公共服务的私人供给: 来自医疗救助随机分配的证据

American Economic Review · 2022 · [{"name": "Danil Agafiev Macambira", "affiliation": ["Boston University", "Hoover Institution", "National Bureau of Economic Research", "Brown University", "Yale University", "The University of Texas at Austin"]}, {"name": "Michael Geruso", "affiliation": ["Boston University", "Hoover Institution", "National Bureau of Economic Research", "Brown University", "Yale University", "The University of Texas at Austin"]}, {"name": "Anthony Lollo", "affiliation": ["Boston University", "Hoover Institution", "National Bureau of Economic Research", "Brown University", "Yale University", "The University of Texas at Austin"]}, {"name": "Chima D. Ndumele", "affiliation": ["Boston University", "Hoover Institution", "National Bureau of Economic Research", "Brown University", "Yale University", "The University of Texas at Austin"]}, {"name": "Jacob Wallace", "affiliation": ["Boston University", "Hoover Institution", "National Bureau of Economic Research", "Brown University", "Yale University", "The University of Texas at Austin"]}]

中文摘要

本文考察了美国社会医疗保险私有化的影响。我们以Medicaid（医疗补助）项目为背景研究这一问题——该项目是美国最大的医疗保险提供者，也是全国最大的家计调查型项目，服务于超过9000万低收入家庭和残障人士。利用一项自然实验，近10万名Medicaid参保者被随机分配至州政府管理的按服务付费体系或私人管理式医疗计划，我们发现，被分配到管理式医疗计划的参保者支出降低了近10%。这些节省集中体现在处方药方面，我们发现事前授权是各计划用以减少过度使用、并鼓励转向低成本替代方案而不降低质量的关键机制。这与私有化对医疗福利的影响截然不同——在医疗福利方面，私人计划降低了服务质量、损害了消费者利益，却并未实现费用节省。与我们的发现所隐含的公私服务有效分工相反，Medicaid历来倾向于处方药的公共提供和医疗护理的私人外包。

Abstract

This paper examines the effects of privatizing social health insurance in the United States. We study this question in the context of the Medicaid program, the largest health insurer in the US and the largest means-tested program in the nation -serving over 90 million low-income families and individuals with disabilities. Exploiting a natural experiment wherein nearly 100,000 Medicaid enrollees were randomly assigned between a state-administered fee-for-service system and private managed care, we find that spending was nearly 10% lower for enrollees assigned to managed care plans. These savings were concentrated in prescription drugs, where we show that prior authorization was the key mechanism plans used to reduce overuse and encourage substitution to lower-cost alternatives without reducing quality. This was distinct from the effects of privatization on medical benefits, where private plans lowered quality and abraded consumers without achieving savings. In contrast to what our findings imply for an efficient public-private division of services, Medicaid has historically favored the public provision of prescription drugs and private outsourcing of medical care.