In 2001, The Institute of Medicine published its recommendations for bringing high quality care to all people of the United Sates. That solution involved fulfilling criteria expressed in the acronym, STEEEP. Care must be: Safe, Timely, Effective, Efficient, Equitable and Patient Centered (Institute of Medicine 2001). While improvements were made in terms of infant mortality, longevity, and deaths amenable to quality care, healthcare in the United States has remained fragmented with much work yet to be done. This leaves many uninsured individuals without access to affordable healthcare. Despite the implementation of policies such as the Affordable Care Act and the American Rescue Plan, which have expanded Medicaid and given access to many, it still falls short. Approximately 24.9 million people remain uninsured. The rising costs of healthcare in the U.S. have led to both insured and uninsured patients being exposed to medical debt, lower health status, and limited access to care. Safety net clinics, such as free clinics, have become essential for many uninsured individuals who rely on them to receive medical care. Free clinics are an example of safety nets that give medical access to the uninsured. These clinics have positive results on health outcomes and help to lower healthcare expenditures, particularly in emergency room visits. Studies have shown that uninsured individuals are more likely to use emergency services, which results in higher healthcare costs. Free clinics provide preventative care and early interventions that can help prevent costly emergency visits and hospitalizations. Moreover, free clinics serve as a place for volunteers to grow their skills and become better providers of medicine. Volunteers include physicians, nurses, medical students, and other healthcare professionals who dedicate their time and expertise to help those in need. Volunteers at free clinics are provided with a unique opportunity to enhance their skills by working with a diverse patient population that often has complex medical conditions. Free clinics are essential safety nets that provide medical access to the uninsured and underserved communities. Without these clinics, many uninsured individuals would be left without access to care, leading to poor health outcomes and higher healthcare costs. The importance of free clinics cannot be overstated, and unless there is a change in the current healthcare system, free clinics should be given the place they deserve, including more volunteer and funding support. As the U.S. healthcare system continues to evolve, it is critical to recognize the value of free clinics and the role they play in ensuring access to care for all individuals, regardless of their insurance status.

Purpose: To assess the impact of dental Medicaid reform in Virginia on dental practice settings (private practice, corporate practice and safety net clinics). Methods: This retrospective cohort study of 16.2 million dental claims is from the Virginia Department of Medical Assistance Services, which included claims for providers participating in Virginia’s Medicaid program during a 10-year period (2002-2012). The dividing date for the reform was July 1, 2005. The outcome measure was mean claims per participating provider. A Poisson regression model was used to predict the mean number of claims per provider with the following predictors: reform period, practice setting, provider specialty, practice location. Results: The mean number of claims after program reform was significantly higher depending on practice setting and provider specialty, but not practice location. Conclusion: Medicaid reform has resulted in a significant increase in the number of dental claims, providers, and practice settings in Virginia.

This dissertation consists of three essays examining the role of transfer-program interactions for families and households who participate in the social safety net. The safety net is comprised of many different programs, run by different agencies, governed by different rules, and often administered by disparate and secluded entities. However, many households participate in multiple programs, subjecting them to the milieu of administrative hurdles. In this dissertation, I try to untangle some of the intended and unintended effects of program participation that may be experienced by these households. In Essay 1, I examine the effect of the Patient Protection and Affordable Care Act of 2010 (ACA) on food hardship in US households, utilizing food security information from the Food Security Supplement of the Current Population Survey. Because states adopted the Medicaid expansions provided under the ACA at different times beginning in 2014, the cross-state, over time variation allows me to separate the impact of the ACA on food hardship using triple difference specifications. The richness of questions in the Food Security Supplement allows me to examine the effect of the ACA across different measures of food hardship, and also examine differential response for households participating in the Supplemental Nutrition Assistance Program (SNAP). Examining the mechanisms through which the ACA could affect food insecurity, I find the ACA not only increased average weekly food expenditure, but also the probability a household participates in SNAP. I employ a two-stage, control function approach to address reverse causality between SNAP and food insecurity. I find that the ACA reduced the probability that a household participating in SNAP falls into the two lowest food security categories by 6.5 percentage points and reduced the probability of being food insecure by 14.2 percentage points. Across specifications, I find strong evidence for increasing returns to program participation, and evidence of a differential impact of the ACA across the distribution of food hardship. In Essay 2, I examine how grant funding and fiscal structure affect program response over the business cycle. I compare child enrollment in Medicaid, a matching grant funding program, with enrollment the State Children's Health Insurance Program, a block grant funded program, utilizing the similarities in beneficiaries, program benefits, and administration to isolate the impact of fiscal structure. I utilize administrative enrollment records, along with individual level participation data, and find a one percentage point increase in the unemployment rate leads to a 7.6% decrease in the number of beneficiaries per person enrolled in block grant funded programs, and a 10% decrease in state expenditure per person decreases the probability of enrollment in a block grant program by 0.58 percentage points. I also find that enrollment is much more persistent among matching grant funded programs, and being enrolled in a block grant funded program the previous period increases the probability of enrolling in a matching grant program this period 75% more than remaining enrolled in the block grant funded program. Finally, in Essay 3 I explore the effect of the minimum wage on the self-reported value of public assistance program benefits, and the joint effect of the minimum wage and public assistance programs on the income to poverty ratio using data from the 1995-2016 Current Population Survey Annual Social and Economic Supplement. In the first stage, I estimate a Tobit model controlling for the censoring of received benefits from below at zero, and examine the effect of changes in the minimum wage on the self-reported dollar value of benefits received for food stamps/the Supplemental Nutrition Assistance Program (SNAP), Aid to Families with Dependent Children (AFDC)/Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), and the Earned Income Tax Credit (EITC), as well as the total sum of benefits. I find that the minimum wage reduces the value of means-tested benefits, but that this effect is strongest for programs with strong work requirements. Utilizing the residuals from the first stage, I employ a control function approach to estimate the joint effect of the minimum wage and program benefits on the income to poverty ratio. I find the own-effect of the minimum wage provides a small increase in the income to poverty ratio, but that the total effect, accounting for changes in benefits, attenuates by approximately 30%.

acase@tulane.edu

Today, millions of people are living in poverty and in emergency situations with lack of basic needs. This thesis will look into cash transfers in emergencies in Kenya and Kenya’s cash transfer program; Hunger Safety Net Program. Cash transfers are money transfers from organizations/donors to households that intent to provide the beneficiaries with the opportunity to purchase basic needs, in order to assist them to get out of poverty and to address Sustainable Development Goal 1; No poverty.  The aim of the thesis is to get a larger understanding of when cash transfers intervention are appropriate during emergencies and to get a view of the current image of cash transfers in Kenya. The thesis will have the following research questions;  When it is appropriate to deliver cash transfer in emergencies?   What is the image of Hunger Safety Net Program and cash transfers in emergencies perceived by different actors? To be able to answer the research question in this thesis, information was gathered through semi-structured interviews and focus groups from four different actor groups; funding sources, implementing agencies, local chief in Lodwar and beneficiaries in two different location in Turkana county. The thesis provides information that cash transfers has a positive impact on the beneficiaries and the local communities. Moreover the findings from the thesis suggests that the cash transfers should be transferred in prevention stage along with other intervention steps, in line with the theoretical frameworks of sustainable livelihood and WHO conceptual framework for the role of cash transfer.  The thesis also provides findings that the image is diverse, however the findings from beneficiaries are that they do not receive their money they are entitling to. The funding source and the implementing agencies claim the opposite and praise the monitoring system that is in place. The thesis findings and conclusions are based on perceptions and therefore no physical evidence is proven, it is up to further research and organizations to investigate where the money is and who is benefitting from the program. The thesis contribution to knowledge are; the cash is appropriate to deliver in prevention stage and at the moment the cash from the Hunger Safety Net Program appears to not reach the beneficiaries, therefore the findings are highly important for knowledge to various stakeholders and for the public.

This study seeks to provide information relevant to public policy that will lead to increased access and utilization among this vulnerable population and to reinforce the validity of the behavioral model for vulnerable populations. This study is a secondary analysis of data collected in a study that examined adult, working-aged patients within the John Peter Smith Health Network, which is a large, urban, tax supported county health care system in Fort Worth, Texas. From a sampling frame of 10,000 patients, the study analyzed data for 243 low-income, white, working-age males, collected from computer assisted telephone interviews in 2000. Cross-tabulations and bivariate logistic regressions were used to analyze the effect of 8 independent variables (age, marital status, insurance, employment status, a usual source of care, competing needs, experiences with paperwork, and perceived health status upon 5 dependent variables pertaining to unmet health care, unmet prescription medicine needs, unmet dental needs, utilization of doctors in emergency departments, and overnight hospital stays. The results show the safety net system is failing to meet the needs of this vulnerable population. The findings indicate white men who found it necessary to forgo health care due to other needs were almost five (4.973) times as likely as those who did not find it necessary to forgo care due to other needs, to report having a problem getting the health care that they need (p = ≤ .001). The odds of having a problem getting needed dental care are about 66% lower for white men who have private insurance through work compared to those who do not have private insurance through work (p ≤ .05).

Food insecurity (not having continuing access to nutritious food to maintain health) is common in the United States, especially in working poor households. The Supplemental Nutrition Assistance Program (SNAP) is a well-documented safety net for individuals and families struggling with food insecurity. Little is known about the effect of SNAP policy on food insecurity in working poor military households. The purpose of this qualitative phenomenological study was to investigate the lived experiences of food-insecure Army families and the perceived influence of SNAP policy on their food-insecurity. The theoretical framework was policy feedback theory. Data were collected from semistructured interviews with 13 Army heads of households. Data were coded and categorized to identify 3 themes: impact of Army culture, federal programs as stabilization, and limiting SNAP policy. Participants struggle with food insecurity due to unique aspects of military culture, such as transition, and the limitations of current SNAP policy. Findings may be used to inform policymakers of the influence of SNAP policy on food insecurity in the U.S. Army.

BACKGROUND: Patient reported outcomes (PROs) are important cancer outcomes that can be measured electronically but are understudied in the safety-net hospital setting. Routine electronic screening to address social determinants of health (SDH) has been established in primary care clinics and the emergency department of New England’s largest safety-net hospital. The burden of SDH in safety-net oncology patients is less well-studied. This study aimed to determine the feasibility and challenges of routine administration of ePROMs in a safety-net Radiation Oncology clinic, describe treatment toxicities and quality of life (QOL) experienced by this vulnerable population during radiotherapy, and evaluate SDH and the need for SDH screening in the oncology clinic. METHODS: Patients with lung or head and neck cancer scheduled for radiation oncology consultation from 3/2019–1/2020 were deemed eligible for electronic questionnaire participation based on primary language spoken and absence of metastases. At consultation, patients were administered a set of baseline ePROMs (EQ-5D-3L, FACT, PRO-CTCAE) and a social needs screener (THRIVE) using a widely-used cloud-based, patient-centered outcomes platform. Associations between patient demographics and questionnaire completion were retrospectively evaluated. The set of ePROMs were collected at the end of treatment to characterize treatment-related toxicities and changes in self-reported QOL. RESULTS: In total, 99 eligible head and neck cancer (51.5%) and lung cancer (48.5%) patients were identified. Median age was 65. The majority of patients were male (71.7%), and English-speaking (82.8%). Whites, Blacks, and Asians/Others comprised 42.4%, 38.4%, and 6.1% of patients, respectively. Fifteen patients were Hispanic (15.2%). Patients were most likely to have private health insurance (39.4%), followed by joint Medicare-Medicaid (25.3%), Medicaid (17.2%), and Medicare (16.2%). Two patients were insured by Corrections (2.0%). Eight patients (8.1%) no-showed or cancelled, while 91 patients were seen in consultation. Forty-four patients (48.4%) completed the initial questionnaires. For the remaining 47 patients (51.6%), the most common reason for lack of ePROM completion was clinic understaffing and/or clinical decision based on the absence of indication for radiotherapy (n=27, 57.4%). Ten patients refused to complete questionnaires (21.3%), with reasons cited including length of questionnaires and low energy. Ten patients were physically unable to attempt questionnaires (21.3%), for reasons including disabilities and low-literacy. Age, language, race, ethnicity, insurance, marital status, gender, and disease site were not significantly associated with ePROM completion (P≥0.05). For patients who completed the general (QOL) questionnaire EQ-5D-3L, there was no significant difference in general QOL domains nor self-reported overall health score at baseline vs. end of treatment. For head and neck cancer patients, FACT-H&N Total scores, measuring disease-specific QOL, were significantly worse at end of treatment vs. baseline (P=0.006). For lung cancer patients, FACT-L Total scores at the end of radiation treatment were not significantly worse at end of treatment vs. baseline (P=0.953). For head and neck cancer patients who completed PRO-CTCAE, there was a significant increase in the number with moderate to very severe taste issues (P=0.008) and decrease in appetite (P=0.025) by end of treatment. For lung cancer patients, there was a trend towards an increase in the number reporting moderate to very severe nausea (P=0.083). Eighty-one of 99 patients (81.8%) were screened for at least one SDH domain using the THRIVE screener at the study hospital. Nineteen patients (19.1%) had all 8 THRIVE social determinants of health statuses documented. Only housing status was documented for 61 patients (61.6%). There was a trend for married individuals (P=0.068) and females (P=0.074) to be associated with the completion of at least one THRIVE domain. Age, race, language, and insurance status were not associated with THRIVE screening (P>0.05). Transportation to appointments (21.1%), food insecurity (20%), and affording medications (10.5%) were the most prevalent concerns among these oncology patients, with 100% of patients who reported insecurities with medication and transportation requesting resources for these needs. CONCLUSION: Routine ePROs collection in a busy safety-net oncology setting is feasible, but challenging and labor-intensive. Implementation was met with both patient and staff challenges and revealed the need for dedicated project management, staff training, and opportunities to increase patient accessibility. Preliminary PROs analyses revealed several significant detriments in quality of life and increased symptoms for this patient population during treatment, but additional data collection is required. Safety-net oncology patients report significant social needs. Routine SDH screening and resource referral should be considered in these vulnerable patients. Efforts in a specialized department such as Radiation Oncology could fill gaps in existing efforts in a large safety-net hospital. Safety-net oncology clinics can likely help vulnerable cancer patients access available community resources and reduce disparities due to SDH.

This thesis consists of three essays that explore incentives and disincentives in the U.S. social safety net. In the first essay, my coauthors and I measure the size and impact of U.S. marriage taxation. Our marriage tax measure incorporates all major federal and state taxes and transfer programs. The measure is calculated as the expected percentage loss in lifetime spending from marriage, controlling for partner choice. We find an average marriage tax of 2.69 percent that is substantially higher for low-income individuals. Exploiting state-level variation, we find that the marriage taxes strongly disincentivize marriage. Among females with children, a one percentage point increase in the marriage tax rate decreases the probability of marrying by 3.69 percentage points. The second essay evaluates the effects of free pre-kindergarten (Pre-K) programs on maternal labor force participation (LFP). Pre-K rules vary across U.S. states, and most states have income eligibility requirements. To estimate the causal effects of access to Pre-K on labor supply, we examine the change in the LFP of mothers whose child becomes age-eligible for Pre-K controlling for individual factors. We find that access to Pre-K increases overall maternal LFP by 2.3 percentage points. However, the effect is significant only for mothers with certain demographic characteristics. Our results are robust across a series of placebo tests and alternative specifications and sample restrictions. In the third essay I estimate how the Affordable Care Act (ACA) changed the returns to work and affected labor supply decisions. First, I identify three natural experiments where the ACA changed work incentives. I find that depending on the experiment and affected population, the ACA changed weekly hours worked by between -3 and +2. Next, I use an exogenous shock to effective marginal tax rates (EMTRs) introduced by the ACA as an instrument to estimate the overall labor supply elasticity. I find it to be 0.1. Using this elasticity, I estimate the aggregate effect of the ACA on work effort. I find that, in the aggregate, the ACA did not affect US labor supply. However, for some groups the effect was economically and statistically significant.

Compared to the general population, socially disadvantaged patients have higher rates of chronic illness and require more complex medical care. They also endorse higher levels of psychological distress and tend to engage in behavioral risk factors such as poor diet, physical inactivity, and smoking. These issues are particularly concerning given that this population tends to adhere less to medical recommendations, has limited access to health resources, and receives poorer treatment from providers. In an effort to address this disparity, The Affordable Care Act will expand health care access to an additional 23 million uninsured and 17 million underinsured Americans. However, simply expanding access to health care without examining and improving upon factors related to the physician-patient relationship would not fully address the health care needs of this population. This study sought to improve the quality of care received by socially disadvantaged patients by better understanding the role of race and gender on the physician-patient communication process and patient outcomes in a safety net primary care clinic. The study sample consisted of 330 low-income, uninsured/underinsured African American and White patients and 41 resident physicians. Overall, African American patients and their doctors and White doctors and their patients were viewed as engaging in the highest levels of communication. South Asian physicians, and male South Asian physicians in particular, had the lowest levels of communication and the patients of these providers experienced less improvement in their physical health. Patient education level influenced physicians’ perceptions of their patients to the extent that patients with higher educational levels were viewed as engaging in lower levels of communication. Last, indicators of a good physician-patient relationship were associated with higher levels of patient reported adherence. Practice implications and areas for future research are discussed.