آیا بیمه سلامت کارفرمایان در دسترس محدود به تنظیمات عرضه نیروی کار برای شوک های سلامتی است؟ شواهد جدید در زنان مبتلا به سرطان سینه

Employment-contingent health insurance may create incentives for ill workers to remain employed at a sufficient level (usually full-time) to maintain access to health insurance coverage. We study employed married women, comparing the labor supply responses to new breast cancer diagnoses of women dependent on their own employment for health insurance with the responses of women who are less dependent on their own employment for health insurance, because of actual or potential access to health insurance through their spouse's employer. We find evidence that women who depend on their own job for health insurance reduce their labor supply by less after a diagnosis of breast cancer. In the estimates that best control for unobservables associated with health insurance status, the hours reduction for women who continue to work is 8 to 11% smaller. Women's subjective responses to questions about working more to maintain health insurance are consistent with the conclusions from observed behavior.

When workers are faced with serious health conditions thatrequire expensive treatment and long periods of recovery, provi-sion of health insurance through an employer can complicate theirdecisions. Although workers may want to invest in their healthby taking time away from work for treatment and recovery, theirdemand for health insurance rises because of the increased riskof health care expenses. Employer-provided health insurance isoften only offered to or taken up by full-time employees, in whichcase ill workers must also work enough hours to keep their healthinsurance benefits. The potential loss of insurance coverage (or anincreased cost of health insurance if workers reduce hours andpurchase coverage) therefore raises the cost of forgoing work fortreatment (or recovery) (Bradley et al., 2006). The need to main-tain labor supply at a level sufficient to keep health insurancecould have adverse health consequences; work could conflict with recovery, or it could influence treatment decisions or adherencewith a treatment plan.Workers who become ill and lose their employer-providedhealth insurance have limited alternative options to obtaininsurance. One possibility is continuing coverage through the Con-solidated Omnibus Budget Reconciliation Act of 1985 (COBRA).However, former employees pay the full cost of group coverage, andthe policy is usually limited to 18 to 36 months – making contin-uation of coverage via COBRA a prohibitively expensive option formany and only a temporary measure even for those who can affordit.1Alternatively, the Health Insurance Portability and Accountabil-ity Act of 1996 (HIPAA) allows employees to add to their insurancepolicy a spouse or other dependent who loses job-related coverage,without waiting until the next open enrollment cycle. However,HIPAA offers no protection to many ill workers, including those whose spouses are not employed and those with employed spouseswhose employer does not offer health insurance coverage for fam-ily members.2The Family Medical Leave Act (FMLA) entitles eligibleemployees of covered employers to take unpaid, job-protectedleave for specified family and medical reasons with continuationof group health insurance coverage (United States Department ofLabor, Wage and Hour Division, 2012). However, not all workers arecovered by FMLA and some workers may fear that using FMLA willresult in adverse consequences at work. Nonetheless, FMLA seemslikely to mute the extent to which people with health shocks areconstrained to remain at work and not reduce their hours.This paper studies labor supply changes following health shocks,comparing married women newly diagnosed with breast cancerand dependent on their own job for health insurance to simi-lar women who are insured through a spouse’s policy or withaccess to insurance through a spouse. We survey these womenthree times to cover three distinct periods: just prior to diagno-sis (retrospectively) and two and nine months after initiation oftreatment. By focusing on the time period immediately followingtreatment initiation, we observe labor supply behavior when treat-ment demands are greatest and therefore entail decisions aboutlabor supply (including whether to remaining employed).We include a core set of analyses that replicate Bradley et al.(2006), but we use a sample specifically constructed to address therelationship between labor supply and dependence on one’s job forhealth insurance in a breast cancer context. Moreover, we presenta number of new analyses based on comparisons of women whodepend on their jobs for health insurance to subsets of women whoare less dependent on their own employment for health insurancebut who are more likely to be similar in terms of unobservablessuch as job characteristics and commitment to work. The alterna-tive comparisons are intended to better account for unobservedheterogeneity associated with the prior choice of health insurancesource that could affect labor supply changes over time, perhapsalso including labor supply in responses to a new diagnosis of breastcancer. When we simply compare women offered health insurancethrough their employer (which we term ECHI, for “employment-contingent health insurance”) to those without ECHI, differencesin labor supply behavior may be driven by the other differencesbetween women who do or do not have ECHI, or differences intheir jobs. In contrast, for example, one new comparison we intro-duce restricts attention to women offered ECHI, and distinguishesbetween those who enrolled in ECHI and those who declined (andinstead took insurance through their spouses’ employers). Womenoffered ECHI are likely to have more similar types of jobs andcareers, so among those offered ECHI, the difference between thosewomen who do and do not enroll should better isolate differencesin labor supply responses attributable solely to how dependentthey are on their own job for insurance. A second comparison isagain only among the more homogeneous group of women withECHI, but contrasting those who have the option to switch to aspouse’s policy with those who do not.

DiscussionThe evidence supports the hypothesis that ECHI incentivizeswomen newly diagnosed with breast cancer to maintain higherlabor supply than they would otherwise. The estimated differencein labor supply responses to the health shock is modest – about8–11% – and the evidence is somewhat sensitive to the choice ofcomparison groups. However, the evidence is strongest statisti-cally when we compare women who differ in their dependencyon their jobs for continued insurance, but are otherwise most sim-ilar in terms of personal and job characteristics, which in our viewstrengthens the conclusion. In particular, the strongest evidenceemerges from comparing women with ECHI, but differentiated onlyby whether their spouses are offered employer-provided healthinsurance that would cover the woman if she lost coverage throughher employer. The evidence from the inclusion of the CPS samplesupports our findings, producing very similar coefficients on theeffects of ECHI for women diagnosed with breast cancer. In addi-tion, subjective responses of women diagnosed with breast cancerto questions about whether they are working more to maintainhealth insurance are consistent with the conclusions from observedbehavior.Our study advances what is known about the relationshipbetween ECHI and labor supply, and has two advantages over priorstudies. First, we collected data on a rich set of control variables,including disease and treatment characteristics, job characteris-tics, and respondent and spouse characteristics, which were usedto help rule out competing explanations of the observed effects.Second, we improved upon prior assessments of ECHI’s effecton labor supply (our own included) by using alternative, morehomogeneous comparison groups that better identify the effectsof dependence on one’s job for health insurance. In general, thesealternative comparisons led to stronger evidence that dependenceon one’s employment for health insurance moderates labor supplyreductions in response to breast cancer.Our evidence consistently points to smaller labor supply reduc-tions in response to breast cancer for women who depend ontheir own employment for health insurance, although the mag-nitudes are modest and in many cases not statistically significant.Our results can be viewed as consistent with the job lock litera-ture, which has generally found modest estimates of the effect ofemployment-contingent health insurance in reducing job mobility,despite a few early papers that suggested large effects. Our researchdiffers in providing evidence on a different channel by whichemployer-provided health insurance may constrain worker’s labormarket decisions – which we might think of as “hours lock” thatconstrains labor supply, rather than job lock that constrains jobmobility.In addition to drawing inferences from observed labor supplybehavior, we questioned the women in our sample – all of whomhad a breast cancer diagnosis – about their motivation to con-tinue employment. Although the responses to these questions mayreflect unobserved preferences for both employment and healthinsurance, women dependent on their own employment for healthinsurance report that they are working – or are working more –in order to maintain health insurance, which may explain wor-ries related to insurance expressed by participants in qualitativestudies of cancer survivorship (Schwartz et al., 2009). Althoughfew women stopped working during the study period, concernsregarding health insurance insecurity are probably well foundedgiven the strong correlation between job loss and loss of healthinsurance coverage (Cawley et al., 2011).There are limitations to the study, although there are some jus-tifications for these limitations. First, the study is confined to asingle state, which may limit whether it can be generalized to othersettings. To mitigate this possibility, we enrolled subjects from aca-demic and private practices and from rural and urban settings. Anadvantage of focusing on a single state is that women in the samplewere most likely subject to similar economic conditions that mayaffect employment.Second, we study a single disease where treatment is largelyprovided on an outpatient basis and is reasonably uniform acrosspractices. Again, this limits generalizability, but it avoids problemsfrom heterogeneity of disease, morbidity, and treatment. Theseconditions strengthen the internal validity, but at the expense ofexternal validity. Therefore, it would be valuable to gain moreknowledge about how health insurance that is tied to one’s jobinfluences labor supply responses to different types of healthshocks, particularly those that require long absences from work,although collecting the requisite data, as in our study, is expensive.Third, we study married women, so the findings may not gen-eralize to single women (or men) who do not have the option toswitch to a spouse’s policy, nor to married men who are less likelyto have the option to switch to a wife’s policy. Prior work suggeststhat men will be more constrained by ECHI following the diagnosisof a serious illness because they are likely to have fewer optionsthan women to switch to their spouse’s employer-provided healthinsurance (Bradley et al., 2012).Fourth, in spite of our attempts to enroll and study similargroups of women, in the absence of randomization of employeesto equivalent ECHI policies and spouse ECHI policies, dissimilar-ities between the treatment and control groups are inevitable.Dissimilarities can occur between study subjects, comparability ofinsurance policies, and jobs. We therefore cannot completely ruleout bias from selection into different health insurance statuses.Absent an experimental design, we tried to overcome or assess thislimitation by studying more similar groups of women. The over-all consistency of our findings, and the fact that they are strongerwhen we use comparisons among more homogeneous groups ofwomen who are still differentiated by how dependent they are ontheir own employment for health insurance, should bolster confi-dence in the findings. Nonetheless, we cannot definitively rule outa role for unobserved characteristics that are associated with theoffer and acceptance of health insurance through one’s job, andsubsequent labor supply changes.The evidence that dependence on employment for health insur-ance creates an incentive to maintain higher labor supply whenfaced with a health shock, and that women strongly perceivethis incentive, suggests that employer-provided health insurancemay lead to anxiety or stress among people who experience ahealth shock and are dependent on employment for their healthinsurance. Moreover, the resulting constraint on reducing laborsupply may influence treatment decisions and adherence behav-ior to avoid reducing labor supply as much as might be optimalfor recovery. Future research will explore the effects on treat-ment, adherence, and health consequences of the dependence onemployment for health insurance. From a public policy perspective,having better and cheaper options for health insurance outside ofthe employer may benefit some workers. At the same time, therelatively modest differences we find in labor supply responsesto health shocks suggest that providing these options outside theemployer-based system are unlikely to trigger substantial reduc-tions in labor supply.