Essays on nursing homes and nursing home workers in the U.S.
Creators: name: Xu, Lili
Publisher: name: University of Iowa
Year: 2025
Subjects: public abstract

description: Nursing homes provide post-acute and long-term care services to over a million individuals every year and employ approximately 1.7 million workers. However, declining occupancy, low profit margins, and workforce shortages have adverse impacts on the sustainability of nursing homes. Every year, over 100 nursing homes close but the impacts of such closures on other nursing homes and the community are not well understood. Moreover, there are also concerns about low insurance coverage for nursing home workers but the effect of national policies such as the Affordable Care Act (ACA) Medicaid expansions on insurance coverage among this workforce is unclear. Using multiple national datasets and quasiexperimental research designs, this dissertation addresses the gaps in understanding the impact of nursing home closure on local employment and nearby nursing homes and the effects of the ACA Medicaid expansion on insurance coverage of nursing home aides.
description: The first study examines the impact of nursing home closure on local employment. Nursing homes are major employers of the healthcare workforce, especially in rural areas, and nursing home closure potentially leads to job losses for healthcare workers. Using a differencein-difference study design, we examined the effects of nursing home closure on local employment. We also evaluated the heterogeneous effects by rurality. This study finds that nursing home closure was associated with a 3.2-4.1% reduction in health sector employment. Rural counties experienced the largest decline in health sector employment (7.2-9.4%). Moreover, the reduction in health sector employment persisted over time, particularly in rural counties. A large and persistent reduction in healthcare employment following a nursing home closure would further limit the ability to sustain healthcare services, particularly in rural areas.
description: The second study investigates the spillover effects of nursing home closure on the occupancy and finances of remaining nursing homes in the same market. Displaced residents from closed facilities are most likely to relocate to available nursing homes in the same market. Depending on the availability of nursing homes and alternative care options in the local longterm care markets, there might be heterogeneity in the spillover effects of nursing home closure. Estimates suggest positive spillover effects of nursing home closure on the occupancy rates and finances of nearby nursing homes in rural counties only. Specifically, in rural noncore counties, there was an increase in occupancy rates by 3.31 percentage points for remaining nursing homes following a closure. There was also suggestive evidence of increases in total profit margins (1.48 percentage points) and operating margins (1.65 percentage points). These findings have important implications for policymakers when considering inventions targeted at nursing home closure.
description: The third study examines the impact of the ACA Medicaid expansion on health insurance among low-income nursing home aides. This study shows that insurance coverage for lowincome nursing home aides increased from about 60% to nearly 90% in expansion states but rose to only about 80% in nonexpansion states. Medicaid expansion was associated with a 5.1 percentage-point increase in overall insurance coverage. Expansion states had a 12.2 percentagepoint gain in Medicaid that was partially offset by a 6.4 percentage-point reduction in private insurance coverage. The ACA Medicaid expansion is instrumental in reducing the uninsured rate among low-income nursing home aides. Considering the substantial crowd-out of private insurance due to Medicaid expansion, policymakers should also consider incentivizing affordable private health insurance options for this workforce.