Hospital Waiting Lists in British Columbia: Evidence and Policy Implications

This study reports the results of a survey of specialist physicians practicing in British Columbia. The survey identifies the extent to which patients are waiting for hospital treatments and attempts a rough quantification of the costs to the provincial economy associated with the rationing of health care. The identifiable costs associated with reduced productivity should be weighed against the resource savings gained from rationing access to the health care system.     

Contestability, queues, and governmental entry deterrence

This paper demonstrates that a perverse kind of entry deterrence can result when government subsidized production is combined with non-price rationing in the form of queuing. Even though queuing leads to a total cost to the consumer (not including the tax cost) that is higher than the cost of an unsubsidized private supplier, and even though the government's money price is rigid, the market is not contestable. The key to the result is that the waiting cost portion of the consumer's acquisition cost declines immediately upon entry and losses would be forced upon the entrant. Privatization would negate the entry deterrence, thus leading to entry, increased output at lower full prices, lower average production costs, decreased waiting costs, increased profits, and increased consumer surplus.     

COMBATING HEALTHCARE COST INFLATION WITH CONCERTED ADMINISTRATIVE ACTIONS IN A CHINESE PROVINCE

This article defies the traditional notion that cost inflation in healthcare could hardly be curbed without the significant revision of economic incentive scheme, but demonstrates the possibility of containing cost inflation with concerted administrative actions in the Chinese context. It examines the case of Fujian Province that embarked on a health bureaucracy‐led policy reform without an alteration of economic levers but mainly using administrative tools to combat cost escalation. Through clearly defined, well designed, targeted and concerted administrative measures, effective cost containment is attainable in China's healthcare sector, at least in the short run. If combined well with the powerful economic instruments, administrative tools would be able to augment their effects in cost containment, provided with the government's possession of hospital ownership. At the heart of Fujian's case are the reassertion of the government stewardship, the reconstruction of the collapsed accountability mechanisms, the reconfiguration of policy instruments, and the revision of administrative incentives, rather than the decreased costs per se. Copyright © 2011 John Wiley & Sons, Ltd.     

Transaction costs and inter‐jurisdictional cooperation: an application to land use collaboration

• The costs and benefits of inter‐jurisdictional cooperation and how these impede strategic alliances among jurisdictions is an issue of growing importance worldwide. The reason is the potential cost savings, efficiency increase and economic development benefits that can be realized through cooperation. The literature has increasingly mentioned transaction costs as obstacles that mitigate cooperation and as a key component of cooperation costs, which must be outweighed by cooperation benefits in order for communities to perceive advantageous strategic alliances. However, a framework is lacking in the literature for evaluating the implications of transaction costs for inter‐jurisdictional cooperation. This paper develops a framework for evaluating the nature and dynamics of transaction costs and their implications for inter‐jurisdictional cooperation, with an application to land use. A simple cost function model is used to explain the costs and challenges associated with managing coordinated, cooperative or consolidated relationships, and the dynamics of such costs. The analysis highlights the importance of such things as degree of complexity, inter‐party diversity and the relative sizes of collaborating partners. An application to land use cooperation in Michigan suggests that policies to eliminate transaction costs could help reduce the barriers to cooperation of various types.

Copyright © 2010 John Wiley & Sons, Ltd.     

On the accuracy of regulatory cost estimates

This study compares ex ante estimates of the direct costs of individual regulations to ex post assessments of the same regulations. For total costs the results support conventional wisdom, namely that the costs of regulations tend to be overestimated. This is true for 14 of the 28 rules in the data set discussed, while for only 3 rules were the ex ante estimates too low. For unit costs, however, the story is quite different. At least for EPA and OSHA rules, unit cost estimates are often accurate, and even when they are not, overestimation of abatement costs occurs about as often as underestimation. In contrast, for those rules that use economic incentives, unit costs are consistently overestimated. The difference between the total‐cost and the unit‐cost results is caused by frequent errors in estimates of the effects of individual rules, which suggests, in turn, that the rule's benefits may also be overestimated. The quantity errors are driven both by difficulties in determining the baseline and by incomplete compliance. In cases of unit‐cost overestimation, unanticipated technological innovation appears to be an important factor — especially for economic incentive rules, although procedural and methodological explanations may also apply. © 2000 by the Association for Public Policy and Management.     

Setting limits through global budgeting: hospital cost containment in Rhode Island

In 1974, hospitals in Rhode Island have participated in annual negotiations with state officials and representatives from Blue Cross to determine the allowed increase in statewide hospital costs (the "Maxicap") for the next fiscal year, based on projected increases in hospitals' revenues, changes in patient volume and operating expenses. Individual hospital budgets may be above or below the Maxicap as long as the total increase in hospital costs for all hospitals in the state does not exceed the negotiated amount. At a time when regulatory solutions are increasingly under fire, continued support for Rhode Island's approach to hospital cost containment from third party payers, providers and public officials stands in stark contrast to other states where rate setting was either dismantled or discredited as a cost control strategy. A negotiated global cap on hospital expenditures offers an alternative to formula-based state rate-setting methodologies which could be incorporated as part of an all-payer reimbursement methodology or as an incremental step towards more comprehensive reform.     

X-efficiency,rent-seeking and social costs

This paper investigates shifts in cost functions of monopoly and regulated firms operating under conditions of X-inefficiency and rent-seeking behavior. We show that X-inefficiency and rent seeking have significantly different implications for economic welfare. Distinctions are drawn between pecuniary and real X-inefficiency and between sunk and continuing rent-seeking costs. In general, for a given cost shift rent-seeking behavior implies larger social costs than does X-inefficiency theory. However, cost shifts caused by either X-inefficiency or rent seeking are observationally equivalent. This implies empirically measured cost shifts cannot unambiguously be attributed to either cause.     

Applying Insights from Transaction Cost Economics to Improve Cost Estimates for Public Sector Purchases: The Case of U.S. Military Acquisition

ABSTRACT

This article uses Transaction Cost Economics (TCE) to help characterize, explain, and ultimately reduce the cost growth that plagues many of today's major investments in military capabilities. There is mounting evidence of a systematic bias in initial cost estimates of new weapon systems purchased by the U.S. military. Unrealistically low cost estimates result in cost overruns. Fixing cost overruns can substantially impact public budgets and military readiness. Cost estimates serve a dual function: first, as an integral part of the decision-making process to evaluate military purchases/investments, and second, as a baseline for future defense budgets. In the first case, underestimating costs can result in too many new weapon program starts and excessive investments in those systems. In the second case, unrealistically low cost estimates result in overly optimistic budgets. Budgets planned on the basis of optimistic cost estimates create the illusion of more resources available than actually exist. Two factors are often blamed for unrealistically low cost estimates: bad incentives (psychological and political-economic explanations), and bad forecasts (methodological explanations). While briefly exploring the former, the focus of this study is on cost estimating methodology. Conventional public cost estimating techniques focus on the production costs of public purchases (input costs, learning curves, economies of scale and scope, etc.). The goal of this article is to improve cost estimates by expanding conventional cost estimating methodology to include TCE considerations. The primary insight of TCE is that correctly forecasting economic production costs of government purchases or acquisitions is necessary, but not sufficient. TCE emphasizes another set of costs—coordination and motivation costs (search and information costs; decision, contracting, and incentive costs; measurement, monitoring, and enforcement costs, etc.). This study encourages public officials and cost analysts to capture these costs and to understand key characteristics of public-private transactions (uncertainty, complexity, frequency, asset specificity, and market contestability) to generate more complete and reliable cost estimates and improve public sector purchases.     

State health reform: Effects on labor markets and economic activity

Individual states are actively weighing health care reform proposals and their potential impacts on many levels, including states' own economies. This article considers the effects on state economies of two instruments of health reform: employer mandates and cost containment. The literature suggests that an employer mandate will reduce employees' wages in the long run. In the short run, however, to compensate for the costs associated with mandated health care insurance for their employees, firms may raise their prices to consumers, reduce the number of employees or allow a drop in profit margins. By increasing health care spending and the number of insured persons, mandates would also increase states' levels of economic activity. Though cost containment may dampen the stimulative effects of expanded coverage, resources not spent on health care as a result of effective cost containment might be redistributed to other sectors in a state's economy.     

Comment on David Listokin,Barbara Listokin,and Michael Lahr's “The contributions of historic preservation to housing and economic development”

Abstract

Listokin, Listokin, and Lahr laud the economic benefits of historic preservation but fail to delve deeply enough into the negative impacts and how they might be mitigated. Preservation projects tend to displace lower‐income households and small businesses, and the jobs they generate tend to be low paying. In areas with high potential for displacement, local government and civic leaders should act cautiously and not intervene in ways that overheat these markets. We are unlikely to see new federal policies that substantially mitigate displacement. Nonetheless, the historic rehabilitation tax credit could be revised to encourage more modest and affordable preservation projects.

The extra costs associated with historic rehabilitation standards can be more burdensome than the authors describe. To reduce these costs, the administration of the Secretary of the Interior's Standards for Rehabilitation could be made more consistent and cost‐sensitive.     

The economic approach to political behavior: Governors,bureaucrats, and cost commissions

Cost control commissions provide two primary types of recommendations: widespread benefits-widespread costs and widespread benefits-narrow costs. Both types of recommendations are not of the form predicted by the standard economic models of political behavior. The paper explores why governors sanction these commissions and the types of recommendations governors will accept. Legislators use the maxim of concentrate benefits-spread costs to maximize votes. Governors, however, face a lower return to concentrated benefit policies and a lower cost from concentrated cost policies. This leads a governor to favor at the margin, policies which have widespread benefit-widespread cost or widespread benefit-concentrated cost. Evidence from 5 state cost control commissions support the difference between the politicians. The cost control commissions sanctioned by governors have proposed recommendations of the widespread benefit-widespread cost and widespread benefit-concentrated cost form. Governors accepted approximately two-thirds of the widespread benefit-concentrated cost proposals, although they were more likely to accept recommendations of the widespread benefit-widespread cost nature. Recommendations which required legislative approval saw a lower likelihood of acceptance. This is consistent with the view that legislators prefer concentrated to widespread benefit recommendations. qu][The politician's] favorite strategy is to create a commission to study a problem and make recommendations that may then be used as political cover. Call it government by commission.     

Illegal markets and the social costs of rent-seeking

This paper argues that making goods or services illegal results in an increase in the social costs associated with rent-seeking. The increased social cost is in the form of negative externalities that result from market participants use of coercion and violence in attempts to control trade in the illegal good. Consequently, the social costs of rent-seeking will exceed the value of resources dissipated in rent-seeking competition. And, where the external costs exceed the undissipated portion of the Tullock cost, the social cost of rent-seeking is greater than the sum of Tullock and Harberger costs.     

Perceptions,fear, and economic loss: an application of prospect theory to environmental decision making

Most of the analysis of costs associated with the introduction of risky prospects has concerned contingent costs amenable to insurance programs. An important missing element is the current cost associated with changes in uncertainty. These costs are not amenable to insurance plans and require compensation in order to prevent transfers. In a novel approach, this paper develops an application of prospect theory to such questions, in an intergenerational context. The importance of such an application is demonstrated in a case study of the high-level nuclear waste repository (HNWR) siting decision. As a case study, the costliness of obtaining some elements of the analysis leads to a simulation approach, comparing prospect costs at the three sites that were under consideration by the U.S. Department of Energy. Finding that such costs can be large, we argue for a reassessment of current risk analysis approaches. On a policy note, on the basis of the prospect cost analysis here, the choice of the Yucca Mountain, Nevada, HNWR site seems ill-advised.     

INTERNATIONAL HEALTH CARE REFORM: THE NEED FOR COMPREHENSIVE MICRO-COMPARATIVE ANALYSIS

Microcomparison, or single‐component analysis, of health care systems offers a potentially better basis for reform than traditional macrocomparison analysis of aggregate elements. Using macroanalysis, available evidence shows that Germany provides cheaper but more effective hospital care than the United States. To find the causes for this outcome, we developed a microanalytic model of hospital administrators’ perceptions, financial ratios, medical outcomes, and pharmaceutical costs. However, only data on pharmaceutical costs were available and similar in both countries. Our significant outcome was development of a microcomparative model that gives world medical care providers new criteria for analyzing and improving cost to care rafios.     

Low Cost Earth Orbit Access: A Look at Physics,Economics, and Reality

Engineering problems are one factor limiting low cost access to low earth orbit. Insurance and range costs also hinder low cost access. Achieving low cost orbital access requires dealing with economic limitations of chemical rockets, lack of business planning, and failure to identify a workable path that will take us from an immature to a mature launch industry. A mature launch industry exhibiting low cost to orbit and significant flight rates by reusable vehicles with long lifetimes will not evolve unless this multifactorial problem is solved.     

Comparing the Life-Cycle Costs of New Construction and Acquisition-Rehab of Affordable Multifamily Rental Housing

The cost of producing multifamily affordable housing may differ based on development type. Past attempts to compare the costs of producing multifamily housing through new construction or acquisition-rehab have been limited by an inability to adjust for variations in unit quality among different projects. The authors overcome this challenge by estimating the costs of developing and maintaining a property over a 50-year life cycle. Applying this approach to a convenience sample of 269 properties, the authors find new construction associated with life-cycle costs that are 25% to 45% higher than those of acquisition-rehab.     

Housing vouchers versus housing production: Assessing long‐term costs

Abstract

Possibly the single largest debate in the field of affordable rental housing concerns the use of tenant‐based assistance versus project‐based assistance. The accepted wisdom is that project‐based assistance costs anywhere from 50 to 100 percent more than tenant‐based assistance. This premium for project‐based housing is based on a comparison of subsidy costs at the start of a project's life rather than on a comparison of the discounted present value of the costs over the long term.

The subsidy costs of samples of Section 8 new construction projects have been compared to those of Section 8 certificates over a long period of time. The results indicate that the cost premium associated with project‐based assistance may be lower than conventionally believed, around 40 percent, and may get even lower if the cost comparison could extend to longer time periods and could control for the quality of the housing units.     

Expanding access to health care for Social Security Disability Insurance beneficiaries: early findings from the accelerated benefits demonstration

Most Social Security Disability Insurance (DI) beneficiaries must complete a 5-month waiting period before they become entitled to DI cash benefits and an additional 24-month waiting period before Medicare benefits begin. The Accelerated Benefits (AB) demonstration is a randomized experiment designed to test the effects of providing newly entitled DI beneficiaries who do not have health insurance with a generous health benefits package during the Medicare waiting period. This article presents early findings on the prevalence of health insurance coverage among newly entitled beneficiaries and the characteristics of those without health insurance. It also examines the effects of AB on health care utilization, the extent to which AB reduces unmet medical needs, and the costs of providing the AB health benefits package.     

Municipal Bond New Issue Transaction Costs

As with any market, there are transaction costs associated with the sale of municipal bonds. Only a small number of studies have examined this topic, and therefore we have only a limited understanding of the magnitude and determinants of new issue municipal bond transaction costs. We use data on California municipal bond transaction costs from 2007 to 2009 to test whether scale economies exist. We find that there are considerable transaction cost scale economies for California municipal bonds and that pooling bond sales would likely save substantial amounts of money.     

The Impact of Tax Price on Spending Preferences

In this article, we explore the influence of tax price information on citizen preferences for taxes and spending using mail surveys. We explore the effects on service support when varying levels of cost information. We also observe how the magnitude of service costs influences service support. While the presence of cost information corresponded with lower levels of respondent support for the most costly services, it was associated with higher levels of support for less expensive services. These effects were the same whether the tax price represented the respondent's actual household cost or the jurisdiction average household cost for each service.