ORCID

https://orcid.org/0009-0004-6747-7812

Date of Award

Summer 2026

Language

English

Embargo Period

7-21-2026

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College/School/Department

Department of Economics

Program

Economics

First Advisor

Pinka Chatterji

Second Advisor

Chun-Yu Ho

Committee Members

Byoung G. Park

Keywords

Nursing home closures; long-term care; post-acute care; health disparities; racial and ethnic disparities; geographic disparities; nursing home access; market concentration; nursing home quality; staffing; resident health outcomes; rural health; difference-in-differences

Subject Categories

Health Economics | Labor Economics | Public Economics

Abstract

This dissertation examines the consequences of nursing home closures for access to care, local economic conditions, and resident health in the United States. As the long-term care system shifts toward home- and community-based services and the nursing home sector contracts, facility closures have become an increasingly important policy concern. Although closures may reflect necessary market restructuring in some settings, they may also reduce access, weaken local economies, and place pressure on surviving facilities. Across three essays, this dissertation shows that the consequences of nursing home contraction are uneven and depend on racial and ethnic composition, rurality, local market concentration, and the quality of remaining facilities.   The first essay examines racial, ethnic, and geographic disparities in access to nursing home care from 2009 to 2020. Using county-level data, it measures access to overall nursing home beds, high-quality nursing home beds, and Alzheimer's care beds. The results show that access declined broadly, but losses were larger in rural counties with large Black and Hispanic populations, particularly in access to high-quality nursing homes and Alzheimer's care beds. These findings suggest that aggregate declines in nursing home capacity can mask widening disparities in access to specialized and higher-quality care.   The second essay studies the local economic consequences of nursing home closures from 2009 to 2019. Using a staggered difference-in-differences framework, it finds that closures reduce total employment, health sector employment, non-health sector employment, and labor force size while increasing unemployment, poverty, and uninsurance. These adverse effects are concentrated in rural counties, where nursing homes often represent important sources of employment and local economic activity. These findings suggest that policies addressing nursing home closures should consider not only continuity of care, but also the broader economic vulnerability of the communities in which facilities operate.   The third essay examines spillover effects of nursing home closures on residents who remain in nearby surviving facilities. Using Minimum Data Set assessments linked to facility, quality, and county characteristics from 2011 to 2017, it finds limited evidence that closures generate broad deterioration in acute outcomes such as mortality, hospitalization, stroke, or fractures. The effects on chronic health outcomes, however, vary substantially by local market concentration. In concentrated markets, closure exposure is associated with increases in heart failure, Alzheimer's disease, and dementia, whereas effects in competitive markets are smaller or less adverse. Mechanism analyses show that closures increase occupancy in surviving facilities, particularly in concentrated markets, without corresponding increases in staffing intensity. Lower-rated facilities in concentrated markets experience the clearest combination of increased occupancy and worsening heart failure and depression outcomes. These findings suggest that closure oversight should extend beyond displaced residents to include the capacity, staffing conditions, and baseline quality of nearby surviving facilities, particularly in concentrated markets where substitute capacity is limited.

License

This work is licensed under the University at Albany Standard Author Agreement.

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