Three essays in health economics: Public hospital presence and workers' insurance choice risk preferences and insurance choice managed care market penetration and hospital expenses

This dissertation consists of three separate but related essays that examine particular issues relating to insurance markets. The first essay, found public hospital presence and its associated charity care to have a significant impact upon the insurance choices of workers. Independent of income level, access to a public hospital system increases the probability that a worker is uninsured. The magnitude of the effect does depend upon income, with a ten percentage point increase in percent public beds causing a 5.0 point increase in the uninsured amongst the poor while the same change actually decreases the uninsured by 0.1 points for the wealthiest workers. The same change in public hospital presence drives decreases in the supply of employer sponsored insurance ranging from 4.2 percentage points for the poor to 0.1 percentage points for the wealthiest workers. This study was unable to establish whether this decrease in the supply of ESI reflects a lower demand for employer sponsored plans or partially causes the higher uninsured rate by reducing access to group plans.; The second essay found workers' risk tolerances to have a significant impact upon their insurance choice decision. Risk characteristics affected both the worker's risk aversion and expectations of medical loss. The characteristics identified by a drunk driving indicator had significant effects upon risk aversion as income increased, and the characteristics identified by childhood smoking implied a lower demand for insurance at all income levels. The two risk indicators exhibited little overlap in their influences, and jointly they accounted for 16.6% of the total uninsured in the model.; The third essay examined the impact of managed care presence and its contracting with hospitals on community level hospital expenditures. For 1991–1997, managed care presence produced significantly lower total market hospital expenditures when measured as expenses per bed and expenses per adjusted admission. Supplemental models traced the sources of the expenditure savings through the local hospital systems with most savings being attributed to reduced staffing levels per bed and reduced prevalence of new medical technologies.