Where it hurts

Kevin Lewis

September 09, 2019

The Policy Consequences of Health Bias in Political Voice
Julianna Pacheco
Political Research Quarterly, forthcoming

Although research on the link between health and political behavior at the individual level has flourished, there have been no systematic analyses regarding the policy consequences of health inequalities in political voice. Using a unique dataset that measures the health bias in voter turnout across the fifty states from 1996 to 2012, I find that state electorates that are disproportionately more representative of healthy citizens spend less on health and have less generous Medicaid programs. The negative relationship between the degree of health bias in state electorates and these outcomes remain after controlling for the degree of class bias in voter turnout. These findings have important implications for democratic theory and policy responsiveness, as well as our understanding of variations in population health and health policy across the American states.

Can Medicaid Expansion Prevent Housing Evictions?
Heidi Allen et al.
Health Affairs, September 2019, Pages 1451-1457

Evictions are increasingly recognized as a serious concern facing low-income households. This study evaluated whether expansions of Medicaid can prevent evictions from occurring. We examined data from a privately licensed database of eviction records in fourteen states (286 counties) and used a difference-in-differences research design to compare rates of eviction before and after California’s early Medicaid expansion (51 counties). Early Medicaid expansion in California was associated with a reduction in the number of evictions, with 24.5 fewer evictions per month in each county from a pre-expansion average of 224.7. These results imply that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. Additionally, we found a 2.9-percentage-point reduction in evictions per capita associated with early expansion. The effects were concentrated among counties with the highest pre-expansion rates of uninsurance. We conclude that health insurance coverage is associated with improved housing stability.

The Effects of the ACA Medicaid Expansion on Nationwide Home Evictions and Eviction-Court Initiations: United States, 2000–2016
Naomi Zewde et al.
American Journal of Public Health, October 2019, Pages 1379-1383

Methods: Using nationally representative administrative data from The Eviction Lab at Princeton University, we estimated the effects of the ACA Medicaid expansions on county-level evictions and filings from 2000 to 2016 with a difference-in-difference regression design.

Results: We found that Medicaid expansions were associated with an annual reduction in the rate of evictions by 1.15 per 1000 renter-occupied households (P < .001), a reduction of 1.59 eviction filings per 1000 renter-occupied households (P < .001), and a reduction in the average number of evictions by 46 (P < .05). We found additional evidence that increasing rates of African American residents in a county was associated with a greater rate of evictions filed, and increased rates of poverty and rent burdens relative to income were associated with more evictions both filed and completed.

The Effect of Public Health Insurance on Criminal Recidivism
Erkmen Aslim et al.
George Mason University Working Paper, July 2019

The prevalence of mental health and substance abuse disorders is high among incarcerated individuals. Many ex-offenders reenter the community without receiving any specialized treatment and return to prison with existing behavioral health problems. We consider a Beckerian law enforcement theory to identify different sources through which access to health care may impact ex-offenders' propensities to recidivate, and empirically estimate the effect of access to public health insurance on criminal recidivism. We exploit the plausibly exogenous variation in state decisions to expand Medicaid under the Affordable Care Act. Using administrative data on prison admission and release records from 2010 to 2016, we find that the expansions decrease recidivism for both violent and public order crimes. In addition, we find that the public coverage expansions substantially increase access to substance use disorder treatment. The effect is salient for individuals who are covered by Medicaid and referred to treatment by the criminal justice system. These findings are most consistent with the theory that increased access to health care reduces ex-offenders' perceived non-monetary benefits from committing crimes.

The Impact of the ACA on Insurance Coverage Disparities After Four Years
Charles Courtemanche et al.
NBER Working Paper, August 2019

The purpose of this paper is to estimate the impact of the major components of the ACA (Medicaid expansion, subsidized Marketplace plans, and insurance market reforms) on disparities in insurance coverage after four years. We use data from the 2011–2017 waves of the American Community Survey (ACS), with the sample restricted to nonelderly adults. Our methods feature a difference-in-difference-in-differences model, developed in the recent ACA literature, which separately identifies the effects of the nationwide and Medicaid expansion portions of the law. The differences in this model come from time, state Medicaid expansion status, and local area pre-ACA uninsured rate. We stratify our sample separately by income, race/ethnicity, marital status, age, gender, and geography in order to examine access disparities. After four years, we find that the fully implemented ACA eliminated 44 percent of the coverage gap across income groups, with the Medicaid expansion accounting for this entire reduction. The ACA also reduced coverage disparities across racial groups by 26.7 percent, across marital status by 45 percent, and across age groups by 44 percent, with these changes being partly attributable to both the Medicaid expansion and nationwide components of the law.

Effect of the Affordable Care Act’s Medicaid Expansions on Food Security, 2010–2016
Gracie Himmelstein
American Journal of Public Health, September 2019, Pages 1243-1248

Methods: With data on adult respondents to the Food Security Supplement to the Current Population Survey in US states for the years 2010 to 2013 and 2015 to 2016, I used a difference-in-difference design to compare trends in very low food security (VLFS) among low-income childless adults in states that did and did not expand Medicaid in 2014 under the ACA.

Results: Among low-income, nonelderly childless adults, VLFS rose from 17.4% before ACA to 17.5% after ACA in nonexpansion states, and fell from 17.6% to 15.9% in expansion states. In difference-in-difference analysis, Medicaid expansion was associated with a significant adjusted 2.2-percentage-point decline in rates of VLFS, equivalent to a 12.5% relative reduction.

The Impact of the ACA Medicaid Expansion on Disability Program Applications
Lucie Schmidt, Lara Shore-Sheppard & Tara Watson
NBER Working Paper, August 2019

The Affordable Care Act (ACA) expanded the availability of public health insurance, decreasing the relative benefit of participating in disability programs but also lowering the cost of exiting the labor market to apply for disability program benefits. In this paper, we explore the impact of expanded access to Medicaid through the ACA on applications to the Supplemental Security Income (SSI) and Social Security Disability Income (SSDI) programs. Using the fact that the Supreme Court decision of June 2012 made the Medicaid expansion optional for the states, we compare changes in county-level SSI and SSDI caseloads in contiguous county pairs across a state border. We find no significant effects of the Medicaid expansion on applications or awards to either SSI or SSDI, and can reject economically meaningful impacts of Medicaid expansions on applications to disability programs.

US Physicians’ Reactions To ACA Implementation, 2012–17
Lindsay Riordan et al.
Health Affairs, September 2019, Pages 1530-1536

Physicians play a key role in implementing health policy, and US physicians were split in their opinions about the Affordable Care Act (ACA) soon after its implementation began. We readministered elements of a prior survey of US physicians to a similar sample to understand how US physicians’ opinions of the ACA may have changed over a crucial five-year implementation period (2012–17), and we compared responses across both surveys. Of the 1,200 physicians to whom we sent a survey in the summer of 2017, 489 responded (a response rate of 41 percent). A majority of respondents (60 percent) believed that the ACA had improved access to care and insurance, yet many (43 percent) felt that it had reduced the affordability of coverage. More physicians agreed in 2017 than in 2012 that the ACA “would turn United States health care in the right direction” (53 percent versus 42 percent), despite reporting perceived worsening in several practice conditions over the same time period. After we adjusted for specialty, political party affiliation, practice setting type, perceived social responsibility, age, and sex, we found that only political party affiliation was a significant predictor of support for the ACA in the 2017 results.

The Role of Behavioral Frictions in Health Insurance Marketplace Enrollment and Risk: Evidence from a Field Experiment
Richard Domurat, Isaac Menashe & Wesley Yin
NBER Working Paper, August 2019

We experimentally varied information mailed to 87,000 households in California's health insurance marketplace to study the role of frictions in insurance take-up. Reminders about the enrollment deadline raised enrollment by 1.3 pp (16 percent), in this typically low take-up population. Heterogeneous effects of personalized subsidy information indicate systematic misperceptions about program benefits. Consistent with an adverse selection model with frictional enrollment costs, the intervention lowered average spending risk by 5.1 percent, implying that marginal respondents were 37 percent less costly than inframarginal consumers. We observe the largest positive selection among low income consumers, who exhibit the largest frictions in enrollment. Finally, the intervention raised average consumer WTP for insurance by $25 to $54 per month. These results suggest that frictions may partially explain low measured WTP for marketplace insurance, and that interventions reducing them can improve enrollment and market risk in exchanges.

Quality Information Disclosure and Patient Reallocation in the Healthcare Industry: Evidence from Cardiac Surgery Report Cards
Tae Jung Yoon
Marketing Science, forthcoming

In a healthcare industry with capacity constraints, the best healthcare providers are often congested after quality information disclosure. This congestion can lead to the reallocation of urgent patients to low-quality healthcare providers. The reallocation can have a detrimental impact on the overall patient survival rate if sicker patients benefit more from the best providers. This paper provides the first empirical evidence regarding this problem in the context of the publication of cardiac surgery report cards. I find that these report cards can have a negative impact on positive assortative matching between patients and surgeons because of a reallocation of high-risk patients to low-quality surgeons. Despite the quality improvement in response to these report cards, such patient reallocation can still be a problem, conditional on the improved quality, and, thus, should not be ignored.

Impact of Rural and Urban Hospital Closures on Inpatient Mortality
Kritee Gujral & Anirban Basu
NBER Working Paper, August 2019

This paper examines the impact of California's hospital closures occurring from 1995-2011 on adjusted inpatient mortality for time-sensitive conditions: sepsis, stroke, asthma/chronic obstructive pulmonary disease (COPD) and acute myocardial infarction (AMI). Using a difference- in-difference approach on California's Office of Statewide Health Planning and Development (OSHPD) data, the impact of hospital closures on inpatient mortality is estimated. Outcomes of admissions in hospital service areas (HSAs) with and without closure(s) are compared before and after the closure year. The paper aims to fill gaps in prior work by using a reconciled list of California's hospital closures and by studying differential impacts of rural and urban hospital closures. To our best knowledge, this is also the first paper explicitly studying patient outcomes of California's rural closures. Results suggest that when treatment groups are not differentiated by hospital rurality, closures appear to have no measurable impact. However, estimating differential impacts of rural and urban closures shows that rural closures increase inpatient mortality by 0.46% points (an increase of 5.9%), whereas urban closures have no impact. Results differ across diagnostic conditions; the general effect of closures is to increase mortality for stroke patients by 3.1% and for AMI patients by 4.5%, and decrease mortality for asthma/COPD patients by 8.8%.

Correlation between hospital finances and quality and safety of patient care
Dean Akinleye et al.
PLoS ONE, August 2019

Methods: This 2014 cross-sectional study investigated hospital financial condition and hospital quality and safety at acute care hospitals. The hospital financial data from the Centers for Medicare and Medicaid Services (CMS) cost report were used to develop a composite financial performance score using principal component analysis. Hospital quality and patient safety were measured with a composite quality/safety performance score derived from principal component analysis, utilizing a range of established quality and safety indicators including: risk-standardized inpatient mortality, 30-day mortality, 30-day readmissions for select conditions, patient safety indicators from inpatient admissions, process of care chart reviews, CMS value-based purchasing total performance score and patient experience of care surveys. The correlation between the composite financial performance score and the composite quality/safety performance score was calculated using linear regression adjusting for hospital characteristics.

Results: Among the 108 New York State acute care facilities for which data were available, there is a clear relationship between hospital financial performance and hospital quality/safety performance score (standardized correlation coefficient 0.34, p<0.001). The composite financial performance score is also positively associated with the CMS Value Based Purchasing Total Performance Score (standardized correlation coefficient 0.277, p = 0.002); while it is negatively associated with 30 day readmission for all outcomes (standardized correlation coefficient -0.236, p = 0.013), 30-day readmission for congestive heart failure (standardized correlation coefficient -0.23, p = 0.018), 30 day readmission for pneumonia (standardized correlation coefficient -0.209, p = 0.033), and a decrease in 30-day mortality for acute myocardial infarction (standardized correlation coefficient -0.211, p = 0.027). Used alone, operating margin and total margin are poor predictors of quality and safety outcomes.

Conclusions: Strong financial performance is associated with improved patient reported experience of care, the strongest component distinguishing quality and safety. These findings suggest that financially stable hospitals are better able to maintain highly reliable systems and provide ongoing resources for quality improvement.

Emergency Department Closures And Openings: Spillover Effects On Patient Outcomes In Bystander Hospitals
Renee Hsia & Yu-Chu Shen
Health Affairs, September 2019, Pages 1496-1504

High-occupancy hospitals may be sensitive to neighboring emergency department (ED) closures and openings, as they already operate at or near capacity. We conducted a retrospective analysis using data for the period 2001–13 to examine outcomes of and treatment received by patients with acute myocardial infarction at so-called bystander EDs that had been exposed to nearby ED closures or openings. We used changes in driving time between an ED and the next-closest one as a proxy for a closure or opening: If driving time increased, for instance, it meant that a nearby ED had closed. When a high-occupancy ED was exposed to a closure that resulted in increased driving time of thirty minutes or more to the next-closest ED, one-year mortality and thirty-day readmission rates increased by 2.39 and 2.00 percentage points, respectively, while the likelihood of receiving percutaneous coronary intervention (PCI) declined by 2.06 percentage points. Exposure to ED openings that resulted in decreased driving times of thirty minutes or more was associated with reductions in thirty-day mortality at bystander hospitals and an increased likelihood of receiving PCI. Our findings suggest that limited resources at high-occupancy bystander hospitals make them sensitive to changes in the availability of emergency care in neighboring communities.

Capacity Pooling in Hospitals: The Hidden Consequences of Off-Service Placement
Hummy Song et al.
Management Science, forthcoming

Hospital managers struggle with the day-to-day variability in patient admissions to different clinical services, each of which typically has a fixed allocation of hospital beds. In response, many hospitals engage in capacity pooling by assigning patients from a service whose designated beds are fully occupied to an available bed in a unit designated for a different service. This “off-service placement” occurs frequently, yet its impact on patient and operational measures has not been rigorously quantified. This is, in part, because of the challenge of properly accounting for the endogenous selection of off-service patients. We use an instrumental variable approach to quantify the causal effects of off-service placement of hospitalized medical/surgical patients, having accounted for the endogeneity issues. Using data from a large academic medical center with 19.6% of medical/surgical patients placed off service on average, we find that off-service placement is associated with a 22.8% increase in remaining hospital length of stay (LOS) and a 13.1% increase in the likelihood of hospital readmission within 30 days. We find no significant effect on in-hospital mortality or clinical trigger (rapid response) activation. We identify longer distances to the service’s home unit as a key mechanism that drives the effect on LOS. In contrast, a mismatch in nursing specialization does not seem to explain this effect. By quantifying the effects of off-service placement on patient and operational outcomes, we enable clinicians and hospital managers to make better-informed short-term decisions about off-service placement and longer-term decisions about capacity allocation.

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