JOB MARKET PAPER
+ Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D
Overdose deaths from prescription opioids are on the rise, and policymakers seek solutions to curb opioid misuse. Recent proposals call for price-based solutions, such as opioid taxes and removal of opioids from insurance formularies. However, there is limited evidence on how opioid consumption responds to price stimuli. This study addresses that gap by estimating the effects of prices on the utilization of opioids as well as other prescription painkillers. I use nationally representative individual-level data on prescription drug purchases to exploit the introduction of Medicare Part D in 2006 as an exogenous change in out-of-pocket drug prices. I find that new users have a relatively high price elasticity of demand for prescription opioids, and that consumers treat over-the-counter painkillers as substitutes for prescription painkillers. My results suggest that increasing out-of-pocket prices of opioids, through formulary design or taxes, may be effective in reducing new opioid use.
+ Coverage For Self-Employed And Others Without Employer Offers Increased After 2014 (with Sandra Decker and Asako Moriya, Health Affairs)
Little is known about how the Affordable Care Act might have differentially affected insurance coverage for self-employed workers, wage earners with and without offers of employer-sponsored insurance, and people not employed. We found that the self-employed and wage earners without employer coverage offers had coverage gains equal to or greater than those of people not employed.
+ Third Year of Survey Data Shows Continuing Benefits of Medicaid Expansions for Low-Income Childless Adults in the U.S. (with John Cawley and Kosali Simon, Journal of General Internal Medicine)
Background: The Affordable Care Act (ACA) of 2010 incentivized states to expand eligibility for their Medicaid programs. Many did so in 2014, and there has been great interest in understanding the effects of these expansions on access to health care, health care utilization, and population health. Objective: To estimate the longer-term (three-year) impact of Medicaid expansions on insurance coverage, access to care, preventive care, self-assessed health, and risky health behaviors. Design: A difference-in-differences model, exploiting variation across states and over time in Medicaid expansion, was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2010–2016. Participants: Low-income childless adults aged 19–64 years in the BRFSS. Main Measures: Outcomes included insurance coverage, access to care, several forms of preventive care (e.g., routine checkups, flu shots, HIV tests, dental visits, and cancer screening), risky health behaviors (e.g., smoking, alcohol abuse, obesity), and self-assessed health. Key Results: The previously documented benefits of Medicaid expansions on insurance coverage, access to care, preventive care, and self-assessed health have persisted 3 years after expansion. There was no detectable effect on risky health behaviors. Conclusions: The Affordable Care Act was motivated in part by a desire to increase health insurance coverage, improve access to care, and increase use of preventive care. The Medicaid expansions facilitated by the ACA are helping to achieve those objectives, and the benefits have persisted 3 years after expansion.
+ The Medicaid Expansions of 2014 Increased Overall and Early Stage Cancer Diagnoses (with John Cawley, Kosali Simon, and Lindsay Sabik, American Journal of Public Health)
Objectives: To determine whether the 2014 Medicaid expansions facilitated by the Affordable Care Act (ACA) impacted early cancer diagnosis for non-elderly adults. Methods: Using SEER Cancer Registry data from 2010 through 2014, we estimated a difference-in-differences model of cancer diagnosis rates, both overall and by stage, comparing changes in county-level diagnosis rates in states that expanded Medicaid in 2014 to those that did not expand Medicaid. Results: Among the 611 counties in this study, overall cancer diagnoses increased by 8.0 per 100,000 population (95% CI, 0.3 to 15.6) or 3.4%. Early stage diagnoses increased by 9.0 per 100,000 population (95% CI, 3.2 to 14.8) or 6.4%. Late stage diagnoses did not change significantly. Conclusions: In their first year, Medicaid expansions were associated with an increase in cancer diagnosis, particularly at the early stage. Public Health Implications: Expanding public health insurance may be an avenue for improving cancer detection, which is associated with improved patient outcomes, including reduced mortality.
+ Changes in Insurance Coverage Among Cancer Patients After the Affordable Care Act (with Lindsay Sabik, Kosali Simon, and Benjamin Sommers, JAMA Oncology)
The Affordable Care Act (ACA) has reduced uninsurance to an historic low. Debate continues about potential changes to the law, which could affect coverage for millions, particularly those with pre-existing conditions. Meanwhile, cancer is the leading cause of death among Americans under age 65. Cancer treatment is often unaffordable for uninsured patients, and some studies suggest expanding insurance could improve cancer diagnosis, treatment, and outcomes. Our objective was to quantify changes in health insurance under the ACA among patients newly diagnosed with cancer.
Press coverage: ABC News, US News & World Report, Los Angeles Times, MSN, Indiana Public Radio, Reuters, EurekAlert, Drugs.com, Oncology Nurse Advisor, Medical Xpress, Newswise, EHE + Me, Doctors Lounge, Health Medicine Network, MedIndia, Science Newsline, Medscape, Health Day, Medical Research, Healio
+ Medicaid Expansion Status and State Trends in Supplemental Security Income Program Participation (with Marguerite Burns, Laura Dague, & Kosali Simon, Health Affairs)
Before 2014, the primary path to Medicaid eligibility for non-elderly childless adults was the Supplemental Security Income program (SSI). The SSI program typically confers immediate Medicaid eligibility to adults with a work-limiting disability, low income, and limited assets. After 2014, in the 32 states and DC that expanded Medicaid, low-income adults became eligible for Medicaid without having to obtain “disabled” status. In the non-expansion states, SSI (which allows for lower earnings limits than the 2014 Medicaid expansion) remained the primary avenue for non-elderly childless adults to obtain Medicaid. We use data from the American Community Survey and the Social Security Administration to estimate the impact of the Medicaid expansion on SSI participation. We find that in states that expanded Medicaid, participation in the SSI program decreased by about 3 percent relative to pre-expansion levels. This suggests Medicaid expansion may reduce SSI participation.
+ Medicaid Expansion under the Affordable Care Act and Insurance Coverage in Rural and Urban Areas (with Kosali Simon and Michael Hendryx, Journal of Rural Health)
Purpose: To analyze the differential rural-urban impacts of the Affordable Care Act Medicaid expansion on low-income childless adults’ health insurance coverage. Methods: Using data from the American Community Survey years 2011-2015, we conducted a difference-in-differences regression analysis to test for changes in the probability of low-income childless adults having insurance in states that expanded Medicaid versus states that did not expand, in rural versus urban areas. Analyses employed survey weights, adjusted for covariates, and included a set of falsification tests as well as sensitivity analyses. Findings: Medicaid expansion under the Affordable Care Act increased the probability of Medicaid coverage for targeted populations in rural and urban areas, with a significantly greater increase in rural areas (P < .05), but some of these gains were offset by reductions in individual purchased insurance among rural populations (P < .01). Falsification tests showed that the insurance increases were specific to low-income childless adults, as expected, and were largely insignificant for other populations. Conclusions: The Medicaid expansion increased the probability of having “any insurance” for the pooled urban and rural low-income populations, and it specifically increased Medicaid coverage more in rural versus urban populations. There was some evidence that the expansion was accompanied by some shifting from individual purchased insurance to Medicaid in rural areas, and there is a need for future work to understand the implications of this shift on expenditures, access to care and utilization.
+ The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions (with Kosali Simon and John Cawley, Journal of Policy Analysis and Management)
The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.
Press coverage: Newswise, UPI, Health Medicine Network, Healio, Science Daily, Becker's Hospital Review, Insurance News Net, EurekAlert, myScience, Breitbart, Medical XPress, Health Management Technology, IU Bloomington Newsroom, Indiana Daily Student, Cornell Chronicle, WVPE 88.1, WBOI 89.1, APPAM Public Policy News, Health Affairs Blog
+ PAPERS UNDER REVIEW
- Gains in Health Insurance Coverage Explain Variation in Democratic Vote Share in the 2016 Presidential Election (with Alex Hollingsworth, Aaron Carroll, John Cawley, and Kosali Simon)
- How Have Recent Health Insurance Expansions Affected Coverage Among Artist Occupations? (with Joanna Woronkowicz, Seth Freedman, and Kosali Simon)
- Levels of Employment and Community Engagement among Medicaid-Eligible Adults: Implications for Work Requirements (with Cong Gian, Kosali Simon, and Benjamin Sommers)
+ WORKS IN PROGRESS
- The Impact of Market Concentration on Premiums in the Employer Sponsored Insurance Market (with Haizhen Lin and Yaying Zhou)
- Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D
- Consumption Effects of Health Insurance Expansions: Evidence from Scanner Data.
- Drugs and Diet: Ex-Ante Moral Hazard Effects of Prescription Drug Insurance.
- Impacts of Increased Pharmaceutical Access on Health Outcomes and Long-Term Care Utilization: Evidence from Medicare Part D.
- The Impacts of Prescription Drug Monitoring Programs on Opioid Hospitalizations (with Seth Freedman, Alex Hollingsworth, and Kosali Simon)
American Economic Association. "Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D." January 2019. Atlanta, GA. (forthcoming)
Southern Economic Association. "Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D." November 2018. Washington, DC. (forthcoming)
Association for Public Policy Analysis and Management. "Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D." November 2018. Washington, DC. (forthcoming)
American Society of Health Economists. "Health Insurance, Price Changes, and the Demand for Pain Relief Drugs: Evidence from Medicare Part D." June 2018. Atlanta, GA.
American Society of Health Economists. "The Impact of the Affordable Care Act on Racial/Ethnic Disparities in Cancer Diagnosis and Outcomes." June 2018. Atlanta, GA.
IU/UofL/VU Health Economics and Policy Workshop. "Drugs and Diet: The Impact of Prescription Drug Coverage on Food Habits." December 2017. Louisville, KY.
Association for Public Policy Analysis and Management. "Consumption Effects of Health Insurance Expansions: Evidence from Scanner Data." November 2017. Chicago, IL.
Association for Public Policy Analysis and Management. "Are Prescription Drugs and Over-the-Counter Medicines Substitutes or Complements?: Evidence from Medicare Part D." November 2017. Chicago, IL.
Population Health Science Research Workshop. "The Medicaid Expansions of 2014 Increased Early Stage Cancer Diagnoses." (Poster) October 2017. Boston, MA.
International Health Economics Association. "Affordable Care Act Medicaid Expansion Led to Increased Early Stage Cancer Diagnoses." July 2017. Boston, MA.
AcademyHealth Annual Research Meeting. "Impact of Tennessee Medicaid Disenrollment in Rural Areas: An ACA Presage?." June 2017. New Orleans, LA.
AcademyHealth Health Economics Interest Group. "Expanded Insurance Coverage Options are Associated with Increased Coverage for Workers without Access to Group Insurance." (Best Poster Award) June 2017. New Orleans, LA.
Eastern Economic Association. "Medicaid Expansion Status and State Trends in Supplemental Security Income Program Participation." February 2017. New York, NY.
IU/UofL/VU Health Economics and Policy Workshop. "The Impact of Public Health Insurance Expansions on Over-the-Counter Purchases." December 2016. Bloomington, IN.
American Society of Health Economists. "The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions." (Poster) June 2016. Philadelphia, PA.
Association for Public Policy Analysis and Management. "Mental Illness and College Educational Outcomes: Evidence from State Equal Coverage Laws." Presenting author: Keisha T. Solomon, Temple University. November 2018. Washington, DC. (forthcoming)
Association for Public Policy Analysis and Management. "Insurance Expansions and Children’s Use of Substance Use Disorder Treatment." Presenting author: Sarah Hamersma, Syracuse University. November 2018. Washington, DC. (forthcoming)
Association for Public Policy Analysis and Management. "How Protected Classes in Medicare Part D Influence Drug Spending and Utilization: Evidence from the Synthetic Control Method." Presenting author: Courtney R. Yarbrough, Emory University. November 2017. Chicago, IL.
Association for Public Policy Analysis and Management. "Examining the Effect of the Affordable Care Act in Colorado on Access to Care, Financial Strain, Utilization and Health Status." Presenting author: Michael Hatch, American University. November 2017. Chicago, IL.
Association for Public Policy Analysis and Management. "US Family Firearm Ownership and Firearm-Related Child Mortality from 1976 to 2014." Presenting author: Kate C. Prickett, University of Chicago. November 2017. Chicago, IL.
International Health Economics Association. "Gains in Coverage in 2014, by Length of Time Uninsured." Presenting author: Salam Abdus, Agency for Healthcare Research and Quality. July 2017. Boston, MA.
Eastern Economic Association. "Does Medicaid Expansion Affect Employment Transitions." Presenting author: Erkmen G. Aslim, Lehigh University. February 2017. New York, NY.