This dissertation comprises three discrete empirical papers, with an introductory essay that evaluates the impact of different federal policies on prescription drug prices, utilization, and spending. Two main databases are used: (a) Medicaid State Drug Utilization Data and (b) the Medical Expenditure Panel Survey (MEPS) data. These two databases are designed to track Medicaid drug utilization and overall medical use and expenditures, respectively. The variables of interest in this dissertation are prescription drug price, prescription drug use and spending, and overall drug expenditures. The objective of the first paper (Chapter 2) is to examine whether oncology drug prices have significantly changed because the Medicaid rebate increased under the Patient Protection and Affordable Care Act (ACA). The analytic sample includes top-selling oncology drugs, both branded and generic, over an 8-year time period. The prices of top-selling oncology drugs in 2006 were followed through 2013 to find the extent to which drug prices have changed while controlling for state fixed-effect, package size, type of manufacturer, brand or generic, and drug strength. Thus, this study examines whether and to what extent oncology drug prices have changed after the increase in the Medicaid rebate under the ACA. The second paper’s objective (Chapter 3) is to study whether Medicare Part D has reduced racial disparities in diabetes drug use, coverage, and spending since its implementation in 2006. The analytic sample includes individuals aged 55 years and older who had diabetes from 2001 to 2010. Although the impact of Medicare Part D has been studied from different perspectives, its impact on racial disparities in drug use, coverage, and expenditures among diabetics has not been studied yet. The third paper (Chapter 4) focuses on the association between closing the Medicare doughnut hole and prescription drug utilization and spending for Medicare Part D beneficiaries with chronic diseases through 2013. The objective of the third paper is to determine whether the provisions of the ACA that close the coverage gap have affected prescription drug utilization and out-of-pocket (OOP) spending among Medicare seniors with Part D coverage.

Medicaid expansion under the Affordable Care Act (ACA) facilitates access to care among vulnerable populations, but 21 states have not yet expanded the program. Tennessee’s Medicaid program experienced a dramatic Medicaid contraction when the program disenrolled approximately 170,000 nonelderly adults in 2005. Pre-ACA expansions were associated with better access to and utilization of healthcare services. However, little is known about the effect of these policy changes on improvement in health outcomes for women diagnosed with breast cancer, access to care for cancer survivors, and the effect of generosity and duration of expansion on access to care. This dissertation has three objectives. First, to assess the effects of the Tennesse’s Medicaid disenrollment on stage at diagnosis and delay in surgery for breast cancer among nonelderly women. Second, to compare access to care between cancer survivors living in non-expansion states and survivors living in expansion states. Third, to examine the effect of generosity and duration of the pre-ACA Medicaid expansions on access to and utilization of healthcare services. I use three different types of datasets: the 2002-2008 data from Tennessee Cancer Registry, the 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS), and the 2012 Medical Expenditure Panel Survey (MEPS) data. I estimate difference-in-difference models and perform multiple logistic regression models to examine the impact of these policy changes on the different measurement outcomes. While many states are expanding Medicaid eligibility under the Affordable Care Act, there has been discussion among policymakers in some states about reducing eligibility under the Affordable Care Act once full federal funding expires. This study suggests that Medicaid disenrollment leads to later stage at diagnosis for breast cancer patients, indicating negative health impacts of contractions in Medicaid coverage. Prior to the passage of the Affordable Care Act, cancer survivors living in expansion states had better access to care than survivors living in non-expansion states. Failure to expand Medicaid could potentially leave many cancer survivors without access to routine care. The study informs policy makers that, relative to no expansion, moderate or generous expansion is associated with improvement in access to and utilization of healthcare services.

“Strange Bedfellows” examines how the political economy of Medicaid and hospital provision shaped the social, political, and thus material response to the HIV/AIDS epidemic in the United States. By doing so, this study explores the consequences of a decade-plus shift that began in the late 1960s, wherein federal, state, and local policymakers deemphasized epidemic preparedness and acute care in favor of downsized hospitals, increased outpatient services, and more “personal responsibility.” Over the course of seven chapters, the study links the transformation of Medicaid into a welfare medicine program; federal health planning’s shift from the pursuit of equality to cost-cutting; the role that anti-inflation policy played in curtailing subsidies for hospitals and clinics, which reduced access to acute care; the diminution of civil rights protections for quality healthcare; and the effects these developments had on the response to HIV/AIDS. Challenging the notion that the HIV/AIDS epidemic was unforeseen and, thus, impossible to plan for, the study demonstrates how a series of purposeful decisions by presidential administrations, Congress, state legislatures, and city officials led to chronic underinvestment in public and voluntary hospitals that served poor people and people of color. A story of the neoliberal transformation of the Medicaid program and public and voluntary safety net hospitals, this dissertation illustrates how healthcare and welfare politics intertwined from the mid-1960s to the new millennium in ways that confounded the United States’ epidemic preparedness. A healthcare system focused on chronic disease by the 1960s and cost cutting in the 1970s could not cope with an emergent infectious disease like HIV/AIDS.

Objective: To investigate and determine periodontal treatment needs by the use of the Community Periodontal Index of Treatment Needs (CPITN) of a Medicaid expansion population in the state of Iowa (DWP) in comparison with patients insured by the traditional Medicaid State Plan, patients with private dental insurance, and self-pay patients, while evaluating for systemic health conditions and socio-behavioral factors. Methods: A secondary data analysis of electronic health records (EHR) from the University of Iowa College of Dentistry was completed and analyzed. Univariate and bivariate analyses were conducted. Logistic regression models were used to analyze relationships between predictors and periodontal treatment need. Results: Out of the study population, 54% were indicated for scaling and root planing (SRP). Predictors of indicating the need for SRP treatment were found to be: Age (p< .0001), gender (p< .0001), medical diagnosis of diabetes (p=.031), smoking status (p< .0001), and not receiving regular dental check-ups (p< .0001). Discussion: Our findings are consistent with common periodontal disease predictors found in the literature. Interestingly, insurance status was not a significantly associated predictor of periodontal treatment needs. However, approximately 50% patients with all insurance types were indicated for SRP. Implications: DWP patients must earn benefits by maintaining dental appointments. This earned benefits approach delays periodontal treatment as patients must earn this procedure, potentially leading to deteriorating periodontal health. Further assessment of periodontal burden in the DWP population should be conducted and potential program structure evaluated.

In 2009, the Government Accountability Office reported that 15% of federal nursing home (NH) recertification surveys nationwide and 25% of surveys in nine states underscored serious deficiencies in nursing care provided to 1.5 million residents residing in NHs. The state nursing home survey agencies' surveyors attributed the Centers for Medicare and Medicaid Services (CMS) administrative rules and the documents in the surveyor guidance manual as too complex and ambiguous to correctly assign deficiency severity scores. In review of nursing literature, it was noted that standardized nursing language can increase the clarity of complex systems. The premise of this exploratory study was to determine if the standardized language of the Nursing Outcomes Classification (NOC) could provide a cross-linkage of the CMS rules, indicators of substandard nursing care, and the full guidance manual used to assign deficiency severity scores. The study attempted to achieve this goal by aligning select NOC outcomes and indicators with nursing outcomes indicators in the CMS administrative rules, select documents in the surveyor guidance manual and select documents in the Quality Indicator Survey. The data analysis suggested the relationship of the origin of the CMS rule and documents to the degree of alignment with the select NOC outcomes and indicators. It was also found that the intent of the CMS rule and select documents shared common themes. In addition, the data analysis revealed that the CMS rule and select documents aligned in various degrees with all of the selected NOC outcomes and respective indicators. The data analysis confirmed that there is sufficient evidence of a degree of alignment of select NOCs with the CMS rule and documents in the guidance manual for activities of daily living and functional status. Furthermore, the data analysis confirmed that this body of work can be a baseline for future research to develop an NOC specific to NHs as a viable cross-link to the CMS rules and guidance manual.

The UpliftU® program is a long-term residential program for women and families who are homeless or at risk for homelessness. This program is one part of a larger, community-based non-profit organization serving low-income and homeless families in Hillsborough County, Florida for over 35 years. This program is not an emergency shelter program, but rather offers up to 18 months of participation in a self-sufficiency program to single women and families. The goal of the program is to prevent future homelessness for residents by helping them to reach their highest level of self-sufficiency. After volunteering at this organization for nine months, I completed an internship as the Health Specialist Case Manager for the UpliftU® program during the summer of 2008. The internship was conducted using ethnographic research methods to understand counseling team members' and resident mothers' perceptions of access to health care resources and their experiences in utilizing area health care services. This thesis compares the perspectives of the counseling team members with the resident mothers' perspectives, and examines barriers to and gaps in service provision, as reported by both groups. Findings from qualitative data analysis suggest that counseling team members conceptualize the barriers to health care as originating at the individual level with resident mothers' behaviors and actions, while resident mothers' expressed that they experience barriers to health care services at interpersonal and institutional levels. Resident mothers described how health professionals and staff treating them poorly leads to barriers to health care at an interpersonal level, and that at an institutional level the bureaucratic hassles associated with public insurance and public clinics also acted as barriers to care. Such differences in perception of causality of barriers to health care services between counseling team members and resident mothers have significant ramifications for resident mothers' health and ability to access health care services.

In the fiscal year 2014, approximately 1,337 health care providers lost their provider license to Medicare/Medicaid fraud. Out of the 1,318 criminal convictions reported by the U.S. Medicaid Fraud Control Units (MFCU), 395 (30%) were home health care aides who claimed to have rendered services not provided. The purpose of this multiple case study was to explore licensed and certified home health care business managers' strategies to mitigate Medicare/Medicaid fraud risk. A purposive sampling of 9 business managers and chief executive officers from 3 licensed and certified home health care businesses in Franklin County, Ohio participated in semistructured face-to-face interviews. Data from the interviews were transcribed, coded, and analyzed to identify themes regarding Medicare/Medicaid fraud risk management strategies. Drawing from the Committee of Sponsoring Organization's internal control framework and fraud management lifecycle theory, 5 themes emerged: the control environment, risk assessment, control activities, information and communication, and monitoring activities. Findings from this study included maintenance of integrity and culture, training and educating both staff and clients about fraud reporting processes and the consequences of fraud, rotating staff on a regular basis, performing fraud risk assessments, implementing remote timekeeping and monitoring system, and compensating shift leaders to coordinate activities in the clients' residences. The implication for positive social change includes reducing healthcare cost for all taxpayers through Medicare/Medicaid fraud reduction.

Many people in the United States have untreated dental disease due to a lack of dental insurance, a lack of oral health knowledge, and a lack of priority placed on dental health. Despite an increase in dental service use by Medicaid recipients as a result of local programs, children enrolled in Medicaid often have low rates of use of dental services. Using the health literacy framework of the Paasche-Orlow and Wolf (POW) model, the purpose of this study was to explore to the relationship between oral health literacy of parents and dental service use for children enrolled in Medicaid and the differences in use rates between preventive and restorative services. A cross-sectional research design was employed within a convenience sample of parents who presented to a nonprofit clinic for a medical appointment. Participants completed a demographic profile, an oral health questionnaire, and REALD-30 survey. Responses were correlated with dental claims retrieved from 1 reference child for each parent. Pearson's correlation revealed no significant relationship between oral health literacy and dental service utilization, r = -.056 (p = .490). An ANOVA revealed no difference in utilization between preventive and restorative services, F (2, 149) = .173, p = .841, ç2 = .002. However, high rates of use for restorative services were observed, suggesting a high prevalence of tooth decay in children. Although this study did not find a significant relationship between oral health literacy and dental utilization, barriers continue to exist that contribute to the high rates of tooth decay in children enrolled in Medicaid. This study impacted social change by highlighting the importance of preventive care in reducing the prevalence of tooth decay.

Oral health impacts general health and well-being throughout the lifespan. Recent trends in the United States towards cessation of community water fluoridation (CWF) may increase disparities in oral health. The purpose of this quantitative retrospective cohort study was to analyze Medicaid dental claims records for caries related procedures among 0 to18-year-old patients during an optimal CWF year 2003 (n = 854) and compare them to claims records from 2012 (n = 1,053), 5 years after CWF was ceased. The theoretical framework of this study was the diffusion of innovations theory. Statistically significant results included higher mean number of caries related procedures among 0 to18 year and < 7-year aged patients in the suboptimal CWF group (2.57 vs. 2.43, p < 0.001; 2.68 vs. 2.01, p = 0.004, respectively). Mean caries related treatment costs per patient was also higher in the 0 to18 year and < 7-year suboptimal CWF groups compared to the optimal CWF group (583.70 vs 344.34 $, p < 0.0001; 692.87 vs. 350.13 $, p < 0.0001, respectively). Binary logistic regression analysis results indicated a protective effect from optimal CWF for the 0 to18 and < 7 year age groups ([OR] 0.75, 95% CI [0.62, 0.90], p = 0.002); OR = 0.70, 95% CI [0.52, 0.95], p = 0.02, respectively). The results confirm optimal CWF exposure prevents dental decay, expand the evidence base of caries epidemiology under CWF cessation, and indicate patients without early childhood CWF exposure experience more dental caries procedures and treatment costs. These findings may create opportunities for social change by supplying evidence that can be used to improve equity oriented oral health public policies that protect population health.

Significant efforts have been undertaken in medicine to identify hospital and primary care service areas (eg, the Dartmouth Atlas of Health Care) using patient origin information. Similar research in dentistry is nonexistent. The goal of this dissertation was to develop and refine methods of defining dentist service areas (DSAs) using dental insurance claims. These service areas were then used as spatial units of analysis in studies that examined relationships between utilization of oral health services, dentist workforce supply, and service area characteristics. Enrollment and claims data were obtained from the Iowa Medicaid program for children and adolescents ages 3-18 years during calendar years 2008 through 2010. The first study described rates of treatment by orthodontists in children ages 6-18 years. Orthodontic DSAs were identified by small area analysis in order to examine regional variability in utilization. The overall rate of utilization was approximately 3%; 19 DSAs were delineated. Interestingly, children living in small towns and rural areas were significantly more likely to have received orthodontic services than those living in metropolitan and micropolitan areas. The second study identified 113 DSAs using claims submitted by primary care dentists (ie, general and pediatric dentists). Characteristics of these primary care DSAs were then compared with counties. Localization of care was used as a measure of how well each region approximated a dental market area. Approximately 59% of care received by Medicaid-enrolled children took place within their assigned service area versus 52% of care within their county of residence. Hierarchical logistic regression was used in the final study to examine the influence of spatial accessibility and the importance of place on the receipt of preventive dental visits among Medicaid-enrolled children. Children living in urban areas were more likely to have received a visit than those living in more rural areas. Spatial accessibility assessed using measures of dentist workforce supply and travel cost did not appear to be a major barrier to care in this population. More studies are needed to explore the importance of spatial accessibility and other geographic barriers on access to oral health services. The methods used in this dissertation to identify service areas can be applied to other populations and offer an appropriate method for examining revealed patient preferences for oral health care.