Thesis (Ph.D.)--Virginia Commonwealth University, 2010. / Prepared for: Dept. of Health Administration. Title from title-page of electronic thesis. Bibliography: leaves 133-143.

Thesis (Ph. D.)--Case Western Reserve University, 2006. / [School of Medicine] Department of Epidemiology and Biostatistics. Includes bibliographical references. Available online via OhioLINK's ETD Center.

Thesis (Ph. D.)--Case Western Reserve University, 2006. / [School of Medicine] Department of Epidemiology and Biostatistics. Includes bibliographical references. Available online via OhioLINK's ETD Center.

A key feature of the market for health insurance is selection: a consumer's decision to purchase coverage can affect the costs for producers and the prices faced by other consumers. In three essays, I explore factors that influence consumers to take up insurance coverage, selection in market where a new insurance product was introduced, and the effects of a recent policy to expand coverage among young adults. The first essay examines whether language barriers and network effects can explain disparities in Medicaid participation among low-income immigrants. Using the American Community Survey, I show that linguistic networks facilitate Medicaid enrollment among non-English speaking adults. The identification method follows Bertrand et al. (2000) and employs local variation in the density of immigrant populations and nationwide variation in Medicaid participation among ethnic groups. I also find that the availability of foreign-language Medicaid information online is associated with significantly higher participation. The second essay examines consumer choice in the context of a health insurance exchange. Using data from the Federal Employees Health Benefits program, I examine the extent to which the sudden introduction of high-deductible plans into the system in 2004 may have generated adverse selection. While entry by the newer plan type does not appear to affect premiums of more traditional plan types for federal workers, enrollees in high-deductible plans are more likely to be younger and male. The final essay analyzes one of the earliest coverage-related provisions of the Affordable Care Act to take effect, the extension of health insurance coverage to child dependents up to age 26. Survey data reveal the law resulted in a marked increase in the number of young adults covered by private insurance. Analysis of medical claims data from private health insurance shows a relative decrease in average spending among young adults after the law took effect, implying that the dependent coverage provision brought healthier young adult individuals into the risk pool.

OBJECTIVES: (1) to investigate trends in non-traumatic dental visits (NTDV) to hospital-based emergency departments (ED) in Rhode Island (RI) and to compare them with those for other ambulatory sensitive care conditions (ACSC); (2) to examine the effect of expansion of Medicaid coverage on the rate NTDV to ED; (3) and to examine community-level factors associated with NTDVs. METHODS: Data for ED visits in 2005–2014 were obtained from RI hospital discharge data and annual population estimates from the U.S.Census Bureau, and were used to calculate annual visit rates. Medicaid enrollment report for the calendar years 2013 and 2014 were used to calculate monthly enrollment and an interrupted time series analysis was used to examine the effect of expansion of Medicaid coverage on visit rates. Zip code was used as a unit of analysis for community-level factor analysis, 2010 data. A negative binomial regression model with log link was performed. RESULTS: From January 2005 to December 2014, the annual average number of ED NTDV was 7440, accounting for 1.4–2.1% of all ED visits each year, there was a slight but not statistically significant decrease in the NTDV rate between 2005 and 2014. Visits for asthma also declined slightly, but the decrease was statistically significant. There were statistically significant increases in ED visit rates for diabetes and back pain. The NTDV rate increased by 34.8/100,000 enrollees per month immediately and significantly after expansion, amounting to more than 1000 additional ED visits. ED visits for asthma and back pain declined immediately after the expansion of coverage, but not significantly so. Community-level factors associated with NTDVs were higher level of poverty and communities with younger population (more individuals aged 20–34 years) which had significantly higher ED NTDV rates. CONCLUSION: RI NTDVs slightly declined, but still accounts for around 1.6% of ED visits. Medicaid expansion under the ACA, caused an immediate increase in NTDVs to ED, that might be attributed to the increased number of Medicaid enrollees, with no change in the workforce. Among community-level factors, high poverty level and high percent of young population had the highest impact on visit rates. / 2019-09-26T00:00:00Z

This dissertation evaluates the effectiveness of public interventions in tax policy (such as a tax compliance campaign in Greece), the performance of public institutions that dictate land zoning (corruption of zoning officials in Greece and Spain) and public health (publicly-provided health insurance; namely, Medicaid). The common underlying theme of the dissertation is the public nature of the policies examines with an empirical emphasis. The ultimate goal of this research body is to provide credible policy solutions for the improvement of public administration.

acase@tulane.edu / Background It is estimated 3 to 5 million individuals in the U.S. are chronically infected with the Hepatitis C virus (HCV). (Durham DP, 2016) More than 12,000 deaths occur annually in the U.S. as a result of HCV-related liver disease. (Wieland A, 2015) The cost of treatment medication for an individual with HCV genotype-1 is approximately $100,000 for 12 weeks of therapy. (Reau N, 2014) The exorbitant cost of HCV treatment has led to fears that many who could benefit from treatment will not receive it considering many with HCV are uninsured or have Medicaid. Purpose The purpose of this study is to quantify the cost, cost-effectiveness, and adverse outcomes associated with denying or delaying HCV treatment among the Louisiana Medicaid (LA-Medicaid) HCV GT-1 population. Methodology This project evaluates the cost and cost-effectiveness of treating HCV compared to not treating; initiating early treatment compared to late treatment and HCV-related health outcomes. A decision tree and Markov model simulates progression through the various states of health involved in progressive HCV disease, including death (hepatic and other causes). Results Don’t Treat/Treat Comparison Treatment was generally cost-effective, exhibiting an incremental cost-effectiveness ratio (ICER) of $21,670/life-year and $37,067/QALY (Quality-Adjusted Life-Years) gained. Optimal Treatment Stage Comparison Treatment of a person at F0 was cost effective, exhibiting an ICER of $6,482/QALY and $6,194/year of life compared to not treating at all and treating at F1, F2, F3, F4 or after LT. Conclusion Treatment of HCV-infected patients without liver fibrosis or in early stages of liver fibrosis appear to be more cost-effective than treating in advance stages of liver fibrosis or denying treatment. / 1 / Dwana Green

With over 20 million Americans living in food deserts, it is no wonder why the children who living in these areas are consuming more processed foods. Processed foods and lack of proportional diet can have an adverse effect on the oral health of children and adults leading to tooth decay. Early Childhood Caries (ECC) is the most chronic disease in children and it is especially chronic within children who come from disadvantage backgrounds. The objective of this study is to explore the multiple paradigms of tooth decay that exist within the minority population of children. The mechanism behind what leads to tooth decay will be evaluated in conjunction with other factors such as: disparities within minority children, insurance coverage, and agriculture to demonstrate the high prevalence of ECC within minority children. What goes in a child’s mouth can really determine the state of their oral healthcare, however more times than not children lack the responsibility and depend heavily upon their guardian to get their dental needs met. The development of ECC can lead to more severe problems if left untreated, and currently there is a high prevalence of untreated ECC in predominantly minority neighborhoods where families are typically low income. Low-income means they are less likely to have a primary dentist leading to more untreated ECC, however it is also important to look at the federally funded programs. The government has been able to take strides in helping provided coverage for these at-risk children. ECC is chronic and can be detrimental to a child’s healthcare. What goes in the child’s mouth is also important in that in low-income neighborhoods there are deserts full of no organic options. This can have an adverse effect on the child’s help by their famine nutritional needs. There is a need for new policy to be implemented in order to increase the rate at which children go to the dentist as well as gain access to avoidable options. Although there were limits within this study, there are many suggested improvements and directions for future research to address. In conclusion, although the data reported here supports the conclusion that more evidence is needed that will lead to significant policy reform to eliminate the high prevalence of ECC especially within children coming from minority backgrounds. Positive progress is being made due to the constant support from both the government and community resources as well as dental practitioners who are focused on making a difference in the oral health and overall well-being of children.

Importance: Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer. Objective: To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer. Design, Setting, and Participants: This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021. Exposures: State Medicaid expansion status. Main Outcomes and Measures: Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses. Results: Among a total of 340552 patients with newly diagnosed genitourinary cancers, 94033 (27.6%) had kidney cancer, 25770 (7.6%) had bladder cancer, and 220749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas. Conclusions and Relevance: These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.

The study was an investigation into health care accessibility for children with autism spectrum disorder (ASD) following the transition to a private Medicaid system in the state of Florida. Pilot studies of managed Medicaid programs focused on costs and did not address how changes to the system impacted access to health care services. There were limited studies designed to understand how a change in the system, such as a privatization, would affect vulnerable populations such as young children with ASD. Additional concerns existed for children that were historically underserved by the health care system such as African American and Latino children because they typically had more difficulty accessing health care services in general. A modified version of the Consumer Assessment of Health Providers and System (CAHPS) Survey 4.0 was used in this study. The modifications to the survey included reducing the number of survey questions and adding open-ended questions. 86 participants were recruited from local organizations that supported children and families affected by ASD. Findings generated using nonparametric tests such as the Mann-Whitney U test and chi-square revealed delays in accessing therapeutic health care services that were pervasive in both private and public insurance groups. Furthermore, the qualitative analysis indicated that participants did not view their difficulties in accessing therapeutic health care services as related to race or ethnicity. Limitations of the study included the modifications made to the survey instrument. Implications for positive social change include a better understanding of the scope of the issue of therapeutic health care access for those advocating on behalf of children and families affected by autism.