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CHAPTER 1. BANKRUPTCY 7 The Emergency Medical Treatment and Active Labor Act (EMTALA) requires that hospitals treat patients with emergency medical conditions, and prohibits them from delaying treatment to inquire about insurance status or means of payment. 7 As a matter of practice, most hospitals provide non-emergency medical care on credit as well. Hospitals generally lack the infrastructure to bill patients at the point of service (?) and rarely deny service when repayment is unlikely. 8 Having received medical care on credit, bankruptcy law allows households to write off this debt in exchange for assets or future earnings. Chapter 7 is the most pop- ular form of personal bankruptcy, accounting for about 70 percent of all filings (?). Under Chapter 7, households can discharge most unsecured debt such as credit card debt, installment loans, and medical bills. In return, creditors can seize assets above exemption levels that vary by asset type and state of residence. Chapter 13 is the other bankruptcy option. Under Chapter 13, households discharge most unsecured debt in exchange for payments out of disposable income over the following 3 to 5 years. By statute, these payments must be of at least the value that creditors would receive in Chapter 7. They are rarely larger because, in the period I study, all households have the option to file for Chapter 7. 9 Following ?, I use seizable assets under Chapter 7 to characterize payments under both chapters of the bankruptcy code. Households, however, do not have to formally declare bankruptcy to receive the implicit insurance it provides. Under the threat-point of bankruptcy, households and medical providers often resolve payments without an actual bankruptcy filing. There are multiple junctures where this occurs. Discounts on the list price of treatment— known as charity care—are offered at the point of service to the obviously indigent. 10 7 U.S.C. 42 §1395dd. 8 In a survey of nonprofit hospitals, 90 percent reported never denying any medical services to patients with no insurance (?). For-profit hospitals seem to operate similarly. For example, ? rejects the hypothesis that for-profit hospitals have a lower preference for charity care. ? find that the majority of emergency departments offer preventative care to uninsured patients. 9 The Bankruptcy Abuse Prevention and Consumer Protection Act (BAPCPA), effective in October 2005, established a “means test” for Chapter 7. It restricted households earning more than the state median income from filing under Chapter 7 in most circumstances. The households most effected by the reform are unlikely to be marginal to the mechanism I analyze. 10 Federal and state laws also influence charity care provision. Nonprofits use charity care to meet
CHAPTER 1. BANKRUPTCY 8 After treatment, many hospitals encourage financially strapped households to nego- tiate discounts, requiring the submission of information on income and assets (e.g., W-2s and mortgage payments) as part of their charity care applications. 11 Even when charity care is not provided, the lion’s share of medical debt is charged off in the collection process. Despite contracting with debt collection agencies, providers recover only about 10 to 20 percent of bills submitted to the uninsured (?). Overall, bad debt from the uninsured was estimated at about $16 to $18 billion in 2004 (LeCuyer and Singhal, 2007). While the exact proportion of debt discharged without a bankruptcy filing is unknown, ? find that the ratio of “medical” to “non- medical” bankruptcies, according to their definition, is the same for households with and without insurance coverage, suggesting that a large portion of the uninsured’s medical debt is charged off outside of formal bankruptcy. This is not unique to medical debt. ? report that the majority of credit card debt is charged off in what they call “informal bankruptcy.” 1.2.2 A Model of Bankruptcy as High-Deductible Health In- surance To bring together these institutional features, I build a stylized model of households, medical providers, and bankruptcy. Households have a representative agent with expected utility preferences over wealth w = w E +w S , composed of exempt assets w E (net wealth that cannot be seized in a bankruptcy filling) and seizable assets w S (net wealth that can be seized by creditors). 12 They face medical shocks with list price m drawn from distribution M and choose whether to purchase health insurance to protect against this financial risk. Medical providers are obligated to provide medical services m and then attempt their Community Benefit requirement. Some states subsidize care to the indigent through unpaid care pools. I account for these factors in the empirical analysis. 11 When this information is not provided, hospitals run credit checks on indebted patients, filing suit if they find evidence of a mortgage or savings that could be claimed (“In Their Debt,” Baltimore Sun, December 12, 2008 to December 24th, 2008). 12 I discuss endogenizing wealth at the end of this section.
Page 1 and 2: ESSAYS IN PUBLIC FINANCE AND INDUST
Page 3 and 4: I certify that I have read this dis
Page 5 and 6: insurance choice. Among other thing
Page 7 and 8: Acknowledgements I am deeply thankf
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Page 13 and 14: List of Tables 1.1 Asset Exemption
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Chapter 3 Private Coverage and Publ
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CHAPTER 3. MEDIGAP 119 be of intere
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CHAPTER 3. MEDIGAP 121 hazard for i
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CHAPTER 3. MEDIGAP 123 have benefit
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CHAPTER 3. MEDIGAP 128 We use boots
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CHAPTER 3. MEDIGAP 130 of costs and
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CHAPTER 3. MEDIGAP 132 policy that
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CHAPTER 3. MEDIGAP 134 3.6.2 Causal
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CHAPTER 3. MEDIGAP 136 3.6.3 Robust
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CHAPTER 3. MEDIGAP 138 calculated u
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CHAPTER 3. MEDIGAP 140 (10000,11000
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