Macroeconomic Consequences of Alternative Reforms to the Health Insurance System in the U.S. Zhigang Feng Department of Economics University of Miami

January 18, 2009

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Background National health expenditures account for 16.3% of the U.S. GDP in 2007, compared with 5.2% in 1960. In 2007, 17.3% non-elderly living in the U.S. lack health insurance. The 47 million uninsured imposes a financial externality on the insured through uncompensated care, whose costs were estimated to be about $41 billion in 2004. Policymakers have considered substantial changes to the U.S. health care system. However, little work has been done to evaluate such reforms.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Related literature

L IFE CYCLE MODELS WITH HEALTH SHOCKS : Palumbo (1999), De Nardi, et al. (2006), French and Jones (2007) H EALTH POLICIES AND MACROECONOMY: Gruber (2008), Jeske and Kitao (2008) M Y C ONTRIBUTIONS : 1

Endogenize both health expenditure labor supply; make a distinction between public and private insurances.

2

Provide a theoretical framework to quantify the costs and general equilibrium effects of a broad set of health care reforms.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

What I do Quantitative study of the impacts and costs of alternative health care reforms on the macro-economy and on welfare. Stochastic OLG model with endogenous health expenditure, labor supply and demand for health insurance. Calibrate the model using MEPS data set to match the current pattern of health expenditure and insurance demand. Consider implications of alternative reform proposals on: 1

total health expenditure, # of uninsured, insurance premiums;

2

aggregate labor supply, savings and GDP;

3

welfare.

Consider alternative ways to fund the reforms. Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Alternative reform proposals

E XP. A - expansion of Medicare to the entire population E XP. B - expansion of Medicaid E XP. C - an individual mandate E XP. D - the removal of the tax subsidy to purchase the private insurance E XP. E - providing a refundable tax credit for insurance purchases

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Preview of results Reforming the health care system has a quantitatively relevant impact on the number of uninsured, hours worked, and welfare. Details on how to fund the reforms matter a lot. # OF UNINSURED: Medicare expansion and individual mandate can achieve universal health care, while the removal of the tax subsidy to purchase private insurance reduce # of insured substantially. H OURS WORKED: the impact of the health care reforms on the aggregate labor supply is in the range of −9.1% and 6.8%. To fund the reform through labor income tax creates stronger distortion on the labor supply than through income tax. W ELFARE: an increasing in insurance coverage does not always improve welfare. Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Model Three-period OLG framework. Population grows at an exogenous rate of n. ¯ an Agents are born with same amount of health stock h, idiosyncratic endowment e0 , and a health risk type ih . Agents work for two periods, those that survive retire in the third period. Exogenous health shock εg at each period. ˜ t eξh l, profit Agents accumulate wealth through labor income w distributions Π, and saving ag . Storage technology with gross interest rate R = 1 + r . Main forces working are idiosyncratic health risk and heterogenous endowment.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Model

Preferences: hg1−η u(cg , Lg , hg ) = log cg + γ2,g log Lg + γ3,g 1−η Health production: hg = (1 − δh )hg−1 + εg F (Am, m)

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

The role of health

Each agent chooses optimal amount of health expenditure m to build up health capital h. Health capital affects utility and labor productivity. Agents survive from one period to the next with probability ρ(h).

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Medical expense and health insurance

P RIVATE HEALTH INSURANCE: Premium πpr is tax exemptible, coverage ratio qpr (pm mt ). P UBLIC HEALTH INSURANCE : 1

2

Medicaid: Agent is eligible to Medicaid if y ≤ Yma with an exogenous probability χ. Premium πma , coverage ratio qma (pm mt ). Medicare: All retirees are enrolled in the Medicare program. Premium πmr , coverage ratio qmr (pm mt ).

H EALTH INSURANCE CHOICES : 1 2 3

purchase private insurance(in = private insurance); apply for Medicaid (in = Medicaid); choose to be uninsured (in = uninsured).

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Agent Worker’s state: s = (x, hg−1 , g, ih ). Worker receives income through wage, interest income, profit. Worker makes the insurance decisions in(s) and chooses a set of state-contingent decision rules: 1 2 3 4

consumption c(s, ε); saving a(s, ε); medical usage m(s, ε); leisure L(s, ε).

Retiree: the same as worker, but there is no choice on insurance and labor supply.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Timeline of the individual’s decision

(1 + n)t t, a measure of                   agent enters the economy.

Y Young

health shock revealed,  agent makes consumption,  saving, labor supply and  medical usage decisions.

(ih , x , h0 ) agent observes                   ,  makes insurance decision     int based on her expectation  ε1 about health shock     .

t+1, agent survives with  ρ (h1) a probability           .  

Middl Middle-aged d

t+2, agent survives with  ρ (h2 ) a probability           .  

t+3, agent leaves  the economy.

Old

health shock revealed,  agent makes consumption,  saving, labor supply and  medical usage decisions. agent observes                   , (ih , x , h1 ) makes insurance decision      int +1 based on her expectation  about health shock     . ε2

(ih , x, h2 , ε 3 ) agent observes                       , makes consumption, and  p medical usage decisions.

Individual’s problem max Et

⎧ 3 ⎨ ⎩





β g−1 Πρ(hg−1 ) · u cg , Lg , hg | σt

g=1

⎫ ⎬ ⎭

s.t. ˜ (pm m1 , in1 )] · pm m1 + π ˜ (in1 ) + a1 (1 + τc )c1 + [1 − q  ξh  ˜ e 1 l1 − 1{in1 =pr } π ≤ e0 + Πt + (1 − 0.5τmr ) w ˜ (in1 ) − T (y1 ) ˜ (pm m2 , in2 )] · pm m2 + π (1 + τc )c2 + [1 − q ˜ (in2 ) + a2  ξh  ˜ 2 l2 − 1{in2 =pr } π ≤ Ra1 + Πt + (1 − 0.5τmr ) we ˜ (in2 ) − T (y2 ) (1 + τc )c3 + [1 − qmr (pm m3 )] · pm m3 + πmr ≤ Ra2 + Πt − T (y3 ) ag ≥ 0 Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Components in the budget constraint ε g exp Am mgζ

hg

= (1 − δh )hg−1 +

˜t w

= (1 − 0.5τmr )wt (1 − α)Yt  = fg dsg g={1,2,3} μg ⎧ ⎨ πpr , if in = private insurance πma , if in = Medicaid = ⎩ 0 if in = uninsured ⎧ ⎨ qpr (pm mg ), if in = private insurance qma (pm mg ), if in = Medicaid = ⎩ 0 if in = uninsured ⎧ ξh 1 ˜ t e l1 + Π − 1{in=pr } π ˜ (in), if g = 1 ⎨ w ˜ t+1 eξh2 l2 + Π − 1{in=pr } π = ra1 + w ˜ (in), if g = 2 ⎩ ra2 + Π if g = 3

Πt π ˜ (in)

˜ (pm mg , in) q

yg

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Firms and insurance companies

Firms: max At Etα − wt Et     Et = μg (t) eξhg l fg ds g={1,2}

Profits Πt are uniformly distributed back to agents in a lump-sum payment. Insurance companies take q pr (·), the distribution of agents and health expenditures as given and charge actuarially fair premiums.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Government

Government collects revenues from income taxation, Medicare taxation, consumption taxation, Medicare & Medicaid premium and accidental bequests. Exogenously given government spending. Government imposes Medicare tax to balance budget.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Stationary competitive equilibrium A Stationary Competitive Equilibrium is i) fiscal variables {G, τc , T (·), τmr }, ii) prices for medical services {pm }∞ t=0 ; iii) agents’ decisions; iv) firm’s choice E; v) insurance premium πpr ; vii) distributions of agents fg (s) over the state space S, such that 1. individual optimal choices solve the consumers problem taking prices and taxes as given; 2. given the distribution fg∗ of households, the insurance companies choose πpr such that the budget constraint of insurance companies holds;

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Stationary competitive equilibrium

3. the government sets τmr to balance the budget constraint; 4. given wages, the labor market clears; 5. the accidental bequests matches the remaining assets; 6. the aggregate resource constraint holds; 7. there is consistency between beliefs and the actual prices; 8. the distribution of agents over the state space S is stationary.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Data set used in this paper

The Household Component of the Medical Expenditure Panel Suvery (MEPS) which is based on a series of national surveys conducted by the U.S. Agency for Health Care Research and Quality (AHRQ). The MEPS consists of ten two-year panels from 1996/1997 up to 2005/2006. The Household Component of the MEPS includes data on demographics, income, health expenditure, insurance and health status.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Parameter values

Parameters Preferences preference over leisure Demographics population growth rate Health depreciation rate of health Production labor share in income TFP impact of health on productivity Government Medicare tax Medicaid coverage ratio Medicare coverage ratio Medicare premium Private Ins. insurance coverage ratio insrance premium

Notation

Value

Source

γ2,g

{1.3, 0.85, 1.3}

Match working hrs.

n

1.25

U.S. Census

δg

{0.4, 0.4, 0.5}

MEPS

α A ξ

0.66 8.0 0.1393

NIPA Normalization MEPS

τmr qma (x) qmr (x) πmr

2.5% β0 + β1 log x + β2 (log x)2 β0 + β1 log x + β2 (log x)2 2.11% of per capita GDP

determined in equi. MEPS MEPS MEPS

qpr (x) πpr

β0 + β1 log x + β2 (log x)2

MEPS determined in equi.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Parameter values

Parameters Preferences preference over health risk aversion over health Health productivity of medical service effect of medical usage on health

Notation

Value

γ 3,g η

{0.05, 0.5, 2.5} 1.35

Am ζ

1.96 0.52 ⎛ ⎞ −0.5 −10 ⎝ −2.5 −10 ⎠ −10 −20 1.52

(ε1g , ε2g )

health shocks price of medical service

Zhigang Feng (U Miami)

pm

Health Care Reform & Macroeconomy

Model vs. data

All insured (in % of non-elderly) Health expd. (in % of GDP) Labor supply (in % of total time) Ratio of retired to active population (in %) Ave. marginal income tax (in %) Medicare tax (in %) Ave. ins. premium (in % of per capita GDP) Size of Medicaid & Medicare (in % of GDP) Gross saving rate (in %) Consumption and health expd. profiles

Zhigang Feng (U Miami)

Data 82 15.8 33.3 19.2 21 − 32 2.9 10.9 4.6 21

Benchmark 84.8 16.6 30.6 18 24.6 2.5 10.1 4.8 25.8 see figure

Health Care Reform & Macroeconomy

Model v.s. Data

0.4

Health expenditure

0.35

Benchmark Data

0.3 0.25 0.2 0.15 0.1 0.05 35

40

45

50

55 Age

60

65

70

75

45

50

55 Age

60

65

70

75

0.7

Consumption

0.65

Benchmark Data

0.6 0.55 0.5 0.45 0.4 0.35 35

40

Figure: Life cycle profiles of health expenditure and consumption

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Policy experiments

Government spending G, medicare tax τ mr , consumption tax τc remain the same as in the benchmark. Reforms are funded via income taxes.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment A: expansion of Medicare A: government supplies a standard insurance policy (Medicare premium, private insurance coverage) to non-elderly. Average individual: 1

2 3 4

cheaper insurance → higher spending in health, better health → working hrs ↑; higher tax → working hrs ↓; better health → longer life expectancy → saving ↑; better insurance → decreased exposure to health shock → precautionary saving ↓.

Welfare: 1 2

tax distortion on the labor supply → welfare ↓; higher productivity, longer life expectancy, reduced adverse selection → welfare ↑; Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment A: expansion of Medicare

Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of per capita GDP) Output Aggregate saving rate (in %) Average consumption Average health stock CEV from transition all young (in %) young w/ e0 > Yma (in %) young w/ e0 ≤ Yma (in %) % w/ CEV > 0 (young)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.1 100.0 25.8 100 46.6

inc. tax 100.0 2.5 29.4 28.7 57.3 16.9 2.1 98.0 26.6 97.1 46.9

labor tax 100.0 8.9 24.7 27.9 55.7 16.8 2.1 96.1 26.4 96.6 46.9

lump sum 100.0 2.5 25.4 30.6 61.0 16.7 2.1 99.8 26.3 99.3 46.8

− − − −

2.6 5.9 −4.3 72.6

1.8 5.5 −5.6 72.6

2.7 5.9 −3.9 72.6

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment B: expansion of Medicaid

B: Public health insurance expansion. Agents with y ≤ Y ma will be covered by Medicaid. Low income agent: 1

2

a guaranteed public insurance → higher spending in health, better health → working hrs ↑; higher tax → working hrs ↓;

High income agent: 1

higher tax → working hrs ↓.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment B: expansion of Medicaid

Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of per capita GDP) Output Aggregate saving rate (in %) Average consumption Average health stock CEV from transition all young (in %) young w/ e0 > Yma (in %) young w/ e0 ≤ Yma (in %) % w/ CEV > 0 (young) Zhigang Feng (U Miami)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.8 100.0 25.8 100.0 46.6

B 89.5 2.5 25.9 30.2 60.4 17.0 10.8 99.9 25.9 99.2 46.7

− − − −

−0.3 −1.1 1.3 10.9

Health Care Reform & Macroeconomy

Experiment C: Individual mandate

C: Individual mandate. Average individual: 1

2

the risk pooling more inclusive → premium ↓ → better health → working hrs ↑; more agents receive subsidy for purchasing insurance → higher tax → working hrs ↓;

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment C: Individual mandate

Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of per capita GDP) Output Aggregate saving rate (in %) Average consumption Average health stock CEV from transition all young (in %) young w/ e0 > Yma (in %) young w/ e0 ≤ Yma (in %) % w/ CEV > 0 (young) Zhigang Feng (U Miami)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.8 100.0 25.8 100.0 46.6

C 100.0 2.5 25.2 30.7 61.3 17.0 9.5 100.2 26.7 99.1 47.1

− − − −

−0.6 −0.3 −1.3 0.0

Health Care Reform & Macroeconomy

Experiment D, E: abolishing tax deductibility of private insurance premium and providing tax credit D: Abolish insurance deductibility from income tax base; E: Abolish insurance deductibility from income tax base and provide credit for individuals who purchase private insurance. Average individual: 1

2

3

4

removal of private insurance deductibility → private insurance less attractive → insurance purchase ↓ → price of insurance ↑ → more people drop insurance; lower insurance coverage rate → health expenditure ↓ → health status ↓ → working hrs ↓; removal of private insurance deductibility → lower tax → working hrs ↑. tax credit → higher tax → working hrs ↓. Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Experiment D, E: abolishing tax deductibility of private insurance premium and providing tax credit Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of per capita GDP) Output Aggregate saving rate (in %) Average consumption Average health stock CEV from transition all young (in %) young w/ e0 > Yma (in %) young w/ e0 ≤ Yma (in %) % w/ CEV > 0 (young) Zhigang Feng (U Miami)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.8 100.0 25.8 100.0 46.6

D 49.1 2.5 23.1 30.8 61.1 15.4 12.1 100.0 25.8 102.4 46.4

E 94.2 2.5 27.5 29.8 59.4 16.9 9.7 99.2 26.2 98.3 46.8

− − − −

1.8 1.6 2.1 73.9

−0.2 0.8 −2.3 67.1

Health Care Reform & Macroeconomy

Fund the reforms through a lump-sum transfer

Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of GDP) Average consumption Average health stock CEV from transition all young (in %) % young w/ e0 > Yma % young w/ e0 ≤ Yma % w/ CEV > 0 (young)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.1 100.0 46.6

A 100.0 2.5 25.4 30.6 60.9 16.7 2.1 99.3 46.8

B 89.5 2.5 24.7 30.7 61.3 17.0 10.1 99.8 46.7

C 100.0 2.5 24.6 30.8 61.5 16.8 9.7 99.6 45.0

E 94.2 2.5 25.3 30.7 61.2 16.8 9.6 99.6 46.8

− − − −

2.7 5.9 −3.9 72.6

0.3 −1.1 1.5 10.9

−0.4 −0.1 −0.9 5.5

−0.1 0.8 −2.1 67.1

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Fund the reforms through labor income tax

Insured non-elderly (in %) Medicare tax (in %) Ave. income tax (in %) Ave. Working hrs. Ave. Effective Working hrs. Health exp. (in % of GDP) πE (in % of GDP) Average consumption Average health stock CEV from transition all young (in %) % young w/ e0 > Yma % young w/ e0 ≤ Yma % w/ CEV > 0 (young)

Bench. 84.8 2.5 24.6 30.6 61.1 16.6 10.8 100.0 46.6

A 100.0 8.9 24.7 27.9 55.7 16.8 2.1 97.2 46.9

B 89.5 7.8 24.1 29.2 58.4 17.1 10.1 97.4 46.7

C 100.0 5.6 24.2 30.1 60.2 17.1 9.7 98.0 47.4

E 74.7 9.3 24.6 28.9 57.5 16.3 10.5 95.8 46.4

− − − −

1.8 5.5 −5.6 72.6

−1.6 −1.9 −0.9 9.6

−1.3 0.8 −2.5 0.0

−3.5 −2.9 −4.8 0.0

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Conclusions Build a micro-founded dynamic general equilibrium model with a labor-leisure choice and endogenous health expenditure. Study the impacts of alternative health care reforms on the hours worked, # of uninsured, GDP and welfare. The impact of the health insurance reforms on the aggregate labor supply is in the range of −9.1% and 6.8%. To fund the reform through payroll tax creates stronger distortion on the labor supply than through income tax. There is no correlation between changes in # of uninsured and welfare implications.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Extension

Endogenous health production sector. Endogenous price for medical service. Understand how health care policy affects the medical technology adoption.

Zhigang Feng (U Miami)

Health Care Reform & Macroeconomy

Macroeconomic Consequences of Alternative Reforms ...

Jan 18, 2009 - MY CONTRIBUTIONS: 1. Endogenize both health expenditure labor supply; make a distinction between public and private insurances. 2.

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