Who benefits from public financing of home care for low-income seniors? [Draft]
The past few decades have seen the emergence of a large formal home care industry as a significant source of long-term care for the elderly and disabled, who previously relied heavily on unpaid family members and nursing home care. Most formal home care is financed publicly through Medicaid programs, and this paper seeks to understand the implications of this financing. Using data from the 2000-2016 waves of the Health and Retirement Study and a difference-in-difference and triple-difference design, I investigate the effects of a policy adopted at the state level that increased the use of formal home care among Medicaid-eligible seniors by more than 50%. I show that rather than displace nursing home care or reach seniors who would otherwise be going without care, the policy's main effect is to replace informal care from family members, particularly spouses and daughters. For daughters, I find that this decrease in care supplied is accompanied by an increase in labor supply: for every 2.4-3 daughters whose parent receives formal home care as a result of the benefit, one works full-time as a result of the policy. These results suggest that daughters who care for frail seniors may be a significant and overlooked beneficiary of public efforts to increase access to home care for seniors.
The COVID-19 pandemic has taken a significant toll on nursing homes in the US, with upwards of a third of deaths occurring in nursing homes, and more in long-term care facilities. By combining data on facility-level COVID-19 deaths with facility-level data on the neighborhoods where nursing home staff reside for a sample of eighteen states, this paper finds that staff neighborhood characteristics are a large and significant predictor of COVID-19 outbreaks. One standard deviation increases in average staff tract population density, public transportation use, and non-white share were associated with 1.3 (SE .33), 1.4 (SE .35), and 0.9 (SE .24) additional deaths per 100 beds, respectively. These effects are larger than all facility management or quality variables, and larger than the effect of the nursing home's own neighborhood characteristics. These results suggest that staff communities are likely to be an important source of infection, and that disparities in nursing home outbreaks may be related to differences in the types of neighborhoods nursing home staff live in.
Increasing the use of medication-assisted treatment for opioid use disorder (with Eric Barrette and Leemore Dafny). [draft available upon request]
Medication-assisted treatment (MAT) is considered the standard of care for patients with opioid use disorder, but in claims data for one-quarter of the commercially-insured, nonelderly U.S. population from 2008-2016, we find that only a minority of patients receive MAT after a new OUD diagnosis. This paper aims to evaluate the effectiveness of two different policies on increasing the use of MAT: (1) insurance benefit mandates for equal coverage of substance abuse treatment, and (2) increasing provider supply of physicians eligible to prescribe buprenorphine. Using a difference-in-differences specification that compares small group enrollees to large group enrollees before and after the Affordable Care Act extended parity requirements to small groups, we find that while insurance parity increases the use of residential treatment, the use of MAT actually declines for groups that gain access to parity, suggesting that these treatments are potential substitutes. We hypothesize that more targeted policies may be more effective in supporting the use of MAT than broad insurance mandates. Using variation across counties (within each state and year) in the share of MDs who are eligible to prescribe buprenorphine, we find that increases in this share as associated with greater utilization of buprenorphine, modest improvements in clinical outcomes and significantly lower non-drug-treatment spending.
Police officer discretion in arrest and citation activity during patrol shifts: evidence from Tulsa. [draft coming soon]
Individual police officers are known to vary in their rates of misconduct. However, reports of misconduct represent an extremely small share of decisions made by officers each day. This paper studies variation in arrest and citation activity on patrol shifts using officer-level data from the Tulsa Police Department. Using empirical Bayes methods, I find that variation across officers can explain 17% of the total variation in the number of arrests and citations on each shift, with greater amounts of discretion for citations than arrests. I validate these measures using quasi-experimental evidence from changes in shift assignments across years. High activity officers are less experienced, earn higher evaluation scores, receive more complaints, and are more likely to receive special unit assignments. I do not find differences in the likelihood of a charge being dropped between high- and low-activity officers, suggesting that this additional activity has downstream consequences for the people arrested and cited by these officers. I hypothesize that these relationships are due to an incentive structure that rewards more activity from police officers, and use the introduction of COMPSTAT to study the effects on high- and low-productivity officers. I find that low-productivity officers are most likely to increase their activity after the introduction of COMPSTAT.
Karen Shen, Eric Barrette, and Leemore S. Dafny. “Treatment of Opioid Use Disorder Among Commercially Insured US Adults, 2008–17.” Health Affairs, 39.6 (2020): 993-1001. [Publisher's Version]
David O. Lucca, Taylor Nadauld, and Karen Shen. “Credit Supply and the Rise in College Tuition: Evidence from the Expansion in Federal Student Aid Programs.” The Review of Financial Studies, 32.2 (2019): 423-466. [Publisher's Version].
"Overtime pay in the home care industry" (with Liz Engle)
Home care occupations are among the fastest growing jobs nationally, and also among the lowest paid. In 2013, the Department of Labor removed an exemption for home care workers from the Fair Labor Standards Act. The extension granted personal care aides the rights to the minimum wage, overtime pay, and compensation for travel time between work sites, but some states had previously extended these rights to home care workers. We find that the federal policy change significantly reduced employment growth in personal care in states that did not previously require overtime pay. We then study how this change affects the use of residential and informal care in order to understand the welfare effects of increasing pay for home care workers.