reports counts of study observations for each of the admission categories. There were 368,782 (10.7%) patient discharges near the SNH events. For Hispanics, the dominant reason for admission was births. Births and ambulatory care sensitive conditions were major reasons for admission for non-Hispanic Whites and non-Hispanic Blacks.
Study Observations by Admission Category, Race/Ethnicity, and Community Type
Descriptive data on the dependent variable are presented in . The data indicate that travel distances were significantly shorter in the ending year relative to the base year, regardless of whether patients were near or not near a SNH event. These changes in distance may reflect the greater diffusion of certain services, declining ability of health plans to steer patients to certain facilities, or idiosyncratic changes in zip code definitions. Overall, they indicate the importance of using a difference-in-difference approach to examine effects of SNH changes.
Average Travel Distance for Hospital Services for Patients in Different Community Types (Standard Errors in Parentheses)
presents descriptive information. About 30% of the study observations were elderly. Medicare coverage was the dominant insurer, with Medicaid covering about 25% of the observations. Non-Hispanic Blacks and Hispanics represented about 35% of the study observations. As noted above, 65.6% -- or nearly two-thirds – of SNH beds were affected by the SNH closure/conversion for those living near these events.
Multivariate regressions for the combined sample are reported in . These models were also estimated by racial/ethnic groups (results available from lead author). The variables of primary interest are those associated with the SNH closure/conversion but their coefficients are not directly interpretable because they represent partial effects rather than the desired difference-in-difference measures. Generally, the regression estimates for most variables conform to what others have found (Dranove et al. 1993
, Morrisey and White 1998, Mobley and Frech 2000
reports the difference-in-difference estimates of changes in travel distance over the study period. Two sets of comparisons are present. The first set of columns reports changing travel for Medicaid patients or the uninsured across areas with and without SNH changes, and for simplicity, we refer to these as “across area differences”. The second set of columns reports changing travel for Medicaid patients or the uninsured relative to the privately insured, all of whom live in areas near SNH changes, and we refer to these as “within area differences”.
Summary of Differential Effects of SNH Closure and For-Profit Conversion on Added Miles Traveled by Patients: Overall and Race/Ethnicity Payer Differences (Bootstrapped standard errors in parentheses)
Looking at the across area differences, we observe that there are no significant travel distance changes for the uninsured or Medicaid patients when we compare areas with and without SNH events in the first four diagnosis categories. Nor do these findings suggest a consistent pattern of positive signs, which would be indicative of relatively longer travel for Medicaid patients or the uninsured across the study areas. The across area results do, however, suggest that uninsured women living near SNHs that closed/converted overall did travel 3.29 additional miles in the ending year to give birth relative to similar women in areas without SNH change. But this combines a relative decline in travel for non-Hispanic Black uninsured women (-6.19 miles) and a relative increase for Hispanic uninsured women (+5.87). These different effects across minority groups are interesting, suggesting that perhaps uninsured non-Hispanic Black women initially bypassed nearer hospital options to get to a preferred SNH whereas Hispanic uninsured women may have lost SNH resources to which they were more proximate. The across area findings also suggest that Hispanic women covered by Medicaid traveled relatively farther to give birth after nearby SNH changes than their counterparts in areas without these events.
Looking at the within area differences, the results provide more indications that Medicaid and uninsured patients may have been differentially disadvantaged by SNH changes relative to the privately insured who lived in their communities. The within area differences indicate that the uninsured traveled relatively farther after SNH events to give birth in comparison to privately insured women, and this was especially true for Hispanic uninsured women. Also, the within area results suggest significant relative increases in travel for mental health and substance abuse admissions, for both non-Hispanic Black uninsured and Medicaid patients. The within area comparisons suggest that Hispanic Medicaid patients had relatively shorter increases in travel distance for referral sensitive conditions when compared to similarly affected privately insured (-5.23 miles) and the reason for this paradoxical finding is unclear. Other than the referral sensitive condition category, most other differential travel estimates for the within area comparisons are positive and sometimes fairly large in value for the uninsured, although large standard errors are present due to high variation in estimates around mean values.
We conducted an analysis excluding patient observations where SNH conversions occurred, focusing only on SNH closures. In conversion communities, the capacity of the original hospital is still present and local stakeholders may have required new for-profit owners to continue mission-related activities. For the combined race and ethnic group analysis, the statistically significant findings were identical to those in the analysis that included both SNH closures and conversions.4
The relative increase in added travel for the uninsured and Medicaid patients was greater when one examined only SNH closures relative to the results in . However, none of the findings for the racial/ethnic subgroup analysis was significant. This likely reflected growing power issues as we examined a limited number of natural events in smaller subgroups of patients.