Individually Mandated Health Insurance and the Labor Market ...

Individually Mandated Health Insurance and the Labor Market ...

Mandate-Based Health Reform and the Labor Market: Evidence from the Massachusetts Reform Jonathan T. Kolstad Wharton School, University of Pennsylvania and NBER Amanda E. Kowalski Department of Economics, Yale and NBER October 2012 ACA and the Massachusetts Reform are Mandate-Based Health Reforms ACA is biggest change to health policy since introduction of Medicare and Medicaid in 1965 3 Key elements of Mandate-Based Reform 1. Mandate that employers must offer coverage or pay a penalty 2. Mandate that individuals must have coverage or pay a penalty 3. Expansions in publicly-subsidized coverage outside of employment Mandate-based reforms depend critically on relationship between ESHI and the labor market Vast majority of nonelderly have employersponsored health insurance (ESHI) CBO predicts 7-8 million newly insured through employersponsored health insurance by 2019 We build and estimate a model of mandatebased reform and the labor market Develop a simple model of mandate-based health

reform 1. Characterize compensating differential for ESHI 2. Characterize the welfare impact of mandate-based reform relative to tax-based reform in terms of key sufficient statistics, which depend on the compensating differential Rely on the Massachusetts reform to estimate the empirical analog of our theoretical model 1. Estimate the compensating differential for ESHI 2. Estimate the welfare impact of mandate-based reform relative to counterfactual tax-based reform Our model extends existing theory of ESHI and the labor market Our model extends Summers (1989) Adds empirical content, allowing us to recover all model parameters Cost of ESHI to employers, underlying valuation of ESHI, labor supply and demand elasticities, behavioral responses to individual and employer mandates and subsidies Demonstrates value of capturing policy interactions Employer mandate increases distortion if individual mandate

already in place Our findings contribute to empirical lit. on ESHI and the labor market 1. We find a compensating differential for ESHI of the expected theoretical sign and a magnitude cost of providing ESHI Most estimates of compensating differential from literature are wrong-signed (workers with ESHI also have higher wages) Estimates of expected theoretical sign rely on incremental changes in cost of ESHI Gruber 1994: mandated maternity benefits Baicker and Chandra (2005): increasing malpractice costs Our estimate of the compensating differential reflects the full cost of ESHI to employers 2. We translate our compensating differential into key sufficient statistics for welfare analysis Mandate-based reform is substantially more efficient than alternative tax-based reform: 2% of DWL Key Question for Supreme Court: Is the individual mandate penalty a tax?

JUSTICE ALITO: General Verrilli, today you are arguing that the penalty is not a tax. Tomorrow you are going to be back and you will be arguing that the penalty is a tax. We inform the economics of a mandate penalty vs. a tax Outline I. II. III. IV. V. Massachusetts Reform and the ACA Model of Mandate-Based Health Reform Identification and Estimation Results Robustness and Implications for National Reform VI. Conclusion Much Discussion with Little (but growing) Evidence

Evidence on the labor market? Massachusetts Reform, A Model for National Reform the fact of the matter is, we used the same advisers, and they say its the same plan. -President Obama, First Presidential Debate 2012 Key Provisions of Massachusetts and National Health Reform Massachusetts Reform, April 2006 Individual mandate Penalty is up to 50% of basic plan by months without coverage Employers mandated to offer coverage >10 FTEs Penalty is $295/worker

Medicaid expansions Up to 100% of FPL for adults Subsidized private plans through exchanges Subsidies up to 300% of FPL Reference: Kaiser Family Foundation Key Provisions of Massachusetts and National Health Reform Massachusetts Reform, April 2006 Individual mandate Penalty is up to 50% of basic plan by months without coverage National Reform, March 2010 Individual mandate Penalty is higher of 2.5% of income or $2,085 >50 FTEs Penalty is $2,000 per FTE for not offering any insurance

Penalty is $3,000 per FTE for not offering affordable coverage, for all employees receiving tax credit (not assessed on first 30 employees) Employers mandated to offer coverage >10 FTEs Penalty is $295/worker Medicaid expansions Up to 100% of FPL for adults Subsidized private plans through exchanges Subsidies up to 300% of FPL Reference: Kaiser Family Foundation Employers mandated to offer coverage Medicaid expansions Up to 133% of FPL

Subsidized private plans through exchanges Subsidies up to 400% of FPL Impact on Nonelderly Coverage Diff-in-Diff Coverage Impact from CPS Significant decline in unisurance 49% reduction relative to MA pre-reform Magnitude of increase after reform was similar for ESHI and Medicaid coverage A Model of the Labor Market with MandateBased Health Reform Alternate approaches to evaluation of policy options for health reform: Reduced form evaluation of health insurance expansion: Identify a policy experiment (e.g. Massachusetts) See what happened to aggregate labor market outcomes and coverage rates Requires fewer assumptions and gives clear identification of parameters Structural model of demand for health insurance, wages and employment:

Model individuals distributions of health care risk, risk aversion parameters, beliefs about risk, marginal tax rate Estimate why individual does not have coverage and how willing individual would be to gain coverage Relate to model of labor market outcomes Develop a simple model that nests the full range of structural parameters in sufficient statistics that can be measured in labor market outcomes Build on the intuition of Summers (1989) and Gruber and Krueger (1991) Can express policy parameters in the same framework extend to a general model of mandate-based policy and the labor market Use key, observable parameters in the spirit of Chetty (2009) The Model Build on the basic framework of Summers (1989) and Gruber and Krueger (1991) Key features of the model and mandate-based health reform Cost of a standardized health benefit: b Individuals valuation of the benefit: 0 Individual penalty for non-compliance (individual mandate): t (0,1)

Employer penalty for non-compliance (employer mandate): t (0,1) Subsidy level: xt (0,1) Labor market equilibrium: Labor supply: ,t NoESHI ,t LtS LESHI ( w b b b ) ESHI L ( w)(1 ESHIt ) S t xt t

S Labor demand: ,t ,t LtD LESHI ( w b) ESHIt LNoESHI ( w t b)(1 ESHIt ) D D Key Provisions of Massachusetts and National Health Reform Massachusetts Reform, April 2006 Individual mandate Penalty is up to 50% of basic plan by months without coverage Employers mandated to offer coverage >10 FTEs National Reform, March 2010

Individual mandate Penalty is higher of 2.5% of income or $2,085 Medicaid expansions >50 FTEs Up to 100% of FPL for adults Subsidized private plans through exchanges Subsidies up to 300% of FPL Reference: Kaiser Family Foundation Employers mandated to offer coverage Medicaid expansions Up to 133% of FPL

Subsidized private plans through exchanges Subsidies up to 400% of FPL Key Provisions of Massachusetts and National Health Reform Massachusetts Reform, April 2006 Individual mandate Penalty is up to 50% of basic plan by months without coverage Employers mandated to offer coverage >10 FTEs National Reform, March 2010 Individual mandate

Penalty is higher of 2.5% of income or $2,085 Medicaid expansions >50 FTEs Up to 100% of FPL for adults Subsidized private plans through exchanges Subsidies up to 300% of FPL Reference: Kaiser Family Foundation Employers mandated to offer coverage Medicaid expansions Up to 133% of FPL

Subsidized private plans through exchanges Subsidies up to 400% of FPL Key Provisions of Massachusetts and National Health Reform Massachusetts Reform, April 2006 Individual mandate Penalty is up to 50% of basic plan by months without coverage Employers mandated to offer coverage >10 FTEs National Reform, March 2010 Individual mandate

Penalty is higher of 2.5% of income or $2,085 >50 FTEs Medicaid expansions Up to 100% of FPL for adults Subsidized private plans through exchanges Subsidies up to 300% of FPL Reference: Kaiser Family Foundation Employers mandated to offer coverage Medicaid expansions Up to 133% of FPL x

Subsidized private plans through exchanges Subsidies up to 400% of FPL We can use the model to characterize 1. Compensating differential for ESHI (1 t ) s ( t xt ) b d s Hours differential for ESHI 1 t ( t xt ) b d s 2. Sufficient statistics for welfare impact of based reform 2 DWLm mandate- b (1 ( After x , After )) 2 ESHI After 2 After (1 ESHI After ) s( s d )

Welfare impact relative to tax-based reform 2 DWLm b 2 (1 ( After x , After )) 2 ESHI After 2 After (1 ESHI After ) DWL Graphical Representation Allows us to visualize the compensating and hours differentials for ESHI and the welfare impact of mandate-based reform relative to taxbased reform We build up the graphical representation with one policy at a time Tax Employer Mandate (full-compliance, pay-or-play) Individual Mandate (pay-or-play) Subsidies Graphical Model No Employer-Sponsored Health Ins (ESHI) w wNoESHI ,Before , Before LNoESHI S A

, Before LNoESHI D L LNoESHI ,Before Employer Tax to Finance Health Insurance w T wNoESHI ,Before wNoESHI , After ,t LNoESHI S A T , Before LNoESHI D b

LNoESHI , After , After LNoESHI D L LNoESHI ,Before Employer Tax to Finance Health Insurance w T wNoESHI ,Before wNoESHI , After DWL: TAT ,t LNoESHI S A T , Before LNoESHI D

b , After LNoESHI D LNoESHI , After L LNoESHI ,Before Full-Compliance Employer Mandate Summers (1989) DWL if ESHI,After=1: DAD DWL if ESHI,After=0: not possible Employer mandate decreases DWL! LNoESHI ,t w T S D wNoESHI ,t A

b ,t LESHI S D T wESHI ,t ,t LNoESHI D D b ,t LESHI D LESHI ,t LNoESHI ,t L Pay-or-Play Employer Mandate

DWL if ESHI,After=1: DAD DWL if ESHI,After=0: BAB w T D wNoESHI ,Before wNoESHI , After ,t LNoESHI S B A b B D T wESHI ,t , Before LESHI S

D , Before b LNoESHI D , After LNoESHI D b ,t LESHI D LESHI ,t LNoESHI , After LNoESHI ,Before L Pay-or-Play Individual Mandate Only w T ,t LNoESHI S D wNoESHI ,t

DWL if ESHI,After=1: FAF DWL if ESHI,After=0: 0 F F A b , Before LESHI S ( x )b , After LESHI S D T wESHI ,Before wESHI , After , Before LNoESHI D

D F b ,t LESHI D LESHI ,Before LESHI , After LNoESHI ,t L Pay-or-Play Employer Mandate And Pay-or-Play Individual Mandate DWL if ESHI,After=1: FAF DWL if ESHI,After=0: BAB Employer mandate increases DWL! LNoESHI ,t w T D wNoESHI ,Before wNoESHI , After

S B F F A b , Before LESHI S ( x )b B D T wESHI ,Before wESHI , After , After LESHI S , Before

b LNoESHI D D F , After LNoESHI D b ,t LESHI D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L Key to Identification: Differences Between Labor Market Equilibria Express compensating and hours in terms of wages (w) and hours (L) Preferred compensating differential: ( ) Preferred hours differential: ( ) Express all sufficient statistics in terms of wages (w) and hours (L)

Cost of ESHI to employers = ( ) ( ) Penalty-and-subsidy-inclusive valuation of ESHI s( LF LA ) ( wF wA ) x b Compensating Differential w T D wNoESHI ,Before wNoESHI , After ,t LNoESHI S B F F A b ( x )b

B D T wESHI ,Before wESHI , After , Before LESHI S , After LESHI S , Before b LNoESHI D D F , After LNoESHI D b ,t

LESHI D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L Hours Differential w T D wNoESHI ,Before wNoESHI , After ,t LNoESHI S B F F A b ( x )b

B D T wESHI ,Before wESHI , After , Before LESHI S , After LESHI S , Before b LNoESHI D D F , After LNoESHI D b ,t LESHI

D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L Cost of ESHI to Employers b DWL of tax-based reform proportional to b2 w T D wNoESHI ,Before wNoESHI , After ,t LNoESHI S B F F A b ( x )b

B D T wESHI ,Before wESHI , After , Before LESHI S , After LESHI S , Before b LNoESHI D D F , After LNoESHI D b ,t

LESHI D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L Cost of ESHI to Employers b DWL of mandate-based reform for ESHI,After=1 proportional to (1-(+- x))2 w T D wNoESHI ,Before wNoESHI , After ,t LNoESHI S B F F A b

( x )b B D T wESHI ,Before wESHI , After , Before LESHI S , After LESHI S , Before b LNoESHI D D F , After LNoESHI D

b ,t LESHI D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L All Sufficient Statistics are Differences Between Labor Market Equilibria Taking the Model to MA Minimum needed for identification 8 data points from within MA ESHI, NoESHI and After,Before for w,L Add more variation to identify parameters more convincingly MA vs. Non-MA Within individual over time Small (exempt) firms vs. large firms preferred specification Add more variation to identify more parameters Different subsidy amounts based on eligibility Separately identify individual penalty from subsidy Separately identify behavioral responses to different subsidy amounts for different eligibility categories

Estimation Wage and Hours Equations Estimate separate equations for w and L Baseline no firm size interactions (bracketed) Preferred firm size interactions Sufficient Statistics In Terms of Coefficients Data Survey of Income and Program Participation (SIPP) Longitudinal data from January 2004-December 2007 2004: 72,057 unique individuals, 2,047 in MA 2007: 28,661 unique individuals, 685 in MA Includes health insurance coverage Issues of seam bias and alternate panel weights Also examine restricted-use MEPS, but dont have enough sample size (only 15% size of SIPP) Oct-Dec 03 Jan-Feb 04 Mar-Apr 04 May-Jun 04 July-Aug 04 Sep-Oct 04 Nov-Dec 04

Jan-Feb 05 Mar-Apr 05 May-Jun 05 July-Aug 05 Sep-Oct 05 Nov-Dec 05 Jan-Feb 06 Mar-Apr 06 May-Jun 06 July-Aug 06 Sep-Oct 06 Nov-Dec 06 Jan-Feb 07 Mar-Apr 07 May-Jun 07 July-Aug 07 Sep-Oct 07 Nov-Dec 07 Log Wage Premium for ESHI vs. No ESHI MA*ESHI ESHI 0.2 0.15 0.1

0.05 0 -0.05 -0.1 -0.15 -0.2 -0.25 -0.3 Regression coefficients with w as dependent variable. See text for details. Wages and ESHI are two-month indicators. May-June 2006 are normalized to zero. Oct-Dec 03 Jan-Feb 04 Mar-Apr 04 May-Jun 04 July-Aug 04 Sep-Oct 04 Nov-Dec 04 Jan-Feb 05 Mar-Apr 05 May-Jun 05

July-Aug 05 Sep-Oct 05 Nov-Dec 05 Jan-Feb 06 Mar-Apr 06 May-Jun 06 July-Aug 06 Sep-Oct 06 Nov-Dec 06 Jan-Feb 07 Mar-Apr 07 May-Jun 07 July-Aug 07 Sep-Oct 07 Nov-Dec 07 Wage Premium for ESHI vs. No ESHI MA*ESHI ESHI 3 2 1 0 -1

-2 -3 Regression coeffi cients with w as dependent variable. See text for details. Wages and ESHI are two-month indicators. May-June 2006 are normalized to zero. Preliminary Evidence on the Compensating Differential Figure assumes no employer penalty (~ 0 because small), therefore, NoESHI, After is an additional control group Recall that model predicts that ESHI wages will fall (individual penaltyand-inclusive valuation) AND NoESHI wages will fall (employer penalty) in MA after reform Figure shows ESHI wages lower than NoESHI wages by approximately 10% or $2.13/hour ($4,435 annually for fulltime) KFF Survey from 2007 suggests average premium of $4,355 and $11,770 for individual and families, respectively Weighting by family structure and employer share in the SIPP gives $6,105 on average First evidence for relatively high valuations of ESHI among those impacted by reform Recall Theoretical Graph w T D

wNoESHI ,Before wNoESHI , After ,t LNoESHI S B F F A b ( x )b B D T wESHI ,Before wESHI , After , Before LESHI S

, After LESHI S , Before b LNoESHI D D F , After LNoESHI D b ,t LESHI D LESHI ,Before LESHI , After LNoESHI , After LNoESHI ,Before L Graphical Depiction of Preferred Estimates w 3

T 2 D F'' -8 -6 -4 -2 F' B' A B 0 -1 T -2 FB LSNoESHI,t 1

bb 2 4 LDNoESHI,Before LDNoESHI,After (+-)b L ESHI,After S -3 -4 L LDESHI,After Estimated Compensating and Hours Differentials Annualized compensating differential: -2.572x40x52=-5,350 Substantial fraction of $6,105 from KFF valuation will be high 05, 2.626] .454** 95, 1.183] .878**

08, 0.378] 351*** 30, 3.031] .059** 61, 1.914] .026** 98, 2.242] [1.940, 3.192] -0.551** [-1.380, 0.263] -0.209** [-0.658, 0.288] 0.661*** [0.169, 1.014] 0.901*** [0.338, 1.563] 0.586*** [0.136, 1.139] [0.631, 1.001] 0.740 1.000 - Estimated Sufficient Statistics And Welfare Impact of Health Reform 0.150*** [0.007, 1.076]

0.021*** [0.002, 0.101] 79,423 460,630 Penalty-and-subsidy-inclusive 0.753 0.836 nce intervals reported; CIs block bootstrapped by state.84% valuation: Monthly weights used. Annualized cost of ESHI b: $6,007 Annualized DWLm: $8 per year per full-time worker, 2% DWL Robustness to Calibrated Values Compensating and hours differentials do not reflect calibrated values 95% CI for compensating differential (-$7,956, -$3,122) Efficiency of mandate-based relative to tax-based health reform (DWL ratio = 2%) reflects calibration 95% CI for DWL ratio (0.2% to 10.1%) is smaller than actual Increase employer penalty from $295 (4.9% of b) to 25% of b, DWL ratio = 7% Increase b/ from 1 to 1.1, DWL ratio = 6.5%, increase b/ to 1.5 (gov. has 50% loading), DWL ratio = 12%

Increase supply elasticity from 0.1 to .2, DWL ratio=9.5% Decrease demand elast. from -0.2 to -0.4, DWL ratio=10.6% Robustness to Estimation Sample Allow underlying valuation to vary across individuals Can examine incidence across employee groups in model with heterogeneity Test of robustness in true model Restrict estimation sample to different groups New England only Larger compensating and hours differentials, penaltyand-subsidy-inclusive valuation: 0.77, DWL ratio: 3.8% Married people only (different valuation?) Penalty-and-subsidy-inclusive valuation: 0.71 Robustness to Intensive Margin Only Fixed cost of ESHI may favor hours margin over employment margin (Cutler and Madrian, 1998) Baseline specification allows for an effect on both Restrict sample only to workers 1. Paid job & w>0 in given period 2. Paid job & w>0 in entire SIPP 3. Paid job & w>0 & same job in entire SIPP Can estimate levels and logs specifications Still observe compensating differential in all specifications,

DWL ratio from 4.6% to 18.4% Suggests that extensive margin decision of whether to work and job switches do not drive our results Implications for National Reform ACA has higher employer penalty Penalty of $3,000/employee (46% of b) increases DWL ratio to 10.8% ACA has higher individual penalty Decreases distortion relative to MA ACA has smaller subsidies Decreases distortion relative to MA ACA extends subsidies to more people Increases distortion relative to MA Conclusion I: We extend existing theory of ESHI and the labor market Our model extends Summers (1989) Adds empirical content, allowing us to recover all model parameters Cost of ESHI to employers, underlying valuation of ESHI, labor supply and demand elasticities, behavioral responses to individual and employer mandates and subsidies

Demonstrates value of capturing policy interactions Employer mandate increases distortion if individual mandate already in place Conclusion II: We find compensating differential for full cost of ESHI We find a compensating differential for ESHI of the expected theoretical sign and a magnitude cost of providing ESHI Most estimates of compensating differential from literature are wrong-signed (workers with ESHI also have higher wages) Estimates of expected theoretical sign rely on incremental changes in cost of ESHI Gruber 1994: mandated maternity benefits Baicker and Chandra (2005): increasing malpractice costs Our estimate of the compensating differential reflects the full cost of ESHI to employers Conclusion III: We find DWL lower under mandatebased reform relative to tax-based reform We

translate our compensating differential into key sufficient statistics for welfare analysis Mandate-based reform is substantially more efficient than alternative tax-based reform: 2% of DWL This result is robust Broader Research Agenda on Massachusetts & National Reforms Hospital and preventive care (JPubEc, 2012) Testing for adverse selection (AER P&P, May 2012) Welfare cost of adverse selection (coming soon) Risk-protective benefits of health insurance Separating risk type from risk preference Extra Slides Pay-or-Play Employer Mandate And Pay-or-Play Individual Mandate And Subsidy w T CD B B E F

F E C C D ESHI ,t , III S L , After , II LESHI S ,t , x LNoESHI S , Before ,{ I , II } LESHI S b b , After , I LESHI S

III b D T A DWL if ESHI,After=1: EAE DWL if ESHI,After=0: BAB E F II b , Before , x b LNoESHI D , After , x LNoESHI D b ,t , x LNoESHI D L

Summary Statistics Full Population MA Non-MA MA-Non-MA Before After Before After Before After After-Before w: Weekly earnings / baseline hours per week 14.45 15.11 18.56 20.62 14.36 14.99 1.443*** w|paid job & w>0 20.75 22.36 25.36 26.94 20.64 22.24 0.140 Log(w|paid job & w>0)

2.77 2.84 2.96 3.03 2.76 2.83 0.001 L: Hours per week 29.23 28.80 30.19 31.05 29.21 28.75 1.196*** L|paid job & L>0 39.05 38.85 38.27 37.82 39.07 38.87 -0.285*** Log(L|paid job & L>0) 3.61 3.61 3.57 3.56 3.61

3.61 -0.004 Hours per week in all jobs 41.24 40.93 40.63 39.48 41.25 40.97 -0.990*** Paid job 0.78 0.78 0.82 0.84 0.78 0.78 0.030*** Employed by Large Firm|paid job 0.85 0.84 0.86 0.82 0.85 0.85 -0.021*** Any Health Insurance 0.83 0.84

0.90 0.95 0.83 0.83 0.036*** ESHI 0.66 0.65 0.74 0.74 0.65 0.65 0.013*** <150%FPL 0.13 0.11 0.09 0.08 0.13 0.11 0.003 150-300%FPL 0.19 0.16 0.14 0.09 0.19 0.16 -0.011***

Age 40.01 40.27 40.50 40.79 40.00 40.25 0.026 Married 0.56 0.55 0.54 0.50 0.56 0.55 -0.028*** Female 0.51 0.51 0.51 0.52 0.51 0.51 0.000 FPL category defined for each individual based on status in the Jan-June 2006 period. 2004 SIPP Panel. Monthly weights used. Full 18-64 population. Only includes interview months. Before: October 2003 - June 2006; After: July 2007 - December 2007. Statistics are averages over the relevant period. MA-Non-MA After-Before is the coefficient on MA*After from a regression of the outcome on MA*After, MA, and After.

***p<0.01, **p<0.05, *p<0.1, block bootstrapped by state. w and L measures include individuals without a paid job with w=0 or L=0, respectively, unless noted otherwise. 3.6% of sample gains health insurance relative to non-MA Model predicts w and L decrease for people who change ESHI status In aggregate labor market, expect no or small neg. change, but w and L increase Suggests that we need to control for MA-specific factors after reform Wage Trends in MA vs. Non-MA MA, ESHI MA, no ESHI Non-MA, ESHI Non-MA, no ESHI 30 25 20 15 10 5 Oct-07 Jul-07 Apr-07

Jan-07 Oct-06 Jul-06 Apr-06 Jan-06 Oct-05 Jul-05 Apr-05 Jan-05 Oct-04 Jul-04 Apr-04 Jan-04 Oct-03

0 Weekly earnings / baseline hours per week, including without paid job (wage=0). Full 18-64 population. Monthly weights are used to calculate means. Log Wage Trends in MA vs. Non-MA MA, ESHI MA, no ESHI Non-MA, ESHI Non-MA, no ESHI 3.5 3 2.5 2 1.5 1 0.5 Oct-07 Jul-07 Apr-07 Jan-07

Oct-06 Jul-06 Apr-06 Jan-06 Oct-05 Jul-05 Apr-05 Jan-05 Oct-04 Jul-04 Apr-04 Jan-04 Oct-03 0

Log (weekly earnings / baseline hours per week | paid job & weekly earnings > 0). Full 18-64 population. Monthly weights are used to calculate means. Compensating and Hours Differentials In Terms of Coefficients Sufficient Statistics In Terms of Coefficients Express Equilibria in Terms of Coefficients Hours in Terms of Coefficients: replace with Welfare Impact of Health Reform Where identification does not come from changes induced by the MA reform, we calibrate values Accounting for Relationship Between Penalty and Valuation Simple model adds underlying valuation and penalty in valuation More realistically, higher valuations are associated with lower impact of the penalty People who already have health insurance because they value it are not impacted by penalty Model the statutory penalty flexibly to account for

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