Job Market Paper

Access to Care in Equilibrium

Abstract:  This paper studies consumer access to medical care as an equilibrium outcome of a market without prices. I use data from the Northern Ontario primary care market to estimate an empirical matching model where patients match with physicians. The market is cleared by a non-price mechanism: the effort it takes to find a physician. I use the model to study the distribution and determinants of access to care and to evaluate the effectiveness of policy remedies. I find that access to care is low and unevenly distributed. 26% of patients who would see a physician in a full access environment do not receive care in 2014. The issue is particularly acute in rural areas. Further, physicians discriminate in favor of patients with higher expected utilization, thereby increasing access for older and sicker patients while decreasing access for younger and healthier patients. The estimated model is used to evaluate two policies: grants to incentivize physicians to practice in low-access areas and a payment reform that provided incentives for physicians to increase the numbers of patients on their books. While both policies are partially successful, the model suggests potential improvements.

Other Research

Market Segmentation and Competition in Health Insurance

(with Kate Ho and Michael Dickstein)

Abstract: We study the welfare consequences of market segmentation in private health insurance in the US, where households obtain coverage either through an employer or via an individual marketplace. Using a model of insurance demand and insurer pricing, we demonstrate that recent policies to combine the two markets may generate both benefits and costs to society. A larger population in the individual market may stabilize the risk pool and attract more insurers, with competition leading to premium reductions relative to the small group market. However, if households' price sensitivity and sickness severity varies substantially across populations, pooling may lead to market instability and unraveling (Cutler and Reber (1998)) or to inefficient reallocation of enrollees across plan coverage levels. We employ data from Oregon's small group and individual markets to estimate household preferences and predict premiums and costs under a counterfactual pooled market. Households in the small group market in 2014-16 have lower annual medical spending than individual market enrollees but face higher plan markups and higher premiums, conditional on tax policy. We use the estimated model to simulate the welfare consequences of pooling markets, accounting for plan premium setting, household participation and the allocation of households across coverage levels.

Access to Care or Money Down the Drain? Evaluating the National Health Service Corps’ Effects on Staffing Outcomes of Health Clinics

(with Iain Bamford)

Abstract:  The National Health Service Corps provides school loan repayments and scholarships to incentivize health practitioners to practice in underserved areas. To participate in the program, health practitioners must practice in eligible locations or clinics. This paper exploits quasi-exogenous variation in clinic eligibility to estimate the effect of the program on health clinic outcomes, including nurse to physician ratios and physician compensation. Quasi-exogenous variation has two sources. First, similar clinics on different sides of a political border can differ in eligibility status. Second, in some programs, eligibility is determined by a cut-off rule.