Date of Award

1-1-2023

Language

English

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College/School/Department

Department of Economics

Content Description

1 online resource (xi, 131 pages) : illustrations (some color)

Dissertation/Thesis Chair

Chun-Yu Ho

Committee Members

Baris Yoruk

Keywords

Medical care, Rural hospitals, Health services accessibility

Subject Categories

Economics

Abstract

The first chapter examines whether losing access to hospital-based emergency department services play a role in heightening mortality in rural areas using Vital Statistics death certificate records from 2005-2018. Our analysis reaches several results. First, rural populations residing in counties experiencing complete loss of emergency department services suffer an increase in mortality from drug overdoses for two years. The effect is mainly driven by males aged between 15-44 living in the Rust Belt. Such effect is stronger among Black and Hispanic individuals than white individuals. Second, in the Mountain Census Division, which is a geographically dispersed region, rural populations residing in counties experiencing complete loss of emergency department services suffer a persistent increase in mortality from acute myocardial infarction, which is a time-sensitive illness. Overall, our results highlight two roles of emergency department closures in driving mortality in rural areas: ED closures amplify deaths of despair in rural counties and raise the vulnerability of rural populations in remote areas to mortality from time-sensitive illnesses. The second chapter examines whether loss of locally available hospital-based obstetric services affects racial/ethnic disparities in intrapartum care access and birth outcomes in rural areas of the US. To conduct causal inference, we combine difference-in-difference and propensity score matching methods to control for observable and time-invariant unobservable heterogeneity across counties. Using data from Vital Statistics birth certificate records from 2005-2018 from rural counties in the mainland US, our empirical analysis reaches several findings. Women in counties that lost obstetric services travel further for obstetric care; are more likely to receive intrapartum care outside their counties of residence; and are more likely to deliver in an urban county compared to women in matched counties. We find that obstetric unit closure is associated with reduced maternal morbidity but is not associated with infant health in the full sample. Among Black mothers, however, obstetric unit closure is associated with increased risk of having infants with low APGAR scores. The adoption of scope-of-practice laws for certified nurse midwives, the adoption of telehealth payment parity laws and the ACA Medicaid expansions do not appear to narrow racial/ethnic disparities in health in response to obstetric unit closures. The third chapter examines access to local healthcare services and market structures in the U.S. rural area health markets. The hospital markets in the rural area of the U.S. can be separated into plenty small local markets with continuous number of hospital and relative market characteristics variables. Based on completeness and availability of the data, the hospital markets in the rural area are ideal for the healthcare market study. Under the background that Affordable Care Act (ACA) starts in year 2010, and full implements in year 2014, so we use 2006 as matching year for 2014 with year 2010 in the middle. Using data 2006 and 2014, we investigate how the entry behavior of hospitals is affected by the market structure, demand shifters and cost shifters, and how the entry effects on the access to healthcare and other factors. Preliminary results indicate that, with the influence of policy, the second hospital can achieve a reasonable market structure in 2006 and the third hospital can be lowest barrier of healthcare in 2014. All the effects of new entry are diminished as time goes.

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