Regional disparities in healthcare access and health outcomes are well-documented in the United States. Rural localities face worse health outcomes and greater challenges to accessing care than urban localities, particularly in the South. This study examines national and regional trends in hospital establishments (openings and closings), employment, size (employees per establishment), and regional concentration over three decades. We document an era of declining hospital counts and increasing employment within the industry, highlighting how the trends have differed across regions and rurality. Finally, we consider how these trends relate to the current policy environment in the United States.
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The Underserved Have Less Access to Employer-Sponsored Telemedicine Coverage
September 2022
Working Paper Number:
CES-22-40
Telemedicine has been proposed as one means of improving health care access for underserved communities, and information about insurance coverage for telemedicine (TMC) is important in understanding its utilization and provision. We use 2018-2019 Medical Expenditure Panel Survey-Insurance Component data on employer-sponsored coverage to examine pre-pandemic TMC relative to employer, worker, and health plan characteristics. We find that the share of employees in private sector establishments offering TMC was lower in the most rural counties, in smaller firms, in establishments without unionized employees, and in establishments where most workers were low wage, part-time and older when compared to other establishments. These findings reflect differences across establishments in insurance offers, as well as differences in TMC conditional on an insurance offer, which suggests that TMC may function as a premium plan feature with limited availability and potential support for improving healthcare access for the underserved.
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The Hidden Costs of Decline: Health Disparities in America's Diminishing Micropolitan Areas
September 2025
Working Paper Number:
CES-25-70
This study examines the relationship between long-term population change and health outcomes in U.S. micropolitan areas, with a focus on life expectancy and mortality disparities. Using a county typology based on the historical population trajectories of micropolitan cores from 1940 to 2020, this analysis reveals that health outcomes are substantially worse in places that experienced sustained decline. These disparities persist even after controlling for demographic and socioeconomic characteristics, suggesting that population loss itself is a key driver of poor public health. Declining micropolitan areas are older, less educated, and report high rates of behavioral risk factors, including smoking, excessive drinking, and physical inactivity. By linking historical demographic trends to tract-level data, this analysis highlights the distinct challenges facing the urban cores of shrinking micropolitan areas. Population decline emerges not only as a demographic trend, but as a marker of structural disadvantage with measurable consequences for community health.
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The Effect of the Minimum Wage on Childcare Establishments
August 2025
Working Paper Number:
CES-25-53
Childcare is essential for working families, yet it remains increasingly unaffordable and inaccessible for parents and offers poverty-level wages to many employees. While research suggests minimum wage policies may improve the welfare of low-wage workers, there is also evidence they may increase firm exits, especially among smaller, low-profit firms, which could reduce access and harm consumer well-being. This study is the first to examine these trade-offs in the childcare industry, a labor-intensive, highly regulated sector where capital-labor substitution is limited, and to provide evidence on how minimum wage policies affect a dual-sector labor market in the U.S., where self-employed and waged providers serve overlapping markets. Using variation from state-level minimum wage increases between 1995 and 2019 and unique microdata, I implement a cross-state county border discontinuity design to estimate impacts on the stocks, flows, and composition of childcare establishments. I find that while county-level aggregate establishment stocks and employment remained stable, establishment-level turnover increased, and employment decreased. I reconcile these findings by showing that minimum wage increases prompted reallocation, with larger establishments in the waged-sector more likely to enter and less likely to exit, making this one of the first studies to link null aggregate effects to shifts in establishment composition. Finally, I show that minimum wage increases may negatively affect the self-employed sector, resulting in fewer owners with advanced degrees and more with only high school education. These findings suggest that minimum wage policies reshape who provides care in ways that could affect both quality and access.
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Establishment and Employment Dynamics in Appalachia: Evidence from the Longitudinal Business Database
December 2003
Working Paper Number:
CES-03-19
One indicator of the general economic health of a region is the rate at which new jobs are created. The newly developed Longitudinal Business Database has been used in this paper to develop a detailed portrait of establishment formation and attrition and job creation and destruction in the Appalachian Region. The foremost finding is that the pace of reallocation in Appalachia is lower than it is for the U.S.. This is evident in Appalachia's relatively lower establishment birth and death rates and job creation and destruction rates. For example, on average over the study time period, the U.S. job creation rate exceeds 45 percent, while the Appalachian job creation rate is 43 percent. Similarly, the U.S. job destruction rate is about 35 percent, while the Appalachian job destruction rate is about 33 percent. Even when controlling for other differences, job creation rates are 1.2 percentage points lower and job destruction rates are 3.4 percentage points lower in Appalachia relative to the rest of the U.S. Another indicator of the general economic health of a region is the quality of its jobs. The quality of jobs is measured in this paper by the average wage paid at the establishment. Here too there is cause for concern about the economic health of Appalachia. The analysis shows that wages are about 10 percent lower in Appalachia than in the U.S. even when controlling for differences in other characteristics across the two areas. This wage discrepancy has not narrowed over the time of the study. Moreover, new establishments have a similar wage gap. Employees at new establishments earn wages 10 percent less than at new establishments in the rest of the U.S.
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A Note on the Locational Determinants of the Agricultural Supply Chain
July 2021
Working Paper Number:
CES-21-16
Over the past several decades, an increasing share of the agricultural supply chain is located beyond the farmgate, implying that some set of economic factors are influencing the location decisions of food and agricultural establishments. We explore the location decisions of several food and agricultural industries for employer and non-employer establishments by expanding on the empirical implications of Carpenter et al. (2021)'s demand threshold models. While Carpenter et al. (2021) focus on methods to estimate these industries' demand thresholds using restricted access data, we focus on expanding the interpretations of their empirical research and explore additional industries along the agricultural supply chain using their refined methods. Results highlight the influential role of the Land Grant University system for specific establishment types, the importance of diverse industries within local economies, and the changing rurality of the agricultural supply chain.
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A Shore Thing: Post-Hurricane Outcomes for Businesses in Coastal Areas
September 2020
Working Paper Number:
CES-20-27
During the twenty-first century, hurricanes, heavy storms, and flooding have affected many areas in the United States. Natural disasters and climate change can cause property damage and could have an impact on a variety of business outcomes. This paper builds upon existing research and literature that analyzes the impact of natural disasters on businesses. Specifically, we look at the differential effect of eight hurricanes during the period 2000-2009 on establishments in coastal counties relative to establishments in coastal-adjacent or inland counties. Our outcomes of interest include establishment employment and death. We find that following a hurricane event, establishments located in a coastal county have lower employment and increased probability of death relative to establishments in non-coastal counties.
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Addressing Data Gaps:
Four New Lines of Inquiry in the 2017 Economic Census
September 2019
Working Paper Number:
CES-19-28
We describe four new lines of inquiry added to the 2017 Economic Census regarding (i) retail health clinics, (ii) management practices in health care services, (iii) self-service in retail and service industries, and (iv) water use in manufacturing and mining industries. These were proposed by economists from the U.S. Census Bureau's Center for Economic Studies in order to fill data gaps in current Census Bureau products concerning the U.S. economy. The new content addresses such issues as the rise in importance of health care and its complexity, the adoption of automation technologies, and the importance of measuring water, a critical input to many manufacturing and mining industries.
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Business Dynamics Statistics of Coastal Counties: A Description of Differences in Coastal Areas Over Time
January 2025
Working Paper Number:
CES-25-08R
The Business Dynamics Statistics of Coastal Counties (BDS-CC) is a new experimental data product extending the set of statistics published by the Business Dynamics Statistics (BDS) program to provide more detail on businesses operating in coastal regions of the United States. The BDS-CC provides annual measures of employment, the number of establishments and firms, job creation, job destruction, openings, and closings for businesses in Coastal Shoreline (CS), Coastal Non-Shoreline (CNS), and Non-Coastal (NC) counties. Counties are grouped into these categories based on definitions from the National Oceanic and Atmospheric Administration (NOAA). This product allows for comparisons across industries and coastal regions of the impact of natural disasters and other events that affect coastal areas. The BDS-CC series provides annual statistics for 1978 to 2022 for each of the coastal categories by firm size and firm age, initial firm size, establishment size and establishment age, initial establishment size, sector, 3-digit NAICS code, 4-digit NAICS code, urban/rural categories, and various coastal regions. Following a description of the data and methodology, we highlight some historical trends and analyses conducted using these data.
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The Role of Retail Chains: National, Regional, and Industry Results
December 2005
Working Paper Number:
CES-05-30
We use the establishment level data in the Longitudinal Business Database to measure changes in market structure in the U.S. Retail Trade sector during the period, 1976 to 2000. We use firm ownership information to construct measures of firm entry and exit and also to categorize four types of retail firms: single location, and local, regional, and national chains. We use detailed location data to examine market structure in both national and county markets. We summarize the county level results into three groups: metropolitan, micropolitan, and rural. We find that retail activity is increasingly occurring at establishments owned by chain firms, especially large national chains. On average, we find that all types of retail firms are increasing in size during the period. We also find that larger markets experience more firm turnover. Finally, we see that entry and exit rates vary across two-digit retail industries.
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Older Workers' Access to Employer-Sponsored Retiree Health Insurance, 2000-2004
April 2007
Working Paper Number:
CES-07-12
Using a multivariate framework, we analyze recent trends in employer provision of retiree health insurance (RHI), eligibility for new retirees, and retiree contribution requirements. We also explore whether local labor market characteristics such as the unemployment rate influence RHI provision. Finally, we examine whether the Medicare Modernization Act (MMA) was associated with diverging trends in RHI access for Medicare-eligible and early retirees. Data come for the Medical Expenditure Panel Survey'Insurance Component (MEPS-IC). We find that, while RHI provision to existing retirees remained stable, eligibility for new retirees declined, and contribution requirements increased between 2000 and 2004. The local labor market had no effect on RHI provision. While early retiree coverage was more common than coverage for Medicare-eligible retirees, we did not find a divergence subsequent to MMA. These results suggest growing financial instability for retirees, both because RHI contribution requirements increased, and because businesses dropped coverage for new retirees.
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