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Dissertation Papers
Dissertation Papers
Dissertation Paper 1 — Job Market Paper. Under review.
The Trump administration's 2019 expansion of the public charge rule made Medicaid receipt a negative factor in certain immigration determinations and generated widespread concern that eligible families would avoid health coverage. I study whether that fear translated into measurable coverage losses among populations formally exempt from the rule. Using American Community Survey data on 1,622,582 Medicaid-eligible U.S. citizen children below 200% of the federal poverty level from 2016 to 2024, I estimate difference-in-differences and event-study models comparing citizen children in mixed-status families with those in citizen-only families. I complement the national child analysis with restricted-use California Health Interview Survey data on 220,925 adults from 2015 to 2024, which permits a four-level decomposition of citizenship status (U.S.-born, naturalized, green-card holder, no green card). In the national analysis, citizen children in mixed-status families experienced a 2.0 percentage point decline in Medicaid enrollment after the September 2018 public charge announcement (p < 0.001), with no evidence of pre-policy divergence in the preferred event study (joint Wald test p = 0.92). Effects persisted through the policy reversal period and deepened during the 2023-2024 Medicaid redetermination restart ("unwinding"). Two additional ACS specifications further refine the chilling channel: (i) decomposing the citizen-only ACS control group reveals that the chilling effect concentrates in families with a noncitizen parent (–1.81 pp Medicaid relative to U.S.-born-parent baseline, p = 0.003) rather than across immigrant-connected families broadly (naturalized-parent × post: +1.41 pp, p = 0.07); (ii) excluding seven jurisdictions that extended Medicaid (or near-equivalent state-funded coverage) to undocumented adults during the paper window (California, Illinois, Oregon, New York, Colorado, Washington, and the District of Columbia) tightens the chilling estimate to –2.6 pp (p < 0.001), consistent with state policy environments partially counter-programming the federal rule. In California, naturalized citizens experienced a 1.3 percentage point Medi-Cal decline (p = 0.030), and the restricted-CHIS data identify large fear-based avoidance gradients: undocumented adults are 20.5 percentage points more likely than naturalized citizens to report having declined a non-cash benefit because of immigration concerns (p < 10⁻³⁰). California's contemporaneous full-scope Medi-Cal expansions for undocumented adults (January 2020 ages 19–25, May 2022 ages 50+, January 2024 ages 26–49) preclude a clean within-state estimate of coverage-chilling, even in the cleanest within-state cell (age 26–49 in 2019–2021): Medi-Cal coverage among adults without green cards rose +6.8 pp rather than fell. Taken together, the clearest coverage losses appear among eligible citizen children — concentrated in mixed-status families and in non-expansion states — while the California adult evidence provides supporting evidence on spillovers, fear-based avoidance, and administrative vulnerability rather than a coverage-chilling estimate for directly exposed adults.
Dissertation Paper 2. Under review.
When individuals are incarcerated, states may either suspend or terminate their Medicaid eligibility. Under suspension, coverage is paused during incarceration and reactivated upon release without a new application; under termination, eligibility is ended entirely and the individual must reapply after release, navigating documentation requirements, processing delays, and bureaucratic complexity at a moment of acute vulnerability. I estimate the intent-to-treat association between state Medicaid suspension policies and post-release Medicaid enrollment, employment, earnings, and mortality among state prison release cohorts, exploiting the staggered rollout of suspension across U.S. states between 2005 and 2022. Linking a newly constructed state-year policy panel triangulated from six independent sources to the Census Bureau's Criminal Justice Administrative Records System (CJARS) Justice Outcomes Explorer---which provides administratively linked aggregate outcomes for state prison release cohorts across 31 states---I implement two-way fixed effects, heterogeneity-robust local projections difference-in-differences (LP-DiD), and Callaway-Sant'Anna group-time average treatment effect estimators. Because the outcome is measured at the release-cohort level, the estimates should be interpreted as intent-to-treat effects of state suspension policy on the full release cohort, not as individual-level treatment effects among those whose Medicaid was actually suspended. Suspension is associated with a 22.4 percentage-point increase in 1-year post-release Medicaid enrollment (LP-DiD, p = 0.001), with similar estimates from TWFE (22.2 pp) and Callaway-Sant'Anna (25.8 pp), and similarly large estimates at 3-year (18.7 pp) and 5-year (20.7 pp) horizons. I find no significant effects on W-2 employment or earnings. Mortality estimates are suggestive but not robust across estimators and should be treated as exploratory. The enrollment finding survives leave-one-out checks (including dropping each never-treated state and dropping South Carolina), policy-coding sensitivity, weighted estimation, and a pre-ACA-only restriction; design-based randomization inference is more conservative and does not reach conventional thresholds. These results provide multi-state, state-level, longer-horizon evidence on Medicaid suspension complementing prior single-state individual-level evidence from South Carolina (Packham and Slusky, 2024) and Wisconsin pre-release enrollment-assistance evidence (Burns et al., 2022), and they offer an implementation benchmark for the federal prohibition on terminating Medicaid eligibility solely because of inmate status that took effect on January 1, 2026 under Section 205 of the Consolidated Appropriations Act, 2024.
Dissertation Paper 3. Under review.
Thirty-three states participate in interstate Medicaid drug purchasing pools, yet there is almost no causal evidence on whether pooling actually raises the supplemental rebates states extract from manufacturers. I assemble a primary-source panel of pool membership for all 50 states from 2002 through 2024 — reconciled from state Medicaid manuals, archived web materials, agency correspondence, and public-records requests — and link it to CMS-64 supplemental rebate data and State Drug Utilization Data drug-mix measures. Using estimators that are robust to staggered timing and to pool exit (Sun-Abraham for the absorbing Sovereign States Drug Consortium, or SSDC; de Chaisemartin-D’Haultfœuille for the reversing vendor pools), with wild-cluster-bootstrap inference appropriate to the small number of treated clusters, I find that joining a pool modestly raises supplemental rebate capture. Among SSDC later adopters (first treated in 2012 or after), the average post-adoption effect on the supplemental rebate share of drug spending is 3.4 percentage points (wild-cluster p = 0.051; it sharpens to 0.03–0.04 under valid outcome-construction covariates), and the estimate is stable across five alternative estimators and leave-one-state-out. The effect is heterogeneous by pool type: the National Medicaid Pooling Initiative (NMPI) and the state-owned SSDC are positive (NMPI 1.9 pp; any-pool 1.2 pp), while The Optimal PDL Solution (TOP$) estimates are centered near zero and rule out effects as large as those estimated for later SSDC adopters, but modest positive or negative effects remain possible. Smaller states gain about twice as much as larger states, consistent with a countervailing-buyer-power mechanism, though the size and switcher cuts are not statistically distinct under small-cluster inference. A coarse state-year test of the class-substitutability prediction
is non-confirmatory. The binding constraint on precision is structural: by 2024 most states had pooled, leaving only thirteen never-pooled comparison states, so several confidence intervals hug zero and I bound this imprecision explicitly rather than overclaim. The headline is a measured, mechanism-consistent positive effect, not a clean win — and the governance-controlled specifications are shown to over-condition on post-treatment mediators and to be identified on a restricted post-2010 sample, so the uncontrolled total effect is the primary specification. This study contributes a primary-source multi-pool membership panel as a public good and the first quasi-experimental multi-pool estimates of Medicaid supplemental rebate capture. The paper studies rebate capture, not net drug spending; the language of “savings” is reserved for explicit comparisons against net spending. However, a back-of-the-envelope calculation where all non-SSDC states join SSDC and obtain their rebate levels indicates up to ~2 billion dollars in savings per year.
Other Manuscripts in Review
Other Manuscripts in Review
I provide a first multi-state causal evaluation of Electronic Visit Verification, the Medicaid home-care monitoring mandate introduced by the 21st Century Cures Act. Using staggered implementation timing across 51 jurisdictions, I estimate effects on personal care services and home health care spending, utilization, provider participation, and service patterns in T-MSIS claims and CMS Financial Management Report data. EVV compliance has no statistically significant effect on quarterly PCS claims spending, total HCBS claims spending, prices per claim, claims per provider, provider counts, or beneficiary counts. FMR estimates corroborate the null. The design is underpowered to rule out the smaller savings projected by CBO, and home-health estimates are sensitive to measurement conventions and fail pre-trend checks. I interpret the strongest evidence as a bounded null on large aggregate spending reductions and large provider-exit effects. EVV may still affect documentation, compliance, or smaller utilization margins, but the public aggregate data do not support large fiscal effects.
Working Papers
Working Papers
I evaluate the long-run consequences of capped federal Medicaid financing in Puerto Rico and the other U.S. territories. I assemble a 1950-2024 panel of territorial and state Medicaid financing, coverage, and population-health outcomes, combining CDC WONDER, NCHS mortality files, vital-statistics volumes, CMS financing data, and newly extracted Puerto Rico registry materials. Synthetic-control analyses do not detect a differential 1968 cap effect on Puerto Rico's infant-mortality decline, a null that I interpret as a level-mismatch and power problem rather than proof that capped financing was harmless. The 2011 ACA funding bump produces no detectable coverage effect, while the FY2020 funding cliff is confounded by Hurricane Maria, COVID-19, and bridge appropriations. The clearest contribution is prospective: applying cap regimes to states would mechanically remove very large federal Medicaid transfers, and literature-based mortality elasticities imply policy-relevant infant and adult mortality consequences. I frame territorial caps as a structural fiscal-architecture problem with limited historical causal leverage but large contemporary stakes.
I study how local Social Security Administration field-office closures interact with the federalist SSI-Medicaid linkage. In Section 1634 states, SSI approval automatically confers Medicaid; in Section 209(b) states, Medicaid eligibility runs through a separate state process. Using 2005-2023 ACS and BRFSS data in a Callaway-Sant'Anna staggered difference-in-differences design, I compare disabled-adult Medicaid coverage around office closures across these two institutional regimes. The pooled effect is close to zero, but it decomposes sharply by linkage type: coverage falls in 1634 states and rises in 209(b) states, producing an estimated 1634-versus-209(b) contrast of roughly four percentage points. Small-cluster procedures agree on sign and magnitude, though inference is close to conventional thresholds. I interpret the finding as evidence that field-office access matters differently when federal SSI administration is the gateway to Medicaid, and that reductions in SSA infrastructure may have larger coverage consequences in automatic-linkage states.
I study early labor-supply responses to state Section 1115 waivers extending children's Medicaid continuous eligibility from the federal 12-month standard to multi-year protection through early childhood. Using the staggered adoption of waivers in Oregon, Washington, and New Mexico, I combine cross-state difference-in-differences, a within-state age-based triple difference, and a SIPP sibling fixed-effects specification. The main estimates suggest that parents of children ages 0-6 in waiver states work about 0.7 more hours per week and are 1.7 percentage points more likely to work full time after adoption, with little movement on labor-force participation. Effects survive controls for unwinding intensity and heterogeneity-robust event-study specifications. Coverage effects for children are smaller and do not survive all controls, while sibling fixed-effects estimates are positive but imprecise. I interpret the pattern as an intensive-margin Medicaid-lock response: parents already attached to work appear more willing to increase hours when children's coverage is protected from income fluctuations.
I estimate how optional state Medicaid coverage of GLP-1 receptor agonists for obesity affects prescription utilization. I link Medicaid State Drug Utilization Data from 2018-2025 to a primary-source coverage adoption panel and compare obesity-indication prescriptions with diabetes-indication prescriptions, which are mandatorily covered. Staggered difference-in-differences and within-state triple-difference models show that obesity coverage is associated with an increase of about 2.4 log points in obesity-indication prescriptions per 1,000 Medicaid enrollees, roughly a tenfold increase from a near-zero pre-Wegovy baseline. The diabetes-indication placebo is null, and the result survives restriction to states with exact primary-source adoption dates. Because several states rolled back coverage in early 2026, I treat the 2022-2025 expansion as a potentially reversible access shock. The findings show that state coverage choices, rather than demand alone, strongly ration Medicaid access to obesity-indication GLP-1 medications.
I develop a public-data linkage playbook for Medicaid program-integrity triage. Public records cannot establish fraud, but they can help oversight teams convert broad provider universes into more targeted queues before subpoena, claims review, chart audit, beneficiary interview, or bank-record analysis. The framework distinguishes public setup traces, including enrollment records, addresses, officers, sanctions, litigation, ownership, public-company disclosures, and site records, from restricted records needed to validate claim execution. A New York Medicaid demonstration across six provider categories shows how public data can produce related-entity maps, signal domains, confidence-tiered linkages, and targeted restricted-data requests. In a 928-NPI home-care subset, the workflow reduces a 441-provider public baseline queue representing $49.4 billion in payment exposure to a 66-provider public-linkage priority queue representing $8.5 billion. These figures are not fraud estimates or overpayment findings. I present the workflow as an operating model for pre-investigation prioritization.
I map California counties' continuing responsibility for indigent care under Welfare and Institutions Code Section 17000 as Medi-Cal coverage becomes less certain. After the ACA, Medi-Cal expansion, and AB 85, county backstops receded from view, but state and federal policy changes scheduled for 2026 and 2027 could increase county exposure to adults losing coverage, including some noncitizens. Using legal, budget, and county program documents, I classify the current county landscape. Thirty-five counties participate in the shared County Medical Services Program. Among the 23 self-administered counties, 19 maintain visible county-branded indigent-care or uninsured-adult access programs, while four rely on county hospitals, behavioral-health systems, FQHCs, and payment-assistance structures rather than a named program. I argue that Section 17000 was submerged, not superseded. As Medi-Cal retrenchment unfolds, county institutional capacity and program design will shape local equity, affordability, and fiscal strain.
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