Essays in Health Care and Public Economics
This dissertation has been motivated by my two broad areas of interest - the nonprofit sector and health care, - and in particular by the growing number of community health centers in the United States in the last decade. The dissertation consists of three chapters: In the first chapter, I estimate the causal impact of community health centers on the utilization of emergency rooms in California, in 2006-2010. In the second chapter, I study the San Francisco healthcare reform of 2007-2008. And in the third chapter, I analyze California's Nonprofit Integrity Act of 2004 and its impact on governance and revenue growth of nonprofit organizations. The First Chapter is titled "The Effect of Community Health Centers on Utilization of Emergency Care: Evidence from California." The United States has a long list of programs that aim to reduce disparities in access to health care, including public health insurance, subsidies, and health insurance mandates on employers, insurers, and private citizens. This paper focuses on an alternative but complementary way of bringing medical care to medically underserved populations: community health centers (CHCs). CHCs provide primary health care services to two main groups - the uninsured and Medicaid enrollees - who face barriers to accessing primary health services and often turn to their local emergency departments (EDs) for non-urgent medical care. To examine the effect of CHCs on ED visits that do not result in an immediate hospital admission, I first use an event study that relies on an ED patient's proximity to a CHC and exploits the variation in the number of clinics in each zip code over time. To deal with endogenous clinic entry, I use a second differences-in-differences strategy that uses proximity to a highway to model the patient's level of access to a CHC. I find that recent expansions in the CHC sector have been effective in reducing the number of non-hospitalization ED visits by uninsured non-elderly adults and have had no impact on the number of ED visits by patients with private or public insurance. The results are robust to different measures of access, sample composition, and choices of specification. The Second Chapter is titled "Impact of the San Francisco Health Care Reform of 2007-2008 on the Utilization of Emergency Departments." In July 2007, the city and county of San Francisco launched the Healthy San Francisco Program (HSF) that aimed to substantially increase access to a broad range of medical services for uninsured residents of San Francisco. In March 2011, about 54,500 uninsured San Franciscans between the ages of 18 and 64 (or roughly two thirds of the city's non-elderly adults without any medical coverage) were enrolled in HSF to take advantage of affordable and well-coordinated primary and preventive health care. In the first half of 2008, the city also enacted the Health Care Security Ordinance (HCSO), by which San Francisco-based employers must spend a certain minimum amount on employee health care either through the provision of employer-sponsored health insurance, or by contributing to the Healthy San Francisco or Health Savings Accounts. In this paper, I analyze the impact of Healthy San Francisco and the Health Care Security Ordinance on the utilization of emergency rooms by non-elderly adults in San Francisco. My main specification is based on a differences-in-differences strategy, in which I take zip codes in the nearby Bay Area as a comparison group. I also perform a within-San Francisco analysis. Both strategies produce a consistent set of results for uninsured patients. Overall, I find that HSF and HCSO reduced the number of non-admission ED visits by uninsured by an average of 30.1% between 2007 and 2009-2010. However, because this reduction coincides with a higher use of emergency rooms by patients with private insurance and by those covered by county funds, the lower number of ED visits by uninsured may be partially due to their "switch" to a different payor category, rather than their actual substitution away from EDs as a source of regular care. I discuss the validity of these results in the context of various control groups and data limitations. The Third Chapter is titled "Impact of the Nonprofit Integrity Act (2004) on Governance and Growth of Charities in California." The Nonprofit Integrity Act (NIA) took effect in California on January 1, 2005. Its goals are to improve governance and financial transparency in the charitable sector, to increase its oversight, and to prevent fraudulent solicitations. NIA imposes certain restrictions on charity managers and boards, and explicitly requires organizations whose annual revenue is at or above $2 million (net of government grants) to have an independent audit of financial statements. In this paper, I evaluate NIA's impact on large charitable organizations in California. Specifically, I use a simple differences-in-differences framework to examine the effect of NIA on various financial and governance outcome measures. I find that in the two years following the enactment of NIA, California charities with an average 2002-2004 (pre-treatment) income "just below" the $2 million threshold grew by about 7.7-7.9% less than similar charities in other U.S. states, and by 15-18% less than California charities with the pre-treatment revenue "just above" $2 million. These differences in growth rates are not detectable by year 2007. The Nonprofit Integrity Act appears to have had little impact on other major financial measures of charities. With respect to the available set of governance measures, it seems that the majority of California's charitable organizations affected by NIA had already used select NIA-prescribed governance and management practices before the law came into effect. It is also possible that the adoption of some new governance measures (e.g., audit committees) and their incorporation into by-laws did not happen immediately following NIA's enactment because of natural organizational rigidities.
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