tions. The national income accounts already measure the monetary flows associated with payments for these goods and services. As noted, however, there are a variety of other inputs to health that also should be measured.

Recommendation 6.2: Market inputs to health such as expenditures on medical care—already measured in the NIPAs—should be included in the health satellite account. The account should go further, however, and measure both the quantity and quality of medical care and include nonmarket inputs relating to time, diet, exercise, and other factors.

The second major health input—care service provided without payment—is missed in the national accounts. There are two types of noncompensated care services—volunteer services and services provided by family members. Many hospitals utilize volunteer labor, for example, to perform tasks ranging from fund raising to providing ambulance service. The more important category of noncompensated services is that of family members who provide care for sick or injured relatives. For an elderly person with infirmities who is cared for by a spouse or child, no monetary transaction is involved, and so the services are not reflected in the national income accounts. This exclusion is particularly important in the case of long-term care services. Recent estimates suggest that the value of nonmonetary long-term care services may be even greater than the value of market-provided services. LaPlante et al., (2002)—using data from the National Health Interview Survey on Disability, a nationally representative household survey conducted between 1994 and 1997—show that more people receive unpaid personal assistance services than paid services, and that the average weekly amount of unpaid help per noninstitutionalized adult is also higher.

It is easy to see the relevance of measuring unpaid care time to health care policy. For example, apparent cost savings associated with recent reductions in the length of hospital stays have been partly offset by an increased nonmarket burden on families who have to care for patients who are discharged “quicker and sicker” (Pamuk et al., 1998). In such a case, policy makers should be aware of both market and nonmarket costs.

Until recently, the data available to measure volunteer and family time devoted to health care activities have been limited. For the past several years, a supplement to the Current Population Survey has collected information on volunteerism, which it defines as persons who do unpaid work for or through an organization. There are real questions, however, about how accurately people can report time devoted to such activities over a period as long as a year and the coding of the type of volunteer work performed is very broad. The information on time use being collected in the American Time Use Survey (ATUS) should be both more accurate and more detailed. Many of the relevant activities will be reported within the “caring for and helping household members” top-level category; some entries in the “caring for and helping non-household members” category also will be relevant.



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