Why States Hate Nursing Homes

Medicaid is a health insurance program for those with low incomes, funded largely by states. Overall it accounts for less than 20% of US medical spending. But there is one area where it is the dominant payer: nursing homes. Nursing homes are expensive, and Medicare (the typical insurance for those over 65) won’t cover them after the first hundred days, so most nursing home residents end up paying out of pocket until they burn through all their savings and wind up on Medicaid. At which point, Medicaid pays about $100,000 per year to the nursing home for the rest of their life.

States are responsible for up to half of that cost, and so start looking for ways to save money. One idea they have is to make it harder to build nursing homes: if there aren’t beds available, potential nursing home patients will have to stay home instead, where they can’t rack up Medicaid spending the same way. In fact, some states go all the way to a complete moratorium on new nursing homes:

Source: Institute for Justice

Some other states allow new nursing homes, but only with a special permission slip called a Certificate of Need (CON). CON is often required for other types of health facilities as well, like hospitals or dialysis centers. Research by me and others has generally found that CON doesn’t work as a way to reduce spending, and in fact actually increases it. CON might reduce the number of facilities, but that reduction of supply and competition gives the remaining facilities more power to raise prices.

So which effect dominates- does the smaller number of facilities reduce total spending, or do the higher prices increase it? It depends on the elasticity of demand:

In health care demand is typically quite inelastic, so the price effect dominates, and spending goes up:

But nursing homes could be an exception here. Elasticity of demand could be relatively high because of the number of potential substitutes- home care or assisted living for those with relatively low medical needs, hospitals for those with relatively high medical needs. Plus this is the one type of health care where Medicaid is the dominant payer. They could be especially resistant to price increases here, both due to their market power and their willingness to keep prices so low that facilities won’t take Medicaid patients (another way to save money!).

A new paper by Vitor Melo and Elijah Neilson finds that this is indeed the case. Indiana, Pennsylvania, and North Dakota repealed their nursing home CON requirements in the ’90s, and at least for IN and PA their Medicaid spending went way up. The paper uses a new “synthetic difference in difference” technique that seems appropriate, and creates figures that seem confusing at first but get a ton of information across:

They correctly note that they don’t evaluate the welfare effects of the policy; it’s possible that the extra nursing home beds following CON repeal bring huge benefits to seniors that are worth the higher spending. But nursing homes could be the exception to the general rule that CON fails to achieve the goals, like reduced spending, that advocates set for it.

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