Do health vouchers broaden the choices of citizens with low socioeconomic status? An analysis of Medicaid in Brooklyn

Abstract

Background: Many governments worldwide have committed to extending choices in public service delivery. However, the extent to which policies ensure equity is unclear. We investigated whether Medicaid programs in the United States improve hospital accessibility among patients with low socioeconomic status, compared to those with non-low socioeconomic status who are non-Medicaid recipients or uninsured.Methods: We employed a difference-in-difference-in-differences approach using a rich dataset of information on inpatients and their choice of hospitals from Statewide Planning Research and Cooperative System and information on hospitals from the American Hospital Association in Brooklyn, New York, from 2003 to 2009 Results: The ndings indicated that Medicaid has failed to broaden the range of the hospital choices for patients with low socioeconomic status, assessed in terms of bypassing behaviors.Conclusions: Medicaid is a public program that offers choices driven by purchasing power. The ndings of this study imply that this program has some limitations in alleviating existing socioeconomic inequities in available hospital choices. BackgroundIn public service delivery, expanding upon existing consumer choices is central to the wider principles of recent service reforms in the Swedish elderly care sector [1], British health care sector [2], American education and health sectors [3,4], and Korean social service sector [5, 6]. Such reforms aim to improve not only providers' e ciency but also their responsiveness to public service users, which can be modi ed to better satisfy the requirements of consumer sovereignty [3,7]. However, conceptualizing and measuring the value of consumer choices is problematic in both theory and practice because the criteria to determine whether a choice is welfare-enhancing are rarely suggested [8].The Medicaid system in the United States is a consumer-driven purchasing policy that provides a mechanism for state and local governments to provide services in a manner that enhances consumer choices and improves the purchasing relationship between the government, providers, and consumers. Accordingly, patients are given a Medicaid entitlement that they can present at a hospital of their choosing to receive government-provided health insurance funds that align with their choice [2, 3]. This study explored whether Medicaid can broaden patients' choice of hospitals because Medicaid patients can use their purchasing power to pit hospitals against each other, and thus receive higher quality services [3,7]. However, while the natural motivation for such programs is to improve the health of lowerincome persons [9], little research has been conducted to determine whether offering greater purchasing power for choices through existing health markets contributes to equity in accessing services; moreover, the existing programs are poorly documented in the public administration eld.

Does Citizen Sector-based Preference Relate to Citizen Satisfaction with Public Service Organizations?

“…Accordingly, compared to traditional public service provision, sector can be used as a reference point that functions as a baseline for citizens’ evaluations, especially in complex public service provision such as collaborative service delivery or cross-sector public service delivery. Considering that multisectoral public service provision has been central to recent reforms and has been accelerated by demand-driven programs in many countries (Lee, 2023; Steuerle et al, 2010). This approach is crucial to understanding how citizens evaluate public service organizations in such contexts.…”

“…Unlike supply-driven instruments, demand-driven ones offer citizens purchasing power that covers the difference between the costs of in-kind services or goods and what citizens can afford to purchase them. Their application can be observed in numerous service domains, including housing, food, childcare, primary and secondary education, higher education, employment, training, and medical care (Fotaki, 2009; Lee, 2023). The rise of these demand-driven policy instruments has led nonprofit and for-profit organizations to play important roles in delivering government-funded services alongside public sector organizations.…”

Understanding Gaps Between Objective and Subjective Performance Measures: Accreditation of Public Service Organizations and Citizen Satisfaction

“…Another strategy governments use to measure the performance of external private agents is collecting citizen evaluations, such as satisfaction surveys (Charbonneau & Van Ryzin, 2012; James, 2011; Lee & Shin, 2023) or monitoring service recipients’ behavioral changes or intentions to act (Jilke et al, 2016; Lee, 2023). Assessments of citizen satisfaction are probably the most widely used method for collecting feedback in the public sphere.…”