A Longitudinal Study of Medicaid Payment, Private-Pay Price and Nursing Home Quality

  • David C. Grabowski


Quality of care problems have persisted for decades within U.S. nursing homes. A potential state-level policy towards addressing this concern is the level of Medicaid payment. However, a number of studies have found that an increase in Medicaid payment is associated with lower quality in the presence of certificate-of-need (CON) laws and bed construction moratorium regulations, which serve as barriers to entry within the nursing home industry. Instead of relying on potentially confounded cross-sectional comparisons, this study presents novel, panel-based evidence that incorporates aggregate private-pay price data. These estimates almost uniformly indicate that an increase in the Medicaid payment rate raises nursing home quality. When compared to the earlier literature, these new findings are attributed to changes over time in the market for nursing home care related to the growth in nursing home substitutes.

quality nursing homes Medicaid regulation 


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  1. Banaszak-Holl, J., J. S. Zinn and V. Mor. (1996). “The Impact of Market and Organizational Characteristics on Nursing Care Facility Service Innovation: A Resource Dependency Perspective.” Health Services Research 31(1), 97–117.Google Scholar
  2. Besley, T. and A. Case. (2000). “Unnatural Experiments? Estimating the Incidence of Endogenous Policies.” Economic Journal 110(467), F672–F694.Google Scholar
  3. Bishop, C. E. (1999). “Where Are the Missing Elders? The Decline in Nursing Home Use, 1985 and 1995.” Health Affairs 18(4), 146–155.Google Scholar
  4. Cameron, A. C. and P. K. Trivedi. (1998). Regression Analysis of Count Data. Cambridge, United Kingdom: Cambridge University Press.Google Scholar
  5. Centers For Medicare & Medicaid Services. (2003). Health Care Industry: Market Update. Nursing Facilities. Accessed May 30, 2003 at: 05202003.pdf.Google Scholar
  6. Cohen, J. W. and W. D. Spector. (1996). “The Effect of Medicaid Reimbursement on Quality of Care in Nursing Homes.” Journal of Health Economics 15(1), 23–48.Google Scholar
  7. Davis, M. A. (1991). “On Nursing Home Quality: A Review and Analysis.” Medical Care Review 48(2), 129–166.Google Scholar
  8. Fries, B. E. (1990). “Comparing Case-Mix Systems for Nursing Home Payment.” Health Care Financing Review 11(4), 103–119.Google Scholar
  9. Gertler, P. J. (1989). “Subsidies, Quality, and the Regulation of Nursing Homes.” Journal of Public Economics 38(1), 33–52.Google Scholar
  10. Gertler, P. J. (1992). “Medicaid and the Cost of Improving Access to Nursing Home Care.” The Review of Economics and Statistics 74(2), 338–345.Google Scholar
  11. Gertler, P. J. and D. M. Waldman. (1992). “Quality-Adjusted Cost Functions and Policy Evaluation in the Nursing Home Industry.” Journal of Political Economy 100(6), 1232–1256.Google Scholar
  12. Grabowski, D. C. (2001a). “Does an Increase in Medicaid Reimbursement Improve Nursing Home Quality?” Journal of Gerontology: Social Sciences 56B(2), S84–S93.Google Scholar
  13. Grabowski, D. C. (2001b). “Medicaid Reimbursement and the Quality of Nursing Home Care.” Journal of Health Economics 20(4), 549–569.Google Scholar
  14. Grabowski, D. C., R. L. Ohsfeldt and M. A. Morrisey. (2003). “The Effects of CON Repeal on Medicaid Nursing Home and Long Term Care Expenditures.” Inquiry 40(2), 146–157.Google Scholar
  15. Harrington, C., H. Carillo, S. C. Thollaug and P. R. Summers. (1998). Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1991 Through 1996. San Francisco, CA: University of California, Department of Social and Behavioral Sciences.Google Scholar
  16. Harrington, C., J. H. Swan, V. Wellin, W. Clemena and H. M. Carillo. (1999). 1998 State Data Book on Long Term Care Program and Market Characteristics. San Francisco, CA: University of California, Department of Social and Behavioral Sciences.Google Scholar
  17. Hausman, J., B. H. Hall and Z. Griliches. (1984). “Econometric Models for Count Data with an Application to the Patents-R&D Relationship.” Econometrica 52(4), 909–938.Google Scholar
  18. HCIA. (1996). The Guide to the Nursing Home Industry. Baltimore, MD: HCIA Inc. and Arthur Andersen LLP.Google Scholar
  19. Institute of Medicine. (1986). Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press.Google Scholar
  20. Institute of Medicine. (2001). Improving the Quality of Long-Term Care. Washington, DC: National Academy Press.Google Scholar
  21. Manning, W. G., J. P. Newhouse, N. Duan, E. B. Keeler, A. Leibowitz and M. S. Marquis. (1987). “Health Insurance and the Demand for Medical Care: Evidence from a Randomized Experiment.” American Economic Review 77(3), 251–277.Google Scholar
  22. Miller, N. A., S. Ramsland and C. Harrington. (1999). “Trends and Issues in the Medicaid 1915(c)Waiver Program.” Health Care Financing Review 20(4), 139–160.Google Scholar
  23. Moulton, B. R. (1990). “An Illustration of a Pitfall in Estimating the Effects of Aggregate Variables on Micro Units.” The Review of Economics and Statistics 72(2), 334–338.Google Scholar
  24. National Association of State Budget Officers. (2001). The Fiscal Survey of States: December 2001. Washington, DC: National Governors Association and the National Association of State Budget Officers.Google Scholar
  25. Norton, E. C. (2000). “Long-Term Care.” In A. J. Cuyler and J. P. Newhouse (eds.), Handbook of Health Economics. Amsterdam: Elsevier Science, pp. 955–994.Google Scholar
  26. Nyman, J. A. (1985). “Prospective and 'Cost-plus' Medicaid Reimbursement, Excess Medicaid Demand, and the Quality of Nursing Home Care.” Journal of Health Economics 4(3), 237–259.Google Scholar
  27. Nyman, J. A. (1988a). “Excess Demand, the Percentage of Medicaid Patients, and the Quality of Nursing Home Care.” Journal of Human Resources 23(1), 76–92.Google Scholar
  28. Nyman, J. A. (1988b). “The Effect of Competition on Nursing Home Expenditures Under Prospective Reimbursement.” Health Services Research 23(4), 555–574.Google Scholar
  29. Nyman, J. A. (1989a). “Analysis of Nursing Home Use and Bed Supply: Wisconsin, 1983.” Health Services Research 24(4), 511–537.Google Scholar
  30. Nyman, J. A. (1989b). “Excess Demand, Consumer Rationality, and the Quality of Care in Regulated Nursing Homes.” Health Services Research 24(1), 105–128.Google Scholar
  31. Nyman, J. A. (1993). “Testing for Excess Demand in Nursing Home Care Markets.” Medical Care 31(8), 680–693.Google Scholar
  32. Nyman, J. A. (1994). “The Effects of Market Concentration and Excess Demand on the Price of Nursing Home Care.” Journal of Industrial Economics 42(2), 193–204.Google Scholar
  33. Scanlon, W. J. (1980). “A Theory of the Nursing Home Market.” Inquiry 17(1), 25–41.Google Scholar
  34. Smith, V., K. Gifford and R. Ramesh. (2003). State Budgets Under Stress: How are States Planning to Reduce the Growth in Medicaid Costs? Washington, DC: Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured.Google Scholar
  35. Strahan, G.W. (1997). “An Overviewof Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Home Survey.” Advance Data Number 280. National Center for Health Statistics, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.Google Scholar
  36. U.S. General Accounting Office. (1998). California Nursing Homes: Care Problems Persist Despite Federal and State Oversight. Pub. No. HEHS-98-202. Washington, DC: U.S. General Accounting Office.Google Scholar
  37. U.S. Senate. (1974). Nursing Home Care in the United States: Failure in Public Policy. Washington, DC: U.S. Government Printing Office.Google Scholar
  38. Zinn, J. S. (1993). “The Influence of Nurse Wage Differentials on Nursing Home Staffing and Resident Care Decisions.” The Gerontologist 33(6), 721–729.Google Scholar
  39. Zinn, J. S. (1994). “Market Competition and the Quality of Nursing Home Care.” Journal of Health Politics, Policy and Law 19, 555–582.Google Scholar

Copyright information

© Kluwer Academic Publishers 2004

Authors and Affiliations

  • David C. Grabowski
    • 1
  1. 1.Department of Health Care Organization and PolicySchool of Public Health, University of Alabama at BirminghamUSA

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