Department of Economics

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Access to Health Insurance and the Use of Inpatient Medical Care: Evidence from the Affordable Care Act Young Adult Mandate
(Elsevier, 2015-01) Antwi, Yaa Akosa; Moriya, Asako S.; Simon, Kosali; Department of Economics, School of Liberal Arts
The Affordable Care Act of 2010 expanded coverage to young adults by allowing them to remain on their parent's private health insurance until they turn 26 years old. While there is evidence on insurance effects, we know very little about use of general or specific forms of medical care. We study the implications of the expansion on inpatient hospitalizations. Given the prevalence of mental health needs for young adults, we also specifically study mental health related inpatient care. We find evidence that compared to those aged 27–29 years, treated young adults aged 19–25 years increased their inpatient visits by 3.5 percent while mental illness visits increased 9.0 percent. The prevalence of uninsurance among hospitalized young adults decreased by 12.5 percent; however, it does not appear that the intensity of inpatient treatment changed despite the change in reimbursement composition of patients.
Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study
(2014) Hsia, Renee Y; Akosa Antwi, Yaa; Weber, Ellerie
This article aims to examine the between-hospital variation of charges and discounted prices for uncomplicated vaginal and caesarean section deliveries, and to determine the institutional and market-level characteristics that influence adjusted charges. Using data from the California Office of Statewide Health Planning and Development (OSHPD), we conducted a cross-sectional study of all privately insured patients admitted to California hospitals in 2011 for uncomplicated vaginal delivery (diagnosis-related group (DRG) 775) or uncomplicated caesarean section (DRG 766). Hospital charges and discounted prices were adjusted for each patient's clinical and demographic characteristics. We analysed 76,766 vaginal deliveries and 32,660 caesarean sections in California in 2011. After adjusting for patient demographic and clinical characteristics, we found that the average California woman could be charged as little as US$3,296 or as much as US$37,227 for a vaginal delivery and US$8,312–US$70,908 for a caesarean section depending on which hospital she was admitted to. The discounted prices were, on an average, 37% of the charges. We found that hospitals in markets with middling competition had significantly lower adjusted charges for vaginal deliveries, while hospitals with higher wage indices and casemixes, as well as for-profit hospitals, had higher adjusted charges. Hospitals in markets with higher uninsurance rates charged significantly less for caesarean sections, while for-profit hospitals and hospitals with higher wage indices charged more. However, the institutional and market-level factors included in our models explained only 35–36% of the between-hospital variation in charges. These results indicate that charges and discounted prices for two common, relatively homogeneous diagnosis groups—uncomplicated vaginal delivery and caesarean section—vary widely between hospitals and are not well explained by observable patient or hospital characteristics.
A bargain at twice the price? California hospital prices in the new millennium.
(2009) Akosa Antwi, Yaa; Gaynor, Martin S.; Vogt, William B.
We use data from California to document and offer possible explanations for the sharp increase in hospital prices charged to private payers after 1999. We find a downward trend in price for private pay patients in the 1990s and a rapid upward trend beginning in 1999, amounting to an annual average increase of 10.6% per year over 1999-2005. Prices in 2006 were almost double prices in 1999. By contrast, there was little discernable trend in prices for Medicare and Medicaid patients, although these prices varied from year-to-year. Surprisingly, the increase in prices is not correlated, geographically, with the change in hospital market concentration. For example, the greatest price rises came from hospitals in monopoly and highly concentrated counties which experienced little or no change over our sample period. Two recent California state hospital regulations, the seismic retrofit mandate and the mandatory nurse staffing ratio affected hospital costs. However, the cost increases due to the nursing staffing regulations are not large enough to account for the price increase, and the price increase is not substantially correlated with the costs of compliance with the seismic retrofit mandate. Therefore, the source of the near-doubling of California hospital prices remains something of a mystery.
Bundling and Joint Marketing by Rival Firms
(Wiley, 2017) Jeitschko, Thomas D.; Jung, Yeonjei; Kim, Jaesoo; Economics, School of Liberal Arts
We study joint marketing by firms who price discriminate between consumers who patronize only one firm (single purchasers) and those who purchase from both (bundle purchasers). Firms either set the price of the bundle and then compete along side the bundle; or they determine a rebate that is applied to joint purchasers and then set prices. Even though the pricing structure in the joint marketing scheme is determined noncooperatively, the commitment to the joint marketing agreement allows firms to leverage their stand-alone prices—leading to higher profits and lower consumer surplus in either case, compared to both uniform pricing and independent price discrimination without a joint marketing agreement. Nevertheless the two schemes differ dramatically, in that rebates increase joint purchasing, whereas bundle pricing diminishes bundle purchases.
Charitable Giving in Nonprofit Service Associations: Identities, Incentives, and Gender Differences
(Sage, 2017) Qu, Heng; Steinberg, Richard; Economics, School of Liberal Arts
Nonprofit service associations, such as the Lions Clubs, Rotaries, and Kiwanis, provide collective goods. Membership in a service association involves two essential elements: members’ shared interest in the club’s charitable service and private benefits stemming from social interactions with other members, such as networking, fellowship, and fun. We report results from a laboratory experiment designed to test the effect of membership and priming on charitable giving. The two experimental conditions activate chains of associative memory linked to the service or socializing aspects of membership. We find that female subjects give significantly smaller donations after receiving the socializing stimulus. Male subjects are less sensitive to our experimental conditions, giving slightly more in the socializing condition, but the differences are not statistically significant. We discuss three mechanisms that may explain our results: social identity theory, reputation and image motivations, and quality inference.
Comparison of health information exchange data with self-report in measuring cancer screening
(BMC, 2023-07-25) Bhattacharyya, Oindrila; Rawl, Susan M.; Dickinson, Stephanie L.; Haggstrom, David A.; Economics, School of Liberal Arts
Background: Efficient measurement of the receipt of cancer screening has been attempted with electronic health records (EHRs), but EHRs are commonly implemented within a single health care setting. However, health information exchange (HIE) includes EHR data from multiple health care systems and settings, thereby providing a more population-based measurement approach. In this study, we set out to understand the value of statewide HIE data in comparison to survey self-report (SR) to measure population-based cancer screening. Methods: A statewide survey was conducted among residents in Indiana who had been seen at an ambulatory or inpatient clinical setting in the past year. Measured cancer screening tests included colonoscopy and fecal immunochemical test (FIT) for colorectal cancer, human papilloma virus (HPV) and Pap tests for cervical cancer, and mammogram for breast cancer. For each screening test, the self-reported response for receipt of the screening (yes/no) and 'time since last screening' were compared with the corresponding information from patient HIE to evaluate the concordance between the two measures. Results: Gwet's AC for HIE and self-report of screening receipt ranged from 0.24-0.73, indicating a fair to substantial concordance. For the time since receipt of last screening test, the Gwet's AC ranged from 0.21-0.90, indicating fair to almost perfect concordance. In comparison with SR data, HIE data provided relatively more additional information about laboratory-based tests: FIT (19% HIE alone vs. 4% SR alone) and HPV tests (27% HIE alone vs. 12% SR alone) and less additional information about procedures: colonoscopy (8% HIE alone vs. 23% SR alone), Pap test (13% HIE alone vs. 19% SR alone), or mammography (9% HIE alone vs. 10% SR alone). Conclusion: Studies that use a single data source should consider the type of cancer screening test to choose the optimal data collection method. HIE and self-report both provided unique information in measuring cancer screening, and the most robust measurement approach involves collecting screening information from both HIE and patient self-report.
Counting unreported abortions: A binomial-thinned zero-inflated Poisson model
(2017-01) Tennekoon, Vidhura S.; Department of Economics, School of Liberal Arts
Background: Self-reported counts of intentional abortions in demographic surveys are significantly lower than the actual counts. To estimate the extent of misreporting, previous research has required either a gold standard or a validation sample. However, in most cases, a gold standard or a validation sample is not available. Objective: Our main intention here is to show that a researcher has an alternative tool to estimate the extent of underreporting in a given dataset, particularly when neither a valid gold standard nor a validation sample is available. Methods: We adopt a binomial-thinned zero-inflated Poisson model and apply it to a sample dataset, the National Survey of Family Growth (NSFG), for which an alternative estimate of the average reporting rate (38%) is available. We show how this model could be used to estimate the reporting probabilities of intentional abortions by each individual in addition to the overall average reporting rate. Results: Our model estimates the average reporting rate in the NSFG during 2006‒2013 as 35.3% (SE 8.2%). Individual reporting probabilities vary significantly. Conclusions: Our estimate of the average reporting rate of the dataset used is qualitatively and statistically similar to the available alternative estimate.
A Cross-Sectional Analysis of Variation in Charges and Prices across California for Percutaneous Coronary Intervention
(2014) Hsia, Renee Y.; Akosa Antwi, Yaa; Weber, Ellerie; Nath, Julia Brownell
Though past studies have shown wide variation in aggregate hospital price indices and specific procedures, few have documented or explained such variation for distinct and common episodes of care. We sought to examine the variability in charges for percutaneous coronary intervention (PCI) with a drug-eluting stent and without major complications (MS-DRG-247), and determine whether hospital and market characteristics influenced these charges. We conducted a cross-sectional analysis of adults admitted to California hospitals in 2011 for MS-DRG-247 using patient discharge data from the California Office of Statewide Health Planning and Development. We used a two-part linear regression model to first estimate hospital-specific charges adjusted for patient characteristics, and then examine whether the between-hospital variation in those estimated charges was explained by hospital and market characteristics. Adjusted charges for the average California patient admitted for uncomplicated PCI ranged from $22,047 to $165,386 (median: $88,350) depending on which hospital the patient visited. Hospitals in areas with the highest cost of living, those in rural areas, and those with more Medicare patients had higher charges, while government-owned hospitals charged less. Overall, our model explained 43% of the variation in adjusted charges. Estimated discounted prices paid by private insurers ranged from $3,421 to $80,903 (median: $28,571). Charges and estimated discounted prices vary widely between hospitals for the average California patient undergoing PCI without major complications, a common and relatively homogeneous episode of care. Though observable hospital characteristics account for some of this variation, the majority remains unexplained.
Dirty hands on troubled waters: Sanitation, access to water and child health in Ethiopia
(Wiley, 2019-11) Manalew, Wondimu S.; Tennekoon, Vidhura S.; Economics, School of Liberal Arts
In this paper, we investigate the impact of access to drinking water sources and sanitation facilities on the incidence of diarrheal diseases among children below 5 years of age in Ethiopia using the propensity score matching technique with a polychotomous treatment variable. We find that among the water sources traditionally considered as improved, only water piped into dwelling, yard or plot leads to a large percentage point reduction in diarrhea incidence. The other water sources, generally believed as clean, are not effective in reducing diarrhea even compared with some of the unimproved water sources. We also find that some unimproved water sources and sanitation facilities are less inferior than they are believed to be. These results suggest that the traditional way of categorizing different types of improved and unimproved water sources and sanitation facilities into a dichotomous variable, “improved” or “unimproved”, could be misleading as it masks the heterogeneous effects of the water sources and the sanitation facilities.
Effects of Federal Policy to Insure Young Adults: Evidence from the 2010 Affordable Care Act's Dependent-Coverage Mandate
(2013) Akosa Antwi, Yaa; Moriya, Asako S.; Simon, Kosali
Using data from the Survey of Income and Program Participation (SIPP), we study the health insurance and labor market implications of the recent Affordable Care Act (ACA) provision that allows dependents to remain on parental policies until age 26. Our comparison of outcomes for young adults aged 19-25 with those who are older and younger, before and after the law, shows a high take-up of parental coverage, resulting in substantial reductions in uninsurance and other forms of coverage. We also find preliminary evidence of increased labor market flexibility in the form of reduced work hours.

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