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This dissertation consists of three essays on access to primary care and the design of health insurance markets. These essays share a methodological framework. In each, I estimate a model of the market using detailed administrative data sets. Then, I employ the estimated model to answer policy-relevant research questions. The first chapter, entitled Access to Care in Equilibrium, studies consumer access to medical care as an equilibrium outcome of a market without prices. I use data from the Northern Ontario primary care market to estimate an empirical matching model where patients match with physicians. The market is cleared by a non-price mechanism: the effort it takes to find a physician. I use the model to study the distribution and determinants of access to care. By employing a model of the market, I am able to define a measure of access to care that accounts for patient preferences and market conditions: the probability that a patient who would attain care in a full access environment currently attains care. I find that access to care is low and unevenly distributed. On average, a patient who would attain care in a full access environment will receive care 73% of the time. The issue is particularly acute in rural areas. Further, physicians discriminate in favor of patients with higher expected utilization, thereby increasing access for older and sicker patients while decreasing access for younger and healthier patients. The estimated model is used to decompose access into its contributing factors. In rural areas, the geographic distribution of physicians is the primary determinant of low access. In contrast, low access in urban areas is primarily driven by capacity constraints of physicians. Interestingly, equating physician to population ratios across Northern Ontario would not improve rural access. In the second chapter, entitled Increasing Access to Care Through Policy: A Case Study of Northern Ontario, Canada, I employ the estimated model from Chapter One to assess the impact of policy on access to medical care. I study two policies: (1) grants to incentivize physicians to practice in low-access areas and (2) a payment reform that provided incentives for physicians to increase the numbers of patients on their books. Using the estimated model, I simulate market outcomes in counterfactuals where each policy is removed. By comparing these simulations to outcomes in the current market, I estimate policy impacts while accounting for equilibrium effects. I find that both policies are effective at increasing access to care. However, the policies target different subsets of the population. The grant program increases access most for rural patients, whereas the payment reform increases urban access most. Lastly, Chapter Three is a paper co-authored with Kate Ho and Michael Dickstein entitled Market Segmentation and Competition in Health Insurance. We study the welfare consequences of market segmentation in private health insurance in the US, where households obtain coverage either through an employer or via an individual marketplace. We use comprehensive and detailed data from Oregon’s small group and individual markets to demonstrate several facts. First, enrollees in the small group market have lower health care spending than those in the individual market conditional on plan coverage level. Second, small group enrollees benefit from tax exemptions and employer premium subsidies that create a wedge between premiums charged by insurers and the prices they face. However, these benefits are offset by relatively high plan markups over costs, which generate premiums (prior to employer contributions) that are at least as high as those in the individual market. These findings suggest that recent policies to merge the two markets, allowing small group enrollees to shop on the individual exchanges while maintaining their tax exemptions and employer contributions, may stabilize the individual market without much loss to small group enrollees. However, the new equilibrium outcome depends crucially on the preferences and characteristics of the two populations. We use a model of health plan choice and subsequent utilization to estimate household preferences in both markets and predict premiums and costs under a counterfactual pooled market. We find that integration mitigates adverse selection issues in the individual market, while decreasing government and employer expenditures on premium subsidies. Small group households benefit from lower premiums for low coverage plans in the merged market. However, they face higher premiums for high coverage plans and are constrained to a smaller set of insurance options. Thus, the effects of integration on small group households are heterogeneous.

In the U.S., the healthcare sector is highly regulated -- government regulation touches almost every dimension of healthcare, from health insurance to pharmaceuticals to medical services. The healthcare sector and the policies that govern it present an interesting setting to study many classic questions in public economics: how does regulation interact with or change individual and firm behavior? How do you monitor third parties who decide how to spend public funds? What happens when policy changes spill over from one segment of the economy to others? The three papers in this dissertation seek to answer these questions via the lens of the U.S. healthcare system. The first paper, "Job Lock, Retirement, and Dependent Health Insurance: Evidence from the Affordable Care Act,'' considers the extent to which changes in policies governing health insurance spill over onto individual labor market decisions. In particular, it looks at whether parents with young adult children eligible for the Affordable Care Act's dependent mandate delayed retirement to take advantage of the mandate. The second paper, "Regulated Revenues and Hospital Behavior: Evidence from a Medicare Overhaul'' (with Tal Gross, Adam Sacarny, and David Silver), considers how healthcare providers respond to changes in regulated prices. In it, we study a major reform that increased Medicare prices for some hospitals but decreased them for others, and consider how hospitals responded to these payment changes. Finally the third paper, "The Costs and Benefits of Monitoring Providers: Evidence from Medicare Audits,'' studies the efficacy of policies aimed at monitoring healthcare providers for wasteful expenditure. It studies a large monitoring program run by Medicare, and estimates the costs and benefits of this monitoring for the government, providers, and patients.

Thesis (MBA)--Stellenbosch University, 2012. / An exploratory, cross-sectional, qualitative survey was conducted to describe the market of lower income mothers who had recently given birth to a child in a state hospital in the Western Cape (WC) region of South Africa. These mothers were viewed by the researcher as potential consumers of low cost maternity plans which would provide for maternity care in Active Birthing Units (ABUs) in the private healthcare sector in South Africa. The motivation behind the research stems from various sources. The currently inequitable healthcare system in South Africa, which has been described as a two tier system in the recent Policy Paper on National Health Insurance (Republic of South Africa, 2011: 4-5), is one such source. Reports of poor maternity care in the South African public healthcare system (Vogel, 2011: E1097-E1098), is another source of motivation behind the research report. It was apparent to the researcher that given the low quality of maternity care in state hospitals, a potential market of healthcare consumers – who would be willing to pay a small premium for what they considered to be a more acceptable level of maternity care in the private healthcare sector – could exist. This view was supported by research conducted by Joan Costa and Jaume Garcia (2003: 587-599) in which the “quality gap” was confirmed as a driving force behind the demand for private health care. This focus on the lower socioeconomic groups as a market for private sector goods and services was found to be well described by Prahalad (2005). The researcher conducted interviews amongst mothers who had delivered a child in a public hospital in the previous two years. A convenience sample of 100 mothers was selected in a shopping mall in the Western Cape (WC). The researcher administered a structured questionnaire during a face-to-face interview with each of the 100 respondents. The respondents were rewarded with a shopping voucher to the value of 50 ZAR, which was both a prerequisite specified by the management of the shopping mall and consistent with rewards offered in similar studies (Francis, Battle-Fisher, Liverpool, Hipple, Mosavel, Soogun, & Nokuthula, 2011). Data collected from the questionnaire included both data on willingness to pay (WTP), as well as demographic data, which provided interesting insights into a relatively under-researched market segment. A statistical analysis of the data collected revealed that 31 respondents (31%) reported a positive WTP for private maternity care. A statistically significant relationship was revealed between respondents’ WTP and the birth experience the respondents had had during their most recent pregnancy, whereby mothers who had described their most recent birth experience as “poor” were significantly more likely to exhibit a positive WTP for private maternity care (p=0.00006). Significant relationships between respondents' WTP for private maternity care and their age and household size were also discovered, whereby younger mothers were more likely to be willing to pay than older mothers (p=0.02) and mothers from smaller households were also significantly more likely to be willing to pay than mothers from larger households (p=0.02). Amongst a sub group of 32 respondents deemed to have potential monthly savings, those with a higher monthly household income were more likely to exhibit positive WTP (p=0.02753) than were those with higher levels of monthly expenditure (p=0.04093). The researcher acknowledged that the limitations of the research included the fact that respondents were selected non-randomly, as a small isolated sample, which made the extrapolation of the results to the larger population of South African mothers impossible. The research did, however, serve to describe the demographic characteristics of a new and relatively under researched target market of mothers from the lower socioeconomic segment of the WC. Data gleaned from this survey will serve to inform further research into this target market, so as to complete a more comprehensive feasibility analysis for the establishment of low cost maternity care packages and ABUs in South Africa.

Chile has experienced great success in terms of economic growth in the last decades. This growing economy brings changes in the Chilean health care system. Its health care system was primarily funded by state sources until 1981, when a major reform was introduced that established new rules for the health insurance market. Since then, Chile has a public-private mixed health care system, both in financing and delivery of services. Citizens can choose for coverage between the Public National Health Insurance and the Private Health Insurance system. However, these systems have a common funding source coming from the mandatory contribution of employees, equivalent to 7% of their taxable income with an approximate limit of US$2,800 dollars. One of the more important Chilean health reforms towards the establishment of social guarantees was effective on July 2005, when the Regime of Explicit Health Guarantees, also known as Plan AUGE became effective. Plan AUGE is a health program that benefits all Chileans without discrimination of age, gender, economic status, health care, or place of residence. This plan includes the 69 diseases with higher impact on Chilean population in its different stages, but with feasibility of effective treatments. Changes in the health care system and its last reform brought questions about their impact on the distribution of health care services throughout country. Is Chile moving towards a better and more equitable health care system? The main purpose of this thesis is to investigate equity in health system finance and health care utilization as well as to explore alternative measurement of access to health care in Chile. The first two manuscripts examine equity issues in Chile. The purpose of the first one is to assess equity in health system finance in Chile, accounting for all finance sources. While equity in health system finance has been well studied in OECD countries, there are still few published empirical studies on Latin American health care systems, where there tends to be a wider gap in income-wealth distribution among states. This gap may increase the financial burden for people in the lower spectrum of income groups, which is the main concern in the first manuscript. It will focus on identifying policy variables that may contribute to more equitable distribution of the financial burden in health care. The equity principle we adopt for this study is the ability to pay principle. Based on this, we explore factors that contribute to inequities in the health care system finance and issues about who bears the heavier burden of out-of pocket (OOP) payment, progressivity of OOP payment, and the redistributive effect of OOP payment for health care as a source of finance in the Chilean health care system. Our analysis is based on data from the National Socioeconomic Survey (CASEN), and the 2006 National Survey on Satisfaction and OOP payments. Results from this study provide comprehensive understanding of the financial burden of health care in Chile. This study identified evidence of inequity, in spite of the progressivity of the health care system. Furthermore, our assessment of equity in health system finance identified relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. Such findings will also benefit other Latin American countries that are concerned about equity in health system finance. The purpose of the second manuscript was to assess equity in health care utilization in Chile. Secondary data analyses from the National Socioeconomic Survey (CASEN) were performed to estimate the impact of different factors including AUGE in the utilization of health care services. We used a two-part model for the analysis of frequency of health care use in the country. Four other separate two-part models were also specified to estimate the frequency of use of preventive services, general practitioner services, specialty care and emergency care. An assessment of horizontal equity was also included. Results suggest the presence of pro-rich inequities in the use of medical care. The estimation of the two-part model found key factors affecting utilization of health care services such as education and the implementation of the AUGE program. These findings provide timely evidence to policy-makers to understand the current distribution and equity of health care utilization, and to strengthen availability of health services accordingly. The third manuscript was motivated by the previous findings. Its purpose was to explore an alternative measurement for health care access. The majority of studies nowadays use a single proxy to estimate access: the use of health care services. However, we saw many limitations on this approach since it only considers people that are already using the system and ignores those that are not. The final manuscript proposed a model to estimate access to health care services based on communitarian claims. The model identified barriers to health care access as well as the preferences of the community for priority settings. / Graduation date: 2012