Race for the cure
More Insurers Lower Premiums: Evidence from Initial Pricing in the Health Insurance Marketplaces
Leemore Dafny, Jonathan Gruber & Christopher Ody
NBER Working Paper, May 2014
Abstract:
First-year insurer participation in the Health Insurance Marketplaces (HIMs) established by the Affordable Care Act is limited in many areas of the country. There are 3.9 participants, on (population-weighted) average, in the 395 ratings areas spanning the 34 states with federally facilitated marketplaces (FFMs). Using data on the plans offered in the FFMs, together with predicted market shares for exchange participants (estimated using 2011 insurer-state market shares in the individual insurance market), we study the impact of competition on premiums. We exploit variation in ratings-area-level competition induced by United Healthcare’s decision not to participate in any of the FFMs. We estimate that United’s nonparticipation decision raised the second-lowest-price silver premium (which is directly linked to federal subsidies) by 5.4 percent, on average. If all insurers active in each state’s individual insurance market in 2011 had participated in all ratings areas in that state’s HIM, we estimate this key premium would be 11.1% lower and 2014 federal subsidies would be reduced by $1.7 billion.
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Adam Bonica, Howard Rosenthal & David Rothman
JAMA Internal Medicine, forthcoming
Objective: To analyze campaign contributions that physicians made from the 1991 to 1992 through the 2011 to 2012 election cycles to Republican and Democratic candidates in presidential and congressional races and to partisan organizations, including party committees and super political action committees (Super PACs).
Design, Setting, and Participants: We explored partisan differences in physician contributions by sex, for-profit vs nonprofit practice setting, and specialty using multiple regression analysis. We studied the relation between the variation in the mean annual income across specialties and the mean percentage of physicians within each specialty contributing to Republicans.
Results: Between the 1991 to 1992 and the 2011 to 2012 election cycles, physician campaign contributions increased from $20 million to $189 million, and the percentage of active physicians contributing increased from 2.6% to 9.4%. Of physicians who contributed during the study period, the mean percentage contributing to Republicans was 57% for men and 31% for women. Since 1996, the percentage of physicians contributing to Republicans has decreased, to less than 50% in the 2007 to 2008 election cycle and again in the 2011 to 2012 election cycle. Contributions to Republicans in 2011 to 2012 were more prevalent among men vs women (52.3% vs 23.6%), physicians practicing in for-profit vs nonprofit organizations (53.2% vs 25.6%), and surgeons vs pediatricians (70.2% vs 22.1%). In 1991 to 1992, these contribution gaps were smaller: for sex, 54.5% vs 30.9%; for organizations, 54.2% vs 40.0%; and for specialty, 65.5% vs 32.7%. The percentage of physicians contributing to Republicans across specialties correlated 0.84 with the mean log earnings of each specialty; specialties with higher mean earnings had higher percentages of physicians contributing to Republicans.
Conclusions and Relevance: Between 1991 and 2012, the political alignment of US physicians shifted from predominantly Republican toward the Democrats. The variables driving this change, including the increasing percentage of female physicians and the decreasing percentage of physicians in solo and small practices, are likely to drive further changes.
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The Effect of Child Health Insurance Access on Schooling: Evidence from Public Insurance Expansions
Sarah Cohodes et al.
NBER Working Paper, May 2014
Abstract:
Public health insurance programs comprise a large share of federal and state government expenditure, and these programs are due to be expanded as part of the 2010 Affordable Care Act. Despite a large literature on the effects of these programs on health care utilization and health outcomes, little prior work has examined the long-term effects of these programs and resultant health improvements on important outcomes, such as educational attainment. We contribute to filling this gap in the literature by examining the effects of the public insurance expansions among children in the 1980s and 1990s on their future educational attainment. Our findings indicate that expanding health insurance coverage for low-income children has large effects on high school completion, college attendance and college completion. These estimates are robust to only using federal Medicaid expansions, and they are mostly due to expansions that occur when the children are older (i.e., not newborns). We present suggestive evidence that better health is one of the mechanisms driving our results by showing that Medicaid eligibility when young translated into better teen health. Overall, our results indicate that the long-run benefits of public health insurance are substantial.
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Health-Insurer Bargaining Power and Firms' Incentives to Manage Earnings
Francesco Bova, Yiwei Dou & Ole-Kristian Hope
University of Toronto Working Paper, May 2014
Abstract:
Health-insurance premiums account for a significant portion of the cost base of U.S. corporations. A recent study in The American Economic Review (Dafny 2010) finds that health-insurance premiums increase for firms that experience positive profit shocks, suggesting that the health-insurance market is not perfectly competitive. Motivated by this finding and the economic importance of health-insurance premiums, this is the first study to examine firms’ earnings-management incentives in the face of insurance carriers with strong bargaining power. Using an innovative dataset for a large sample of U.S. firms with detailed information on insurance premiums and insurance-plan characteristics, we find that firms manage their reported earnings downward when insurance providers have strong bargaining power. This finding holds using both association tests and a natural experiment. We further show that this effect is more pronounced in settings in which there are ex-ante reasons to expect stronger incentives to manage earnings. We also provide preliminary evidence suggesting that downward earnings management has the intended effect of reducing future health-insurance premiums. Our analyses highlight an inefficient health-insurance market as an important determinant of firms’ accounting choices.
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Silvia Barbaresco, Charles Courtemanche & Yanling Qi
NBER Working Paper, May 2014
Abstract:
The first major insurance expansion of the Affordable Care Act – a provision requiring insurers to allow dependents to remain on parents’ health insurance until turning 26 – took effect in September 2010. We estimate this mandate’s impacts on numerous health-related outcomes using a difference-in-differences approach with 23-25 year olds as the treatment group and 27-29 year olds as the control group. For the full sample, the dependent coverage provision increased the probabilities of having insurance, a primary care doctor, and excellent self-assessed health, while decreasing unmet medical needs because of cost. However, we find no evidence of improvements in preventive care utilization or health behaviors. Subsample analyses reveal particularly striking gains for college graduates, including reduced obesity. Finally, we show that the mandate’s impacts on 19-22 year olds were generally weaker than those on 23-25 year olds, although we observe a reduction in pregnancies for unmarried 19-22 year old women.
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Do Physicians Possess Market Power?
Abe Dunn & Adam Hale Shapiro
Journal of Law and Economics, February 2014, Pages 159-193
Abstract:
We study the degree to which greater physician concentration leads to higher service prices charged by physicians in the commercially insured medical care market. Using a database of physicians throughout the United States, we construct physician-firm concentration measures based on market boundaries defined by fixed driving times, which we label the fixed-travel-time Herfindahl-Hirschman index. We link these concentration measures to health insurance claims. We find that physicians in more concentrated markets charge higher service prices; a physician in the 90th percentile of market concentration will charge 14–30 percent higher fees than a physician in the 10th percentile. Our estimates imply that physician consolidation has caused about an 8 percent increase in fees on average over the last 20 years and substantially higher increases in concentrated markets.
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The Effect of Public Insurance Coverage for Childless Adults on Labor Supply
Laura Dague, Thomas DeLeire & Lindsey Leininger
NBER Working Paper, May 2014
Abstract:
This study provides plausibly causal estimates of the effect of public insurance coverage on the employment of non-elderly, non-disabled adults without dependent children (“childless adults”). We use regression discontinuity and propensity score matching difference-in-differences methods to take advantage of the sudden imposition of an enrollment cap, comparing the labor supply of enrollees to eligible applicants on a waitlist. We find enrollment into public insurance leads to sizable and statistically meaningful reductions in employment up to at least 9 quarters later, with an estimated size of from 2 to 10 percentage points depending upon the model used.
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Payment Systems in the Healthcare Industry: An Experimental Study of Physician Incentives
Ellen Green
Journal of Economic Behavior & Organization, forthcoming
Abstract:
Policy makers and the healthcare industry have proposed changes to physician payment structures as a way to improve the quality of health care and reduce costs. Several of these proposals require healthcare providers to employ a value-based purchasing program (also known as pay-for-performance [P4P]). However, the way in which existing payment structures impact physician behavior is unclear and therefore, predicting how well P4P will perform is difficult. To understand the impact physician payment structures have on physician behavior, I approximate the physician-patient relationship in a real-effort laboratory experiment. I study several prominent physician payment structures including fee-for-service, capitation, salary, and P4P. I find that physicians are intrinsically motivated to provide high quality care and relying exclusively on extrinsic incentives to motivate physicians is detrimental to the quality of care and costly for the healthcare industry.
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Malpractice Law, Physicians’ Financial Incentives, and Medical Treatment: How Do They Interact?
Ity Shurtz
Journal of Law and Economics, February 2014, Pages 1-29
Abstract:
The effects of malpractice law and financial incentives on physicians are typically studied independently. This paper shows that to make both positive and normative statements about medical malpractice liability, one must consider physicians’ legal and financial incentives jointly. I develop a simple model to show that when treatment is unprofitable at the margin, mitigation of liability lowers treatment levels; conversely, when treatment is profitable, mitigation of liability raises them. Motivated by this simple theoretical framework, I analyze the impact of a tort reform in Texas that mitigated malpractice liability. Consistent with the theory, the rate of cesarean sections among commercially insured mothers, for whom the procedure is considered profitable, increased by 2 percentage points relative to the rate of cesarean sections among mothers covered by Medicaid, for whom the procedure is thought to be unprofitable.
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Do the Poor Benefit from More Generous Medicaid Physician Payments?
Alice Chen
University of Chicago Working Paper, February 2014
Abstract:
This paper examines how changes in Medicaid physician payments affect provision of care to both Medicaid patients and the uninsured. I find that payment increases generate an increase in supply of care to Medicaid patients but a more than offsetting decrease in supply to the uninsured. Using survey data, I additionally show that physicians encourage their uninsured patients to enroll in Medicaid. Finally, I demonstrate that when Medicaid eligibility is high, physicians are less likely to substitute between caring for Medicaid patients and treating the uninsured. Because higher eligibility magnifies the Medicaid supply response to a payment change, my results suggest that payment increases should be coupled with eligibility expansions in order to improve access to care among the poor.
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Effects of Cuts in Medicaid on Dental-Related Visits and Costs at a Safety-Net Hospital
Martha Neely et al.
American Journal of Public Health, June 2014, Pages e13-e16
Abstract:
We used data from Boston Medical Center, Massachusetts, to determine whether dental-related emergency department (ED) visits and costs increased when Medicaid coverage for adult dental care was reduced in July 2010. In this retrospective study of existing data, we examined the safety-net hospital’s dental-related ED visits and costs for 3 years before and 2 years after Massachusetts Health Care Reform. Dental-related ED visits increased 2% the first and 14% the second year after Medicaid cuts. Percentage increases were highest among older adults, minorities, and persons receiving charity care, Medicaid, and Medicare.
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The Association Between Community-level Insurance Coverage and Emergency Department Use
Laurence Baker & Renee Hsia
Medical Care, June 2014, Pages 535-540
Background: Emergency departments (EDs) nationwide are key entry points into the health care system, and their use may reflect changes in access and need in their communities. However, no studies to date have empirically and longitudinally studied how changes in a community’s level of insurance coverage, a key determinant of access, affect ED utilization.
Objective: To determine the effects of changes in a community’s rate of insurance coverage on its population’s ED use.
Methods: We conducted a longitudinal analysis of all California counties between 2005 and 2010 using comprehensive ED visit data from the California Office of Statewide Health Planning and Development. Using Poisson regression with county and year fixed effects, we determined how changes in the rate of insurance coverage within a given county affect ED visits per 1000 residents.
Results: We found that changes in the rate of insurance coverage within a county had a slight but significant inverse relationship with ED visits per 1000 residents for both adults and children. For example, if a county’s rate of insurance coverage among adults jumped from the 10th (73.22%) to the 90th percentile (84.93%), an estimated 2 fewer ED visits would occur per 1000 adult residents.
Conclusions: As the rate of insurance coverage increased within California counties, overall ED utilization declined only slightly. Thus, expanding insurance coverage may not lead to significant decreases in overall ED use.
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Long-Term Impact of Medicare Payment Reductions on Patient Outcomes
Vivian Wu & Yu-Chu Shen
Health Services Research, forthcoming
Objective: To examine the long-term impact of Medicare payment reductions on patient outcomes for Medicare acute myocardial infarction (AMI) patients.
Data Sources: Analysis of secondary data compiled from 100 percent Medicare Provider Analysis and Review between 1995 and 2005, Medicare hospital cost reports, Inpatient Prospective Payment System Payment Impact Files, American Hospital Association annual surveys, InterStudy, Area Resource Files, and County Business Patterns.
Study Design: We used a natural experiment — the Balanced Budget Act (BBA) of 1997 — as an instrument to predict cumulative Medicare revenue loss due solely to the BBA, and basing on the predicted loss categorized hospitals into small, moderate, or large payment-cut groups and followed Medicare AMI patient outcomes in these hospitals over an 11-year panel between 1995 and 2005.
Principal Findings: We found that while Medicare AMI mortality trends remained similar across hospitals between pre-BBA and initial-BBA periods, hospitals facing large payment cuts saw smaller improvement in mortality rates relative to that of hospitals facing small cuts in the post-BBA period. Part of the relatively higher AMI mortalities among large-cut hospitals might be related to reductions in staffing levels and operating costs, and a small part might be due to patient selection.
Conclusions: We found evidence that hospitals facing large Medicare payment cuts as a result of BBA of 1997 were associated with deteriorating patient outcomes in the long run. Medicare payment reductions may have an unintended consequence of widening the gap in quality across hospitals.
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David Hutton et al.
Health Affairs, June 2014, Pages 931-939
Abstract:
The biologic drugs bevacizumab and ranibizumab have revolutionized treatment of diabetic macular edema and neovascular age-related macular degeneration, leading causes of blindness. Ophthalmologic use of these drugs has increased and now accounts for roughly one-sixth of the Medicare Part B drug budget. The two drugs have similar efficacy and potentially minor differences in adverse-event rates; however, at $2,023 per dose, ranibizumab costs forty times more than bevacizumab. Using modeling methods, we predict ten-year (2010–20) population-level costs and health benefits of using bevacizumab and ranibizumab. Our results show that if all patients were treated with the less expensive bevacizumab instead of current usage patterns, savings would amount to $18 billion for Medicare Part B and nearly $5 billion for patients. With an additional $6 billion savings in other health care expenses, the total savings would be almost $29 billion. Altering patterns of use with these therapies by encouraging bevacizumab use and hastening approval of biosimilar therapies would dramatically reduce spending without substantially affecting patient outcomes.
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Dominated Choices and Medicare Advantage Enrollment
Christopher Afendulis, Anna Sinaiko & Richard Frank
NBER Working Paper, May 2014
Abstract:
Research in behavioral economics suggests that certain circumstances, such as large numbers of complex options or revisiting prior choices, can lead to decision errors. This paper explores the enrollment decisions of Medicare beneficiaries in the Medicare Advantage (MA) program. During the time period we study (2007-2010), private fee-for-service (PFFS) plans offered enhanced benefits beyond those of traditional Medicare (TM) without any restrictions on physician networks or additional cost, making TM a dominated choice relative to PFFS. Yet more than three quarters of Medicare beneficiaries remained in TM during our study period. We explore two possible explanations for this behavior: status quo bias and choice overload. Our results suggest that status quo bias plays an important role; the rate of MA enrollment was significantly higher among new Medicare beneficiaries than among incumbents. Our results also provide some evidence of choice overload; while the MA enrollment rate did not decline with an increase in the number of plans, among incumbent beneficiaries it failed to increase. Our results illustrate the importance of the choice environment that is in place when enrollees first enter the Medicare program.
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The Effect of Medicaid Premiums on Enrollment: A Regression Discontinuity Approach
Laura Dague
Journal of Health Economics, September 2014, Pages 1–12
Abstract:
This paper estimates the effect that premiums in Medicaid have on the length of enrollment of program beneficiaries. Whether and how low income-families will participate in the exchanges and in states’ Medicaid programs depends crucially on the structure and amounts of the premiums they will face. I take advantage of discontinuities in the structure of Wisconsin's Medicaid program to identify the effects of premiums on enrollment for low-income families. I use a three year administrative panel of enrollment data to estimate these effects. I find an increase in the premium from zero to ten dollars per month results in 1.4 fewer months enrolled and reduces the probability of remaining enrolled for a full year by 12 percentage points, but other discrete changes in premium amounts do not affect enrollment or have a much smaller effect. I find no evidence of program enrollees intentionally decreasing labor supply in order to avoid the premiums.
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Electronic Discovery and the Adoption of Information Technology
Amalia Miller & Catherine Tucker
Journal of Law, Economics, and Organization, May 2014, Pages 217-243
Abstract:
After firms adopt electronic information and communication technologies, their decision-making leaves a trail of electronic information that may be more extensive and accessible than a paper trail. We ask how the expected costs of litigation affect decisions to adopt technologies, such as electronic medical records (EMRs), which leave more of an electronic trail. EMRs allow hospitals to document electronically both patient symptoms and health providers’ reactions to those symptoms and may improve the quality of care that makes the net impact of their adoption on expected litigation costs ambiguous. This article studies the impact of state rules that facilitate the use of electronic records in court. We find evidence that hospitals are one-third less likely to adopt EMRs after these rules are enacted.
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A Simple Change To The Medicare Part D Low-Income Subsidy Program Could Save $5 Billion
Yuting Zhang, Chao Zhou & Seo Hyon Baik
Health Affairs, June 2014, Pages 940-945
Abstract:
Medicare Part D provides a subsidy to beneficiaries with incomes below 150 percent of the federal poverty level. Enrollees with the low-income subsidy accounted for 75 percent of the $60 billion in total federal Part D spending in 2013. The government randomly assigns any new beneficiary who automatically qualifies for the subsidy, or who successfully applies for it without indicating a preferred plan, to a stand-alone Part D plan whose premium is equal to or below the average premium for the basic Part D benefit in the region. We used an intelligent reassignment algorithm and 2008–09 Part D drug use and spending data to match enrollees to available plans according to their medication needs. We found that such a reassignment approach could have saved the federal government over $5 billion in 2009, for mean government savings of $710 (median: $368) per enrollee with a low-income subsidy. Implementing that simple change to reassign beneficiaries would have also lowered the proportion of prescriptions that required utilization review from 29 percent to 20 percent, and the proportion of prescriptions with quantity limits from 27 percent to 19 percent.
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Chapin White
Health Services Research, forthcoming
Objective: To measure spillover effects of Medicare inpatient hospital prices on the nonelderly (under age 65).
Primary Data Sources: Healthcare Cost and Utilization Project State Inpatient Databases (10 states, 1995–2009) and Medicare Hospital Cost Reports.
Study Design: Outcomes include nonelderly discharges, length of stay and case mix, staffed hospital bed-days, and the share of discharges and days provided to the elderly. We use metropolitan statistical areas as our markets. We use descriptive analyses comparing 1995 and 2009 and panel data fixed-effects regressions. We instrument for Medicare prices using accumulated changes in the Medicare payment formula.
Principal Findings: Medicare price reductions are strongly associated with reductions in nonelderly discharges and hospital capacity. A 10-percent reduction in the Medicare price is estimated to reduce discharges among the nonelderly by about 5 percent. Changes in the Medicare price are not associated with changes in the share of inpatient hospital care provided to the elderly versus nonelderly.
Conclusions: Medicare price reductions appear to broadly constrain hospital operations, with significant reductions in utilization among the nonelderly. The slow Medicare price growth under the Affordable Care Act may result in a spillover slowdown in hospital utilization and spending among the nonelderly.
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Measuring the Hospital Length of Stay/Readmission Cost Trade-Off under a Bundled Payment Mechanism
Kathleen Carey
Health Economics, forthcoming
Abstract:
If patients are discharged from the hospital prematurely, many may need to return within a short period of time. This paper investigates the relationship between length of stay and readmission within 30 days of discharge from an acute care hospitalization. It applies a two-part model to data on Medicare patients treated for heart attack in New York state hospitals during 2008 to obtain the expected cost of readmission associated with length of stay. The expected cost of a readmission is compared with the marginal cost of an additional day in the initial stay to examine the cost trade-off between an extra day of care and the expected cost of readmission. The cost of an additional day of stay was offset by expected cost savings from an avoided readmission in the range of 15% to 65%. Results have implications for payment reform based on bundled payment reimbursement mechanisms.
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Physician Payment Reform and Hospital Referrals
Kate Ho & Ariel Pakes
American Economic Review, May 2014, Pages 200-205
Abstract:
Commercial health insurers in California use provider capitation payments to different extents. These are similar to arrangements introduced by the recent health reforms to give physicians incentives to control costs. In a previous paper we showed that patients whose insurers used capitation incentives traveled further to access lower-priced, similar-quality hospitals than other same-severity patients. This paper predicts the implied effects of a move to widespread capitation. We show that, if the introduction of capitation prompted low-capitation insurers to act like high-capitation insurers, this would generate a 4–5 percent cost saving with some reduction in patient convenience but no reduction in quality.
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Measuring Low-Value Care in Medicare
Aaron Schwartz et al.
JAMA Internal Medicine, forthcoming
Objectives: To develop claims-based measures of low-value services, examine service use (and associated spending) detected by these measures in Medicare, and determine whether patterns of use are related across different types of low-value services.
Design, Setting, and Participants: Drawing from evidence-based lists of services that provide minimal clinical benefit, we developed 26 claims-based measures of low-value services. Using 2009 claims for 1 360 908 Medicare beneficiaries, we assessed the proportion of beneficiaries receiving these services, mean per-beneficiary service use, and the proportion of total spending devoted to these services. We compared the amount of use and spending detected by versions of these measures with different sensitivity and specificity. We also estimated correlations between use of different services within geographic areas, adjusting for beneficiaries’ sociodemographic and clinical characteristics.
Results: Services detected by more sensitive versions of measures affected 42% of beneficiaries and constituted 2.7% of overall annual spending. Services detected by more specific versions of measures affected 25% of beneficiaries and constituted 0.6% of overall spending. In adjusted analyses, low-value spending detected in geographic regions at the 5th percentile of the regional distribution of low-value spending ($227 per beneficiary) exceeded the difference in detected low-value spending between regions at the 5th and 95th percentiles ($189 per beneficiary). Adjusted regional use was positively correlated among 5 of 6 categories of low-value services (mean r for pairwise, between-category correlations, 0.33; range, 0.14-0.54; P ≤ .01).
Conclusions and Relevance: Services detected by a limited number of measures of low-value care constituted modest proportions of overall spending but affected substantial proportions of beneficiaries and may be reflective of overuse more broadly. Performance of claims-based measures in supporting targeted payment or coverage policies to reduce overuse may depend heavily on how the measures are defined.
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Doctors with borders: Occupational licensing as an implicit barrier to high skill migration
Brenton Peterson, Sonal Pandya & David Leblang
Public Choice, July 2014, Pages 45-63
Abstract:
Research on the political economy of immigration overlooks the specificity of human capital in skilled occupations and its implications for immigration preferences and policymaking. Conclusions that skilled Americans are unconcerned about labor market competition from skilled migrants build on a simple dichotomy between high and low skill migrants. In this article we show that natives turn to occupational licensing regulations as occupation-specific protectionist barriers to skilled migrant labor competition. In practice, high skill natives face labor market competition only from those high-skill migrants who share their occupation-specific skills. Licensure regulations ostensibly serve the public interest by certifying competence, but they can simultaneously be formidable barriers to entry by skilled migrants. From a collective action perspective, skilled natives can more easily secure sub-national, occupation-specific policies than influence national immigration policy. We exploit the unique structure of the American medical profession that allows us to distinguish between public interest and protectionist motives for migrant physician licensure regulations. We show that over the 1973–2010 period states with greater physician control over licensure requirements imposed more stringent requirements for migrant physician licensure and, as a consequence, received fewer new migrant physicians. By our estimates over a third of all US states could reduce their physician shortages by at least 10 percent within 5 years just by equalizing migrant and native licensure requirements. This article advances research on the political economy of immigration and highlights an overlooked dimension of international economic integration: regulatory rent-seeking as a barrier to the cross-national mobility of human capital, and the public policy implications of such barriers.
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One Pool to Insure them All?: Age, Risk and the Price(s) of Medical Insurance
Thomas Koch
International Journal of Industrial Organization, July 2014, Pages 1–11
Abstract:
Asymmetric information can lead to adverse selection and market failure. In a dynamic setting, asymmetric information also limits reclassification risk. This certainty offsets the costs of adverse selection. Using a dynamic model of endogenous insurance choice and price calibrated to the U.S. medical insurance market, I find that asymmetric information is Pareto improving when information is fully asymmetric. However, when insurers can discriminate by age group, but not within age groups, the young benefit by paying less for insurance. The insurance market for the near elderly collapses because it is no longer implicitly subsidized by the participation of the young.
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Dan Shane & Padmaja Ayyagari
Medical Care, June 2014, Pages 528-534
Objectives: We used data from the Medical Expenditure Panel Survey to assess the impact of the Affordable Care Act’s dependent coverage mandate on disparities in health insurance coverage rates and evaluated whether non-Hispanic blacks and Hispanics gained coverage at the same rates as non-Hispanic whites.
Methods: To estimate changes in insurance rates, we employed a difference-in-difference regression approach comparing 7962 young adults aged 19–25 to 9321 adults aged 27–34. Separate regressions were estimated for non-Hispanic blacks, Hispanics, and non-Hispanic whites to understand whether the mandate had differential effects by race/ethnicity. Separate regressions by income level and race/ethnicity were also estimated.
Results: Insurance rates increased by 9.3 percentage points among non-Hispanic whites, 7.2 percentage points among Hispanics, and 9.4 percentage points among non-Hispanic blacks. These changes were not significantly different from each other. Among individuals with income of <133% of the Federal Poverty Level, non-Hispanic whites experienced significantly larger gains, whereas at higher-income levels, non-Hispanic blacks experienced significantly larger gains than other racial/ethnic groups.
Conclusions: The dependent coverage mandate of the Affordable Care Act increased insurance rates among all racial and ethnic groups but did not change overall disparities. Disparities may have widened among low-income populations which highlights the importance of Medicaid expansions in reducing disparities. Among higher-income populations, disparities between non-Hispanic blacks and non-Hispanic whites were reduced.
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Intended and Unintended Consequences of Minimum Staffing Standards for Nursing Homes
Min Chen & David Grabowski
Health Economics, forthcoming
Abstract:
Staffing is the dominant input in the production of nursing home services. Because of concerns about understaffing in many US nursing homes, a number of states have adopted minimum staffing standards. Focusing on policy changes in California and Ohio, this paper examined the effects of minimum nursing hours per resident day regulations on nursing home staffing levels and care quality. Panel data analyses of facility-level nursing inputs and quality revealed that minimum staffing standards increased total nursing hours per resident day by 5% on average. However, because the minimum staffing standards treated all direct care staff uniformly and ignored indirect care staff, the regulation had the unintended consequences of both lowering the direct care nursing skill mix (i.e., fewer professional nurses relative to nurse aides) and reducing the absolute level of indirect care staff. Overall, the staffing regulations led to a reduction in severe deficiency citations and improvement in certain health conditions that required intensive nursing care.
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Does regulating private long-term care facilities lead to better care? A study from Quebec, Canada
Gina Bravo et al.
International Journal for Quality in Health Care, June 2014, Pages 330-336
Participants: Random samples of disabled residents aged 65 years and over. In total, 451 residents from 145 care settings assessed in 1995–2000 were compared with 329 residents from 102 care settings assessed in 2010–12.
Intervention: Regulation introduced by the province in 2005, effective February 2007.
Results: After regulation, fewer small-size facilities were in operation in the private market. Between the two study periods, the proportion of residents with severe disabilities decreased in private facilities whereas it remained >80% in their public counterparts. Meanwhile, quality of care improved significantly in private facilities, while worsening in their public counterparts, even after controlling for confounding.
Conclusions: The private industry now provides better care to its residents. Improvement in care quality likely results in part from the closure of small homes and change in resident case-mix.