1. Medicare Growth, Technological Advances, and the Distribution of Health Care Benefits Jonathan Skinner Weiping Zhou

2. A Simple Question Have the billions of health care dollars spent during the 1990s improved or worsened inequality in health and well- being in the elderly population?

3. A Not So Simple Answer Expenditures/utilization for health care: High income people get: Less (Battachyaria and Lakdawalla, 2003)) More (Le Grand, 1982; McClellan and Skinner, 2003, Sanchez et. al., 1992).

4. A Not So Simple Answer Improvements in Outcomes: High education / non- minority people get Less (McDermott, 1978) More ( (Glied and Lleras-Muney, 2003; Goldman and Smith, 2002; Lichtenberg and Lleras-Muney, 2002)

5. A Not So Simple Answer Improvements in Outcomes: High education / non- minority people get Less (McDermott, 1978) More ( (Glied and Lleras-Muney, 2003; Goldman and Smith, 2002; Lichtenberg and Lleras-Muney, 2002) How do you measure inequality in health or in full income anyway?

6. Our Strategy Expenditures: Fuchs proto-full income measure (Medicare expenditures plus adjusted CPS income) –Data sources: Current Medicare History Survey (CMHS), CPS

7. Our Strategy Expenditures: Fuchs proto-full income measure (Medicare expenditures plus adjusted CPS income) –Data sources: Current Medicare History Survey (CMHS), CPS Outcomes: CMHS Utilization: Cooperative Cardiovascular Project (CCP) data on heart attack patients (1994/95) Two measures of income: per capita family (CPS) and zip code (CMHS, CCP)

8. Percentage Increase in Money Income 1992-2001

9. Percentage Increase in Full Income (1): Money Income plus Medicare Expenditures, 1992-2001

10. Medicare Expenditures (Males Age 80-84) 1987 and 1997, by Income Decile Source: McClellan and Skinner, 2003

11. How Big is a Big Twist? Decile 10 spending increase ($3300) less Decile 1 spending increase ($1600)

12. How Big is a Big Twist? Decile 10 spending increase ($3300) less Decile 1 spending increase ($1600) Average EITC Payments per family receiving EITC (1997) Source: Brookings-Urban Website

13. Average Home Health Care Spending By Decile 1987-2001: Men Age 80-84 in 1987 1997$ 0 500 1000 1500 2000 2500 1987 1989 1991 1993 1995 1997 1999 2001 Lowest Income Decile Highest Income Decile

14. Home Health Care Expenditures 1996 by Region

15. Next Measure: Changes over time in Income Including Lifespan

16. How Does One Place a Dollar Value on Lifespan Extension? Approach number 1: value gains in life-years for low income households by more (Cost-Benefit Analysis) Approach number 2: Value gains in life-years for low income households by less (Becker et. al. “WTP”)

17. 10-Year Survival Rates Rose in Highest Income Deciles by More than in Lowest Income Deciles 1982-91 1992-2001

18. Percentage Increase in Full Income (2): Money Income plus Value of Life Extension, 1992-2001

19. A Third Approach: Focus on Utilization of “Effective” Technological Innovations

20. Causes of 90-Day AMI Mortality Decline, 1975-1990 Source: Heidenrich and McClellan, 2001 No Significant Impact: CABG, calcium antagonists, PTCA (non-primary), nitrates, anticoagulants, etc.

21. Effective Care Following AMI: By Zip Code Income Beta Blocker ACE Inhibitor Reper- fusion Smoking Cessation Advice Decile 1 40573233 Decile 10 47593735 Difference 7252

22. Percent of “Ideal” Patients Receiving Beta Blockers at Discharge Following AMI (1994-95) Beta Blocker Use By Region Source: Dartmouth Atlas

23. Income per Capita in 2000 and Average 1-Year AMI Mortality (1989-2000) by State

24. Putnam’s Social Capital Index and Average 1-Year Mortality (1989-2000) by State

25. Medicare Expenditures (Age 70-74 M) by Year (1982-91 or 1992-2001) Decile 1 in 1992 Decile 10 in 1992 Decile 1,10 in 1982