Judging Healthcare

Kevin Lewis

September 21, 2020

Physician-patient racial concordance and disparities in birthing mortality for newborns
Brad Greenwood et al.
Proceedings of the National Academy of Sciences, 1 September 2020, Pages 21194-21200


Recent work has emphasized the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can ameliorate outgroup biases, boost communication, and increase trust. We explore concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. We find no significant improvement in maternal mortality when birthing mothers share race with their physician.

Heterogeneous Effects Of Health Insurance On Birth Related Outcomes: Unpacking Compositional Vs. Direct Changes
Jie Ma & Kosali Simon
NBER Working Paper, August 2020


When women of childbearing age gain health insurance, we expect their birth outcomes to improve, but comparing births that occur before and after policy changes may confound two separate impacts of coverage. For one, health insurance could affect who gives birth, through reduced costs of contraception. Health insurance could also directly improve maternal and child health among those who give birth, through additional prenatal resources. We address this question using the Affordable Care Act young adult provision, comparing birth related outcomes for those aged 24-25 years after the law, to outcomes among older young adults. We show that since the law subsidized contraceptives mainly among higher socioeconomic groups, the composition of mothers shifted towards less advantaged groups. Accounting for this shift, we find evidence of direct improvements in prenatal care and pregnancy-related health (reduced gestational diabetes and hypertension).

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015
Jason Buxbaum et al.
Health Affairs, September 2020, Pages 1546-1556


Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and −7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

The impact of the Affordable Car Act on health care access and self‐assessed health in the Trump Era (2017‐2018)
Charles Courtemanche et al.
Health Services Research, forthcoming

Data Source: The 2011‐2018 waves of the Behavioral Risk Factor Surveillance System (BRFSS), with the sample restricted to nonelderly adults. The BRFSS is a commonly used data source in the ACA literature due to its large number of questions related to access and self‐assessed health. In addition, it is large enough to precisely estimate the effects of state policy interventions, with over 300 000 observations per year.

Design: We estimate difference‐in‐difference‐in‐differences (DDD) models to separately identify the effects of the private and Medicaid expansion portions of the ACA using an identification strategy initially developed in Courtemanche et al (2017). The differences come from: (a) time, (b) state Medicaid expansion status, and (c) local area pre‐2014 uninsured rates. We examine ten outcome variables, including four measures of access and six measures of self‐assessed health. We also examine differences by income and race/ethnicity.

Principal Findings: Despite changes in ACA administration and the political debate surrounding the ACA during 2017 and 2018, including these fourth and fifth years of postreform data suggests continued gains in coverage. In addition, the improvements in reported excellent health that emerged with a lag after ACA implementation continued during 2017 and 2018.

Medicaid Work Requirements In Arkansas: Two-Year Impacts On Coverage, Employment, And Affordability Of Care
Benjamin Sommers et al.
Health Affairs, September 2020, Pages 1522-1530


In June 2018 Arkansas became the first US state to implement work requirements in Medicaid, requiring adults ages 30–49 to work twenty hours a week, participate in “community engagement” activities, or qualify for an exemption to maintain coverage. By April 2019, when a federal judge put the policy on hold, 18,000 adults had already lost coverage. We analyze the policy’s effects before and after these events, using a telephone survey performed in late 2019 of 2,706 low-income adults in Arkansas and three control states compared with data from 2016 and 2018. We have four main findings. First, most of the Medicaid coverage losses in 2018 were reversed in 2019 after the court order. Second, work requirements did not increase employment over eighteen months of follow-up. Third, people in Arkansas ages 30–49 who had lost Medicaid in the prior year experienced adverse consequences: 50 percent reported serious problems paying off medical debt, 56 percent delayed care because of cost, and 64 percent delayed taking medications because of cost. These rates were significantly higher than among Arkansans who remained in Medicaid all year. Finally, awareness of the work requirements remained poor, with more than 70 percent of Arkansans unsure whether the policy was in effect.

The effects of public health insurance on health behaviors: Evidence from the fifth year of Medicaid expansion
Aparna Soni
Health Economics, forthcoming


This study examines the longer term relationship between public health insurance expansions and health behaviors. I leverage geographic and temporal variation in the implementation of the Affordable Care Act‐facilitated Medicaid expansions and provide the first estimates of the expansions' behavioral impacts during their first 5 years. Using national survey data from the 2010 to 2018 Behavioral Risk Factors Surveillance System and a difference‐in‐differences regression design, I show that the Medicaid expansions increase utilization of certain forms of preventive care, while reducing heavy drinking. I also find suggestive evidence that the expansions reduce smoking and increase the probability of exercise. These results stand in contrast with earlier studies that used only 2 or 3 years of postexpansion data and found no detectable effect of the Medicaid expansions on health behaviors in the short run. My results, combined with evidence from previous studies, suggest that public insurance expansions may not prompt an immediate change in health behaviors, but newly eligible populations do increase investments in healthy behaviors over time. In the long run, Medicaid expansions may help reduce engagement in risky behaviors like drinking and smoking among low‐income people.

Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes
Adam Dean, Atheendar Venkataramani & Simeon Kimmel
Health Affairs, forthcoming


More than 40% of all reported coronavirus disease 2019 (COVID-19) deaths in the United States have occurred in nursing homes. As a result, health care worker access to personal protective equipment (PPE) and infection control policies in nursing homes have received increased attention. However, it is not known if the presence of health care worker unions in nursing homes is associated with COVID-19 mortality rates. Therefore, we used cross-sectional regression analysis to examine the association between the presence of health care worker unions and COVID-19 mortality rates in 355 nursing homes in New York State. Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions. Unions were also associated with greater access to PPE, one mechanism that may link unions to lower COVID-19 mortality rates.

Who Pays for Health Care Costs? The Effects of Health Care Prices on Wages
Daniel Arnold & Christopher Whaley
RAND Working Paper, July 2020


Over 150 million Americans receive health insurance benefits from an employer as a form of compensation. In recent years, health care costs have grown rapidly, raising concerns that increased health care spending crowds-out wage increases. We leverage geographic variation in health care price growth caused by changes in hospital market structure, and in particular, mergers, to test the impact of health care prices on wages and benefit design. We find that hospital mergers lead to a $521 increase in hospital prices, a $579 increase in hospital spending among the privately insured population and a similar, $638 reduction in wages. Both the hospital price and spending increases and the reduction in wages are driven by mergers that occur within hospital markets, rather than cross-market hospital mergers. Our results imply that consumers bear the price effects of hospital mergers in the form of reduced wages. We also find evidence of changes in benefit design structure and adoption of high-deductible health plans. Overall, our results show how rising health care costs caused by provider concentration are passed to workers in the form of lower wages and less generous benefits.

What Good Are Treatment Effects without Treatment? Mental Health and the Reluctance to Use Talk Therapy
Christopher Cronin, Matthew Forsstrom & Nicholas Papageorge
NBER Working Paper, August 2020


Mounting evidence across disciplines shows that psychotherapy is more curative than antidepressants for mild-to-moderate depression and anxiety. Yet, few patients use it. This paper develops and estimates a structural model of dynamic decision-making to analyze mental health treatment choices in the context of depression and anxiety. The model incorporates myriad costs suggested in previous work as critical impediments to psychotherapy use. We also integrate links between mental health and labor outcomes to more fully capture the benefits of mental health improvements and the costs of psychotherapy. Finally, the model addresses measurement error in widely-used mental health variables. Using the estimated model, we find that mental health improvements are valuable, both directly through increased utility and indirectly through earnings. We also show that even though psychotherapy improves mental health, counterfactual policy changes, e.g., lowering the price or removing other costs, do very little to increase uptake. We highlight two conclusions. As patient reluctance to use psychotherapy is nearly impervious to a host of a priori reasonable policies, we need to look elsewhere to understand it (e.g., biases in beliefs about treatment effects, stigma, or other factors that are as yet unknown). More broadly, large benefits of psychotherapy estimated in randomized trials tell only half the story. If patients do not use the treatment outside of an experimental setting — and we fail to understand why or how to get them to — estimated treatment effects cannot be leveraged to improve population mental health or social welfare.

Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women
Jamie Daw et al.
Health Affairs, September 2020, Pages 1531-1539


Insurance churn, or moving between different insurance plans or between insurance and uninsurance, is common during the perinatal period. We used survey data from the 2012–17 Pregnancy Risk Assessment Monitoring System to estimate the impact of Affordable Care Act–related state Medicaid expansions on continuity of insurance coverage for low-income women across three time points: preconception, delivery, and postpartum. We found that Medicaid expansion resulted in a 10.1-percentage-point decrease in churning between insurance and uninsurance, representing a 28 percent decrease from the prepolicy baseline in expansion states. This decrease was driven by a 5.8-percentage-point increase in the proportion of women who were continuously insured and a 4.2-percentage-point increase in churning between Medicaid and private insurance. Medicaid expansion improved insurance continuity in the perinatal period for low-income women, which may improve the quality of perinatal health care, but it also increased churning between public and private health insurance.

Are health care scams infectious? Empirical evidence on contagion in health care fraud
Rajeev Goel
Managerial and Decision Economics, forthcoming


This paper examines the presence of contagion in health care fraud across jurisdictional boundaries. Using state‐level data for the United States, we find evidence of contagion in medical fraud. There are also spillovers from border corruption on medical fraud, but no evidence of spillovers from international borders. In other findings, greater urbanization, greater elderly population, and higher hospital occupancy positively contribute to medical fraud, while nursing employment has a mitigating effect. Further, it is economic inequality rather than economic prosperity that seems relevant. The main findings are robust to consideration of simultaneity, but dependent upon the prevalence of fraud across states.

The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events
Sophie Terp et al.
Medical Care, September 2020, Pages 793-799

Objectives: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation.

Materials and Methods: A retrospective analysis of observational data on EMTALA enforcement (2005–2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year.

Results: Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32–1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11–1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0–1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10–1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14–2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital’s ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals.

Conclusions: For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.

The Consequences of Medicare Pricing: An Explanation of Treatment Choice
Elena Falcettoni
Federal Reserve Working Paper, August 2020


Primary care physicians (PCPs) provide more specialty procedures in less-urban areas, where specialists are fewer. Using a structural random-coefficient model and the demographic and time variation in the data, this paper shows that changes in policy-set reimbursements lead to a reallocation of the suddenly-more-remunerative procedures away from specialists and toward PCPs, and this effect is stronger, the more rural an area is. A reimbursement-unit increase for a given procedure leads to outside-metro PCPs gaining 7-15% market share more than metro PCPs in that procedure, at the expense of specialists. Small metropolitan areas and very rural areas are the most affected.

Evaluating inpatient adverse outcomes under California's Delivery System Reform Incentive Payment Program
Michelle Keller et al.
Health Services Research, forthcoming

Objective: The California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program's impact on reductions in sepsis mortality, central line–associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital‐acquired pressure ulcers (HAPUs).

Study Design: We used a pre‐post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing.

Principal Findings: Discharges from DPHs and non‐DPHs both saw decreases in the four outcomes over the DSRIP period (2010‐2014). The difference‐in‐difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: −2.90 percent, 95% CI: −5.08, −0.72 percent) and 2010 with 2014 (DD: −5.74, 95% CI: −8.76 percent, −2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: −1.30, 95% CI: −3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: −3.05 percent, 95% CI: −6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non‐DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010.

Conclusions: We did not find that DPHs participating in DSRIP outperformed non‐DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.


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