James Okun

It has been widely documented that patients in the US who are associated with disadvantaged demographics receive care at lower quality nursing homes. To understand the role that selective admissions may play in contributing to this pattern, we conducted a nationwide audit study of the impact of patient race, payer, and medical condition on responses to about 5,500 availability inquiries sent to about 3,000 nursing homes. We find 10-15% lower availability for Medicaid patients compared to private-pay patients and for patients with Alzheimer's disease compared to those without; these availability gaps generally increase with nursing home quality. We find no statistically significant evidence of differential availability by race. To quantify the implications of these selective admissions practices, we embed the audit study results in a model of constrained nursing home choice. We estimate that if, counterfactually, Medicaid patients had the same choice sets as their private-pay counterparts, they would attend higher quality nursing homes on average, but the private-Medicaid gap in quality would be reduced by only 5-10%. Our results suggest that supply-side availability differences by payer are widespread, but that they are unlikely to be the primary factor behind the observed gap in quality of nursing homes attended.

Governments can lower the cost of providing in-kind benefits by restricting beneficiaries to a single supplier's products, which induces manufacturers to compete through discounts. When private retailers distribute these benefits, their responses to procurement rules can affect the choices available to private-market consumers. We study this tradeoff in infant formula procurement by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), where three manufacturers bid for contracts that require retailers to keep the contracted brand in stock. We find evidence that retailers' stocking decisions are a driver of the increase in the contracted brand's private-market share. We rationalize this with a model in which consumers substitute across brands during stockouts, so keeping the contracted brand reliably in stock lowers retailers' return to keeping competing brands in stock. Counterfactual simulations show that, among designs that keep formula free for beneficiaries, contracting with two brands and requiring retailers to keep both in stock raises annual private-market consumer surplus by $340 million (12% of current private-market formula spending), while leaving net program spending essentially unchanged. This design broadens product availability for private-market consumers through the stocking requirements, while preserving competition for contracts, since manufacturers still face the threat of exclusion.

We use detailed data on the evolution of health for about 0.8 million Black and 5.4 million white nursing home patients covered by Medicare between 2011 and 2019 to estimate race-specific value-added measures for more than 8,000 nursing homes in the United States. We estimate that the average nursing home value-added experienced by Black patients is about 30% lower than that received by white patients. Most of this gap reflects differences in value-added experienced by similar Black and white patients within the same nursing home, rather than differences in value-added across the nursing homes they go to.

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We estimate the impact of district-level schooling mode (in-person versus hybrid or virtual learning) in the 2020–2021 school year on students' pass rates on standardized tests in grades 3–8 across 11 states. Pass rates declined from 2019 to 2021: an average of 12.8 percentage points in math and 6.8 in English language arts (ELA). Focusing on within-state, within-commuting zone variation in schooling mode, we estimate that districts with full in-person learning had significantly smaller declines (13.4 pp in math, 8.3 in ELA). The value to in-person learning was larger for districts with larger populations of Black students.