Helen Levy

Worker Sorting and the Risk of Death on the Job

This article examines worker sorting across occupations in response to the risk of death on the job. We use family structure as a proxy for willingness to trade safety for wages to test the proposition that workers with strong aversion to this risk sort into safer jobs. We estimate conditional logit models of occupation choice as a function of injury risk and other job attributes. Our results confirm the sorting hypothesis: within gender, single moms and dads are the most averse to risk. Overall, differences in the risk of death across occupations explain about one‐quarter of occupational gender segregation.

Treating early-stage breast cancer: hospital characteristics associated with breast-conserving surgery.

Despite growing acceptance of the fact that women with early-stage breast cancer have similar outcomes with lumpectomy plus radiation as with mastectomy, many studies have revealed the uneven adoption of such breast-conserving surgery. Discharge data from the Hospital Cost and Utilization Project, representing multiple payers, locations, and hospital types, demonstrate increasing trends in breast-conserving surgery as a proportion of breast cancer surgeries from 1981 to 1987. Women with axillary node involvement were less likely to have a lumpectomy, even though consensus recommendations do not preclude this form of treatment when local metastases are present. Non-White race, urban hospital location, and hospital teaching were associated with an increased likelihood of having breast-conserving surgery.

Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage

OBJECTIVES To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect. METHODS We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status. RESULTS In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs. CONCLUSIONS The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.

Referral Without Access: For Psychiatric Services, Wait for the Beep

STUDY OBJECTIVE We examine access to care for acute depression by insurance status compared to access for acute medical conditions in 9 metropolitan areas in the United States. METHODS Using an audit study design, trained research assistants posing as patients referred from a local emergency department (ED) for treatment of depression called each clinic twice, with differing insurance status. The main outcome measure was the ability to schedule a mental health appointment within 2 weeks of the ED visit. RESULTS In 45% of 322 calls to mental health clinics, the research assistant reached an answering machine compared with 8% of calls to medical clinics. As a result, only 31% of callers with depression vignettes were able to determine whether they could get an appointment versus 78% of callers with medical complaints. When they reached appointment personnel by telephone, 57% of depression callers successfully arranged an appointment (39% within 14 days). Among depression callers who reached appointment personnel, 67% of privately insured and 33% of Medicaid callers were able to make an appointment, for overall appointment rates of 22% and 12%, respectively. Appointment success for the uninsured was comparable to that of Medicaid patients. The high percentage of callers who encountered answering machines prevented us from completing the designed analysis of paired calls to individual clinics. CONCLUSION Our findings indicate that the process for obtaining urgent follow-up appointments is systematically different for patients seeking behavioral health care than for those with physical complaints. The use of voicemail, in lieu of having a person answer the telephone, is much more prevalent in behavioral than physical health settings. More work is needed to determine the effect of this practice on depressed individuals and vulnerable populations.

Does the Incidence of Group Health Insurance Fall on Individual Workers

Economic models predict that the cost of health insurance is borne by workers. In this paper we ask two questions. First, is cost shifting individual-specific: does a worker with higher expected medical expenses bear this cost? Second, how do explicit employee contributions affect cost shifting? We estimate wage change regressions that include as explanatory variables changes in health insurance coverage, changes in employee premium contributions, health status, and an interaction between health insurance changes and health status. We find no evidence of a significant wage offset at either the individual or group level and conclude that changes in health insurance status are not exogenous.

Coordination versus Competition in Health Care Reform

Many proposals to increase the value of care focus on improved coordination. But by generating incentives for provider consolidation, these efforts may unintentionally be at odds with another strategy for improving value: promoting competition in health care markets.

Is Welfare Reform Responsible for Low-Skilled Women's Declining Health Insurance Coverage in the 1990s?

We use data from the 1989–2001 March Supplements to the Current Population Survey to determine whether welfare reform contributed to declines in health insurance coverage experienced by low-skilled women. Between 1988 and 2000, women with less than a high school education experienced an 8.0 percentage point decline in the probability of having health insurance. Against this backdrop of large declines, welfare waivers and TANF are associated with modest increases in coverage for low-skilled women of 2.3 and 3.6 percentage points respectively. Overall, our findings suggest that welfare reform did not contribute to declines in coverage but rather offset them somewhat.

Employer Health Insurance Mandates and the Risk of Unemployment

Employer health insurance mandates form the basis of many health care reform proposals. Proponents make the case that they will increase insurance, while opponents raise the concern that low-wage workers will see offsetting reductions in their wages and that in the presence of minimum wage laws some of the lowest wage workers will become unemployed. We construct an estimate of the number of workers whose wages are so close to the minimum wage that they cannot be lowered to absorb the cost of health insurance, using detailed data on wages, health insurance, and demographics from the Current Population Survey. We find that 33 percent of uninsured workers earn within

What do people buy when they don't buy health insurance and what does that say about why they are uninsured?

3 of the minimum wage, putting them at risk of unemployment if their employers were required to offer insurance. Assuming an elasticity of employment with respect to minimum wage increase of -0.10, we estimate that 0.2 percent of all full-time workers and 1.4 percent of uninsured full-time workers would lose their jobs because of a health insurance mandate. Workers who would lose their jobs are disproportionately likely to be high school dropouts, minority, and female. This risk of unemployment should be a crucial component in the evaluation of both the effectiveness and distributional implications of these policies relative to alternatives such as tax credits, Medicaid expansions, and individual mandates, and their broader effects on the well-being of low-wage workers.

Health Literacy and Access to Care

Using data from the Consumer Expenditure Survey, this study compares household spending on different goods by insured versus uninsured households, controlling for total spending and demographic characteristics. The analysis shows that uninsured households, on average, spend more on housing, food, alcohol, and tobacco compared to insured households. These results suggest that both prices and preferences, in addition to income, help explain why some households do not buy coverage; the findings also raise the possibility that the uninsured may lack coverage in part because they face higher prices for basic needs like housing and food.