Public opinion surveys uniformly show low support for medical-care systems in developed countries. The longstanding conflict between equal access to care and efficient service provision partly explains this dissatisfaction. But the trade-off is particularly acute in medical care, as new technologies developed over time have increased the cost of care and made the equity commitment even more expensive. Countries first dealt with rising costs by maintaining equal access and restricting total spending. Efficiency suffered, however. As a result, many countries are considering a move away from spending controls and toward incentive-based medical-care reform.

This paper examines the effect on health outcomes of moving from cost-based to prospective reimbursement of hospitals. The paper reaches two conclusions. First, hospitals that experienced average price declines had a greater share of deaths occur in the hospital or shortly after discharge. By one year postdischarge, however, this increased mortality was eliminated. Second, there was an increase in readmission rates as hospitals were no longer reimbursed for marginal units of care they provided. This increased readmission appears to be due to accounting changes on the part of hospitals rather than changes in patient morbidity.

This paper examines the generational aspect of the current Medicare system and some stylized reforms. We find that the rates of return on Medicare for today's workers are higher than those for Social Security and that the Medicare system is shifting a greater share of the burden on future workers than is Social Security. Nonetheless, the rates of return on Medicare, using the Medicare Trustees assumptions, are still not that high--roughly 2 percent for today's youngest workers. But forecasting future Medicare expenditures is quite difficult. Under an alternative higher-cost baseline, which we consider plausible, rates of return for today's youngest workers will exceed 3 percent. Putting Medicare on a sustainable basis by raising the payroll tax or reducing benefits would greatly reduce the rate of return for today's workers. Under the Trustees assumptions, for example, the payroll tax would have to be increased by 2.0 percent of payroll to put the Medicare system in balance in perpetuity. This policy would reduce the rate of return on today's youngest workers to about 1.3 percent.

There is a great deal of geographic variation in Medicare spending. For example, while the average Medicare cost per beneficiary was around $5200 in 1996, Medicare spending, adjusted for diffences in regional prices and demographic composition, was about $8000 per person in Miami, but only $3500 in Minneapolis. In this paper, we explore the source of this variation. We find that a substantial amount can be explained by differences across areas in the health of the elderly population. This finding suggests that some of the geographic variation in Medicare spending is efficient. But even accounting for differences in the health of the population, significant variation remains. We have been able to explain some of the remaining variation. The strongest factors are supply variables: for-profit hospitals and specialist physicians both increase Medicare spending. If these factors are exogenous, public policy may want to consider the supply of medical services more than it currently does. We do not find that expensive places spend a disproportionate amount on those near death.

Preference Heterogeneity and Insurance Markets: Explaining a Puzzle of Insurance by David M. Cutler, Amy Finkelstein and Kathleen McGarry. Published in volume 98, issue 2, pages 157-62 of American Economic Review, May 2008

Charity Care, Risk Pooling, and the Decline in Private Health Insurance by Michael Chernew, David Cutler and Patricia Seliger Keenan. Published in volume 95, issue 2, pages 209-213 of American Economic Review, May 2005

The introduction of Medicare in 1965 was the single largest change in health insurance coverage in U.S. history.Many economists and commentators have conjectured that the introduction of Medicare may have also been an important impetus for the development of new drugs that are now commonly used by the elderly and have substantially extended their life expectancy.In this paper, we investigate whether Medicare induced pharmaceutical innovations directed towards the elderly.Medicare could have played such a role only if two conditions were met.First, Medicare would have to increase drug spending by the elderly.Second, the pharmaceutical companies would have to respond to the change in market size for drugs caused by Medicare by changing the direction of their research.Our empirical work finds no evidence of a "first-stage" effect of Medicare on prescription drug expenditure by the elderly.Correspondingly, we also find no evidence of a shift in pharmaceutical innovation towards therapeutic categories most used by the elderly.On the whole, therefore, our evidence does not provide support for the hypothesis that Medicare had a major effect on the direction of pharmaceutical innovation.