Women’s access to substance use disorder (SUD) treatment is affected by their social status and policies that present both opportunities and barriers to treatment. Motherhood, including pregnancy, tends to increase participation in health care and thus opportunities for referral to and engagement in SUD treatment. However, the multiple challenges of motherhood along with the social and legal sanctions that may be visited on mothers who use alcohol or drugs may impede access to treatment. Moreover, motherhood and drug use lie at the focus on great public and policy concerns due to the ways it has been construed in health policy discourse. There is a moral connotation regarding the criminalization of substance use during pregnancy. Mothers’ pathways to SUD treatment are complex, at turn they may be positively supported or seek to avoid opprobrium. Moreover, the opportunities and barriers continue to evolve. This dissertation sought to elucidate the contemporary settings in which mothers access SUD treatment, focusing on women’s use of health and social services and macro-level public policies, particularly the expansion of Medicaid with the Affordable Care Act and state laws that specifically criminalize drug use by mothers. In Study 1, I reviewed the literature on access to SUD treatment services among pregnant women and women who have children. I found that women have unique opportunities and barriers to access treatment services. I built a conceptual model of women’s pathways into care according to the type of barriers that may encounter by each “gateway.” Gateways are formal institutions or settings that may act as “gates” between pathways and may refer patients to treatment, but not all gateways may be actively referring patients. These sources became the foundation for Study 2, in which I empirically tested whether women’s engagement in gateways identified in Study 1 would be an effective mechanism for promoting SUD treatment. The findings suggest that Medicaid eligibility and criminal justice involvement increased women’s access to SUD treatment services. In Study 3, I examined the effects of Medicaid Expansion on medications for opioid use disorder (MOUD) and treatment completion as it relates to state laws that criminalize substance use during pregnancy among pregnant women. I found that criminalization policies prevented Medicaid expansion from realizing its full effect on increasing access to MOUD for pregnant women. Altogether, these studies elucidated the need for women-centered and life-course adjusted approaches in engaging women in treatment. / 2023-05-14T00:00:00Z

This thesis seeks to investigate the 2014 Medicaid expansion’s effect on maternal mortality rates for New York and California. The CDC reported in 2019 that maternal mortality rates have been increasing. These findings are concerning for mothers and are a problem for developed nations like the United States with improved healthcare. Furthermore, women of color are disproportionately affected relative to white women. Previous research has indicated that healthcare expansions positively affect decreasing death rates among pregnant women. In this study, I investigate how increased access to healthcare through the 2014 Medicaid expansion under the Affordable Care Act affects maternal mortality for New York and California. I utilize the publicly available CDC Wonder Underlying Cause of Death 1999-2020 data to conduct my research for this analysis. For my analysis, I chose to observe the years 2006-2016. I plotted each state’s mortality rates by year to observe any visual trends or changes in reported data and then after ran regressions of each race on deaths. The results exhibited that women of color tend to experience higher maternal mortality ratios. When observing how deaths have changed post-expansion, the coefficients were not statically significant to a degree that would allow me to make confident conclusions that mortality rates had improved. This study contributes to the literature that women of color are more likely to suffer worse maternal health outcomes than white women. It brings to light the importance of attaining a solution to this issue.

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This dissertation studies the impact of Medicaid expansion on the liability insurance industry. Within the three chapters, the first two chapters focus on the medical liability insurance industry, and the third chapter focuses on the auto insurance industry. Chapter 1, “Medicaid Expansion and Medical Liability Costs”, examines the impact of health insurance expansion on medical liability costs using the case of the Affordable Care Act’s (ACA) Medicaid expansion. Medicaid expansion has increased the demand for medical services, but in doing so it may also have increased physicians’ liability in medical practice. By studying malpractice costs to insurers, medical practitioners, and hospitals in the U.S. for the period 2010–2018, we find insurers operating in states with Medicaid expansion experienced significantly higher medical liability costs than those in non-expansion states. While insurers in expansion states did increase premiums, the increase was not enough to fully offset rising costs. Moreover, we find that tort reforms did not mitigate ACA-induced malpractice liability costs. We show this is because Medicaid expansion increased malpractice costs mainly by increasing claim frequency while tort reforms generally focus on reducing claim severity. We further find little evidence that hospitals paid higher malpractice insurance premiums, self-insurance, or incurred higher out-of-pocket medical liability losses after Medicaid expansion. Taken together, our results imply that it is medical practitioners and malpractice insurers who bear the rising medical liability costs. Chapter 2, “Medicaid Expansion and Medical Liability Insurance Prices” extends the first chapter to study the impact of Medicaid expansion on medical liability insurance prices for three specialties, internal medicine, general surgery, and obstetrics-gynecology (OB-GYN). As Medicaid expansion increased medical liability costs to insurers, they may react by increasing medical malpractice insurance prices. By studying counties in expansion states and non-expansion states and bordering counties with different Medicaid expansion status over the years from 2010-2018, we find that Medicaid expansion leads to significantly higher medical liability insurance prices two years after the expansion on average and the impact is strongest for internal medicine and general medicine but less so for OB-GYN. Our finding suggests that the expansion of health insurance could increase liability costs to medical practitioners. Auto insurance provides coverage of healthcare for injured drivers even for those without traditional health insurance coverage. The expansion of public health insurance provides low-income injured drivers with an additional source of coverage for medical bills. This may change drivers’ incentives for using auto insurance and the ultimate payments made by auto insurers. In Chapter 3, “Public Health Insurance Expansion and Auto Insurance: The Case of Medicaid Expansion”, we first use a simple theoretical model to illustrate how obtaining public health insurance mitigates the incentive of insured drivers to engage in claims buildup. We then empirically test how the Affordable Care Act (ACA)’s Medicaid expansion changed the medical costs covered by auto insurance. By studying private passenger auto insurers in expansion states and non-expansion states between 2010 and 2018, we find that Medicaid expansion led to significantly lower auto insurance losses and premiums. We further show that the results were driven by the decreasing losses and premiums for third-party liability insurers but not in the states with no-fault insurance. / Business Administration/Risk Management and Insurance

Introduction: The volume of antipsychotic medications prescribed to children and adolescents has risen sharply since second generation antipsychotics, also referred to as atypical antipsychotics, were introduced in the 1990’s. The concern surrounding the expanded use of antipsychotics was that the medications have significant adverse metabolic side effects and they were often prescribed to treat conditions in young children for which they have not been proven to be safe and effective. While it is not unlawful for health care providers to prescribe medications for uses beyond which they have been approved by the United States Food and Drug Administration, the lack of empirical evidence guiding much of the antipsychotic use in children had professional pediatric medical groups and policy makers concerned for the well-being of children receiving the medications. Several states, including Pennsylvania, enacted prior authorization policies in an attempt to restrict prescribing to children where a medical need has been established. However, the impact of the policies is largely unknown since published data on the topic is sparse. Methods: This retrospective, medical claims-based cohort study, used de-identified administrative Medicaid data from January 2008 to December 2010 to investigate the impact of Pennsylvania’s September 2008 antipsychotic prior authorization policy on antipsychotic prescribing prevalence in children targeted by the policy. Descriptive methods and segmented regression of the interrupted time series were used to assess the effects of the policy on monthly antipsychotic prescribing prevalence. A difference-in-difference analysis compared Pennsylvania’s prescribing to Ohio, a geographically proximate and demographically similar state without a prior authorization policy; and Delaware, a state that enacted a policy 3 years prior to Pennsylvania. The potential for compensatory prescribing was assessed by reporting the prevalence of other psychotropic medications over the study period. Results: An average of 99,074 Pennsylvania Medicaid enrollees ages 0-6 were identified as meeting the study criteria annually from 2008-10. Immediately following the policy intervention, an abrupt, significant reduction in monthly prescriptions of antipsychotics was observed (-51 prescriptions per 100,000; p=0.0052) and sustained over the observation period. The proportion of children filling prescriptions for antipsychotics dropped approximately 46% and the average number of antipsychotic prescriptions filled per month was reduced by 53% in 2010 compared to 2008. In Ohio, a state without such a policy, the proportion of children receiving an antipsychotic increased nearly 10% in 2010 compared to 2008 and the average number of monthly prescriptions increased 30%. Reductions in antipsychotic prescribing in Delaware, a state that had its antipsychotic policy in place since 2005, were comparable to Pennsylvania. There was no evidence that non-antipsychotic psychotropic medications were prescribed in place of the medications restricted by the policy. Conclusions: Pennsylvania’s 2008 prior authorization policy was associated with a significant decrease in annual and monthly antipsychotic prescribing prevalence in Medicaid-insured children targeted by the policy, those ages 0-6 years of age. Reductions in most other psychotropics was also observed, indicating changes in prescribing behavior may have extended beyond antipsychotics. While this analysis suggests the policy may have achieved its primary aim of reducing antipsychotic prescribing, more research is needed to better understand the complex array of factors influencing provider behavior and to explore potential unintended consequences of the policy. / Public Health

This study sought to investigate the effect of state-level policies, pertaining to hate crimes and mental health care, on the association between sexual orientation and the prevalence of depression, suicidal ideation, suicide attempt, and bullying amongst adolescents. State-level policies included whether hate crime laws included sexual orientation as a protected category, and rates of follow-up care after hospital discharge amongst acutely mentally ill youth covered by public health insurance (Medicaid or the Children's Health Insurance Program; CHIP). Data were from the 2019 State-Level Youth Risk Behavior Survey (YRBS), completed by a representative sample (N = 153,215) of U.S. students in grades 9-12 across 44 states. The YRBS is one of the few population-based studies to gather sexual orientation data in a youth sample. Compared with living in states with hate crime laws extending protections to lesbian, gay, and bisexual (LGB) people, living in states without inclusive hate crime laws did not predict a significantly stronger association between LGB status and mental health. However, the association between LGB status and electronic (i.e., cyber) bullying was significantly greater in states with hate crime laws that excluded sexual orientation as a protected category than in states with inclusive hate crime laws. The association between LGB status and suicide attempt was significantly greater in states with lower rates of follow-up mental health care for acutely ill youth than in states with higher rates of follow-up care. This is the first known study to find an association between residing in a state with higher quality government-funded mental health care for acutely ill youth and reduced suicide attempt among LGB youth. These findings underscore the urgent need for state-level policies that increase legal protections and improve access to mental health care for sexual minority youth. / Doctor of Philosophy / This study investigated the relationship between state-level policies, mental health, and bullying among lesbian, gay, and bisexual (LGB) high school students. State-level policies included whether hate crime laws included sexual orientation as a protected category, and rates of follow-up care after hospital discharge amongst severely mentally ill youth enrolled in Medicaid or the Children's Health Insurance Program (CHIP). Data were from the 2019 State-Level Youth Risk Behavior Survey (YRBS), completed by 153,215 U.S. students in grades 9-12 across 44 states. The YRBS is one of the few large studies to gather information about sexual orientation in a youth sample. Participants were more likely to be cyber-bullied if they lived in states that didn't include sexual orientation as a protected category. LGB high school students living in these states were at even greater risk of being cyber-bullied than their heterosexual peers. Youth residing in states with better follow-up care were less likely to attempt suicide. LGB youth living in states with worse follow-up care were at even greater risk of attempting suicide than their heterosexual peers. This is the first known study to find a relationship between residing in a state with higher quality government-funded mental health care and reduced suicide attempt among LGB youth. These findings underscore the urgent need for state-level policies that increase legal protections and improve access to mental health care for sexual minority youth.