Almost 100 years ago the US Supreme Court opined that children are “not mere creatures of the state”, noting that parents should be the final arbiter of what is best for each child in the vast majority of cases. Yet this principle falls strangely short in protecting the rights of parents when addressing concerns surrounding certain forms of sexuality education in public school. This article argues that the sex education by necessity is freighted with moral meaning and to many parents that meaning has religious significance. I attempt to persuade the reader that because of the religious dimensions of our understanding of human sexuality a robust conception of religious liberty requires public schools to allow parental control over the sex education of children and that doing so poses little or no threat to legitimate state interests in education, health and public safety.
Studies of intergenerational mobility have largely ignored health despite the central importance of health to welfare. We present the first estimates of intergenerational health mobility in the US by using repeated measures of self-reported health status (SRH) during adulthood from the PSID. Our main finding is that there is substantially greater health mobility than income mobility in the US. A possible explanation is that social institutions and policies are more effective at disrupting intergenerational health transmission than income transmission. We further show that health and income each capture a distinct dimension of social mobility. We also characterize heterogeneity in health mobility by child gender, parent gender, race, education, geography and health insurance coverage in childhood. We find some important differences in the patterns of health mobility compared with income mobility and also find some evidence that there has been a notable decline in health mobility for more recent cohorts. We use a rich set of background characteristics to highlight potential mechanisms leading to intergenerational health persistence.
A vast literature suggests that economic inequality has important consequences for politics and public policy. Higher inequality is thought to increase demand for income redistribution in democracies and to discourage democratization and promote class conflict and revolution in dictatorships. Most such arguments crucially assume that ordinary people know how high inequality is, how it has been changing, and where they fit in the income distribution. Using a variety of large, cross‐national surveys, we show that, in recent years, ordinary people have had little idea about such things. What they think they know is often wrong. Widespread ignorance and misperceptions emerge robustly, regardless of data source, operationalization, and measurement method. Moreover, perceived inequality—not the actual level—correlates strongly with demand for redistribution and reported conflict between rich and poor. We suggest that most theories about political effects of inequality need to be reframed as theories about effects of perceived inequality.
What does it mean to discriminate based on health? This is an introduction to a symposium dedicated to our forthcoming book, Jessica Roberts & Elizabeth Weeks, Healthism: Health Status Discrimination and the Law (2017). It provides an overview of the articles contributed by Lindsay Freeman Wiley, Brendan Maher, Jennifer Bennett Shinall, and Jacqueline Fox. Our book, and the symposium, broadly explore the topic of healthism, a concept we repurpose to describe undesirable discrimination based on health status.
The U.S. Constitution requires that people receive equal protection regardless of their race, ethnicity, national origin, or religion, absent a compelling governmental interest. To a somewhat lesser degree, the government is prohibited from discriminating on the basis of gender, illegitimacy, and, most recently announced in the Supreme Court’s landmark Obergefell v. Rogers decision, sexual orientation. By statute, Congress has limited certain private actors from discriminating also on the basis of disability, pregnancy, genetic information, immigration status, or military affiliation. Conspicuously absent from this list of protected statuses though, is health. Should the law allow unhealthy individuals to be treated less favorably than healthy ones? Or should we recognize a new type of impermissible discrimination, that is to say, healthism?
“Healthism,” like the other “isms” that have preceded it, represents socially undesirable differentiation on the basis of a particular trait, in this case health status. So used, the term carries a pejorative meaning. But not all differentiation on the basis of health necessarily constitutes healthism. In fact, differentiating on the basis of health can be neutral and, in some cases, even desirable. Hence, our project is to distinguish the “good” health-based distinctions from the “bad,” or “healthist,” ones. This book surveys and evaluates the legal regulation of health in a variety of settings, both historically and especially in the wake of recent comprehensive federal health-care reform.
The central suggestion in this book is that the law, and, more generally, society at large, should be attuned to the pervasiveness of an under-recognized and under-theorized form of discrimination based on health status. This book stops short of offering an overarching solution to the problem of health-status discrimination across contexts. What we offer instead is a vocabulary and rubric for naming and categorizing the troubling phenomenon.
We investigate the effect of the Risk Corridors (RC) program on premiums and insurer participation in the Affordable Care Act (ACA)’s Health Insurance Marketplaces. The RC program, which was defunded ahead of coverage year 2016, and ended in 2017, is a risk sharing mechanism: it makes payments to insurers whose costs are high relative to their revenue, and collects payments from insurers whose costs are relatively low. We show theoretically that the RC program creates strong incentives to lower premiums for some insurers. Empirically, we find that insurers who claimed RC payments in 2015, before defunding, had greater premium increases in 2017, after the program ended. Insurance markets in which more insurers made RC claims experienced larger premium increases after the program ended, reflecting equilibrium effects. We do not find any evidence that insurers with larger RC claims in 2015 were less likely to participate in the ACA Marketplaces in 2016 and 2017. Overall we find that the end of the RC program significantly contributed to premium growth.
Spillovers can arise in markets with multiple purchasers relying on shared producers. If producers are constrained in their ability to adjust quality and cost across purchasers, then the influence of a dominant purchaser affects the entire market. Prior studies have found such spillovers in health care, from managed care to non-managed care populations — reducing spending, utilization, and improving outcomes. Similar effects have been identified in the Medicare Advantage market as well, with studies finding declines in utilization and reductions in resource use among the Traditional Medicare population associated with increases in county-level Medicare Advantage penetration. However, no study to date has provided plausibly causal estimates of such spillovers in the post-Affordable Care Act era. Our study does so by exploiting idiosyncratic differences in payments to Medicare Advantage plans that are unrelated to traditional Medicare spending. Further controlling for health status and other potential confounders, we estimate that a one percentage point increase in county-level Medicare Advantage penetration results in a $146 (1.7%) reduction in standardized per enrollee Traditional Medicare spending. We find evidence for reductions in utilization both on the intensive and extensive margins (including reductions in the number of inpatient stays) and across many types of health care services, not all of which have been analyzed in prior Medicare Advantage spillover studies. Our results suggest that spillovers from Medicare Advantage to Traditional Medicare have persisted in the post-Affordable Care Act era.
We re-visit the relationship between private health insurance mandates, access to employer-sponsored health insurance, and labor market outcomes using the National Longitudinal Survey of Youth 1979. We model employer-sponsored health insurance access and labor market outcomes across the lifecycle as a function of the number of high cost mandates in place at labor market entrance. We find no evidence that high cost state health insurance mandates discourage employers from offering insurance to employees. Employers adjust wages and labor demand to offset mandate costs. Mandate effects are persistent but not permanent. We document heterogeneity across worker-types.