College of Behavioral & Social Sciences
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Item Essays in Labor and Health Economics(2022) Hou, Claire; Hellerstein, Judith; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Chapter 1 investigates the impact of the opioid crisis on the foster care system, motivated by a growing literature suggesting that the opioid crisis has negatively impacted children. This paper builds on prior work by separately identifying the causal effects of parental illicit opioid use and prescription opioid (PO) misuse on foster care entry and caseload after 2010. Two baseline opioid supply measures from 2000, at the onset of the opioid crisis, instrument for post-2010 changes in opioid overdose death rates among adults of prime parenting age. Using county-level mortality data and administrative foster care records, I find that moving from the 10th to the 90th percentile of change in the illicit opioid death rate leads to a 1.1 (2.4) standard deviations larger percent growth in foster care entry (caseload). In contrast, a 10th to 90th percentile difference in the change in PO misuse does not significantly affect total entry or caseload. Female illicit opioid use has larger effects than male illicit opioid use. Effects are similar across child age at the time of removal. Illicit opioid use has similar effects across all placement settings, whereas PO misuse only increases entry to kinship care. Chapter 2 studies how an expansion of public health insurance affects self-employment dynamics. I investigate this question in the context of the Affordable Care Act (ACA) Medicaid expansion, which made Medicaid available to all non-elderly adults with family income up to 138% of the federal poverty level. By increasing access to health insurance outside of wage employment, expanding Medicaid eligibility could (i) induce some wage workers to become self-employed, and (ii) increase persistence in self-employment for the currently self-employed. Using the 2003-2016 CPS-ASEC linked to respondents' earnings histories from tax returns, I estimate the effect of expanding Medicaid eligibility on the probability of self-employment, wage employment to self-employment transition, and self-employment persistence among childless adults, the group that saw the largest increase in Medicaid eligibility as a result of the expansion. Using difference-in-differences that takes into account pre-ACA cross-county variation in population shares of "at-risk" groups and triple differences, I find suggestive evidence that the expansion of Medicaid eligibility may have increased persistence in self-employment for those with a relatively high valuation of health insurance, but no effects on wage employment to self-employment transitions or self-employment rates. Chapter 3 (with Katharine Abraham, John Haltiwanger, Kristin Sandusky, and James Spletzer) examines the role of self-employment in older workers' transitions to retirement. Self-employment rates rise with age, especially past the age of 50. Using unique integrated survey and administrative data, we find the share of the employed who are primarily self-employed more than doubles from age 47-52 to 65-70 – rising from under 10% to more than 20%. This growth reflects the differential patterns by age of all of the transitions among wage and salary employment, self-employment and non-employment. There is a sharp decline in the likelihood that workers switch from self-employment to wage and salary employment with age, but not the reverse. The share of wage and salary workers who transition to non-employment each year rises more rapidly with age between 53-58 and 65-70 than is the case for the self-employed. Just as important, there is a much sharper decline with age in the pace of transitions from non-employment to wage and salary employment than in the pace of transitions from non-employment to self-employment. The interaction of these changing transition rates, as opposed to simply their individual effects, plays a large role in accounting for the increase in the self-employment rate with age. We investigate how education, cumulative earnings over the prior 20 years, and earnings volatility over the prior 20 years affect these changing transition dynamics by age. We find, for example, that wage and salary workers who are more educated and have higher cumulative earnings are more likely to move to self-employment and less likely to move to non-employment, with both of these effects larger at older ages.Item The Effect of Medicaid Disease Management Programs on Medicaid Expenditures(2011) Kranker, Keith; Duggan, Mark; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Disease Management (DM) programs for Medicaid patients with chronic diseases have become very popular, with a majority of states having introduced some type of DM program in the last decade. These programs provide interventions designed to assist patients and their health care providers appropriately manage their chronic health condition(s) according to established clinical guidelines. Cost-containment has been a key justification for the creation of DM programs, despite mixed evidence that DM actually saves money for the Medicaid program or for society as a whole. While most studies on the impact of DM focus on estimating the impact of a single DM program, Chapter 2 estimates the average, national impact of state Medicaid DM programs by linking a detailed survey of state Medicaid programs to the nationally representative Medical Panel Expenditure Survey. Difference-in-difference models are used to test the hypothesis that medical expenditures change after a DM program is implemented, exploiting variation in the timing at which state Medicaid programs implemented DM programs. DM coverage also varies within states over time due to variation in program eligibility by disease, insurance category, and/or county of residence. Although the models estimate the effect of DM imprecisely, point estimates are stable across multiple specifications and indicate that DM programs for common chronic diseases may decrease total medical expenditures, potentially by 10 percent or more. Chapter 3 evaluates one DM program in the state of Georgia using a proprietary data set. By exploiting a natural experiment that delayed the introduction of high-intensity services for several thousand high and moderate risk patients, the research identifies the causal impacts of the program's interventions on total Medicaid expenditures, categories of health care utilization, and other indicators. These patients are observationally similar to those who received interventions at the beginning of the program. For example, I find the interventions lowered health costs and hospital utilization, after controlling for unobservable individual characteristics. Health expenditures were lowered about 4.4 percent for patients with positive expenditures. Heterogeneous treatment effect analysis indicates that the savings were largest at the most expensive tail of the distribution.Item Essays in Health Economics(2009) Hayford, Tamara Beth; Duggan, Mark; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Health care expenditures have risen dramatically in the last several decades. Various agents have responded by reforming their practices in an effort to protect their budgets. My dissertation studies the implications of two of these changes on both quality and expenditure dimensions. The first chapter introduces and briefly discusses these topics. The second chapter discusses the implications of hospital mergers. A large body of research has examined their financial consequences, while little has analyzed the effect on patient health and experiences. This chapter aims to fill this gap, utilizing 17 years of hospital discharge data to study the impact of 40 California hospital mergers on changes in treatment choices and health outcomes. I use an empirical strategy that is based on geography of residence to enable a market level analysis. My findings indicate that hospital mergers result in increased utilization of intensive treatments for heart disease, such as bypass surgery and angioplasty. This result could be driven by increased access to intensive procedures as well as a change in hospital treatment practices. I also find evidence of a small increase in inpatient mortality which could be driven by an increase in average travel time to the nearest facility offering cardiac services. In chapter three, co-authored with Mark Duggan, we analyze the implications of a widespread Medicaid reform: contracting out health care treatment of Medicaid recipients to managed care organizations. State governments rapidly shifted Medicaid enrollees into managed care during the 1990s, perhaps partly as a response to increasing Medicaid expenditures. This reform has not previously been studied at the national level. We use state-level aggregate administrative data for the years 1991-2003 in conjunction with a unique data set on mandatory managed care enrollment policies to estimate the average national impact. Results suggest that this policy may have increased the expense of the Medicaid program, particularly for HMO-style insurance plans. We extend our analysis to investigate the impact of these policies on enrollment decisions. Using CPS data, we find mixed responses to mandatory managed care policies, though all changes in take-up were small and did not appear to increase uninsurance rates.