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Ways in which the implementation of the Patient Protection and Affordable Care Act (ACA) affect parents with chronically ill children are not well understood. The purpose of this phenomenographic study was to gain greater insight into the perceived experiences of parents of chronically ill children regarding implementation of the ACA in a southern state. Argyris's intervention theory provided the framework for the study. Face-to-face interviews were conducted with a purposeful sample of 12 female parents who are caregivers of chronically ill children. Data were analyzed and coded to identify categories and themes. Findings indicated that parents view physicians and policymakers as key actors in their communities to create more equitable services for parents of chronically ill children through the expansion of Medicaid services in southern state. Many participants did not perceive that the ACA had made significant changes to services received prior to its implementation. Findings may assist health care providers, insurance companies, legislators, and other policymakers to develop appropriate health care policies and interventions to lessen the financial burden experienced by parents of chronically ill children. Providing more support services that address the physical, emotional, and financial needs of parents may improve the health outcomes of their chronically ill children.

There are over 3 million seasonal and migrant farmworkers in the U.S. agricultural industry with a significant percentage of farmworkers documented or native to the United States. Migrant farmworkers live below the federal poverty levels at high rates and experience low health care access and utilization. Guided by the fundamental cause theory, the purpose of this phenomenological study was to examine the lived experiences of migrant farmworkers and identify the factors impacting their health care access and utilization. Face-to-face interviews were conducted with 12 migrant farmworkers who had worked in Southwest Texas agricultural stream. Data were analyzed and coded to identify themes. Findings indicated that although lack of health insurance was a decisive factor in whether migrant farmworkers accessed or utilized health care services, distance to services, inflexible working hours, and cultural factors related to seeking care also influenced participants' lack of access to and utilization of health care services. Results may be used to aid local, state, and federal agencies in assisting migrant farmworkers in bridging the gap in health care and obtaining needed services.

Using the Health and Retirement Study Panel core files from 1996 to 2014, I analyze how Medicare Part D impacted access to prescription drug coverage by various demographic factors such as race, gender, and income. In Chapter 1, I find the highest take-up rates for those who were white, female, and with higher incomes. However, increases in coverage were high across the board, such that Medicare Part D also improved drug insurance coverage for those who were black, male, and with lower income. Thus, although Medicare Part D did increase prescription drug insurance coverage for seniors across the board, I also find potential for improvement in enrollment for difficult-to-reach groups. Next, Chapter 2 examines the impact of Medicare Part D on mortality. Although I do not find an impact on the life expectancy of respondents as a whole, I do find a significant positive effect for black respondents, indicating that Medicare Part D may have mattered more for disadvantaged groups. The largest impact is for black men, who have an additional 9 percentage point chance of living to age 73 for an additional 8 years of coverage (significant at the 5% level). When looking only at cardiovascular mortality, which is more likely to be influenced by drug coverage, I find improvements in life expectancy for the total population, with stronger effects for minorities and men. Overall, my findings suggest that Medicare Part D did move the needle on its goal: to improve the health of those who, without government intervention, had the most difficulty paying for prescription drugs. Chapter 3 looks at the impact of Medicare Part D prescription drug coverage on cost-related medication adherence, food insecurity, and finances among seniors. It would be reasonable to assume that Medicare Part D, which led to near-universal drug coverage among senior citizens, could allow seniors to shift money previously spent on drug expenditures to other areas. The strongest effect of Medicare Part D is on cost-related medication nonadherence, leading to a 21% decrease for an additional 8 years of Medicare Part D coverage. The impact is even stronger for the black male population (30%). I fail to reject the null hypothesis that Medicare Part D did not reduce food insecurity or household debt. Overall, Medicare Part D appears to have improved the financial stability of seniors.

This thesis is concerned with changes over time in the social characteristics of doctors who have entered prepaid group health plans. It focuses on the past social positions which these doctors have occupied and on their status, or rank. The general expectation is that both the rank and positions occupied by doctors prior to entering prepaid group plans have varied as the prestige of these plans has varied. The entrance of physicians into prepaid group health plans was conceptualized as mobility between different contexts of work. Blau’s exchange theory of mobility proved to be the most fruitful source of hypotheses for this study. Blau states that extrinsic rewards are the major incentives for mobility and that intrinsic rewards interact with extrinsic rewards in influencing mobility. From these basic propositions two hypotheses were generated: 1) As the status of prepaid group health plans increases, the status of physicians entering these plans will increase. 2) As the status of prepaid group health plans increases, high status recruits will less frequently come from positions offering intrinsic rewards similar to those found in prepaid group plans. The design of this research was a longitudinal case study. Data were obtained relevant to one prepaid group health plan, the Portland Kaiser Foundation Health Plan. The universe included all physicians who had practiced as full-time, salaried staff in Kaiser at any time since 1945 when Kaiser was first opened to the public. Indicators were obtained from various sources of data. The Kaiser personnel records provided data on physicians’ social characteristics. Data on the status of Kaiser came from an official salary schedule and records of personnel advertisements. Informants were used to rank medical schools and the AMA’s Directory of Approved Internships and Residencies provided a ranking of teaching hospitals. The evidence for the first hypothesis was generally negative. The data indicated that although the status of Kaiser had increased over the years, the status of physicians entering Kaiser had decreased. This conclusion was reached on the basis of findings using prestige of medical school as an indicator for physicians’ achieved status as well as findings using nationality and length of practice as indicators for their ascribed status. Thus, the first hypothesis of this study had to be rejected. The evidence for the second hypothesis was inconclusive: it indicated that as the status of Kaiser increased, the percentage of high status recruits from certain positions with intrinsic rewards similar to Kaiser’s decreased, whereas the percentage from other positions increased. High status physicians have less frequently entered Kaiser a) having held positions emphasizing the scientific aspects of care, b) having memberships in scientific or specialty societies, c) having changed the location of their practice, and d) having changed their specialty. They have more frequently entered Kaiser a) having had postgraduate training b )having had at least five years of training, c) having held jobs in bureaucratic contexts, d) having graduated from medical schools in the North Central and Western states, and e) having engaged in two of more different types of activities. In sum, it was unclear whether the second hypothesis should be accepted or rejected.

Continued escalation in health care expenditures in the United States has led to an unsustainable model that consumes almost 20% of GDP. Policymakers have recognized the need for industry reform and have taken action through the passage of the Affordable Care Act (ACA). The purpose of this quantitative, longitudinal study was to examine the relationship between the type of health insurance and health care costs. Mechanism theory and game theory provided the theoretical framework. The analysis of secondary data from the Healthcare Cost and Utilization Project included a sample of 1,956,790-inpatient hospital stays from 2007 to 2014. Results of one-way ANOVAs indicated that between 2% and 9% of health care costs could be attributed to type of health insurance, a statistically significant finding. Results also supported the effectiveness of the ACA in stabilizing health care costs. The average annual rate of health care cost increase was 38.6% from 2007 until 2010, decreasing to an average annual increase of 4.3% from 2011 until 2014. Results provide important information to generate positive social change for consumers, providers, and policymakers. This includes improving decisions related to health care costs, improved understanding of the costs of health care services, increased transparency, increased patient engagement, maximizing consumer utility, facilitation of reduction of waste within the industry, and increased understanding of the impact of health policy on health care costs and efficiencies within newly created health policies. Results may also improve transparency of health care costs, which allows consumers, providers, and policymakers to take specific action to reduce health care costs, resulting in a more just and sustainable health care model.

This thesis consists of three independent essays, unified by the common theme of the distributional impacts of government. The first paper estimates the price elasticity of demand for pharmaceuticals amongst high-income older people in Australia. It exploits a natural experiment by which some people gained entitlement to a price reduction through the Commonwealth Seniors Health Card (CSHC). The preferred model is a nonlinear Instrumental Variable (IV) difference-in-difference regression, estimated on repeated cross sectional survey data using the Generalised Method of Moments. No significant evidence is found for endogenous card take-up, and so cross-sectional estimates are also considered. Taking all of the results and possible sources of bias into account, the ??headline?? estimate is -0.1, implying that quantity demanded is not highly responsive to price. The elasticity estimate is a key input into the second paper which analyses the distributional impact of the CSHC. I consider the trade-off between moral hazard and risk pooling. There have been few previous attempts internationally to address this trade-off empirically for any health insurance scheme. The utility gain through risk-pooling is found to be negligible. However, the deadweight loss through moral hazard may be considerable. I also use an illustrative model to demonstrate the possible effects of the CSHC on inter-temporal savings behaviour. While the CSHC may induce some people to save, it may have the opposite effect on others. The net impact was not determined. The third paper estimates the Australian public sector wage premium. It includes a detailed critical review of the methods available to address this issue. The chosen approach is a quasi-differenced panel data model, estimated by nonlinear IV, which has many advantages over other methods and has not been used before for this topic. I find a positive average public sector wage premium for both sexes. The best estimates are 10.0% for men and 7.1% for women. The estimate for men is statistically significant (p < 0.04) and borders on significance for women (p < 0.07). No evidence is found to suggest that the public sector has an equalising effect on the wages of its workers.

從世界各國實施社會性健康保險的經驗來看，醫療費用上漲是共同面臨的難題。本論文從道德危險的角度探討醫療服務需求面及供給面的濫用與浪費，針對部分負擔與支付制度抑制道德危險的效果，分析世界主要國家制度改革的的成效，以供我國實施全民健保的參考。 從文獻探討中可以知道：消費者會因自付價格下降，引發需求面的道德危險；而基於消費者無知及資訊不對稱之特性，醫療服務供給者會誘發道德危險。面對道德危險，實施醫療費用部分負擔可抑制醫療利用，其中以定率負擔制最能發揮功能。而具有正面誘因的支付制度，能鼓勵醫院及醫師增進醫療提供之成本控制、效率及公平性，其中，以論病例計酬制最具這些功能。 由本文實證研究的結果可看出，要有效抑制道德危險，應該注意以下幾點： 1.高部分負擔不一定對抑制道德危險有效，在商業醫療保險普及下，反而會增加低收入者的負擔。 2.為避免改革只收到短期的效果，必須同時在支付制度及部分負擔上做持續性的改革。 3.健康照護制度中的成員，本身對政策之配合度也是影響制度改革能否收到成效的重要因素。 4.影響醫療利用的因素錯綜複雜，仍有許多部分負擔及支付制度以外的因素在影響醫療資源的使用，在實施制度改革時，應同時也把其他因素納入考慮中。

The focus of this study is the vicious circle of poverty and ill-health. The case is injuries but it could have been any lasting and severe disease. Poverty and health have very close links to economic development and to how health care is financed. Out-of-pocket payment seems to increase the risk of poverty while prepaid health care reduces it. The overall objective is to investigate the “injury poverty trap” and suggest possible solutions for it. A cohort of 23,807 people living in 5,801 households in Bavi district of Vietnam was followed from 1999 to 2003 to investigate income losses caused by non-fatal unintentional injuries in 2000 as well as the relationships between social position in 1999 and those injuries. For the possible solutions, a survey in 2064 household was performed to elicit people’s preferences and willingness to pay for different health care financing options. The results showed that unintentional injuries imposed a large economic burden on society, especially on the victims. By two pathways – treatment costs and income losses – unintentional injury increased the risk of being poor. The losses for non-poor and poor injured households were about 15 and 11 months of income of an average person in the non-poor and poor group, respectively. Furthermore, poverty was shown to be a probable cause of non-fatal unintentional injuries. Specifically, poverty led to home injuries among children and the elderly, and adults 15 – 49 years of age were particularly at risk in the workplace. The middle-income group was at greatest risk for traffic injuries, probably due to the unsafe use of bicycles or motorbikes. About half of the population preferred to keep an out-of-pocket system and the other half preferred health insurance. People’s willingness to pay suggested that a community-based health insurance scheme would be feasible. However, improvements in the existing health insurance systems are imperative to attract people to participate in these or any alternative health insurance schemes, since the limitations of the existing systems were generalized to health insurance as a whole. A successful solution should follow two tracks: prepayment of health care and some insurance based compensation of income losses during the illness period. If the risk of catastrophic illness is more evenly spread across the society, it would increase the general welfare even if no more resources are provided.