Over the past twenty years, physician practices, emergency departments, and inpatient hospitals have been consolidating and closing. At the same time, urgent care centers have rapidly expanded and are now accessible to the majority of Americans. Using claims data for publicly and privately insured individuals, I find that the impact of urgent care access on take-up of of other forms of care, such as emergency departments and routine office visits, and preventive screenings, varies significantly with patient age. Specifically, while the first urgent care to enter a county induces approximately 1.7 percent of patients in my sample to visit urgent care, this effect is driven primarily by children, two percent of whom are induced to visit urgent care compared to just 0.4 percent of adults aged 55 and older. This has implications for the overall cost and spending, since the impact of urgent care on take-up of other forms of care also varies significantly with age. Reductions in emergency department visits associated with urgent care entry are driven almost exclusively by patients under 18, who are also less likely to receive preventive care following entry. In contrast, adults 35 and over are significantly more likely to visit a physician following urgent care entry and are more likely to receive preventive screenings for common cancers. I find an increase in total healthcare spending only among adults aged 55 and older.
The number of nurse practitioners (NPs) working in the United States has more than doubled in the past decade. Meanwhile, many states have adopted policies allowing nurse practitioners to diagnose and treat patients without physician oversight, with the goal of reducing physician shortages in underserved areas. I use the introduction of over 160 new nurse practitioner education programs between 2011 and 2022 in a staggered difference-in-differences design to estimate the impact of these programs on local labor markets and population health. I find that these programs increase the number of locally practicing NPs by 20% in full scope of practice states, but similar programs in reduced scope of practice states do not increase the local NP labor supply. In full scope of practice states, I find evidence that NPs substitute away from physicians assistants. I find an increase in RN employment following program entry, suggesting an increase in overall availability of care, but a reduction in RN wages. I find no significant impacts on employment for general practitioners and OBGYNs, and I find no impact of these programs on population mortality.
I investigate the barriers to prescription adherence for prescription oral contraceptives. I find that fifteen percent of women prescribed daily oral contraceptives experience a gap in prescription coverage of between one and three months in a given year. These coverage gaps are associated with a .1 percentage point (25 percent) increase in the probability of experiencing a pregnancy in the following eight months. The likelihood of experiencing a coverage gap increased significantly in early 2021, potentially due to barriers to physician access during the COVID19 pandemic. I do not find an effect of abortion bans on prescription adherence.
In response to the severe economic shock induced by the COVID-19 pandemic, Congress passed the $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act. Using data on savings, income, and expenses from the Survey of Consumer Finances, we show that cash assistance included in the CARES Act allows almost all families to cover their normal, recurring expenses in the event of long-term unemployment. In the absence of government support, nearly half of families who lose their income for six months would not be able to cover their expenses due to low levels of liquid saving and standard unemployment insurance benefits that do not fully replace income.
Most financial advisors recommend storing three to six months of expenses in liquid assets in case of an emergency. Yet we estimate that more than half of U.S. families do not have at least three months of their non-discretionary expenses in liquid savings. We find that financial literacy is strongly predictive of having three months of liquid savings, controlling for income, income variability, and even parental resources. We also find that financial literacy predicts liquid savings across the income distribution. These results indicate that accumulation of an emergency fund is not simply a function of income. Finally, financial literacy is predictive of liquid savings even among high illiquid wealth households. This suggests that the phenomenon of “wealthy hand-to-mouth” families may reflect financial mistakes rather than portfolio optimization. Our paper highlights the importance of financial knowledge in explaining families’ preparedness to deal with unexpected expenses or disruption in their income.
For many Americans, emergency departments are the only source of health care outside of business hours. This can result in overcrowding at emergency departments, decreased quality of care, and gaps in care over the weekends. Weekend office closures can delay physician visits for up to two days. Using hospital admissions data from the 1980s, I identify the health consequences of treatment delays by looking for variation in preventable complications from infection over days of the week. I find that conditional on being admitted to a hospital for antibiotic treatable infections including urinary tract infections, staph infections, and bacterial meningitis, those admitted in the early week (Monday-Tuesday) suffer worse health outcomes. This suggests that delaying treatment for common treatable illnesses for just two days results in significant negative health consequences.