Economics Papers
Jain, R. (2021) Private Hospital Behavior Under Government Insurance: Evidence from Reimbursement Changes in India. Working Paper.
In a major shift away from direct public provision, governments around the world are expanding public insurance programs that contract the private sector to deliver health services at pre-specified reimbursement rates. These rates are a key policy lever to shape provider incentives, but there is little evidence on their effects in lower-income contexts with limited regulatory capacity. Using over 1.6 million insurance claims and 20,000 patient surveys, and exploiting a policy-induced natural experiment, this paper provides evidence on private hospital responses to reimbursement rate changes under government health insurance in India. It shows that: 1) Private hospitals engage in coding manipulation to increase revenues at government expense. Manipulation is highly responsive to changes in the relative reimbursement rates of similar services. 2) Rate increases also induce an increase in service volumes. 3) Hospitals charge patients for care that should be free under program rules. Raising rates reduces these charges significantly, but hospitals capture about half of the increase. Pass-through is driven entirely by less concentrated markets, suggesting that competition limits hospital capture of public subsidies. There is no evidence of changes in care quality or patient composition. These findings highlight the critical role of prices and market structure when contracting the private sector for delivery of social services.
Winner of the International Health Economics Association (IHEA) 2021 Adam Wagstaff Award for Outstanding Research on the Economics of Healthcare Financing and Delivery in Low- and Middle-Income Countries.
Media coverage: BBC news. Interview: Ideas of India podcast.
Dupas, P. and Jain, R. (2023) Women Left Behind: Gender Disparities in Utilization of Government Health Insurance in India. NBER Working Paper 28972. Conditionally accepted, American Economic Review.
Using administrative data on 4 million hospital visits, we document large gender disparities within a government health insurance program that entitles 46 million poor individuals to free hospital care in Rajasthan, India. Females account for only 45\% of hospital visits overall and 33\% among children. These shares are lower for more expensive care and far lower than sex differences in illness prevalence can explain. As a result, almost two-thirds of program spending is on males. We combine these data with patient survey, census, and electoral data to show that: 1) care is not free in practice---patients face unauthorized hospital charges and travel costs---and higher costs are associated with larger disparities; 2) but lowering care costs by expanding hospital access does not reduce gender disparities because males benefit at least as much, proportionally, as females; 3) however, long-term exposure to local female leaders reduces disparities, though effects are small, by directly addressing factors that lower female care-seeking. In the presence of gender bias, subsidizing social services may increase levels of female utilization but fail to address gender inequalities without actions that specifically target females.
Policy blog post: VoxDev, Ideas4India (IGC), Development Asia (ADB). Media coverage: ThePrint, IndiaSpend.
Dupas, P. and Jain, R. (2023) Can Beneficiary Information Improve Hospital Accountability? Experimental Evidence from a Public Health Insurance Scheme in India. Journal of Public Economics, 220, 104841. Ungated version.
We study hospital compliance with a public health insurance program in a large Indian state. Using patient surveys, we first document that participating hospitals regularly charge fees to patients eligible to receive free care, resulting in high levels of out-of-pocket payments in and outside the hospital; and that eligible patients lack information about the program. To test whether information is sufficient to enable intended beneficiaries to hold hospitals accountable, we conduct a randomized phone-based information intervention among approximately 1,100 patients requiring chronic kidney disease management. We find that the intervention effectively increases program awareness and triggers some patients to switch provider, but has heterogeneous impacts on patients' ability to obtain cheaper or more comprehensive care. The intervention dramatically reduced out-of-pocket payments for patients at public hospitals, but not at private hospitals. Our findings suggest patient-driven accountability is an important tool in improving service delivery, but may not substitute for top-down monitoring in the context of specialized tertiary care.
Policy blog post: Ideas4India and short Twitter thread summarizing results
Papers in Health Journals
Jain, R., Dupas, P. (2022). The Effects of India's COVID-19 Lockdown on Critical Non-COVID Health Care and Outcomes: Evidence from Dialysis Patients. Social Science and Medicine, 114762.
Policy blog post: Ideas4India (IGC). Media coverage: The Telegraph, The New Indian Express, Mint, DownToEarth. Research summary.
Jain, R., Chopra, A., Falezan, C., Patel, M., Dupas, P. (2021). COVID-19 Related Immunization Disruptions in Rajasthan, India: A Retrospective Observational Study. Vaccine, 39(31), 4343-4350.
Research summary.
Novosad, P., Jain, R., Campion, A., Asher, S. (2020). “The COVID-19 Mortality Effects of Underlying Health Conditions in India: A Modelling Study.” BMJ Open, 10(12), e043165.
Eggleston, K., Jain, R. (2020). “Cost-effective Interventions to Prevent Non-communicable Diseases: Increasing the Evidence Base in India and Other Low- and Middle-income Settings.” BMC Medicine 18(1), 1-3.
Policy blog post: Development Asia (ADB).
New Projects
Strategies to Counteract Intrahousehold Gender Bias in Resource Allocation for Health Care
Strengthening Government Oversight of Private Agents to Improve Health Service Delivery
The Drivers of Gender Disparities Across the Care-seeking Process
Migration, Urbanization, and the Changing Geography of Health and Health Care in India