Essays on the effect of health insurance on utilization and health

This dissertation presents evidence of the causal link between health insurance, health care utilization and health using evidence from a large-scale field experiment in Mexico. The experiment was designed to evaluate the implementation of Seguro Popular, a health insurance program for those without access to social security. The original results from the experiment showed that despite reducing catastrophic health expenditures, it had no effect on utilization. These results seem at odds with experimental evidence in other settings where reductions in the price of health care increase utilization. The first chapter of the dissertation revisits these findings by linking administrative data on hospitalizations into the experimental design that evaluated Seguro Popular. This allows us to increase power, for a relatively rare event such as hospitalizations. Hospital stays were covered only in some public facilities by Seguro Popular, but not in social security institutions or private providers. Our results indicate that there was a large increase in hospitalizations only in facilities covered by Seguro Popular. To explore whether the increase in hospitalizations in covered facilities comes from crowd-out (switching from private to public providers) or increased demand for hospitalizations services, we look at data on childbirths. Whereas an important part of this increase stemmed from crowd-out, a sizeable share stemmed from births that would have taken place outside the healthcare system altogether in the absence of insurance.;The second chapter explores in more detail the causal relationship between health insurance, maternal care and infant health by using the same experiment in Mexico. By linking administrative data on vital statistics, we are able to explore the effect of health insurance on outcomes not considered in the original experiment, such as neonatal mortality. Our findings suggest that insurance increased the use of some diagnostic procedures during prenatal care visits, but had no impact on the utilization of prenatal care. In addition, there was a large increase of childbirths in public facilities that served those benefiting from the increased coverage. An important component of this increase came from reduced deliveries in non-medical facilities and a related rise in births attended by doctors. This last effect came mostly form the poorest regions. Despite these results, there is no evidence of changes in fertility or infant health outcomes closely related to maternal care.;The results of the first two chapters indicate that crowd-out among childbirth hospitalization services was an important effect of the introduction of Seguro Popular. Whether women switching from private to public providers are better off with Seguro Popular would depend on the relative quality of public and private providers. The third chapter explores differences in quality between public and private providers in Mexico by looking at differences in cesarean sections after accounting for a rich set of observable risk factors. The results indicate that a large share of cesarean sections in the private sector are not medically indicated as determined by what the average doctor would perform for women with similar characteristics. Moreover, there is evidence of overdiagnosis among private providers of conditions difficult to observe to the mother, but that could lead to a cesarean section such as breech presentation and umbilical cord entanglement.