Previous studies find that the uninsured receive less health care than the insured, yet differences in health outcomes have rarely been studied. In addition, selection bias may partly explain the difference in care received. This paper focuses on an unexpected health shock—severe automobile accidents where victims have little choice but to visit a hospital. Another innovation is the use of a comparison group that is similar to the uninsured: those who have private health insurance but do not have automobile insurance. The medically uninsured are found to receive 20% less care and have a substantially higher mortality rate.

This paper uses the randomization of families to child protection investigators to estimate causal effects of foster care on adult crime. The analysis uses a new data set that links criminal justice data to child protection data in Illinois, and I find that investigators affect foster care placement. Children on the margin of placement are found to be two to three times more likely to enter the criminal justice system as adults if they were placed in foster care. One innovation describes the types of children on the margin of placement, a group that is more likely to include African Americans, girls, and young adolescents.

Little is known about the effects of placing children who are abused or neglected into foster care. This paper uses the placement tendency of child protection investigators as an instrumental variable to identify causal effects of foster care on long-term outcomes--including juvenile delinquency, teen motherhood, and employment--among children in Illinois where a rotational assignment process effectively randomizes families to investigators. Large marginal treatment effect estimates suggest caution in the interpretation, but the results suggest that children on the margin of placement tend to have better outcomes when they remain at home, especially older children.

Abstract Over 130,000 juveniles are detained in the United States each year with 70,000 in detention on any given day, yet little is known about whether such a penalty deters future crime or interrupts social and human capital formation in a way that increases the likelihood of later criminal behavior. This article uses the incarceration tendency of randomly assigned judges as an instrumental variable to estimate causal effects of juvenile incarceration on high school completion and adult recidivism. Estimates based on over 35,000 juvenile offenders over a 10-year period from a large urban county in the United States suggest that juvenile incarceration results in substantially lower high school completion rates and higher adult incarceration rates, including for violent crimes. In an attempt to understand the large effects, we found that incarceration for this population could be very disruptive, greatly reducing the likelihood of ever returning to school and, for those who do return, significantly increasing the likelihood of being classified as having an emotional or behavioral disorder.

Children spend years in foster care, and bureaucratic hurdles can unnecessarily prolong their stays. The Mi Abogado program was introduced in Chile to enhance legal aid for foster children and accelerate family reunification. In a novel approach, the Chilean government randomized the introduction of the program for children living in institutions to evaluate effects on child well-being. Using registry data, we find the program significantly reduced the duration of foster care without increasing subsequent maltreatment and placements. The exposure also decreased criminal justice involvement and improved school attendance. Results suggest that strengthening foster care services can cost-effectively improve child well-being. (JEL I21, I31, J13, K36, O15, O17)

Little is known about the role birth order plays in delinquency and adult crime outcomes that carry significant externalities. We use rich data sets from Denmark and Florida to examine these outcomes and explore potential mechanisms. Despite large environmental differences between the areas, we find remarkably consistent results: in families with two or more children, secondborn boys are 20%–40% more likely to be disciplined in school and enter the criminal justice system than are their firstborn male siblings. We rule out health at birth and school quality as mechanisms but find evidence for the role of parental time investment.

Hospital quality measures are crucial to a key idea behind health care payment reforms: "paying for quality" instead of quantity. Nevertheless, such measures face major criticisms largely over the potential failure of risk adjustment to overcome endogeneity concerns when ranking hospitals. In this paper we test whether patients treated at hospitals that score higher on commonly-used quality measures have better health outcomes in terms of rehospitalization and mortality. To compare similar patients across hospitals in the same market, we exploit ambulance company preferences as an instrument for hospital choice. We find that a variety of measures used by insurers to measure provider quality are successful: choosing a high-quality hospital compared to a low-quality hospital results in 10-15% better outcomes.

A key policy question is whether the benefits of additional medical expenditures exceed their costs. We propose a new approach for estimating marginal returns to medical spending based on variation in medical inputs generated by diagnostic thresholds. Specifically, we combine regression discontinuity estimates that compare health outcomes and medical treatment provision for newborns on either side of the very low birth weight threshold at 1,500 grams. First, using data on the census of U.S. births in available years from 1983 to 2002, we find that newborns with birth weights just below 1,500 grams have lower one-year mortality rates than do newborns with birth weights just above this cutoff, even though mortality risk tends to decrease with birth weight. One-year mortality falls by approximately one percentage point as birth weight crosses 1,500 grams from above, which is large relative to mean infant mortality of 5.5% just above 1,500 grams. Second, using hospital discharge records for births in five states in available years from 1991 to 2006, we find that newborns with birth weights just below 1,500 grams have discontinuously higher charges and frequencies of specific medical inputs. Hospital costs increase by approximately $4,000 as birth weight crosses 1,500 grams from above, relative to mean hospital costs of $40,000 just above 1,500 grams. Under an assumption that observed medical spending fully captures the impact of the “very low birth weight” designation on mortality, our estimates suggest that the cost of saving a statistical life of a newborn with birth weight near 1,500 grams is on the order of $550,000 in 2006 dollars.

Medicare spending exceeds 4% of GDP in the US each year, and there are concerns that moral hazard problems have led to overspending. This paper considers whether hospitals that treat patients more aggressively and receive higher payments from Medicare improve health outcomes for their patients. An innovation is a new lens to compare hospital performance for emergency patients: plausibly exogenous variation in ambulance-company assignment among patients who live near one another. Using Medicare data from 2002-2010, we show that ambulance company assignment importantly affects hospital choice for patients in the same ZIP code. Using data for New York State from 2000-2006 that matches exact patient addresses to hospital discharge records, we show that patients who live very near each other but on either side of ambulance service area boundaries go to different types of hospitals. Both identification strategies show that higher-cost hospitals achieve better patient outcomes for a variety of emergency conditions. Using our Medicare sample, the estimates imply that a one standard deviation increase in Medicare reimbursement leads to a 4 percentage point reduction in mortality (10% compared to the mean). Taking into account one-year spending after the health shock, the implied cost per at least one year of life saved is approximately $80,000. These results are found across different types of hospitals and patients, as well across both identification strategies.

We develop empirical tools for studying discrimination in multi-phase systems, and apply them to the setting of foster care placement by child protective services. Leveraging the quasi-random assignment of two sets of decision-makers-initial hotline call screeners and subsequent investigators-we study how unwarranted racial disparities arise and propagate through this system. Using a sample of over 200,000 maltreatment allegations, we find that calls involving Black children are 55% more likely to result in foster care placement than calls involving white children with the same potential for future maltreatment in the home. Call screeners account for up to 19% of this unwarranted disparity, with the remainder due to investigators. Unwarranted disparity is concentrated in cases with potential for future maltreatment, suggesting that white children may be harmed by "under-placement" in high-risk situations.