Essays in health economics and public policy

health economics;hospitals;medicaid;crime

Vogler, Jacob E

关键词: health economics;    hospitals;    medicaid;    crime;   

Others  :  https://www.ideals.illinois.edu/bitstream/handle/2142/107921/VOGLER-DISSERTATION-2020.pdf?sequence=1&isAllowed=y

美国|英语

来源: The Illinois Digital Environment for Access to Learning and Scholarship

【 摘 要 】

This dissertation consists of three papers that, together, analyze the role of healthcare institutions in rural economies and evaluate how access to health insurance for low-income individuals impacts mortality and risky behavior.In Chapter 1, I study the local economic impacts of rural hospital closures in the United States. The analysis begins with a difference-in-differences approach using county-by-year panel data on all hospital closures from 2003 through 2017. The results indicate that closures adversely affect employment, income, labor force participation, establishments, population, housing prices, and the unemployment rate. Estimated effect sizes grow over time and are explained largely by rural counties that lose their only hospital and in counties where hospitals occupy a large share of the local labor market. While there is little or no evidence of pre-trends, I estimate a range of robustness checks designed to further address endogeneity concerns, such as forward-looking behavior among hospital owners. The results are consistent across these specifications. I also document spillovers, as evidenced by a 1.8 percent decrease in non-hospital employment, an effect that explains 40 percent of the total employment loss. To characterize the significance of the adverse effects, I combine the reduced-form estimates with a spatial equilibrium model of various agents in a local economy. Analysis of the model indicates that rural hospital closures significantly harm welfare, an outcome that is internalized by workers, older residents no longer in the labor force, and landowners.In Chapter 2, co-authored with Mark Borgschulte, we estimate the effect of the Affordable Care Act Medicaid expansion on county-level mortality in the first four years following expansion using restricted-access microdata covering all deaths in the United States. To adjust for pre-expansion differences in mortality rates between treatment and control, we use a propensity-score weighting model together with techniques from machine learning to match counties in expansion and non-expansion states. We find a reduction in all-cause mortality in ages 20 to 64 equaling 11.36 deaths per 100,000 individuals, a 3.6 percent decrease. This estimate is largely driven by reductions in mortality in counties with higher pre-expansion uninsured rates and for causes of death likely to be influenced by access to healthcare. A cost-benefit analysis shows that the improvement in welfare due to mortality responses may offset the entire net-of-transfers expenditure associated with the expansion.In Chapter 3, I investigate the causal relationship between access to health care and crime following state decisions to expand Medicaid coverage after the Affordable Care Act. I combine state-level crime data from the Federal Bureau of Investigation Uniform Crime Reports with variation in insurance eligibility generated by state decisions to expand Medicaid between the years 2009 and 2018. Using a difference-in-differences design, my findings indicate that states that expanded Medicaid have experienced a 5.3 percent reduction in annual incidents of violent crime relative to non-expansion states. This effect is explained by decreases in aggravated assaults and corresponds to 17 fewer incidents per 100,000 people. The estimated decrease in reported crime amounts to an annual cost savings of approximately $4 billion.