How do Multistate Firms Design their Compensation Packages When Local Conditions Vary? Evidence from Interstate Spillover Effects of the Affordable Care Act Medicaid Expansions? Thomas A. Hegland. Working paper (draft).
Businesses operating establishments across multiple states face a trade-off between offering standardized pay and benefits packages and tailoring their compensation to the economic and policy circumstances of each state. To better understand how businesses navigate this trade-off, I study how large firms adjusted their benefits in response to the Affordable Care Act Medicaid expansions by comparing changes in their health insurance offer rates and related outcomes before and after the expansions between businesses varying in their degree of company-wide exposure to the expansions. Using this approach, I find evidence that more heavily exposed businesses responded to the Medicaid expansions by reducing their health insurance offer rate in a standardized company-wide fashion, reducing benefit availability in both expansion states and non-expansion states rather than tailoring their response to local conditions. This overall effect is difficult to detect using a traditional state difference-in-differences research design, as the interstate spillover effects generated by firms' standardizing behavior contaminate the design's control group, violating its Stable Unit Treatment Value Assumption and biasing its treatment effect estimates toward zero. Beyond effects on the health insurance offer rate, I also find that more exposed businesses responded to the expansions by exhibiting reduced health insurance costs, increased employee turnover rates, and increased employment of part-time workers. I do not find evidence that workers' annual levels of pay increased in response to the expansions. Overall, my results point toward firms favoring standardization over tailoring when designing key aspects of employee compensation packages. They also highlight that in settings where firms engaging in standardizing behavior are important determinants of key outcomes, researchers face considerable methodological challenges to employing research designs that rely on geographic variation in policy adoption to identify treatment effects. Finally, my results suggest that policymakers should carefully consider the broader landscape of policies outside their jurisdiction when designing policies of their own, as whether and how businesses respond to a new policy initiative may depend significantly on how it relates to policies adopted in other jurisdictions where those businesses have significant operations.
Nursing Home Staffing Subsidies: Increasing Quality or Facilitating a Transition to Serving New Patient Populations? (draft) Thomas A. Hegland. Revise and Resubmit at Journal of Health Economics.
Ensuring nursing homes provide high quality care to their long-term Medicaid-enrolled residents is a perennial policy challenge for state Medicaid programs, which are the dominant financiers of long-stay nursing home care in the United States, and typically have lower reimbursement rates than private insurance. In this policy space, programs aimed at increasing nursing home staffing levels are commonly proposed as a method for improving nursing home care quality. In this research, I study a slate of nursing home staffing subsidies offered by state Medicaid programs using a mixture of data from nursing home inspection surveys and from the Minimum Data Set, evaluating the impact of these subsidies on nursing home staffing levels, the type of residents admitted to the nursing home, and nursing home resident health outcomes. I find evidence that the staffing subsidies substantially increased nursing home staffing levels, by approximately 7.5%. However, I also find evidence that nursing homes receiving the subsidies shifted the composition of residents they admitted toward those with lower care needs and away from those using Medicaid to pay for care. This evidence is consistent with nursing homes using newly hired staff to facilitate a transition toward serving more Medicare-enrolled and privately-insured short-term rehabilitation patients and fewer Medicaid-enrolled long-term care residents. I find no evidence of effects on resident health outcomes. My results highlight the difficulty associated with designing policies to improve nursing home care quality when nursing homes are competing for patients of varying types: increasing staffing levels might benefit Medicaid patients by improving care quality, but improved care quality might also allow nursing homes to shift away from serving the Medicaid market. My results also support prior theoretical and empirical work considering this trade-off in the context of overall nursing home reimbursement rates by Gertler (1989) and Nyman (1989).
Medicaid Coverage of Adult Psychologist Services Reduces Crime. Thomas A. Hegland. Health Economics, May 2025. (link)
Access to Pediatric Bed Capacity According to Social Determinants of Health: All Beds Are Not Created Equal. Thomas A. Hegland, R. Thomas Day Jr., and Katie M. Moynihan. The Journal of Pediatrics, December 2024. (link)
New Linked Employee-Employer Data Show Workforce Composition Is Associated With Health Insurance Offers Among Small Employers. Alice Zawacki, Thomas A. Hegland, Patricia S. Keenan, and G. Edward Miller. Medical Care Research and Review, October 2024. (link)
GLP-1 Medication Use for Type 2 Diabetes Has Soared. Thomas A. Hegland, Zhengyi Fang, and Karen Bucher. JAMA, Aug 30th, 2024. (link)
Same-Sex Marriage and Employer Choices about Domestic Partner Benefits. Christopher S. Carpenter, Benjamin J. Harrell, and Thomas A. Hegland. American Journal of Health Economics, Spring 2024. (link)
A Comparative Analysis of Methods for Drive Time Estimation on Geospatial Big Data: A case study in U.S.. Xiaokang Fu, Devika Kakkar, Junyi Chen, Katie Moynihan, Thomas Hegland, and Jeff Blossom. The International Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences, July 2023. (link)
Introducing the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR): Description, Data Construction Methodology, and Quality Assessment. Thomas A. Hegland, Alice Zawacki, and G. Edward Miller. MEPS Methodology Report 35; CES Working Paper Number CES-22-29. August 2022. (link) (slides from 2022 Federal Committee on Statistical Methodology conference presentation)
New Evidence on Geographic Disparities in United States Hospital Capacity. Thomas A. Hegland, Pamela L. Owens, and Thomas M. Selden. Health Services Research, June 2022. (link)
High Job Flexibility And Paid Sick Leave Increase Health Care Access And Use Among US Workers. Thomas A. Hegland and Terceira A. Berdahl. Health Affairs, June 2022. (link)
Time Costs and Access to Care: Evidence from Medical Appointment Wait Times. Thomas A. Hegland and Jessica Lazerov.
What Were the General Equilibrium Wage Effects of the US High School Education Expansion Movement? Thomas A. Hegland and Ethan Kaplan.