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Show Hingkley Journal of Politics 2006 who are not up to specification in efficiency, quality, or both access to the market anyway. These factors all conspire to raise the cost of providing healthcare, and thus the MCOs will pass the extra costs on to their customers in the form of higher premiums or co-payments. Empirical Evidence Unfortunately, unambiguous data supporting any one conclusion is rare at best. Members of both sides of the debate continually point to a plethora of studies done by various organizations, but there always seems to be some kind of string attached to each one. Other contributing factors are that most AWP legislation is fairly recent, and much of it has been tied up in various levels of the court system. Even the currently available data is rarely impervious to criticism. With these caveats in mind, some of the most commonly cited studies over the past decade are: The Carroll study. AWP supporters like to point out one particular study, published in the December 2002 issue of the Journal of Health Politics, Policy and Law, and entitled "Any-Willing-Provider Laws: Their Financial Effect on HMOs". Conducted by Anne Carroll of Rider University and Jan M. Ambrose of La Salle University (and thus commonly referred to as "The Carroll Study"), it focused on two different types of AWP laws: those that applied only to pharmacies and those that applied to all healthcare providers. However, they kept their study limited only to AWP laws that explicitly affect HMOs. They studied the effects in seven states that apply the law to all healthcare providers (Arkansas, Idaho, Kentucky, Louisiana, Minnesota, New Mexico, and Wyoming), and thirteen that apply it only to pharmacies (Arkansas, Delaware, Georgia, Louisiana, Massachusetts, Mississippi, New Hampshire, New Jersey, North Carolina, South Carolina, South Dakota, Texas and Wisconsin). The researchers went to great lengths to ensure that the study accurately reflected an average HMO by controlling for differences in both the administrative structure of the HMOs and the markets they in which they operate. They acknowl-edge that many outside factors may influence the financial Profitability of an HMO, and they were quite meticulous in controlling for these factors to determine the impact of AWP legislation. They concluded that "all-provider AWP laws do not appear to present a financial constraint to HMOs", but do concede that "pharmacy AWP laws have a greater effect on the financial performance" (Carroll and Ambrose, 2002, p. ^43). In other words, general AWP laws do not seem to have an effect on the profitability of HMOs that are subjected to them. Initially, this conclusion does appear to support the claim toade by proponents that AWP will not in itself raise costs in the healthcare market. After all, if their profitability remains the same, why would an HMO need to raise its premiums? Unfortunately, the findings in the Carroll study are not anywhere near conclusive, as the researchers admit: Because the scope of this study is limited to investigating how AWP laws affect HMO financial performance, we are unable to draw conclusions about the other effects that AWP laws may have in HMO markets. Whether AWP laws. affect enrollment, market entry and exit, premium levels, physi-cians' incomes, patient health, or patient satisfaction are some of the larger questions remaining for future research (Carroll and Ambrose, 2002, pp. 943-944). The Carroll Study simply evaluated past data and concluded that AWP legislation did not directly impede the bottom line of HMOs - but the question of why that did not happen needs to be addressed. Perhaps AWP legislation really does not have a major effect on the functionality of HMOs, or maybe the industry has simply kept their bottom lines intact by increasing their premiums or co-payment levels. The Jensen study. In January of 1999 the Health Insurance Association of America (HIAA) published a study entitled "Employer Sponsored Insurance and Mandated Benefit Laws". Gail A. Jensen of Wayne State University and Michael A. Morrissey of the University of Alabama-Birmingham performed the study. The HIAA asked Jensen and Morrissey "to examine the cost and consequences of [health] benefit mandates" (Jensen and Morrisey, 1999, p. 425); however the legal mandates that were included in the study covered a very wide variety of state and federal legislation - AWP being just one example. Other types of legislation included were state or federal mandates that, among other things, required health insurance plans to cover specific treatments, provide benefits in certain areas (such as dental or psychiatric), or simply to cover the costs associated with some specific conditions or diseases. The study reached four distinct conclusions which support opponents of AWP legislation in varying degrees. Perhaps the most important for their argument is that "there is clear evidence that the increase in numbers of uninsured Americans can be partly tied to [legal] mandates." They also cited the findings of another study that buttresses their conclusion: "The best work on this topic has been done by Sloan and Conover (1998), indicating that a fifth to a quarter of the uninsured are without health insurance because of state mandates." (Jensen and Morrisey, 1999, pp. 453-454). Furthermore, the study found that this rise in costs "falls disproportionately on workers in small firms because these firms are less able to self-insure and avoid the consequences of the mandates." They also concluded that "workers pay for such health insurance mandates in the form of lower wages". (Jensen and Morrisey, p. 453). While this would tend to indicate that employers are passing on the higher costs of health insurance by lowering wages instead of (or before they are) decreasing their insurance coverage, either outcome is unde- 79 |