Research
Publications
Same-Sex Marriage and Employer Choices about Domestic Partner Benefits, with Ben Harrell and Christopher (Kitt) Carpenter. Forthcoming at the American Journal of Health Economics. (link)
We provide the first evidence on employer health insurance decisions regarding same-sex domestic partner (SSDP) benefits before and after nationwide legal same-sex marriage (SSM) was adopted in the United States in Obergefell vs. Hodges (2015). Using rich microdata on over 250,000 establishments from the 2013-19 Medical Expenditure Panel Survey – Insurance Component (MEPS-IC), we show that private employers were 7 percentage points more likely to offer SSDP benefits than different-sex domestic partner (DSDP) benefits prior to 2015. After Obergefell, however, these employers significantly reduced SSDP benefits back to the rate at which they offer DSDP benefits. This effect is entirely driven by large private employers; there were no similar effects for public employers or small private employers. Interestingly, there was no differential reduction of SSDP benefits in states that had not legalized SSM prior to 2015 (for whom Obergefell was more of a binding treatment) compared to states that had adopted SSM before Obergefell. Our results are the first to document dynamic trends in SSDP benefit offerings by large private employers and suggest the importance of national (in addition to local) norms in these decisions.
Introducing the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR): Description, Data Construction Methodology, and Quality Assessment, with Alice Zawacki and G. Edward Miller. CES Working Paper Number CES-22-29; MEPS Methodology Report 35. August 2022. (link) (slides from 2022 Federal Committee on Statistical Methodology conference presentation)
This report introduces a new dataset, the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR), consisting of MEPS-IC survey data on establishments and their health insurance benefits packages linked to Decennial Census data and administrative tax records on MEPS-IC establishments’ workforces. These data include new measures of the characteristics of MEPS-IC establishments’ parent firms, employee turnover, the full distribution of MEPS-IC workers’ personal and family incomes, the geographic locations where those workers live, and improved workforce demographic detail. Next, this report details the methods used for producing the MEPS-ICAR. Broadly, the linking process begins by matching establishments’ parent firms to their workforces using identifiers appearing in tax records. The linking process concludes by matching establishments to their own workforces by identifying the subset of their parent firm’s workforce that best matches the expected size, total payroll, and residential geographic distribution of the establishment’s workforce. Finally, this report presents statistics characterizing the match rate and the MEPS-ICAR data itself. Key results include that match rates are consistently high (exceeding 90%) across nearly all data subgroups and that the matched data exhibit a reasonable distribution of employment, payroll, and worker commute distances relative to expectations and external benchmarks. Notably, employment measures derived from tax records, but not used in the match itself, correspond with high fidelity to the employment levels that establishments report in the MEPS-IC. Cumulatively, the construction of the MEPS-ICAR significantly expands the capabilities of the MEPS-IC and presents many opportunities for analysts.
New evidence on geographic disparities in United States hospital capacity, with Pamela L. Owens and Thomas M. Selden. Health Services Research, June 2022. (link)
Objective: To characterize the quantity and quality of hospital capacity across the United States.
Data Sources: We combine a 2017 near-census of U.S. hospital inpatient discharges from the Healthcare Cost and Utilization Project (HCUP) with American Hospital Association Survey, Hospital Compare, and American Community Survey data.
Study Design: This study produces local hospital capacity quantity and care quality measures by allocating capacity to zip codes using market shares and population totals. Disparities in these measures are examined by race and ethnicity, income, age, and urbanicity.
Data Collection/Extraction Methods: All data derive from pre-existing sources. All hospitals and zip codes in states, including the District of Columbia, contributing complete data to HCUP in 2017 are included.
Principal Findings: Non-Hispanic Black individuals live in zip codes supplied, on average, 0.11 more beds per 1000 population (SE = 0.01) than places where non-Hispanic White individuals live. However, the hospitals supplying this capacity have 0.36 fewer staff per bed (SE=0.03) and perform worse on many care quality measures. Zip codes in the most urban parts of America have the least hospital capacity (2.11 beds per 1000 persons; SEM=0.01) from across the rural-urban continuum. While more rural areas have markedly higher capacity levels, urban areas have advantages in staff and capital per bed. We do not find systematic differences in care quality between rural and urban areas.
Conclusions: This study highlights the importance of lower hospital care quality and resource intensity in driving racial and ethnic, as well as income, disparities in hospital care related outcomes. This study also contributes an alternative approach for measuring local hospital capacity that accounts for cross-hospital service area flows. Adjusting for these flows is necessary to avoid underestimating the supply of capacity in rural areas and overestimating it in places where non-Hispanic Black individuals tend to live.
High Job Flexibility And Paid Sick Leave Increase Health Care Access And Use Among US Workers, with Terceira Berdahl. Health Affairs, June 2022. (link)
Job flexibility is an important yet underresearched aspect of work that has implications for health care access and use. This study explored the impact of job flexibility, including both its informal aspects and access to paid sick leave, on health care access and use. We analyzed data from a nationally representative sample of US workers responding to the Medical Expenditure Panel Survey–Household Component during 2017–19, combined with occupational data from the Occupational Information Network database, version 25.0. Results showed that a one-unit increase in job flexibility was associated with a 2.15-percentage-point increase in the likelihood of having an office-based health care visit in the past year and a 2.42-percentage-point increase in the likelihood of having a usual source of care. Access to paid sick leave was associated with a 3.83-percentage-point increase in the likelihood of having an office-based health care visit. Black and Hispanic workers, as well as workers with low-wage jobs, had less job flexibility and less access to paid sick leave. Reforms that increase job flexibility and efforts by health care providers to better accommodate people with inflexible jobs could improve access, utilization, and equity.
Working Papers and Work in Progress
How Do Payroll Subsidies Affect Employment and Wages? New Evidence from Establishment-Varying Subsidies to Nursing Homes (draft)
Payroll subsidies hold promise as a tool for increasing employment, but raise concerns that they may involve large inframarginal payments that recipient firms could divert toward other purposes. I study the effect of a set of payroll subsidies offered by state Medicaid programs to nursing homes on nursing home employment and various categories of expenditure, including on subsidized workers, other workers, administration, and capital. These subsidies were designed to subsidize only increases in nurse and nursing assistant payroll expenditure relative to a nursing home’s expenditure in an initial year. They also were structured so that the maximum subsidy amounts offered varied across nursing homes within each state. I identify the effect of subsidies using this within-state, establishment-level variation in subsidies, in contrast to prior literature that relied on across-state variation in subsidy adoption. My results imply that the average nursing home increased its employment per resident-day of nurses and nursing assistants by 4.6% in response to subsidies, with not-for-profit nursing homes exhibiting larger employment responses. I also find that each dollar of subsidies offered elicited at least as much expenditure on direct care workers, suggesting that they had an incidence consistent with the full value of subsidies being passed on to subsidized workers. I find little evidence suggesting nursing homes substituted nurses and nursing assistants for other inputs, but rather find evidence consistent with nursing homes using subsidies to expand their scale, either by offering more services or taking in residents with greater care needs. Overall, the pattern of responses to these payroll subsidies suggests that they were highly effective tools for increasing nursing home employment while minimizing diversion of subsidy payments to other purposes.
Medicaid Coverage of Adult Psychologist Services Reduces Crime (draft)
Adult psychologist services are an optional coverage benefit under traditional Medicaid that a number of state Medicaid programs chose to cover for the first time in the 2000s and early 2010s. This research examines the effect of these mental health coverage expansions on crime by comparing changes in crime rates before and after the coverage expansions between places within the same state that have varying exposure to Medicaid. I find that the average person in a treated state lived in a place where index crimes fell by 3.25 crimes per 1000 persons in response to the coverage expansions, or by about 7.3% of the sample average crime rate, with the averted crimes primarily being property crimes. At the same time, treatment also led to an increase in employment in psychology-related industries of a magnitude implying that each person induced to work by the policy was associated with 10.63 averted crimes. Overall, these results suggest that efforts to expand access to behavioral healthcare may prove fruitful for reducing crime, even when expansions are not coupled with outreach programs explicitly aimed at extending resources to persons at a high risk of either committing crimes or being victimized by crimes.