100% The Effect of Disenrollment from Medicaid on Employment, Insurance Coverage, Health and Health Care Utilization
This study examines the effect of a Medicaid disenrollment on employment, sources of health insurance coverage, health, and health care utilization of childless adults using longitudinal data from the 2004 Panel of the Survey of Income and Program Participation. From July through September 2005, TennCare, the Tennessee Medicaid program, disenrolled approximately 170,000 adults following a change in eligibility rules. Following this eligibility change, the fraction of adults in Tennessee covered by Medicaid fell by over 5 percentage points while uninsured rates increased by almost 5 percentage points relative to adults in other Southern states. There is no evidence of an increase in employment rates in Tennessee following the disenrollment. Self-reported health and access to medical care worsened as hospitalization rates, doctor visits, and dentist visits all declined while the use of free or public clinics increased. The Tennessee experience suggests that undoing the expansion of Medicaid eligibility to adults that occurred under the Affordable Care Act likely would reduce health insurance coverage, reduce health care access, and worsen health but would not lead to increases in employment.
following the disenrollment. Self-reported health and access to medical care worsened as hospitalization
rates, doctor visits, and dentist visits all declined while the use of free or public clinics increased.
The Tennessee experience suggests that undoing the expansion of Medicaid eligibility to adults that
occurred under the Affordable Care Act likely would reduce health insurance...
99% The Effect of Medicaid on Adult Hospitalizations: Evidence from Tennessee’s Medicaid Contraction
Ausmita Ghosh, Kosali Simon
The 2010 Affordable Care Act (ACA) Medicaid expansions aimed to improve access to care and health status among low-income non-elderly adults. Previous work has established a link between Medicaid coverage expansion and reduced mortality (Sommers, Baicker and Epstein, 2012), but the mechanism of this reduction is not clearly understood. Prior to the ACA, one of the largest policy changes in non-elderly adult Medicaid access was a 2005 contraction through which nearly 170,000 enrollees lost Medicaid coverage in Tennessee. We exploit this change in Medicaid coverage to estimate its causal impact on inpatient hospitalizations. We find evidence that the contraction decreased the share of hospitalizations covered by Medicaid by 21 percent and increased the share uninsured by nearly 61 percent, relative to the pre-reform levels and to other states. We also find that 75 percent of the increase in uninsured hospitalizations originated from emergency department visits, a pattern consistent with losing access to medical homes. However, uninsured hospitalizations increased for both avoidable and unavoidable conditions at the same rate, which does not suggest a lack of preventive care. Although there may be limited symmetry in response to Medicaid expansion and contraction, these findings are also consistent with the substantial decrease in uncompensated care costs in the states that have thus far expanded Medicaid under the ACA. These results also help shed light on the mechanisms by which Medicaid might affect mortality for non-elderly adults.
...TENNESSEE’S MEDICAID CONTRACTION
Working Paper 21580
NATIONAL BUREAU OF ECONOMIC RESEARCH
1050 Massachusetts Avenue
Cambridge, MA 02138
We would like to thank Seth Freedman, Anne Royalty and Joseph Terza for many helpful comments
and suggestions. The views expressed herein are those of the authors and do not necessarily...
99% Physician Fee Policy and Medicaid Program Costs
Jonathan Gruber, Kathleen Adams, Joseph P. Newhouse
We investigate the hypothesis that increasing access for the indigent to physician offices shifts care from hospital outpatient settings and lowers Medicaid costs (the so-called offset effect'). To evaluate this hypothesis we exploit a large increase in physician fees in the Tennessee Medicaid program, using Georgia as a control. We find that beneficiaries shifted care from clinics to offices, but that there was little or no shifting from hospital outpatient departments or emergency rooms. Thus, we find no offset effect in outpatient expenditures. Inpatient admissions and expenditures fell, reducing overall program spending eight percent. Because the inpatient reduction did not occur in ambulatory-care-sensitive diagnoses, however, we cannot demonstrate a causal relationship with the fee change.
...in the Tennessee Medicaid program, using Georgia as a control. We find that beneficiaries shifted care from clinics to offices, but that there was little or no shifting from hospital outpatient departments or emergency rooms. Thus, we find no offset effect in outpatient expenditures. Inpatient admissions and expenditures fell, reducing overall program spending eight percent. Because the inpatient...
99% College Remediation Goes Back to High School: Evidence from a Statewide Program in Tennessee
Thomas J. Kane, Angela Boatman, Whitney Kozakowski, Christopher Bennett, Rachel Hitch, Dana Weisenfeld
Many U.S. students arrive on college campus lacking the skills expected for college-level work. As state leaders seek to increase postsecondary enrollment and completion, public colleges have sought to lessen the delays created by remedial course requirements. Tennessee has taken a novel approach by allowing students to complete their remediation requirements in high school. Using both a difference-in-differences and a regression discontinuity design, we evaluate the program’s impact on college enrollment and credit accumulation, finding that the program boosted enrollment in college-level math during the first year of college and allowed students to earn a modest 4.5 additional college credits by their second year. We also report the first causal evidence on remediation's impact on students' math skills, finding that the program did not improve students’ math achievement, nor boost students’ chances of passing college math. Our findings cast doubt on the effectiveness of the current model of remediation—whether in high school or college—in improving students’ math skills. They also suggest that the time cost of remediation—whether pre-requisite or co-requisite remediation—is not the primary barrier causing low degree completion for students with weak math preparation.
...Tennessee Higher Education
Commission), Nate Schwartz, Jonathan Attridge, and Lacey Hartigan (from the Tennessee
Department of Education), Robert Denn, Jeannette Tippett, and Abbie Alexander (from the
SAILS program), Russ Deaton and Chris Tingle (from the Tennessee Board of Regents), Gregory
Kienzl (ACT) and Tammy Lemon (P20 Connect). We received much helpful advice and
feedback from our program...
99% Losing Insurance and Behavioral Health Hospitalizations: Evidence from a Large-scale Medicaid Disenrollment
Johanna Catherine Maclean, Sebastian Tello-Trillo, Douglas Webber
We study the effects of losing insurance on behavioral health – mental health and substance use disorder (SUD) – community hospitalizations. We leverage variation in public insurance eligibility offered by a large-scale Medicaid disenrollment. Losing insurance decreased SUD-related hospitalizations but mental illness hospitalizations were unchanged. Use of Medicaid to pay for behavioral health hospitalizations declined post-disenrollment. Mental illness hospitalization financing shifted to private insurance, Medicare, and patients, while SUD treatment financing shifted entirely to patients. We investigate implications of reliance on data that is not representative at the level of the treatment variable and propose a possible solution.
...Tennessee Department of Health, Division of TennCare for excellent data assistance. Errors are our own. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.
NBER working papers are circulated for discussion and comment purposes. They have not been peer-reviewed or been subject to the review by the NBER Board of...
99% State Reproductive Policies and Adolescent Pregnancy Resolution: The Case of Parental Involvement Laws
Theodore Joyce, Robert Kaestner
State laws regulating abortion have increased markedly in the wake of recent Supreme Court decisions. We test whether one form of abortion regulation, parental involvement laws, affects how pregnancies are resolved. Specifically, we examine whether laws that require minors to notify or obtain consent from a parent before receiving an abortion affect the likelihood that a pregnancy will be terminated. We use individual data on births and abortions from three southern states, South Carolina, Tennessee, and Virginia. A distinguishing characteristic of our data is the large sample of abortions, the quality of reporting, and information on individual and county characteristics. We detect no significant effects of parental involvement laws on the probability of abortion for minors as a single treatment group, a finding contrary to several recent studies. We do find, however, that for non-black minors 16 years of age, South Carolina's parent consent statute is associated with a 10 percentage point fall in the probability of abortion, a relative decline of over 20 percent. We believe this to be an upper bound estimate given potential underreporting of induced terminations. We also find a comparatively weak relationship between distance from an abortion provider and the probability that a pregnancy is aborted. We conclude that minors include their parents in the decision to terminate a pregnancy. Other minors seek abortion in a neighboring state. Overall, the impact of parental involvement laws on the pregnancy resolution of minors is not large.
...Tennessee, and Virginia. A distinguishing characteristic of our data is the large sample of abortions, the quality of reporting, and information on individual and county characteristics. We detect no significant effects of parental involvement laws on the probability of abortion for minors as a single treatment group, a finding contrary to several recent studies. We do find, however, that for non...
98% Unemployment and Infant Health: Times-Series Evidence from the State of Tennessee
Theodore J. Joyce, Naci H. Mocan
The relationship between unemployment and health continues to absorb social scientists. The primary reason is the potential significance of an association. If a substantial deterioration in aggregate health is related to economic downturns, then the cost of a recession may be much greater than the foregone output. This paper investigates the aggregate time-series relationship between unemployment and low birthweight with monthly data from the state of Tennessee from 1970 through 1989. The study differs from previous work in that we decompose the unemployment rate into its structural and cyclical components. Moreover, we use vector autoregressions to test the reduced form relationship between unemployment and low birthweight. The well-defined exogeneity of unemployment and the lag length restriction imposed by the duration of a pregnancy strengthens the specification considerably. We fail to find a relationship between unemployment and low birthweight. This basic finding remains unchanged irrespective of whether we test structural or cyclical unemployment, or whether we use total or race-specific rates of low birthweight.
...of Tennessee from 1970 through 1989. The study differs from previous work in that we decompose the unemployment rate into its structural and cyclical components. Moreover, we use vector autoregressions to test the reduced form relationship between unemployment and low birthweight. The well-defined exogeneity of unemployment and the lag length restriction imposed by the duration of a pregnancy...
98% Hospitals as Insurers of Last Resort
Craig Garthwaite, Tal Gross, Matthew J. Notowidigdo
American hospitals are required to provide emergency medical care to the uninsured. We use previously confidential hospital financial data to study the resulting uncompensated care, medical care for which no payment is received. We use both panel-data methods and case studies from state-wide Medicaid disenrollments and find that the uncompensated care costs of hospitals increase in response to the size of the uninsured population. The results suggest that each additional uninsured person costs local hospitals $900 each year in uncompensated care. Similarly, the closure of a nearby hospital increases the uncompensated care costs of remaining hospitals. Increases in the uninsured population also lower hospital profit margins, which suggests that hospitals cannot simply pass along all increased costs onto privately insured patients. For-profit hospitals are less affected by these factors, suggesting that non-profit hospitals serve a unique role as part of the social insurance system.
...and Tennessee. Estimates from these reforms isolate the effect of sudden, plausibly
exogenous increases in the uninsured population. Exploiting both within- and across-state sources of
Policymakers have long recognized the unique nature of the health care sector in that hospitals often provide services
without compensation. As a result, policymakers have created funding streams to compensate...
96% Local Economic Development, Agglomeration Economies, and the Big Push: 100 Years of Evidence from the Tennessee Valley Authority
Patrick M. Kline, Enrico Moretti
We study the long run effects of one of the most ambitious regional development programs in U.S. history: the Tennessee Valley Authority (TVA). Using as controls authorities that were proposed but never approved by Congress, we find that the TVA led to large gains in agricultural employment that were eventually reversed when the program's subsidies ended. Gains in manufacturing employment, by contrast, continued to intensify well after federal transfers had lapsed - a pattern consistent with the presence of agglomeration economies in manufacturing. Because manufacturing paid higher wages than agriculture, this shift raised aggregate income in the TVA region for an extended period of time. Economists have long cautioned that the local gains created by place based policies may be offset by losses elsewhere. We develop a structured approach to assessing the TVA's aggregate consequences that is applicable to other place based policies. In our model, the TVA affects the national economy both directly through infrastructure improvements and indirectly through agglomeration economies. The model's estimates suggest that the TVA's direct investments yielded a significant increase in national manufacturing productivity, with benefits exceeding the program's costs. However, the program's indirect effects appear to have been limited: agglomeration gains in the TVA region were offset by losses in the rest of the country. Spillovers in manufacturing appear to be the rare example of a localized market failure that cancels out in the aggregate.
...Tennessee Valley Authority (TVA). Using as controls authorities that were proposed but never approved by Congress, we find that the TVA led to large gains in agricultural employment that were eventually reversed when the program's subsidies ended. Gains in manufacturing employment, by contrast, continued to intensify well after federal transfers had lapsed - a pattern consistent with the presence...
96% Hospital Conversions Is the Purchase Price Too Low?
Frank A. Sloan, Donald H. Taylor, Chris Conover
in The Changing Hospital Industry: Comparing For-Profit and Not-for-Profit Institutions, David M. Cutler, editor
...Tennessee than in the
Carolinas, our empirical analysis of conversions based on secondary data
includes Tennessee as well as North Carolina and South Carolina. Some
parts of the analysis were limited to Tennessee due in part to data availability. Section 1.5 presents our analysis of rates of return on the investments that the buyers made as well as of the cost of capital prevailing at
the time of...
96% Beyond Job Lock: Impacts of Public Health Insurance on Occupational and Industrial Mobility
Ammar Farooq, Adriana Kugler
We examine whether greater Medicaid generosity encourages mobility towards riskier but better jobs in higher paid occupations and industries. We use Current Population Survey Data and exploit variation in Medicaid thresholds across states and over time through the 1990s and 2000s. We find that moving from a state in the 10th to the 90th percentile in terms of Medicaid income thresholds increases occupational and industrial mobility by 7.6% and 7.8%. We also find that higher income Medicaid thresholds increase mobility towards occupations and industries with greater wage spreads and higher separation probabilities, but with higher wages and higher educational requirements.
where Medicaid generosity declined substantially, to examine if occupational and
industrial mobility fell in this state. We find that after the fall in Medicaid
generosity in Tennessee in 2000, occupational and industrial transitions fell and
that workers moved towards occupations and industries with smaller wage spreads
and lower likelihood of separations. Moreover, the fall in...
95% State Casket Sales and Restrictions: A Pointless Undertaking?
Judith Chevalier, Fiona Scott Morton
We utilize a new micro dataset of prices of funeral goods and services at individual funeral homes, plus data from the Census to examine the effects of state regulations that restrict entry into funeral goods market. In particular, some states have regulations that allow only licensed funeral homes to sell caskets, while others allow unlicensed retailers, such as Costco, to compete with funeral homes in the sale of caskets. However, as caskets and funeral services are complements, generally purchased in one-to-one proportions, it is not a priori clear that casket sale restrictions can expand the rent extraction capabilities of licensed funeral homes. Our results suggest that when courts lift funeral goods sales restrictions the prices of funeral goods fall but the prices of funeral services rise by nearly as much. Overall, our results support the "one monopoly rent" hypothesis; we do not find that overall funeral home revenues decline when funeral goods sales are lifted.
...Tennessee law restricting the sale of funeral goods to
The FTC Funeral Rule may be viewed at:
licensed funeral homes (Craigmiles vs. Giles). However, the United States Court of
Appeals for the 10
Circuit upheld Oklahomas very similar statute (Powers vs. Harris),
95% Contagion During the Initial Banking Panic of the Great Depression
Erik Heitfield, Gary Richardson, Shirley Wang
The initial banking crisis of the Great Depression has been the subject of debate. Some scholars believe a contagious panic spread among financial institutions. Others argue that suspensions surged because fundamentals, such as losses on loans, drove banks out of business. This paper nests those hypotheses in a single econometric framework, a Bayesian hazard rate model with spatial and network effects. New data on correspondent networks and bank locations enables us to determine which hypothesis fits the data best. The best fitting models are ones incorporating network and geographic effects. The results are consistent with the description of events by depression-era bankers, regulators, and newspapers. Contagion - both interbank and spatial - propelled a panic which healthy banks survived but which forced illiquid and insolvent banks out of operations.
...Tennessee, but with subsidiaries in several nearby states.
The crisis initially spread through interbank networks extending from the Caldwell conglomerate.
Later, runs on banks radiated geographically from the vicinity of counterparty cascades (McFerrin
(1939), Richardson (2007), Wicker (1980)).
The debate remains unresolved for several reasons. Scholars lack data about paths of contagion,
95% Teachers, Race and Student Achievement in a Randomized Experiment
Thomas S. Dee
Recommendations for the aggressive recruitment of minority teachers are based on hypothesized role-model effects for minority students as well as evidence of racial biases among non-minority teachers. However, prior empirical studies have found little or no association between exposure to an own-race teacher and student achievement. This paper presents new evidence on this question by evaluating the test score data from Tennessee's Project STAR class-size experiment, which randomly matched students and teachers within participating schools. Empirical results based on these data confirm that the racial pairings of students and teachers in this experiment were independently given. Models of student achievement indicate that a one-year assignment to an own-race teacher significantly increased the math and reading achievement of both black and white students by roughly three to four percentile points.
...Tennessee's Project STAR class-size experiment, which randomly matched students and teachers within participating schools. Empirical results based on these data confirm that the racial pairings of students and teachers in this experiment were independently given. Models of student achievement indicate that a one-year assignment to an own-race teacher significantly increased the math and reading...
95% Disruption, Achievement and the Heterogeneous Benefits of Smaller Classes
Graham J. McKee, Steven G. Rivkin, Katharine R.E. Sims
With few exceptions, empirical research investigating the possibility of heterogeneous benefits of class size reduction lacks a conceptual framework about specific dimensions of potential heterogeneity. In this paper we develop a model of education production that incorporates disruption and student achievement and illustrates how these underlying sources of variation may drive heterogeneity in the benefits of class size reductions. We test for results consistent with this model using the Tennessee STAR data. The estimates show that students in higher poverty schools and with greater learning aptitude realize larger benefits from smaller classes.
STAR data. The estimates show that students in higher poverty schools and with greater learning aptitude
realize larger benefits from smaller classes.
Graham J. McKee
Department of Economics
Amherst, MA 01002-5000
Steven G. Rivkin
Department of Economics
P.O. Box 5000
Amherst, MA 01002-5000
95% Learning Job Skills from Colleagues at Work: Evidence from a Field Experiment Using Teacher Performance Data
John P. Papay, Eric S. Taylor, John H. Tyler, Mary Laski
We study on-the-job learning among classroom teachers, especially learning skills from coworkers. Using data from a new field experiment, we document meaningful improvements in teacher job performance when high- and low-performing teachers working at the same school are paired and asked to work together on improving the low-performer’s skills. In particular, pairs are asked to focus on specific skills identified in the low-performer’s prior performance evaluations. In the classrooms of low-performing teachers treated by the intervention, students scored 0.12 standard deviations higher than students in control classrooms. These improvements in teacher performance persisted, and perhaps grew, in the year after treatment. Empirical tests suggest the improvements are likely the result of low-performing teachers learning skills from their partner.
Department of Education, and particularly Nate Schwartz, Laura Booker, Tony Pratt, Luke Kohlmoos,
and Sara Heyburn for their collaboration throughout. Finally, we thank Verna Ruffin, superintendent
in Jackson-Madison County Schools, and the principals and teachers who participated in the program.
All opinions and errors are our own. The views expressed herein are those of the authors and...
94% Patronage Politics and the Development of the Welfare State: Confederate Pensions in the American South
Shari Eli, Laura Salisbury
Beginning in the 1880s, southern states introduced pensions for Confederate veterans and widows. They continued to expand these programs through the 1920s, while states outside the region were introducing cash transfer programs for workers, poor mothers, and the elderly. Using legislative documents, application records for Confederate pensions, and county-level census and electoral data, we argue that political considerations guided the enactment and distribution of these pensions. We show that Confederate pensions programs were introduced and funded during years in which Democratic gubernatorial candidates were threatened at the ballot box. Moreover, we offer evidence that pensions were disbursed to counties in which these candidates had lost ground to candidates from alternative parties.
...in Tennessee. While many states initially required applicants to have been injured or
widowed during the war, by the turn of the century most pension programs functioned essentially
as welfare for Confederate veterans and widows. Much like the Union Army pension, southern
pension programs had evolved to cover all veterans and widows in need.
Although Confederate pensions were substantially less...
94% Experimental Estimates of Education Production Functions
Alan B. Krueger
This paper analyzes data from Project STAR, an experiment in which 11,600 Tennessee kindergarten students and teachers were randomly assigned to one of three types of classes beginning in the 1985-86 school year: small classes (13-17 students), regular-size classes (22-25 students) teacher's aide. According to the original design, students were to remain in their initial class type through the third grade. In practice, however, students in regular-size classes were randomly re-assigned at the end of kindergarten, and about 10 percent of students moved between class types in second and third grade. Attrition was also common. Several statistical methods are used to investigate the impact of these limitations. The main conclusions are: (1) on average, performance on standardized tests increases by about 4 percentile points the first year students are assigned to a small class, irrespective of the grade in which the student first attends a small class; (2) after initial assignment to a small class, student performance increases by about one percentile point per year relative to those in regular-size classes; (3) teacher aides have little effect on student achievement; (4) class size has a larger effect on test scores for minority students and for those on free lunch; (5) the beneficial effect of smaller classes does not appear to result from Hawthorne effects.
...Tennessee kindergarten students and teachers were randomly assigned to one of three types of classes beginning in the 1985-86 school year: small classes (13-17 students), regular-size! classes (22-25 students), and regular-size classes with a teacher's aide. According to the original design, students were to remain in their initial class type through the third grade. In practice, however, students...
94% Organization and Operations of the Electric Home and Farm Authority
Joseph D. Coppock
in Government Agencies of Consumer Instalment Credit, Joseph D. Coppock
...the Tennessee Valley Authority to a board of eight trustees,
all of whom, except the Administrator of the Rural Electrification Administration, were officers of the Reconstruction
Finance Corporation. As reorganized, EHFA was no longer
limited to the Tennessee Valley region but was now to cooperate closely with the Rural Electrification Administration
'Dated December 19, 1933.
94% The Economic Foundations of East-West Migration During the Nineteenth Century
Richard H. Steckel
This paper argues that latitude-specific investments in seeds and human capital provided an incentive for farmers to move along east-west lines. The incentives were greatest during the early and mid 1800s. Towards the end of the century migration patterns changed as farmers learned about farming in different environments, as settlement reached the Great Plains and beyond, and as farming declined in importance. Census manuscript schedules and Mormon family-group records form the basis for empirical work.
...Tennessee, and northern Arkansas (Gray, 1933, pp. 888-893). Tobacco can be grown under a wide range of climatic conditions, but the value of the crop depends heavily on the environment where it is grown (Martin et al., 1976, p. 849). During the nineteenth century the most successful tobacco growing areas were in Maryland, Virginia, northern North Carolina, northern Tennessee, Kentucky, southern...