Job Market Paper

Nurse Practitioner Prescriptive Authority and Prescription Opioid Use

Since its beginnings in the mid-1980s, nurse practitioner (NP) deregulation has spurred debate about the trade-offs between affordable access to care and the quality of that care. Despite a growing body of evidence that NP deregulation improves patient welfare, most studies are limited in geographic scope and sample periods. This paper addresses these limitations by merging nationwide data from the Medical Expenditure Panel Survey (MEPS) over 18 years (1996-2013) with data on state laws. I then exploit variation in these laws over time to create a quasi-natural experiment and to estimate the causal impact of NP deregulation on prescription opioid use, which has increased 140% over the sample period and is closely associated with the current opioid epidemic. I find, relative to patients living in more restrictive states, that patients who live in states with more flexible NP laws reduce their prescription opioid use by 7% to 9%. I also find that health outcomes either slightly improve or remain unaffected by the enactment of these laws, and the likelihood of a hospitalization declines by about 10%. Taken together, these results indicate that NP deregulation slows the trend in prescription opioid growth while potentially improving patient outcomes. Furthermore, suggestive evidence implies that these effects may be even larger for the least restrictive states, opening the door for future reforms.

Other Chapters

Substituting Higher Education for Medicaid: A Study on the Growth in Entitlements

Co-authored with Andrew Litten

In this paper, we seek to identify the causal relationship between increased state Medicaid obligations and higher education spending. After several decades of federal mandates and high rates of health cost inflation, Medicaid spending has taken an increasingly larger share of state budgets, forcing states to make offsetting cuts elsewhere. We argue that state governments are likely to cut higher education in response to these changes, as institutions of higher education have the capacity to and additional revenues elsewhere. We use federally administered Supplemental Security Income (SSI) enrollments to instrument for state Medicaid spending. We nd that a $1.00 increase in Medicaid costs leads to a decrease in higher education subsidies of 20 cents to 37 cents. Our approach provides estimates which are both more credible and more precise than those which have previously been used in the literature.

Prescription Drug Monitoring Programs and Prescription Opioid Utilization