The impact of scope-of-practice restrictions on access to medical care
Jiapei Guo, Angela Kilby & Mindy Marks
Journal of Health Economics, March 2024
We study the impact of scope-of-practice laws in a highly regulated and important policy setting, the provision of medication-assisted treatment for opioid use disorder. We consider two natural experiments generated by policy changes at the state and federal level that allow nurse practitioners more practice autonomy. Both experiments show that liberalizations of prescribing authority lead to large improvements in access to care. Further, we use rich address-level data to answer key policy questions. Expanding nurse practitioner prescribing authority reduces urban-rural disparities in health care access. Additionally, expanded autonomy increases access to care provided by physicians, driven by complementarities between providers.
Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs
Caroline King et al.
Health Affairs, January 2024, Pages 64-71
Drug overdose deaths among adolescents are increasing in the United States. Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. Using the Substance Abuse and Mental Health Services Administration’s treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.
Price Sensitivity and Information Barriers to the Take-up of Naloxone
Mireille Jacobson & David Powell
NBER Working Paper, January 2024
We conducted a field experiment that randomized advertisements, advertisement content, and prices across 2,204 counties in the United States to study the impacts on online purchases of naloxone, an opioid overdose reversal drug. Advertising increased website users but only impacted purchases when combined with a price reduction. Messages emphasizing the discreet nature of online sales had no additional impact on purchases. Comparing counties with advertisements featuring a highly discounted price to those featuring the full price, we estimate a price elasticity of demand for online naloxone of -1.3. Price is a significant barrier to online purchases of this life-saving medication.
“Long GFC”? The global financial crisis, health care, and COVID-19 deaths
Antonio Moreno et al.
Economic Inquiry, forthcoming
Do financial crises affect long-term public health? To answer this question, we examined the relationship between the 2007–2009 Global Financial Crisis (GFC) and the 2020–2022 COVID-19 pandemic. Specifically, we examined the relationship between the financial losses derived from the GFC, and the health outcomes associated with the first wave of the pandemic. European countries that were more affected by the financial crisis had more deaths relative to coronavirus cases. An analogous relationship emerged across Spanish provinces and US states. Part of the transmission from finances to health outcomes appears to have occurred through cross-sectional differences in health care facilities.
The Impact of Youth Medicaid Eligibility on Adult Incarceration
Samuel Arenberg, Seth Neller & Sam Stripling
American Economic Journal: Applied Economics, January 2024, Pages 121-156
This paper identifies an important spillover associated with public health insurance: reduced incarceration. In 1990, Congress passed legislation that increased Medicaid eligibility for individuals born after September 30, 1983. We show that Black children born just after the cutoff are 5 percent less likely to be incarcerated by age 28, driven primarily by a decrease in incarcerations connected to financially motivated offenses. Children of other races, who experienced almost no gain in Medicaid coverage as a result of the policy, demonstrate no such decline. We find that reduced incarceration in adulthood substantially offsets the initial costs of expanding eligibility.
Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition
Sneha Kannan, Joseph Dov Bruch & Zirui Song
Journal of the American Medical Association, 26 December 2023, Pages 2365-2375
Design, Setting, and Participants: Data from 100% Medicare Part A claims for 662 095 hospitalizations at 51 private equity–acquired hospitals were compared with data for 4 160 720 hospitalizations at 259 matched control hospitals (not acquired by private equity) for hospital stays between 2009 and 2019. An event study, difference-in-differences design was used to assess hospitalizations from 3 years before to 3 years after private equity acquisition using a linear model that was adjusted for patient and hospital attributes.
Results: Hospital-acquired adverse events (or conditions) were observed within 10 091 hospitalizations. After private equity acquisition, Medicare beneficiaries admitted to private equity hospitals experienced a 25.4% increase in hospital-acquired conditions compared with those treated at control hospitals (4.6 [95% CI, 2.0-7.2] additional hospital-acquired conditions per 10 000 hospitalizations, P = .004). This increase in hospital-acquired conditions was driven by a 27.3% increase in falls (P = .02) and a 37.7% increase in central line–associated bloodstream infections (P = .04) at private equity hospitals, despite placing 16.2% fewer central lines. Surgical site infections doubled from 10.8 to 21.6 per 10 000 hospitalizations at private equity hospitals despite an 8.1% reduction in surgical volume; meanwhile, such infections decreased at control hospitals, though statistical precision of the between-group comparison was limited by the smaller sample size of surgical hospitalizations. Compared with Medicare beneficiaries treated at control hospitals, those treated at private equity hospitals were modestly younger, less likely to be dually eligible for Medicare and Medicaid, and more often transferred to other acute care hospitals after shorter lengths of stay. In-hospital mortality (n = 162 652 in the population or 3.4% on average) decreased slightly at private equity hospitals compared with the control hospitals; there was no differential change in mortality by 30 days after hospital discharge.
Discovery of a structural class of antibiotics with explainable deep learning
Felix Wong et al.
The discovery of novel structural classes of antibiotics is urgently needed to address the ongoing antibiotic resistance crisis. Deep learning approaches have aided in exploring chemical spaces; these typically use black box models and do not provide chemical insights. Here we reasoned that the chemical substructures associated with antibiotic activity learned by neural network models can be identified and used to predict structural classes of antibiotics. We tested this hypothesis by developing an explainable, substructure-based approach for the efficient, deep learning-guided exploration of chemical spaces. We determined the antibiotic activities and human cell cytotoxicity profiles of 39,312 compounds and applied ensembles of graph neural networks to predict antibiotic activity and cytotoxicity for 12,076,365 compounds. Using explainable graph algorithms, we identified substructure-based rationales for compounds with high predicted antibiotic activity and low predicted cytotoxicity. We empirically tested 283 compounds and found that compounds exhibiting antibiotic activity against Staphylococcus aureus were enriched in putative structural classes arising from rationales. Of these structural classes of compounds, one is selective against methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci, evades substantial resistance, and reduces bacterial titres in mouse models of MRSA skin and systemic thigh infection. Our approach enables the deep learning-guided discovery of structural classes of antibiotics and demonstrates that machine learning models in drug discovery can be explainable, providing insights into the chemical substructures that underlie selective antibiotic activity.
Medicaid generosity and food hardship among children
Nicholas Moellman & Cody Vaughn
Journal of Policy Analysis and Management, forthcoming
We explore the role of the largest means-tested transfer program, Medicaid, on multiple measures of food hardship among households with children, including measures that capture hardship explicitly experienced by children. Using data from the 2001 to 2020 waves of the December Current Population Survey, we identify the effect of having a Medicaid-eligible child on household food hardship by exploiting between-state, over-time, and between-household income eligibility criteria. We find that having an eligible child reduces rates of household food insecurity and very low food security by 20% and 26%, respectively. Among children themselves, eligibility reduces rates of food insecurity and very low food security by 22% each. The effects are stronger for households headed by Black and Hispanic individuals as well as households that have children under 6 years old.
Patient Costs and Physicians' Information
Michael Dickstein, Jihye Jeon & Eduardo Morales
NBER Working Paper, January 2024
Health insurance plans in the U.S. increasingly use price mechanisms to steer demand for prescription drugs. The effectiveness of these incentives, however, depends both on physicians' price sensitivity and their knowledge of patient prices. We develop a moment inequality model that allows researchers to identify agents' preferences without fully specifying their information. Applying this model to diabetes care, we find that physicians lack detailed price information and are more price-elastic than full-information models imply. We predict that providing physicians detailed information on prices at the point of prescribing can save patients 12-23% of their out-of-pocket costs for diabetes treatment.
Time Aggregation in Health Insurance Deductibles
Long Hong & Corina Mommaerts
American Economic Journal: Economic Policy, forthcoming
Health insurance plans increasingly pay for expenses only beyond a large annual deductible. This paper explores the implications of deductibles that reset over shorter timespans. We develop a model of insurance demand between two actuarially equivalent deductible policies, in which one deductible is larger and resets annually and the other deductible is smaller and resets biannually. Our model incorporates borrowing constraints, moral hazard, mid-year contract switching, and delayable care. Calibrations using claims data show that the liquidity benefits of resetting deductibles can generate welfare gains of 3–10% of premium costs, particularly for individuals with borrowing constraints.
Accessing the Safety Net: How Medicaid Affects Health and Recidivism
Analisa Packham & David Slusky
NBER Working Paper, December 2023
We estimate the causal impact of access to means-tested public health insurance coverage (Medicaid) on health outcomes and recidivism for those recently released from incarceration. To do so, we leverage a policy change in South Carolina that allowed simplified Medicaid re-enrollment for previously incarcerated eligible individuals. Using linked administrative data on criminal convictions and health insurance claims, we find that reducing barriers in access to Medicaid for vulnerable populations increases enrollment and utilization of health care services. However, we do not find that this improved health care insurance access reduces 1-year or 3-year recidivism, suggesting that effectiveness of such policies is context dependent.
Did the Affordable Care Act's Medicaid eligibility expansions crowd out private health insurance coverage?
Journal of Policy Analysis and Management, forthcoming
The Affordable Care Act (ACA) provided funding to help states expand Medicaid eligibility to those earning up to 138% of the Federal Poverty Level. Such expansions in Medicaid eligibility, however, could “crowd out” private insurance coverage, including changes in coverage relating to other ACA provisions. To estimate the extent of such crowd out, I use a difference-in-differences empirical approach, examining changes in health insurance coverage sources among low-income Americans in states that expanded eligibility relative to comparable individuals in states that did not. Using American Community Survey data from 2009 to 2019, I find a 43% crowd-out rate, consisting of a 10.7 percentage point relative increase in Medicaid coverage among low-income adults and a 4.6 percentage point relative decline in private health insurance among respondents in states that expanded Medicaid eligibility. Among working adults, my estimates imply a larger 56% rate of crowding out. Event study analyses provide support for a causal interpretation for my findings. I further show that my estimates are robust to different sample restrictions and estimation choices, are not subject to the issues raised by the new difference-in-differences literature, and are similar when I use approaches to identifying crowd out common in the existing literature.