Health Economics

The Effect of Medicaid Expansion on the Take-up of Disability Benefits by Race and Ethnicity (with Becky Staiger and Maddie Helfer)

Health Economics. 2023.

Public disability programs provide financial support to 12 million working-age individuals per year, though not all eligible individuals take up these programs. Mixed evidence exists regarding the impact of Medicaid eligibility expansion on program take-up, and even less is known about the relationship between Medicaid expansion and racial and ethnic disparities in take-up. Using 2009–2020 Current Population Survey data, we compare changes in Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) take-up among respondents with disabilities living in Medicaid expansion states to respondents with disabilities living in non-expansion states, before and after Medicaid expansion. We further explore heterogeneity by race/ethnicity. We find that Medicaid expansion reduced SSI take-up by 10% overall, particularly among White and Hispanic respondents (10% and 21%, respectively). Medicaid expansion increased SSDI take-up by 8% overall, particularly among White and Black respondents (9% and 11%, respectively). Moreover, we find that Medicaid expansion reduced the probability that respondents with disabilities had employer-sponsored health insurance by approximately 8%, suggesting that expansion may have reduced job-lock among the SSDI-eligible, contributing to the observed increase in SSDI take-up.

Comparing Health Outcomes of Privileged US Citizens With Those of Average Residents of Other Developed Countries (with Ezekiel Emanuel, Emily Gudbranson, Mette Gortz, Jon Helgeland, and Jonathan Skinner)

JAMA Internal Medicine. 2020. doi:10.1001/jamainternmed.2020.7484

Question:  Are the health outcomes of White US citizens living in the 1% and 5% richest counties better than the health outcomes of average residents in other developed countries?

Findings : In this comparative effectiveness study of 6 health outcomes, White US citizens in the 1% and 5% highest-income counties obtained better health outcomes than average US citizens but had worse outcomes for infant and maternal mortality, colon cancer, childhood acute lymphocytic leukemia, and acute myocardial infarction compared with average citizens of other developed countries.

Meaning: For 6 health outcomes, the health outcomes of White US citizens living in the 1% and 5% richest counties are better than those of average US citizens but are not consistently better than those of average residents in many other developed countries, suggesting that in the US, even if everyone achieved the health outcomes of White US citizens living in the 1% and 5% richest counties, health indicators would still lag behind those in many other countries.

Primary Care Physician Practice Styles and Patient Care: Evidence from Physician Exits in Medicare (with Itzik Fadlon)

Journal of Health Economics, 2020. 71: 1--18. doi:10.1016/j.jhealeco.2020.102304

Primary care physicians (PCPs) provide frontline health care to patients in the U.S.; however, it is unclear how their practice styles affect patient care. In this paper, we estimate the long-lasting effects of PCP practice styles on patient health care utilization by focusing on Medicare patients affected by PCP relocations or retirements, which we refer to as "exits." Observing where patients receive care after these exits, we estimate event studies to compare patients who switch to PCPs with different practice style intensities. We find that PCPs have large effects on a range of aggregate utilization measures, including physician and outpatient spending and the number of diagnosed conditions. Moreover, we find that PCPs have large effects on the quality of care that patients receive, and that all of these effects persist for several years. Our results suggest that switching to higher-quality PCPs could significantly affect patients' longer-run health outcomes.

Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care (with Weifeng Weng, Jonathan Skinner, Brenda Sirovich, and Rebecca Lipner)

JAMA Network Open, 2020. 3(4):e202494. doi:10.1001/jamanetworkopen.2020.2494

Question:  How does the health care environment in a region influence internists’ clinical capabilities, particularly the ability to practice high-value care?

Findings:  This cohort study of 2714 newly certified internists (in 2002) who relocated to a new region after completing residency found that higher intensity of use of health care services in a physician’s destination region was associated with reduced ability to practice appropriately conservative care 1 decade later compared with that ability measured at the end of residency.

Meaning:  The demands of practicing in high-intensity service regions may erode internists’ ability to practice high-value, conservative care.

ACA Marketplace Premiums Grew Faster In Areas With Monopoly Insurers Than In Areas With More Competition

Health Affairs, 2018. 37(8) pg. 1-10 doi: 10.1377/hlthaff.2018.0054 

Premiums have increased rapidly in the health insurance Marketplaces, with notable variation across state rating areas. Some experts have speculated that these increases are due to greater enrollment among sicker patients, the expiration of market stabilization policies, or the federal government's discontinuation of funding for cost-sharing subsidies. However, these factors do not explain why some rating areas have experienced rapid premium growth, while others have experienced modest increases. I used a comprehensive database of information about premiums and market characteristics for rating areas in states with federally facilitated Marketplaces to demonstrate that higher premiums are associated with local health insurance monopolies. In 2018, Marketplace premiums were 50 percent ($180) higher, on average, in rating areas with monopolist insurers, compared to those with more than two insurers. This was driven by large premium increases for the monopolist insurers' lowest-cost plans. Understanding how insurer competition has affected enrollment, costs, and quality will help guide future individual-market reforms.

Association Between Medicare Expenditure Growth and Mortality Rates in Patients with Acute Myocardial Infarction: A Comparison From 1999 Through 2014 (with Donald Likosky, Jonathan Skinner, Weiping Zhou, William Borden, and Milton Weinstein)

JAMA Cardiology. 2018. doi:10.1001/jamacardio.2017.4771

Question:  What is the association between growth in Medicare expenditures and decreased mortality between January 1, 1999, and June 30, 2014?

Findings:  In this cross-sectional analysis study of Medicare beneficiaries with acute myocardial infarction, reductions in mortality varied by hospital and were associated with diffusion of cost-effective care, such as early percutaneous coronary interventions, rather than overall spending.

Meaning:  Increased adoption of cost-effective care at the hospital level could improve patient outcomes and, if accompanied by cuts in cost-ineffective care (whether in the acute care or postacute care setting), may also reduce expenditures.

Provider Practice Style and Patient Health Outcomes: The Case of Heart Attacks (with Janet Currie and W. Bentley MacLeod)

Journal of Health Economics, 2016. 47 pg. 64-80

When a patient arrives at the Emergency Room with acute myocardial infarction (AMI), the provider on duty must quickly decide how aggressively the patient should be treated. Using Florida data on all such patients from 1992 to 2014, we decompose practice style into two components: The provider’s probability of conducting invasive procedures on the average patient (which we characterize as aggressiveness), and the responsiveness of the choice of procedure to the patient’s characteristics. We show that within hospitals and years, patients with more aggressive providers have consistently higher costs and better outcomes. Since all patients benefit from higher utilization of invasive procedures, targeting procedure use to the most appropriate patients benefits these patients at the expense of the less appropriate patients. We also find that the most aggressive and responsive physicians are young, male, and trained in top 20 schools. 

Variation in Physician Practice Styles Within and Across Emergency Departments

PLOS One, 2016. 11(8) pg. 1-19 doi:10.1371/journal.pone.0159882 

Despite the significant responsibility that physicians have in healthcare delivery, we know surprisingly little about why physician practice styles vary within or across institutions. Estimating variation in physician practice styles is complicated by the fact that patients are rarely randomly assigned to physicians. This paper uses the quasi- random assignment of patients to physicians in emergency departments (EDs) to show how physicians vary in their treatment of patients with minor injuries. The results reveal a considerable degree of variation in practice styles within EDs; physicians at the 75th percentile of the spending distribution spend 20% more than physicians at the 25th percentile. Observable physician characteristics do not explain much of the variation across physicians, but there is a significant degree of sorting between physicians and EDs over time, with high-cost physicians sorting into high-cost EDs as they gain experience. The results may shed light on why some EDs remain persistently higher-cost than others.