Maestas, NicoleSalant, Ilana M2026-07-0720262026-06-052026Salant, Ilana M. 2026. Essays on Ownership, Supply, and Use in Medicare Home Health Care. Doctoral Dissertation, Harvard University Graduate School of Arts and Sciences.32449497https://dash.harvard.edu/handle/1/42743998Medicare home health care accounts for over $18 billion in annual spending and serves 3.5 million beneficiaries per year, with demand growing alongside population aging and a broader shift toward community-based care. Yet key features of the program remain poorly understood. It is unclear whether home health substitutes for more expensive post-acute care or instead adds to Medicare spending. And despite for-profit agencies accounting for roughly 83 percent of the market, the implications of ownership for utilization and program value—particularly in a setting with concerns about overuse and fraud—remain understudied. This dissertation examines how ownership structure, payment incentives, and provider supply shape utilization and spending in Medicare home health care, a program that serves a broader and more heterogeneous population than is typically recognized, with community-admitted patients comprising nearly half of all spending and episodes. In the first chapter, I study Arkansas's 2016 sale of its statewide public home health agency network to a national for-profit chain. The standard concern with privatization is underprovision: private firms cutting costs in ways that reduce quality or restrict access to unprofitable populations. I document a different mechanism. When reimbursement is endogenous to provider behavior, as under prospective payment systems that reward coding intensity and service mix decisions, privatization may instead induce overprovision, raising spending without improving care. Difference-in-differences estimates using Medicare administrative data from 2010–2021 show that the ownership transition increased statewide home health use by roughly 10 percent and effective reimbursement per episode at treated agencies by 27 percent, with no evidence of reduced access for rural or high-cost populations. Spending rose substantially while measurable quality and outcomes remained flat. These findings suggest that the consequences of privatization depend critically on the institutional environment: when payment systems allow providers to influence their own reimbursement, overprovision rather than underprovision may be the first-order concern. In the second chapter, I leverage variation in home health agency entry and exit across time and local areas to examine supply sensitivity and its downstream consequences. Distinguishing between post-acute and community-entry patients reveals stark differences in responsiveness: changes in agency supply have minimal effects on post-acute care use but substantially increase community-entry use. Beyond these direct effects, expanded access generates complex shifts in broader healthcare utilization operating through both substitution and complementarity channels—reducing hospitalizations and Medicaid-funded nursing home stays while increasing prescription drug use, physician and other Part B services, and hospice use. The net increase in total Medicare spending suggests that expanded home health access represents an addition to Medicare services rather than pure substitution, challenging the conventional view of home health as primarily a substitute for institutional post-acute care. In the third chapter, I directly characterize the community-admitted population that the first two chapters show to be central to understanding home health spending and supply responses. Using data from 2008–2021, I document that community-entry users are older, more often dual-eligible, and have greater cognitive impairment than post-acute users, and are more frequently served by for-profit agencies. Community-entry users also use home health more intensively than post-acute users, and community-entry prevalence varies widely across states, explaining 60 percent of cross-state variation in per-capita Medicare home health spending. Despite representing a distinct population with unique needs, Medicare takes a largely one-size-fits-all approach to home health policy, suggesting value in tailoring reimbursement, benefit design, and regulation accordingly.application/pdfenEconomicsPublic policyHealth care managementThesis or Dissertation2026-07-070000-0001-8200-9620