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 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
Impact of Medicare Advantage Supplemental Benefit Expansion on Startup Funding
by Judy Tianhong Zhong
Abstract
In 2018, the Center for Medicare and Medicaid Services (CMS) announced that they would expand the supplemental benefits that can be included in Medicare Advantage (MA) plans. The goal was to encourage insurers to innovate and test new benefit offerings that could improve health outcomes and reduce healthcare spending. A key player in this transformation is the MA vendor that provides supplemental benefit offerings to insurance plans, but this market is rather underdeveloped. To assess the implementation of this supplemental benefit expansion, this study examines the flow of funding into the emerging market of MA vendors. This paper uses a longitudinal approach and Crunchbase data on funding for 79,004 firms from 2014 to 2018 to determine whether there is a significant jump in funding toward MA vendors with supplemental benefit services following the policy change. The results show that both the average amount of funding per deal and the number of deals a MA vendor firm receives significantly increased following the expansion when compared with all other firms. This suggests that the policy may have been successful in promoting the development of the MA vendors market and the innovation of benefit offerings as more funding goes towards these companies.
Kate Bundorf, Faculty Advisor
David Ridley, Faculty Advisor
Michelle Connolly, Faculty Advisor
JEL Codes: I1; I11; I18
Impact of Language Access Laws on LEP Infant Mortality Rates
by Andrew Ryan Griffin
Abstract
Starting with Executive Order 13166 in 2000, the United States federal government
began to address the language disparity issues in health care. Around the same time, several
states have begun to pass language access (LA) legislation mandating translation and
interpretation services at hospitals for limited English proficient (LEP) individuals. This study
uses these multiple discontinuities to evaluate the effect of language access laws on infant
mortality rates, adequacy of care, Apgar scores, and the number of prenatal visits from the years
1995 to 2004 for limited English proficient families. I find ambiguous results of language access
laws positively impacting infant mortality rates or Apgar scores, but I find clear positive impacts
on the adequacy of care and the number of prenatal visits. These findings suggest that language
access laws have a clear effect on reducing barriers for limited English proficient mothers, and
improving the care mothers receive. Furthermore, there is limited evidence that it improves
infant health or outcomes, but the increase of prenatal visits and adequacy of care likely
indirectly leads to improving infant mortality rates and Apgar scores. More research is needed
into discovering how those mechanisms work and the costs of language services.
Professor Michelle Conolly, Faculty Advisor
JEL Codes: I10, I18, I19
The Effect of Workforce Participation and Household Income Contribution on Women’s Healthcare Empowerment in Rural Bangladesh
By Hannah Wang
Abstract
Women in Bangladesh have gained increased access to paid work in the past decade yet still experience limited choices and access to resources, which threatens their ability to exercise control over healthcare for themselves and their children. Several collective household bargaining theories hypothesize a link between women’s workforce participation and empowerment. This paper uses a cross-sectional approach and survey data collected at the end of a randomized trial field experiment in rural Bangladesh from 2007 to 2017 to examine health empowerment outcomes for 7,151 young women ages 14 to 32. The results show that women who work for income are expected to be more health empowered, specifically due to an increased ability to make their own health decisions. As a woman contributes more income to her household, her health empowerment is expected to increase, through increased abilities to make her own health decisions, purchase medicine for herself, and seek medical treatment independently. Greater mobility and stronger female-positive attitudes towards gender norms are potential mechanisms through which paid work and household income contribution can translate into health empowerment. Furthermore, higher total household income, having children, and being more educated than her husband are expected to increase a woman’s health empowerment. These results are significant while controlling for the effects of various individual and household characteristics.
Professor Erica M. Field, Faculty Advisor
Professor Michelle P. Connolly, Faculty Advisor
JEL Codes: J1; J16; I15
A perfect storm: The effect of natural disasters on child health
by Cheyenne Danielle Quijano
Abstract
Typhoons and their accompanying flooding have destructive effects, including an increase in the risk of waterborne disease in children. Using a spatial regression discontinuity design, I explore the immediate to short-term effects of flooding as a result of Typhoon Labuyo on the incidence of diarrhea and acute respiratory infection in the Philippines by comparing children living in a flooded barangay (town) to children living just outside of the flooded area. I build on the existing literature by accounting for both incidence and intensity of the typhoon’s flooding in my model. I construct this new flooding measure using programming techniques and ArcGIS by manipulating data collected by the University of Maryland’s Global Flood Monitoring System. This data as well as health data from the 2013 Philippines National Demographic Health Surveys were collected the day after Typhoon Labuyo left the Philippines, providing a unique opportunity to explore the immediate impact of the typhoon on child health. Most of my results are insignificant, but subgroup analyses show that the effect of flooding on waterborne disease incidence is less impactful in the immediate term following a flood and more impactful in the medium-term. This is important, because understanding the detrimental health effects of flooding is of utmost importance, especially because climate change will only increase the frequency and intensity of natural disasters.
Professor Erica M. Field, Faculty Advisor
Professor Michelle P. Connolly, Faculty Advisor
JEL Codes: I150, O120, O130, Q540
Long-term Benefits of Breastfeeding: Impact on Education in Indonesia
by Natalie Gulrajani
Abstract
Healthy breastfeeding behaviors have been shown to produce many long-term health benefits including improved cognition. This study uses data from the Indonesian Family Life Survey (IFLS) to assess the longitudinal impact of exclusive breastfeeding duration and early life breastfeeding practices on education. Though a positive correlation was found between breastfeeding duration and years of schooling in naïve regressions, the significance and magnitude of this effect decreased when household fixed effects were added. A stronger correlation was found between early life breastfeeding and schooling, with income-stratified results demonstrating that poorer households are potentially subject to greater benefits.
Professor Erica Field, Faculty Advisor
JEL Codes: I0; I12; I21
