Seeing Providers
Mortality Effects of Healthcare Supply Shocks: Evidence Using Linked Deaths and Electronic Health Records
Engy Ziedan, Kosali Simon & Coady Wing
NBER Working Paper, October 2022
Abstract:
The contraction in health care consumption at the start of the pandemic provides insight into central economic questions of waste and productivity in the U.S. health care system. Using linked mortality and Electronic Medical Records, we compare people who had outpatient appointments scheduled for dates in 30 day periods immediately before and after the Covid-19 emergency declaration. Appointment cancellation rates were 77% higher for people with appointments in the shutdown period. Intent to treat estimates imply that having a scheduled appointment date right after the emergency declaration increased one-year mortality rates by 4 deaths per 10,000. Instrumental variable estimates suggest that a cancelled appointment increased one-year mortality by 29.7 deaths per 10,000 among compliers, implying that a 10% increase in health care appointments reduces mortality rates by 2.9%. The mortality effects are rooted in two mechanisms: a complier sub-population with high marginal benefits from care, and a cascade of delayed or missed follow-up care that lasted for about 3 months. Healthcare spending accounted for 19.7% of U.S. GDP in 2021, and controlling health spending is a major policy objective. Our results quantify health tradeoffs from cutting every-day non-emergency visits, illustrating the importance of cost-control efforts that differentiate between medical care with the largest and smallest benefits for patient health.
Moving for Health: The Effect of ACA Medicaid Expansion on Homelessness
Johabed Olvera, Julio Alberto Ramos Pastrana & Hilary Wething
Pennsylvania State University Working Paper, October 2022
Abstract:
People who experience homelessness often migrate to new places, seeking more stable access to food, shelter, income, and services. Under the Affordable Care Act, 36 states expanded Medicaid, a means-tested program that increased states' capacity to provide and administer health care and social services to its most vulnerable residents. Using Continuums of Care data from the HUD Point-In-Time Homelessness Count, we evaluate the impact of the Medicaid expansion on homelessness rates. We find that homelessness increased in states that expanded Medicaid by 12 percent and that these increases were primarily driven by unsheltered and chronically homeless populations. The results contribute quasi-experimental evidence to support the welfare magnet hypothesis and show that individuals who have fewer resources and are in a state of permanent homelessness, will migrate to gain access to social services.
Helping Nurses or Hurting Patients: The Effect of Workplace Inspections in Nursing Facilities
Ling Li
American Journal of Health Economics, forthcoming
Abstract:
This study evaluates the impacts of workplace inspections on workplace safety and service quality in nursing facilities. To identify the effect of inspections, I exploit a nationwide program of the Occupational Safety and Health Administration (OSHA), which prioritized establishments for workplace inspections if their injury rates exceeded a threshold. Using a regression discontinuity design and establishment-level data from OSHA and the Centers for Medicare & Medicaid Services (CMS), I find that inspections were associated with fewer nurse injuries, but worse healthcare quality. The results suggest that improving workplace safety may come at the expense of service quality.
The Impact of Social Insurance on Household Debt
Gideon Bornstein & Sasha Indarte
University of Pennsylvania Working Paper, August 2022
Abstract:
This paper investigates how the expansion of social insurance affects households' accumulation of debt. Insurance can reduce reliance on debt by lessening the financial impact of adverse events like illness and job loss. But it can also weaken the motive to self-insure through savings, and households' improved financial resilience can increase access to credit. Using data on 10 million borrowers and a quasi-experimental research design, we estimate the causal effect of expanded insurance on household debt, exploiting ZIP code-level heterogeneity in exposure to the staggered expansions of one of the largest US social insurance programs: Medicaid. We find that a one percentage point increase in a ZIP code's Medicaid-eligible population increases credit card borrowing by 0.74%. Decomposing this effect in a model of household borrowing, we show that increased credit supply in response to households' improved financial resilience fully accounts for this rise in borrowing and contributed 33% of the net welfare gains of expanding Medicaid.
Nathan Petek
Journal of Health Economics, forthcoming
Abstract:
Whether policies that change health care consumption affect health depends on the marginal benefit of the affected health care. I use variation in access to hospitals caused by nearly 1,300 hospital entries and exits to show that hospital entries cause sharp increases and exits cause sharp decreases in the quantity of inpatient care and emergency department visits with no short-term effect on the mortality rate. Thus, preventing hospital exit is not a cost effective way to save lives on average. However, exits of some hospitals with larger impacts on access to care increase the mortality rate and produce lower cost per life saved estimates.
Pathways into Opioid Dependence: Evidence from Practice Variation in Emergency Departments
Sarah Eichmeyer & Jonathan Zhang
American Economic Journal: Applied Economics, October 2022, Pages 271-300
Abstract:
We use practice variation across physicians to uncover the role of medical care in causing opioid dependence. Using health records of 2 million US veterans with emergency department visits, we find that quasi-random assignment to a top (versus bottom) decile prescribing provider significantly increases subsequent opioid use and misuse rates. Instrumental variable results show that opioid prescription receipt leads to a 20 percent increase in the probability of long-term prescription opioid use and sizable increases in the development of opioid use disorder and opioid overdose mortality. We find suggestive evidence of transition into illicit opioids due to prescription opioid exposure.
Effects of Public Price Transparency Tools on Shopping for Health Care
Austin Knies
Indiana University Working Paper, July 2022
Abstract:
Public-facing price transparency tools have become increasingly common, but whether patients actually shop more with access to these tools is unclear. In this paper, I exploit a unique statewide price transparency roll-out to study changes in patient shopping through distance traveled to care. Using a difference-in-differences methodology with Arizona and Iowa inpatient records, I find that price transparency tools have little to no impact on distance to care, while billed charges decrease upon implementation and increase after obsolescence of price transparency reform. I observe this disconnect between distance and charge movement for relatively homogeneous inpatient procedures as well. Medicaid expansion and insurance status, facility closures and openings, and time of year can explain changes in distance to care but not charges. Results suggest that additional steps should be taken to target consumer behavior if curbing health expenditures is the primary goal of price transparency reform.
The Long Arm of Childhood: Does It Vary According to Health Care System Quality?
Matthew Andersson, Lindsay Wilkinson & Markus Schafer
Journal of Health and Social Behavior, forthcoming
Abstract:
Increasing evidence points to the salience of early life experiences in shaping health inequalities, but scant research has considered the role of institutional resources as buffers in this relationship. Health care systems in particular are an understudied yet important context for the generation of inequalities from childhood into adulthood. This research investigates associations between childhood disadvantage and adult morbidity and examines the role of health care system quality in this relationship. We also consider the role of adult socioeconomic status. We merge individual-level data on major disease (2014 European Social Survey) with nation-level health care indicators. Results across subjective and objective approaches to health care system quality are similar, indicating a reduced association between childhood socioeconomic status and adult disease in countries with higher quality health care. In total, our results reiterate the long-term influence of childhood disadvantage on health while suggesting health care's specific role as an institutional resource for ameliorating life course health inequalities.
The Affordable Care Act and regulation: Coverage effects of guaranteed issue and ratings reform
Reagan Baughman
Health Economics, forthcoming
Abstract:
An important part of the Affordable Care Act (ACA) that has received relatively little research attention is regulatory reform in the small and non-group markets, particularly guaranteed issue and rating restrictions. In order to identify the effect of this part of the ACA, I use states that already had these policies before 2014 as a control group for states newly exposed to them under the ACA. Overall, the reforms do not have any effect in states that expanded Medicaid but are associated with a 1.64 percentage point (or 2.16%) increase in the probability of having health insurance coverage in states that did not expand Medicaid. Effects are seen across broad age range, and are strongest for those whose incomes are slightly above the Medicaid threshold and qualify them for the highest Marketplace subsidy levels.
Insurance Subsidies, the Affordable Care Act, and Financial Stability
Samuel Dodini
Journal of Policy Analysis and Management, forthcoming
Abstract:
This paper measures the effects of subsidies in the Affordable Care Act on adverse financial outcomes using administrative tax data and credit data on financial outcomes. Using a difference-in-differences design with propensity score reweighting, I find that at $100 per capita, ACA premium tax credits and cost-sharing reduction subsidies reduced consumer bankruptcies and severe auto delinquency by 8 percent and 7 percent, respectively, and substantially reduced right-tail delinquent debt and third-party collections. The value of recipients' risk protection against medical debt payments amounts to approximately 16 to 21 percent of the cash costs of the subsidies, while the subsidies provided substantial indirect transfers to external parties.