Publications by Randall R. Bovbjerg for Health Policy Center

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More about Randall R. Bovbjerg's areas of expertise can be found on this Urban Institute expert's page.

Nurses are health care's backbone, spending the most time with patients, and working with teams of caregivers in institutions and serving as advanced practice nurses in primary care settings. Short-term shortages wax and wane, but concerns about a shortage are more serious now because the next decade may see more older nurses retiring than new ones entering the workforce. Education needs to be augmented and improved, but no precise estimation method can show how many nurses society "should" produce. Policy should focus more on nurses' scopes of practice and aligning how they are treated and paid with the value they add to patient care.

The Federal Employees Health Benefits Program is the nation's largest employer-sponsored health plan, offering enrollees numerous options for health insurance. The program has long kept participation high, administrative costs low, and premiums affordable-making it an enticing model for health reformers of all political stripes. Most curent federal reform proposals include a similar insurance "exchange" to offer a range of private-market insurance choices to a broader population. While opening the FEHBP to non-federal employees or replicating its features nationally is not feasible, program experience suggests lessons about benefits design, relations with participating health plans, and avoiding adverse selection in enrollment.

In this paper and brief, the authors discuss alternative ways that health reform could be financed. They analyze different options including several proposals for delivery system reforms and for reduction in Medicare and Medicaid payments. They estimate the cost savings that could occur due to the introduction of a public plan option. Finally, they explore a range of revenue options. The key message of the paper is that health reform can be paid for, but it is best to obtain funds from a large number of measures to spread the burden broadly.

The Reinsurance Institute provided quantitative modeling and qualitative analysis to states as they explored reinsurance as an element of health reform. The project estimated the impacts of reinsurance, including changes in premiums, employer offer and enrollee take-up of coverage, numbers of people insured, and costs to the state. Small numbers of high spenders account for a large share of health spending, but most spending occurs in lower corridors of expense. Medical spending varies widely by age and health status, creating pressure for risk segmentation. Lastly, defining the eligible population determined whether reinsurance would cover new enrollees or solidify current coverage.

The Reinsurance Institute simulated the effects of reinsurance on individual and employer behavior, observing state-specific characteristics. We constructed a baseline database for each state by reweighting and combining multiple data sources to create a profile of individual-level demographics and health expenditures, allowing for the computation of individual-level premiums. We grouped health insurance units together into risk pools consistent with state market rules to calculate the change a reinsurance subsidy would have on the premium levels faced by individuals and employers. These price changes drove simulated changes in premium and coverage levels, offer and take-up rates, and state costs.

If current budgetary trends persist, sometime between 2016 and 2020 existing federal revenues will cover only health entitlements, Social Security, debt service, and a smaller defense budget, leaving nothing for anything else. The researchers warn that budget-driven reforms in health policy must aim to end automatic year-to-year budget growth and push Congress to formally recognize when it chooses health cost increases over other priorities. Rather than get derailed on the search for one grand reform, they suggest a host of reforms that would empower government, provider, insurer, and citizens alike to choose a better and more efficient health delivery system. Health Affairs_ 27(3):633-644 (May/June 2008).

This report estimates the benefits and costs of alternative forms of state-funded medical reinsurance in Washington using the Urban Institute's Reinsurance Model. A subsidy targeted at all small firms would substantially increase primary coverage but would be very expensive, as most benefit would flow to already insured people. Targeting the conventional small group market by excluding association health plans would reduce state cost per newly uninsured person and would bolster existing regulatory requirements for that sector;s insurers to use modified community rating. Any practical program also needs to identify secure funding and maintain cost consciousness among newly reinsured health plans.

Having health insurance is important for several reasons. Uninsured people receive less medical care and less timely care, they have worse health outcomes, and lack of insurance is a fiscal burden for them and their families. Moreover, the benefits of expanding coverage outweigh the costs for added services. Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance. These findings are supported by much research, although some cautions are appropriate in using these results.

This study, funded by the Maine Health Access Foundation, presented alternative estimates of the costs of health care that uninsured Maine residents receive and determined how much public revenue was available to offset those costs. Using data from health care providers, the study estimated that the costs of caring for the uninsured in Maine were $138 million in 2005, with hospitals and Veterans' Affairs facilities identified as the largest providers. Estimates based on household survey data from the Medical Expenditure Panel Survey showed that uncompensated care costs for the uninsured were only $81 million in 2005. The report discusses possible reasons for the large discrepancy between these two sources. Our review of federal and state funding sources in 2005 suggests there were roughly $110 million available to offset these costs of caring for the uninsured.

About 2.5 million New Yorkers were uninsured in 2005, and medical providers that serve them incurred some $2.8 billion in uncompensated care. Two separate analyses in this report agreed on this estimate, one using provider cost reports and the other household survey data. Budgetary and other sources showed that state, local, and federal governments supplied about $3.5 billion in revenues that offset these costs, through a complex mix of programs. If these uninsured people had all had insurance for the full year, their projected medical spending would have been higher by about $4.1 billion. Any insurance expansion program would incur these and additional costs as well.

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