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, alt link)

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.

Work In Progress

The Affordable Care Act Medicaid Expansions Did Not Affect Employee Turnover Rates (Even Though Theory Says They Should've), with Patricia Keenan

Did COVID Pandemic Related School School Closures Affect Student Mental Health? with Jessica Monnet

How Do Nursing Homes Respond to Minimum Staffing Requirements: New Evidence Using Nursing Home Accounting Data

Do Minimum Wage Increases Affect Employer Health Insurance Offerings?

On the General Equilibrium Wage Effects of Education Expansions, with Ethan Kaplan and Danny Koliner

Did the NIRA Work Week Hours Rules Persistently Affect Work Week Length?