Jim Marton's Papers - updated 8/30/11
Publications:
1.
The
Effects
of
Premium
Increases
on Enrollment in SCHIP Programs:
Findings from Three States -
Inquiry, 43 (4), Winter 2006/2007,
pp.378-392.
(with Jenny Kenney, Andy Allison, Julia
Costich,
Josh McFeeters)
(earlier version also available here)
Abstract: This study examines the effects
of
higher premiums on SCHIP enrollment in Kansas, Kentucky, and New
Hampshire; three states that implemented premium changes in
2003. We
used state administrative enrollment records from 2001 to
2004-05 to
track changes in total caseloads, new enrollments, and
disenrollment
timing in premium-paying categories
of SCHIP before and after the premium changes were implemented.
We
found
that premium increases were associated with lower caseloads in
SCHIP in
the three states and with earlier disenrollment in Kentucky and
New
Hampshire.
Premium increases appeared to have greater disenrollment effects
on
lower-income families.
2.
State
Government Cash and In-Kind Benefits: Intergovernmental
Fiscal
Transfers and Cross-Program Substitution - Journal of Urban
Economics, 61 (1), January 2007, pp. 1-20.
(with Dave
Wildasin)
Abstract: US states provide both
cash
and health insurance benefits for the poor, partially financed
by fiscal
transfers from the Federal government. The 1996 welfare
reform
drastically
reduces Federal support for cash transfers at the margin
,
lowering
the relative price to states of providing benefits to the poor
through
Medicaid.
This paper analyzes the comparative-statics response of
state
governments
to such changes in intergovernmental transfers, showing (in
central
cases)
that they can contribute not only to reductions in state
expenditures
on cash benefits but to increases in expenditures on
Medicaid,
whether
or not beneficiary populations are mobile among states.
3.
The
Impact
of
the
Introduction
of
Premiums
into a SCHIP Program - Journal
of
Policy
Analysis
and
Management,
26 (2), Spring 2007, pp. 237-255.
Abstract: This
paper
examines
the
introduction
of
premiums into the SCHIP program in Kentucky.
Kentucky introduced a $20 monthly premium for SCHIP coverage for
children
with family incomes between 151% and 200% of the federal poverty
level
in December 2003. Administrative data between 2001 and
2004 is
used
to estimate a Cox proportional hazard model that predicts
enrollment
duration
in this premium-paying category. The results suggest that
a
premium
reduces the length of enrollment and that the effect is much
stronger
in
the first two months after the introduction of the
premium.
Similar
results are not found for the non-premium category.
4.
Medicaid
Expenditures
and
State
Budgets:
Past, Present, and Future - National Tax Journal, 60 (2),
June
2007, pp. 279-304. (with Dave Wildasin)
(earlier version also
available
as IFIR
working
paper
2007-04)
Abstract: Rapid spending growth has
made Medicaid a major element in state budgets; financial
support from
Federal matching grants is now a main component of state
government
revenue and of intergovernmental fiscal relations.
We
discuss recent, ongoing, and prospective reforms of
intergovernmental
finances and regulations, including the 1996 welfare reform, the
introduction of Medicare Part D, Section 1115 waivers, SCHIP
reauthorization, and a shift to block grants. Each would
affect
the assignment of responsibilities between the state and Federal
governments, the viability of which is questionable due to
current and
future interstate demographic and policy variation, population
aging,
and Federal fiscal imbalances.
5.
Responses
to Declining Retiree Health
Benefit Coverage - in Government
Spending and the Elderly, edited by D. B. Papadimitriou,
2007,
New York: Palgrave Macmillan. (with Steve Woodbury)
Abstract:
Employer-provided health
benefit coverage for workers who retire before age 65 has fallen
over
the last decade. We examine a cohort of male workers from the
Health
and Retirement Survey to examine questions about the dynamics of
retiree health benefits and the relationship between retiree
health
benefit and retirement behavior. Having a better understanding
of this
relationship is important for the policy debate over the best
way to
increase health coverage for older Americans without reducing
the
incentive to work. On dynamics, we find that between 1992 and
1996, 24
percent of full-time workers who had retiree health benefits
lost their
coverage, while 15 percent of full-time workers who lacked
coverage
gained it. Also, of the full-time employed men who were covered
by
retiree health benefits in 1992 and had retired by 1996, 3
percent were
uninsured, and 15 percent were covered by health insurance other
than
employer-provided insurance. On the relationship between retiree
health
benefits and retirement, we find that workers with retiree
benefits
were 29 to 55 percent more likely to retire than those without.
We also
find that workers who are eligible for retiree health benefits
tend to
take advantage of them when they are relatively young.
6.
Assessing
Effects
of
SCHIP
Premiums:
Findings
from
Arizona and Kentucky - Health
Services
Research, 42 (6p2),
December 2007, pp. 2354-2372.
(with Jenny Kenney,
Julia Costich,
Josh McFeeters)
(earlier version also
available here)
Abstract: In this study we use administrative data
from
two states, Arizona and Kentucky,
which
introduced new premiums for
certain income categories in their SCHIP programs in 2004 and
2003,
respectively. We use multivariate
hazard models to study rates of disenrollment and
re-enrollment for the
recipients
who had been enrolled in the categories of SCHIP in which the
new
premiums were
implemented. Competing hazard
models are
used to determine if recipients leaving SCHIP following the
introduction
of the premium were obtaining other public coverage or exiting
public
insurance
entirely at higher rates. We also
usedtime-series models to measure the effect of premiums on
changes in
caseloads in
premium-paying SCHIP and other categories of public coverage
and we
assessed
the budgetary implications of imposing premiums.
7.
A
Model of
Commodity Differentiation with Indivisibilities and
Production -
Economic Theory,
34
(1),
January 2008, pp. 85-106. (with Marco
Castaneda)
(earlier version also available here)
Abstract: This paper presents an
existence theorem in a general equilibrium model of a production
economy with commodity differentiation and
indivisibilities. The
model is motivated by the existence of markets with indivisible
commodities, such as the markets for automobiles, health
insurance, and
computers. As is standard in the literature, the space of
commodity characteristics is described by a compact metric space
and a
commodity vector is described by an integer-valued Borel measure
on the
space of commodity characteristics. An atomless measure
space of
producers and consumers is assumed to overcome the problem of
non-convexity of the production and consumption sets induced by
indivisibilities.
8.
Employee
Choice
of
Flexible
Spending
Account
Participation
and Health Plan - Health Economics, 17(7), July 2008, pp. 793-813. (with
Bart
Hamilton)
(earlier version also available here)
Abstract: Despite the
fact that flexible spending accounts (FSAs) are becoming an
increasingly
popular employer-provided health benefit, there has been very
little
empirical
study of FSA use among employees at the individual level.
This
study
contributes to the literature of FSAs through the use of a
unique
dataset
that provides three years of employee level matched benefits
data.
We
examine the determinants of FSA participation and contribution
levels
using
yearly order probit models and a random effects ordered probit
model.
FSA
participation and health plan choice decisions are also modeled
jointly
in
each year using conditional logit models. We find that,
even
after
controlling for a number of other demographic characteristics,
non-whites
are less likely to participate in the FSA program than whites.
We
also
find evidence that choosing health plans with more expected out
of
pocket
expenses is correlated with use of the FSA program.
9.
SCHIP
Premiums,
Enrollment,
and
Expenditures: A
Two
State, Competing Hazard Analysis -
Health
Economics, 19(7),
July 2010, pp. 772-791. (with
Pat Ketsche and Mei Zhou)
Abstract: Policymakers
may
impose
or
increase premiums for
SCHIP recipients under an assumption that family income is
exogenous,
implying
no spill-over effects on other public health insurance such as
Medicaid. Using state
administrative data on the
introduction of a new premium in Kentucky’s SCHIP program and
an
increase in
existing premiums in Georgia’s SCHIP program, we test this
assumption
by
estimating competing risk models that differentiate between
different
exit
routes from SCHIP coverage. The
theoretical motivation for this analysis is a model of family
budget
constraints in which changes in SCHIP premiums create notches
in the
budget
constraint that may cause families to re-evaluate their labor
/ leisure
trade-off. We
find the premium changes in each state lead to an increase
in the
likelihood of
children leaving the SCHIP program for no public health
insurance
coverage in
the months immediately following the premium changes. This short run disenrollment
effect in each
state is offset to some extent by a short run increase in
the
likelihood that
children transfer to lower income eligibility / lower
premium
categories of
SCHIP. In Kentucky we also find
a short
run increase in the likelihood that children exit SCHIP by
transferring
to
Medicaid coverage. SCHIP
covered children
in Georgia are found to be less likely to transfer into
Medicaid
immediately
following the premium increase.
10.
CHIP
Premiums,
Health
Status,
and the Insurance
Coverage of Children
- Inquiry, 47(3),
Fall
2010, pp. 199-214. (with
Jeff Talbert)
Abstract:
This study uses the introduction of premiums into Kentucky's
Children's
Health Insurance Program (KCHIP) to examine whether the
enrollment
impact of new premiums varies by child health type. We also
examine the
extent to which children find alternative coverage after premium
nonpayment. Public insurance claims data suggest that those with
chronic health conditions are less likely to leave public
coverage. We
find little evidence of a differential impact of premiums on
enrollment
among the chronically ill. Our survey of nonpayers shows that
56% of
responding families found alternative private or public health
coverage
for their children after losing CHIP.
11. Funding Trauma Care
in Georgia - Journal of the Medical
Association of Georgia 99(4),
December 2010,
pp. 19-20. (with Pat Ketsche)
Abstract:
On
November 2, Georgia voters rejected legislatively-referred
constitutional
amendment
number 2 that would have provided funds to support the statewide
trauma
care
network, with 53% of votes against the measure. This
amendment
was placed on the November ballot
by the Georgia legislature and it imposed a $10 annual trauma
charge on
each motor vehicle designed to carry ten or fewer persons.
These funds were to be placed in a designated trauma trust fund
and
would have raised an
estimated $80 million per year in a manner that is proportional
to
citizens
engagement in an activity related to trauma care, driving.
Potential
opposition to the amendment may have
been due to some distaste for any new taxes or fees during a
time of
economic
uncertainty and some unwillingness from parts of the state with
greater
trauma
care coverage to subsidize coverage for other parts of the
state.
The purpose of this paper is to discuss the background related
to
trauma care funding in Georgia and general challenges associated
with
funding trauma care.
12.
Disparate Effects of CHIP
Premiums on Disenrollment for Minorities
- Current
Issues in Health Economics, Volume
290, edited by D. Slottje and R.
Tchernis, December 2010, United
Kingdom: Emerald Group. (with Cynthia Searcy and Jennifer Ghandi)
(earlier version
also
available here)
Abstract: This
paper
examines
whether
or not the introduction of a new $20 family
premium in
Kentucky’s CHIP program in late 2003 had a differential
impact on the
enrollment duration of children in different demographic
groups, with a
special
focus on any potential differences by race/ethnicity.
A competing
risk hazard model is estimated in
order to differentiate between children exiting CHIP via a
transfer to
Medicaid
and children that exited public coverage completely.
We find that
non-white children are generally
more likely to exit than white children.
This general white / non-white difference increases
immediately
following the introduction of the $20 premium.
13. The Effects of
Medicaid and
CHIP Policy Changes on Receipt of
Preventive Care among Children in Kentucky and Idaho
- Health
Services
Research 46 (1p2), February 2011, pp.
298-318. (with
Jenny
Kenney,
Jennifer Pelletier, Ariel Klein, and Jeff Talbert)
Abstract: The objective of this
paper
is to examine children’s receipt of
preventive care in
Medicaid/CHIP in two states that adopted policy changes aimed
at
promoting
greater provision of preventive care to children using Medicaid/CHIP claims and
enrollment data
from Idaho and Kentucky
from 2004 to 2008. Linear
probability
and
hazard
models are used to estimate policy
effects with either a pre-post model or a pre-post model with a
comparison
group. Models control for age, gender, race/ethnicity, and
eligibility
category. The effects of the
increased
reimbursement for well-child care
were small, suggesting at most an increase in the probability of
having
any
annual well-child visit of 1 to 3 percentage points.
The introduction of the Wellness PHA benefit
in Idaho
was
associated with between 11 and 29 percentage point increases in
well-child
receipt among the three key target groups and with quicker
receipt of
well-child care following CHIP enrollment.
Children
were
1
to
6 percentage points more likely to receive
preventive
dental care and received preventive dental care more quickly
after the
policy
changes. Policy changes such as fee
increases,
incentives, and delivery system changes
can lead to increases in preventive care use among children.
However,
additional policy changes would be required to address the
persistent
shortfalls in preventive care receipt for children.
Papers
Under
Review / Revision Requests:
1. The
Influence of Retiree Health Benefits on Retirement Patterns
(with
Steve
Woodbury)
-- revision
requested
(earlier version available as an Upjohn
Institute
staff working paper 09-149)
Abstract:
We
estimate the effect of employer offers of retiree health
benefits (RHBs) on the timing of retirement using a sample of
Health
and Retirement
Study (HRS) men observed over a period of up to 12 years. We
hypothesize that
the effect of RHBs differs for workers of different ages—a
hypothesis
we can
test now that the main HRS cohort has aged sufficiently. We
apply three
well-know panel data estimators and find that, for men in their
50s,
RHBs have
little or no effect on retirement decisions; however, a
substantial
effect
emerges for men in their early 60s. We use simulations to
illustrate
the
changing pattern of retirement resulting from RHBs.
2. Employer
Provided Health Insurance and the
Adverse Selection Problem (with
Marco
Castaneda) --
revision requested
Abstract:
Establishing
the existence of equilibrium in insurance markets has always
been a
challenging
task for economists due to imperfect information. As
illustrated
by
Rothschild and Stiglitz (1976), imperfect information may lead
to
complete
market failure. This paper extends the standard model of
adverse
selection
by introducing employers that choose the set of policies that
are
offered
to consumers. Introducing employers allows for the
existence of
multiple
pooling and a unique separating equilibrium. Data on age
and
insurance
premiums from the 1987 National Medical Expenditure Survey
provides
evidence
of pooling in the employer-provided health insurance
market.
3. The Effects of Medicaid Policy
Changes on Adults’ Service
Use Patterns in Kentucky and Idaho (with Jenny Kenney,
Jennifer
Pelletier, Ariel Klein, and
Jeff Talbert)
-- under review
Abstract:
In
2006, Idaho and Kentucky became two of the first states in the
nation
to implement changes to their Medicaid programs under authority
granted
by the
2005 Deficit Reduction Act (DRA) (PL 109-171).
Concerns about Medicaid spending growth in both states led to a
desire
for Medicaid reform to make the programs sustainable for future
generations and
to encourage the greater use of preventive care and the adoption
of
healthier
lifestyles. The purpose of this paper is to examine the
impact of the key reforms in each state on the utilization rates
among
non-elderly adult Medicaid recipients for a variety of services,
including
physician visits, dental visits, emergency room visits,
inpatient
stays, and
prescription drugs. While the majority
of adults in Medicaid in both states received primary medical
care in
the past
year, rates of preventive care and dental care utilization are
very
low.
The introduction of service limits on brand
name prescriptions in Kentucky led to a shift towards
generics.
New copayments for a variety of services in
Kentucky did not appear to have a dramatic impact on
utilization.
The addition of an adult wellness exam to the
Medicaid benefit package in Idaho had modest effects on service
use.
The adoption of managed care for dental
provision for nondisabled adults increased both the use of
overall and
preventive
dental care.
4. A Tale of Two Cities? The
Heterogeneous Impact of Medicaid Managed Care in Kentucky
(with
Aaron
Yelowitz
and Jeff Talbert) -- under review
(earlier version
available as an Andrew Young School of
Policy Studies working paper 11-28)
Abstract:
Does
managed
care produce lower health care utilization and
costs through
better aligned financial incentives and
alternative delivery methods
(the “pure HMO” effect) or by attracting more
healthy enrollees (plan
endogeneity)? The purpose of this paper is to
shed new light on this
fundamental question using a
quasi-experimental approach that exploits
the timing and county specific implementation
of Medicaid managed care
plans in two distinct sub-sets of Kentucky
counties in the late 1990s.
We find large differences in the relative
success of each region in
reducing utilization that are likely driven by
important differences in
plan design. Asthmatic children enrolled in
the plan that was
successful at reducing utilization did not
appear to suffer adverse
health outcomes as a result.
Working
Papers:
1. Enhanced
Citizenship Verification and Children's Medicaid Coverage
(with
Angie Snyder and Mei Zhou)
Abstract: This
paper examines the
impact of Deficit Reduction Act of 2005 mandated
citizenship verification
requirements on the Medicaid coverage of children using
state
administrative data from Georgia. Our analysis suggests that children
enrolled via
the “Low
Income Medicaid” eligibility category of Georgia Medicaid
(based on the
1996
Aid to Families with Dependent Children (AFDC) standards) that
were
enrolled
prior to the reform were slightly more likely to exit during
the first
"high
impact" recertification in which the enhanced citizenship
verification
was
binding than children whose first recertification occurred
just prior
to the
reform. In addition, we observe a
slightly lower re-entry probability among children exiting
during a
"high
impact" first recertification. Assuming
at
least
some
of the exiting children are non-citizens, the fact that the
exit
and re-entry rates associated with a “high impact” first
recertification are
only modestly different from other first recertification months
suggests that
the reform is probably not having a dramatic impact on citizens.
2. Estimating
Premium Elasticities for
Public Health Insurance
Coverage (with Pat Ketsche, Kathleen Adams, Angie
Snyder,
and
Mei Zhou)
Abstract:
The purpose of this paper is to estimate the duration of
CHIP
enrollment as a function of
premiums that vary within and between income groups and over
time. A
secondary
objective is to simulate changes in enrollment and calculate
price
elasticities
controlling for health status and age.
We
use administrative CHIP application and eligibility data
to estimate the duration of enrollment as a function of the
effective
premium. We control for family
characteristics (family
income, family size, number of adults in the home, parental age,
location
(rural, urban, other), race/ethnicity, prior participation in
public
coverage)
and county characteristics such as unemployment rate, share
uninsured,
and
poverty rate. We also control for health status of the child by
matching claims
to eligibility data to identify children with chronic conditions
and
high
dollar claims. We conduct
sensitivity
analysis
including children starting their spell with zero premium in the
first
month of
enrollment. Consistent
with
prior
research,
we find that increasing premiums results in shorter
duration
of
enrollment. Price
elasticity
for
the
cohort as a whole is -0.20, consistent with price
elasticities
identified in
the private sector for moderate income families. However,
among
children facing
zero premium at the start of the spell, premium changes
result in a
significantly larger response (-0.33) than among children
facing a
positive
premium at the start of the spell (-0.15).
High utilization and the presence of chronic
conditions reduce
price
elasticity.
3. Does
More
Public Health Spending Buy
Better Health Outcomes? (with
Chris Parker, Karen Minyard, and Peggy Honore)
Abstract: In this paper we
attempt
to address a persistent
question in the health policy literature: Does more public
health
spending buy
better health outcomes? This is a
difficult question to answer due to unobserved differences in
public
health
preferences across locations as well as the potential for an
endogenous
relationship between public health spending and public health
outcomes. We take advantage of
the unique way in which
public health is funded in the state of Georgia to avoid the
endogeneity
problem. Using a seven year panel
dataset on Georgia county public health expenditures and
outcomes, we
find that
more public health spending decreases infant and cancer
mortality
rates, as
well as cancer and diabetes morbidity rates.