Health insurance and subjective well-being: Evidence from two healthcare reforms in the United States
Seonghoon Kim & Kanghyock Koh
Health Economics, January 2022, Pages 233-249
We study the role of access to health insurance coverage as a determinant of individuals' subjective well-being (SWB) by analyzing large-scale healthcare reforms in the United States. Using data from the Behavioral Risk Factor Surveillance System and Panel Study of Income Dynamics, we find that the 2006 Massachusetts reform and 2014 Affordable Care Act Medicaid expansion improved the overall life satisfaction of Massachusetts residents and low-income adults in Medicaid expansion states, respectively. The results are robust to various sensitivity and falsification tests. Our findings imply that access to health insurance plays an important role in improving SWB. Without considering psychological benefits, the actual benefits of health insurance may be underemphasized.
The effect of the Affordable Care Act Medicaid expansion on marriage
Matt Hampton & Otto Lenhart
Economic Inquiry, forthcoming
This paper investigates the impact of the Affordable Care Act Medicaid expansions on marital behavior. We use data from the American Community Survey from 2008 to 2019 and estimate difference-in-differences models to test for effects on marriage and divorce outcomes. We find that expansions led to a 0.95% reduction in marriage stock and a 2.22% increase in divorce stock, with effects being larger among low educated individuals. We believe that two factors play a role as underlying mechanisms: (1) reduced reliance on spousal insurance coverage and (2) deciding to forego marriage or get divorced to meet eligibility restrictions.
The Impact Of Household Health Insurance Coverage Gains On Children’s Achievement In Iowa: Evidence From The ACA
Health Affairs, January 2022, Pages 35-43
Low family income is associated with worse child academic achievement. Little is known about how health insurance expansions affect children’s achievement in low-income households. This study examined the effects of the Affordable Care Act’s coverage expansions primarily for Medicaid and Marketplace enrollment, beginning in 2014, on children’s academic achievement in Iowa. The study employed a unique linkage of birth certificates and data on standardized school tests for children in Iowa and took advantage of differences in uninsurance rates across areas in the state before the ACA insurance expansions. There is evidence that the ACA expansions beginning in 2014 were associated with higher reading scores after three years for children born to mothers with a high school education or less. There is no consistent evidence of an effect on math scores. Overall, these findings suggest broad spillover benefits from health insurance expansions to the well-being and development of children in low-income households that should be part of the continuing policy debate surrounding state and national health insurance reforms.
Variation in reported hospital cash prices across the United States and how they compare to reported payer-specific negotiated rates
Gerardo Ruiz Sánchez
Economics Letters, forthcoming
There is little empirical evidence on the hospital “cash” prices that self-paying patients (e.g., self-paying uninsured patients) face, and little empirical evidence of how these hospital cash prices compare to payer-specific negotiated rates. To address this gap in the literature, I use new data from U.S. hospitals on their reported cash prices and payer-specific negotiated rates for fourteen “shoppable” hospital services that are subject to mandated disclosure under a new federal rule that took effect on January 1, 2021. I find that the cash prices reported by hospitals for these services vary meaningfully across the United States. For example, hospitals with brain MRI cash prices in the 90th percentile of the distribution of my data have cash prices 7.9 times more expensive than hospitals in the 10th percentile. I also find that it is common for the reported cash price to be lower than several payer-specific negotiated rates within a given hospital. For example, for a given private payer (e.g. Aetna, Cigna), the share of reported payer-specific negotiated rates that are higher than the cash price within the same hospital ranges from 41.0 to 57.3 percent. These findings raise further questions about how hospitals decide to price services for the self-pay uninsured population and how these cash pricing decisions compare to transaction rates they negotiate with other payers.
Lobbying Physicians: Payments from Industry and Hospital Procurement of Medical Devices
Alon Bergman, Matthew Grennan & Ashley Swanson
NBER Working Paper, December 2021
We draw upon newly merged administrative data sets to study the relationship between payments from medical technology firms to physicians and medical device procurement by hospitals. These payments (and the interactions that accompany them) may facilitate the transfer of valuable information to and from physicians. However, they may also influence physicians’ treatment decisions, and in turn hospital device procurement, in favor of paying firms. Payments are pervasive: 87 percent of device sales in our sample occurred at a hospital where a relevant physician received a payment from a device firm. Payments are also highly correlated with spending within a firm-hospital pair: event studies suggest that a large positive increase in payments to a given hospital from a given firm ($438 per physician on average, or 112 percent of the mean) is associated with 27 percent higher expenditures on the paying firm’s devices post-event. Finally, we explore how payments mediate the relationship between expertise and device procurement patterns. Hospitals affiliated with the top Academic Medical Centers (AMCs), which plausibly represent an expert benchmark, purchase a different mix of devices than other hospitals, and payments to hospitals outside the top AMCs are correlated with larger deviations from the procurement patterns of top AMC hospitals.
Medicaid Expansion and Cancer Mortality by Race and Sex in Louisiana
Kevin Callison, Lindsey Segal & George Zacharia
American Journal of Preventive Medicine, forthcoming
Data from the National Vital Statistics System mortality files were used to quantify deaths from cancer between 2010 and 2019 for Louisiana and a sample of states that had yet to adopt the Affordable Care Act's Medicaid expansion as of December 2019. A series of population-weighted comparative interrupted time series models were estimated to determine whether Louisiana's Medicaid expansion was associated with reduced cancer mortality. Analyses were conducted in May 2021–August 2021.
Medicaid expansion was associated with an average of 3.3 (95% CI= −6.4, −0.1; p=0.045) fewer quarterly cancer deaths per 100,000 Black female Louisiana residents and an average of 5.8 (95% CI= −10.4, −1.1; p=0.015) fewer quarterly cancer deaths per 100,000 Black male residents. There were no statistically significant changes in cancer mortality for White people in Louisiana associated with Medicaid expansion. Following expansion, the Black–White mortality gap in cancer deaths declined by approximately 57% for female individuals (4.6–2.0) and 49% for male individuals (10.1–5.2).
Did the Affordable Care Act increase the availability of employer-sponsored health insurance?
Southern Economic Journal, forthcoming
The 2010 Affordable Care Act (ACA) included two provisions, the Employer Shared Responsibility Provision (the “employer mandate”) and the Small Business Health Options Program (“SHOP”), aimed at increasing the availability of employer-sponsored health insurance (ESI) among workers at small firms. To examine whether these provisions led to greater ESI availability, I use 2011–2017 Medical Expenditure Panel Survey (MEPS) data in a difference-in-difference framework that compares changes in ESI availability among workers at small and large firms before and after the ACA's provisions come into effect. My estimates show that there is a 3.5 percentage point increase in ESI availability among workers at smaller firms after 2013. When focusing on workers most likely to be affected by the employer mandate, I find a larger 5.2 percentage point increase in ESI availability, amounting to a 39% decline in the proportion who do not have ESI available. However, I find no evidence that greater ESI availability led to increases in ESI coverage rates. Instead, descriptive estimates suggest that gains in health insurance coverage after 2013 consist of significant increases in the number of working adults who report having Medicaid coverage, including among workers who are offered ESI. I use MEPS data for my analysis because, along with employment, firm size, and health insurance details, MEPS also provides health status and healthcare access/utilization information. Looking at changes in these health measures, I find only limited evidence to suggest that the ACA's provisions improved access to care or measures of health status for workers.
Physician Group Influences on Treatment Intensity and Health: Evidence from Physician Switchers
Joseph Doyle & Becky Staiger
NBER Working Paper, December 2021
Treatment intensity varies remarkably across physicians, yet the key drivers are not well understood. Meanwhile, the organization of healthcare is undergoing a secular transformation as physicians increasingly work in groups. This paper tests whether physicians' group affiliation matters for practice styles and patient health. Using Medicare inpatient claims data, we compare these outcomes before and after physicians switch between groups of varying treatment intensity while remaining in the same hospital to control for practice setting. Event studies show that internists who join more-intensive groups immediately increase their own treatment intensity, with an elasticity of approximately 0.3; the opposite is found for internists who switch to groups that are less intensive. This change in Medicare spending largely stems from greater quantities of care provided, with some evidence of a change in coding behavior. We do not detect a change in health outcomes, suggesting that treatment intensity induced by group affiliation may not be productive.
Decreased Racial and Ethnic Disparities in Emergency Department Wait Time in the United States
Abubakar-Sadiq Abdulai, Fahad Mukhtar & Michael Ehrlich
Medical Care, January 2022, Pages 13-21
Publicly available ED subsample of the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2003–2017.
A retrospective cross-sectional analysis of a nationally representative sample of visits to US EDs from 2003 to 2017. Joinpoint statistical analysis and survey-weighted regression were used to assess changes in ED wait time by race/ethnic group over time.
For non-Hispanic White patients, median ED wait time increased annually by 1.3 minutes from 2003 through 2008, decreased by 3.0 minutes from 2008 through 2012, and decreased by 1.7 minutes from 2012 to 2017. For non-Hispanic Black patients, median wait time increased annually by 2.0 minutes from 2003 through 2008, decreased by 3.8 minutes from 2008 through 2015, and remained fairly unchanged from 2015 through 2017. For Hispanic patients, the trend in median wait time remained statistically unchanged from 2003 through 2009. It decreased by annually by 4.7 minutes from 2009 to 2012 and by 1.5 minutes from 2012 through 2017. By the end of 2017, median ED wait time decreased to under 20 minutes across all 3 groups.
Bringing Health Care to Appalachia: The Long-Run Impact of a Rural Health Care System
Theodore Figinski & Erin Troland
Economic Development Quarterly, forthcoming
The U.S. government has supported rural hospitals through direct subsidies and staff recruitment programs. However, little is known about the long-run impact of large-scale changes to rural health care. The authors explore the long-run trajectory of Appalachian counties where a coal mining union introduced a pioneering rural health care program in the 1950s, anchored by a chain of high-quality hospitals. Hospital beds per capita in counties where the union built its hospitals are persistently high through 2006, even when compared to similar counties and accounting for a variety of supply- and demand-side factors. In particular, union counties defied a national hospital consolidation trend starting in the 1980s. Results are consistent with a supply-side explanation where the scale and/or innovation of the union's investment allowed hospital markets to thrive and attract patients from a broad geography.
Does Nonprofit Ownership Matter for Firm Performance? Financial Distress and Ownership Conversion of Nursing Homes
Lauren Xiaoyuan Lu & Susan Feng Lu
Management Science, forthcoming
In the past two decades, many nursing homes converted their ownership status from nonprofit to for-profit (NP-to-FP). These conversions have drawn public scrutiny and triggered a debate about the implications of ownership conversions on nursing home performance. Exploring a nationwide panel data set of U.S. nursing homes from 2006 to 2017, we observe that nursing homes with higher financial distress are associated with higher likelihood of NP-to-FP conversions. The postconversion operating margins increased significantly. Converted nursing homes improved their financial performance by reducing operating costs while keeping net resident revenues unchanged. Both cutting registered nurse staffing and cutting overhead staffing contributed to reductions in operating costs; however, only the former cost-reduction measure had a negative impact on quality. On average, the postconversion quality of care declined. The effects of NP-to-FP conversions on nursing homes were moderated by preconversion financial distress: High-distress nursing homes aggressively cut registered nurse staffing and experienced severe quality decline, whereas low-distress ones kept registered nurse staffing unchanged and largely avoided quality decline. These findings lead to both policy and managerial insights. To nursing home regulators, we recommend increased oversight on NP-to-FP conversions of nursing homes with high preconversion financial distress. To managers of nursing homes undergoing NP-to-FP conversions, our findings suggest that although cost reduction is an effective strategy to improve financial performance, they need to avoid the pitfall of cutting registered nurse staffing and instead focus on streamlining overhead operations in order to increase operating efficiency without compromising quality.
Treatment consolidation after vertical integration: Evidence from outpatient procedure markets
Michael Richards, Jonathan Seward & Christopher Whaley
Journal of Health Economics, January 2022
Hospital ownership of physician practices has grown across the US and these strategic decisions seem to drive higher prices and spending. Using detailed physician ownership information and a universe of Florida discharge records, we show novel evidence of hospital-physician integration foreclosure effects within outpatient procedure markets. Following hospital acquisition, physicians shift nearly 10% of their Medicare and commercially insured cases away from ambulatory surgery centers (ASCs) to hospitals and are up to 18% less likely to use an ASC at all. Altering physician choices over treatment setting can be in conflict with patient and payer cost, convenience and quality preferences.
An Equilibrium Analysis of the Long-Term Care Insurance Market
Review of Economic Studies, forthcoming
Informal care provided by adult children substitutes for formal long-term care services. However, information about children is not used in pricing long-term care insurance which pays only for formal care. I start by providing descriptive evidence that private information about children’s informal care likelihood results in adverse selection: the market attracts a disproportionate number of individuals who face higher formal care utilization risk due to a lower probability of receiving care from their children. To quantify the welfare consequence of adverse selection, I develop and estimate a dynamic intergenerational model featuring long-term care insurance, savings, informal care provision, and employment choices. Based on the estimated equilibrium insurance market framework, I show that using information about children in pricing insurance contracts reduces adverse selection and results in the average welfare gain of $6,200 per family. Using the non-cooperative feature of the model, I also quantify to what extent parents forgo long-term care insurance to avoid diminishing children’s informal care incentive.
Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for Four Specialties in California
Abigail Burman & Simon Haeder
Journal of Health Politics, Policy and Law, forthocming
We used large, random, and representative surveys of provider directories for all managed care plans in California for four specialties obtained from the California Department of Managed Health Care with a total of 657,012 observations (290,711 for 2018 and 475,524 for 2019).
Surveys were able to verify provider directory entries for the four specialties for 59% to 76% of listings or 78% to 88% of providers reached. Moreover, we found that consumers were able to schedule urgent care appointments for 28% to 54% of listings or 44% to 72% of appropriately listed providers. For general care appointments, the percentages ranged from 35% to 64% of listed providers or 51% to 87% of appropriately listed providers. Differences across markets were generally small related to accuracy. Medi-Cal plans outperformed other markets with regards to timely access. Primary care consistently outperformed all other specialties. Timely access rates were higher for general appointments than for urgent care appointments.
The Effect of a Public Transportation Expansion on No-Show Appointments
Laura Barrie Smith et al.
Health Services Research, forthcoming
A new light rail line was opened in a major metropolitan area in June 2014. We obtained electronic health records data from an integrated health delivery system in the area with over three million appointments at 97 clinics between 2013 and 2016.
We used a difference-in-differences research design to compare whether no-show appointment rates differentially changed among patients and clinics located near vs. far from the new light rail line after it opened. Models included fixed effects to account for underlying differences across clinics, patient zip codes, and time.
The probability of no-show visits differentially declined by 0.5 percentage points (95% C.I. -0.9 to −0.1), or 4.5% relative to baseline, for patients living near the `new light rail compared to those living far from it, after the light rail opened. The effects were stronger among patients covered by Medicaid (−1.6 percentage points [95% C.I. -2.4 to −0.8], or 9.5% relative to baseline).