With the passage of the Affordable Care Act, states were given the option to expand their Medicaid programs. Since then, thirty-eight states and Washington, D.C., have done so. Previous work has identified the widespread effects of expansion on enrollment and the financial implications for individuals, hospitals, and the federal government, yet administrative expenditures have not been considered. Using data from all fifty states for the period 2007-17, our study estimated the effects of Medicaid expansion overall, as well as differing effects by the size and nature of the expansions. Using a quasi-experimental approach, we found no overall effect of expansion on administrative spending. However, the size of the expansion may have produced differing effects. States with small expansions experienced some increases in administrative spending, whereas states with large expansions experienced some decreases in administrative spending, including a $77 reduction in per enrollee administrative spending compared with nonexpansion states. As more states consider expanding their Medicaid programs, our findings provide evidence of potential effects.

American’s agree that dental health is important and vital to our overall wellbeing. However, not every American is achieving the same degree of oral health. Obstacles that American’s face include dental health disparities, limited access to affordable dental care, and limited access to dental insurance. This study examined how disease risk is shaped within the culture of oral health in Florida. This study examined those who provide dental care, those who cannot afford dental health insurance but earn too much money to qualify for Medicaid, and those with dental insurance. Hypotheses two and three were proven to be true, while hypotheses one and four were proven to be false. Research indicated that the participants believe that pleasingly aesthetic teeth are highly desirable. It revealed that the poor and working poor are unable to utilize dental health insurance, and do not seek annual preventive dental health services due to the cost.

The first chapter examines the impacts of health care provider exits on patient outcomes and subsequent reallocation. Using administrative data on the universe of nursing home patients, I estimate the mortality effects of 1,109 nursing home closures on incumbent residents with a matched difference-in-differences approach. I find that displaced residents face a short-run 15.7% relative increase in their mortality risk. Yet this increase is offset by long-run survival improvements, so the cumulative effect inclusive of the initial spike is a net decline in mortality risk. These gains are driven by patients reallocating to higher quality providers. I also find significant heterogeneity by local market conditions: the survival gains accrue only to patients in competitive nursing home markets, whereas residents in concentrated markets experience no survival improvements. I then develop and estimate a dynamic model of the nursing home industry with endogenous exit. Combining the model estimates with the mortality results, I examine the effects of counterfactual reimbursement policy experiments on nursing home closures and resident life expectancy. A universal 10% increase in the Medicaid rate decreases the frequency of closures, but causes some low-quality providers to remain open in competitive areas. In contrast, targeted subsidies for facilities in areas with limited alternatives improves overall life expectancy by averting the costliest nursing home closures. In the second chapter (co-authored with Szymon Sacher), we estimate a mortality-based Bayesian model of nursing home quality accounting for selection. We then conduct three exercises. First, we examine the correlates of quality, and find that public report cards have near-zero correlation. Second, we show that higher quality nursing homes fared better during the pandemic: a one standard deviation increase in quality corresponds to 2.5% fewer Covid-19 cases. Finally, we show that a 10% increase in the Medicaid reimbursement rate raises quality, leading to a 1.85 percentage point increase in 90-day survival. Such a reform would be cost-effective under conservative estimates of the quality-adjusted statistical value of life. The third chapter (co-authored with Michael Barnett and Adam Sacarny) examines why efforts to raise the productivity of the U.S. health care system have proceeded slowly. One potential explanation is the fragmentation of payment across insurers. Each insurer's efforts to improve care could influence how doctors practice medicine for other insurers, leading to unvalued externalities. We study these externalities by examining the unintended private insurance spillovers of a public insurer's intervention. In 2015, Medicare randomized warning letters to doctors to curtail overuse of antipsychotics. Even though the letters did not mention private insurance, they reduced prescribing to privately insured patients by 12%. The reduction to Medicare patients was 17%, and we cannot reject one-for-one spillovers. If private insurers conducted a similar intervention with their own limited information, they would stem half as much prescribing as a social planner able and willing to better target the intervention. Our findings establish that insurers can affect health care well outside their direct purview, raising the question of how to match their private objectives with their scope of influence.

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The study sought to identify reasons for non-compliance among a particular medical aid scheme's members and their dependants registered for the asthma disease risk management (DRM) programme. A quantitative descriptive study was undertaken, using postal questionnaires. The research results indicated that most asthma patients were not compliant with the DRM programme because they lacked knowledge about the programme. Asthma patients' compliance with the DRM programme can be enhanced by health providers' and case managers' positive attitudes, better promotion of the programme, and by involving the patients in managing their illnesses. Asthma patients require education about healthy lifestyles, empowering them to successfully manage their condition, preventing asthma attacks and/or hospital admissions. When asthma is well-managed the patients' quality of life and general wellbeing will improve and the medical aid scheme's costs will be contained. / HEALTH STUDIES / MA (HEALTH STUDIES)

Purpose: The purpose of this study was to report the distribution of procedures provided to Virginia Medicaid children by three types of dental providers in rural and urban areas. Methods: Medicaid claims filed for dental patients younger than 21 were obtained and analyzed for fiscal years 1994 and 1995. Dental providers were categorized according to their practice type: general practice (GP), pediatric (PD) and public health (PH) dentists. Each type of practice was categorized as practicing in a Metropolitan, Urban, Rural or Completely Rural location and evaluated for percentages of preventive, diagnostic, and corrective services provided.Results: The number of procedures was shown to differ depending upon: year, practice type, location, significant provider status, and the type of procedure.Conclusion: General, pediatric and public health dentists in Metropolitan and Urban areas perform slightly more diagnostic services and much less corrective services than practitioners in more rural areas.

Oral caries is the most prevalent chronic disease among US children, and disproportionately impacts those of low socioeconomic status. Studies have shown that the Special Supplemental Nutrition Program for Women Infants and Children (WIC) improves access to dental care among Medicaid children. This study investigated the impact of WIC, Medicaid, and the State Children's Health Insurance Program (SCHIP) on the prevalence of dental caries among low-income children. The 1999-2000 and 2001-2002 NHANES data were utilized for this analysis. Children 2-4 years old who participated in WIC, Medicaid, or SCHIP, or who were uninsured, and for whom both interview and complete oral health exam data were available (n = 597) were included in the study. Multivariate logistic regression modeling was conducted to examine the effects of program participation on caries. There was no statistically significant association between dental caries and participation in public assistance programs. The risk of dental caries for children in MedicaidSCHIP only was comparable to the risk for children in WIC and MedicaidSCHIP (OR = 1.04; 95%CI = 0.622, 1.745) and also to uninsured children (OR = 0.96; 95%CI = 0.523, 1.773). Dental caries were not impacted if the child did not have a preventive dental visit in the past 6 months (OR = 0.68; 95% CI = 0.436, 1.063) or did not have a regular dental care provider (OR = 1.15; 95% CI = 0.646, 2.044). Participation in WIC and MedicaidSCHIP does not improve the oral health of low-income children. Because this population is a high-risk group requiring more specialized efforts, improving access to care is not sufficient to improve oral health. In addition to increased utilization of services, the program partnership between WIC and MedicaidSCHIP must provide targeted, educational interventions to prevent dental caries. It may also be necessary to increase the recommended number of preventive visits for low-income children.

Self-directed supports, as a method of service delivery, have grown from small pilot programs in a handful of states to at least one program in every state. For individuals with intellectual and developmental disabilities (IDD), self-direction presents unique opportunities to engage in self-determined behavior and shape the services upon which they rely. Although the evidence base for self-direction is relatively robust, there is a significant lack of information on how implementation of self-direction is faring on the national level. The purpose of this study is to understand how the political and economic factors within and across states have impacted the implementation of a self-directed service delivery system.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.