Blocking FcRn in humans reduces circulating IgG levels and inhibits IgG immune complex-mediated immune responses.

The neonatal crystallizable fragment receptor (FcRn) functions as an intracellular protection receptor for immunoglobulin G (IgG). Recently, several clinical studies have reported the lowering of circulating monomeric IgG levels through FcRn blockade for the potential treatment of autoimmune diseases. Many autoimmune diseases, however, are derived from the effects of IgG immune complexes (ICs). We generated, characterized, and assessed the effects of SYNT001, a FcRn-blocking monoclonal antibody, in mice, nonhuman primates (NHPs), and humans. SYNT001 decreased all IgG subtypes and IgG ICs in the circulation of humans, as we show in a first-in-human phase 1, single ascending dose study. In addition, IgG IC induction of inflammatory pathways was dependent on FcRn and inhibited by SYNT001. These studies expand the role of FcRn in humans by showing that it controls not only IgG protection from catabolism but also inflammatory pathways associated with IgG ICs involved in a variety of autoimmune diseases.

Worker decisions to purchase health insurance.

Studying worker health insurance choices is usually limited by the absence of price data for workers who decline their employer's offer. This paper uses a new Medical Expenditure Panel Survey file which links household and employer survey respondents, supplying data for both employer insurance takers and declines. We test for whether out-of-pocket or total premium better explains worker behavior, estimate price elasticities with observed prices and with imputed prices, and test for worker sorting among jobs with and without health insurance. We find that out-of-pocket price dominates, that there is some upward bias from estimating elasticities with imputed premiums rather than observed premiums, and that workers do sort among jobs but this does not affect elasticity estimates appreciably. Like earlier studies with less representative worker samples, we find worker price elasticity of demand to be quite low. This suggests that any premium subsidies must be large to elicit much change in worker take-up behavior.

The health status of workers who decline employer-sponsored insurance.

This paper uses data from the 1997 National Health Interview Survey to compare workers who decline employers' offers of health insurance (decliners) with comparison groups of workers who take up offers of employer coverage and those who do not have such offers. Uninsured decliners fare much worse than coverage takers on every mental health measure. While the evidence on physical health measures is somewhat mixed, decliners who are not healthy appear to have greater difficulty obtaining needed services than do workers who take up employer coverage, although decliners tend to have somewhat better access than do the uninsured who are not offered such coverage.

Did the Medicaid expansions for children displace private insurance? An analysis using the SIPP.

Using data from the 1990 panel of the Survey of Income and Program Participation (SIPP), we address the question: Did the Medicaid expansions for children cause declines in private coverage? We use a multivariate approach that attributes a displacement effect to declines in private coverage for children targeted by the Medicaid expansions exceeding declines for a comparison group of older low-income children. We find that 23% of the movement from private coverage to Medicaid due to the expansions was attributable to displacement. There is no evidence of displacement among those starting uninsured, leading to an overall displacement effect of 4%.

A different kind of 'new federalism'? The Health Insurance Portability and Accountability Act of 1996.

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has been praised and criticized for asserting federal authority to regulate health insurance. We review the history of federalism and insurance regulation and find that HIPAA is less of a departure from traditional federal authority than it is an application of existing tools to meet evolving health policy goals. This interpretation could clarify future health policy debates about appropriate federal and state responsibilities. We also report on the insurance environments and the HIPAA implementation choices of thirteen states. We conclude with criteria for judging the success of HIPAA and the evolving federal/state partnership in health insurance regulation.

Reform of the Medicare AAPCC: learning from previous proposals. Average Adjusted Per Capita Costs.

Since 1982, Medicare has contracted with health maintenance organizations (HMOs) on a risk-contract basis, paying plans based on Average Adjusted Per Capita Costs (AAPCCs). The calculation of the AAPCCs has been criticized on several fronts. A congressional proposal encompassed in the failed 1995 Balanced Budget Act would have altered the formula by which Medicare determines payments to risk-contracting HMOs. Many of its provisions were enacted through the 1997 Balanced Budget Act. This paper models the effect of the earlier proposal on AAPCC rates and discusses the extent to which the proposal and the reforms in the 1995 Balanced Budget Act would address shortcomings identified in the original rate formula.

The Health Insurance Portability and Accountability Act of 1996: summary of provisions and anticipated effects.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA; PL 104-191), popularly known as the Kassebaum-Kennedy legislation, contains a broad array of provisions with collective implications for a large segment of the population. The legislation contains provisions affecting the private insurance markets, the federal tax code, and strategies for decreasing fraud and abuse and for increasing the simplification of administrative procedures. Two objectives hold together the disparate pieces of this legislation. The first objective is to improve the accessibility of insurance for individuals with preexisting medical conditions. The second objective is to make health insurance and health services more affordable. This article is designed to provide an overview of the multiple components of HIPAA, and to identify the parties that are likely to be affected by each component. It concludes with a discussion of how well HIPAA can be expected to fulfill its two goals.

First, do no harm: developing health insurance market reform packages.

Health insurance reform is complex, and discussions about preferred reforms are often marked by confusion. This paper focuses on the fundamental issue: how best to address adverse selection. We develop four reform packages that could improve insurance market performance without aggravating risk selection problems. We then compare the principles applied in our packages with two specific proposals that formed the basis for the compromise federal legislation passed in August 1996. We also review the evidence to date on the effects of small-group reforms on health insurance markets in various states, and conclude with suggestions for further research.

Strategies for implementing global budgets.

Implementing global budgets requires setting a desired level of spending as well as establishing a set of policies to assure the budget will be met. Four alternative approaches are analyzed: one relies on all-payer rate setting coupled with volume controls; the second is a system of premium regulation that controls both the levels and rates of insurance premium increase; in another system, price competition among insuring organizations limits growth in spending while incorporating a global budget that limits the aggregate costs of all premiums; finally, either managed competition or premium regulation is combined with all-payer rate setting. The fourth model is singled out for its ability to control costs. An independent policy toward capital expenditures could increase the likelihood of success under any of the strategies.