Implications of rising medical care spending.

摘要

Personal health care spending accounts for a growing share of the economy and creates pressure on individual and government budgets. Rising spending creates policy challenges because the main driver of increases, medical technology, contributes to health improvements and attracts substantial public and political support. In three papers, this thesis focuses on implications of rising spending for quality of care and scope of insurance coverage.; The first paper focuses on a potential way to improve quality, as rising spending creates pressure to get better value from spending, particularly as people are living longer with chronic diseases. Using panel survey data, I find that older adults who develop new health conditions are three times more likely to quit smoking, and have modest weight loss, relative to individuals without new conditions. People with new conditions account for half of observed quits and dampen an overall weight increase. New health conditions may be a teachable moment to promote health behavior change as secondary prevention through the health care system.; The second paper focuses on Medicare regulatory decisions on coverage of new treatments, as rising spending also creates pressure on scope of benefits. I propose a bureaucratic decisionmaking framework where the agency acts to mediate tensions in underlying goals in the context of complex evidence and pluralistic stakeholder input. Using qualitative evidence from case studies and interviews, I find that decisions follow strong clinical evidence. When evidence is less certain, decisions for high cost treatments reflect greater scrutiny of evidence, while some decisions for salient diseases with limited treatment alternatives interpret uncertain evidence more broadly. Technology assessment is one among a set of inputs into decisions.; The final paper assesses the role of rising costs in declines in coverage, recognizing that rising spending also creates pressure on availability of coverage. Using multiple data sets and econometric techniques, this paper shows that rising premiums account for over half of the decline in health insurance over the 1990s. Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.