NBER Working Papers · 2026 · Marika Cabral、David C. Chan Jr、Seth Neller
中文摘要
本文考察老年退伍军人在公共与私人医疗体系之间的选择。这些退伍军人具有双重医疗资格，既可通过公共运营的退伍军人健康管理局（VA）获得医疗服务，也可接受由联邦医疗保险（Medicare）出资的私人医疗服务。我们分析了迁居于VA使用率不同地区的退伍军人所作的医疗体系选择，以量化个体特定因素（如偏好、收入和健康状况）与地区特定因素（如当地医疗服务的可及性、质量和便利性）的相对重要性。估计结果表明，VA使用率的地区差异中有50%–60%可归因于需求侧的个体因素，其余部分则由基于地域的因素解释。我们还发现，不同类型的医疗服务之间存在重要的异质性：与门诊和初级医疗相比，基于地域的因素对住院和急诊医疗的作用更大。进一步分析表明，近期立法所强调的供给侧特征——与VA医疗机构的距离和等待时间——仅能解释估计地区效应中的一小部分。这些发现凸显了个体因素在医疗体系选择中的重要性，并对旨在缩小VA使用率地区差异的政策具有启示意义。
Abstract
This paper examines the choice between public and private healthcare systems among elderly veterans, who are dually eligible to obtain care through the publicly operated Veterans Health Administration (VA) and through private providers financed by Medicare. We analyze health system choice among veterans who move across areas with differing rates of VA utilization to quantify the relative importance of individual-specific factors (e.g., preferences, income, health) and place-specific factors (e.g., local access, quality, and convenience). Our estimates indicate that 50–60% of geographic variation in VA use is attributable to demand-side individual factors, with the remainder explained by place-based factors. We also document important heterogeneity across types of care, with place-based factors playing a larger role for inpatient and emergency care than for outpatient and primary care. Additional analysis suggests that the supply-side features emphasized in recent legislation—distance to VA facilities and wait times—explain only a small share of estimated place effects. These findings highlight the importance of individual factors in health system choice and have implications for policies aimed at reducing geographic disparities in VA utilization.