent of nonunion workers. Overall, 94.2 percent of union workers had employment-based health benefits, compared with 76.4 percent of nonunion workers. Although union workers were less likely than nonunion workers to have employment-based coverage as a dependent (11.5 percent and 18.2 percent, respectively), union workers are much less likely to be uninsured. Only 2.9 percent of union workers were uninsured in September 2007, compared with 14.2 percent uninsured among nonunion workers. Since union workers account for a declining share of the working population in the private sector, further erosion of unionization is likely to coincide with overall erosion in the percentage of workers with employment-based health benefits, all else equal. Furthermore, any future decline in the size of the public sector that is unionized will only exacerbate the overall erosion in the percentage of workers with employment-based health benefits. The paper also examines the job characteristics of union and nonunion workers, as well as health benefits and job characteristics for union and nonunion workers. Union workers are more likely to be employed in the public sector, manufacturing industry, blue-collar occupations, and in full-time jobs. Union workers have higher annual earnings than nonunion workers.

RONEN AVRAHAM, University of Texas at Austin - School of Law
Email: ravraham@law.utexas.edu
LEEMORE S. DAFNY, Northwestern University - Department of Management & Strategy, National Bureau of Economic Research (NBER)
Email: l-dafny@kellogg.northwestern.edu
MAX M. SCHANZENBACH, Northwestern University - School of Law
Email: m-schanzenbach@law.northwestern.edu

We evaluate the effect of tort reform on employer-sponsored health insurance premiums by exploiting state-level variation in the timing of reforms. Using a dataset of healthplans representing over 10 million Americans annually between 1998 and 2006, we find that caps on non-economic damages, collateral source reform, and joint and several liability reform reduce premiums by 1 to 2 percent each. These reductions are concentrated in PPOs rather than HMOs, suggesting that can HMOs can reduce defensive healthcare costs even absent tort reform. The results are the first direct evidence that tort reform reduces healthcare costs in aggregate; prior research has focused on particular medical conditions.