This dissertation consists of three essays on access to primary care and the design of health insurance markets. These essays share a methodological framework. In each, I estimate a model of the market using detailed administrative data sets. Then, I employ the estimated model to answer policy-relevant research questions. The first chapter, entitled Access to Care in Equilibrium, studies consumer access to medical care as an equilibrium outcome of a market without prices. I use data from the Northern Ontario primary care market to estimate an empirical matching model where patients match with physicians. The market is cleared by a non-price mechanism: the effort it takes to find a physician. I use the model to study the distribution and determinants of access to care. By employing a model of the market, I am able to define a measure of access to care that accounts for patient preferences and market conditions: the probability that a patient who would attain care in a full access environment currently attains care. I find that access to care is low and unevenly distributed. On average, a patient who would attain care in a full access environment will receive care 73% of the time. The issue is particularly acute in rural areas. Further, physicians discriminate in favor of patients with higher expected utilization, thereby increasing access for older and sicker patients while decreasing access for younger and healthier patients. The estimated model is used to decompose access into its contributing factors. In rural areas, the geographic distribution of physicians is the primary determinant of low access. In contrast, low access in urban areas is primarily driven by capacity constraints of physicians. Interestingly, equating physician to population ratios across Northern Ontario would not improve rural access. In the second chapter, entitled Increasing Access to Care Through Policy: A Case Study of Northern Ontario, Canada, I employ the estimated model from Chapter One to assess the impact of policy on access to medical care. I study two policies: (1) grants to incentivize physicians to practice in low-access areas and (2) a payment reform that provided incentives for physicians to increase the numbers of patients on their books. Using the estimated model, I simulate market outcomes in counterfactuals where each policy is removed. By comparing these simulations to outcomes in the current market, I estimate policy impacts while accounting for equilibrium effects. I find that both policies are effective at increasing access to care. However, the policies target different subsets of the population. The grant program increases access most for rural patients, whereas the payment reform increases urban access most. Lastly, Chapter Three is a paper co-authored with Kate Ho and Michael Dickstein entitled Market Segmentation and Competition in Health Insurance. We study the welfare consequences of market segmentation in private health insurance in the US, where households obtain coverage either through an employer or via an individual marketplace. We use comprehensive and detailed data from Oregon’s small group and individual markets to demonstrate several facts. First, enrollees in the small group market have lower health care spending than those in the individual market conditional on plan coverage level. Second, small group enrollees benefit from tax exemptions and employer premium subsidies that create a wedge between premiums charged by insurers and the prices they face. However, these benefits are offset by relatively high plan markups over costs, which generate premiums (prior to employer contributions) that are at least as high as those in the individual market. These findings suggest that recent policies to merge the two markets, allowing small group enrollees to shop on the individual exchanges while maintaining their tax exemptions and employer contributions, may stabilize the individual market without much loss to small group enrollees. However, the new equilibrium outcome depends crucially on the preferences and characteristics of the two populations. We use a model of health plan choice and subsequent utilization to estimate household preferences in both markets and predict premiums and costs under a counterfactual pooled market. We find that integration mitigates adverse selection issues in the individual market, while decreasing government and employer expenditures on premium subsidies. Small group households benefit from lower premiums for low coverage plans in the merged market. However, they face higher premiums for high coverage plans and are constrained to a smaller set of insurance options. Thus, the effects of integration on small group households are heterogeneous.

The growth rate and percent of GDP spend on health care has brought necessary attention to discussions on cost and quality within the health industry. This research posits that in order to tackle issues within these cost and quality-conscious discussions, consumers require increased literacy in the health insurance shopping and utilization processes. Health insurance literacy is relatively new terminology. In regard to consumer literacy measures in purchasing, the findings in Chapter 1 demonstrate that studies on health insurance literacy are inconsistent, with no consensus on which metrics are most appropriate to measure health insurance literacy. While there is a generally agreed upon definition of health insurance literacy, there is currently no standard scale to determine one’s literacy level. Additionally, literacy, in a broader construct, can assist consumers in making better informed choices about how to engage with and manage their health insurance. One particular example of a poor utilization habit is the use of the Emergency Room (ER) for non-emergent conditions. The findings in Chapter 2 demonstrate that educated consumers can be influenced to choose alternative sites for ER care. This research suggests that taking measures to advance health insurance literacy can improve both shopping and utilization behavior and, in turn, positively impact health care costs and efficiencies. The conclusion of this research theorizes on the best approach to influence literacy in health insurance; ultimately furthering the body of research that moves toward a more efficient, effective, and literate health insurance industry. / Business Administration/Interdisciplinary

This thesis is missing page 168. The other copies do not have this page. -Digitization Centre / The Canadian Health Insurance program has been in place for quite some time now and it has always been said that Canadians have some of the best healthcare in the world. Canadian healthcare is very well known throughout the world because every Canadian citizen has the right to healthcare without having to pay for it. The benefits of this program are quite well known but some benefits one might think would result, just might not be there. This paper looks at whether the inception of Canadian Health Insurance has had an effect on the mortality rates of Canadians. Through a statistical analysis, this paper shows that there is no evidence that the Canadian Health Insurance program has had an effect on Canadian aggregate mortality rates. This paper shows that Canadian mortality rates follow a trend to that of the United States. To say Canadians have a similar trend in mortality rate to the United States is perhaps surprising since Canadians are supposed to have a far superior healthcare system. / Thesis / Master of Science (MS)

published_or_final_version / Social Work / Master / Master of Social Work

Thesis (M.M. (Public and Development Management))--University of the Witwatersrand, Faculty of Commerce, Law and Management, Graduate School of Public and Development Management, 2015. / This study examines the views of Primary Health Care (PHC) nurses towards the National Health Insurance (NHI) in Johannesburg District D2. The main aim of this study is to respond on the views of PHC nurses towards NHI that is going to be implemented in 2015 and how to avoid, and manage, any challenges that might emerge with the implementation of the project. Primary data was collected by means of interviews guide with PHC nurses from the Johannesburg district D 2. The study is qualitative. Purposive sampling was used to identify participants who are knowledgeable about the NHI. Nine participants were selected and interviewed. The sample selected was non-probability sampling. For this study, purposive or judgmental sampling is used. Data was collected by means of interviews questionnaires with PHC nurses from the Johannesburg district D2. The research questions addressed the concepts which are critical on the views of PHC nurses towards NHI in Johannesburg Metro district D2. The findings indicate that the general views of the nurses are positive towards the NHI. Nurses are positive and ready to support the implementation of the project but proper buy-ins, stakeholder engagement and proper planning needs to be in place in order for the successful implementation of the project. The study recommends that the training of nurses should take place before the implementation the project. Sufficient availability of resources to ensure that quality health care service is rendered. There should a sufficient workforce to ensure that a quality service is not compromised.

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Objectives: The purpose of this study was to analyze the health insurance status and medical utilization and its related factors for foreigners at Kaohsiung-Pingtung area in Taiwan. Methods: The study used secondary data to attain the research purposes. Data from Bureau of National Health Insurance Kao-Ping Branch between 2004 to 2007 were used. A total of 119,100 cases were analyzed. Descriptive analysis was used to examine foreigners¡¦ health insurance and medical utilization. T -test was used to investigate the differences between medical utilization and personal characteristics, such as demography, nationality and insured payrolls. Regression analysis was applied. Logistic regression was employed to examine whether the foreigners used the services both from inpatients or outpatients. Multiple regressions were applied to predict the medical expenditures and times. Results: Most of cases were aged from 21 to 40, females, category 1 insured, low income, dangerous work and seeking medical care for pregnancy and maternity care. The results from logistic regression revealed that males had lower odds to use medical care (OR=0.636 CI: 0.616 to 0.657), outpatient care (OR=0.634 CI: 0.614 to 0.655) and inpatient care (OR=0.804 CI: 0.757 to 0.853) compared with females. Insured came from mainland have higher odds to use inpatient care (OR=1.184 CI: 1.124 to 1.246) compared with other countries. People had 2 to 3 insured years used higher medical care (OR=5.873 CI: 5.636 to 6.119) and outpatient care (OR=5.886 CI: 5.649 to 6.314) compared with those whose insured under 1 year. If insured period over 3 years, they would have 5 more times probabilities to inpatient care than whose time under 1 year (OR=5.017 CI: 4.664 to 5.398). Category 5, low-income insured, had more than 8 times probabilities to use inpatient services than category 1 who had stable work. Results from multiple linear regressions indicated longer insured period, came from mainland and catastrophic illnesses patients would have more outpatient and inpatient visiting times significantly. So did the medical expenditures. Conclusions: Gender, age, nationality, insurers¡¦ category, qualified, the insured payroll, catastrophic illness and occupational accidents were the determination of medical utilization among foreigners at Kaohsiung-Pingtung Area in Taiwan. Future researchers could use questionnaire to get more complete relevant factors and follow the medical utilization and health status of foreigners. To provide the policymakers facilitate the planning of public health interventions.

Thesis (Ph. D.)--School of Public Policy, Georgia Institute of Technology, 2004. Directed by Gregory B. Lewis, Georgia State University. / Vita. Includes bibliographical references (leaves 252-261).

No description available.

The three chapters of this dissertation explore the ties among health insurance, changing cultural institution, and labor economics. The first chapter focuses on the relationship between health insurance and wages by taking advantage of states that extended health insurance dependent coverage to young adults before the Patient Protection and Affordable Care Act. Using American Community Survey and Census data, I find evidence that extending health insurance to young adults raises their wages, both while they are eligible for insurance through their parents' employers and afterwards. The increases in wages can be explained by increases in human capital and increased flexibility in the labor market that comes from people no longer having to rely on their own employers for health insurance. The second chapter focuses on understanding the impact of allowing coverage of spouses through employer-sponsored health insurance. The fact that people choose to enter into marriage makes comparing the differences between married and unmarried couples uninformative. To get around this, I examine how shocks to access to insurance through a spouse's employer brought on by extensions in legal recognition have influenced health insurance and labor force decisions for same-sex couples. I find extending legal recognition to same-sex couples results in female same-sex couples being more likely to have one member not in the labor force. The third chapter examines what extending legal recognition to same-sex couples has done to marriage rates in the United States using a strategy that compares how marriage rates change after legal recognition in states that alter legal recognition versus states that do not. Despite claims that allowing same-sex couples to marry will reduce the marriage rate for opposite-sex couples, I find no evidence that allowing same-sex couples to marry reduces the opposite-sex marriage rate. The opposite-sex marriage rate does decrease, however, when domestic partnerships are available to opposite-sex couples. / text