Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment Net Present Value (NPV) / MBA Resources

Introduction to Net Present Value (NPV) - What is Net Present Value (NPV) ? How it impacts financial decisions regarding project management?

NPV solution for Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment case study

At Oak Spring University, we provide corporate level professional Net Present Value (NPV) case study solution. Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment case study is a Harvard Business School (HBR) case study written by Amitabh Chandra, Anjani Datla. The Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment (referred as “Health Oregon” from here on) case study provides evaluation & decision scenario in field of Leadership & Managing People. It also touches upon business topics such as - Value proposition, Health, Market research, Personnel policies, Social enterprise, Social responsibility.

The net present value (NPV) of an investment proposal is the present value of the proposal’s net cash flows less the proposal’s initial cash outflow. If a project’s NPV is greater than or equal to zero, the project should be accepted.

NPV = Present Value of Future Cash Flows LESS Project’s Initial Investment

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Case Description of Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment Case Study

In 2008, the state of Oregon had the budget to enroll 10,000 individuals into Medicaid. But officials knew that demand for Medicaid would be far greater. To give all poor, uninsured Oregonians a fair chance at receiving health insurance, the state established a lottery. In this simple lottery, renowned economists Katherine Baicker (at Harvard) and Amy Finkelstein (at MIT) found a rare and promising natural experiment. For decades, evidence on the impacts of health insurance on health was dominated by observational studies, which offered inconclusive answers. Under the Oregon lottery, some individuals were randomly selected from a waiting list to receive insurance while others were not, enabling comparison between the two groups, and in effect creating a randomized experiment. The Oregon health experiment, as it came to be known, would finally give economists and policymakers rigorous evidence on how access to health insurance affected the provision and use of health care, and ultimately, influenced the health and well-being of the population. By 2016, as part of the Patient Protection and Affordable Care Act, an estimated 25 million Americans were set to obtain health insurance, 12 million under Medicaid alone; driving home the need to find conclusive answers to these longstanding questions. Case number 2019.0

Case Authors : Amitabh Chandra, Anjani Datla

Topic : Leadership & Managing People

Related Areas : Health, Market research, Personnel policies, Social enterprise, Social responsibility

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Calculating Net Present Value (NPV) at 6% for Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment Case Study

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 6 %	Discounted Cash Flows
Year 0	(10023474)	-10023474	-	-
Year 1	3470415	-6553059	3470415	0.9434	3273976
Year 2	3975527	-2577532	7445942	0.89	3538205
Year 3	3966210	1388678	11412152	0.8396	3330106
Year 4	3222085	4610763	14634237	0.7921	2552193
TOTAL			14634237		12694481

The Net Present Value at 6% discount rate is 2671007

In isolation the NPV number doesn't mean much but put in right context then it is one of the best method to evaluate project returns. In this article we will cover -

Different methods of capital budgeting

What is NPV & Formula of NPV,
How it is calculated,
How to use NPV number for project evaluation, and
Scenario Planning given risks and management priorities.

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Capital Budgeting Approaches

Methods of Capital Budgeting

There are four types of capital budgeting techniques that are widely used in the corporate world –

1. Payback Period
2. Profitability Index
3. Net Present Value
4. Internal Rate of Return

Apart from the Payback period method which is an additive method, rest of the methods are based on Discounted Cash Flow technique. Even though cash flow can be calculated based on the nature of the project, for the simplicity of the article we are assuming that all the expected cash flows are realized at the end of the year.

Discounted Cash Flow approaches provide a more objective basis for evaluating and selecting investment projects. They take into consideration both –

1. Timing of the expected cash flows – stockholders of Health Oregon have higher preference for cash returns over 4-5 years rather than 10-15 years given the nature of the volatility in the industry.
2. Magnitude of both incoming and outgoing cash flows – Projects can be capital intensive, time intensive, or both. Health Oregon shareholders have preference for diversified projects investment rather than prospective high income from a single capital intensive project.

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Formula and Steps to Calculate Net Present Value (NPV) of Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment

NPV = Net Cash In Flowt1 / (1+r)t1 + Net Cash In Flowt2 / (1+r)t2 + … Net Cash In Flowtn / (1+r)tn
Less Net Cash Out Flowt0 / (1+r)t0

Where t = time period, in this case year 1, year 2 and so on.
r = discount rate or return that could be earned using other safe proposition such as fixed deposit or treasury bond rate. Net Cash In Flow – What the firm will get each year.
Net Cash Out Flow – What the firm needs to invest initially in the project.

Step 1 – Understand the nature of the project and calculate cash flow for each year.
Step 2 – Discount those cash flow based on the discount rate.
Step 3 – Add all the discounted cash flow.
Step 4 – Selection of the project

Why Leadership & Managing People Managers need to know Financial Tools such as Net Present Value (NPV)?

In our daily workplace we often come across people and colleagues who are just focused on their core competency and targets they have to deliver. For example marketing managers at Health Oregon often design programs whose objective is to drive brand awareness and customer reach. But how that 30 point increase in brand awareness or 10 point increase in customer touch points will result into shareholders’ value is not specified.

To overcome such scenarios managers at Health Oregon needs to not only know the financial aspect of project management but also needs to have tools to integrate them into part of the project development and monitoring plan.

Calculating Net Present Value (NPV) at 15%

After working through various assumptions we reached a conclusion that risk is far higher than 6%. In a reasonably stable industry with weak competition - 15% discount rate can be a good benchmark.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 15 %	Discounted Cash Flows
Year 0	(10023474)	-10023474	-	-
Year 1	3470415	-6553059	3470415	0.8696	3017752
Year 2	3975527	-2577532	7445942	0.7561	3006070
Year 3	3966210	1388678	11412152	0.6575	2607847
Year 4	3222085	4610763	14634237	0.5718	1842238
TOTAL					10473907

The Net NPV after 4 years is 450433

(10473907 - 10023474 )

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Calculating Net Present Value (NPV) at 20%

If the risk component is high in the industry then we should go for a higher hurdle rate / discount rate of 20%.

Years	Cash Flow	Net Cash Flow	Cumulative     Cash Flow	Discount Rate @ 20 %	Discounted Cash Flows
Year 0	(10023474)	-10023474	-	-
Year 1	3470415	-6553059	3470415	0.8333	2892013
Year 2	3975527	-2577532	7445942	0.6944	2760783
Year 3	3966210	1388678	11412152	0.5787	2295260
Year 4	3222085	4610763	14634237	0.4823	1553860
TOTAL					9501916

The Net NPV after 4 years is -521558

At 20% discount rate the NPV is negative (9501916 - 10023474 ) so ideally we can't select the project if macro and micro factors don't allow financial managers of Health Oregon to discount cash flow at lower discount rates such as 15%.

Acceptance Criteria of a Project based on NPV

Simplest Approach – If the investment project of Health Oregon has a NPV value higher than Zero then finance managers at Health Oregon can ACCEPT the project, otherwise they can reject the project. This means that project will deliver higher returns over the period of time than any alternate investment strategy.

In theory if the required rate of return or discount rate is chosen correctly by finance managers at Health Oregon, then the stock price of the Health Oregon should change by same amount of the NPV. In real world we know that share price also reflects various other factors that can be related to both macro and micro environment.

In the same vein – accepting the project with zero NPV should result in stagnant share price. Finance managers use discount rates as a measure of risk components in the project execution process.

Sensitivity Analysis

Project selection is often a far more complex decision than just choosing it based on the NPV number. Finance managers at Health Oregon should conduct a sensitivity analysis to better understand not only the inherent risk of the projects but also how those risks can be either factored in or mitigated during the project execution. Sensitivity analysis helps in –

What are the uncertainties surrounding the project Initial Cash Outlay (ICO’s). ICO’s often have several different components such as land, machinery, building, and other equipment.

What are the key aspects of the projects that need to be monitored, refined, and retuned for continuous delivery of projected cash flows.

Understanding of risks involved in the project.

What can impact the cash flow of the project.

What will be a multi year spillover effect of various taxation regulations.

Some of the assumptions while using the Discounted Cash Flow Methods –

Projects are assumed to be Mutually Exclusive – This is seldom the came in modern day giant organizations where projects are often inter-related and rejecting a project solely based on NPV can result in sunk cost from a related project.

Independent projects have independent cash flows – As explained in the marketing project – though the project may look independent but in reality it is not as the brand awareness project can be closely associated with the spending on sales promotions and product specific advertising.

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Negotiation Strategy of Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment

References & Further Readings

Amitabh Chandra, Anjani Datla (2018), "Expanding Health Insurance to Millions: Learning from the Oregon Health Insurance Experiment Harvard Business Review Case Study. Published by HBR Publications.