Working Papers

“Competition Between Long-Term Care Providers: Evidence from the Introduction of Nursing Home Compare”

Nursing homes (NH) have long been the backbone of residential long-term care provision in the US. During the last 20 years, there has been explosion of alternative residential care providers, assisted living facilities (ALF), that face different regulatory and licensing regimes. It remains to be seen how much these new providers compete with nursing homes for private-pay patients. We used the introduction of Nursing Home Compare Five Star Quality Ratings to examine the building activity and pricing decisions of ALFs in response to this new publicly reported information on nursing home quality. We find that ALFs respond to this new quality information in much the same ways that NH competitors would–they increase supply, particularly in competitive areas. We also find a spike in ALF prices immediately following the introduction of NH Compare that declines over the remainder of the study period.

“Insurance Take-up Among the Near-Elderly in the Age of the Affordable Care Act”

Near-elderly individuals, those 60 to 64 years old, have high health care needs and, if uninsured, often delay costly care until they enroll in Medicare (Card et al. (2008), McWilliams, et al. (2009)). The passage of the Affordable Care Act (ACA) in 2014 provided new coverage options to uninsured near-elderly individuals. Although understanding the extent to which the ACA affected the near-elderly is key to future health policy decisions, little focus has been given to the near-elderly. I provide the first assessment of the ACA’s effect on near-elderly insurance coverage using three nationally representative surveys. I replicate and update the findings from Card et al. (2008), then extend the analysis by using a difference-in-regression discontinuity design to quantify the effect of the ACA on insurance rates just prior to individuals transitioning into Medicare. I find that the gap in insurance coverage rates between 64- and 65-year olds declines by almost half, from 8 to 4.5 percentage points, after the ACA went into effect in 2014. Consistent with these changes being attributable to the ACA, I also find that most coverage gains come from Medicaid in states that expanded Medicaid eligibility, while coverage gains in non-Medicaid-expansion states come from the kinds of insurance plans available on the exchanges. These results raise questions about the extent to which increasing coverage for the near-elderly may ease demand upon their entry into Medicare and the consequences of an ACA repeal on their access to health care.

“Understanding Trends in Medicare Spending, 2007-2014” with Laura Keohane, Robert Gambrel, David Stevenson, and Melinda Buntin (R&R at Health Services Research)

“Risk Adjusting for Medicaid Participation in Medicare Advantage” with Laura Keohane, David Stevenson, Sunita Thapa, Lucas Stewart, and Melinda Buntin

“Trends in Medicare Spending Growth for Dual-Eligible Beneficiaries, 2007-2014” with Laura Keohane, David Stevenson, Sunita Thapa, Lucas Stewart, and Melinda Buntin

“Factors Underlying Slow Growth in Medicare Spending” with Laura Keohane, David Stevenson, Sunita Thapa, Lucas Stewart, and Melinda Buntin

Work in Progress

“Effect of Urgent Care and Retail Clinic Entry on Emergency Department Discharges”