2974	Assessment
Abstract	Okay
Research Question	The general sense of the research goals are fairly clear, to assess whether emergency care treatment outcomes for the insured and uninsured have changed since the passage of Affordable Care Act, depending on state adoption of alternative responses.  How this would be translated into a more specific research question is unclear.
Literature Review	The literature review shows promise, but seems a bit eccentric at this point.  While there are many reasons to have interest in research in other nations, it seems doubtful that much is to be gained from studies in Ghana and India that have very different insurance systems, medical systems, cultures, and economic conditions.  This is not my area, but I suspect there exists considerable research on insurance and medical treatment in the U.S.
Data	The HCUP data indicated in the proposal appear to be excellent data on hospital patients.  However, according to the HCUP web site, it seems that state identifying information has been withheld from the data beginning in 2012, which makes it difficult to see how this data will be used for an analysis for select states.  Is this a mistaken understanding? The draft proposal provides little information on the dataset (including its sampling strategy) or the variables planned to use in this research project.  The final draft should include this information,  explaining and justifying the choices of independent, dependent, and control variables.  In addition, since the proposal suggests a plan to use relatively advanced statistical techniques (instrumental variables and difference-in-differences), it should describe how these techniques are an improvement on traditional OLS results, and be more specific about the models that will be used. It is entirely legitimate to "borrow" a research design from a published work to apply with adaptations to different data.  In this case, it appears that all aspects of the intended research procedure are borrowed directly from the Sommers, et al. "Three-Year Impacts Of The Affordable Care Act ..." article.  To do this, however, we need to show that we understand all aspects of the research methodology and that it is applicable to our data and research problem.  Here that would mean showing an understanding of instrumental variables strategies and difference-in-differences models.  The draft proposal does not accomplish this.
Causal Interpretations	The draft proposal does not really provide causal interpretations.  It focuses on the purely empirical questions of the quality of health outcomes under different conditions.  This is not, of itself, wrong, but it does leave the research somewhat unmoored.  The proposal also seems to lose track of the meaning of its own plan to study the outcomes for emergency room arrivals.  Much of medical care in the U.S. does not involve emergency rooms, which are the common destination of the unexpected severe medical condition of the insured and wide ranging medical needs of the uninsured.  A difference-in-differences strategy may make some sense for assessing changes in the profiles and outcomes for the insured and the uninsured who come to emergency rooms.  It seems considerably less likely to allow effective assessment of the value that insurance has for medical care, which is implied by the focus on the passage of the ACA. Passage of the ACA meant many more people were insured, which also means that use of the emergency room has changed.  In short, which people arrive at emergency rooms with insurance or arrive without insurance would both be expected to change as a result of the ACA.  This creates a potential issue with selection bias in the comparisons.  This seems unrecognized in the proposal.
Research Value	The claim that it would be valuable knowing how having or not having insurance affects the health care people receive seems unassailable.  However, it is not apparent that this project can provide such information and it is also not apparent from the draft proposal what knowledge already exists about such questions.
Timetable	No real schedule appears.
Citations & Biblio	The citations and bibliography are formally okay.
Quality of writing	The writing is clear and sparse.
Priorities for Revising for Final Draft	While it is possible to see the foundations for a research project in the draft proposal, it appears to need considerable work.  The specific research question, the literature review, the data to be used, the causal models in the background, and the research design all seem underdeveloped here.
Miscellaneous Notes