My current research agenda is centered on analyzing public policies affecting maternal and child health outcomes, household resources, and food insecurity. My other recent research interest is analyzing consolidation and location decisions in the hospital industry, and the effects of such decisions on the quality of health care.
“The Effect of Free School Meals on Household Food Purchases: Evidence from the Community Eligibility Provision” with Michelle M. Marcus. Journal of Health Economics, vol. 84, July 2022. [Ungated Version] [Online Appendix] [NBER WP 29395]
We find evidence that exposure to universal free school meals through the Community Eligibility Provision (CEP) had a meaningful impact on grocery spending for households with children, with monthly food purchases declining by about $11, or 5 percent. For households in zip codes with higher exposure, the decline is as high as $39 per month, or 19 percent. We also show evidence that the composition of food purchases changes, with low income households experiencing an increase in the dietary quality of their food purchases by about 3 percent after CEP. Finally, we show CEP exposure is associated with an 11 percent decline in the percent of households that ran short of money or tried to make their food money go further, and an almost 5 percent decline in households classified as food insecure. Our results on the heterogeneous effects of CEP exposure by prior free/reduced price lunch eligibility reveal large benefits in terms of both spending, dietary composition, and food insecurity for previously eligible low-income families, suggesting that the stigma of free school meals may be declining after universal access.
(Presented at APPAM, November 2020; Accepted for presentation at ASHEcon, June 2020; Presented poster at ASHEcon, June 2019)
“Referee Bias and Stoppage Time in Major League Soccer: A Partially Adaptive Approach” with Steven B. Caudill and Franklin G. Mixon Jr., Econometrics, vol. 2(1), February 2014.
“The Effect of Hospital Postpartum Care Regulations on Breastfeeding and Maternal Time Allocation” with Emily C. Lawler. Resubmitted to American Economic Journal: Applied Economics.
We study the effects of state adoption of hospital regulations intended to increase breastfeeding by requiring certain care standards for new mothers and their babies during their postpartum hospital stay. Using data from the National Immunization Survey-Child, 2003-2017, we find that these regulations significantly increased breastfeeding initiation by 4.3 percentage points (5.6 percent) and the probability of breastfeeding at 3 and 6 months postpartum by approximately 8 percent. We further show using data from the American Time Use Survey and Current Population Survey that following policy adoption, mothers significantly increased their time spent on primary childcare and reduced their time spent on formal work.
(Accepted for presentation at ASHEcon, June 2020, June 2021, SEA November 2021)
Food insecurity is associated with several adverse health outcomes, including anemia, asthma, depression, and diabetes. With over 14 million households facing food insecurity every year, these health issues are of policy importance. This paper leverages the roll out of a novel program that provides universal free school meals for school-aged children to study the impact of increased access to food on teen health behaviors and outcomes. I use data from the CDC’s Youth Risk Behavior Surveillance System (YRBSS) for 2001-2017 to examine teen access to food, asthma, sleep, and mental health. I supplement this with the National immunization Survey of Teens (NIS-Teen) for 2008-2017 which has information on teen doctor visits, and the American Time Use Survey (ATUS) for 2003-2018 which has information on how much time respondents spend on food-related activities. Using a difference-in-differences design and event studies that leverage plausibly exogenous variation in program availability, I find that high school students go to the doctor less, have fewer incidences of asthma, are more likely to get 8 or more hours of sleep, and report improved mental health following the increased access to meals at school. I also show additional evidence that the incidence of teens going hungry because of a lack of food in the household decreases after universal free school meals become more available, and that households with school-aged children report spending more time eating and drinking.
(Presented at ASHEcon, June 2022; SEA Annual Meeting, November 2021)
This study analyzes the effect of hospital consolidation on inpatient safety indicators and mortality as a clinical measure of hospital quality. The hospital industry is unique in several aspects, including price structure and the role of insurance networks in determining consumer choice sets, which makes understanding the effect of consolidation on consumer welfare important. Additionally, the high value of life and health imply that even modest improvements in clinical quality may justify hospital mergers that would potentially raise prices or otherwise decrease consumer welfare. To study the effect on quality, I analyze within- hospital changes in mortality rates and rates of adverse safety events for various patient subsets, before and after consolidation. Fixed effects estimates reveal mixed results on the effect of hospital acquisitions on quality of inpatient health care and outcomes. There is evidence of longer lengths of stay for some groups of patients with specific admitting diagnoses (increasing their costs), but no associated change in mortality. Instead, I found that hospitals improved mortality rates only in the specific procedure of coronary artery bypass grafts, but not the others studied, and slightly improved quality of care by decreasing the number of postoperative hip fractures and preventing respiratory failure for surgical patients after surgery in hospitals. Conversely, there is also a worsening of quality of caring for perioperative hemorrhages or hematomas after an acquisition. Given that the overall the welfare changes are specific to the patient’s diagnosis and the procedures performed, and that the number of patients involved in these specific procedures is relatively low, the high value of health and life improvements might not outweigh the economic costs associated with decreased competition.
(Presented at Vanderbilt University Empirical Applied Microeconomics seminar, December 2015, Vanderbilt University/Indiana University Health Economics and Policy Conference, December 2015, Tennessee Empirical Applied Microeconomics Festival student session, May 2016)
“Quantifying Travel Costs: A Case Study Analyzing the Welfare Effects of a Hospital Merger in South Carolina”
This study analyzes the predicted effects of a proposed hospital merger in South Carolina utilizing a travel cost model of demand similar to that used by the Federal Trade Commission. The model examines the change in consumer welfare that results from counterfactually removing each of the relevant hospitals from the consumer choice sets. Since consumers do not generally pay prices directly for health services, but instead have insurance that covers some portion of the costs, travel time is used as a proxy for the price that consumers pay when choosing any given hospital. The travel cost method of analyzing hospital mergers used by the FTC has been criticized in the literature for generating unrealistic estimates of the opportunity cost of time. Within this study, I compare the travel cost model predictions to those generated in a model that does not use time in determining the consumer choice. I then calculate the predicted merger effects. I find that features of the travel cost model account for about 52% of the explained change in willingness to pay that drives bargaining and market power for merging hospitals.
Selected Works in Progress
“The Effect of Hospital Breastfeeding Laws on Health and Health Behaviors” with Emily Lawler and Meghan Skira
“The Effect of Increased Access to Free School Meals on Emergency Department Visits and Inpatient Hospital Utilization” with Carmen Astorne-Figari and Michelle Marcus
“State Education Requirements for Substance Use Prevention and Household Purchases of Alcohol and Tobacco”
“Academic Benefits of Universal Access to Free School Meals: Evidence from the Community Eligibility Provision”
Reports and Policy Briefs
“Policy Considerations to Address Chronic Disease in Kentucky” with Mary Curnutte and Melissa Eggen, Issue Brief, Commonwealth Institute of Kentucky, University of Louisville, August 2022.
Kentucky consistently ranks among the worst states states for both the lifestyle behaviors of its residents and chronic disease incidence. This brief describes selected past and potential future policy interventions designed to decrease chronic disease in Kentucky through targeted lifestyle behavior improvements.
“Kentucky Extends Medicaid to One-Year Postpartum” with Melissa Eggen and Liza Creel, Issue Brief, Commonwealth Institute of Kentucky, University of Louisville, June 2022.
On April 20, 2022, Governor Andy Beshear signed
SB178, which extends Kentucky’s Medicaid coverage for pregnant women from 60 days to 12 months postpartum and directs the Kentucky Cabinet for Health and Family Services (CHFS) to seek federal approval for this change. This means that pregnant and postpartum women up to 200% FPL ($33,975/year for a single adult) will remain covered by Medicaid for up to one year after giving birth. A national study estimated that approximately 10,000 additional Kentucky women would receive Medicaid coverage with the extension.
Medicaid covers many services, including those necessary during pregnancy and the postpartum period. In 2020, Medicaid was the primary payer for nearly 25,000 births in Kentucky, representing approximately 48% of all births in the state. An increasing percentage of Kentucky Medicaid births are to women of color who also are disproportionately impacted by maternal morbidity and mortality. Because Medicaid funds a large portion of births in Kentucky, changes in structure and benefit design can have a significant impact on the health and well-being of women in the postpartum period. The postpartum extension is expected to increase continuity of care and expand access to needed services in the postpartum period. Nationally, more than 70% of health care spending in the postpartum period occurs after 90 days, suggesting that important medical services are needed beyond 60 days postpartum.
Louisville Metro Crisis Call Diversion Program Pilot Evaluation Report. with Brian Schaefer, Seyed Karimi, Liza Creel, et al., Commonwealth Institute of Kentucky, University of Louisville, June 2022.
This report evaluates the Louisville Crisis Call Diversion Program (CCDP) pilot that launched in March 2022. The goals of the CCDP pilot are:
- Provide support to callers in the Fourth Division [a police-designated area of Louisville] who are experiencing a behavioral health crisis
- Deflect non-emergent calls away from Louisville Metro Police Department
The CCDP pilot evaluation includes both a process and impact evaluation centering on four research questions:
- To what extent was the CCDP implemented as designed and how was it adapted to meet community needs and expectations? (Process)
- To what extent do individuals in crisis receive needed assistance and what type of assistance is provided? (Process)
- How does the CCDP contribute to community safety? (Impact)
- What are the economic implications of the deflection efforts? (Impact)
This mixed-methods evaluation used both quantitative and qualitative data to answer these questions and provide insight into the first seven weeks of the pilot and expansion potential across Louisville Metro.
Media“Universal access to free meals at schools can lead to lower grocery bills and healthier food purchases”. The Conversation. with Michelle Marcus. May 3, 2022.
To learn more about my funded projects, please see my research funding page.