اجتناب از بیمه سلامت جمعیت میانگین: شواهد درمان به عنوان قانون پرداخت کننده ثانویه

The cost of expanding health insurance coverage increases when people who would otherwise purchase insurance obtain public coverage. This paper investigates the effects of one of the first efforts to target insurance benefits to the most needy, the 1982 medicare as secondary payer (MSP) provisions. We find strong evidence of low compliance with the MSP both in terms of medical bill payments (payment compliance) and employer-sponsored insurance coverage (coverage compliance). We estimate payer compliance at approximately 33%. Coverage compliance is lower, at under 25%. We find weak evidence that the MSP caused older workers to shift toward MSP-exempt jobs.

Many people who are eligible for public insurance coverage would have obtained private insurance coverage if these public programs had not been adopted (Cutler and Gruber, 1995). The governmental cost of expanding insurance coverage is increased when those who would have otherwise purchased private coverage participate in a public program. Such subsidized purchases of insurance substitute for — or “crowd-out” — previously unsubsidized purchases. Universal insurance programs necessarily generate 100% crowd-out of previously existing private coverage. As the costs of universal programs have risen, however, legislators have become increasingly interested in targeting public benefits only to those who need them. Before the current crowd-out debate began, Congress made changes in medicare to try to reverse some of the insurance substitution due to the program’s universal coverage of the elderly. The 1982 medicare as secondary payer (MSP) legislation requires employers who offer health insurance to any of their workers to provide it, on similar terms, to their workers age 65 and over, and requires that any such insurance be “primary” to medicare. This paper examines the effects of that law. Anti-crowd-out provisions raise two concerns. First, given the fragmented nature of the US health insurance market, the provisions may be very difficult to enforce. Second, the provisions may alter labor market behavior. Using data from the National Medical Care Expenditure Survey (NMCES) (1977), the National Medical Expenditure Survey (NMES) (1987), and the Current Population Survey for 1980–1988, a period surrounding passage and implementation of the MSP, we estimate the extent and nature of compliance with the legislation. We then estimate the extent of labor market responses to the tax by examining the hours worked by and types of firms where these workers were employed and the extent to which the legislation affected wages and employment.1 Our findings suggest that the MSP legislation was largely unsuccessful in forcing employers to provide primary insurance coverage for their elderly workers. Our estimates suggest that the MSP achieved only between 25 and 33% of its intended savings, mostly because of non-compliance with the legislation. We find some evidence that employers and employees changed their behavior to avoid complying with the mandate, and that these effects were concentrated in the largest firms.

The MSP mandate did not actually accomplish much of what it set out to do. Payer compliance with the mandate was only about one-third and was concentrated entirely among the largest claims. Coverage compliance was under 25%, even assuming the distribution of hours worked as constant. We also observe some evidence of MSP avoidance, particularly in the largest firms, further reducing the impact of the legislation. By contrast, we find no observable effect of the mandate on wage and employment outcomes. We decompose the lack of savings from lack of compliance and tax avoidance and summarize these results in Table 8. In the first column, we report the results of a decomposition that includes both payment and coverage compliance (employers both acted as primary payers when they were obligated to, and provided coverage for workers age 65 and over at similar rates to those under age 65). The second column reports the decomposition of savings assuming payment compliance only. Our results suggest net savings from MSP between US$ 309 and US$ 459 million in 1985, consistent with HCFA’s reported savings of US$ 450 million.