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Abstract:
A critical question for Social Security policy is how program incentives affect retirement behavior. We use the wealth of new data available through the Health and Retirement Survey (HRS) to examine the impact of Social Security incentives on male retirement. We implement forward-looking models of retirement whereby individuals consider not just the incentives to work in the next year but in all future years as well. We find that such forward looking incentive measures for Social Security are significant determinants of retirement decisions. Our findings suggest that Social Security policies which increase the incentives to work at older ages can significantly reduce the exit rate of older workers from the labor force.

Abstract:
A critical question for Social Security policy is how program incentives affect retirement behavior. We use the wealth of new data available through the Health and Retirement Survey (HRS) to examine the impact of Social Security incentives on male retirement. We implement forward-looking models of retirement whereby individuals consider not just the incentives to work in the next year but in all future years as well. We find that such forward looking incentive measures for Social Security are significant determinants of retirement decisions. Our findings suggest that Social Security policies which increase the incentives to work at older ages can significantly reduce the exit rate of older workers from the labor force.

Social Security, retirement

Abstract:
One of the major social policy issues facing the U.S. in the first decade of the 21st century is the large number of Americans lacking health insurance. This article surveys the major economic issues around covering the uninsured. I review the facts on insurance coverage and the nature of the uninsured; focus on explanations for why the U.S. has such a large, and growing, uninsured population; and discuss why we should care if individuals are uninsured. I then focus on policy options to address the problem of the uninsured, beginning with a discussion of the key issues and available evidence, and then turning to estimates from a micro-simulation model of the impact of alternative interventions to increase insurance coverage.

Abstract:
Religion plays an important role in the lives of many Americans, but there is relatively little study by economists of the implications of religiosity for economic outcomes. This likely reflects the enormous difficulty inherent in separating the causal effects of religiosity from other factors that are correlated with outcomes. In this paper, I propose a potential solution to this long standing problem, by noting that a major determinant of religious participation is religious market density, or the share of the population in an area which is of an individual's religion. I make use of the fact that exogenous predictions of market density can be formed based on area ancestral mix. That is, I relate religious participation and economic outcomes to the correlation of the religious preference of one's own heritage with the religious preference of other heritages that share one's area. I use the General Social Survey (GSS) to model the impact of market density on church attendance, and micro-data from the 1990 Census to model the impact on economic outcomes. I find that a higher market density leads to a significantly increased level of religious participation, and as well to better outcomes according to several key economic indicators: higher levels of education and income, lower levels of welfare receipt and disability, higher levels of marriage, and lower levels of divorce.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
The one-third rise in the teen smoking rate in the 1990s has led to considerable interest in understanding the determinants of the youth smoking decision. We explore four aspects of this decision. First, we consider the demographic correlates of smoking participation, and find that smoking participation is not simply concentrated among the most disadvantaged youth; indeed, increasingly over time youth smoking is taking place among white, suburban youth with college educated parents and good grades. Second, we show that neither changes in demographic characteristics nor changes in attitudes towards smoking can explain the striking increase in smoking rates in the 1990s. Third, we document that price is a powerful determinant of smoking for high school seniors; using state fixed effects models on data for the 1991-1997 period we estimate an elasticity of smoking participation of -0.67, which suggest that the drop in cigarette prices in the early 1990s can explain 26% of the subsequent upwards smoking trend for seniors. But price is not important for younger teens, although we do find some evidence that restrictions on access to cigarette purchases can lower the quantity that younger teens smoke. Finally, we document that there is an important intertemporal correlation in the decision to smoke. In particular, we find that there is a significant correlation across cohorts in teen smoking and later smoking of adults, and that the taxes that teens face on cigarettes have a significant negative effect on their smoking later in life. These findings suggest that between 25 and 50% of the rise in youth smoking in the 1990s will persist into adulthood for this cohort; rough calculations suggest that the long run cost to the U.S. will be at least 1.6 million years of life lost from this youth smoking increase.

Abstract:
We investigate the effect of health insurance coverage on the decision of individuals to apply for Disability Insurance (DI). Those who qualify for DI receive public insurance under Medicare, but only after a two-year waiting period. This raises concerns that many disabled are going uninsured while they wait for their Medicare coverage. Moreover, the combination of this waiting period and the uncertainty about application acceptance may deter those with health insurance on their jobs, but no alternative source of coverage, from leaving work to apply for DI.

Data from the Health and Retirement Survey show that, in fact, uninsurance does not rise during the waiting period for DI benefits; reductions in own employer coverage are small, and are offset by increases in other sources of insurance. Correspondingly, we find that imperfect insurance coverage does deter DI application. Those who have an alternative source of insurance coverage (coverage from a spouse's employer or retiree coverage), are 26 to 74% more likely to apply for DI than those without such an alternative. Thus, limiting this waiting period would not increase the insurance coverage of the disabled in the U.S., but it would significantly increase applications to the DI program.

Abstract:
We investigate the effect of health insurance coverage on the decision of individuals to apply for Disability Insurance (DI). Those who qualify for DI receive public insurance under Medicare, but only after a two-year waiting period. This raises concerns that many disabled are going uninsured while they wait for their Medicare coverage. Moreover, the combination of this waiting period and the uncertainty about application acceptance may deter those with health insurance on their jobs, but no alternative source of coverage, from leaving work to apply for DI. Data from the Health and Retirement Survey show that, in fact, uninsurance does not rise during the waiting period for DI benefits; reductions in own employer coverage are small, and are offset by increases in other sources of insurance. Correspondingly, we find that imperfect insurance coverage does deter DI application. Those who have an alternative source of insurance coverage (coverage from a spouse's employer or retiree coverage), are 26 to 74% more likely to apply for DI than those without such an alternative. Thus, limiting this waiting period would not increase the insurance coverage of the disabled in the U.S., but it would significantly increase applications to the DI program.

Abstract:
The continued interest in public insurance expansions as a means of covering the uninsured highlights the importance of estimates of "crowd-out", or the extent to which such expansions reduce private insurance coverage. Ten years ago, Cutler and Gruber (1996) suggested that such crowd-out might be quite large, but much subsequent research has questioned this conclusion. We revisit this issue by using improved data and incorporating the research approaches that have led to varying estimates. We focus in particular on the public insurance expansions of the 1996-2002 period. Our results clearly show that crowd-out is significant; the central tendency in our results is a crowd-out rate of about 60%. This finding emerges most strongly when we consider family-level measures of public insurance eligibility. We also find that recent anti-crowd-out provisions in public expansions may have had the opposite effect, lowering take-up by the uninsured faster than they lower crowd-out of private insurance.

Abstract:
This paper provides a critical review of the empirical literature on the relationship between health insurance, labor supply, and job mobility. We review over 50 papers on this topic, almost exclusively written in the last 10 years. We reach five conclusions. First, there is clear and unambiguous evidence that health insurance is a central determinant of retirement decisions. Second, there is fairly clear evidence that health insurance is not a major determinant of the labor supply and welfare exit decisions of low income mothers. Third, there is fairly compelling evidence that health insurance is an important factor in the labor supply decisions of secondary earners. Fourth, while there is some division in the literature, the most convincing evidence suggests that health insurance plays an important role in job mobility decisions. Finally, there is virtually no evidence in the literature on the welfare implications of these results. We present some rudimentary calculations which suggest that the welfare costs of job lock are likely to be modest. Our general conclusion is that health insurance has important effects on both labor force participation and job choice, but that it is not clear whether or not these effects results in large losses of either welfare or efficiency.

Abstract:
The growing labor force participation of women with small children in both the U.S. and Canada has led to calls for increased public financing for childcare. The optimality of public financing depends on a host of factors, such as the "crowd-out" of existing childcare arrangements, the impact on female labor supply, and the effects on child well-being. The introduction of universal, highly-subsidized childcare in Quebec in the late 1990s provides an opportunity to address these issues. We carefully analyze the impacts of Quebec's "$5 per day childcare" program on childcare utilization, labor supply, and child (and parent) outcomes in two parent families. We find strong evidence of a shift into new childcare use, although approximately one third of the newly reported use appears to come from women who previously worked and had informal arrangements. The labor supply impact is highly significant, and our measured elasticity of 0.236 is slightly smaller than previous credible estimates. Finally, we uncover striking evidence that children are worse off in a variety of behavioral and health dimensions, ranging from aggression to motor-social skills to illness. Our analysis also suggests that the new childcare program led to more hostile, less consistent parenting, worse parental health, and lower-quality parental relationships.

Abstract:
This is the introduction to and summary of the second stage of a international research project to study the relationship between social security provisions and retirement. The project relies on the analyses of a large group of economists in 12 countries who conduct the analysis for each of their countries. In the first stage we documented the enormous disincentives for continued work at older ages in many countries. The introduction to the first volume from the project concluded with a striking graph showing a strong relationship across countries between social security program incentives to retire and the proportion of older persons out of the labor force. The results in this volume show the large magnitude of these effects. Across 12 countries with very different social security programs and labor market institutions, the results consistently show that program incentives accord strongly with retirement decisions. The magnitude is illustrated by the simulations reported in each country paper. Considering the average across all countries, a reform that delays benefit eligibility by three years would likely reduce the proportion of men 56 to 65 out of the labor force between 23 and 36 percent, perhaps closer to 36 percent in the long run. On the other hand, an illustrative 'common reform' - with early retirement at age 60, normal retirement age 65, and actuarial reduction in benefits between 65 and 60 - has very disparate effects across the countries, depending on the provisions of the current program in each country. There is a strong correspondence between the simulation results and a priori expectations. The results leave little doubt that social security incentives have a strong effect on retirement decisions. And the estimates show that the effect is similar in countries with very different cultural histories, labor market institutions, and other social characteristics. While countries may differ in many respects, the employees in all countries react similarly to social security retirement incentives. The simulated effects of illustrative reforms reported in the country papers make clear that changes in the provisions of social security programs would have very large effects on the labor force participation of older employees.

Abstract:
A central tax policy parameter that has recently received much attention, but about which there is substantial uncertainty, is the overall elasticity of taxable income. We provide new estimates of this elasticity which address identification problems with previous work, by exploiting a long panel of tax returns to study a series of tax reforms throughout the 1980s. This identification strategy also allows us to provide new evidence on both the income effects of tax changes on taxable income, and on variation in the elasticity of taxable income by income group. We find that the overall elasticity of taxable income is approximately 0.4; the elasticity of real income, not including tax preferences, is much lower. We also estimate small income effects on tax changes on reported income, implying that the compensated and uncompensated elasticities of taxable income are very similar. We estimate that this overall elasticity is primarily due to a very elastic response of taxable income for taxpayers who have incomes above $100,000 per year, who have an elasticity of 0.57, while for those with incomes below $100,000 per year the elasticity is less than one-third as large. Moreover, high income taxpayers who itemize are particularly responsive to taxation. We then derive optimal income tax structures using these elasticities. Our estimates suggest that the optimal system for most redistributional preferences consists of a large demogrant that is rapidly taxed away for low income taxpayers, with lower marginal rates at higher income levels.

Abstract:
A standard model of addictive process is Becker and Murphy's rational addiction' model, which has the key empirical prediction that the current consumption of addictive goods should respond to future prices, and the key normative prediction that the optimal government regulation of addictive goods should depend only on their interpersonal externalities. While a variety of previous studies have supported this empirical contention, we demonstrate that these results are very fragile. We propose a new empirical test for the case of cigarettes, using state excise tax increases that have been legislatively enacted but are not yet effective, and monthly data on consumption. We find strong evidence that consumption drops when there are announced future tax increases, providing more robust support for the key empirical prediction of the Becker and Murphy model. But we also propose a new formulation of this model that makes only one change, albeit a major one: the incorporation of the inconsistent preferences which are likely to provide a much better platform for understanding the smoking decision. We find that with these preferences the model continues to yield the predictions for forward-looking behavior that have been tested by others and by ourselves. But it has strikingly different normative implications, as with these preferences optimal government policy should depend as well on the internalities' imposed by smokers on themselves. We estimate that the optimal tax per pack of cigarettes should be at least one dollar higher under our formulation than in the rational addiction case.

Abstract:
Recent litigation against major tobacco companies culminated in a Master Settlement Agreement (MSA) under which the participating companies agreed to compensate most states for Medicaid expenses. We outline the terms of the settlement and analyze whether it was a move toward economic efficiency using data from Massachusetts. Medicaid spending will fall, but only a modest amount ($0.1 billion). The efficiency issue turns mainly on the treatment of health benefits from reduced smoking induced by the settlement. We conclude that the settlement was a move towards economic efficiency.

Abstract:
The National Compensation Survey, which underlies theEmployment Cost Index (ECI), is used to assess the impact of tax subsidies on afirm's insurance offering, insurance spending, and on the distribution ofcharacteristics of workers within each firm from 1983 to 1995. Information wascollected from the Bureau of Labor Statistics' ECI database. Results from basic tax price regression analyses show significant negativecoefficients for the firm's decision to offer insurance and the amount ofspending on the offering. Insurance offering rises with firm size, and as taxprice increases, insurance spending decreases. Alternative tax price measuresreveal no significant findings for weighting functions. Elasticity analysisshows a reasonably sized elasticity of insurance offering after-tax prices anda larger elasticity of insurance spending due to premium sharing. Additionally,it is found that small firms are particularly sensitive to taxes in theirinsurance offering, while large firms are sensitive to taxes in theirconditional spending decisions. Comparing this method of analysis to alternative approaches reveals higherestimated elasticities of offerings and lower estimated elasticities ofconditional spending. A reduction in employer-provided health insurancespending can be achieved by three possible tax reforms. (NEE)

Employment Cost Index (US Bureau of Labor Statistics), National Compensation Survey (U.S. Dept of Labor), Taxes, Taxes, Public policies, Institutional reforms, Tax subsidies, Health insurance, Employee benefits

Abstract:
We investigate the impact of tax subsidies on the firms decision to offer insurance, and on conditional firm spending on insurance. We do so using the micro-data underlying the Employee Compensation Index, which has a major advantage for this exercise: the matching of very high quality compensation data with information on a sample of workers in the firm. We find that, overall, there is a modest elasticity of insurance offering with respect to after-tax prices (elasticity of -0.31 to -0.41), but a larger elasticity of insurance spending (elasticity of 0.66 to 0.99). We also find that the elasticity of offering is driven solely by small firms, for whom the elasticity is much larger, but that spending is more elastic in large firms. We provide some evidence on how the aggregation of worker preferences determines benefits provision decisions. In particular, we find evidence to support a median voter model of benefits determination, along with some additional influence for the most highly compensated workers in the firm. Our simulation results suggest that major tax reform could lead to an enormous reduction in employer-provided health insurance spending.

Abstract:
There are a host of potentially risky behaviors in which youth engage, which have important implications for both their well being as youth and their life prospects. The past decade has seen dramatic shifts in the intensity with which youths pursue these risky activities: for example, youth homicide fell by 40%; teen births decline by 20%; youth smoking rose by 33%; and marijuana use among youth virtually doubled. This paper, and the volume it introduces, explores the determinants and implications of risky behaviors by youths. I begin by reviewing perspectives on youth risk-taking from traditional rational-choice economics, developmental psychology, and behavioral economics. I then discuss both cross-sectional and time series evidence on risk-taking by youths, and how this compares to adults. I review the evidence on youth risk taking from the studies in this volume, and highlight the conclusions that (a) economic incentives and macroeconomic conditions are powerful predictors of risk taking by youths, (b) despite this, these factors are not very successful in predicting the dramatic time series swings we see in youth risk taking, and (c) risk taking by youths appears to have important implications for risky behaviors later in life. I also comment on the implications of these findings for policy, and for future economic research.

Abstract:
To measure how policy changes affect social welfare, economists typically look at how policies affect behavior, and use a formal model to infer welfare consequences from the behavioral responses. But when different models can map the same behavior to very different welfare impacts, it becomes hard to draw firm conclusions about many policies. An excellent example of this conundrum is the taxation of addictive substances such as cigarettes. Existing empirical evidence on smoking is equally consistent with two models that have radically different welfare implications. Under the rational addiction model, cigarette taxes make time consistent smokers worse off. But, under alternative time inconsistent models, smokers are made better off by taxes, as they provide a valuable self-control device. We therefore propose an alternative approach to assessing the welfare implications of policy interventions: examining directly the impact on subjective well-being. We do so by matching information on cigarette excise taxation to separate surveys from the U.S. and Canada that contain data on self-reported happiness. And we model the differential impact of excise taxes on those predicted to be likely to be smokers, relative to others, in order to control for omitted correlations between happiness and excise taxation. We find consistent evidence in both countries that excise taxes make predicted smokers happier. This evidence suggests that the time inconsistent model of smoking is more appropriate, and that as a result welfare is improved by higher cigarette taxes.

Abstract:
Despite a $140 billion existing tax break for employer-provided health insurance, tax policy remains the tool of choice for many policy-makers in addressing the problem of the uninsured. In this paper, I use a microsimulation model to estimate the impact of various tax interventions to cover the uninsured, relative to an expansion of public insurance designed to accomplish the same goals. I contrast the efficiency of these policies along several dimensions, most notably the dollars of public spending per dollar of insurance value provided. I find that every tax policy is much less efficient than public insurance expansions: while public insurance costs the government only between $1.17 and $1.33 per dollar of insurance value provided, tax policies cost the government between $2.36 and $12.98 per dollar of insurance value provided. I also find that targeting is crucial for efficient tax policy; policies tightly targeted to the lowest income earners have a much higher efficiency than those available higher in the income distribution. Within tax policies, tax credits aimed at employers are the most efficient, and tax credits aimed at employees are the least efficient, because the single greatest determinant of insurance coverage is being offered insurance by your employer, and because most employees who are offered already take up that insurance. Tax credits targeted at non-group coverage are fairly similar to employer tax credits at low levels, but much less efficient at higher levels.

Abstract:
We explore the causes of the dramatic rise in employee contributions to health insurance over the past two decades. In 1982, 44% of those who were covered by their employer-provided health insurance had their costs fully financed by their employer, but by 1998 this had fallen to 28%. We discuss the theory of why employers might shift premiums to their employees, and empirically model the role of six factors suggested by the theory. We find that there was a large impact of falling tax rates, rising eligibility for insurance through the Medicaid system and through spouses, and deteriorating economic conditions (in the late 1980s and early 1990s). We also find much more modest impacts of increased managed care penetration and rising health care costs. Overall, this set of factors can explain about one-quarter of the rise in employee premiums over the 1982-1996 period.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
Patient cost-sharing for primary care and prescription drugs is designed to reduce the prevalence of moral hazard in medical utilization. Yet the success of this strategy depends on two factors: the elasticity of demand for those medical goods, and the risk of downstream hospitalizations by reducing access to beneficial health care. Surprisingly, we know little about either of these factors for the elderly, the most intensive consumers of health care in our country. We remedy both of these deficiencies by studying a policy change that raised patient cost-sharing for retired public employees in California. We find that physician office visits and prescription drug utilization are price sensitive, with implied arc-elasticities that are similar to those of the famous RAND Health Insurance Experiment (HIE). However, unlike the HIE, we find substantial “offset� effects in terms of increased hospital utilization in response to the combination of higher copayments for physicians and prescription drugs. These offset effects are concentrated in patients for whom medical care is presumably efficacious: those with a chronic disease. Finally, we find that the savings from increased cost-sharing accrue mostly to the supplemental insurer, while the costs of increased hospitalization accrue mostly to Medicare; thus, there is a fiscal externality associated with cost-sharing increases by supplemental insurers. Our findings suggest that health insurance should be tied to underlying health status, with chronically ill patients facing lower cost-sharing. We also conclude that the externalities to Medicare from supplemental insurance coverage may be more modest than previously suggested due to these offsets.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
A distinctive feature of the health insurance market in the U.S. is the restriction of group insurance availability to the workplace. This has a number of important implications for the functioning of the labor market, through mobility from job-to-job or in and out of the labor force, wage determination, and hiring decisions. This paper reviews the large literature that has emerged in recent years to assess the impact of health insurance on the labor market. I begin with an overview of the institutional details relevant to assessing the interaction of health insurance and the labor market. I then present a theoretical overview of the effects of health insurance on mobility and wage/employment determination. I critically review the empirical literature on these topics, focusing in particular on the methodological issues that have been raised, and highlighting the unanswered questions which can be the focus of future work in this area.

Abstract:
This is the introduction to and summary of Phase III of an international research project to study the relationship between social security provisions and retirement. The project relies on the work of a large group of economists in 12 countries who conduct the analysis for each of their countries. The first phase described the retirement incentives inherent in plan provisions and documented the strong relationship across countries between social security incentives to retire and the proportion of older persons out of the labor force. The second phase illustrated the large effects that changing plan provisions would have on the labor force participation of older workers. This third phase shows the consequent fiscal implications that extending labor force participation would have on net program costs - reduced government social security benefit payments less increased government tax revenues.
The findings are conveyed by simulating the implications of illustrative reforms. One reform increases benefit eligibility ages by three years. Another illustrative reform reduces actuarially benefits received before the normal retirement age. A common reform prescribes the same provisions in each country. The financial implications of the illustrative reforms are very large in many instances, often as much as 20 to 40 percent of current program costs. The savings amount to as much a 1 percent or more of country GDP. The results make clear that reforms like those considered in this volume can have very large fiscal implications for the cost of social security benefits as well as for government revenues engendered by changes in the labor force participation of older workers.

Abstract:
After steadily declining over the previous 15 years, youth smoking began to rise precipitously in 1992, and by 1997 had risen by roughly one-third from its 1991 trough. We know very little about what caused this time trend and what public policy can do to reverse it. This paper therefore provides a comprehensive analysis of the impact of prices and other public policies on youth smoking in the 1990s, drawing on three separate data sets. I find that the most important policy determinant of youth smoking, particularly among older teens, is prices. Prices are a significant and sizeable determinant of smoking by older teens in all tree data sets, although the estimated price elasticity varies significantly. On the other hand, price does not appear to be an important determinant of smoking by younger teens. There is little consistent evidence of robust effect of other public policies targeted to reducing youth smoking, although there is some suggestion that restrictions on youth purchase of cigarettes reduce the quantity of cigarettes reduce the quantity of cigarettes smoked. And I find that black youth and those with less educated parents are much more responsive to cigarette price than are white teens and those with more educated parents, suggesting a strong correlation between price sensitivity and socioeconomic status.

Abstract:
Most states in the U.S. allow for unilateral divorce, which increases the ease of divorce by not requiring the explicit consent of both partners. Such regulations have come under fire for their perceived negative consequences for marital stability and resulting child outcomes, but there is no evidence to date to support the contention that easier divorce regulations are actually bad for children. I assess the long run implications for children of growing up in a unilateral divorce environment, by measuring how such youth exposure affects adult outcomes. Using 40 years of census data to exploit the variation across states and over time in changes in divorce regulation, I confirm that unilateral divorce regulations do significantly increase the incidence of divorce. I also find that adults who were exposed to unilateral divorce regulations as children are less well educated and have lower family incomes. They are also more likely themselves to be both married and separated, and both of these effects appear to reflect primarily a shift towards earlier marriage and separation. Women in these exposed cohorts are less attached to the labor force, while men are somewhat more attached; the timing of these effects appears consistent with a causal role for marriage. Thus, exposure to easier divorce regulation as a youth appears to worsen adult outcomes along a number of dimensions, but the ultimate implications depend on the long run impacts of earlier family formation among this cohort.

Abstract:
The populations in all industrialized countries are aging rapidly and life life expectancies are increasing. Yet older workers are leaving the labor force at younger and younger ages. In some countries, the labor force participation rates of 60 to 64 year old men have fallen by 75% over the past 30 years. This decline magnifies population trends, further increasing the number of retirees relative to the number of people working. Together these trends have put enormous pressure on the financial solvency of social security systems around the world. Ironically, the provisions of the systems themselves typically contribute to the labor force withdrawal. This paper is a summary of the findings of the evidence in 11 industrialized countries. We distill the key conclusions drawn from the collective findings of the individual papers. It is clear there is a strong correspondence between the age at which benefits are available and departure from the labor force. Social security programs often provide generous retirement benefits at young ages. Also, the provisions of these programs often imply large financial penalties on earnings beyond the social security early retirement age.Furthermore, in many countries disability and unemployment programs effectively provide early retirement benefits before the official social security early retirement age. We conclude that social security program provisions have contributed to the decline in labor force participation of older persons, substantially reducing the potential productive capacity of the labor force. It seems evident that if the trend to early retirement is to be reversed, as will almost surely be dictated by demographic trends, changing the provisions of social security programs that induce early retirement will play a key role.

Abstract:
A central parameter for evaluating tax policies is the price elasticity of demand for cigarettes. But in many countries this parameter is difficult to estimate reliably due to widespread smuggling, which significantly biases estimates using legal sales data. An excellent example is Canada, where widespread smuggling in the early 1990s, in response to large tax increases, biases upwards the response of legal cigarette sales to price. We surmount this problem through two approaches: excluding the provinces and years where smuggling was greatest; and using household level expenditure data on smoking, where there is a downward bias to estimated elasticities from smuggling. These two approaches yield a tightly estimated elasticity in the range of -0.45 to -0.47. We also show that the sensitivity of smoking to price is much larger among lower income Canadians. In the context of recent behavioral models of smoking, whereby higher taxes reduce unwanted smoking among price sensitive populations, this finding suggests that cigarette taxes may not be as regressive as previously suggested. Finally, we show that price increases on cigarettes do not increase, and may actually decrease, consumption of alcohol; as a result, smuggling of cigarettes may have raised consumption of alcohol as well.

Abstract:
The traditional normative analysis of government policy towards addictive bads is carried out in the context of a 'rational addiction' model, whereby the only role for government is in correcting the external costs of consumption of such goods. But available evidence is at least as consistent, if not more so, with an alternative where individuals are 'time inconsistent' about decisions such as smoking, having a higher discount rate between this period and the next than between future periods. We develop this time inconsistent model, and show that this alternative formulation delivers radically different implications for government policy towards smoking. Unlike the traditional model, our alternative implies that there is a role for government taxation of addictive bads even if there are no external costs; we estimate that the optimal tax on cigarettes is $1 or more higher than that implied by the traditional model. And we estimate that cigarette excise taxes are much less regressive than previously believed, and indeed for most parameter values are progressive, since lower income groups are much more price elastic and therefore benefit more from the commitment device provided by higher excise taxes.

Abstract:
We use data from the March 1968-2001 Current Population Surveys to document the evolution of elderly poverty over this time period, and to assess the causal role of the Social Security program in reducing poverty rates. We develop an instrumental variable approach that relies on the large increase in benefits for birth cohorts from 1885 through 1916, and the subsequent decline and flattening of real benefits growth due to the Social Securing 'notch', to estimate of Social Security on elderly poverty. Our findings suggest that over all elderly families the elasticity of poverty to benefits is roughly unitary. This suggests that reductions in Social Security benefits would significantly alter the poverty of the elderly.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
One of the benefits commonly claimed for expanded public health insurance is improved efficiency of medical care delivery, but this claim has little rigorous empirical support. We provide such support by assessing the impact of the Medicaid expansions over the 1983-1996 period on the incidence of avoidable hospitalizations. We find that expanded public insurance eligibility leads to a significant decline in avoidable hospitalization: over this period Medicaid eligibility expansions were associated with a 22% decline in avoidable hospitalization. But we also find that there is a countervailing and larger impact in terms of increased access to hospital care for newly eligible children, so that there is an overall 10% rise in child hospitalizations due to the expansions. The expansions have mixed implications for treatment intensity, but appear to be associated with a significant shift in the types of hospitals at which children are treated, with fewer children treated in public hospitals and more in for-profit facilities.

Abstract:
The economic argument for subsidizing charitable giving relies on the positive externalities of charitable activities, particularly from the religious institutions that are the largest recipients of giving. But the net external effects of subsidies to religious giving will also depend on a potentially important indirect effect as well: impacts on religious participation. Religious participation can be either a complement to, or a substitute with, the level of charitable giving. Understanding these spillover effects of charitable giving may be quite important, given the existing observational literature that suggests that religiosity is a major determinant of well-being among Americans. In this paper I investigate the impact of charitable subsidies on a measure of religious participation, attendance at religious services. I do so by using data over three decades from the General Social Survey, as well as confirming the impact of such subsidies on religious giving using the Consumer Expenditure Survey. I find strong evidence that religious giving and religious attendance are substitutes: larger subsidies to charitable giving lead to more religious giving, but less religious attendance, with an implied elasticity of attendance with respect to religious giving of -0.92. These results have important implications for the debate over charitable subsidies. They also serve to validate economic models of religious participation.

Abstract:
The single most important long run fiscal issue facing the developed world is the aging of its populations. In virtually every developed country, there will be a steep increase in the ratio of the elderly to the working age population over the first half of the 21st century. The purpose of our paper is to provide an international perspective on public policies directed towards the elderly, and to discuss the implications of these policies for both the elderly and for government budgets. We begin by briefly reviewing the panoply of public programs targeted to the elderly, and document wide variation among the otherwise similar OECD nations in government spending directed towards the elderly. We then review what this increased spending is buying the elderly by providing some evidence on the relationship between social insurance program incentives and labor supply, between public spending and average elderly incomes, and between public spending and elderly poverty rates. We provide some suggestive evidence that public spending on the elderly is doing little to raise their incomes on average, perhaps due to increased early retirement, but that it is significantly protecting them against poverty. We then ask what the demographic transition bodes for the future: if countries do not change their behavior, what is the likely path for their fiscal situations? We also show that, if the past is any guide, the burden of paying these high fiscal bills is likely to be paid through reduced spending elsewhere, particularly on programs for the non-elderly.

Abstract:
This paper examines the history, rules, and economic implications of the Medicaid program. I begin by providing a detailed overview of how the program works. I then provide information on who is covered, who is eligible, and spending patterns. I then turn to a review of the economic issues involved in studying the Medicaid program: assessing the impacts on insurance coverage (public and private), health, labor supply, family structure, and savings. I follow this with a review of the empirical literature on each of these topics. Finally, I conclude with a discussion of the policy issues and unanswered questions surrounding the Medicaid program.

Abstract:
Workers' compensation insurance provides cash payments and medical benefits to workers who incur a work-related injury or illness. Many features of the workers' compensation program parallel features of proposed mandated employer-paid health insurance plans. This paper empirically examines the incidence of the workers' compensation program to infer the likely consequences of mandated health insurance proposals. In certain industries, such as trucking and carpentry, workers' compensation insurance costs are quite large, and vary tremendously within states over time, and across states at a moment in time. This variation is used to identify the incidence of the program. Empirical analysis of two data sets suggest that changes in employers' costs of workers' compensation insurance are largely shifted to employees in the form of lower wages. In addition, higher insurance costs are found to have a negative but statistically insignificant effect on employment. The implied elasticity of labor demand from our results is about -.50.

Abstract:
Social Security is the largest social insurance program in the U.S., and has been shown to be a major determinant of the labor supply decisions of older workers. As such, reforming the Social Security system can have two fiscal impacts: a "mechanical" effect through changing the rules on benefits entitlements or taxation, and a "behavioral" effect through individual responses to these changes in benefits or taxes. We build a simulation model that computes these effects for major reforms to the system, building on estimated retirement responses to changing net Social Security entitlements. We then estimate the fiscal impact of reform for the 1931-1941 cohort of workers represented by the Health and Retirement Survey. We find that raising the early and normal retirement age by three years would reduce net costs for this cohort by roughly 30%, and that moving to a much higher benefit level would raise net costs by roughly 55%. Importantly, we find that in both cases the behavioral impacts on net costs are relatively small, at most one-third, and generally less than one-fifth of the total. The reason for these small effects is that the U.S. Social Security system is roughly actuarially fair, so that delaying or inducing retirement has relatively little impact on system balances; most of the effects that do arise are due to changes in general income and consumption taxes.

Abstract:
Recently economists have begun to consider the causes and consequences of religious participation. An unanswered question in this literature is the effect upon individuals of changes in the opportunity cost of religious participation. In this paper we identify a policy-driven change in the opportunity cost of religious participation based on state laws that prohibit retail activity on Sunday, known as "blue laws." Many states have repealed these laws in recent years, raising the opportunity cost of religious participation. We construct a model which predicts, under fairly general conditions, that allowing retail activity on Sundays will lower attendance levels but may increase or decrease religious donations. We then use a variety of datasets to show that when a state repeals its blue laws religious attendance falls, and that church donations and spending fall as well. These results do not seem to be driven by declines in religiosity prior to the law change, nor do we see comparable declines in membership or giving to nonreligious organizations after a state repeals its laws. We then assess the effects of changes in these laws on drinking and drug use behavior in the NLSY. We find that repealing blue laws leads to an increase in drinking and drug use, and that this increase is found only among the initially religious individuals who were affected by the blue laws. The effect is economically significant; for example, the gap in heavy drinking between religious and non religious individuals falls by about half after the laws are repealed.

Abstract:
Previous research on unemployment insurance (UI) has focused on the costs of the program, in terms of the distorting effects of generous UI benefits on worker and firm behavior. For assessing the optimal size of an unemployment insurance program, however, it is also important to gauge the benefits of increased UI generosity, in terms of smoothing consumption across periods of joblessness. I do so through a reduced form approach which directly measures the effect of legislated variations in UI benefits on consumption changes among individuals becoming unemployed. I use annual observations on food consumption expenditures for 1968-1987 from the Panel Study of Income Dynamics, matched to information on the UI benefits for which unemployed persons were eligible in each state and year. I estimate that a 10 percentage point increase in the UI replacement rate leads to a consumption fall upon unemployment which is 2.7% smaller. Over this period, the average fall in consumption for the unemployed was 7%; my results imply that, in the absence of unemployment insurance, this fall would have been over three times as large. I also find that the positive effect of UI only extends for one period, smoothing consumption during initial job loss but having no permanent effect on consumption levels; that individuals who anticipate layoff see a smaller consumption smoothing effect; and that UI appears to somewhat crowd out other forms of public consumption insurance. Despite the substantial estimated consumption smoothing effect, however, my results imply that the optimal UI benefit level is within the range of current replacement rates only at fairly high levels of risk aversion.

Abstract:
This paper reviews the formation and outcomes of health policy making during the Clinton Administration. We begin by reviewing the state of the health economy at the dawn of the Clinton era. We then review the promise and pitfalls of the Health Security Act, and its implications for all health policy that followed. We then turn to discussing accomplishments and failures in a variety of other areas of health policy: coverage expansions; insurance market regulation; Medicaid reforms; long term care; tobacco regulation; and other public health. We conclude that the dramatic failure of the HSA led to a very cautious and incremental approach to health policy making in subsequent years, but that viewed from the perspective of that that low point the health policy gains in the Clinton years were actually quite substantial.

Abstract:
Interest in religious organizations as providers of social services has increased dramatically in recent years. Churches in the U.S. were a crucial provider of social services through the early part of the twentieth century, but their role shrank dramatically with the expansion in government spending under the New Deal. In this paper, we investigate the extent to which the New Deal crowded out church charitable spending in the 1930s. We do so using a new nationwide data set of charitable spending for six large Christian denominations, matched to data on local New Deal spending. We instrument for New Deal spending using measures of the political strength of a state's congressional delegation, and confirm our findings using a different instrument based on institutional constraints on state relief spending. With both instruments we find that higher government spending leads to lower church charitable activity. Crowd-out was small as a share of total New Deal spending (3%), but large as a share of church spending: our estimates suggest that church spending fell by 30% in response to the New Deal, and that government relief spending can explain virtually all of the decline in charitable church activity observed between 1933 and 1939.

Abstract:
One approach to covering the uninsured that is frequently advocated by policy makers is subsidizing the employee portion of employer-provided health insurance premiums. But, since the vast majority of those offered employer-provided health insurance already take it up, such an approach is only appealing if there is a very high takeup elasticity among those who are offered and uninsured. Moreover, if plan choice decisions are price elastic, then such subsidies can at the same time increase health care costs by inducing selection of more expensive plans. We study an excellent example of such subsidies: The introduction of pre-tax premiums for postal employees in 1994, and then for the remaining federal employees in 2000. We do so using a census of personnel records for all federal employees from 1991 through 2002. We find that there is a very small elasticity of insurance takeup with respect to its after-tax price, and a modest elasticity of plan choice. Our results suggest that the federal government did little to improve insurance coverage, but much to increase health care expenditures, through this policy change.

Abstract:
One popular option for health care reform in the U.S. is to make particular groups, such as children, eligible for public health insurance coverage. A key question in assessing the cost of this option is the extent to which public eligibility will crowd out the private insurance coverage of these groups. We estimate the extent of crowdout arising from the dramatic expansions of the Medicaid program during the 1987-1992 period. Over this time period, Medicaid eligibility for children increased by 50 percent and eligibility for pregnant women doubled. We estimate that between 50 percent and 75 percent of the increase in Medicaid coverage was associated with a reduction in private insurance coverage. This occurred largely because employees took up employer-based insurance less frequently, although employers may have encouraged them to do so by contributing less for insurance. There is some evidence that workers dropped coverage for their family and switched into individual policies.

Abstract:
A common prescription for reducing the number of uninsured is to increase the tax subsidization of health insurance in the U.S. Yet, we already provide over $100 billion per year in tax subsidies to health insurance. This paper provides an assessment of the past and potential impacts of taxation on health insurance coverage and costs. I begin by reviewing the central facts on health insurance and taxation. I then provide a framework for assessing the impacts of tax policies on health insurance coverage and costs, and I review the existing empirical evidence on the key behavioral parameters required to model these impacts. I conclude with the policy implications of these findings for tax policies to expand insurance coverage.

Abstract:
The strong negative correlation over time between smoking rates and obesity have led some to suggest that reduced smoking is increasing weight gain in the U.S. This conclusion is supported by the findings of Chou et al. (2004), who conclude that higher cigarette prices lead to increased body weight. We investigate this issue and find no evidence that reduced smoking leads to weight gain. Using the cigarette tax rather than the cigarette price and controlling for non-linear time effects, we find a negative effect of cigarette taxes on body weight, implying that reduced smoking leads to lower body weights. Yet our results, as well as Chou et al., imply implausibly large effects of smoking on body weight. Thus, we cannot confirm that falling smoking leads in a major way to rising obesity rates in the U.S.

Abstract:
One of the most important economic decisions facing the elderly, and their families, is whether to live independently. A number of previous studies suggest that widows are fairly responsive to Social Security benefits in deciding whether to live independently. But these previous studies have either generally relied on differences in benefits across families or cohorts, which are potentially correlated with other determinants of living arrangements, or have used data from the distant past. We propose a new approach that relies on the large exogenous shifts in benefits generosity for cohorts born in the 1910-1921 period, and we study the impact of this change in living arrangements in the 1980s and 1990s. In this period, benefits rose quickly, due to double-indexing of the benefit formula, and then fell dramatically, as this double-indexing was corrected over a five-year period. Using these legislative changes in benefits that the living arrangements of widows are much more sensitive to Social Security income than implied by previous studies. We also find that the living arrangements of divorcees, the fastest growing group of elderly, are even more sensitive to benefit levels. Overall, our findings suggest that living arrangements are elastically demanded by non-married elderly, privacy is a normal good, and that reductions in Social Security benefits would significantly alter the living arrangements of the elderly. Our estimates imply that a 10% cut in Social Security benefits would lead more than 600,000 independent elderly households to move into shared living arrangements.

Abstract:
Nursing home expenditures are a rapidly growing share of national health care spending with the government functioning as the dominant payer of services. Public insurance for nursing home care is tightly targeted on income and assets, which imposes a major tax on savings; moreover, low state reimbursement for Medicaid patients has been shown to lower treatment quality, and bed supply constraints may deny access to needy individuals. However, expanding eligibility, increasing Medicaid reimbursement, or allowing more nursing home bed slots has the potential to induce more nursing home use, increasing the social costs of long term care. A problem in evaluating this tradeoff is that we know remarkably little about the effects of government policy on nursing home utilization. We attempt to address this shortcoming using multiple waves of the National Long-Term Care Survey, matched to changing state Medicaid rules for nursing home care. We find consistent evidence of no effect of Medicaid policies on nursing home utilization, suggesting that demand for nursing home care is relatively inelastic. From a policy perspective, this finding indicates that changes in overall Medicaid generosity will not have large effects on utilization.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
The "induced demand" model states that in the face of negative income shocks physicians may exploit their agency relationship with patients by providing excessive care in order to maintain their incomes. We test this model by exploiting an exogenous change in the financial environment facing obstetrician/gynecologists during the 1970s: declining fertility in the U.S. We argue that the 13.5% fall in fertility over the 1970-1982 period increased the income pressure on ob/gyns, and led them to substitute from normal childbirth towards a more highly reimbursed alternative, cesarean delivery. Using a nationally representative micro-data set for this period, we show that there is a strong correlation between within state declines in fertility and within state increases in cesarean utilization. This correlation is robust to consideration of a variety of alternative hypotheses, and appears to be symmetric with respect to periods of fertility decline and fertility increase.

Abstract:
The "induced demand" model states that in the face of negative income shocks, physicians may exploit their agency relationship with patients by providing excessive care. We test this model using an exogenous change in the financial environment facing obstetrician/gynecologists: declining fertility in the United States. We argue that the 13.5% fall in fertility over the 1970-1982 period led ob/gyns to substitute from normal childbirth toward a more highly reimbursed alternative, cesarean delivery. Using a nationally representative microdata set for this period, we show that there is a strong correlation between within-state declines in fertility and within-state increases in cesarean utilization.

Abstract:
The largest entitlement program in the United States today is the Social Security program (SS). We provide an overview of the interaction between the SS system and retirement behavior. We begin by documenting historical trends in labor force participation and program receipt, and contemporaneous patterns of work and income receipt for the current cohort of older persons. We then present an overview of the structure of the SS program in the U.S., and review existing evidence on the relationship between SS and retirement. Finally, we present results of a simulation model which measures the implicit tax/subsidy rate on work after age 55 through the SS system. We find that, for married workers, the system is roughly neutral with respect to work after age 62, but that it heavily penalizes work after age 65. But there are larger tax rates on single workers and on high earning workers.

Abstract:
This paper focuses on Social Security benefit claiming behavior, a take-up decision that has been ignored in the previous literature. Using financial calculations and simulations based on an expected utility maximization model, we show that delaying benefit claim for a period of time after retirement is optimal in a wide variety of cases and that gains from delay may be significant. We find that approximately 10% of men retiring before their 62nd birthday delay claiming for at least one year after eligibility. We estimate hazard and probit models using data from the New Beneficiary Data System to test four cross-sectional predictions. While the data suggest that too few men delay, we find that the pattern of delays by early retirees is generally consistent with the hypotheses generated by our theoretical model.

Abstract:
The poor health status of children in the U.S. relative to other industrialized nations has motivated recent efforts to extend insurance coverage to underprivileged children. There is little past evidence that extending eligibility for public insurance to previously ineligible groups will increase health status or even utilization of medical resources. Using data from the Current Population Survey, the National Health Interview Survey, and state-level data on child mortality, we examine the utilization and health effects of eligibility for public insurance. Our models are identified by the recent expansions of the Medicaid program to low income children. We find that these expansions roughly doubled the fraction of children eligible for Medicaid between 1984 and 1992; by 1992, almost 1/3 of all children were eligible. But takeup of these expansions was much less than full even among otherwise uninsured children. Despite this takeup problem, we find that eligibility for Medicaid significantly increased the utilization of medical care along a number of dimensions. Medicaid eligibility was associated with large increases in care delivered in physician's offices, although there was some increase in care in hospital settings as well. While there was no effect of eligibility on parentally-assessed subjective health measures, we do find notable reductions in child mortality. Finally, we find that rising Medicaid eligibility is associated with reductions in racial disparities in the number of visits and in child disparities in the site at which care is delivered.

Abstract:
We study the effect of public insurance for children on their utilization of medical care and health outcomes by exploiting recent expansions of the Medicaid program to low-income U.S. children. These expansions doubled the fraction of children eligible for Medicaid between 1984 and 1992. Take-up of these expansions was much less than full, however, even among otherwise uninsured children. Despite this take-up problem, eligibility for Medicaid significantly increased the utilization of medical care, particularly care delivered in physicians' offices. Increased eligibility was also associated with a sizable and significant reduction in child mortality.

Abstract:
One popular explanation for this low rate of employee coverage is the presence of numerous state regulations which mandate that group health insurance plans must include certain benefits. By raising the minimum costs of providing any health insurance coverage, these mandated benefits make it impossible for firms which would have desired to offer minimal health insurance at a low cost to do so. I use data on insurance coverage among employees in small firms to investigate whether this problem is an important cause of employee non-insurance. I find that mandates have little effect on the rate of insurance coverage; this finding is robust to a variety of specifications of the regulations. I also find that this lack of an effect may be because mandates are not binding, since most firms appear to offer these benefits even in the absence of regulation.

Abstract:
Previous research has convincingly shown that abortion legalization in the early 1970s led to a significant drop in fertility at that time. But this decline may have either represented a delay in births from a point where they were have represented a permanent reduction in fertility. We combine data from the 1970 U.S. Census and microdata from 1968 to 1999 Vital Statistics records to calculate lifetime fertility of women in the 1930s through 1960s birth cohorts. We examine whether those women who were born in early legalizing states and who passed through the early 1970s in their peak childbearing years had differential lifetime fertility patterns compared to women born in other states and in different birth cohorts. We consider the impact of abortion legalization on both the number of children ever born as well as the distribution of number of children ever born. Our results indicate that much of the reduction in fertility at the time abortion was legalized was permanent in that women did not have more subsequent births as a result. We also find that this result is largely attributable to an increase in the number of women who remained childless throughout their fertile years.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
The continued rise in the number of non-elderly Americans without health insurance has led to considerable interest in tax-based policies to raise the level of insurance coverage. This paper describes a detailed microsimulation model that has been developed to evaluate such tax-based polices, and its findings for the impact of polices on government costs and insurance coverage. I find that while tax subsidies could significantly increase insurance coverage, even very generous tax policies could not cover more than a sizable minority of the uninsured population. But there are several design features which can clearly make tax policy more effective: using tax credits rather than deductions; making credits refundable; and addressing the timing mismatch between when insurance purchases are made and tax refunds are received. I also document a clear tradeoff between the scope of tax subsidies and their efficiency.

Abstract:
This is the introduction and summary to the fourth phase of an ongoing project on Social Security Programs and Retirement Around the World. The first phase described the retirement incentives inherent in plan provisions and documented the strong relationship across countries between social security incentives to retire and the proportion of older persons out of the labor force. The second phase documented the large effects that changing plan provisions would have on the labor force participation of older workers. The third phase demonstrated the consequent fiscal implications that extending labor force participation would have on net program costs—reducing government social security benefit payments and increasing government tax revenues.This volume presents the results of analyses of the relationship between the labor force participation of older persons and the labor force participation of younger persons in twelve countries. Why countries introduced plan provisions that encouraged older persons to leave the labor force is unclear. After the fact, it is now often claimed that these provisions were introduced to provide more jobs for the young, assuming that fewer older persons in the labor force would open up more job opportunities for the young. Now, the same reasoning is often used to argue against efforts in the same countries to reduce or eliminate the incentives for older persons to leave the labor force, claiming that the consequent increase in the employment of older person would reduce the employment of younger persons. The validity of such claims is addressed in this volume.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
A key question for health care reform in the U.S. is whether expanded health insurance eligibility will lead to improvements in health outcomes. We address this question in the context of dramatic expansions in the Medicaid eligibility for pregnant women that took place during the 1980s. We build a detailed simulation model of each state's Medicaid policy during the 1979-1990 period, and use this model to estimate 1) the effect of changes in the rules on the eligibility of pregnant women for Medicaid, and 2) the effect of Medicaid eligibility changes on birth outcomes in aggregate Vital Statistics data. We have three main findings. First, the expansions did dramatically increase the Medicaid eligibility of pregnant women, but did so at quite differential rates across the states. Second, the expansions lowered the incidence of infant mortality and low birthweight; we estimate that the 20 percentage point increase in eligibility among 15-44 year old women was associated with a decrease in infant mortality of 7%. Third, earlier, targeted changes in Medicaid eligibility, such as through relaxations of the family structure requirements from the AFDC program, had much larger effects on birth outcomes than broader expansions of eligibility to all women with somewhat higher income levels. We suggest that the source of this difference was the much lower takeup of Medicaid coverage by individuals who became eligible under the broader expansions. We find that the targeted expansions, which raised Medicaid expenditures by $1.7 million per infant life saved, were in line with conventional estimates of the value of a life. We conclude that insurance expansions can improve health, but that translating eligibility to coverage may be the key link in making insurance policy effective.

Abstract:
One of the most sizable and least predictable shocks to economic opportunities in developing countries is major illness, both in terms of medical care expenditures and lost income from reduced labor supply and productivity. As a result, families may not be able to smooth their consumption over periods of illness. In this paper, we investigate the extent to which families are able to insure consumption against major illness using a unique panel data set from Indonesia that combines excellent measures of health status with consumption information. We focus on the effect of large exogenous changes in physical functioning. We find that there are significant economic costs associated with these illnesses, albeit more from income loss than from medical expenditures. We also find a robust and striking rejection of full consumption insurance. Indeed, the deviation from full consumption smoothing is significant, particularly for illnesses that severely limit physical function; families are able to smooth less than 30 percent of the income loss from these illnesses. These estimates suggest large welfare gains from the introduction of formal disability insurance, and that the large public subsidies for medical care typical of most developing countries may improve welfare by providing consumption insurance.

Abstract:
The magnitude of provider uncompensated care has become an important public policy issue. Yet existing measures of uncompensated care are flawed because they compare uninsured payments to list prices, not to the prices actually paid by the insured. We address this issue using a novel source of data from a vendor that processes financial data for almost 4000 physicians. We measure uncompensated care as the net amount that physicians lose by lower payments from the uninsured than from the insured. Our best estimate is that physicians provide negative uncompensated care to the uninsured, earning more on uninsured patients than on insured patients with comparable treatments. Even our most conservative estimates suggest that uncompensated care amounts to only 0.8% of revenues, or at most $3.2 billion nationally. These results highlight the important distinction between charges and payments, and point to the need for a re-definition of uncompensated care in the health sector going forward.

Abstract:
We present a detailed analysis of the incentives that Social Security provides for continued work at older ages. We do so using information on older males from the Health and Retirement Study over the 1980-1997 period to calculate the changes in the present discounted value of Social Security entitlements from additional work at each age. We find that the median male worker faces a small tax on work at ages 55-61, a near zero tax at ages 62-64, and a large tax at ages 65-69. However, there is significant heterogeneity in tax rates. We also document significant non-monotonicities in the accrual of Social Security entitlements with additional work, and suggest a more appropriate measure of incentive effects that considers accruals over not just the next year but future years as well.

Abstract:
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Abstract:
Like most other developed nations, Canada has a large income security system for retirement that provides significant and widely varying disincentives to work at older ages. Empirical investigation of their effects has been hindered by lack of appropriate data. We provide an empirical analysis of the retirement incentives of the Canadian Income Security (IS) system using a new and comprehensive administrative data base. We find that the work disincentives inherent in the Canadian IS system have large and statistically significant impacts on retirement. This suggests that program reform can some play a role in responses to the fiscal crises these programs periodically experience. We also demonstrate the importance of controlling for lifetime earnings in retirement models. Specifications without these controls overestimate the effects of the IS system. Finally, our estimates vary in sensible ways across samples lending greater confidence to our estimates.

Abstract:
The Medicaid program, which provides health insurance to low income women and children, has expanded dramatically over the past decade. This expansion provides a `natural laboratory' for learning about the effect of public health insurance eligibility on insurance coverage, health utilization, and health outcomes. This paper provides an overview of what has been learned about these questions from studying the expansions. Medicaid eligibility rose steeply over the 1984-1992 period, but coverage rose much less sharply, due to limited takeup of benefits. This is partly due to the fact that many eligibles already had private insurance coverage, and evidence suggests that a large share of new enrollees dropped their private coverage to join the program. Nevertheless, utilization of preventive care rose substantially as a result of the expansions, and there were significant improvements in health outcomes, specifically infant and child mortality. While these mortality reductions came at significant cost to the Medicaid program, the cost per life saved was low relative to alternative uses of government funds. These findings highlight both the potential benefits of public insurance policy and the importance of appropriately targeting scarce public health dollars.

Abstract:
The Medicaid program, which provides health insurance coverage to low income women and children, has expanded dramatically over the past decade. This expansion provides a "natural laboratory" for learning about the effect of public health insurance eligibility on insurance coverage, health utilization, and health outcomes. This paper provides an overview of what has been learned about these questions from studying the expansions. Medicaid eligibility rose steeply over the 1984-1992 period, but coverage rose much less sharply, due to limited takeup of benefits. This is partly due to the fact that many eligibles already had private insurance coverage, and evidence suggests that a large share of new enrollees dropped their private coverage to join the program. Nevertheless, utilization of preventive care rose substantially as a result of the expansions, and there were significant improvements in health outcomes, specifically infant and child mortality. While these mortality reductions came at significant cost to the Medicaid program, the cost per life saved was low relative to alternative uses of government funds. These findings highlight both the potential benefits of public insurance policy and the importance of appropriately targeting scarce public health dollars.

Abstract:
One of the most important behavioral parameters in macroeconomics is the elasticity of intertemporal substitution (EIS). Starting with the seminal work of Hall (1978), researchers have used an Euler equation framework to estimate the EIS, relating the growth rate of consumption to the after-tax interest rate facing consumers. This large literature has, however, produced very mixed results, perhaps due to an important limitation: the impact of the interest rate on consumption or savings is identified by time series movements in interest rates. Yet the factors that cause time series movements in interest rates may themselves be correlated with consumption or savings decisions. I address this problem by using variation across individuals in the capital income tax rate. Conditional on observable characteristics of individuals, tax rate movements cause exogenous shifts in the after-tax interest rate. Using data on total non-durable consumption from the Consumer Expenditure Survey over two decades, I estimate a surprisingly high EIS of 2. This finding is robust to a variety of specification checks.

Abstract:
This paper examines the implications of a 'major-risk' approach to health insurance using data from the National Medical Expenditure Survey. We study the impact of switching from existing coverage to a policy with a 50 percent coinsurance rate and 10 percent of income limit on out-of-pocket expenditures, as well as several alternative combinations of a high-coinsurance rate with a limited out-of-pocket payment. Our analysis is limited to the population under age 65. Although 80 percent of spending on physicians and hospital care is done by the 20 percent of families who spend over $5,000 in a year, our analysis shows that shifting to a major risk policy could reduce aggregate health spending by nearly 20 percent. The reductions would be greatest among higher income individuals. By reducing excess consumption of health services, the major risk policy increases aggregate economic efficiency. With modest values of both demand sensitivity and risk aversion we find that shifting to a major risk policy would raise aggregate national efficiency by $34 billion a year. Government provision of a major risk policy" to those under 65 could be financed with a premium of about $150 per person because of the increased tax revenue and reduced Medicare outlays that would result from the provision of universal major risk insurance for the population under age 65. Even without government provision, individuals might be induced to select major risk policies by changing existing tax rules to eliminate the advantage of insurance, either by including employer provided insurance in taxable income or by permitting a tax deduction for out-of-pocket medical expenditures.

Abstract:
While there is a large literature investigating the response of treatment intensity to Medicare reimbursement differentials, there is much less work on this question for the Medicaid program. The answers for Medicare may not apply in the Medicaid context, since a smaller share of physician's patients will be Medicaid insured, so that income effects from fee changes may be dominated by substitution effects. We investigate the effect of Medicaid fee differentials on the use of cesarean delivery over the 1988-1992 period. We find, in contrast to the backward-bending supply curve implied by the Medicare literature larger fee differentials between cesarean and normal childbirth for the Medicaid program leads to higher cesarean delivery rates. In particular, we find that the lower fee differentials between cesarean and normal childbirth under the Medicaid program than under private insurance can explain between one-half and three-quarters of the difference between Medicaid and private cesarean delivery rates. Our results suggest that Medicaid reimbursement reductions can cause real reductions in the intensity with which Medicaid patients are treated.

Abstract:
The introduction of legalized abortion in the early 1970s led to dramatic changes in fertility behavior. Some research has suggested as well that there were important impacts on cohort outcomes, but this literature has been limited and controversial. In this paper, we provide a framework for understanding the mechanisms through which abortion access affects cohort outcomes, and use that framework to both address inconsistent past methodological approaches, and provide evidence on the long-run impact on cohort characteristics. Our results provide convincing evidence that abortion legalization altered young adult outcomes through selection. In particular, we find evidence that lower costs of abortion led to improved outcomes in the birth cohort in the form of an increased likelihood of college graduation, lower rates of welfare use, and lower odds of being a single parent. We also find that our empirical innovations do not substantially alter earlier results regarding the relationship between abortion and crime, although most of that relationship appears to reflect cohort size effects rather than selection.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
Disability Insurance (DI) is a public program that provides income support to persons unable to continue work due to disability. The difficulty of defining disability, however, has raised the possibility that this program may be subsidizing the early retirement of workers who are not truly disabled. A critical input for assessing the optimal size of the DI program is therefore the elasticity of labor force participation with respect to benefits generosity. Unfortunately, this parameter has been difficult to estimate in the context of the U.S. DI program, since all workers face an identical benefits schedule. I surmount this problem by studying the experience of Canada, which operates two distinct DI programs, for Quebec and the rest of Canada. The latter program raised its benefits by 36% in January, 1987, while benefits were constant in Quebec, providing exogenous variation in benefits generosity across similar workers. I study this relative benefits increase using both simple `difference-in-difference' estimators and more parameterized estimators that exploit the differential impact of this policy change across workers. I find that there was a sizeable labor supply response to the policy change; my central estimates imply an elasticity of labor force non-participation with respect to DI benefits of 0.25 to 0.32. Despite this large labor supply response, simulations suggest that there were welfare gains from this policy change under plausible assumptions about preference parameters.

Abstract:
We consider the role of spousal labor supply as insurance against spells of unemployment. Standard theory suggests that women should work more when their husbands are out of work (the Added Worker Effect or AWE), but there has been little empirical support for this contention. We too find little evidence of an AWE over the 1984-1993 period. We suggest that one reason for the absence of the AWE may be that unemployment insurance (UI) is providing a state-contingent income stream that counteracts the negative income shock from the husband's unemployment. We in fact find that increases in the generosity of UI lower labor supply among wives of unemployed husbands. Our results suggest that UI is crowding out a sizeable fraction of offsetting spousal earnings in response to unemployment spells, although even in the absence of a UI system the spousal response would only make up a small share of the associated reduction in family income. We also find evidence that families are making labor supply decisions in a life cycle context, since there are effects of UI on the labor supply of wives of employed husbands who face high unemployment risk. Yet, couples do not appear able to smooth the labor supply response to UI income flows equally over periods of employment and unemployment, suggesting the presence of liquidity constraints. Finally, wives in families with small children are more responsive to UI benefits in their labor supply decisions, which is consistent with the notion that they have a higher opportunity cost of market work.

Abstract:
Despite the growing reliance on payroll taxation worldwide, there is limited evidence on the incidence of payroll taxes. I provide new evidence by examining the experience of Chile before and after the privatization of its Social Security system. This policy change led to a sharp exogenous reduction in the payroll tax burden on Chilean firms; the average payroll tax rate in my sample fell from 30% to 5% over this six year period. I use data from a census of manufacturing firms, which contains information on firm specific tax payments and average wages. I find strong evidence that the incidence of payroll taxation was fully on wages, with no effect on employment. A potential weakness with this approach is that some of the variation in firm-specific tax rates may be spurious, for example due to measurement error in wages. I attempt to surmount this problem by using a variety of different estimators, all of which yield consistent evidence of full shifting.

Abstract:
We estimate the impact of changes in abortion access in the early 1970s on the average living standards of cohorts born in those years. In particular, we address the selection inherent in the abortion decision: is the marginal child who is not born when abortion access increases more or less disadvantaged than the average child? Legalization of abortion in five states around 1970, followed by legalization nationwide due to the 1973 Roe v. Wade decision, generates natural variation which can be used to estimate the effect of abortion access. We find that cohorts born after abortion was legalized experienced a significant reduction in a number of adverse outcomes. Our estimates imply that the marginal child who was not born due to legalization would have been 70% more likely to live in a single parent family, 40% more likely to live in poverty, 50% more likely to receive welfare, and 35% more likely to die as an infant. These selection effects imply that the legalization of abortion saved the government over $14 billion in welfare expenditures through 1994.

Abstract:
Two key issues for public insurance policy are the effect of insurance status on medical treatment, and the implications of insurance-induced treat- ment differentials for health outcomes. We address these issues in the context of the treatment of childbirth, using Vital Statistics data on every birth in the U.S. over the 1987-1992 period. The effects of insurance status on treat- ment and outcomes are identified using the tremendous variation in eligibility for public insurance coverage under the Medicaid program over this period. Among teen mothers and high school dropouts, who were largely uninsured before being made eligible for Medicaid, eligibility for this program was associated with significant increases in the use of a variety of obstetric procedures. On average, this more intensive treatment was associated with only marginal changes in the health of infants, as measured by neonatal mortality. But the effect of eligibility on neonatal mortality is sizeable among children born to mothers whose closest hospital had a Neonatal Intensive Care Unit, suggest- ing that insurance-induced increases in use of `high tech' treatments can have real effects on outcomes. Among women with more education there is a counter- vailing effect on procedure use. Most of these women had private insurance before becoming Medicaid-eligible, and some may have been 'crowded out' onto the public program. These women moved from more generous to less generous insurance coverage of pregnancy and neonatal care. This movement was accompanied by reductions in procedure use without any discernable change in neonatal mortality.

Abstract:
While there has been considerable discussion of the adequacy of unemployment insurance (UI) benefits as a form of income replacement, there is little evidence on the other resources that the unemployed have to finance their unemployment spells. In this paper I focus on focus on one form of resources, own wealth holdings. I find that the median worker has financial assets sufficient to finance roughly two-thirds of the income loss from an unemployment spell, but that there is tremendous heterogeneity in wealth holdings; almost one-third of workers can't even replace 10% of their income loss. Most strikingly, ex-ante wealth holdings decline precipitously with realized unemployment durations, both absolutely and (especially) relative to ex-post income loss, suggesting that adequacy could be increased if UI benefits were targeted to those with longer spells. I also find strong evidence that individuals who are eligible for more generous UI draw down their wealth more slowly during unemployment spells. This demonstrates that wealth is used as a consumption smoothing device alongside UI to cope with the income loss from unemployment.

Abstract:
Regular church attendance is strongly associated with a higher probability of voting. It is an open question as to whether this association, which has been confirmed in numerous surveys, is causal. We use the repeal of the laws restricting Sunday retail activity (Blue laws) to measure the effects of church-going on political participation. The repeal of Blue Laws caused a 5 percent decrease in church attendance. We measure the effect of Blue Laws' repeal on political participation and find that following the repeal turnout falls by approximately 1 percentage point. This turnout decline, which is statistically significant and fairly robust across model specifications, is consistent with the large effect of church attendance on turnout reported in the literature, and suggests that church attendance may have significant causal influence on voter turnout.

Abstract:
There has been much debate among economists about whether nursing home quality is a public good across Medicaid and private-pay patients within a common facility. However, there has been only limited empirical work addressing this issue. Using a unique individual level panel of residents of nursing homes from seven states, we exploit both within-facility and within-patient variation in payer source and quality to examine this issue. We also test the robustness of these results across states with different Medicaid and private-pay rate differentials. Across our various identification strategies, the results generally support the idea that quality is a public good within nursing homes. That is, within a common nursing home, there is very little evidence to suggest that Medicaid-funded residents receive consistently lower quality care relative to their private-paying counterparts.

Abstract:
We explore the fiscal implications of reforms to the Canadian retirement income system by decomposing the fiscal effect of reforms into two components. The mechanical effect captures the change in the government's budget assuming no behavioral response to the reform. The second component is the fiscal implication of the behavioral effect, which captures the influence of any induced changes in elderly labor supply on government budgets. We find that the behavioral response can account for up to half of the total impact of reform on government budgets. The behavioral response affects government budgets not only in the retirement income system but also through increased income, payroll, and consumption tax revenue on any induced labor market earnings among the elderly. We show that fully accounting for the behavioral response to reforms can change the cost estimates and distributive impact of retirement income reforms.

Abstract:
No abstract is available for this paper.

Abstract:
While National Health Insurance (NHI) plans in the U.S. are often opposed on the basis of their potential disemployment effects, there is no existing evidence on the effects of NHI on employment. We provide such evidence by examining the employment consequences of NHI in Canada, using the fact that NHI was introduced on a staggered basis across the Canadian provinces. We examine monthly data on employment, wages, and hours across 8 industries and 10 provinces over the 1961- 1975 period. We find that employment actually rose after the introduction of NHI; wages increased as well, while average hours were unchanged.

Abstract:
The Social Security earnings test, a version of which still applies to those ages 62-64, reduces immediate payments to beneficiaries whose labor income exceeds a given threshold. Although benefits are subsequently increased to compensate for any such reduction, the earnings test is typically perceived as a tax on working. As a result, it is considered by many to be an important disincentive to paid work for older Americans. Yet there is little evidence to suggest an economically significant effect of the earnings test on hours of work, and almost no research on the effect of the test on the decision to work at all. We investigate these issues using the significant changes in the structure of the earnings test over the past 25 years, using data over the past 25 years, using data over the 1973-1998 period from the March Supplement to the Current Population Survey (CPS), which provide large samples of observations on the elderly. Our analysis suggests two major conclusions. First, the earnings test exerts no robust influence on the labor supply decisions of men. Neither graphical analyses of breaks in labor supply trends, nor regression estimates that control for underlying trends in labor supply by age group, reveal any significant impact of changes in earnings test parameters on aggregate employment, hours of work, or earnings for men. For women, there is more suggestive evidence that the earnings test is affecting labor supply decisions. Second, loosening the earnings test appears to accelerate benefits receipt among the eligible population, lowering benefits levels, and heightening concerns about the standard of living of these elderly at very advanced ages. Our findings suggest some cause for caution before rushing to remove the earnings test at younger ages.

Abstract:
Government transfers to older persons in Canada are one of the largest and fastest growing" components of the government budget. I provide an overview of the interaction between these" transfer programs and retirement behavior. I begin by documenting historical trends in labor force" participation and program receipt, and contemporaneous patterns of work and income receipt for the" current cohort of older persons. I then present an overview of the structure of this system of" Canadian transfer programs. Finally, I present results of a simulation model which measures the" implicit tax/subsidy rate on work after age 55 through this system. I find that workers, there are modest taxes on work through age 64, that rise to fairly high levels thereafter. But" these taxes are substantially lower for single workers, since they do not have wives eligible for" means-tested transfers, and for workers with substantial other sources of income is not at all eligible for means-tested transfers.

Abstract:
We consider both theoretically and empirically the effect of unemployment insurance (UI) on precautionary savings behavior. Simulations of a stochastic life cycle model suggest that increasing the generosity of UI will substantially lower the asset holdings of the median worker, and that this effect will both rise with unemployment risk and fall with worker age. We test these implications by matching data on potential UI replacement rates to asset holdings in the Survey of Income and Program Participation (SIPP). Our empirical results are quite consistent with the predictions of the model. We find that raising the replacement rate for UI by 10 percentage points lowers financial asset holdings by 1.4 to 5.6%, so that UI crowds out up to one-half of private savings for the typical unemployment spell. We also find that this effect is stronger for those facing higher unemployment risk and weaker for older workers.

Abstract:
Although the vast majority of working individuals aged 55-64 receive health insurance coverage through their employment, many of these individuals face the prospect of losing such coverage should they retire before becoming eligible for guaranteed public coverage through Medicare at age 65. Because the expected medical expenses of this group are large and uncertain, the availability of health insurance coverage after retirement could be a key factor in the retirement decision of older workers. We examine the effect of health insurance on retirement by looking at variation in state and federal 'continuation of coverage' mandates, laws which allow individuals to continue purchasing health insurance through a previous employer for a specified number of months after leaving the firm. By allowing individuals to maintain their employer-provided health insurance after retirement, these laws decrease the cost of early retirement for those who do not have other retiree health insurance available. Using data on 55-64 year old men from the Current Population Survey, we find that one year of continuation benefits increases the probability of being retired by 1 percentage point; this represents a 5.4 percent increase in the baseline probability of being retired for this group. We also find that continuation mandates increase the likelihood of being insured after retirement.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
This paper investigates the current tax subsidy to employer-provided health insurance, and presents new evidence on the economic effects of various tax reforms. It argues that previous analyses have overstated the tax subsidy to employer-provided insurance by neglecting the substantial and growing importance of after-tax employee payments for employer-provided insurance, as well as the tax subsidy for extreme medical expenses, which discourages insurance purchase. Even after considering these factors, however, the net tax subsidy to employer-provided insurance is substantial, with tax factors generating an average reduction of approximately thirty percent in the price of this insurance. Reducing the tax subsidy, either by capping the value of employer-provided health insurance that could be excluded from taxation, or eliminating the exclusion entirely, would have substantial effects on the level of employer-provided insurance and on tax revenues.

Abstract:
Low rates of health insurance coverage among the non-employed have motivated consideration of policies to subsidize the purchase of insurance for those who are without a job. But there is little evidence on the extent to which coverage differentials between the employed and the non-employed reflect the effects of job loss or merely different underlying tastes for insurance. If the latter, subsidies may not be successful in increasing the rate of insurance coverage among the non-employed. Furthermore, subsidies which lower the costs of non-employment may increase both the incidence and duration of joblessness. We provide new evidence on these issues by analyzing longitudinal data on 25-54 year-old men over the 1983-1989 period. We have four findings of interest. First, even after modelling differences in underlying tastes for insurance, the likelihood of insurance coverage drops by roughly 20 percentage points following job separation. Second, limited subsidization of the cost of insurance through state laws mandating continued access to employer-provided health insurance for the non-employed increases the likelihood of having insurance while without a job by 6.7 percent. Third, these mandates also increase the number of individuals with spells of non-employment and the total amount of time spent jobless. Finally, at least some of this increased non-employment appears to be spent in productive job search as the availability of continuation coverage is related to significant wage gains among those who separate from their jobs.

Abstract:
The Medicare Part D Prescription Drug Plan represents the most significant privatization of the delivery of a public insurance benefit in recent history, with dozens of private insurers offering a wide range of products with varying prices and product features; the typical elder had a choice of roughly 40 stand-alone drug plans. In this paper we evaluate the choices of elders across this wide array of Part D options using a unique data set of prescription drug claims matched to information on the characteristics of choice sets. We first document that the vast majority of elders are choosing plans that are not on the efficient portfolio of plan choice in the sense that an alternative plan offers better risk protection at a lower cost. We then estimate several discrete choice models to document three dimensions along which elders are making choices which are inconsistent with optimization under full information: elders place much more weight on plan premiums than they do on expected out of pocket costs; they place almost no value on variance reducing aspects of plans; and they value plan financial characteristics beyond any impacts on their own financial expenses or risk. These findings are robust to a variety of specifications and econometric approaches. We develop an adjusted revealed preference approach that combines data from consumer choices with ex ante restrictions on preferences, and find that in a partial equilibrium setting, restricting the choice set to the three lowest average cost options would have likely raised welfare for elders under the program.

Abstract:
A large international literature has documented the labor market distortions associated with social security benefits for near-retirees. In this paper, we investigate the 'other side' of social security programs, seeking to document improvements in wellbeing arising from the provision of public pensions. To the extent households adjust their savings and employment behavior to account for enhanced retirement benefits, the positive impact of the benefits may be crowded out. We proceed by using the large variation across birth cohorts in income security entitlements in Canada that arise from reforms to the programs over the past 35 years. This variation allows us to explore the effects of benefits on elderly well-being while controlling for other factors that affect well-being over time and by age. We examine measures of income, consumption, poverty, and happiness. For income, we find large increases in income corresponding to retirement benefit increases, suggesting little crowd out. Consumption also shows increases, although smaller in magnitude than for income. We find larger retirement benefits diminish income poverty rates, but have no discernable impact on consumption poverty measures. This could indicate smoothing of consumption through savings or other mechanisms. Finally, our limited happiness measures show no definitive effect.

Abstract:
We propose an explanation for the wide variation in rates of taxation across developed economies, based on differences in labor market institutions. In "corporatist" economies, which feature centralized labor markets, taxes on labor input will be less distortionary than when labor supply is determined individually. Since the level of labor supply is set by a small group of decision-makers, these individuals will recognize the linkage between the taxes that workers pay and the benefits that they receive. Labor tax burdens are indeed higher in more corporatist nations, and non-labor taxes are lower, which is consistent with this theory. There is also some evidence that the distortionary effects of labor taxes are lower in more corporatist economies.

Abstract:
The link between health insurance and the workplace in the U.S. has led to concern over the possibility of insurance-induced reductions in job mobility or 'job-lock". Designing health insurance reforms which retain employer-based insurance coverage but mitigate the extent of job-lock requires an understanding of the policy dimensions to which job-lock is most receptive. We study a policy of limited insurance portability which has been adopted by a number of states and the federal government over the last 20 years. These "continuation of coverage' mandates grant individuals the right to continue purchasing health insurance through their former employers for some period of time after leaving their jobs. We find that the passage of these mandates caused a significant increase in the job mobility of prime age male workers. This suggests that a sizeable share of job-lock arises from short run concerns over portability rather than from long run problems.

Abstract:
While efforts to improve the health of the uninsured have focused on demand side policies such as increasing insurance coverage, supply side changes may be equally important. Yet there is little direct evidence on the effect of policies designed to increase the supply of Medicaid services to the poor. We provide such evidence by examining the relationship between infant mortality and the ratio of Medicaid fees to private fees for obstetrician/gynecologists. We build a state and year specific index of the fee ratio for 1979-1992, a period of substantial variation in relative Medicaid fees. We find that increases in fee ratios are associated with significant declines in the infant mortality rate. We also find that higher fees raise payments made to physicians and clinics under the Medicaid program, but reduce payments to hospitals. Finally, we compare the cost effectiveness of reducing infant mortality by increasing fee ratios to the efficacy of reducing mortality by expanding the Medicaid eligibility of pregnant women. Although our results are sensitive to the time period used, we conclude that raising fee ratios is at least as cost effective as increasing eligibility.

Abstract:
While there has been considerable research on the disincentive effects of cash welfare under the Aid to Families with Dependent Children (AFDC) program, there is little evidence on the benefits of the program for single mothers and their children. One potential benefit of this program is that it provides short-run consumption insurance for women at the point that they become single mothers. This is only true, however, to the extent that the program is not crowding out other sources of support, such as own savings, labor supply, or transfers from others. I assess the importance of this insurance mechanism by measuring the extent to which AFDC smooths the consumption of women who transition to single motherhood. I use longitudinal data on family structure and consumption expenditures on food and housing from the Panel Study of Income Dynamics (PSID), matched to information on the welfare benefits available in each state and year over the 1968-1985 period. I find that raising potential benefits by one dollar raises the food and housing consumption of all women who become single mothers (and their families) by 30 cents. This estimate implies that for each dollar of AFDC received by this population their consumption of these categories of goods rises by up to 95 cents. This consumption smoothing benefit appears to be larger for women who become single mothers through marital dissolution, rather than through out-of-wedlock childbearing; this is due to increased housing expenditures of the former group but not of the latter.

Abstract:
I consider the effects of "group-specific mandated benefits", such as mandated maternity leave, which raise the costs of employing a demographically identifiable group. The efficiency of these policies, relative to more broad-based financing of benefits expansions, will largely be a function of the valuation of the mandated benefit by the targeted group. Such valuation should be reflected in substantial shifting of the cost of the mandate to groupspecific wages; however, there may be barriers to the adjustment of relative wages which impede such shifting. I study several 1976 state mandates which stipulated that childbirth be covered comprehensively in health insurance plans, increasing the cost of insuring women of child-bearing age by as much as 5 % of their wages. I find substantial shifting of the costs of these mandates to the wages of the targeted group. Correspondingly, I find little effect on total labor input for the group which benefitted from these mandates; hours rise and employment falls, as may be expected from an increase in the fixed costs of employment. These results are confirmed by using a 1978 Federal mandate as a "reverse experiment".

Abstract:
The last ten years have seen the introduction of price shopping into medical markets which have previously been dominated by price insensitive consumers. Price shopping has been facilitated by the advent of the Preferred Provider Organization (PPO), which coordinates the demand of a large number of individual health care buyers, thereby gaining market power which it uses to obtain steep discounts off list prices from providers. I study hospital responses to the advent of price competition in California over the 1984-1988 period. I note that, due to the nature of hospital bargaining with PPOs, hospitals should face more competitive pressure in hospital markets that are more competitive ex-ante. This hypothesis is supported by the fact that hospital net prices declined in more ex-ante competitive areas in California after the arrival of PPOs. Hospital average costs did not decline in more competitive areas, however, indicating that there was a reduction in hospital markups. Care to the uninsured by the hospitals, which is financed out of markups, fell substantially as competitive pressure grew; there was a 50 cent reduction in uncompensated care for every one dollar rise in discounts to private payers.

Abstract:
Recent theoretical work suggests that means and asset-tested social insurance programs can explain the low savings of lower income households in the U.S. We assess the validity of this hypothesis by investigating the effect of Medicaid, the health insurance program for low income women and children, on savings behavior. We do so using data on asset holdings from the Survey of Income and Program Participation, and on consumption from the Consumer Expenditure Survey, matched to information on the eligibility of each household for Medicaid. Exogenous variation in Medicaid eligibility is provided by the dramatic expansion of this program over the 1984-1993 period. We document that Medicaid eligibility has a sizeable and significant negative effect on wealth holdings; we estimate that in 1993 the Medicaid program lowered wealth holdings by 17.7% among the eligible population. We confirm this finding by showing a strong positive association between Medicaid eligibility and consumption expenditures; in 1993, the program raised consumption expenditures among eligibles by 5.2%. We also exploit the fact that asset testing was phased out by the Medicaid program over this period to document that these Medicaid effects are much stronger in the presence of an asset test, confirming the importance of asset testing for household savings decisions.

Abstract:
We investigate the hypothesis that increasing access for the indigent to physician offices shifts care from hospital outpatient settings and lowers Medicaid costs (the so-called offset effect'). To evaluate this hypothesis we exploit a large increase in physician fees in the Tennessee Medicaid program, using Georgia as a control. We find that beneficiaries shifted care from clinics to offices, but that there was little or no shifting from hospital outpatient departments or emergency rooms. Thus, we find no offset effect in outpatient expenditures. Inpatient admissions and expenditures fell, reducing overall program spending eight percent. Because the inpatient reduction did not occur in ambulatory-care-sensitive diagnoses, however, we cannot demonstrate a causal relationship with the fee change.

Abstract:
Disability Insurance (DI), which provides income support to disabled workers, has been criticized for inducing a large fall in the labor force participation rate of older workers. We study the effects of one policy response designed to address this moral hazard problem: raising the rate at which DI claims are denied. Initial DI applications are decided at the state level, and, in response to a funding crisis for the DI program in the late 1970s, the states raised their rejection rates for first time applicants by 30% on average. The extent of this rise, however, varied substantially across states. We use this variation to estimate a significant reduction in labor force non-participation among older workers in response to denial rate rises. A 10% increase in denial rates led to a 2.7% fall in non- participation among 45-64 year old males; between 1/2 and 2/3 of this effect is a true reduction in labor force leaving, with the remainder accounted for by the return to work of denied applicants. We find some support for the notion that increases in denial rates effectively target their incentive effects to more able individuals; the fall in labor force non-participation was much stronger among more able workers, according to an anthropometric measure of disability.

Abstract:
The effect of vouchers on sorting between private and public schools depends upon the price elasticity of demand for private schooling. Estimating this elasticity is empirically challenging because prices and quantities are jointly determined in the market for private schooling. We exploit a unique and previously undocumented source of variation in private school tuition to estimate this key parameter. A majority of Catholic elementary schools offer discounts to families that enroll more than one child in the school in a given year. Catholic school tuition costs therefore depend upon the interaction of the number and spacing of a family's children with the pricing policies of the local school. This within-neighborhood variation in tuition prices allows us to control for unobserved determinants of demand with a set fine geographic group fixed effects while still identifying the price parameter. We analyze this variation by using data on over 3700 school tuition schedules collected from Catholic schools around the nation, matched to restricted Census data that identifies precise location that can be matched to the nearest Catholic school. We find that a standard deviation decrease in tuition prices increases the probability that a family will send its children to private school by one half percentage point, which translates into an elasticity of Catholic school attendance with respect to tuition costs of -0.19. Our subgroup results suggest that a voucher program would disproportionately induce into private schools those who, along observable dimensions, are unlike those who currently attend private school.

Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Abstract:
While there has been considerable research on the disincentive effects of cash welfare under the Aid to Families with Dependent Children (AFDC) program, there is little evidence on the benefits of the program for single mothers and their children. One potential benefit of this program is that it provides short-run consumption insurance for women at the point that they become single mothers. This is only true, however, to the extent that the program is not crowding out other sources of support, such as own savings, labor supply, or transfers from others. I assess the importance of this insurance mechanism by measuring the extent to which AFDC smooths the consumption of women who transition to single motherhood through marital dissolution. I use longitudinal data on family structure and consumption expenditures on food and housing from the Panel Study of Income Dynamics (PSID), matched to information on the welfare benefits available in each state and year over the 1968--1985 period. I find that raising potential benefits by one dollar raises the food and housing consumption of women who get divorced (and their families) by 28 cents. This estimate implies that for each dollar of AFDC received by this population their consumption of these categories of goods rises by up to 51 cents. This is roughly the share of food and housing in the consumption bundle of divorced mothers and their families, suggesting little crowdout of other sources of support.

Welfare, AFDC, Single mothers, Insurance

Abstract:
The continued rise in the number of non-elderly Americans without health insurance has led to considerable interest in tax-based policies to raise the level of insurance coverage. This paper describes a detailed microsimulation model that has been developed to evaluate such tax-based policies, and its findings for the impact of policies on government costs and insurance coverage. I find that while tax subsidies could significantly increase insurance coverage, even very generous tax policies could not cover more than a sizeable minority of the uninsured population. But there are several design features that can clearly make tax policy more effective: using tax credits rather than deductions; making credits refundable; and addressing the timing mismatch between when insurance purchases are made and tax refunds are received. I also document a clear tradeoff between the scope of tax subsidies and their efficiency.

Abstract:
We provide direct evidence on the effect of health insurance on health outcomes by examining the dramatic increases in the eligibility of pregnant women for the Medicaid program between 1979 and 1992. We find that the 30-percentage-point rise in Medicaid eligibility significantly lowered the incidence of low birth weight and infant mortality. Targeted changes in Medicaid eligibility that were restricted to specific low-income groups had much larger effects on birth outcomes than broader expansions of eligibility to women with higher income levels because of much lower take-up of this entitlement by the latter group. Even the targeted changes cost the Medicaid program $840,000 per infant life saved, however, raising important issues of cost effectiveness.