Most Popular Books by Jonathan Gruber

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.

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.

The population of the United States, as with the rest of the world, is aging rapidly, with the most rapid growth occurring among the age 85 and older population, those who rely most on long-term care. In this chapter, we review the delivery and financing of long-term care in the U.S. We show that the resources of most elderly in the U.S. are insufficient to finance these ongoing long-term care needs and the public sector finances the majority of long-term care spending. At the same time, informal care plays a critical role, with the elderly at every age and every disability level receiving informal care more frequently than formal care. Indeed, when properly valued, informal care accounts for more than one-third of the nearly 2 percent of U.S. GDP devoted to long-term care.

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.

The Medicare hospice program is intended to provide palliative care to terminal patients, but patients with long stays in hospice are highly profitable, motivating concerns about overuse among the Alzheimer''s and Dementia (ADRD) population in the rapidly growing for-profit sector. We provide the first causal estimates of the effect of for-profit hospice on patient spending using the entry of for-profit hospices over twenty years. We find hospice has saved money for Medicare by offsetting other expensive care among ADRD patients. As a result, policies limiting hospice use including revenue caps and anti-fraud lawsuits are distortionary and deter cost-saving admissions.

The Thai 30 Baht program was one of the largest health system reforms ever undertaken by a low-middle income country. In addition to lowering the cost of care for the previously uninsured in public facilities, it also entailed a fourfold increase in funding provided to hospitals to care for the poorest 30% of the population (who were already publicly insured). For the previously uninsured, we find that the 30 Baht program led to increased health care utilization, as well as a shift from private to public sources of care. But, we find a larger increase for the poor who were previously publicly insured, especially amongst infants and women of childbearing age. Using vital statistics records, we find that the increased access to healthcare by the publicly insured poor led to a reduction in their infant mortality of at least 6.5 per 1,000 births. This suggests significant improvements in infant mortality rates can be achieved through increased access to healthcare services for the poor and marginalized groups.

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

We study the effects of wealth taxation on reported wealth. Our analysis is based on data for Switzerland, which has the highest rate of annual wealth taxation in the developed world. While the wealth tax base is defined at the federal level, tax rates vary considerably across locations and over time. We use aggregate data on wealth holdings by canton and individual-level data for the canton of Bern. Our estimated behavioral elasticities substantially exceed those of the taxable income literature. We also find that taxpayers bunch below the tax threshold, that observed responses are driven by changes in wealth holdings rather than mobility, and that financial wealth is somewhat more responsive than non-financial wealth.

We study how reported wealth responds to changes in wealth tax rates. Exploiting rich intra-national variation in Switzerland, the country with the highest revenue share of annual wealth taxation in the OECD, we find that a 1 percentage point drop in the wealth tax rate raises reported wealth by at least 43% after 6 years. Administrative tax records of two cantons with quasi-randomly assigned differential tax reforms suggest that 24% of the effect arise from taxpayer mobility and 20% from house price capitalization. Savings responses appear unable to explain more than a small fraction of the remainder, suggesting sizable evasion responses in this setting with no third-party reporting of financial wealth.

Using linked housing and tax records from Denmark combined with a major reform of the mortgage interest deduction in the late 1980s, we carry out the first comprehensive long-term study of how tax subsidies affect housing decisions. The reform introduced a large and sharp reduction in the mortgage deduction for top-rate taxpayers, while reducing it much less or not at all for lower-rate taxpayers. We present three main findings. First, the mortgage deduction has a precisely estimated zero effect on homeownership. This holds even in the very long run. Second, the mortgage deduction has a sizeable impact on housing demand at the intensive margin, inducing homeowners to buy larger and more expensive houses. Third, the largest effect of the mortgage deduction is on household financial decisions, inducing them to increase indebtedness. These findings suggest that the mortgage interest deduction distorts the behavior of homeowners at the intensive margin, but is ineffective at promoting homeownership at the extensive margin and any externalities that may be associated with it.

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. Condidtional 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.

We study the impacts of a policy designed to reward mothers who stay at home rather than join the labor force when their children are under age three. We use regional and over time variation to show that the Finnish Home Care Allowance (HCA) decreases maternal employment in both the short and long term. The effects are large enough for the existence of home care benefit system to explain the higher short-term child penalty in Finland than comparable nations. Home care benefits also negatively affect the early childhood cognitive test results of children, decrease the likelihood of choosing academic high school, and increase youth crimes. We confirm that the mechanism of action is changing work/home care arrangements by studying a day care fee reform that had the opposite effect of raising incentives to work - with corresponding opposite effects on mothers and children compared to HCA. Our findings suggest that shifting child care from the home to the market increases labor force participation and improves child outcomes.

The New Cooperative Medical Scheme (NCMS) rolled out in China from 2003-2008 provided insurance to 800 million rural Chinese. We combine aggregate mortality data with individual survey data, and identify the impact of the NCMS from program rollout and heterogeneity across areas in their rural share. We find that there was a significant decline in aggregate mortality, with the program saving more than one million lives per year at its peak, and explaining 78% of the entire increase in life expectancy in China over this period. We confirm these mortality effects using micro-data on mortality, other health outcomes, and utilization.

Individuals with common mental disorders (CMDs) such as depression and anxiety frequently have co-occurring long-term physical health conditions (LTCs) and this co-occurrence is associated with higher hospital utilisation. Psychological treatment for CMDs may reduce healthcare utilisation through better management of the LTC, but there is little previous research. We examined the impact of psychological treatment delivered under the nationwide Improving Access to Psychological Therapies (IAPT) programme in England on hospital utilisation 12-months after the end of IAPT treatment. We examined three types of hospital utilisation: Inpatient treatment, Outpatient treatment and Emergency room attendance. We examined individuals with Chronic Obstructive Pulmonary Disease (COPD) (n=816), Diabetes (n=2813) or Cardiovascular Disease (CVD) (n=4115) who received psychological treatment between April 2014 and March 2016. IAPT episode data was linked to hospital utilisation data which went up March 2017. Changes in the probability of hospital utilisation were compared to a matched control sample for each LTC. Individuals in the control sample received IAPT treatment between April 2017 and March 2018. Compared to the control sample, the treated sample had significant reductions in the probability of all three types of hospital utilisation, for all three LTCs 12-months after the end of IAPT treatment. Reductions in utilisation of Emergency Room, Outpatient and non-elective Inpatient treatment were also observed immediately following the end of psychological treatment, and 6-months after, for individuals with diabetes and CVD, compared to the matched sample. These findings suggest that psychological interventions for CMDs delivered to individuals with co-occurring long-term chronic conditions may reduce the probability of utilisation of hospital services. Our results support the roll-out of psychological treatment aimed at individuals who have co-occurring common mental disorders and long-term chronic conditions.

A fundamental tenet of neoclassical economics is that more choice is good. More choices expand the possibilities set and can only lead to individuals finding outcomes that they prefer. Many econometric models of choice, such as the standard logit choice model, by definition have error structures that show an increase in welfare as choices increase. Yet what has been apparent to lay-people for many years has become clear to economists as well in recent years: too much choice can reduce welfare. A wide variety of papers in behavioral economics has shown how increasing the size of choice sets can reduce participation in the market. Other papers have shown consumers choosing clearly dominated options in choice environments, particularly the elderly who may face cognitive challenges in making appropriate choices. For example, in recent work with Jason Abaluck, I have found clear evidence that the substantial majority elders choosing prescription drug plans under the Medicare Part D plan do not choose the cost minimizing option. This existing literature suffers, however, from the standard problem with empirical work in behavioral economics: it clearly documents a positive anomaly, but leaves us with little normative guidance as to the policy implications. This research suggests that in a variety of contexts we may want to limit choice but how much? And, if choice is to be limited, should it be limited through simply reducing the number of options, or by restricting the space set in which suppliers can compete to provide a more organized choice framework?

Because individuals aged 55-64 face large and uncertain medical expenditures without the guarantee of public insurance coverage provided by Medicare, the availability of post-retirement health insurance could be an important determinant in the retirement decisions of this group. We investigate the effect of health insurance on retirement by focusing on state and federal quot;continuation of coveragequot; mandates which grant the retiree the right to continue purchasing health insurance through a previous employer for a specified number of months after leaving the firm. We exploit variation in the timing and generosity of these laws to identify the effect of the availability of continuation coverage on retirement decisions, using data on 55-64 year-old males from the Current Population Survey and the Survey of Income and Program Participation. We find a sizeable and significant effect of continuation coverage on retirement; one year of mandated continuation benefits raises retirement rates by 20%. The effect appears to be uniform at all ages rather that larger near the age of Medicare eligibility. There is also a large increase in the insurance coverage of individuals who would have retired in the absence of continuation benefits. Our findings have important implications for policies which change the insurance coverage of early retirees, such as national health insurance.

Choices are frequently made from lists where there is by necessity some ordering of options. In such situations individuals can exhibit both primacy bias towards the first option and recency bias towards the last option. We examine this phenomenon in a particularly interesting context: consumer response to the ordering of economics papers in an email announcement issued by the National Bureau of Economic Research (NBER). Each Monday morning Eastern Standard Time (EST) the NBER issues a "New This Week" (NTW) email that lists all of the working papers that have been issued in the past week. This email goes to more than 23,000 subscribers, both inside and outside academia, and the placement order is based on random factors. We show that despite the randomized list placement, papers that are listed first each week are about 30% more likely to be viewed, downloaded, and cited over the next two years. Lower ranking on the list leads to fewer views and downloads, but not cites; however, there is also some recency bias, with the last paper listed receiving more views, downloads and cites. The results are robust to a wide variety of specification checks and are present for both all viewers/downloaders, and for academic institutions in particular. These results suggest that even among expert searchers, list-based searches can be manipulated by list placement.

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

Recent debates over health care reform, including in the context of the Military Health System (MHS) and Veterans Health Administration, highlight the dispute between public and private provision of health care services. Using novel data on childbirth claims from the MHS and drawing on the combination of plausibly exogenous patient moves and heterogeneity across bases in the availability of base hospitals, we identify the impact of receiving obstetrical care on versus off military bases. We find evidence that off-base care is associated with slightly greater resource intensity, but also notably better outcomes, suggesting marginal efficiency gains from care privatization.

"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"--National Bureau of Economic Research web site.