Hospital consolidation and racial/income disparities in health insurance coverage

Health Affairs

Volumn 26, Issue 4, 2007, Pages 1170-1180

  Town, Robert J ^a,d   Wholey, Douglas R ^b,d   Feldman, Roger D ^b,d   Burns, Lawton R ^c,d  

^a UNIVERSITY OF MINNESOTA   (United States)

^b Division of Health Policy and Management

^c Department of Health Care Systems and of Management ^*

^d UNIVERSITY OF PENNSYLVANIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ADULT; ARTICLE; ECONOMICS; ETHNOLOGY; FACTUAL DATABASE; FEMALE; HEALTH CARE DELIVERY; HEALTH CARE FACILITY; HEALTH SERVICE; HUMAN; INCOME; INSURANCE; MALE; MEDICAL SOCIETY; MIDDLE AGED; MINORITY GROUP; PATIENT; POPULATION DYNAMICS; RACE; SOCIOECONOMICS; STATISTICS; UNITED STATES;

ADULT; AMERICAN HOSPITAL ASSOCIATION; CONTINENTAL POPULATION GROUPS; DATABASES, FACTUAL; FEMALE; HEALTH FACILITY MERGER; HEALTH SERVICES ACCESSIBILITY; HUMANS; INCOME; INSURANCE COVERAGE; MALE; MEDICALLY UNINSURED; MIDDLE AGED; MINORITY GROUPS; POPULATION DYNAMICS; SOCIOECONOMIC FACTORS; UNITED STATES; URBAN HEALTH SERVICES;

EID: 34548295134     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.26.4.1170     Document Type: Article

References (29)

1. See B.D. Smedley, A.Y. Stith, and A.R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2003);
2. and A.C. Monheit and J.P. Vistnes, "Race/Ethnicity and Health Insurance Status: 1987 and 1996," Medical Care Research and Review 57, no. 1 Supp. (2000): 11-35.
3. See, for example, S.H. Zuvekas and G.S. Taliaferro, "Pathways to Access: Health Insurance, the Health Care Delivery System, and Racial/Ethnic Disparities, 1996-1999," Health Affairs 22, no. 2 (2003): 139-153;
4. and Smedley et al., eds., Unequal Treatment.
5. Differences in union status, age, health status, and occupation all likely contribute to racial and income differences in coverage. See Monheit and Vistnes, "Race/Ethnicity and Health Insurance Status."
6. See M. Gaynor and W. Vogt, "Antitrust and Competition in Health Care Markets," in Handbook of Health Economics, ed. A.J. Culyer and J.P. Newhouse (Amsterdam: North Holland, 2000), 1405-1488;
7. D. Dranove and M. Satterthwaite, "Industrial Organization of Health Care Markets," in Handbook of Health Economics, ed. Culyer and Newhouse, 1093-1140;
8. and W.B. Vogt and R. Town, "How Has Hospital Consolidation Affected the Price and Quality of Hospital Care?" Research Synthesis Report no. 9, February 2006, http://www.rwjf.org/publications/synthesis/reports_and_briefs/ issue9.html (accessed 3 May 2007).
9. M. Chernew, D.M. Cutler, and P.S. Keenan, "Increasing Health Insurance Costs and the Decline in Insurance Coverage," Health Services Research 40, no. 4 (2005): 1021-1039.
10. Although it is plausible and perhaps even likely that health insurance premium elasticities differ by ethnic group, we have not found any research specifically estimating these.
11. See A. Marshall, Principles of Economics, 8th ed. (London: Macmillan and Co., 1920). We thank Ted Frech for pointing out this observation to us.
12. R. Town et al., "The Welfare Consequences of Hospital Mergers," NBER Working Paper no. 12244 (Cambridge, Mass.: National Bureau of Economic Research, February 2006).
13. Standard errors were calculated using a bootstrap method with MSA-level clustering.
14. Empirically, the lower bound for the HHI is 10,000 divided by N, where N is the number of independent organizations operating in the market.
15. See U.S. Department of Justice and Federal Trade Commission, Horizontal Merger Guidelines (Washington: DOJ/FTC, 1997).
16. Of course, many adults in our sample might qualify for Medicaid coverage.
17. The control variables are logarithm of number of HMOs, age, household income, household income squared, household income cubed, family size, household income per family member, indicators for race, Hispanic status, employment status, union status, marital status, high school graduate, college graduate, post-baccalaureate education, veteran status, household income interacted with martial status, household income interacted with female, time trend interacted with bottom decile of income distribution, time trend interacted with second decile of income distribution, time trend interacted with full-time work status, time trend interacted with household income, employer size indicators, occupational indicators, industry indicators, MSA per capita income, MSA population, percentage in MSA with college degree, MSA hospital beds per capita, percentage in MSA over age sixty-four, MDs per capita in MSA, MSA unemployment rate, MSA hospital beds per capita, and annual dummies.
18. M. Davern et al., "Recent Changes to the Current Population Survey: Sample Expansion, Health Insurance Verification, and State Health Insurance Coverage Estimates," Public Opinion Quarterly 67, no. 4 (2003): 603-626.
19. This correction affects the magnitudes and precision of our estimates but not the qualitative conclusions. See http://www.shadac.umn.edu/img/assets/ 18528/CPSTimeSeries.pdf for an algorithm to implement this correction.
20. We used a "corrected" AHA system ID constructed by Kristin Madison that has been updated by researchers at Carnegie-Mellon University. We thank Madison, Marty Gaynor, and colleagues for providing these data. For more information, see K. Madison, "Multihospital System Membership and Patient Treatments, Expenditures, and Outcomes," Health Services Research 39, no. 4, Part 1 (2004): 749-769.
21. Our qualitative findings were robust to every different cut-off we tried (including no cut-off), which yielded a sufficient number of nonwhite observations.
22. Again, our results are robust to a number of different thresholds and the exclusion of any thresholds.
23. See R. Town, D. Wholey, and R. Feldman, "The Impact of Ownership Conversions on HMO Performance," International Journal of Health Care Finance and Economics 4, no. 4 (2004): 327-342.
24. Consistent with this assertion, our analysis suggests that health insurance take-up in the lowest part of the household income distribution is insensitive to changes in hospital competition.
25. See J. Gruber, "The Effect of Competitive Pressure on Charity: Hospital Responses to Price Shopping in California," Journal of Health Economics 13, no. 2 (1994): 183-212;
26. J. Mann et al., "Uncompensated Care: Hospitals' Responses to Financial Pressures," Health Affairs 14, no. 1 (1995): 263-270;
27. R. Frank and D. Salkever, "The Supply of Charity Services by Not-for-Profit Hospitals: Motives and Market Structures," RAND Journal of Economics 22, no. 3 (1991): 430-445;
28. and C. Garmon, "Hospital Competition and Charity Care," FTC Working Paper no. 285 (Washington: FTC, 2006).
29. See discussion in papers cited in Note 4.