A key feature of the market for health insurance is selection: a consumer's decision to purchase coverage can affect the costs for producers and the prices faced by other consumers. In three essays, I explore factors that influence consumers to take up insurance coverage, selection in market where a new insurance product was introduced, and the effects of a recent policy to expand coverage among young adults. The first essay examines whether language barriers and network effects can explain disparities in Medicaid participation among low-income immigrants. Using the American Community Survey, I show that linguistic networks facilitate Medicaid enrollment among non-English speaking adults. The identification method follows Bertrand et al. (2000) and employs local variation in the density of immigrant populations and nationwide variation in Medicaid participation among ethnic groups. I also find that the availability of foreign-language Medicaid information online is associated with significantly higher participation. The second essay examines consumer choice in the context of a health insurance exchange. Using data from the Federal Employees Health Benefits program, I examine the extent to which the sudden introduction of high-deductible plans into the system in 2004 may have generated adverse selection. While entry by the newer plan type does not appear to affect premiums of more traditional plan types for federal workers, enrollees in high-deductible plans are more likely to be younger and male. The final essay analyzes one of the earliest coverage-related provisions of the Affordable Care Act to take effect, the extension of health insurance coverage to child dependents up to age 26. Survey data reveal the law resulted in a marked increase in the number of young adults covered by private insurance. Analysis of medical claims data from private health insurance shows a relative decrease in average spending among young adults after the law took effect, implying that the dependent coverage provision brought healthier young adult individuals into the risk pool.

Retail clinics are walk-in clinics designed for convenience and for servicing minor health issues and certain acute conditions. The model began as a way of bringing both convenience and care to areas that have lower levels of access to primary care resources. With the implementation of Affordable Care Act (ACA) in March 2010, populations that were previously uninsured were now required to have access to some level of health insurance. These populations presented a potential new market for retail clinics. This research shows that post implementation of the ACA, retail clinics tend to locate in areas with higher incomes and, generally, greater access to primary care.

The Patient Protection and Affordable Care Act drastically transforms the United States healthcare infrastructure. This law, passed in 2008, will shift financial incentives, payment methods, policies, and, in fact, the very way our physicians practice medicine. Currently, the US ranks 1st in healthcare costs, but 37th in healthcare service in the world. It is estimated that there are between 35-42 million uninsured Americans that ultimately cost 50 billion in taxpayer dollars annually. The 4,033 behemoth of a law sets the groundwork to provide high quality healthcare to all Americans with either insufficient or no insurance. Although it will affect every aspect of healthcare and medicine, this paper will assess the changes being made in primary care. The renewed dedication to family medicine provides the foundation to create a more cost efficient healthcare system and a healthier America. We will review the current state of primary care, assess the provisions enacted by the Patient Protection and Affordable Care Act, and evaluate future goals of family medicine. Ultimately the Affordable Care Act attempts to boost primary care, focus on prevention, and use research-based policies in order to lower healthcare costs and provide accessible healthcare. In order to do so, the United States needs to address the insufficiencies of the previous healthcare system and re-evaluate our healthcare expenditures.

Indiana University-Purdue University Indianapolis (IUPUI) / Difficulties caring for people living with dementia (PWD) contribute to their family caregivers’ diverse unmet needs and adverse outcomes in health and well-being. This dissertation research explored the influence of macro systems on individual caregivers' well-being reflecting on the prevalence of online use among caregivers. Caregivers have migrated to online platforms to seek support. However, there is limited understanding of how online social support [OnSS] compares to offline support [OffSS] in terms of caregivers’ well-being. The first study examined the associations of OnSS and OffSS with the psychological well-being [MH] of caregivers. A subsample of the Health Information National Trends Survey (HINTS) from 2017 to 2018 (n=264) was analyzed. The data indicate that OnSS supplemented rather than replaced OffSS. Emotional support delivered offline had a positive direct association with MH, while OnSS did not. OffSS interacted with caregiving stressors while OnSS interacted with life stressors. Caregivers who are in less favorable situations, such as working part-time while caring for a PWD, living with economic hardship, and being unhealthy, tended to be significantly affected by OnSS. The results suggest that practitioners need to incorporate caregivers’ OffSS into OnSS to maximize the available support resources, specifically for those who are in less favorable conditions. There is limited understanding of caregivers’ experiences within the complex health care system, especially after the significant policy changes brought about by the Affordable Care Act (ACA). The second study analyzed caregivers’ perceptions of and experiences with the ACA using national online forum data posted in 2011-2017 (n=514 posts). Text-mining thematic analysis method was used to analyze the posts. Three overall themes emerged: (a) concern about cost implications of placement decisions for care recipients, (b) skepticism about government and healthcare system support of their caregiving roles, and (c) caregivers’ own well-being and concerns about health insurance. Efforts are needed to enhance clear and effective communication among policymakers and health professionals serving service users, including caregivers of PWD. The present dissertation provides preliminary evidence to increase understanding of the complex contexts that affect the overall well-being of caregivers. Implications and suggestions for practitioners, policymakers, and researchers are discussed.

In the wake of the Affordable Care Act, some US states expanded Medicaid eligibility to low-income, working-age adults while others did not. This study investigates whether this divergence induces migration across state borders to obtain Medicaid, especially in border regions of expansion states. It compares border with interior regions’ in-migration in the concerned subgroup before and after the Medicaid expansion in linear probability difference-in-difference and triple difference regression frameworks. Using individual-level data from the American Community Surveys over 2012–2017, this study finds only a statistically significant increase in in-migration to border regions after the expansion in Arkansas. The differing results across states could stem from statistical power issues of the employed regression analysis but might also result from state peculiarities. In Arkansas, the odds of having migrated increase by about 48% in its border regions after the Medicaid expansion compared to before and control regions. If all additional migrants take up Medicaid, the number of Medicaid beneficiaries in these regions increases by approximately 4%. Thus, even if the induced migration is statistically significant, it appears unlikely to impose meaningful fiscal externalities at the regional level. / Im Zuge des Affordable Care Acts haben einige US-Bundesstaaten den Anspruch auf Medicaid auf einkommensschwache Erwachsene im arbeitsfähigen Alter ausgeweitet, während andere Bundesstaaten dies nicht taten. Diese Studie untersucht, ob diese Divergenz zu einer Migration über die Bundesstaatsgrenzen führt, um Medicaid zu erhalten, insbesondere in Grenzregionen von Reformbundesstaaten. Sie vergleicht die Zuwanderung in Grenzregionen mit der Zuwanderung in das Landesinnere in der betroffenen Gruppe vor und nach der Medicaid-Ausweitung in linearen Wahrscheinlichkeits-Differenz-in-Differenz- und Dreifach-Differenz-Regressionsanalysen. Unter Verwendung von Daten auf Individualebene aus den American Community Surveys der Jahre 2012–2017 findet diese Studie nur in Arkansas einen statistisch signifikanten Anstieg der Zuwanderung in die Grenzregionen nach der Ausweitung. Die unterschiedlichen Ergebnisse in den einzelnen Bundesstaaten könnten von Problemen mit der statistischen Aussagekraft der durchgeführten Regressionsanalyse herrühren. Sie könnten aber auch aus Besonderheiten der jeweiligen Bundesstaaten resultieren. Eine zufällig ausgewählte Person in den Grenzregionen von Arkansas hat nach der Medicaid-Ausweitung eine um 48% erhöhte Wahrscheinlichkeit zugewandert zu sein im Vergleich zu vorher und den Kontrollregionen. Falls alle zusätzlichen Migranten Medicaid in Anspruch nehmen, steigt die Zahl der Medicaid-Empfänger in diesen Regionen um etwa 4%. Es scheint somit unwahrscheinlich, dass die induzierte Migration zu bedeutenden fiskalischen Externalitäten auf regionaler Ebene führt, selbst wenn der Migrationseffekt statistisch signifikant ist.

Hospital readmissions are a source of reduced payment as mandated by the Centers for Medicare and Medicaid Services as part of the Affordable Care Act (ACA). The number of dollars used for hospital readmissions has sky rocketed above $17 million for heart failure alone. The changes in the ACA reimbursement guidelines has put stress on many hospitals as they are facing reduced income, increased use of resources, and increased length of stay. This project evaluated the implementation of Project BOOST, its components, and their predictability for hospital readmission. Sample groups were evaluated both pre- and post-implementation of Project BOOST, which included individuals aged 18 and older, who were of Anglo, Hispanic or Native American descent, and living in Northern Arizona. A retrospective chart review was performed and descriptive and predictive statistics were used to analyze obtained data. Patients with cardiovascular disease admitted to the study hospital have high risks for readmission, such as problem medications, polypharmacy, psychological Issues, and principal diagnoses. Integrating elements from Project BOOST significantly decreased 30-day hospital readmissions. Data from this study revealed a statistically significant reduction in 30-day hospital readmission rates from 22% in the pre-intervention period to just 4% in the post-intervention period. Patients who did not receive the risk assessment tool were 14 times more likely to be readmitted to the hospital within 30 days of the index hospitalization.

The Patient Protection and Affordable Care Act (PPACA) expanded access to insurance coverage and health care services for many citizens, and has increased access for women in particular by including preventive reproductive health services as essential health benefits. The current national rates of sexually transmitted infections (STIs), reproductive cancer diagnoses, and unintended pregnancy serve as major areas of concern for women’s health and public health. The present study examined how knowledge of the PPACA influences receipt of preventive reproductive health services among women. Results indicate that higher levels of knowledge of the PPACA are associated with a greater likelihood of receiving cancer and STI screenings, as well as contraceptive counseling, and that increasing contraceptive knowledge, rates of contraceptive counseling, and pap screenings are related to greater use of highly effective contraception. The present study offers support for increased outreach and education efforts, along with additional policy and provider involvement.

Thesis advisor: Rocío Calvo / Hispanics are less likely than non-Hispanic whites to use mental health service, even after controlling for various social, environmental, and health factors. Mental health services disparities between Hispanics and non-Hispanic whites have been well-documented and consistent over time. However, very little is known about the impact mental health care organizations have on Hispanics’ access to mental health care, especially since the implementation of the Patient Protection and Affordable Care Act (ACA). The three papers in this dissertation utilize the 2010, 2014, and 2016 waves of the National Mental Services Survey (N-MHSS) to assess the impact of the ACA on Hispanics’ access to mental health care and mental health care organizations’ provision of integrated services. The N-MHSS is a national repository of data on the mental health organizations in the United States. This dataset was created to report the characteristics and client enrollment at mental health care organizations. Paper 1 uses the 2014 N-MHSS to describe the structural characteristics of mental health care organizations according to the proportion of Hispanics they serve and the organizations’ structural characteristics in Medicaid expansion and non-expansion states. Paper 2 uses the 2010, 2014, and 2016 N-MHSS waves to examines the impact of the ACA and the health safety net on Hispanic admissions at mental health care organizations. These three waves were merged together using a repeated cross-sectional design to assess whether Hispanic admissions increased after the implementation of the ACA. The final paper uses the 2014 and 2016 N-MHSS waves to assesses whether integrated care has increased at Hispanic-serving organizations compared with mainstream organizations two years after the implementation of the ACA. This paper also assessed whether the increased funding for integrated services under the ACA has disproportionately affected mainstream organizations compared with Hispanic-serving organizations. / Thesis (PhD) — Boston College, 2018. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

The Hospital Value-Based Purchasing Program (HVBP), created by Section 3001 of the Patient Protection and Affordable Care Act passed in 2010, enacted a major industry shift in Medicare towards "pay for performance," or paying for high marks on a variety quality metrics rather than the traditional reliance on volume of care delivered. This study examines one of these quality metrics in particular: patient satisfaction. The trajectory of this paper begins with an overview of the current focus on patient satisfaction as a modern quality metric in American healthcare, contextualizes this emphasis on satisfaction within the intellectual movement of "patient-centered care," and moves on to a review of the relevant scholarship that attempts to explain the numerous determinants of patient satisfaction scores (with special attention to the inpatient hospital setting), as well as the robust academic debate over whether satisfaction is even an appropriate quality metric at all relative to clinical outcomes in care. The second half of my discourse moves on to more practical applications - first I break down the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and the impact of its methodology on providers, then the Medicare HVBP program itself and its various directions towards the value-based care model. I conclude with a quantitative analysis of trends in patient satisfaction over time between 1) HVBP-participating providers (as of FY2014) and 2) those providers who have not opted in (including those ineligible to do so). My comparison aims to study the strength of the HVBP incentives to improve patient satisfaction in those subject to the financial incentive relative to those who are not. Additionally, I preface this analysis whether patient satisfaction scores are associated with either clinical process of care scores or outcome scores in the HVBP program. My research questions aim to shed light on the academic debate between patient satisfaction and more traditional clinical outcomes - are they related in the context of FY2014 HVBP? Are the new incentives to improve patient satisfaction actually doing so in a meaningful way among providers newly accountable to these incentives? Finally, in a market defined by zero-sum resources, is there evidence that a financial incentives around patient satisfaction are channeling resources and by extension improvement away from clinical outcome performance? I believe this last question is the true concern of patient satisfaction skeptics, and hope to address it with applicable data. By providing a thorough qualitative grounding in the topic followed by current quantitative analysis, my goal is to create an informed perspective on the use of patient satisfaction as a quality metric in U.S. healthcare, which can be applied meaningfully from policy, provider, and consumer vantage points. With patient satisfaction becoming increasingly more internalized in the value-based care model, these analyses of the initial results in HVBP potentially serve as predictive insight into provider behavior in this area moving forward.

In most markets, competition induces efficiency by ensuring that goods are priced according to their marginal cost. This is not the case in health insurance markets. This is due to the fact that the cost of a health insurance policy depends on the characteristics of the consumer purchasing it, and asymmetric information or regulation often precludes an insurer from matching the price an individual pays to her expected cost. This disconnect between cost and price causes inefficiency: When the premiums paid by consumers do not match their expected costs, consumers may sort inefficiently across plans. In this dissertation, I study the effects of policies used to alleviate selection problems. In Chapter 1, I develop a model to study the effects of risk adjustment on equilibrium prices and sorting. I simulate consumer choice and welfare with and without risk adjustment in the context of a Health Insurance Exchange. I find that when there is no risk adjustment, the market I study unravels and everyone enrolls in the less comprehensive plan. However, diagnosis-based risk adjustment causes over 80 percent of market participants to enroll in the more comprehensive plan. In Chapter 2, we study an unintended consequence of risk adjustment: upcoding. When payments are risk adjusted based on potentially manipulable risk scores, insurers have incentives to maximize those risk scores. We study upcoding in the context of Medicare, where private Medicare Advantage plans are paid via risk adjustment but Traditional Medicare is not. We find that when the same individual enrolls in a private plan her risk score is 5% higher than if she would have enrolled in Traditional Medicare. In Chapter 3, we study two forms of insurance for insurers: Reinsurance and risk corridors. Protecting insurers from risk can lower prices and improve competition by inducing entry into risky markets. It can also induce inefficiencies by causing insurers to manage risk less carefully. We use simulations to compare the power of reinsurance and risk corridors to protect insurers against risk while limiting efficiency losses. We find that risk corridors are always able to limit insurer risk with the lowest efficiency cost.