Katherine Swartz, Ph.D

June 1, 2006

Katherine Swartz, Ph.D. is professor of health policy and economics at the Harvard School of Public Health. Her research interests focus on the population without health insurance and efforts to increase access to health care coverage; reasons for and ways to control episodes of care that involve extremely-high expenditures; and how we might pay for expanded health insurance coverage. She has been conducting research on the uninsured population for almost 25 years, and several HCFO-funded projects played a major role in the content of her just-published book: Reinsuring Health: Why More Middle-Class People Are Uninsured and What Government Can Do, published by the Russell Sage Foundation. The book describes who does not have insurance today and why the middle-class are more likely to be uninsured today than 25 years ago, how insurance companies compete and why people have trouble obtaining health insurance, and why government-sponsored reinsurance for people with very-high expenditures would make small group and individual insurance more accessible and affordable for many of the uninsured. Her proposal about reinsurance is being discussed in a number of states as part of packages of policies they are considering to expand health insurance coverage.

Two HCFO-funded projects played a role in developing Dr. Swartz's premise for Reinsuring Health. The first was a small project funded in 1994, which permitted Swartz to explore ways in which risk is spread to other entities in non-insurance markets. She was interested in alternatives to risk adjustment mechanisms that are intended to compensate health plans that incur adverse risk selection. Swartz closely examined the secondary mortgage market and the futures markets as potential analogs for mechanisms that might permit some risk to be shifted from insurers in the small group and individual markets.

A second HCFO-funded project contributed to Swartz's knowledge of the individual insurance markets, which is a focus of Reinsuring Health. In the late 1990s, Swartz and Deborah Garnick of Brandeis University conducted an evaluation of reforms of New Jersey 's individual health insurance market that had been implemented in 1993. They examined the characteristics of people enrolled in individual policies, what aspects of the reforms most influenced their choices, and what key players perceived as the strengths and weaknesses of the reforms. Swartz and Garnick concluded that New Jersey 's original individual market, know as the Individual Health Coverage Program (IHCP), worked well in terms of offering a variety of insurers and lower premiums to people who could only purchase coverage in the individual market. However, among the mix of incentives to encourage insurer participation, the IHCP had an unsuspected moral hazard (to discourage the mitigation of risk by an individual who has insurance) incentive that led a number of very small insurers to come into the market - something none of the people who crafted the original design for IHCP expected. The small insurers lost money because they under-priced their policies in an effort to gain market share - but almost all of those losses were paid by the larger insurers because of the design of the assessment mechanism for sharing losses. As a result of the losses ($76 million in two years), the small insurers rapidly raised their premiums to try to reduce their enrollees. The increases caused a large number of people to disenroll entirely, even though they could have switched to other insurers. The IHCP loss-sharing assessment mechanism was modified by 1998, but the program has experienced an overall reduction in enrollment relative to its initial years of operation.

Finally, in the late 1980s, Swartz conducted a HCFO-funded study to examine the dynamics of sporadic spells without health insurance. This research offered (and continues to offer) policymakers a different view of the problems of obtaining health insurance. In particular, findings from that project (conducted with John Marcotte and Timothy McBride) showed that about half of all spells without health insurance in the mid-1980s ended within five months but about a quarter lasted more than a year. These findings further demonstrated the extent of heterogeneity among people without health insurance, suggesting again that a variety of policies are needed to reduce the number of uninsured.

In addition to her HCFO-sponsored work, Swartz was the principal investigator for a Commonwealth Fund evaluation of New York State 's Healthy New York Program, which subsidizes health insurance for low-income individuals and small firms with low-wage workers by having a state reinsurance pool for high-cost claims. She conducted this study just as she was outlining the contents of Reinsuring Health, which she began to write during the 2000-01 academic year when she was a Visiting Scholar at the Russell Sage Foundation.

Swartz also is interested in the impact of the mapping of the human genome and its implications for health insurance; in particular, what types of genetic illnesses and conditions will no longer be insurable by private insurance companies, and the role that government may have in providing financing of genetic therapies and tests.

Swartz received her Ph.D. in economics from the University of Wisconsin, Madison and her B.S. in economics from the Massachusetts Institute of Technology. She was a Senior Research Associate at the Urban Institute in Washington, D.C. for ten years before joining the HSPH faculty. Swartz was the 1991 recipient of the Association for Public Policy Analysis and Management's David Kershaw Award for research done before the age of 40 that has had a significant impact on public policy. Since November 1995, she has been the Editor of Inquiry, a journal that focuses on health care organization, provision, and financing.

Dr. Swartz is also a member of HCFO's National Advisory Committee, which provides overall strategic guidance to the program.

For more information on Katherine Swartz, Ph.D., and a list of select publications, please visit her faculty webpage, see www.hsph.harvard.edu/faculty/katherine-swartz/