Essays on Public Health Insurance Expansions PDF Download

Author: Laura Rose Wherry
Publisher:
ISBN: 9781267438805
Category :
Languages : en
Pages : 138

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This dissertation is comprised of two essays examining expansions in eligibility for public health insurance in the U.S. In the first essay, I focus on expanded eligibility for family planning services under Medicaid and the impact on fertility and the utilization of women's preventive care. In the second essay, which is joint work with Bruce D. Meyer, we examine the immediate and longer-term mortality effects of Medicaid eligibility expansions for children. Both of these papers use variation in public health insurance eligibility created by changes in federal or state eligibility rules to identify a causal relationship between public coverage and health-related outcomes.

Author: Jee-Hun Choi
Publisher:
ISBN:
Category :
Languages : en
Pages : 208

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This dissertation consists of three essays in the field of health economics and industrial organization, focusing on the policies on public health insurance in the United States. The first chapter investigates the impact of expanding public health insurance through private insurers on equilibrium insurance market outcomes. Using the Arkansas All-Payer Claims Database, I measure the impact of the Affordable Care Act (ACA) insurance expansions on hospital reimbursement rates and premiums for non-ACA private plans, including employer-sponsored insurance plans not directly affected by the ACA. Using a Nash bargaining model based on the Ho and Lee (2017) framework, I find that the publicly-subsidized expansion decreases hospital reimbursement rates by 5.3% and insurance premiums by 0.6% for privately-insured enrollees who are not covered by the ACA. This spillover effect on reimbursement rates is driven by the increased bargaining leverage of insurers participating in the expansion. The increase in leverage results mainly from the change in the composition of enrollees, which goes hand-in-hand with enrollment increase as a result of the expansion. The second chapter, co-authored with Claire Lim, explores the linkages between government ideology in U.S. states and geographic variation in Medicaid program design and operations. Medicaid eligibility criteria tend to be more generous in liberal states. Simultaneously, fee-for-service reimbursement rates for physician services have been notably lower in liberal states. These two patterns lead to the following question: to what extent does the partisan composition of the government drive eligibility and reimbursement over time? If cost-saving measures accompany eligibility expansion, then what are their consequences for resource allocation? We explore long-run linkages among partisan composition of the government, eligibility, cost-saving measures, and expenditures for the Medicaid expansion from the mid-1990s to 2010. Our analysis consists of four steps. First, we analyze how much the partisan composition of the state government drives eligibility expansion. Second, we explore the tradeoff between breadth of eligibility and fee-for-service reimbursement rates. Third, we investigate driving forces behind the evolution of the delivery systems, i.e., Medicaid managed care diffusion. Fourth, we analyze the resulting patterns of per-enrollee spending. We find that the partisan composition of the state house played a critical role in the relatively later stage of eligibility expansion and the reduction of fee-for-service reimbursement rates over time. While the HMO penetration in the private insurance market drove the Medicaid managed care diffusion, the diffusion also tends to go hand in hand with the reduction of fee-for-service reimbursement rates. Finally, Medicaid per-enrollee spending increased substantially over time despite the adoption of cost-saving measures. This unintended consequence was due to the systematic changes in HMO practices that coincided with the eligibility expansion. The third chapter, co-authored with Claire Lim, investigates determinants of government subsidy in the U.S. health care industry, focusing on the Medicaid Disproportionate Share Hospital (DSH) program. We find that the amount of Medicaid DSH payment per bed increases significantly with increase in hospital size for government hospitals. This is partially explained by the distinctive role that large government hospitals play in the provision of care to the indigent population. However, costs, financial conditions, or types of services by themselves are not enough to explain DSH payments. Large government hospitals tend to have a higher ratio of DSH payments to Medicaid and uninsured costs. The difference in the DSH payment-to-cost ratio across ownership types increases significantly with increase in hospital size. We argue that these key patterns are unlikely to be driven by unobserved heterogeneity, using the Altonji-Elder-Taber-Oster method. Our results on payment-to-cost ratios are consistent with targeting by the state government to counterbalance disparities in hospitals' capability to cross-subsidize across patient types.

Author: Ausmita Ghosh
Publisher:
ISBN:
Category :
Languages : en
Pages : 314

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Book Description
My dissertation is a collection of three essays on the design of public health insurance in the United States. Each essay examines the responsiveness of health behavior and healthcare utilization to insurance-related incentives and draws implications for health policy in addressing the needs of disadvantaged populations. The first two essays evaluate the impact of Medicaid expansions under the Affordable Care Act (ACA) on health and healthcare utilization. The Medicaid expansions that included full coverage of preconception care, led to a decline in childbirths, particularly those that are unintended. In addition, these fertility reductions are attributable to higher utilization of Medicaidfinanced prescription contraceptives. The second essay documents patterns of aggregate prescription drug utilization in response to the Medicaid expansions. Within the first 15 months following the policy change, Medicaid prescriptions increased, with relatively larger increases for chronic drugs such as diabetes and cardio-vascular medications, suggesting improvements in access to medical care. There is no evidence of reductions in uninsured or privately-insured prescriptions, suggesting that Medicaid did not simply substitute for other forms of payment, and that net utilization increased. The effects on utilization are relatively higher in areas with larger minority and disadvantaged populations, suggesting reduction in disparities in access to care. Finally, the third essay considers the effect of Medicaid coverage loss on hospitalizations and uncompensated care use among non-elderly adults. The results show that coverage loss led to higher uninsured hospitalizations, suggesting higher uncompensated care use. Most of the increase in uninsured hospitalizations are driven by visits originating in the ED - a pattern consistent with losing access to regular place of care. These results indicate that policies that reduce Medicaid funding could be particularly harmful for patients with chronic conditions.

Author: Daniel Scott Grossman
Publisher:
ISBN:
Category :
Languages : en
Pages : 198

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Author: Youjin Hahn
Publisher:
ISBN: 9781124703442
Category : Child health insurance
Languages : en
Pages : 118

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The goal of my research is to explore ways to improve the welfare of populations that are targeted by public programs. In particular, my thesis consists of three chapters on health insurance and education. The first chapter looks at Medicaid take-up decisions among poor children. Medicaid is public health insurance that is available to low income individuals, and it is provided freely by the government. However, there is a puzzling observation that many low-income children are uninsured despite their eligibility for Medicaid. As one possible explanation, I propose that the low level of access to health care that Medicaid provides can explain incomplete take-up. Existing literature suggests that the low level of Medicaid fee payments to physicians reduces their willingness to see Medicaid patients, creating an access-to-care problem for these patients. Using variation in the timing of the changes in Medicaid payments across states, I find that improving Medicaid generosity increases the take-up rate and reduces the uninsured rate among poor children. These findings provide a partial explanation for why Medicaid-eligible children in poverty remain uninsured. While my first chapter focuses on traditional means-tested public health insurance which targets mainly low income families, the second chapter explores the issues with a more recent intervention that extends beyond low income families. In recent years, several states have allowed young adults as old as 30 to remain covered under their parents' employer-provided health insurance. For those who qualify for these benefits, the expansion of parental coverage partially reduces the value of being employed by a firm that provides health insurance since adult children can now get health insurance through another channel. We employ quasi-experimental variation in the timing and generosity of states' eligibility rules to identify the effect of the policy change on young adults' labor market choices. Our results suggest that the expansion of parental coverage increases the group coverage rate and reduces labor supply among young adults, particularly in full-time employment. The third chapter analyzes the effect of educational tracking by decomposing it into the separate roles of peer effects and coursework. The practice of tracking often results not only in grouping students by different ability, but also in providing different types of coursework for students. For instance, the advanced track may have both higher achieving peers and higher level coursework. Using detailed panel data from the San Diego Unified School district, I find that having high achieving peer is beneficial, while I do not find convincing evidence that taking more advanced math coursework predicts student's test score.

Author: Jamie Rubenstein Taber
Publisher:
ISBN:
Category :
Languages : en
Pages : 131

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In the first chapter of this dissertation, I study the effect of child support health insurance mandates on children's health insurance coverage. Children are more likely to lose health insurance when their parents divorce or separate, which is problematic because lack of health insurance is associated with reduced preventive care, diagnosis of diseases at later stages, and higher mortality. In order to increase coverage for children and reduce costs associated with public health insurance, many states have passed child support laws which mandate that a parent provide health insurance for the children if it is available at a reasonable cost. This paper is the first to evaluate the impact of these statutes on the number of children who lose health insurance due to parental divorce or separation. I codify the relevant laws by state and year from 1990 through 2007 in terms of the presence of mandates and the number and type of enforcement mechanisms. These variables are then linked to panels of the Survey of Income and Program Participation (SIPP), which provide the remainder of the necessary variables. Three main regressions are estimated. The first measures the overall effect of child support health insurance mandates on children's insurance coverage. The second equation measures the first intermediate step, whether child support health insurance mandates result in an order in the child support agreement to provide health insurance. The third equation measures the second intermediate step, whether an order for the parents to provide health insurance results in insurance coverage for children. I find that child support laws requiring parents to provide health insurance do not significantly impact the presence or type of health insurance coverage for children of divorced or separated parents. Additionally, these laws do not increase the probability that the child support agreement contains an order to provide health insurance, and an order to provide health insurance does not increase the probability of either any coverage or private coverage. In the second paper, we study the relationship between divorce and health insurance. Changing marital status is an important source of health insurance change. However, neither the health nor family economics literatures have examined this phenomenon. Using the SIPP, we document how health insurance status changes over time for men, women, and children as divorce and separation occur, as well as the likely causes of these changes. We find modest changes in overall coverage, but these changes mask large changes in type of coverage as people divorce or separate. In the third paper, we look at the effects of government aid expansions on labor market outcomes. While many studies investigate the magnitude by which public insurance expansions 'crowdout' private coverage, we ask a question new question: are such families able to recoup the benefits of no longer relying on employer provided coverage for children when they move to public coverage? Our findings from the SIPP do not show noticeable improvements, though our findings from the Current Population Survey (CPS) show a positive and significant effect on income and hourly wages.

Author: Matthew John Niedzwiecki
Publisher:
ISBN: 9781303220807
Category : Health insurance
Languages : en
Pages : 109

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My dissertation uses empirical methods to investigate the determinants of medical care demand and to understand how government action affects population health. The first chapter looks at a recent health insurance expansion in the state of Massachusetts and finds that, in the short run, the newly insured seek more hospital care. In the long run, as the supply of primary care physicians expands, care may shift to more efficient points of services. The second and third chapters examine the effect of cash liquidity on the demand for medical care and health insurance. I find liquidity to play an important role in determining the timing of health investments and that the uninsured are more sensitive to liquidity constraints, likely because they face higher prices. Cash-on hand is also shown to be an important fact in maintaining continuous private health insurance coverage.

Author:
Publisher:
ISBN:
Category :
Languages : en
Pages : 0

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This dissertation consists of three essays in health economics related issues. In the first chapter, I estimated health insurance expansion's effects on young adults' employment using MEPS. In 2010 young adults were allowed to stay on their parent's health insurance plan until the age of 26 by a policy change under the ACA. I used a difference-in-differences model to estimate labor supply effects of this policy on young adults. 23-25-year-olds are in the treatment group, and 26-30-year-olds are in the control group. Additionally, I estimated heterogeneity of the policy's labor supply effect by socio-economic groups. I found that extensive and intensive labor supply decreased among males. The effect is greater among men in higher socio-economic group. In the second chapter, I analyzed whether internet use has an effect on patients' mental health using BRFSS data. Over the last decade internet use has become universal. It provides various health related tools and information sources which may affect patients' distress levels in several ways, and health related distress can have large impacts on quality of life. I used variation across states' "right of way" policies during the broadband boom period of 2001-2005. Using rights of way rules' easiness as a proxy for broadband penetration rates, I investigated whether patients' mental health levels changed differently in states with more lenient rights of way rules. I found that among men internet use improves patients' mental health. In the third chapter, I studied labor market effects of the early Medicaid expansions under the ACA in 2010 using data from Current Population Survey. The ACA extends public insurance coverage to low income childless adults, yet we know very little about the effect of a public health insurance extension on childless adults' labor supply. The ACA allowed states to extend Medicaid and a number of states opted in early and extended Medicaid in 2010. I utilized this variation among states to evaluate whether the policy had any effect on childless adults' employment. I found that the policy had no effect on labor supply of the overall population. I found evidence that the policy mainly affected near-retirement-aged childless

Author: Eunkyeong Lee
Publisher:
ISBN:
Category :
Languages : en
Pages : 0

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My dissertation consists of three chapters, each of which empirically examines impacts of U.S. health care policies on hospital care for a subgroup of disadvantaged populations. The first chapter studies the impacts of Medicaid coverage expansions for pregnant women on patient reallocation across hospitals. If patients from low-income zip codes, who are likely to gain coverage after expanded public insurance coverage, have limited hospital options due to a lack of payer source, they may be able to receive care at higher quality hospitals once they obtain coverage. Using Florida hospital data and the Nationwide Inpatient Sample (NIS) for 1988-1995, I find that low-income mothers who gained coverage following the expansions gave birth at higher quality hospitals-facilities with neonatal intensive care units and those with low postnatal complication rates. In the second chapter, I continue investigating the effects of expansion, but examine its impact on hospitals' provision of indigent care, along with the impact of the Balanced Budget Act of 1997, with its reductions in Medicare and Medicaid hospital payments, on hospitals' supply of indigent care. The definition of hospital indigent care is, for the purpose of this dissertation, based on uncompensated care costs in dollars, volume of the uninsured, and amounts of unprofitable services provided. Using the Florida hospital data for 1990-2000, I find that these two health care policies reduced hospitals' provision of indigent care, but to different extents, and that the policy impacts differed by hospital ownership type. The third chapter, a joint project with Kosali Simon, examines the impact of the Children's Health Insurance Program on hospital utilization for low-income children. The expansion of public insurance coverage results in two contrasting effects that could increase or decrease hospital care for low-income children. On the one hand, the gain of public insurance coverage will increase access to primary care, and this may prevent hospitalizations, particularly those with ambulatory care sensitive conditions, to some degree. On the other hand, the coverage gain means lower costs of care and thus may increase hospital care across the board. Using the NIS for 1996-2002, we find that hospitalization rates and intensity of care increased overall, but these increases originated from increased non-ambulatory care sensitive hospitalizations.

Author: Peter J. Huckfeldt
Publisher:
ISBN:
Category :
Languages : en
Pages :

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My dissertation examines issues of accessibility, innovation and cost, and the role of public policy in the United States health care system. Chapter 1 explores the effects of Medicaid and State Children's Health Insurance Program (SCHIP) pregnancy eligibility expansions occurring from 1992 to 2005 on public and private health insurance coverage, prenatal care, and health outcomes. I use two novel sources of data to study the impacts of pregnancy eligibility expansions. The Centers for Disease Control- Pregnancy Risk Assessment Monitoring System (PRAMS) and California Birth Cohort birth certificate data are rich sources of birth data with detailed information on pregnancy health insurance coverage, prenatal care use, and infant and maternal health outcomes. My estimation of event study models shows that public coverage follows an upward trend following eligibility expansions, and that this coincides with smaller but imprecisely measured decreases in private health insurance. Simulated instrumental variables regression results imply public health insurance take-up rates between 14 and 19 percent. However, the private coverage estimates imply that an imprecisely measured but significant portion of the increase in public coverage comes from women who previously would only have private health insurance during pregnancy. Public eligibility expansions increase participation in the WIC program, but there is little evidence that program expansions improve overall prenatal care utilization or health outcomes. Chapter 2 (joint work with Christopher R. Knittel) explores how changes in pharmaceutical patent policy and the structure of health insurance and pharmaceutical markets have affected the use of prescription drugs. Our event study estimates show that utilization of drug molecules starts decreasing in the two years prior to generic entry and continues to decrease in the years following generic entry, despite the decrease in prices offered by generic versions of a drug. We find that this decrease coincides with the market entry and increased utilization of branded reformulations and other branded drugs from the same manufacturer of the drug going off patent. Finally, we find similar utilization patterns across individuals with more and less restrictive health plans, suggesting that cost-sharing and formulary restrictions have little effect on the utilization of new patented products.