Estimating a Theoretically Consistent Human Capital Production Function With an Application to Head Start.

This article describes a conceptual and empirical approach for estimating a human capital production function of child development that incorporates mother- or child-fixed effects. The use of mother- or child-fixed effects is common in this applied economics literature, but its application is often inconsistent with human capital theory. We outline the problem and demonstrate its empirical importance with an analysis of the effect of Head Start and preschool on child and adult outcomes. The empirical specification we develop has broad implications for a variety of applied microeconomic analyses beyond our specific application. Results of our analysis indicate that attending Head Start or preschool had no economically or statistically significant effect on child or adult outcomes.

Why higher copayments for opioids did not reduce use among Medicare beneficiaries.

To examine whether higher cost-sharing deterred prescription opioid use. Medicare Part D claims from 2007 to 2016 for a 20% random sample of Medicare enrollees. We obtain estimates of the effect of cost-sharing on prescription opioid use using ordinary least squares and instrumental variables methods. In both, we exploit the variation (change) in cost-sharing within plans over time for a sample of beneficiaries who remain in the same plan. Focusing on changes in cost-sharing within a plan for a constant sample of beneficiaries mitigates potential bias from plan selection and using a constant set of weights derived from use in year (t) eliminates changes in the cost-sharing indexes due to (endogenous) consumer choice in year (t+1). Part D plans adopted benefit changes designed to reduce opioid use, including moving opioids to higher cost-sharing tiers. Increasing plan copayments for hydrocodone or oxycodone was associated with reductions in plan-paid claims and offsetting increases in cash claims. Widespread availability of low-cost generics combined with the anti-clawback provision in Part D mediated the effect of higher cost sharing to curb opioid use. As plans moved generic opioids to higher cost-sharing tiers, beneficiaries simply paid cash prices and aggregate use remained largely unchanged. The anti-clawback provision in Part D, intended to protect beneficiaries from price gouging, limited plans' ability to constrain opioid use through typical demand-side measures such as increased cost-sharing.

Medicaid physician fees and the use of primary care services: evidence from before and after the ACA fee bump.

We examine whether fees paid by Medicaid for primary care affects the use of health care services among adults with Medicaid coverage who have a high school or less than high school degree. The analysis spans the large changes in Medicaid fees that occurred before and after the ACA-mandated fee increase for primary care services in 2013-2014. We use data from the Behavioral Risk Factors Surveillance System and a difference-in-differences approach to estimate the association between Medicaid fees and whether a person has a personal doctor; a routine check-up or flu shot in the past year; whether a woman had a pap test or a mammogram in the past year; whether a person has ever been diagnosed with asthma, diabetes, cardiovascular diseases, cancer, COPD, arthritis, depression, or kidney diseases; and, whether a person reports good-to-excellent health. Estimates indicate that Medicaid fee increases were associated with small increases in the likelihood of having a personal doctor, or receiving a flu shot, although only having a personal doctor remained significant when accounting for multiple hypothesis testing. We conclude that Medicaid fees did not have a major impact on the use of primary care or on the consequences of that care.

Foreign-Trained Physicians in the United States: A Descriptive Profile.

More than a quarter of physicians in the United States are international medical graduates (IMGs). This statistic, although large, does not fully capture the importance of IMGs in certain specialties and locations. We provide a comprehensive profile of IMGs documenting where and in what specialties they work and how these distributions have changed over time. Estimates show that IMGs disproportionately work in densely populated, low-income communities with sicker residents and low physician density. IMGs are overrepresented in primary care and the lowest paying specialties, and their concentration in these specialties is growing. Calculations show that U.S. medical graduates exit the workforce at 2.5 times the exit rate of IMGs suggesting that in the near future IMGs will likely provide care for an increasingly larger share of Americans.

Impacts of the Affordable Care Act's Medicaid Expansion on Live Births.

BACKGROUND: We hypothesize that the Affordable Care Act's (ACA) Medicaid expansion, which extended health insurance coverage to preconception, between-conception, and postconception periods for women meeting income eligibility guidelines, impacted the number of live births in the United States by increasing access to contraception and financial well-being. These impacts may differ by maternal socioeconomic and demographic characteristics. METHODS: Using data from birth certificates aggregated to the state-year level and a difference-in-differences design, we estimated the association between Medicaid expansion and count of live births. We also examined whether associations differed by socioeconomic and demographic characteristics. RESULTS: Overall, Medicaid expansion was not meaningfully associated with the count of births (difference-in-differences ß = 0.002; 95% confidence interval [CI] = -0.010, 0.015). However, among certain groups, Medicaid expansion was associated with meaningful changes in the count of live births, though all confidence intervals included the null value. The estimate of the relation between Medicaid expansion and the count of live births was -0.025 (95% CI = -0.052, 0.001) for those ages 18-24 years; -0.078 (95% CI = -0.231, 0.075) for those who were married, and -0.035 (95% CI = -0.104, 0.034) for those who were unmarried. CONCLUSIONS: Despite its potential to impact live births, our results indicate that the ACA's Medicaid expansion was not, in general, associated with live births of US residents of reproductive age. However, for younger, married, and unmarried women, the magnitude of estimates supports the hypothesis of a potentially meaningful effect of Medicaid expansions on live births.

Did the Hospital Readmissions Reduction Program Reduce Readmissions? An Assessment of Prior Evidence and New Estimates.

In this article, we provide a comprehensive, empirical assessment of the hypothesis that the Hospital Readmissions Reduction Program (HRRP) affected hospital readmissions. In doing so, we provide evidence as to the validity of prior empirical approaches used to evaluate the HRRP and we present results from a previously unused approach to study this research question-a regression-kink design. Results of our analysis document that the empirical approaches used in most prior research assessing the efficacy of the HRRP often lack internal validity. Therefore, results from these studies may not be informative about the causal consequences of the HRRP. Results from our regression-kink analysis, which we validate, suggest that the HRRP had little effect on hospital readmissions. This finding contrasts with the results of most prior studies, which report that the HRRP significantly reduced readmissions. Our finding is consistent with conceptual considerations related to the assumptions underlying HRRP penalty: in particular, the difficulty of identifying preventable readmissions, the highly imperfect risk adjustment that affects the penalty determination, and the absence of proven tools to reduce readmissions.

Medicaid Expansion Associated With Some Improvements In Perinatal Mental Health.

Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their family. A possible contributing factor to poor perinatal mental health is discontinuity in health insurance coverage, which is particularly important among low-income people. We examined impacts of Medicaid expansion on prepregnancy depression screening and self-reported depression and postpartum depressive symptoms and well-being among low-income people giving birth. Medicaid expansion was associated with a 16 percent decline in self-reported prepregnancy depression but was not associated with postpartum depressive symptoms or well-being. Associations between Medicaid expansion and prepregnancy mental health measures increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.

Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes.

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.

The role of the built environment, food prices and neighborhood poverty in fruit and vegetable consumption: An instrumental variable analysis of the moving to opportunity experiment.

The food environment has been associated with fruit and vegetable consumption, however many studies utilize cross-sectional research designs. This study examined 3,473 participants in the Moving to Opportunity experiment, who were randomized into groups that affected where they lived. The relationship between the built environment, food prices and neighborhood poverty, assessed over four to seven years, on fruit or vegetable consumption was examined using instrumental variable analysis. Higher food prices and neighborhood poverty were associated with lower fruit or vegetable consumption. Policies and programs that address food prices should be implemented and evaluated for their effects on fruit and vegetable consumption.

Distance to an Abortion Provider and Its Association with the Abortion Rate: A Multistate Longitudinal Analysis.

CONTEXT: Although one in four U.S. women has an abortion in her lifetime, barriers to abortion persist, including distance to care. This study evaluates the association between distance to care and the abortion rate, adjusting for abortion demand. METHODS: Two analyses were conducted using a data set linking provider locations and 2000-2014 county-level abortion data for 18 states; data sources included the Census Bureau, state vital statistics offices and the Guttmacher Institute. First, a series of linear regression models were run, with and without adjustment for demographic covariates, modeling distance as both a continuous and a categorical variable. Then, an instrumental variable analysis was conducted in which being 30 or more miles from a large college-enrolled female population younger than age 25 was used as an instrument for distance to a provider. The outcome variable for all models was abortions per 1,000 women aged 25 or older. All models were adjusted for state, year and state-year interaction fixed effects. RESULTS: Increased distance to a provider was associated with a decreased abortion rate. Each additional mile to a provider was associated with a decrease of 0.011 in the abortion rate. Compared with being within 30 miles of a provider, being between 30 and 90 miles from a provider was associated with 0.80-1.46 fewer abortions per 1,000 women. In the instrumental variable analysis, being 30 or more miles from a provider was associated with 5.26 fewer abortions per 1,000 women. CONCLUSIONS: Distance to a provider may present a barrier to abortion by preventing access to care. Therefore, policies that increase travel distances have potential for harm.

Association of Highly Restrictive State Abortion Policies With Abortion Rates, 2000-2014.

Importance: Although abortion is common in the United States, patients face substantial barriers to obtaining an abortion. Recently enacted abortion restrictions pose such barriers. Objectives: To assess the association between a state legislative climate that is highly restrictive toward abortion provision and the abortion rate and to evaluate whether distance to a facility providing abortion care mediates the association between legislative climate and the abortion rate. Design, Setting, and Participants: This cohort study examined county-of-residence abortion rates from all states that publicly provided them and used data on abortion restrictions, facility locations, and county demographic characteristics for the years 2000 to 2014. The association between legislative climate and abortion rates was evaluated using propensity score-weighted, linear regression difference-in-difference analysis. All models included state and year fixed effects and standard errors adjusted for state-level clustering. Exposures: Highly restrictive legislative climate, defined as having at least 3 of 4 types of abortion restrictions; distance to a high-volume facility providing abortion care (ie, performing ≥395 abortions per year) in miles. Main Outcomes and Measures: County-level abortion rate, defined as abortions per 1000 women per year. Results: Abortion rate data were obtained from 1178 counties in 18 states for a median of 12.5 years (range, 5-14). The median abortion rate was 2.89 per 1000 women (interquartile range, 1.71-4.46 per 1000 women). A highly restrictive legislative climate, when compared with a less restrictive one, was associated with 0.48 fewer abortions per 1000 women (95% CI, -0.92 to -0.04 abortions per 1000 women; P = .03). Adjusted for distance to a facility providing abortion care, a highly restrictive legislative climate was associated with 0.44 fewer abortions per 1000 women (95% CI, -0.85 to -0.03; P = .04). Each mile to a facility was associated with 0.02 fewer abortions per 1000 women (95% CI, -0.03 to -0.01 abortions per 1000 women; P = .003). Legislative climate was not significantly associated with distance to a facility providing abortion care (change in distance associated with highly restrictive climate, -2.73 [95% CI, -6.02 to 0.57] miles; P = .10). Conclusions and Relevance: This study provides evidence that a state legislative climate that is highly restrictive toward abortion provision is associated with a lower abortion rate. The cumulative effect of restrictive policies may pose a barrier to abortion access.

Built Environment Exposures of Adults in the Moving to Opportunity Experiment.

This paper describes environmental exposures of adult participants in the Moving to Opportunity for Fair Housing (MTO) experiment over a four to seven year period from baseline to the interim evaluation. The MTO experiment randomized participants living in public housing or private assisted housing at baseline into experimental and control groups and provided a housing voucher for experimental group participants to move to neighborhoods with less than 10 percent of the population below the poverty line. However, few studies have examined how this move affected exposures to health promoting environments. We used data on residential locations of MTO participants and archival data on the built and food environment to construct environmental exposure variables. MTO participants in the experimental and Section 8 groups lived in neighborhoods with higher food prices, less high intensity development and more open space relative to the control group. The findings suggest that housing policies can have potential health consequences by altering health-related environmental exposures.

The Impact of Parental Involvement Laws on the Abortion Rate of Minors.

In this article, we conduct a comprehensive analysis of the effect of parental involvement (PI) laws on the incidence of abortions to minors in the United States. We contribute to the extant literature in several ways. First, we explore differences in estimates of the effect of PI laws across time that may result from changes in contraception, the composition of pregnant minors, abortion access in nearby states, and differences in how these laws are enforced. We find that PI laws enacted before the mid-1990s are associated with a 15% to 20% reduction in abortions to minors, but PI laws enacted after this time are not associated with declines in abortions to minors. Second, we assess the role of out-of-state travel by minors and find that it is not a significant factor moderating the effect of PI laws. Third, we use a synthetic control approach to explore state-level heterogeneity in the effect of PI laws and find large differences in the effect of PI laws on abortions to minors by state that appear unrelated to the type of PI law or whether contiguous states have enacted PI laws. Finally, we show that estimates of the effect of PI laws using data from either the Centers for Disease Control or the Guttmacher Institute do not differ qualitatively once differences in the states and years available across these data are harmonized.

Impacts of Medicaid Expansion on Health Among Women of Reproductive Age.

INTRODUCTION: Preconception and interconception health care are critical means of identifying, managing, and treating risk factors originating before pregnancy that can harm fetal development and maternal health. However, many women in the U.S. lack health insurance, limiting their ability to access such care. State-level variation in Medicaid eligibility, particularly before and after the 2014 Medicaid expansions, offers a unique opportunity to test the hypothesis that increasing healthcare coverage for low-income women can improve preconception and interconception healthcare access and utilization, chronic disease management, overall health, and health behaviors. METHODS: In 2018-2019, data on 58,365 low-income women aged 18-44 years from the 2011-2016 Behavioral Risk Factor Surveillance System were analyzed, and a difference-in-difference analysis was used to examine the impact of Medicaid expansions on preconception health. RESULTS: Expanded Medicaid eligibility was associated with increased healthcare coverage and utilization, better self-rated health, and decreases in avoidance of care because of cost, heavy drinking, and binge drinking. Medicaid eligibility did not impact diagnoses of chronic conditions, smoking cessation, or BMI. Medicaid eligibility was associated with greater gains in health insurance, utilization, and health among married (vs unmarried) women. Conversely, women with any (vs no) dependent children experienced smaller gains in insurance following the Medicaid expansion, but greater take-up of insurance when eligibility increased and larger behavioral responses to gaining insurance. CONCLUSIONS: Expanded Medicaid coverage may improve access to and utilization of health care among women of reproductive age, which could ultimately improve preconception health.

Is Primary Care A Substitute or Complement for Other Medical Care? Evidence from Medicaid.

It is widely believed that Medicaid reimbursement for primary care is too low and that these low fees adversely affect access to healthcare for Medicaid recipients. In this article, we exploit changes in Medicaid physician fees for primary care to study the response of primary care visits and services that are complements/substitutes with primary care, including emergency department, hospitalization, prescription drugs, and imaging. Results from our study indicate that higher Medicaid fees for primary care have modest effects. Among non-blind and non-disabled adults, we find that a 25% (or $10) increase in Medicaid fees for primary care is associated with approximately a 5% of a standard deviation increase in the number of primary care visits. For the same group, we also find that the fee increase is associated with an increase in the probability of having any primary care visits of approximately 3 percentage points. For children, changes in Medicaid fees are not significantly related to the number of primary care visits. In terms of other types of care, we find some evidence that Medicaid fees for primary care are associated with prescription drug use, and no evidence that primary care fees are associated with the use of emergency department, inpatient services, or imaging. Overall, our evidence provides, at best, limited support for the large effects of Medicaid fees on service provision sometimes asserted in policy discussions.

The Effect of the Affordable Care Act Medicaid Expansions on Financial Wellbeing.

We examine the effect of the Medicaid expansions under the 2010 Patient Protection and Affordable Care Act (ACA) on consumer financial outcomes using data from a major credit reporting agency for a large, national sample of adults. We employ the synthetic control method to compare individuals living in states that expanded Medicaid to those that did not. We find that the Medicaid expansions significantly reduced the number of unpaid bills and the amount of debt sent to third-party collection agencies among those residing in zip codes with the highest share of low-income, uninsured individuals. Our estimates imply a reduction in collection balances of approximately $1,140 among those who gain Medicaid coverage due to the ACA. Our findings suggest that the ACA Medicaid expansions had important financial impacts beyond increasing health care use.

Impact of Medication Adherence on Health Services Utilization in Medicaid.

OBJECTIVE: To examine the impact of adherence to chronic disease medications on health services utilization among Medicaid enrollees. SUBJECTS: Eligibility, claims, and encounter data from the Medicaid Analytic Extract files from 10 states (Alabama, California, Florida, Illinois, Indiana, Louisiana, New Hampshire, New Mexico, New York, and Virginia) were used to construct a 3-year (2008-2010), longitudinal dataset of Medicaid recipients 18-64 years of age, including 656,646 blind/disabled individuals and 704,368 other adults. Patients were classified as having ≥1 of 7 chronic conditions: (1) congestive heart failure; (2) hypertension; (3) dyslipidemia; (4) diabetes; (5) asthma/chronic obstructive pulmonary disease; (6) depression; and (7) schizophrenia/bipolar. METHODS: Poisson regression was used to estimate associations between medication adherence [continuous and categorical proportion of days covered (PDC)] and 3 dependent variables: number of inpatient hospitalizations, emergency department visits, and outpatient physician/clinic visits. RESULTS: Full adherence was associated with 8%-26% fewer hospitalizations and 3%-12% fewer emergency department visits among those with congestive heart failure, hypertension, diabetes, and schizophrenia/bipolar. In all analyses, full adherence was associated with up to 15% fewer outpatient physician/clinic visits. Moreover, low and moderate levels of adherence were also related to less health care use. CONCLUSIONS: Substantial reductions in health services utilization and costs may be realized with improved medication adherence in Medicaid. These benefits begin to accrue at adherence levels below the common 0.80 PDC threshold. Therefore, interventions should focus not just on perfecting moderate adherers, but also on encouraging Medicaid patients with chronic conditions to initiate pharmacotherapy.

Childhood Medicaid Coverage and Later-Life Health Care Utilization.

Exploiting a discontinuity in childhood Medicaid eligibility based on date of birth, we find that more years of childhood eligibility are associated with fewer hospitalizations in adulthood. For blacks, we find a 7-15% decrease in hospitalizations and a suggestive 2-5% decrease in emergency department visits, but no similar effect for non-blacks. The effects are pronounced for utilization related to chronic illnesses and for patients living in low-income zip codes. Calculations suggest that lower rates of hospitalizations during one year in adulthood for blacks offset between 2 and 4 percent of the initial costs of expanding Medicaid for all children.

Association Between Prescription Drug Insurance and Health Care Utilization Among Medicare Beneficiaries.

Medicare Part D was associated with reduced hospitalizations, yet little is known whether these effects varied across patients and how Part D was associated with length of stay and inpatient expenditures. We used Medicare claims and the Medicare Current Beneficiary Survey from 2002 to 2010 and an instrumental variables approach. Gaining drug insurance through Part D was associated with a statistically significant 8.0% reduction in likelihood of admission across conditions examined. Reductions were generally greater for younger, healthier, and male individuals. Across all conditions, mean length of stay decreased by 3.2% from a baseline of 5.1 days. Part D was associated with a 3.5% reduction in expenditures per admission, reflecting a decrease of $844 from a mean charge of $24,124 per admission prior to Part D. Thus, Part D was associated with statistically and clinically significant reductions in the probability of admission and length of stay for several common conditions.