پوشش بیمه سلامت و اقتصاد کلان

This paper investigates the relationship between the macroeconomy and health insurance coverage for non-elderly Americans. We find that, for men, state unemployment rate is positively correlated with the probability of health insurance coverage in general and through an employer in particular, and that these correlations are only partly explained by changes in employment status. In contrast, the insurance coverage of women and children appears to be insulated from fluctuations in the unemployment rate by public health insurance programs like Medicaid and State Children's Health Insurance Program (SCHIP). We estimate that 984,000 Americans, nearly all of whom were adult men, lost health insurance due to macroeconomic conditions alone during the 2001 recession.

In March 2001, the longest economic expansion in U.S. history ended, and a recession began that lasted until November 2001 (Business Cycle Dating Committee, 2003). This, combined with recent policy interest in the uninsured (Committee on the Consequences of Uninsurance, 2001 and Committee on the Consequences of Uninsurance, 2004), raises the question: What is the relationship between macroeconomic climate and health insurance coverage among the non-elderly U.S. population? This paper answers that question, plus these others: How does the effect of the macroeconomy on insurance coverage differ for men, women and children? What aspect of the macroeconomy matters: state unemployment rate or real per capita gross state product (GSP)? Does the macroeconomic climate primarily affect rates of uninsurance through changes in employment? Policymakers should be concerned about the loss of health insurance coverage for several reasons. First, some who lose employer-provided health insurance will join the rolls of public health insurance programs such as Medicaid and State Children's Health Insurance Program (SCHIP), increasing the strain on the budgets of those programs. Second, uninsured persons may receive less medical treatment than the insured (Doyle, 2001). Third, uninsured persons may impose costs on the health care system by receiving their care in relatively inefficient ways, such as using the emergency room for conditions that could have been treated with an office visit (Weissman et al., 1992). Fourth, uninsured individuals are at risk of severe financial loss, including bankruptcy, in the event of illness (Jacoby et al., 2000). Only a few studies focus on the link between macroeconomic conditions and health insurance coverage. Gruber and Levitt (2002), a Kaiser Family Foundation brief, studied aggregate March Current Population Survey (CPS) data for 1980–2000 and found that every percentage point rise in unemployment was associated with an increase of 1.2 million uninsured persons. Holahan and Garrett (2001) estimate that a percentage point increase in unemployment is associated with a rise in Medicaid enrollment of 1.5 million. Marquis and Long (2001) find mixed evidence that county unemployment rates are correlated with employer offers of health insurance and employer contributions to health insurance. Glied and Jack (2003) study state-level CPS data and find that unemployment rates are more strongly correlated with insurance coverage for well-educated than less-educated workers, in part because workers with less education are at all times less likely to be offered employer-provided health insurance. A limitation of several of these previous studies is their use of the CPS data. The CPS records whether the respondent was covered by health insurance at any point in the last 12 months; thus, one cannot use the CPS to determine health insurance coverage in a specific month. A contribution of this paper is to provide estimates derived from reports of health insurance coverage in a specific month matched with macroeconomic conditions during that month. The previous literature is also limited by its use of cross-sectional data and inability to remove unobserved time-invariant heterogeneity. This paper contributes to the literature by analyzing longitudinal data and controlling for person-specific fixed effects. Our results indicate that increases in unemployment rate lower the probability of health insurance coverage for adult men. A substantial fraction, but not all, of this correlation is explained by changes in employment status. In contrast, the insurance coverage of women and children appears to be insulated from fluctuations in the unemployment rate by public health insurance programs like Medicaid and SCHIP. For men, women, and children, real per capita gross state product is uncorrelated with the probability of coverage.

We find significant gender differences in the relationship between macroeconomic conditions and the probability of health insurance coverage. For men, the probability of any coverage is negatively correlated with unemployment rate; a one-point increase in state unemployment rate is associated with a decrease in the probability of health insurance coverage through any source of 0.70 percentage points. In contrast, the unemployment rate is not significantly correlated with coverage through any source for women or children. This difference in results between men, women, and children is likely due to Medicaid and SCHIP working counter-cyclically to enroll women and children who lose other types of coverage during periods of high unemployment. We find that unemployment rate is negatively correlated with coverage even controlling for employment status. Our prediction that real per capita gross state product would be positively correlated with the probability of coverage was not supported by the data. Unemployment rate is apparently the most relevant measure of the macroeconomy for determining the risk of uninsurance. From March to November of 2001, the U.S. experienced an economic recession. We use our estimates of the correlation between health insurance coverage and unemployment rate and GSP to predict the number of Americans who lost health insurance during the recession. During the 2001 recession, the national unemployment rate rose from 4.3% in March to 5.6% in November and real per capita GDP fell from US$ 34,764 in the first quarter to US$ 34,499 in the fourth quarter (U.S. Department of Labor, 2004; U.S. Department of Commerce, 2004). Based on these changes, our regression results, and Census estimates of the U.S. population of men aged 18–64, women aged 18–64, and children under age 18 in the year 2001 (U.S. Census Bureau, 2004), we estimate that roughly 984,000 Americans lost health insurance during the 2001 recession. Our estimates indicate that almost all of those who lost health insurance were adult men; specifically, that 908,000 of the 984,000 were men. The remaining 75,000 were virtually all women; our estimates indicate that virtually no children lost health insurance during the recession. Our estimate of the total number losing health insurance during the 2001 recession is less than that of Families USA (2002), which estimated that 2 million Americans lost health insurance due to increased unemployment between March and December of 2001. Three differences between the Families USA study and the present one should be kept in mind when comparing the overall estimates: first, Families USA was based on an extra month (December 2001); second, the Families USA study is based on the CPS rather than SIPP; third, the Families USA study did not take into account the loss in health insurance coverage that occurred as a result of the slight decline in real per-capita GSP. Our estimates also indicate that more than enough Americans have gained coverage during the current recovery to fully offset the loss of coverage during the recession. Between the end of the recession in November 2001 and March 2004, the national unemployment rate rose from 5.6 to 5.7% and real per capita GDP rose from US$ 34,499 to 36,567 (U.S. Department of Labor, 2004; U.S. Department of Commerce, 2004). Based on these figures, and holding constant population at the 2001 levels in order to avoid confusing an increase in population with an increase in the probability of insurance coverage, we estimate that roughly 1.246 million Americans gained health insurance coverage during the current recovery. Of the 1.246 million who gained health insurance, roughly 806,000 were men, 440,000 were women, and virtually none were children. We emphasize that our estimates cover only those who lost (or gained) health insurance because of changes in the macroeconomy. Because of other changes in health insurance markets, labor markets, or society, additional people may have lost (or gained) health insurance.