Medicaid Managed Care and Emergency Department Utilization: A North Carolina Analysis
by Temitope Ayokunmi Ojo
Abstract
In July 2021, North Carolina Medicaid switched from a traditional fee-for-service model to a Medicaid managed care (MMC) network. This thesis explores the effect of this policy change on Emergency Department (ED) utilization for Medicaid beneficiaries in North Carolina. A linear difference-in-difference model was used to estimate the change in ED visits between the treatment group, Medicaid beneficiaries, and two control groups, non-Medicaid 19–64-year-olds and 65+ NC residents. The results indicate a statistically significant decline in ED visits, about 11% decline from pre-policy visit rates, for Medicaid beneficiaries after the mandatory switch to managed care. The reduction in visits was most persistent for those related to chronic condition treatment. Furthermore, we find evidence consistent with both medical care disruption and better management of health as drivers of the decline in ED visits. Determining the cause of these patterns should be explored by deeper analyses of trends in other healthcare delivery avenues (i.e. PCP appointments or hospital admissions) post-policy implementation.
Professor M. Kate Bundorf, Faculty Advisor
Professor Grace Kim, Seminar Advisor
JEL Codes: I11, I13, I18
Keywords: Medicaid, Insurance, Emergency Department
Alcohol Use and Assault: Regression Discontinuity Evidence from the Minimum Legal Drinking Age
by Maggie Hu
Abstract
While it has long been observed that alcohol consumption is a risk factor for violence, the economics literature has up until recently provided minimal persuasive evidence regarding the causal nature of this relationship. In this study, we employ a regression discontinuity (RD) framework to examine how arrest and victimization rates from assault change at age 21, the U.S. minimum legal drinking age (MLDA-21). Utilizing annual FBI arrest data from the past 36 years since 1988, when the last states adopted the MLDA-21, we estimate that for both males and females, reaching the MLDA increases arrest rates for aggravated and other simple assaults by 5 – 8%, with the aggravated assault effect for females restricted to the latter half of the sample period. Analogous effects at slightly older ages are small and insignificant, as well as the effects for demographic and population characteristics expected to trend smoothly across the MLDA-21 threshold. We extend our analysis of assault-related violence by assessing victimization outcomes, particularly the effect of the MLDA-21 nonfatal injury, by leveraging emergency department (ED) data from the CDC’s Web-based Injury Statistics and Query Reporting System (WISQARS) spanning the period 2001–2022. Notably, we observe that ED visits for “struck by or against” assaults rise significantly by 7–10%, indicating increased participation in violent altercations and increased risk of victimization upon obtaining legal access to alcohol. Taken together, these results suggest that alcohol use increases aggression and violent behavior, the consequences of which thereby represent criminal justice and public health costs that would be exacerbated by lowering the MLDA.
Professor Jeffrey DeSimone, Faculty Advisor
JEL Codes: I18, I12, K0, K32
Keywords: Health Economics, Alcohol Policy, Education and Welfare
The Effect of Community Uninsurance Rates on Access to Health Care among the Insured
by Isabella Antonio
Abstract
While the direct effects of being uninsured have been studied extensively, there is significantly less research on how a high community uninsured rate can impact health care access for insured individuals. Using data from SMART BRFSS, I examine the effect of community uninsured rates on access to health care for insured individuals ages 18 to 64 years old. Controlling for MMSA-level fixed effects and year fixed effects, I estimate the effect of community uninsurance on the likelihood of an insured individual skipping care due to cost, the likelihood of an insured individual having at least one personal doctor, and the likelihood of an insured individual delaying a physical exam, cholesterol check, or pap smear. Results suggest that a 10 percentage point increase in the community uninsured rate decreases the likelihood of an insured individual having at least one personal doctor by 0.304 percentage points and increases the likelihood of delaying a physical exam, cholesterol check, or pap smear by 0.590 to 2.31 percentage points. These findings suggests that policies aimed at reducing the uninsured rate, such as the Affordable Care Act and Medicaid expansion, may produce widespread benefits for all Americans, both the uninsured and the insured.
Professor Jeffrey DeSimone, Faculty Advisor
Professor Michelle Connolly, Faculty Advisor
JEL Codes: I1, I11, I13
Keywords: Health insurance, Health care access
(Email for access to data)
Investing in Rural Healthcare: Impact of Private Equity Acquisition on Financial and Utilization Outcomes of Rural Hospitals
by Amanda He
Abstract
Private equity investment in the healthcare sector has risen considerably in recent decades, yet the impact of private equity ownership in rural hospital markets is largely unknown. Existing research points to a correlation between private equity acquisition and increased hospital incomes and charges. Rural hospitals, however, are structurally and operationally different from their urban counterparts, with lower occupancy rates and higher susceptibility to financial distress. This paper seeks to (1) characterize the types of rural hospitals acquired by private equity firms and (2) examine the changes in rural hospital financial, utilization, and survivability outcomes following private equity ownership. Using a 15-year panel of Medicare data, I estimate the impact of 352 private equity deal-hospitals across nine financial and utilization outcomes. Additionally, I estimate the impact of private equity on hospital closures. I find that private equity acquisition improves profitability for both urban and rural hospitals, but the magnitude is smaller for rural hospitals. My results suggest that private equity-owned hospitals increase profits by reducing operating expenses. Among rural hospitals, private equity ownership is associated with fewer discharges and lower occupancy rates, which may be a concern for long-term viability. I find a statistically significant negative correlation between private equity acquisition of rural hospitals and an increased likelihood of closure. PE-acquired hospitals have a negative spillover effect on other hospitals within the same hospital referral region, leading to a higher probability of closing.
Professor Ryan McDevitt, Faculty Advisor
Professor Michelle Connolly, Faculty Advisor
Professor Grace Kim, Faculty Advisor
JEL classification: G23, G33, G34, I10, I11
The Impact of 2021 Advance Child Tax Credit Payments on Low-Income Households’ Labor Supply
by Zixin “Ellen” Zhang
Abstract
Studies have established that the Advance 2021 Child Tax Credit (CTC) payments substantially reduced poverty and food insecurity, but some claim that the CTC payments may create negative labor supply effects that could offset its hardship-reduction benefits. Researchers have used a variety of methods to measure how the monthly CTC payments affect the labor supply of households, but the results vary from significant decreases to no significant change to even increases in household labor supply. Using a method novel to this literature, I estimate the labor supply impacts of Advance 2021 CTC by analyzing labor supply changes in response to real amounts of CTC received, which varies by household depending on regional cost-of-livings. Through fixed effects linear regressions across many different combinations of household type and income level, I find that, on average, receiving Advance CTC caused a statistically significant decrease in household labor supply. However, for different household subgroups, I find both statistically significant and insignificant labor supply impacts as well as both increases, decreases, and no change in households’ labor supply due to monthly CTC payments. This suggests that the impacts of 2021 Advance CTC on household labor depend heavily on a household’s situation, specifically income level and household composition. These household-specific patterns align with prior research on the Advance 2021 CTC and how welfare payments are used by families.
Professor Thomas Nechyba, Faculty Advisor
JEL Codes: C31, H24, I38, J22
School Choice and Neighborhood Change in Post-Katrina New Orleans
by Rosalind Fei Yang
Abstract
As school choice policies weaken the traditional link between neighborhoods and schools, traditional housing patterns previously governed by school zoning are changing. This paper examines the connection between school choice reform, specifically an increase in charter schools, and changes in neighborhood composition, focusing on New Orleans over time. I use data from the American Community Survey, the National Center of Education Statistics, and the Louisiana Department of Education. The goal is to understand how school choice policies influence residential dynamics, with a specific focus on their role in gentrification patterns.
Professor Patrick Bayer, Faculty Advisor
Professor Michelle Connolly, Faculty Advisor
JEL Codes: H75, I21, I28
The Effect of Gun Prevalence on the Occurrence of School Shootings
by Abigail Ullendorff
Abstract
This paper studies how gun prevalence, represented by federal firearm background checks, affects the occurrence of school shootings. While precedent literature has estimated adverse effects of school shootings on exposed children, including reductions in mental health, academic achievement, and labor market earnings, few studies have attempted to identify factors that influence school shooting frequency in the first place. The analysis sample is an annual state panel of shootings during 2000-2021, constructed from the proprietary K-12 School Shooting Database as well as from data on background checks, demographic characteristics, economic conditions, and measures of violence and mental health status. Estimates from difference-in-differences regressions that include state and year by-census region fixed effects and state-specific linear trends indicate a positive relationship between gun prevalence and school shootings, particularly when the dependent variable is specified as a binary indicator of multiple school shootings having occurred. Results are robust to using the annual shooting count or its quartic root, an indicator that a shooting occurred, Poisson regressions of school shooting count models, and quadratic state trends as additional controls. Several types of shootings, including targeted, elementary school, high school, and deadly shootings, increase in frequency and/or likelihood when gun prevalence rises.
Professor Jeffrey DeSimone, Faculty Advisor
Professor Grace Kim, Faculty Advisor
JEL Codes: I18, I29, K42
Free University? An Investigation of Australia’s 1974 Free Higher Education Policy and Its Impact on Enrollment, Degree Completion, Later-Life Occupational Status, and Income
by Yaxuan “Annie” Cui
Abstract
To what extent has the free higher education policy of 1974 impacted Australian
students’ decisions of university enrollment, degree completion, and later-life human capital
development? In this paper, I analyze the impact of the policy from both national descriptive
statistics and individual-level enrollment and degree completion decisions using the Australian
Household Income and Labour Dynamics Survey. I find that the policy has significantly
increased the likelihood of female enrollment in higher education, low-income students’
likelihood of diploma degree completion, and is positively associated with later-life occupational
status. However, this study does not find a clear relationship between the policy, bachelor’s
degree attainment, and later-life disposable income. Policymakers need to carefully consider the
efficiency and efficacy of broad-based tuition policy instruments when imagining bridges to
achieve universal access to higher education.
Professor Robert Garlick, Faculty Advisor
Professor Michelle Connolly, Faculty Advisor
Professor Peter Arcidiacono, Faculty Advisor
JEL Codes: I2, I22; I23; I26
