Life years
Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach
Jacob Goldin, Ithai Lurie & Janet McCubbin
NBER Working Paper, December 2019
Abstract:
We evaluate a randomized pilot study in which the IRS sent informational letters to 3.9 million taxpayers who paid a tax penalty for lacking health insurance coverage under the Affordable Care Act. Drawing on administrative data, we study the effect of the intervention on taxpayers' subsequent health insurance enrollment and mortality. We find the intervention led to increased coverage in the two years following treatment and that this additional coverage reduced mortality among middle-aged adults over the same time period. Our results provide the first experimental evidence that health insurance reduces mortality.
Physician Workforce Effect on Health
Elena Falcettoni
Federal Reserve Working Paper, November 2019
Abstract:
Cities attract both more physicians and healthier people, but whether these two facts are causally related is yet to be determined, as many variables are correlated with both the physician concentration and health outcomes. This paper uses unidentifiable claims data from New Hampshire and treatment-effects analysis to address this question and finds that access to an additional physician per 10,000 residents leads to 4.5 saved lives per 100,000 residents. Using aggregate data and an instrumental-variable approach where I use the procedures carried out across areas joint with the policy-set reimbursement fees to instrument for the number of care providers, I show that these results generalize to the US as a whole. The results are robust to many specifications, to variations in the type of care providers considered, and to variations in how the instrument is constructed.
Out-Of-Network Billing And Negotiated Payments For Hospital-Based Physicians
Zack Cooper et al.
Health Affairs, forthcoming
Abstract:
When physicians whom patients do not choose and cannot avoid can bill out of network for care delivered within in-network hospitals, it exposes patients to financial risk and undercuts the functioning of health care markets. Using data for 2015 from a large commercial insurer, we found that at in-network hospitals, 11.8 percent of anesthesiology care, 12.3 percent of care involving a pathologist, 5.6 percent of claims for radiologists, and 11.3 percent of cases involving an assistant surgeon were billed out of network. The ability to bill out of network allows these specialists to negotiate artificially high in-network rates. Out-of-network billing is more prevalent at hospitals in concentrated hospital and insurance markets and at for-profit hospitals. Our estimates show that if these specialists were not able to bill out of network, it would lower physician payments for privately insured patients by 13.4 percent and reduce health care spending for people with employer-sponsored insurance by 3.4 percent (approximately $40 billion annually).
Hospital-Level Care at Home for Acutely Ill Adults: A Randomized Controlled Trial
David Levine et al.
Annals of Internal Medicine, forthcoming
Patients: 91 adults (43 home and 48 control) admitted via the emergency department with selected acute conditions.
Intervention: Acute care at home, including nurse and physician home visits, intravenous medications, remote monitoring, video communication, and point-of-care testing.
Results: The adjusted mean cost of the acute care episode was 38% (95% CI, 24% to 49%) lower for home patients than control patients. Compared with usual care patients, home patients had fewer laboratory orders (median per admission, 3 vs. 15), imaging studies (median, 14% vs. 44%), and consultations (median, 2% vs. 31%). Home patients spent a smaller proportion of the day sedentary (median, 12% vs. 23%) or lying down (median, 18% vs. 55%) and were readmitted less frequently within 30 days (7% vs. 23%).
Medicaid expansions and labor supply among low-income childless adults: Evidence from 2000 to 2013
Cathy Bradley & Lindsay Sabik
International Journal of Health Economics and Management, December 2019, Pages 235-272
Abstract:
Medicaid expansions to low-income childless adults could have unintended effects on labor supply. Using 2000-2013 current population survey data, we exploit changes in adult Medicaid eligibility across states to estimate its effect on labor supply for three samples of adults most likely to be affected by changes in Medicaid eligibility: those with less than a high school degree, a high school degree only, and income less than 300% of the federal poverty line. Medicaid eligibility was associated with a reduction in labor supply for low-income women with a high school degree. In our preferred estimations, these women were about 7 percentage points less likely to be employed than similar women in states without expanded Medicaid. Only a modest reduction was observed for weekly hours worked and then only for women with less than a high school degree and who were hourly employees (about 3 h), leading us to conclude that the effect is largely driven by those who leave the workforce. Older low-income women with a high school degree had the strongest negative response to changes in Medicaid eligibility. They were 17 percentage points less likely to be employed in states that had expanded Medicaid, possibly since these women are motivated to leave employment because they lack access to employer-sponsored insurance and have health needs that can be addressed with Medicaid coverage. Men's employment appeared largely unaffected by changes in Medicaid eligibility.
Medicaid Expansion and the Unemployed
Thomas Buchmueller, Helen Levy & Robert Valletta
NBER Working Paper, December 2019
Abstract:
We examine how a key provision of the Affordable Care Act -- the expansion of Medicaid eligibility -- affected health insurance coverage, access to care, and labor market transitions of unemployed workers. Comparing trends in states that implemented the Medicaid expansion to those that did not, we find that the ACA Medicaid expansion substantially increased insurance coverage and improved access to health care among unemployed workers. We then test whether this strengthening of the safety net affected transitions from unemployment to employment or out of the labor force. We find no meaningful statistical evidence in support of moral hazard effects that reduce job finding or labor force attachment.
Private equity ownership and nursing home quality: An instrumental variables approach
Sean Shenghsiu Huang & John Bowblis
International Journal of Health Economics and Management, December 2019, Pages 273-299
Abstract:
Since the 2000s, private equity (PE) firms have been actively acquiring nursing homes (NH). This has sparked concerns that with stronger profit motive and aggressive use of debt financing, PE ownership may tradeoff quality for higher profits. To empirically address this policy concern, we construct a panel dataset of all for-profit NHs in Ohio from 2005 to 2010 and link it with detailed resident-level data. We compare the quality of care provided to long-stay residents at PE NHs and other for-profit (non-PE) NHs. To account for unobservable resident selection, we use differential distance to the nearest PE NH relative to the nearest non-PE NH in an instrumental variables approach with and without NH fixed effects. In contrast to concerns of the public regarding quality deterioration associated with PE ownership, we find that PE ownership does not lead to lower quality for long-stay NH residents, at least in the medium term.
Effect Of Population Size On Rural Health Insurance Premiums In The Federal Employees Health Benefits Program
Abigail Barker
Health Affairs, December 2019, Pages 2041-2047
Abstract:
In the study of health insurance access and affordability in rural areas, a recurring issue is to understand the challenges that programs based upon the competitive market model, such as the Affordable Care Act's Marketplaces, may experience in less populated areas. This article analyzes data for 2013-16 from the Federal Employees Health Benefits Program, focusing on premium and enrollment data for "state-specific" plans - which offer insurance policies and set premiums at the regional level. In nonmetropolitan counties, each additional plan enrollee was associated with a $0.10 lower per capita biweekly premium, whereas this effect was trivial in metropolitan counties. Low health care provider counts were not associated with higher premiums in nonmetropolitan areas, nor was the degree of insurer competition an important predictor of premiums. However, there was substantial correlation over time, which suggests that some variables may be viewed less as sources of premium variation and more as influencing long-term premium levels. These findings suggest that small risk pools may contribute to the challenges faced by private plans in rural areas, in which case risk reinsurance is a potential policy solution.
The impact of Medicaid expansion on employer provision of health insurance
Jean Abraham, Anne Royalty & Coleman Drake
International Journal of Health Economics and Management, December 2019, Pages 317-340
Abstract:
Using the 2010-2015 Medical Expenditure Panel Survey-Insurance Component, this study investigates the effect of the Affordable Care Act's Medicaid eligibility expansion on four employer-sponsored insurance (ESI) outcomes: offers of health insurance, eligibility, take-up, and the out-of-pocket premium paid by employees for single coverage. Using a difference-in-differences identification strategy, we cannot reject the hypothesis of a zero effect of the Medicaid eligibility expansion on an establishment's probability of offering ESI, the percentage of an establishment's workforce that takes up coverage, or the out-of-pocket premium for single coverage. We find some evidence suggestive of an inverse relationship between the expansion of Medicaid and the percentage of an establishment's workers eligible for ESI. In line with other employer- and individual-level studies of the effect of the ACA on employment-related outcomes, we find that employer provision of health insurance was largely unaffected by the Medicaid expansions.
The Impact of Expanding Public Health Insurance on Safety Net Program Participation: Evidence from the ACA Medicaid Expansion
Lucie Schmidt, Lara Shore-Sheppard & Tara Watson
NBER Working Paper, November 2019
Abstract:
The expansion of public insurance eligibility that occurred with the Affordable Care Act (ACA) Medicaid expansions may have spillover effects to other public assistance programs. We explore the impact of the ACA on two large safety net programs: the Earned Income Tax Credit (EITC) and the Supplemental Nutrition Assistance Program (SNAP). We use a county border-pair research design, examining county-level administrative measures of EITC and SNAP participation in contiguous county pairs that cross state lines where the county on one side of the border experienced the Medicaid expansion and the county on the other side did not. This approach allows us to focus narrowly on differences arising from the ACA Medicaid expansion choice, implicitly controlling for local economic trends that could affect safety net participation. Our results suggest that the Medicaid expansion increased participation in SNAP, and possibly in the EITC, in counties that expanded relative to nearby counties that did not expand. We corroborate and extend these results using individual level data from the American Community Survey (ACS). Our results show that access to one safety net program may increase take-up of others.
Halos and Egos: Rankings and Interspecialty Deference in Multispecialty U.S. Hospitals
Jerry Kim
Management Science, forthcoming
Abstract:
This paper examines how media rankings shift patterns of collaboration and deference between professional groups within organizations. Diversified and multidisciplinary organizations such as universities and hospitals often face distinct subunit evaluations that can influence coordination on interdependent tasks. Using patient-level treatment data for more than five million in-patient stays, I find that changes in the "best hospitals" rankings do not meaningfully shift treatment patterns by physicians in hospitals. However, when specialties were ranked in the top echelons (i.e., top 10) or had high categorical prestige, they were less likely to involve other specialties (i.e., ego effect) and had a higher chance of performing procedures on patients admitted in other specialties (i.e., halo effect). These effects were mostly confined to minor (i.e., less invasive) procedures, implying that the impact of external rankings on patient outcomes is relatively benign.
Do Children on Medicaid Benefit from a Weak Labor Market? Evidence from the Great Recession
Jiajia Chen
University of Illinois Working Paper, November 2019
Abstract:
In this article, I estimate the association between weak labor market conditions and the quantity of office-based physician services received by children enrolled in Medicaid. I find that children use more services in areas with higher unemployment during the Great Recession, and the result is not influenced by changes in sample composition. The association could reflect either demand factors such as worsening health or supply factors such as changes in the number of physicians willing to accept Medicaid patients. I provide several pieces of evidence supporting a supply-side mechanism: higher unemployment reduces the demand for physician services by privately-insured patients. Physicians respond to the demand shock by serving more Medicaid enrollees.
Decision-Making under Cognitive Constraints: Evidence from the Emergency Department
Priya Shanmugam
Harvard Working Paper, November 2019
Abstract:
Complex, high-stakes decisions are often made solely by human experts. However, many of these decisions are made under significant cognitive constraints. I estimate the causal impact of an increase in cognitive constraints on the quality of Emergency Department care using the universe of ED visits across the state of New York from 2005-2015. I define cognitive constraints as a function of variation in the number and complexity of other patients a doctor sees at the same time. Patients who arrive when the ED is busy versus empty are of similar ex-ante health, but differ in how cognitively constrained their physician is. My empirical analysis focuses on two common complaints: chest pains, where decision-making aids in the form of simple risk-scoring tools are plentiful, and abdominal pains, where no such aids are available. I show that constraints improve survival for high-risk patients, even in the absence of aids. However, cognitive constraints increase mortality for low-risk patients, even when aids are present. Constraints cause doctors to admit more high-risk patients into the hospital, and conduct more diagnostic testing instead of hospital admission for low-risk patients. When aids are present, constraints reduce variation in treatment across hospitals, cause patients to receive more uncommon diagnoses, and create significantly larger increases in patient survival relative to the amount of additional care provided to patients, which suggests that aids assist doctors in identifying patients with the highest expected benefits. Overall, a combination of decision aids and discretion is preferred to either one alone, and the optimal combination hinges critically on patient type.
Health Care Reform and Workers' Compensation: Evidence from Massachusetts
Erin Todd Bronchetti & Melissa McInerney
ILR Review, forthcoming
Abstract:
The authors provide evidence of important spillover effects of comprehensive health care reform on workers' compensation (WC) that are likely to reduce WC costs. Using data on more than 20 million emergency room (ER) discharges in Massachusetts and three comparison states, they find that Massachusetts health care reform caused a 6.2 to 8.2% decrease in the per capita number of ER discharges billed to WC. The authors document heterogeneity in the impacts of the reform, shedding light on the mechanisms generating the overall decline in ER discharges billed to WC. Results indicate a larger decrease in WC claiming for weekday admissions than for weekend admissions and for harder-to-verify musculoskeletal discharges than for wounds. The decline in WC discharges is driven both by injured workers increasingly seeking care outside of the ER and by changes in the propensity to bill WC for a given ER discharge.