<p>My dissertation focuses on employing microeconomic techniques to study markets and questions that are important and complex, and also have potential policy implications. Two of my chapters analyze the health industry with an emphasis on hospitals, patient welfare, and regulation. The remaining chapter focuses on the housing market in Los Angeles and explores real estate flipping.</p><p>The second chapter of my dissertation studies the impact of state level regulations on hospital bed capacity decisions. The regulations are intended to decrease hospital investments without diminishing patient access. I find that the regulation decreases total hospital investment in bed capacity as expected. When running simulations to estimate how hospitals would behave differently were the regulatory policy changed, I find that total patient utility is negatively affected by the presence of the regulation as many patients get turned away from their preferred hospital due to overcrowding. This analysis has important policy implications as it suggests that the regulation has been ineffective in ensuring that patient welfare was unharmed by the restrictions.</p><p>The third chapter is based on joint research with Patrick Bayer and James W. Roberts and studies the housing market in the Los Angeles metropolitan area from 1988 to 2009. Using novel data, I identify which housing transactions involve flippers who aim not to live in the house, but rather to quickly resell it for financial gain. I find that flipper behavior varies based on how frequently I observe the individual engage in such behavior. Experienced flippers, who are observed to flip many houses in the data, target homes being sold at below market value and earn their returns from buying them at a discount. Their effect on long term prices in the neighborhood is negligable. Inexperienced flippers who are less active, seek to earn their profits by timing the market and are more active when house prices were rapidly appreciating from 1999 to 2005. Their activity increases housing prices in the neighborhood in the short term, but decreases them in the long term. Such results are consistent with the claim that real estate flipping contributed to the housing bubble.</p><p>The fourth chapter of my dissertation again focuses on the hospital industry and looks at the question of how patient composition changes as a hospital becomes busier and has to turn patients away. I develop a theoretical model which predicts that hospitals are more likely to turn away less profitable patients. As a result, when a hospital becomes more full and therefore is more likely to have to turn patients away, its composition of patients will change and become more profitable on the whole. I test this theory by empirically analyzing the effect of hospital congestion on the composition of hospital patients using hospital discharge data. The findings are consistent with my theoretical model as when hospitals become more crowded, the fraction of uninsured patients and mental health patients (who are typically not profitable to a hospital) decreases. This result suggests that hospitals are more likely to turn away unprofitable patients while continuing to admit more profitable patients.</p> / Dissertation

The dissertation investigates how individual behaviors and health outcomes interplay with surrounding built environments, in three essays. We conceptually focus on travel behaviors and accessibility. In the first essay, we hypothesize that urban sprawl increases requisite travel time which limits leisure time available as inputs to health production. We utilize the American Time Use Survey to quantify decreases in health-related activity participation due to commuting time. We identify significant evidence of trade-offs between commuting time and exercise, food preparation, and sleep behaviors, which exceed labor time trade-offs on a per-minute basis. Longer commutes are additionally associated with an increased likelihood of non-grocery food purchases and substitution into less strenuous exercise activities. We also utilize daily metropolitan traffic accidents as instruments which exogenously lengthen a particular day’s commute. The second essay tests whether the likelihood of food insecurity and “paradoxical” joint insecurity-obesity occurrences vary over the degree of urban sprawl. We utilize data from the Behavioral Risk Factor Surveillance System’s Social Context Module merged with urban sprawl measures developed by Smart Growth America. We find significantly negative associations between urban sprawl and the likelihood of food insecurity, and that insecurity is more likely in areas of less developed street connectivity. We find that joint outcomes are more likely in less sprawled areas and that likelihood is greater in areas of greater street connectivity, which fails to support theories proposing that healthy food inaccessibility is a determinant of joint outcomes. The third essay evaluates research claims that walking and cycling to school increases students’ physical activity levels in a predominantly urban sample. We utilize the third wave of the Survey of Adults and Youth–a geocoded dataset–to identify determinants of walking or cycling to school, and in turn to explore to what extent active travel impacts adolescents' weekly exercise levels. Consistent with the literature, we find that the distance between home and school is the largest influence on the travel mode decision. We also find no evidence that active travel increases the number of students’ weekly exercise sessions. These results suggest that previous findings may not extend to all environments or populations.

A vast literature acknowledges that minority groups, particularly African-Americans, receive less, and lower-quality treatment than Caucasians in U.S. health facilities. It remains an open question as to how much of this disparity is a result of poverty, and how much, a result of more overt discrimination. Former empirical studies are far from conclusive given the endogeneity of hospital quality, as minorities are overrepresented in areas served by poor health facilities. To remedy this endogeneity issue, we observe visitors to the state of Florida, as well as travelers within Florida. When an individual experiences a health shock far from home, her hospital assignment becomes random. By contrasting treatment intensity, and patient outcomes of minority visitors with the total population, we find that residence plays a substantial role in the provision of healthcare. Our results indicate that though African-Americans as minority group receive less treatment and experience higher mortality rates, these disparities disappear for African-American visitors.

An understanding of both the determinants of health care access and the implications of that access is of crucial importance because it enables us to learn about policies and institutions that are welfare enhancing in health outcomes. The first chapter of my dissertation explores how access to sanitaria aided in tuberculosis control in the time before antibiotics. Results indicate that access to an additional sanitaria bed reduced the death rate from tuberculosis for white residents by nearly .695 per 100,000 and had no impact for black residents. The next two chapters investigate the retail health clinic. First, I construct a choice model of clinic location that accounts for both demand and competition effects. I find that clinics are more likely to locate in areas that are populous, wealthy, educated, and white, and that they are less likely to locate in traditionally underserved communities. Second, I combine the results of my predictive model with data on ED visits to determine if clinics help direct patients away from receiving treatment at expensive emergency rooms. I find that access to retail clinics causes a substantial decrease in the number of ED visits for bronchitis and upper respiratory infections. The savings associated with retail clinic induced ED diversion is conservatively estimated to be at least $88 million in 2012 alone. In California, counterfactual analysis suggests that relaxing the barriers to clinic entry would result in $10.5 million in annual health care savings.

My dissertation focuses on developing and applying program evaluation techniques to better understanding how public policies affect low-income households and social mobility. In general, my research attempts to address three questions regarding the effect of public policies: (1) What is the long-term effect of the policy? (2) Does the policy foster social mobility? (3) Is there an unintended consequence of the policy? In my view, equality of opportunity is one of the pillars of a free society. I favor the idea that poor children have equal opportunities for success. Since children from low-income families grow up in a relatively disadvantaged environment, public policies that redistribute resources to poor children can foster social mobility. However, as well-documented in the literature, redistribution policies lead to a change in incentives. In some cases, these unintended consequences offset the ``benevolence" of the policy. As a labor economist interested in policy analysis, I focus on evaluating a policy from these three perspectives. In the three essays in my dissertation, I answer the policy-relevant questions using different econometric approaches. When an exogenous policy change is available, a simple econometric model with few assumptions can provide credible answers. If we do not have a natural experiment in the context of the question, I model the selection process so that we can still learn from the data. In the first essay, I investigate whether exam preparatory programs in Taiwan are effective. I set up a Bayesian selection model that formalizes the selection process and explicitly takes into account parameter heterogeneity. In the second essay, I study the effect of the expansions of Medicaid in 1990 on childhood obesity. The Omnibus Budget Reconciliation Act 1990 expanded eligibility to children who were born after September 30, 1983 from families below the poverty line. I employ the birth date discontinuity to study the policy effect. In the third essay, I develop a new test based on the empirical distribution functions of the compliers in the Local Average Treatment Effect (LATE) model. This method tests the validity of the LATE model, which is a common empirical strategy when endogeneity is an issue. In my first essay, I estimate the impact of attending exam preparatory programs, in particular “cram schools,” on students’ academic performance. These programs are the product of market system and the Joint Entrance Exam System, which has been in place for decades in Taiwan. I measure the outcome by admission to a public high school and an “elite” high school. Focusing on the problem that students are not randomly assigned to “cram schools,” I approach the issue using propensity score matching and a Bayesian simultaneous-equations model. Using data from a survey of Taiwanese junior high school students in the Taiwan Youth Project, I find evidence that there is an insignificantly negative sorting into exam preparatory programs and attending an exam preparatory program improves a student’s high school placement. Both approaches indicate similar positive treatment effects. The second essay studies the effect of Medicaid expansions on childhood obesity and finds robust evidence of ex-ante moral hazard induced by public insurance. I establish this result by estimating two reduced-form models and a structural model. My reduced-form identification strategy exploits eligibility discontinuity created by the Omnibus Budget Reconciliation Act 1990, which extended Medicaid eligibility to children from families below the federal poverty threshold and born after October 1983. Drawing on the MEPS, I find offering low-income children public insurance leads to an approximately 10-percentage-point increase in the chances of obesity. Combining the MEPS and the SIPP, I am able to investigate the effects of insurance take-up. I estimate a fuzzy regression discontinuity design using Angrist-Krueger two-sample IV estimator (Angrist and Krueger 1992). The results suggest that early insurance take-up induced by the expansions of Medicaid leads to a roughly 5-percentage-point increase in chances of obesity. I also develop and estimate a two-period structural model that quantifies moral hazard, net-wealth effect, and risk preferences. I use the estimates to study the relative importance of income effect and moral hazard in the childhood obesity problem. The estimates of the choice model suggest that net-wealth effect is a statistically significant avenue to the observed policy effect. In the third essay, I develop a method to test the validity of the Local Average Treatment Effect (LATE) model. The LATE model is widely applied to evaluating policies when randomized experiments are impossible. The model relies on two critical assumptions: (1) the existence of a randomly assigned instrument that affects the outcome variable only through the treatment; and (2) the instrument only affects the treatment selection in one direction. The basis for the test is an estimator for the distribution function of the compliers. If the CDFs decrease more than the derived bound, then we reject the assumption of the exclusion restriction. If the CDFs are not completely non-decreasing, then either one of the assumptions fail to hold. To show the applicability, I apply the test to three datasets.

BACKGROUND: Teratology Information Services (TIS) educate the public and health professionals via telephone regarding the safety of drugs and other exposures during pregnancy and lactation. Currently TIS consultations are free, but funding is eroding. A cost-benefit analysis may inform resource allocation. It was hypothesized that an individual TIS consultation regarding anti-depressant use during pregnancy provides a positive net benefit compared to a family doctor (FD) consultation. METHODS: A survey of international TIS was conducted to gauge TIS costs. A discrete choice experiment (DCE) was designed to assess preferences and willingness-to-pay (WTP, an estimate of benefit) for teratology counseling. DCE respondents (local community volunteers) chose between potential counseling services following an anti-depressant exposure during pregnancy. Services were described by five service attributes and one cost attribute, which were generated in focus groups. Preferences and WTP were estimated using logit regression. Incremental benefits and costs of counseling by TIS and FD were compared in a probabilistic sensitivity analysis to obtain the incremental net benefit from both a societal (productivity costs included) and health system perspective. The FD consultation was costed through OHIP billing codes. The TIS consultation was micro-costed. RESULTS: Eighteen TIS in North America and 16 international TIS completed the survey. Most TIS are small (median two employees, median budget US$69,000). The DCE had 175 respondents. The most important attribute of counseling was receiving very helpful information; information delivery methods were less important. WTP for the TIS scenario was CDN$124 (SD $12); WTP for the FD scenario was CDN$79 (SD $8). Service costs were similar for TIS and FD (approximately $32/consultation); FD had higher productivity costs. Incremental TIS benefits were likely to outweigh costs under both the societal and health system perspectives (probability 99% and 97% respectively). CONCLUSIONS: An economic evaluation of a program that delivers pregnancy health information via telephone required a novel approach. While there are some methodological challenges to valuing benefits through willingness-to-pay, it may be appropriate for valuing counseling. TIS should emphasize their ability to provide high quality information. The benefits of an individual TIS consultation on anti-depressant use during pregnancy are likely greater than the costs.

BACKGROUND: Teratology Information Services (TIS) educate the public and health professionals via telephone regarding the safety of drugs and other exposures during pregnancy and lactation. Currently TIS consultations are free, but funding is eroding. A cost-benefit analysis may inform resource allocation. It was hypothesized that an individual TIS consultation regarding anti-depressant use during pregnancy provides a positive net benefit compared to a family doctor (FD) consultation. METHODS: A survey of international TIS was conducted to gauge TIS costs. A discrete choice experiment (DCE) was designed to assess preferences and willingness-to-pay (WTP, an estimate of benefit) for teratology counseling. DCE respondents (local community volunteers) chose between potential counseling services following an anti-depressant exposure during pregnancy. Services were described by five service attributes and one cost attribute, which were generated in focus groups. Preferences and WTP were estimated using logit regression. Incremental benefits and costs of counseling by TIS and FD were compared in a probabilistic sensitivity analysis to obtain the incremental net benefit from both a societal (productivity costs included) and health system perspective. The FD consultation was costed through OHIP billing codes. The TIS consultation was micro-costed. RESULTS: Eighteen TIS in North America and 16 international TIS completed the survey. Most TIS are small (median two employees, median budget US$69,000). The DCE had 175 respondents. The most important attribute of counseling was receiving very helpful information; information delivery methods were less important. WTP for the TIS scenario was CDN$124 (SD $12); WTP for the FD scenario was CDN$79 (SD $8). Service costs were similar for TIS and FD (approximately $32/consultation); FD had higher productivity costs. Incremental TIS benefits were likely to outweigh costs under both the societal and health system perspectives (probability 99% and 97% respectively). CONCLUSIONS: An economic evaluation of a program that delivers pregnancy health information via telephone required a novel approach. While there are some methodological challenges to valuing benefits through willingness-to-pay, it may be appropriate for valuing counseling. TIS should emphasize their ability to provide high quality information. The benefits of an individual TIS consultation on anti-depressant use during pregnancy are likely greater than the costs.

Using 2014 data compiled from a sample of Claremont McKenna undergraduate students, I examine the effect that fitness technology (i.e., mobile and wearable technology) has on users' health outcomes. Specifically, I find no effect of mobile or wearable use on self-reported health. However, I do find some evidence of mobile use on weight but not wearable. Applying a basic OLS regression analysis, I show that mobile users tend to be heavier than non-mobile users irrespective of gender. Furthermore, I find that contemporaneous health on prior mobile use show higher weight levels compared to non- mobile prior users. Such findings provide evidence suggesting that mobile is ineffective in providing users with healthier outcomes.

Health care spending in Canada has been increasing faster than the rate of gross domestic product (GDP). A disproportionate amount of the health care spending is allocated to care of older adults. Non-elective abdominal surgery is an expensive area of care for older adults. Despite this, the factors associated with cost in this patient population remain unclear. OBJECTIVES The primary objective of this study was to estimate the association between perioperative factors (age, American Society of Anesthetists (ASA) classification, operative severity (OS), frailty index (FI), complication severity) and health care costs among older adults undergoing non-elective abdominal surgery. The secondary objectives were: 1. to provide a comprehensive description of costs based on patient-level resource utilization; and 2. to examine the relationship between hospital costs and adverse events (non-fatal complication severity, mortality, and change in living arrangement). METHODS This study was an observational prospective cohort study. Over a 15 month period all patients 70 years or older who underwent non-elective abdominal surgery at the QEII Health Sciences Centre, Nova Scotia, were enrolled. Data were collected on patient demographics, investigations, treatments, and outcomes. Direct hospital health care costs (2012 $CAD) were calculated by tabulating patient-level resource use and assigning specific costs. The association between five perioperative factors and costs were analyzed using univariate non-parametric tests and multiple linear regression. The associations between adverse events and costs were assessed using univariate non-parametric tests and multiple linear regression. RESULTS During the study period, 212 patients who underwent abdominal surgery (median age 78 years (range 70-97)) were enrolled. The median costs of care were $9,166 (range $1,993-$104,403). The largest proportions of spending were non-procedural costs (65% [$2,176,875]) and intensive care costs (16% [$554,523]). The perioperative factors ASA classification (p=0.0010), OS (p<0.0001), FI (p=0.0002) and complication severity (p<0.0001) were all independently associated with health care costs, while age was not (p=0.5330). The following adverse events were independently associated with health care costs: non-fatal complication severity (p<0.0001), change in living arrangement (p=0.0002), and mortality (p=0.0337). Non-fatal complications had the strongest association with hospital costs (standardized β coefficient = 0.3931). CONCLUSION Four perioperative factors (ASA, OS, FI and complication severity) are associated with costs; therefore, representing a potential cost prediction model for this patient group. This study is important for health care administrators, identifying targets for cost reduction. Cost reduction strategies and research should concentrate on mitigating or preventing complications and high cost areas, such as non-procedural costs and intensive care, in order to achieve cost savings.

What purpose do budgetary tools, such as zero-base budgeting, break-down budgeting, net budget, program budget, and multi-year budget serve? Are they methods whereby planners and administrators intend to take the initiative and increase their power at the expense of the political decision-makers? Or, inversely, are they avenues to increased political influence? This dissertation analyses, characteristic by characteristic, different budgetary aspects in health care budgeting and their action alternatives. These aspects are related to three goals; priority setting, influence on action, and administrative contol. The attitudes of key groups – political decision-makers, planners, hospital administrators, and senior physicians – are investigated. The study shows that budgeting is incremental, not comprehensive. Budgetary reforms are of more concern to planners and administrators than to political decision-makers or senior physicians. / Diss. Stockholm : Handelshögsk.