Cervical cancer represents a significant public health problem in the United States. According to the Centers for Disease Control and Prevention, the prognosis is related to stage at diagnosis, with the 5-year survival rate being 91.2% for early stage disease and only 17.0% for those with late stage disease. There is a gap in the literature examining the association of insurance status with late stage cervical cancer diagnosis across a large segment of the United States population. There is also a gap in the literature examining women residing in the United States with late stage cervical cancer diagnosis and identifying their country of birth. Guided by Andersen's behavioral model of healthcare utilization, this study used the Surveillance, Epidemiology, and End Results database, which includes over 28% of the United States population. The independent variables used were insurance, country of birth, race/ethnicity, age at diagnosis, and marital status. The dependent variable was stage at diagnosis. This cross sectional study included data from 7,445 women across the United States for the years 2008-2012. Two-way tests of association and logistic regression were used to analyze the data. The logistic regression (full model) was statistically significant and found that women born outside of the United States have a lower risk of late stage cervical cancer diagnosis and that unmarried women have a greater risk of late stage diagnosis. This study should send a signal to healthcare providers, as well as public health organizations, to direct their actions toward targeting groups that are now being diagnosed with late stage disease.

Indiana University-Purdue University Indianapolis (IUPUI) / Poor oral health is associated with pain, decreased chewing function, negative social perceptions, and reduced quality of life. Low-income adults disproportionally have worse oral health and use dental services at lower rates than higher-income adults. This disparity is associated with individual demographic and socioeconomic factors, cost and coverage barriers, as well as the supply and location of dental providers. Although the full causal pathway remains elusive, evidence suggests an association with poor oral health and an exacerbation of chronic diseases symptoms. Thus, adequate provision of dental care has important population health implications. Despite this importance, dental care use among low-income adults is particularly underexplored. Furthermore, existing research lacks robust methodological designs to mitigate bias from unobserved confounders. Dental coverage for low-income adults through Medicaid is emerging as a way to provide services to this population. However, given state budget constraints, comprehensive public dental benefits are uncommon or at risk of being cut. Therefore, it is important to quantify the individual and economic value of dental care use among adult Medicaid enrollees. This dissertation examines factors and outcomes associated with dental care use among Medicaid-enrolled adults in Indiana. This dissertation includes three studies 1) a pooled cross-sectional analysis that measures the association of individual and community level factors with dental care use, 2) a repeated measures study with individual fixed effects to examine whether receipt of preventive dental care is associated with fewer subsequent non-preventive dental visits and lower total annual dental expenditures, and 3) an empirical study that utilizes an instrumental variable estimation method to examine the effect of preventive dental visits on medical and pharmacy expenditures. Overall, this dissertation attempts to understand the correlates of dental care use, the effectiveness of preventive dental care, and the association between preventive dental care and medical expenditures.

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Objectives: COVID-19 has introduced an unexpected level of uncertainty to every aspect of our lives, and loss of access to care has become a major problem. This study has two main objectives, one being to characterize the frequency of insurance approvals and denials for Medicaid patients seeking orthodontic treatment in Pennsylvania before and during COVID-19, and the second being to identify differences in appointment keeping behavior between Medicaid and non-Medicaid orthodontic patients during those timelines.Methods: 634 Medicaid and 304 non-Medicaid patients were screened at Temple University Kornberg School of Dentistry, Department of Orthodontics from July 2018 to March 2019 (pre-COVID-19) and July 2020 to March 2021 (during COVID-19). Each patient’s Insurance Provider, Salzman Index Score (SEI), the insurance eligibility decision (approval/denial), and history of all attended and failed appointments for both Medicaid and non-Medicaid patients during pre-COVID-19 and during COVID-19 timelines were collected. Results: For the first objective, there were 270 approvals (96%) and 10 denials (4%) pre-COVID-19 and there were 270 approvals (76%) and 84 denials (24%) during COVID-19. There was a significant difference in the rate of insurance approvals and denials pre-and during COVID-19, with a p-value of <0.001. For the second objective, Medicaid patients attended 7221 (81%) and failed to attend 1746 (19%) of 8967 appointments and non-Medicaid patients attended 3419 (85%) and failed to attend 589 (19%) of 4008 appointments pre-COVID-19. During COVID-19, Medicaid patients attended 7115 (81%) and failed 1637 (19%) of 8752 appointments and non-Medicaid patients attended 3171 (87%) and failed 484 (13%) of 3655 appointments. The results showed a significant difference in the number of failed appointments between Medicaid and non-Medicaid groups (p <0.001). At a significance level of 0.01, there were no significant interactions between the number of failed and attended appointments for Medicaid nor non-Medicaid patients pre- and during COVID-19 (p =0.149, p =0.065). Conclusions: These findings suggest that the number of insurance approvals and denials during COVID-19 decreased and increased, respectively. Furthermore, these data show that Medicaid patients have a higher rate of appointment failures than non-Medicaid patients pre- and during COVID-19. / Oral Biology

Pregnant people with substance use disorders (SUD) are at high risk of potentially avoidable morbidity and mortality. In particular, pregnant people with opioid use disorder (OUD) have experienced large increases in maternal mortality, largely driven by rising rates of drug overdose. The majority of pregnant people with SUD receive health insurance through state Medicaid programs, many of which use private Medicaid managed care (MMC) plans to finance and deliver health care services rather than through the state-run fee-for-service (FFS) plan. MMC plans receive capitated payments in exchange for coverage of a defined set of benefits. Pregnant people with SUD are predictably high-cost and high-need, and MMC plans may not be able to recoup the high cost of services used over often short periods of enrollment associated with pregnancy. While capitation may incentivize MMC plans to promote access to high-value services that reduce the risk of poor maternal health outcomes, it might also incentivize plans to restrict access to certain services or alter their provider networks in ways that reduce costs. Despite being the dominant delivery vehicle of insurance coverage to this growing population, no research has examined the association between MMC enrollment and maternal health outcomes among pregnant people with any SUD or with OUD. In this Dissertation, I use the newly-available Transformed Medicaid Statistical Information System Analytic Files (TAF) across all three studies. The newly-available TAF files contain claims data for all Medicaid enrollees from all 50 states and the District of Columbia, and represent the most comprehensive data source for longitudinal inpatient and outpatient health service utilization among Medicaid enrollees. In the first study, I develop and validate an algorithm to identify live births using the TAF data. I find that using claims in both the inpatient and other services files are critical to accurately capture live births at the state-year and state-month level. In the second study, I first estimate the burden of SUD and OUD among pregnant people enrolled in Medicaid, and the prevalence of adverse maternal health outcomes in these groups. Next, I examine the association of severe maternal morbidity (SMM) and MMC enrollment among pregnant people with SUD and, separately, OUD nationally from 2016-2018. I find that SMM within six weeks of delivery is more prevalent among those with any SUD (3.2%) and OUD (3.9%) than those without either diagnosis (1.6%). Moreover, I find that enrollment in MMC (vs. Medicaid FFS) is associated with a 0.54 percentage-point (pp) and a 0.66 pp reduction in the probability of SMM among those with any SUD and among those with OUD, respectively. In the third study, I estimate the effect of MMC enrollment on adverse maternal health outcomes using data from two states (Illinois and Missouri) that expanded MMC to statewide. Using difference-in-differences models, I find that expansion of MMC did not change the probability of adverse maternal health outcomes among pregnant people with any SUD. These results suggest that at a minimum MMC has not worsened health outcomes among those with SUD, and at best, MMC may be driving incremental improvements for this group at high-risk of morbidity and mortality. / 2025-07-25T00:00:00Z

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Indiana University-Purdue University Indianapolis (IUPUI) / The dissertation consists of three essays attempting to assess the impact of expanded health insurance policy on cancer care continuum and measure the unbiased program effects after taking care of mis-measured cancer screening self-reports. The first essay examines the impact of the Affordable Care Act’s Medicaid expansion on time to oral cancer treatment initiation since diagnosis, quality of hospital care such as length of stay in the hospital, planned and unplanned readmissions post-surgery, and care outcome such as ninety-day mortality since surgery. The study uses two-way fixed effects linear model analysis under a difference-in-difference estimation setting to show that Medicaid expansion eligibility reduced overall oral cancer treatment initiation timing since diagnosis, including radiation initiation as well as first surgery of the primary site. It also shortened the length of stay in the hospital post-surgery. The second essay assesses the value of electronic medical records from Indiana health information exchange (IHIE) and survey self-reports of Indiana residents seen at Indiana University Health in measuring population-based cancer screening for colorectal, cervical, and breast cancer. Between the two measures of screening, the study examines association using Spearman’s rank correlation and concordance using Percent Agreement and Gwet’s Agreement Coefficient. Health information exchange and self-reports, both provided unique information in measuring cancer screening, and the most robust measurement approach entails collecting screening information from both HIE and patient self-report. In this study, we find evidence of measurement error in self-reports in terms of reporting bias. The majority of the publicly available datasets collect information on cancer screening behavior through patient interviews which are self-reported and may suffer from potential measurement errors. The third essay uses a nationwide population-based database and examines the true, unbiased impact of Medicaid expansion on cancer screening for breast, colorectal, cervical, and prostate cancers after correcting for any bias due to possible misclassification of the self-reported screening status. This study conducts a modified two-way fixed effects probit model under a difference-in-difference estimation setting to identify and correct the errors in the self-reports and estimate the unbiased program effect which shows positive impact on cancer screening with increased effect sizes.

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