Thesis (Ph. D.)--University of Michigan, 2004. / Includes bibliographical references.

Thesis (Ph. D.)--University of Michigan, 2004. / Includes bibliographical references.

While there is great concern about the potential impact of aging populations on health care systems in the developed world, evidence from recent decades has shown at best a weak relationship between population aging and health expenditures at the aggregate level. This thesis explores the literature that frames the relationship between age and health care utilization in the context of reduced mortality and shorter periods of morbidity at the end of life. We add to this literature with an empirical study of individual health expenditures of the British Columbia senior population in the years 1991-2001 in the categories of hospital services, continuing care, doctor billings, and pharmaceutical prescriptions. Expenditures for decedent and survivors of the same age are compared and are fitted to a model using age and time-to-death as explanatory factors. The partial derivative of the model with respect to age is analyzed for empirical estimates of the effect of age after controlling for time-to-death. Results show that decedent costs rose over the study period while costs for survivors fell, particularly in continuing care, so that the relative cost of dying increased. The effect of age, after controlling for time to death, was muted or negative for hospitals, doctors, and drugs, but strongly positive for continuing care and, as a result, for all services combined. Overall, these results suggest that age is not a ‘red herring’, as some researchers have suggested, with respect to forecasting future demands on health systems. While future reductions in mortality and morbidity could mitigate pressures on hospitals, aging populations will put increased pressure on long-term residential care and other forms of social care.

This thesis aims to reveal the magnitude of the income elasticity of health expenditure and the impact of non-income determinants of health expenditures in the Canadian Provinces. Health can be seen as a luxury good if the income elasticity exceeds unity and as a necessity good if the income elasticity is below unity. The motivation behind the analysis of the determinants of health spending is to identify the forces that drive the persistent increase in health expenditures in Canada and to explain the disparities in provincial health expenditures, thereby to prescribe sustainable macroeconomic policies regarding health spending. Panel data on real per capita GDP, relative price of health care, the share of publicly funded health expenditure, the share of senior population and life expectancy at birth have been used to investigate the determinants of Canadian real per capita provincial total, private and government health expenditures for the period 1975-2002. Dynamic models of health expenditure are analyzed via Generalized Instrumental Variables and Generalized Method of Moments techniques. Evidence confirms that health is far from being a luxury for Canada and government health expenditures are constrained by the relative prices. Results also cast doubt upon the power of quantitative analysis in explaining the increasing health expenditures.

This thesis aims to reveal the magnitude of the income elasticity of health expenditure and the impact of non-income determinants of health expenditures in the Canadian Provinces. Health can be seen as a luxury good if the income elasticity exceeds unity and as a necessity good if the income elasticity is below unity. The motivation behind the analysis of the determinants of health spending is to identify the forces that drive the persistent increase in health expenditures in Canada and to explain the disparities in provincial health expenditures, thereby to prescribe sustainable macroeconomic policies regarding health spending. Panel data on real per capita GDP, relative price of health care, the share of publicly funded health expenditure, the share of senior population and life expectancy at birth have been used to investigate the determinants of Canadian real per capita provincial total, private and government health expenditures for the period 1975-2002. Dynamic models of health expenditure are analyzed via Generalized Instrumental Variables and Generalized Method of Moments techniques. Evidence confirms that health is far from being a luxury for Canada and government health expenditures are constrained by the relative prices. Results also cast doubt upon the power of quantitative analysis in explaining the increasing health expenditures.

While there is great concern about the potential impact of aging populations on health care systems in the developed world, evidence from recent decades has shown at best a weak relationship between population aging and health expenditures at the aggregate level. This thesis explores the literature that frames the relationship between age and health care utilization in the context of reduced mortality and shorter periods of morbidity at the end of life. We add to this literature with an empirical study of individual health expenditures of the British Columbia senior population in the years 1991-2001 in the categories of hospital services, continuing care, doctor billings, and pharmaceutical prescriptions. Expenditures for decedent and survivors of the same age are compared and are fitted to a model using age and time-to-death as explanatory factors. The partial derivative of the model with respect to age is analyzed for empirical estimates of the effect of age after controlling for time-to-death. Results show that decedent costs rose over the study period while costs for survivors fell, particularly in continuing care, so that the relative cost of dying increased. The effect of age, after controlling for time to death, was muted or negative for hospitals, doctors, and drugs, but strongly positive for continuing care and, as a result, for all services combined. Overall, these results suggest that age is not a ‘red herring’, as some researchers have suggested, with respect to forecasting future demands on health systems. While future reductions in mortality and morbidity could mitigate pressures on hospitals, aging populations will put increased pressure on long-term residential care and other forms of social care.

Chronic insomnia is a highly prevalent disorder in general and young adult populations, and contributes a significant economic burden on society. Previous studies have shown healthcare utilization (HCU) is significantly higher for people with insomnia than people without insomnia. One limitation with previous research is accurate measurement of HCU in people with insomnia is difficult due to a high co-morbidity of medical and mental health problems as well as varying operational definitions of insomnia. Assessing HCU in people with insomnia can be improved by applying research diagnostic criteria (RDC) for insomnia, using a population with low rates of co-morbid medical/mental health problems, and measuring HCU with subjective, objective, and predictive methods. The current study found young adults with chronic insomnia had greater HCU than normal sleepers, specifically on number of medications, and chronic disease score (CDS) estimates of total healthcare costs, outpatient costs, and predicted number of primary care visits. The presence of a medical and/or mental health problem acted as a moderating variable between chronic insomnia and HCU. Simple effects testing found young adults with chronic insomnia and a medical/mental health problem had the greatest HCU followed by normal sleepers with a medical/mental health problem, chronic insomnia, and normal sleepers. Exploratory analyses found young adults with chronic insomnia had a greater likelihood of emergency room visits and overnight hospital admissions. More efforts for early identification and intervention of insomnia are necessary to help reduce costs associated with chronic insomnia co-morbid with medical and/or mental health problems.

Este trabalho tem como principal objetivo analisar as despesas com saúde diante de um cenário de envelhecimento populacional, no Brasil, em 2008-2009. Especificamente, objetiva-se detectar quais são os determinantes das despesas relacionadas à saúde, avaliando o quanto a idade influencia na determinação das despesas com assistência à saúde. Além da idade, serão analisadas outras variáveis como a renda, nível de escolaridade, gênero, cor ou raça declaradas pelo indivíduo, e fatores relacionados à localidade. O método de obtenção dessas estimativas foi o tobit. Além disso, objetiva-se calcular a elasticidade-renda das despesas com assistência à saúde, comparando famílias que possuem idosos com as famílias que não possuem idosos. Para isso foram utilizados dados da POF (Pesquisa de Orçamentos Familiares) 2008-2009. Os resultados mostram que as variáveis que se destacaram como determinantes na despesa com assistência à saúde no Brasil foram a renda, a idade e a escolaridade. Um aumento na renda causa um aumento na despesa com saúde quase na mesma proporção. Distinguindo famílias com e sem idosos, um aumento de 10% na renda causa um aumento na despesa com saúde em 8,84% para famílias sem idosos e em 9,21% para famílias com idosos. Planos de saúde, tratamentos dentários e tratamentos médicos e ambulatoriais podem ser considerados como bens superiores, de acordo com os resultados. / The main objective of this study is to analyze health expenditures in the face of a scenario of an aging population, in Brazil, in 2008-2009. Specifically, the objective is to identify the determinants of health-related expenditures, evaluating the influence of the age in the determination of health care expenditures. Beyond the age, other variables such as the income, level of education, gender, color or race declared by the individual, and factors related to the local areas will be analyzed. The method of obtaining these estimates was the tobit. Furthermore, the objective is to estimate the income elasticity of the expenditure on health care, comparing families that have elders with families which do not have elders. To this end, data from HBS (Household Budget Survey) 2008-2009 where used. The results show that the variables that stood out as determinants of health care expenditure in Brazil were income, age and education. An increase in income causes an increase in health spending of almost the same proportion. Differentiating families with and without elderly members, a 10% increase in income causes an increase in health spending of 8.84% for families without elderly and 9.21% for families with elderly pearsons. Health plans, dental and medical treatments and outpatient treatments can be considered as superior goods, according to the results.

Esta dissertação trata do financiamento do Sistema Único de Saúde (SUS), trazendo os gastos tributários em saúde como mecanismo importante de análise nas relações entre o Estado e o Direito sob a influência do capital portador de juros. A temática relaciona-se ao campo da saúde coletiva, que visa contribuir ao debate da economia da saúde. Assim, o objetivo desta pesquisa é analisar os gastos tributários na saúde no orçamento da Seguridade Social, no que tange, especificamente, ao financiamento do SUS, a partir do papel do Estado no contexto da dominância do capital portador de juros. Nesta perspectiva, ressalta-se os gastos tributários proporcionados às pessoas físicas e jurídicas, à indústria farmacêutica (medicamentos e produtos químicos) e às organizações sem fins lucrativos (hospitais filantrópicos), pois estes dispositivos legais podem encorajar determinados comportamentos dos contribuintes, ou então, de viabilizar a redução/isenção do imposto/contribuição a pagar de certos grupos sociais dominantes. Este trabalho se utiliza de dados secundários extraídos das estatísticas da Receita Federal do Brasil, do Instituto de Pesquisa Econômica Aplicada e do Sistema de Integração Financeira do Governo Federal para se evidenciar os gastos tributários em saúde selecionados nesta pesquisa. O referencial teórico que norteia este trabalho é o materialismo histórico dialético de Marx, trazendo a luz aspectos importantes para se compreender a lógica das políticas econômicas brasileiras no capitalismo contemporâneo. Desta forma, a renúncia fiscal (gasto tributário) na saúde realça no curto prazo, o caráter benéfico das famílias e empresas reaverem os dispêndios em bens e serviços privados de saúde. Entretanto, no longo prazo, evidencia-se o agravamento das desestruturas sociais, posto que os trabalhadores e as famílias de baixa renda comprometem-se (proporcionalmente) mais com os gastos em saúde, devido ao caráter regressivo do sistema tributário brasileiro. Além disso, as isenções, deduções e alíquotas zero (gasto tributário) à indústria farmacêutica e aos hospitais filantrópicos, podem exprimir aspecto de distorção na prioridade de recursos direcionados ao SUS. Assim, é possível admitir que, sob a égide do capital portador de juros, o Estado é capaz de transformar o plano ideológico do corpo social da sociedade capitalista. / This dissertation deals with the financing of the Unified Health System (SUS), bringing health tax expenditures as an important mechanism of analysis in the relations between the State and the Law under the influence of interest bearing capital. The theme is related to the field of public health, which aims to contribute to the debate on health economics. Thus, the objective of this research is to analyze health tax expenditures in the Social Security budget, specifically regarding SUS financing, from the role of the State in the context of the dominance of interest bearing capital. In this perspective, the tax expenditures provided to individuals and legal entities, the pharmaceutical industry (medicines and chemical products) and non-profit organizations (philanthropic hospitals) are highlighted, as these legal provisions may encourage certain behaviors of the taxpayers, to enable the reduction / exemption of the tax / contribution payable from certain dominant social groups. This work uses secondary data extracted from the Brazilian Federal Revenue Service, the Institute of Applied Economic Research and the Federal Government\'s Financial Integration System to show the tax expenditures selected in this research. The theoretical framework that guides this work is the dialectical historical materialism of Marx, bringing to light important aspects to understand the logic of Brazilian economic policies in contemporary capitalism. In this way, the fiscal waiver (tax spending) on health highlights in the short term the beneficial character of families and companies recovering the expenditure on private health goods and services. However, in the long term, there is evidence of worsening of social structures, since workers and low-income families are (proportionally) more committed to health spending, due to the regressive nature of the Brazilian tax system. In addition, exemptions, deductions and zero rates (tax expenditures) to the pharmaceutical industry and philanthropic hospitals can express an aspect of distortion in the priority of resources directed to SUS. Thus, it is possible to admit that, under the aegis of interest bearing capital, the state is capable of transforming the ideological plane of the social body of capitalist society

Esta dissertação trata do financiamento do Sistema Único de Saúde (SUS), trazendo os gastos tributários em saúde como mecanismo importante de análise nas relações entre o Estado e o Direito sob a influência do capital portador de juros. A temática relaciona-se ao campo da saúde coletiva, que visa contribuir ao debate da economia da saúde. Assim, o objetivo desta pesquisa é analisar os gastos tributários na saúde no orçamento da Seguridade Social, no que tange, especificamente, ao financiamento do SUS, a partir do papel do Estado no contexto da dominância do capital portador de juros. Nesta perspectiva, ressalta-se os gastos tributários proporcionados às pessoas físicas e jurídicas, à indústria farmacêutica (medicamentos e produtos químicos) e às organizações sem fins lucrativos (hospitais filantrópicos), pois estes dispositivos legais podem encorajar determinados comportamentos dos contribuintes, ou então, de viabilizar a redução/isenção do imposto/contribuição a pagar de certos grupos sociais dominantes. Este trabalho se utiliza de dados secundários extraídos das estatísticas da Receita Federal do Brasil, do Instituto de Pesquisa Econômica Aplicada e do Sistema de Integração Financeira do Governo Federal para se evidenciar os gastos tributários em saúde selecionados nesta pesquisa. O referencial teórico que norteia este trabalho é o materialismo histórico dialético de Marx, trazendo a luz aspectos importantes para se compreender a lógica das políticas econômicas brasileiras no capitalismo contemporâneo. Desta forma, a renúncia fiscal (gasto tributário) na saúde realça no curto prazo, o caráter benéfico das famílias e empresas reaverem os dispêndios em bens e serviços privados de saúde. Entretanto, no longo prazo, evidencia-se o agravamento das desestruturas sociais, posto que os trabalhadores e as famílias de baixa renda comprometem-se (proporcionalmente) mais com os gastos em saúde, devido ao caráter regressivo do sistema tributário brasileiro. Além disso, as isenções, deduções e alíquotas zero (gasto tributário) à indústria farmacêutica e aos hospitais filantrópicos, podem exprimir aspecto de distorção na prioridade de recursos direcionados ao SUS. Assim, é possível admitir que, sob a égide do capital portador de juros, o Estado é capaz de transformar o plano ideológico do corpo social da sociedade capitalista. / This dissertation deals with the financing of the Unified Health System (SUS), bringing health tax expenditures as an important mechanism of analysis in the relations between the State and the Law under the influence of interest bearing capital. The theme is related to the field of public health, which aims to contribute to the debate on health economics. Thus, the objective of this research is to analyze health tax expenditures in the Social Security budget, specifically regarding SUS financing, from the role of the State in the context of the dominance of interest bearing capital. In this perspective, the tax expenditures provided to individuals and legal entities, the pharmaceutical industry (medicines and chemical products) and non-profit organizations (philanthropic hospitals) are highlighted, as these legal provisions may encourage certain behaviors of the taxpayers, to enable the reduction / exemption of the tax / contribution payable from certain dominant social groups. This work uses secondary data extracted from the Brazilian Federal Revenue Service, the Institute of Applied Economic Research and the Federal Government\'s Financial Integration System to show the tax expenditures selected in this research. The theoretical framework that guides this work is the dialectical historical materialism of Marx, bringing to light important aspects to understand the logic of Brazilian economic policies in contemporary capitalism. In this way, the fiscal waiver (tax spending) on health highlights in the short term the beneficial character of families and companies recovering the expenditure on private health goods and services. However, in the long term, there is evidence of worsening of social structures, since workers and low-income families are (proportionally) more committed to health spending, due to the regressive nature of the Brazilian tax system. In addition, exemptions, deductions and zero rates (tax expenditures) to the pharmaceutical industry and philanthropic hospitals can express an aspect of distortion in the priority of resources directed to SUS. Thus, it is possible to admit that, under the aegis of interest bearing capital, the state is capable of transforming the ideological plane of the social body of capitalist society