About

Norma B. Coe, PhD, is a Professor of Medical Ethics and Health Policy at the University of Pennsylvania's Perelman School of Medicine. She is also a Senior Fellow at the Leonard Davis Institute and holds affiliate faculty positions at the Palliative and Advanced Illness Research Center. Dr. Coe serves as Co-Director of the Analysis Core at the Center for Improving Care Delivery for the Aging (CICADA), and is a member of the Institute on Aging and the Population Aging Research Center at the University of Pennsylvania. Her research focuses on health economics, aging, and health policy, with particular attention to long-term care, dementia, and the quality of care for older adults. She has contributed to understanding the impact of staffing mandates, labor unions, and policy interventions on nursing home quality and finances, as well as examining cognitive training effects on dementia diagnosis over time.

Research topics

• Medicine
• Business
• Nursing
• Gerontology
• Finance
• Theology
• Virology
• Actuarial science

Selected publications

• The Effects Of Labor Unions On Nurse Staffing Ratios And Quality Of Care In US Nursing Homes, 2013–21

  Health Affairs · 2026-03-01

  articleOpen access

  Labor unions representing workers in US nursing homes bargain for higher wages and safer working conditions, which may reduce staff turnover and increase the quality of care. However, if higher labor costs lead employers to reduce nurse staffing, unionization may reduce care quality. We used a difference-in-differences event study design to estimate the effects of unionization on nurse staffing ratios for total nurse staffing and separately for registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs), as well as the effects of unionization on the quality of care, during the period 2013-21. We found that unionization had no effect on total nurse staffing levels but had opposing effects on RNs and LPNs. Unionization increased LPN staffing by roughly 2.7 nurse hours per day in the average nursing home, but it decreased RN staffing by roughly 3.2 nurse hours per day. Despite this substitution from RNs to LPNs, we found that unionization did not appear to reduce the quality of care, a result consistent with unions increasing nurse productivity.

  PublisherOA PDFDOI

• Trends in Quality of Life for Older Adults With Cognitive Impairment Across Living and Care Arrangements, 2008–2022

  Journal of the American Geriatrics Society · 2026-04-16

  article

  BACKGROUND: Monitoring trends in key quality of life (QoL) indicators is crucial for effective surveillance and guiding targeted interventions to improve well-being. Few studies have examined population-level trends among older adults with cognitive impairment, particularly across different living and care arrangements. METHODS: We used repeated cross-sectional data from the 2008-2022 Health and Retirement Study (HRS) to examine trends in five key QoL indicators among a nationally representative sample of older adults with cognitive impairment, overall and by living and care arrangements. Logistic regression was applied to estimate prevalence rates of binary outcomes, and linear regression was used to estimate mean values of continuous outcomes, adjusting for covariates. RESULTS: The analytic sample included 7469 older adults with persistent cognitive impairment. Overall trends in poorer self-rated health, elevated depressive symptoms, and loneliness remained relatively stable over time. Among community-dwelling individuals, the prevalence of high life satisfaction increased (2008: 49.7%, 95% CI: 48.9%-50.6%; 2022: 55.8%, 95% CI: 54.3%-57.4%), whereas the prevalence of high purpose in life declined (2008: 55.5%, 95% CI: 54.5%-56.4%; 2022: 49.1%, 95% CI: 47%-51.2%). QoL varied across living and care arrangements. Community-dwelling individuals without Activities of Daily Living or Instrumental Activities of Daily Living (ADL/IADL) limitations consistently reported better QoL. Among those with ADL/IADL limitations, individuals without reported caregiving support had a higher prevalence of loneliness (2022: 33.2% vs. 22.6%) and a lower prevalence of high life satisfaction (2022: 41% vs. 54.2%) compared to those with caregiving support. CONCLUSIONS: Low QoL indicators were more prevalent among community-dwelling individuals with ADL/IADL limitations. These findings emphasize the importance of increasing access to home-based care and tailored interventions to enhance psychosocial well-being in community settings.

  PublisherDOI

• Tiempo Juntos por Nuestra Salud clinical trial: community design and intervention protocol

  SSRN Electronic Journal · 2026-01-01

  preprintOpen access
  PublisherDOI

• Research to Improve the Quality, Impact, and Value of Home and Community-Based Services

  National Bureau of Economic Research · 2026-01-01

  reportOpen access

  Nearly eight million Americans use Medicaid home and community-based services (HCBS) to support long-term services and supports for people with disabilities.Recent legislative changes to Medicaid will require states to make difficult choices about how best to meet these long-term services and supports needs.This paper first characterizes the unique goals of HCBS, which differ from those of traditional medical care services, and the state-federal financing and administrative structure of HCBS.Next, based on a review of the literature and input from a panel of experts in HCBS policy and research, we summarize existing evidence and knowledge gaps regarding the quality and cost implications of HCBS at the federal, state, and direct service provision levels.Based on gaps in the evidence, we propose a research agenda related to state-federal incentives, state program choices regarding HCBS financing and delivery models, and the settings and supports for direct service provision.Finally, we describe existing and novel data sources and other opportunities that could accelerate research to fill these evidence gaps and support states and others in designing, implementing, and delivering sustainable, high-quality HCBS.

  PublisherDOI

• State Nursing Home Minimum Staffing Mandates: Increased Staff Levels, Minimal Impact On Finances And Closures, 2010–23

  Health Affairs · 2026-03-01

  articleOpen access

  Higher levels of direct care staffing in nursing homes improve resident outcomes, yet concerns persist that minimum staffing mandates could strain facility finances or lead to closures. Using longitudinal data from the period 2010-23 on 6,849 nursing homes operating across twenty-two states, we estimated the effects of state minimum staffing mandates on staffing levels, financial health, and closures. Staffing mandates increased total direct care staff by 0.18 hours per resident day, or roughly 5 percent, on average, driven by increases in licensed practical nurses (0.06 hours per resident day) and certified nursing assistants (0.13 hours per resident day). Facilities' annual labor expenses rose by about $273,000, but these costs were offset by higher net patient revenues (approximately $546,000), leaving net margins unchanged. Mandates did not increase the likelihood of facility closure. Overall, our findings indicate that minimum staffing mandates can meaningfully raise staffing levels without undermining the financial viability of nursing homes.

  PublisherOA PDFDOI

• Impact of cognitive training on claims‐based diagnosed dementia over 20 years: evidence from the ACTIVE study

  Alzheimer s & Dementia Translational Research & Clinical Interventions · 2026-01-01 · 1 citations

  articleOpen access1st author

  Abstract INTRODUCTION The very long‐term effect of cognitive training on the risk of Alzheimer's disease and related dementias (ADRD) is unknown. METHODS This study links data from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (a four‐arm randomized controlled trial of cognitive training in a large, diverse sample) to Medicare claims (1999 to 2019). Inclusion in the analyses required being enrolled in traditional Medicare at baseline ( n = 2021). ADRD was measured with the Chronic Conditions Warehouse algorithm. RESULTS Participants randomized to the speed‐training arm who completed one or more booster sessions had a significantly lower risk of diagnosed ADRD (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.59, 0.95), while speed‐trained participants with no booster training did not have a lower risk of diagnosed ADRD (HR: 1.01, 95% CI: 0.81, 1.27). There was no main effect of memory or reasoning training on risk of ADRD. CONCLUSIONS Cognitive training involving speed of cognitive processing has the potential to delay the diagnosis of ADRD. Highlights The ACTIVE study (a four‐arm randomized controlled trial of cognitive training in a large, representative sample) reports that the speed intervention arm of the study showed a reduced likelihood of being diagnosed with ADRD over a 20‐year follow‐up period. No prior cognitive training intervention has been shown to reduce risk of ADRD over a 20‐year period. Cognitive training involving speeded, dual attention, adaptive tasks has the potential to delay the diagnosis of ADRD.

  PublisherOA PDFDOI

• Research to Improve the Quality, Impact, and Value of Home and Community-Based Services

  SSRN Electronic Journal · 2026-01-01

  preprintOpen access
  PublisherDOI

• Effects of caregiving experience on expectations of becoming an Alzheimer’s disease caregiver in the future

  The Journals of Gerontology Series B · 2026-03-03

  articleOpen access

  OBJECTIVES: Research often focuses on persons who are or have been caregivers to a person with dementia. Little is known about stigma reactions in persons who expect to care for a person with Alzheimer's disease (AD). Understanding these beliefs may help guide clinical discussions with family members of persons with AD, particularly those diagnosed in the early stages. METHODS: A sample of 3,527 adults was randomized to read a vignette describing a fictional person with either a positive or a negative AD biomarker test result. Bivariate and multivariable analyses examined associations between AD caregiver status (expected and experienced) and responses on a modified Family Stigma in Alzheimer's Disease Scale (FS-ADS). RESULTS: About 31% (n = 1,090) of participants expected to be a caregiver for a person with AD, and most (63%) had previously been a caregiver. Controlling for differences in caregiving experience and other potential confounders, participants expecting (vs. not) to be AD caregivers reported higher willingness to support, more pity, and fewer negative aesthetic attributions than participants with (vs. without) AD caregiving experience (all p < .05). DISCUSSION: Caregiving experience is a strong predictor of a person's expectations of becoming one in the future, which runs counter to observed caregiving patterns, suggesting that for most people, becoming a caregiver is unexpected. Helping individuals set more accurate expectations for future caregiving roles is essential to support planning and preparation. Specific findings may inform the content of support and education programs that could accompany disclosure of AD biomarkers and early diagnosis.

  PublisherOA PDFDOI

• Retirement and Cognitive Function in Later Life

  SSRN Electronic Journal · 2025-01-01

  articleOpen access
  PublisherDOI

• Provider payment incentives: Evidence from the U.S. hospice industry

  Journal of Public Economics · 2025-06-27 · 1 citations

  article1st author
  PublisherDOI

Recent grants

• Current and Future Costs of Alzheimer's and Dementia Care

  NIH · $2.1M · 2018–2020

• Center on the Demography and Economics of Aging

  NIH · $5.6M · 1997–2026

• Effects of Informal Care for persons with Alzheimer's Disease and related dementias

  NIH · $2.7M · 2017–2023

Frequent coauthors

• Courtney H. Van Houtven

  Duke University

  76 shared

• R. Tamara Konetzka

  University of Chicago

  36 shared

• Anirban Basu

  University of Washington

  29 shared

• Lindsay White

  University of Pennsylvania

  26 shared

• Rachel M. Werner

  23 shared

• David Grembowski

  University of Washington

  23 shared

• Douglas A. Conrad

  University of Washington

  21 shared

• Paul Fishman

  University of Washington

  21 shared

Labs

• Department of Medical Ethics and Health PolicyPI

Education

• B.A., Economics

  College of William and Mary

  1997

• Ph.D., Economics

  Massachusetts Institute of Technology

  2005

Awards & honors

• Senior Fellow, Leonard Davis Institute, University of Pennsy…
• Affiliate Faculty, Palliative and Advanced Illness Research…
• Co-Director, Analysis Core, Center for Improving Care Delive…
• Member, Institute on Aging (IoA), University of Pennsylvania
• Research Associate, Population Aging Research Center, Univer…