Is medical care different? Old questions, new answers

This paper examines whether changes in medical markets may be making them more like other markets. The emergence of HMOs and other managed care systems appears to have increased the consumer's potential ability to make better comparative judgments about the price and quality of medical care, and also seems to have made medical care more like other goods. However, the evidence that medical care is a "reputation good" suggests that it is, in this respect, different from other goods. Finally, the social concerns about medical care use necessarily make medical care different.     

Bad debts and hospital rate-setting

This paper examines the economic foundations for mandatory discounts for insurers based on differences in bad debts experience. It considers critically the arguments Blue Cross plans use in several states. On both equity and efficiency grounds, discounts for actual bad debts are shown to be inappropriate. In contrast, it is shown that there are equity and efficiency reasons to grant a discount for insurance policies which avert bad debt, but that the appropriate discount is less than the amount of bad debt averted. The appropriate discount depends on the size of the subsidy needed to bring about purchase of debt-averting coverage. In some circumstances, this subsidy equals the underwriting loss on the coverage minus any tax subsidy the insurer receives.     

Public protection against misperceived risks: Insights from positive political economy

Citizens often misperceive the nature of risks they face and the impacts of alternative actions on those risks. For example, consumers may underestimate the probability of flood in their area, or they may underestimate the beneficial effect of passive restraints on the likelihood of automobile accident fatality. But recommendations that the government should mandate optimal purchases are often ignored by politicians or rejected in favor of direct public compensation. This paper uses some simple models of public choice to explain why other remedies are used; it explicitly accounts for the fact that the same ignorant consumer whose behavior would have to be constrained are the ones whom the politician must please. In a simple world-of-equals model, such consumer-voters may well favor the alternative devices of implicit mutual insurance and conditional payment. When voters are heterogeneous, the political equilibrium (if one exists) is shown to depend upon the distribution of voters by perceived net benefit of public action and of taxes. Public action may be least feasible exactly when it would do the most good.     

Privatization and bidding in the health-care sector.

Public provision of health care, as under Medicare and Medicaid, traditionally "privatized" major production decisions. Providers of care, largely private physicians and hospitals (but also public hospitals), made significant decisions about public beneficiaries' access to care, the quality and quantity of individual services, and the prices to be paid. The result was high access and quality/quantity, but also high program spending, which has prompted a reassertion of public budgetary control. Newly activist program administration is using various mechanisms to promote economizing. Unable and unwilling to specify standards of public access or quality/quantity too overtly, administration instead seeks to squeeze prices--mainly through administrative price setting but also through competitive bidding and voucherlike arrangements. Under such new incentives, major choices that in many non-American systems would be public are here "reprivatized" to be resolved out of the limelight by beneficiaries, traditional providers, or new intermediaries like Competitive Medical Plans.