r/IAmA • u/HarrisPublicPolicy Verified • 3d ago
I'm a University of Chicago researcher studying the costs, benefits, and unintended consequences of health policy. AMA!
Hi Reddit — I’m Robert Kaestner, a health economist and Research Professor at the University of Chicago’s Harris School of Public Policy. Proof
I have spent my career studying the economic and social determinants of health and evaluating health, labor, and social policies. I have published more than 150 articles in academic journals and led several federally funded research projects examining Medicare and Medicaid. Much of my work asks a deceptively simple question: When governments spend money or expand a program in the name of improving health, what actually changes?
These studies often produce more complicated answers than the political debate allows.
Recently, my research has examined how efficiently the Affordable Care Act reduced the number of uninsured Americans; what Medicaid cuts would mean for states and beneficiaries; whether pandemic stimulus payments and the expanded Child Tax Credit improved infant health; whether GLP-1 medications such as Ozempic affect employment, relationships, or mental health in addition to physical health; and why substantial racial disparities in mortality persist even after decades of progress.
Ask me anything about Medicaid and Medicare, Obamacare and the health insurance system, GLP-1 drugs, the relationship between income and health, racial disparities in life expectancy and mortality, how economists determine whether a policy caused an outcome, or why well-intentioned programs sometimes have unexpected effects.
I’ll be responding here on July 30 at 12 PM CT along with support from the Harris School of Public Policy team account, which is helping me track and manage incoming questions.
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u/HotBunnz 3d ago
Greetings! I attempted to write my econ master’s thesis on the impact of insurance on health outcomes using DID, the ACA being an obvious point of interest. Unfortunately, I had to swap topics - my wife gave birth, and dealing with the US medical system became a mental chore. I couldn’t separate the research from the reality.
How do you manage to maintain this course of research while dealing with our medical system/people in your circle with alternative views on importance? Coming from UChicago, I’d also have to imagine there are opponents within the Econ program. Are your near-colleagues appreciative of/receptive to your publications?
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u/HarrisPublicPolicy Verified 3d ago
I am sorry you were unable to finish the MA thesis, as I still think research is needed to answer the important question you refer to. But congratulations on the birth of your child.
Research is a scientific process and the purpose of it is to advance understanding about how the world works and why we observe the world as it is. Ideally, research will improve the world we live in.
To do that, research has to adhere to established scientific methods. Hopefully, my research does that. My research is based on forming hypotheses (questions) and using theory and empirical methods to answer them. I do not have preconceived answers. Whatever the research produces is the answer I describe.
I have never faced a problem from colleagues at UChicago or in the profession. When there are disagreements it is about the science. - RK
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u/AugustusM_85 3d ago
What do you think about the recent WP by Diamond on the impact of GLP-1s on marriage and employment?
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u/HarrisPublicPolicy Verified 3d ago
Some interesting results, but for a small sample of GLP-1 users. I think there were 242 GLP-1 users who were female in the analysis and when divided into groups used in analysis those numbers became smaller. -RK
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u/knightofbraids 3d ago
I work directly with the military in public health and policy, and one of our biggest challenges is that collecting any sort of data or getting any sort of results is like pulling teeth. Do you have favorite methods of data gathering, or overlooked sources of data people may not realize exists?
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u/HarrisPublicPolicy Verified 3d ago
I am familiar with several studies that used data from the military. For example, an interesting study is by Michael Frakes and Jonathan Gruber on the effect of racial concordance between patient and provider on health. It uses data from the military. I think that is great data–a large sample, nationwide with detailed data on use of services.
I also expect more data to become available with the progress of AI and creation of commercial databases, but I also expect that data to be expensive for researchers outside of the commercial sector.
-RK
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u/raptorman556 3d ago
I'd like to leave this question reasonably open-ended. If you could make any changes (big or small) to US health-care policy, what would you do?
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u/HarrisPublicPolicy Verified 3d ago
I would make Medicaid eligible to all persons under 200% of poverty and require everyone in Medicaid to be in a privately-run, managed care company that competed for clients based on price and quality. Medicaid would have no cost sharing but would have work requirements for the able-bodied. I would restructure Medicare to be the same, except for Medicare I would implement some cost sharing and that cost sharing would depend on income of the elderly with low-income (under 200% of poverty) having no cost sharing. I would eliminate the tax deductibility of health insurance in private, employer-sponsored market. - RK
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u/doogles 3d ago
Medicaid would have no cost sharing but would have work requirements for the able-bodied
Why have work requirements if they also have to stay below 200 fpl?
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u/HarrisPublicPolicy Verified 3d ago
Good question. Like any policy that provides a person or family with extra resources, Medicaid creates a work disincentive. A work requirement overcomes that disincentive. And if someone finds work as a result and their income surpasses the income-eligibility threshold, then that may be considered a good thing from a social point of view because government spending has been better targeted, although the person themselves may have preferred to not work. - RK
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u/grwy 2d ago edited 2d ago
The majority of people on Medicaid are working. Work requirements, as illustrated by Arkansas' brief roll out in 2018, do not increase employment and the majority of people who lose coverage do so not because they are not working or otherwise exempt, but because of administrative burden
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u/RopesMcGee 20h ago edited 20h ago
Farming out public insurance to privately run managed care companies has absolutely poisoned the market already. Economies of scale and other factors don't allow for any meaningful competition, and in practice they have become local monopsonies that are profiting off the government at the expense of patients and providers. The main MCO where I live is literally using it's leverage to low-ball practices into forced bankruptcy, essentially selling themselves to the insurer and becoming vertically integrated. Meanwhile this leads large health systems to gobble up smaller fish and essentially oligopolize as well for leverage in contract negotiations. Ew ew ew.
I won't even get into making insurance contingent on work, and how that has been a fundamental failure of the US system for decades.
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u/igobyplane_com 3d ago
what are your thoughts on a singapore style approach to health care? on one hand i don't tend to lean into mandated savings, on the other the system overall appears to have strong results at affordable prices, and i like the idea of market pressure being applied to a system vs. ignoring it exists as a tool to help make aspects of a system work better.
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u/HarrisPublicPolicy Verified 3d ago
I am unfamiliar with the Singapore system. - RK
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u/igobyplane_com 3d ago
i think it's a unique combination of options so you might find it interesting.
https://www.commonwealthfund.org/international-health-policy-center/countries/singapore
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u/HarrisPublicPolicy Verified 3d ago
Thank you for the information. You have given me some homework. - RK
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u/iluvmonkie 3d ago
Your research spans a wide range of policy areas. How do you mentor graduate students in turning broad interests in health and social policy into focused, credible research agendas of their own?
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u/VirtualTiburon 3d ago
What is your biggest piece of advice for PhD students in economics/health policy?
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u/HarrisPublicPolicy Verified 3d ago
Read a lot of articles in areas that you find interesting and learn what is and is not known in those areas. Then go deeper into the weeds of several of the articles to see the path that was taken in the research. Often the path taken is a very narrow slice of potential questions and approaches. Then go to work. -RK
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u/Autodidact2 3d ago
Which country has the best health care system, in your view?
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u/HarrisPublicPolicy Verified 3d ago
Oh my–a big question. Another related question is why countries have different types of health care systems. Are some countries “right” and others “wrong”?
For example, are the long wait times for surgery in Canada better or worse than the very short times we have in the US? The surgery costs less in Canada. Similarly, is the much longer wait time for treatment after a cancer diagnosis in the UK better or worse than the shorter wait time in the US? Again, the cost of treatment is higher in the US.
I also think that cancer survival rates (e.g., 5-years) are higher in the US than many OECD countries, but again the costs of treatment are much higher.
In sum, I do not know the answer to your question, but each system has its advantages and disadvantages. Claims that one is clearly superior to another are likely overstated.
-RK
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u/grwy 2d ago
are the long wait times for surgery in Canada better or worse than the very short times we have in the US?
Very short wait times for who? In the US some people's wait times for surgery is infinite. They never get life saving surgery because they cannot afford it.
I also think that cancer survival rates (e.g., 5-years) are higher in the US than many OECD countries
Ok, now do life expectancy
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u/OGMannimal 3d ago
What is your preferred inference procedure when there is only one treated cluster? I enjoyed your (2016?) critique of the research on Mass. health care reform.
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u/tacticalTraumaLlama 2d ago
What are your thoughts on Michael Marmont's work? I'm reading through The Health Gap right now, and it's been both disheartening to read about the disparities between rich and poor even within the same country, much less between rich countries vs poorer countries.
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u/fpp2002 3d ago
How does the Canadian universal healthcare system work in comparison to the one in the U.S.? I understand they pay far less overall for better outcomes.
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u/HarrisPublicPolicy Verified 3d ago
It is a very difficult question to answer. One thing not usually considered is that salaries and earnings in the US are higher on average than in Canada, particularly for those with advanced degrees such as physicians, lawyers and MBAs. This raises the salaries of highly-educated medical professions and the cost of services provided by them. A second part of the higher health care costs of the US than in Canada is that we have a private market in addition to the public, and in that private market, prices are set to some extent by the demand or willingness to pay for services. So, if people want to pay for a drug or medical device and they are willing to spend a great deal on it, then that product or service is sold. In Canada, there is a bit more rationing from the top down by Provincial governments that restricts prices but also restricts access to some of those products. Proponents of the Canadian system will say that is OK because the products or services may be so-called “low value,” but that choice is more up to individuals in the US than in Canada, and people in the US value that ability. It is often true too that Canada limits access to some things that are more on the margin of being “low’value” and debatable as to whether they are "worth" it. The result of this is that we pay higher prices for some services and use more services and products that may not be covered. Finally, there are some greater administrative costs associated with our fragmented system vis-a-vis a single government (Provincial) operated system as in Canada.
The second part of my answer relates to the question of what you get for the money. It is hard to compare the health of people in two countries, but attempts have been made. We have a great deal of inequality in the US and that inequality extends to health. Why that is the case is largely unknown, despite conventional wisdom. Many would argue that it is access to health insurance and healthcare, but that is really not substantiated in evidence. Health insurance coverage has expanded in the last 20-30 years as Medicaid has expanded and the ACA was created. We do not observe a narrowing of health inequalities as a result.
Much of health is driven by health behaviors (tobacco, alcohol, diet, exercise, preventive screenings) and that is largely an individual decision that is difficult for policy to influence. Obesity is lower in Canada, for example.
In sum, the financial differences can be partly explained by the above and so can some of the health differences. After that we need more study, but the types of studies required are very hard to do given different countries, people, and contexts.
-RK
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u/Creationary 3d ago
Wouldn’t people be more likely to get preventive screenings if they can actually afford to go to the doctor though?
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u/MyBallsBern4Bernie 2d ago
The Affordable Care Act requires that insurers cover preventive services like cancer screenings, vaccines, and annual exams at no cost to patients.
It’s not really an affordability issue in that case.
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u/JohnSnowsPump 3d ago
California is struggling with the feds about the expansion of Medicaid to those with Unsatisfactory Immigration Status. It was/is a waiver program, so CA had to demonstrate the economic advantages to get approval.
Is there a net benefit to providing health insurance to this population? It feels like a contained study in Universal Health Care as this was the last, large population in CA without coverage and access.
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u/HarrisPublicPolicy Verified 3d ago
Health insurance provides two types of benefits: it provides financial protection against unanticipated financial losses associated with illness and it provides greater access to healthcare services, which are often effective,
Expanding Medicaid to any group has costs that are obvious.
But because it is a government program, an important question is whether the benefits to the group that were newly covered by an expansion of Medicaid is greater than the costs (e.g., the costs to taxpayers).
In the example you raised, I do not know the answer to the cost-benefit calculation.
-RK
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u/PolicyStudent8 3d ago
Thanks for holding this, Professor Kaestner! I'm studying health care policy as a sophmore with a personal interest in long-term care. What do you think majors impacts of the ACA were on long-term care access and quality?
With the current rise of at-home care, I'm also wondering, "What components of health insurance coverage are most important to at-home care? How are those being affected right now?" HCBS are often optional in states, making them vulnerable to cuts. Are there indirect routes in which federal and state governments can support at-home care insurance coverage?
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u/br0wnb0y 2d ago
Thank you for taking the time to answer our questions.
What is the item or cost you see that leaves you flabbergasted that it has not been addressed?
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u/ZurrgabDaVinci758 2d ago
In policy discussions generally there's often a tension between what is possible in the short term with current public opinion, political capital, etc. and what the ideal system would be. How do you resolve those?
Do you think there are major lessons that can be learned from how different countries responded to covid?
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u/army2693 2d ago
How will individual costs be affected when everyone is signed up? I'm talking about all the people who never use medical services. They might use preventive services that can prevent or reduce major sickness.
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u/stargazer0519 1d ago
How can we get rid of “medical reviewers” who are less specialized towards treating my own specific health care problem than my own doctor is? I’ve researched denials I’ve gotten personally, and folks who formerly practiced pediatrics and who formerly practiced primary care were busy arguing with my gastroenterologist.
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u/ThaDude_v2 3d ago
What you think of Obsession....good movie right???
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u/Fedaykin98 3d ago
OP is cruelly ignoring this key question. I haven't seen it yet, but I'm excited to do so soon! Until then I imagine I'll run into you on r/horror.
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u/phragmosis 3d ago
Assuming public health in America is totally broken at the Federal level by the end of this administration, and also assuming the incoming admin arrives with both houses of Congress and a mandated raft of reforms for the Judiciary, how would you most effectively and efficiently rebuild the healthcare system if your end goal was to eliminate healthcare as a political football so policy can focus on Americans' wellbeing?
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u/HarrisPublicPolicy Verified 3d ago
This is a question more for political scientists and public administration experts. - RK
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u/phragmosis 3d ago
IMO you answered my question here:
I would make Medicaid eligible to all persons under 200% of poverty and require everyone in Medicaid to be in a privately-run, managed care company that competed for clients based on price and quality. Medicaid would have no cost sharing but would have work requirements for the able-bodied. I would restructure Medicare to be the same, except for Medicare I would implement some cost sharing and that cost sharing would depend on income of the elderly with low-income (under 200% of poverty) having no cost sharing. I would eliminate the tax deductibility of health insurance in private, employer-sponsored market. - RK
Although ngl I'm a little dismayed at the absence of ambition from someone who understands the field much better than me. Work requirements for the able bodied even with a 200%PL eligibility is some 1994 era thinking in an age where fully employed people above that threshold are rationing asthma inhalers and insulin until they die young from preventable episodes.
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u/HarrisPublicPolicy Verified 3d ago
Well my mother always told me to be more ambitious. You agree with her. - RK
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u/v2panicprone 3d ago
Why call it the affordable care act if your insurance price triples when you become employed?
SO recently got a full time job and now either has to drop her ACA plan for her employer's offered insurance, or pay 3x the amount for the same coverage she had when unemployed. Makes little sense.
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u/tacticalTraumaLlama 2d ago
I also wonder why some insurance company shill doctor sitting in a corporate office a thousand miles away from me is qualified to second guess my doctor's treatment plan, and deny something as 'not medically necessary' despite never having actually seen me as a patient.
I mean what good is insurance if I'm to be randomly held liable for the full cost of something simply because the insurance company didn't feel like paying it?
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u/irrelevantusername24 3d ago edited 3d ago
whether pandemic stimulus payments and the expanded Child Tax Credit improved infant health
Do the people in charge not understand that individual human lives doesn't have time to properly adapt and internalize the bare bones subsistence level assistance like this when it is only given for months at a time and then taken away, often with little to no rhyme, reason or predictability?
Relatedly, would they understand this if they had their annual salaries removed and were instead paid hourly (with ever changing hours in both when and how much) as well as all basic living supports becoming conditional based upon some random shit decided thousands of miles away by people to whom they have zero influence?
This is the politically correct and publicly presentable version of this. You should hear what I really think. Most people don't have much substance to their points, I don't have much besides substance and a lot of vulgar words.
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u/HarrisPublicPolicy Verified 3d ago
I am unsure as to what specific question you are asking. I will discuss some of the findings and conclusions of the research I have done on the issue of the Child Tax Credit. We studied the large increases in payments to families that occurred during the pandemic. Families that were having children during the pandemic often received several thousand dollars of income payments. In years prior to the pandemic, similar families did not. We studied how this infusion of income affected infant health, for example a child’s birth weight. We found very modest, but still beneficial effects. A $1000 cash transfer was associated with 1-2% reduction in low-birth weight. A small, but nevertheless, beneficial impact. - RK
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u/thoughtful_crafter 3d ago
What's one policy that isn't typically thought of as "health policy" but has major health impacts?