Miriam J. Laugesen

Columbia University
Department of Health Policy and Management

600 W. 168th Street
MSPH Box 14
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My work focuses mainly on the role of interest groups in Medicare physician payment rule making. In a project funded by a Robert Wood Johnson Foundation Investigator Award titled "The Politics of Relative Values" I am focusing on an American Medical Association committee representing physician groups that advises the Centers for Medicare and Medicaid Services (CMS) on the underlying components of the Medicare Fee Schedule. Currently I am working on a book manuscript on this topic. Recently my book coauthored with Robin Gauld titled "Democratic Governance and Health" (Otago University Press, 2012) was published. The book traces the development of local elected hospital boards in New Zealand. These are unique governance structures that have persisted through numerous reform efforts by central governments in New Zealand. Past and ongoing collaborative projects on state health policy have explored state variation in children's health insurance coverage, health insurance regulation and vaccine policies.

Laugesen, M.J. and A. Vargas Bustamante. 2010. "A Patient Mobility Framework that Travels: European and North American-Mexican Comparisons." Health Policy 97 (2-3):225-31.
Abstract: OBJECTIVES: To develop a framework that parsimoniously explains divergent patient mobility in the United States and Europe. METHOD: Review of studies of patient mobility; data from the 2007 Flash Eurobarometer and the 2001 California Health Interview Survey was analyzed; and we reviewed government policies and documents in the United States and Europe. RESULTS: Four types of patient mobility are defined: primary, complementary, duplicative, and institutionalized. Primary exit occurs when people without comprehensive insurance travel because they cannot afford to pay for health insurance or directly finance care, as in the United States and Mexico. Second, people will exit to buy complementary services not covered, or partially covered by domestic health insurance, in both the United States and Europe. Third, in Europe, patient mobility for duplicative services provides faster or better quality treatment. Finally, governments and insurers can encourage institutionalized exit through expanded delivery options and financing. Institutionalized exit is developing in Europe, but uncoordinated and geographically limited in the United States. CONCLUSIONS: This parsimonious framework explains patient mobility by considering domestic health system characteristics relating to cost and quality.
URL: http://www.sciencedirect.com/science/article/pii/S0168851010001302
Laugesen, M.J., R. Wada and E. Chen. 2012. "Setting Doctors' Medicare Fees, CMS Almost Always Accepts The Relative Value Update Committee Panel's Advice on Work Values." Health Affairs 31 (5):965-972.
Abstract: My research encompasses the calculation of physicians' fees under Medicare--which in turn influence the physician fee schedules of other public and private payers--one of the essential decisions the Centers for Medicare and Medicaid Services (CMS) must make is how much physician time and effort, or work, is associated with various physician services. To make this determination, CMS relies on the recommendations of an advisory committee representing national physician organizations. Some experts on primary care who are concerned about the income gap between primary and specialty care providers have blamed the committee for increasing that gap. Our analysis of CMS's decisions on updating work values between 1994 and 2010 found that CMS agreed with 87.4 percent of the committee's recommendations, although CMS reduced recommended work values for a limited number of radiology and medical specialty services. If policy makers or physicians want to change the update process but keep the Medicare fee schedule in its current form, CMS's capacity to review changes in relative value units could be strengthened through long-term investment in the agency's ability to undertake research and analysis of issues such as how the effort and time associated with different physician services is determined, and which specialties--if any--receive higher payments than others as a result.
URL: http://content.healthaffairs.org/content/31/5/965.long
Rabinowitz, A. and M. Laugesen. 2010. "Niche Players in Health Policy: Specialty Society Participation in Congressional Hearings, 1969-2002." Social Science & Medicine 71 (7):1341-1348.
Abstract: Scholars and commentators alike have long used ‘organized medicine’ as shorthand for the American Medical Association (AMA). However, organized medicine has increasingly shown signs of fragmentation into specialty societies over the last two decades. While the AMA remains the largest association of physicians, and wields a great deal of influence in political circles, its use as a proxy for organized medicine may warrant reevaluation due to the changing political organization of medicine. We developed a unique database of specialty medical society appearances before all Congressional committees by combining records from Lexis-Nexis Congressional and the Policy Agendas database. Descriptive statistics were used to evaluate the participation of specialty societies by committee and by hearing type. The Herfindahl–Hirschman Index (HHI) was used to measure whether specialty societies develop niche roles with specific committees, and the Chi-Square Goodness of Fit test was used to study the distribution of specialty society testimonies in health hearings more formally. We found that although the AMA participates in Congressional hearings at a higher rate than any other individual medical specialty society, it accounts for a decreasing percentage of all specialty society appearances over time. In addition, specialty societies have developed niche and monopoly roles in health policymaking as well as relationships with particular congressional committees over time. We conclude that the increasing participation of specialty medical societies in the policymaking process is important because medical societies do not testify solely to promote the economic self-interest of their members. Specialization in medicine has segmented lobbying roles, such that specialty societies have a different focus than the AMA. Thus, ‘organized medicine’ and the AMA are no longer synonymous.
URL: http://www.sciencedirect.com/science/article/pii/S0277953610005344
Rodriguez, H.P., M.J. Laugesen, C.A. Watts. 2010. "A Randomized Experiment of Issue Framing and Voter Support of Tax Increases for Health Insurance Expansion." Health Policy 98:245-55.
Abstract: OBJECTIVE: To assess the effect of issue framing on voter support of tax increases for health insurance expansion. METHODS: During October 2008, a random sample of registered voters (n=1203) were randomized to a control and two different 'framing' groups prior to being asked about their support for tax increases. The 'framing' groups listened to one of two statements: one emphasized the externalities or negative effects of the uninsured on the insured, and the other raised racial and ethnic disparities in health insurance coverage as a problem. All groups were asked the same questions: would they support tax increases to provide adequate and reliable health insurance for three groups, (1) all American citizens, (2) all children, irrespective of citizenship, and (3) all military veterans. RESULTS: Support for tax increases varied substantially depending on which group benefited from the expansion. Consensus on coverage for military veterans was highest (83.3%), followed by all children, irrespective of citizenship (64.7%), and all American citizens (60.1%). There was no statistically significant difference between voter support in the 'framing' and control groups or between the two frames. In multivariable analyses, political party affiliation was the strongest predictor of support. CONCLUSIONS: Voters agree on the need for coverage of military veterans, but are less united on the coverage of all children and American citizens. Framing was less important than party affiliation, suggesting that voters consider coverage expansions and related tax increases in terms of the characteristics of the targeted group, and their own personal political views and values rather than the broader impact of maintaining the status quo.
URL: http://www.sciencedirect.com/science/article/pii/S016885101000179X
Laugesen, M.J. and Robin Gauld. 2012. "Democratic Governance and Health: The History, Role and Performance of Local Health Boards in New Zealand." Dunedin: Otago University Press.
URL: http://www.otago.ac.nz/press/booksauthors/2012/democraticgovernance.html
Gresenz, C.R., M.J. Laugesen, A. Yesus, J.J. Escarce. 2011. "Relative Affordability of Health Insurance Premiums under CHIP Expansion Programs and the ACA." Journal of Health Politics, Policy and Law 36 (3):859-877.
Abstract: Affordability is integral to the success of health care reforms aimed at ensuring universal access to health insurance coverage, and affordability determinations have major policy and practical consequences. This article describes factors that influenced the determination of affordability benchmarks and premium-contribution requirements for Children's Health Insurance Program (CHIP) expansions in three states that sought to universalize access to coverage for youth. It also compares subsidy levels developed in these states to the premium subsidy schedule under the Affordable Care Act (ACA) for health insurance plans purchased through an exchange. We find sizeable variability in premium-contribution requirements for children's coverage as a percentage of family income across the three states and in the progressivity and regressivity of the premium-contribution schedules developed. These findings underscore the ambiguity and subjectivity of affordability standards. Further, our analyses suggest that while the ACA increases the affordability of family coverage for families with incomes below 400 percent of the federal poverty level, the evolution of CHIP over the next five to ten years will continue to have significant implications for low-income families.
URL: http://jhppl.dukejournals.org/content/36/5/859.long
Klein, D. B., Laugesen, M. J. and N. Liu. 2013. "The Patient-Centered Medical Home: A Future Standard for American Healthcare?" Public Administration Review 73:92-93.
Abstract: The patient-centered medical home has been promoted as a way of organizing health service delivery to reduce costs while offering superior health outcomes and coordination of care. The Patient Protection and Affordable Care Act of 2010 promotes the patient-centered medical home as a tool to reshape the delivery of health care in the United States. Preliminary findings from demonstration projects indicate positive overall results in terms of access, quality of care, and cost containment, and the model should continue to be reviewed for potential national adoption. However, there is significant variation in individual medical home setups, reimbursement arrangements, and evaluation methods, making the model difficult to assess, compare, and implement. When developing and evaluating this model, policy makers need to provide continuous support for practice transformation, adopt consistent outcome measures, and have realistic expectations about the timeline for such transformation.
URL: http://onlinelibrary.wiley.com/doi/10.1111/puar.12082/abstract
Vargas Bustamante, A., M. Laugesen, P. Rosenau, and M. Caban. 2012. "U.S.-Mexico Cross-Border Health Insurance Efforts: Prospects for Salud Migrante and Medicare in Mexico.” American Journal of Public Health 31 (1):74-80.
Abstract: While U.S. health care reform will most likely reduce the overall number of uninsured Mexican-Americans, it does not address challenges related to health care coverage for undocumented Mexican immigrants, who will remain uninsured under the measures of the reform; documented low-income Mexican immigrants who have not met the five-year waiting period required for Medicaid benefits; or the growing number of retired U.S. citizens living in Mexico, who lack easy access to Medicare-supported services. This article reviews two promising binational initiatives that could help address these challenges-Salud Migrante and Medicare in Mexico; discusses their prospective applications within the context of U.S. health care reform; and identifies potential challenges to their implementation (legal, political, and regulatory), as well as the possible benefits, including coverage of uninsured Mexican immigrants, and their integration into the U.S. health care system (through Salud Migrante), and access to lower-cost Medicare-supported health care for U.S. retirees in Mexico (Medicare in Mexico).
URL: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892012000100011&lng=en&nrm=iso&tlng=en
Gresenz, C.R., S.E. Edgington, M. J. Laugesen, J.J. Escarce. 2012. "Take-Up of Public Insurance and Crowd-out of Private Insurance Under Recent CHIP Expansions to Higher Income Children." Health Services Research 47 (5):1999-2011.
Abstract: Objective To analyze the effects of states' expansions of Children's Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes. Data Sources 2002–2009 Current Population Survey linked to multiple secondary data sources. Study Design Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year. Principal Findings Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound “crowd-out” rate was estimated to be 46 percent. Conclusions The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.
URL: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2012.01408.x/abstract
Rockers, P.C., M.E. Kruk, M.J. Laugesen. 2012. "Perception of the Health System and Public Trust in Government: Evidence from the World Health Surveys." Journal of Health Politics, Policy and Law 37 (3):405-437.
Abstract: In low- and middle-income countries, health care systems are an important means by which individuals interact with their government. As such, aspects of health systems in these countries may be associated with public trust in government. Greater trust in government may in turn improve governance and government effectiveness. We identify health system and non – health system factors hypothesized to be associated with trust in government and fit several multilevel regression models to cross-national data from 51,300 respondents in thirty-eight low- and middle-income countries participating in the World Health Surveys. We find that health system performance factors are associated with trust in government while controlling for a range of non – health system covariates. Taken together, higher technical quality of health services, more responsive service delivery, fair treatment, better health outcomes, and financial risk protection accounted for a 13 percentage point increase in the probability of having trust in government. Health system performance and good governance may be more inter-related than previously thought. This finding is particularly important for low-income and fragile states, where health systems and governments tend to be weakest. Future research efforts should focus on determining the causal mechanisms that underlie the observed associations between health system performance and trust in government.
URL: http://jhppl.dukejournals.org/content/early/2012/02/08/03616878-1573076.full.pdf
Gresenz, C.R., S.E. Edgington, M. J. Laugesen, J.J. Escarce. 2013. "Income Eligibility Thresholds, Premium Contributions, and Children’s Coverage Outcomes: A Study of CHIP Expansions." Health Services Research 48 (2):884–904.
Abstract: OBJECTIVE: To understand the effects of Children's Health Insurance Program (CHIP) income eligibility thresholds and premium contribution requirements on health insurance coverage outcomes among children. DATA SOURCES: 2002-2009 Annual Social and Economic Supplements of the Current Population Survey linked to data from multiple secondary data sources. STUDY DESIGN: We use a selection correction model to simultaneously estimate program eligibility and coverage outcomes conditional upon eligibility. We simulate the effects of three premium schedules representing a range of generosity levels and the effects of income eligibility thresholds ranging from 200 to 400 percent of the federal poverty line. PRINCIPAL FINDINGS: Premium contribution requirements decrease enrollment in public coverage and increase enrollment in private coverage, with larger effects for greater contribution levels. Our simulation results suggest minimal changes in coverage outcomes from eligibility expansions to higher income families under premium schedules that require more than a modest contribution (medium or high schedules). CONCLUSIONS: Our simulation results are useful counterpoints to previous research that has estimated the average effect of program expansions as they were implemented without disentangling the effects of premiums or other program features. The sensitivity to premiums observed suggests that although contribution requirements may be effective in reducing crowd-out, they also have the potential, depending on the level of contribution required, to nullify the effects of CHIP expansions entirely. The persistence of uninsurance among children under the range of simulated scenarios points to the importance of Affordable Care Act provisions designed to make the process of obtaining coverage transparent and navigable.
URL: http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12039/abstract;jsessionid=48209FDF7D4D6DAFB2D2BEFECB9EAF38.f04t03
Sabik, L.M. and Laugesen, M.J. 2012. "The Impacts of Mandated Benefits on the Labor Market and Small Firms." Inquiry 49 (1):37-51
Abstract: To understand the effects of insurance regulation on the labor market and insurance coverage, this study uses a difference-in-difference-in-differences analysis to compare five states that passed minimum maternity length-of-stay laws with states that waited until after a federal law was passed. On average, we do not find statistically significant effects on labor market outcomes such as hours of work and wages. However, we find that employees of small firms in states with maternity length-of-stay mandates experienced a 6.2-percentage-point decline in the likelihood of having employer-sponsored insurance. Implementation of federal health reform that requires minimum benefit standards should consider the implications for firms of differing sizes.
URL: http://www.ncbi.nlm.nih.gov/pubmed/22650016
Laugesen M. J., and S. A. Glied. 2011. "Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared To Other Countries." Health Affairs 30 (9):1647-56.
Abstract: Higher health care prices in the United States are a key reason that the nation's health spending is so much higher than that of other countries. Our study compared physicians' fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians' incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries' national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians? counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.
Laugesen, M.J. 2011. Civilized Medicine: Physicians and Health Care Reform. Journal of Health Politics, Policy and Law 36. (3):507-512.

Substantive Focus:
Health Policy PRIMARY
Defense and Security
Comparative Public Policy SECONDARY

Theoretical Focus:
Policy History
Policy Process Theory SECONDARY
Agenda-Setting, Adoption, and Implementation PRIMARY