Health Policy & Management Theses and Dissertations

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Browsing Health Policy & Management Theses and Dissertations by Subject "Affordable Care Act"

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    Assessing Changes in Access to Health care and Utilization of Preventive Services among Immigrants of African Descent Before and After Implementation of the Affordable Care Act
    (2020) Williams-Parry, Kester F; Chen, Jie; Thomas, Stephen B.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    In the U.S., African Americans experience a disproportionate burden of health disparities. The African American population includes 4.3 million people who are foreign-born. Yet, a paucity of empirical data exists on the health of immigrants of African descent. The lack of data disaggregation by subpopulations of African Americans, disregards the unique characterization of the African American diaspora and the influence of different cultural, linguistic, political, social, economic, environmental, and historical experience on the overall health of the population. Access to health care including lack of health insurance coverage has been a longstanding contributor to poor health outcomes among African Americans. The passage of the Affordable Care Act aimed to improve access to care including health insurance coverage and utilization of preventive services with no cost-sharing. Studies have shown significant reductions in the uninsured rate among African Americans and uptake in some preventive services, but the impact of the ACA on immigrants of African descent is not well understood. This dissertation research examined changes in access to health care, and utilization of preventive screenings for cancer, high blood pressure, diabetes, and high cholesterol among immigrants of African descent and U.S.-born African Americans before and after implementation of the ACA. This research integrated three studies to understand changes in access and utilization of health care using t-test for descriptive analyses and multivariable logistic regressions to assess any differences post-ACA. Results showed lower odds of being uninsured (OR=0.52, p=0.000), delaying care (OR=0.72, p=0.000), and forgoing care (OR=0.71, p=0.000) post-ACA, for all groups. There were higher odds of having cholesterol (OR=1.33, p=0.000) and hypertension screenings (OR=1.32, p=0.000) after the ACA. Cancer screening results found slightly higher odds of obtaining a mammogram (OR=1.07, p=0.069) after the ACA, but lower odds of having a pap smear (OR=0.89, p=0.002) or colorectal cancer (OR=0.91, p=0.021) screening. Citizenship was a significant factor that influenced screening rates with non-citizen immigrants having the lowest screenings for all groups.
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    PREVENTIVE CARE UTILIZATION AND ITS IMPACT ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS: IMPLICATIONS OF MEDICAID COST-SHARING, MEDICAID EXPANSION, AND THE AFFORDABLE CARE ACT FOR VULNERABLE POPULATIONS
    (2017) Bloodworth, Robin; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
    About half of Americans have at least one chronic disease, and chronic diseases account for nearly 90% of healthcare expenditures in the US. Primary care can reduce potentially preventable hospitalizations and overall costs of chronic diseases. However, only about 3% of US healthcare spending is on prevention. Racial/ethnic disparities and income disparities have been well documented in the use of primary care. The ACA expanded insurance coverage for millions of Americans and included a mandate that all insurance plans must cover recommended preventive services at no cost to the patient. Literature shows the ACA resulted in an increase in access to care, but results on utilization rates of primary care post-ACA are mixed. Using nationally representative data sets from 2009-2015, I examined the utilization rates of preventive services among vulnerable populations after the full implementation of the ACA, and how Medicaid state policy and expansion under the ACA affected the utilization of preventive services among vulnerable populations. Next, using the Maryland Medical Care Database from 2012-2014, I examined how continuity of primary care affects the odds of having any hospitalization as well as potentially preventable hospitalizations. I found that the ACA was associated with an increase in preventive services recommended yearly, and the ACA was not associated with disparities in preventive service utilization among vulnerable populations. Additionally, I found that state Medicaid policies on preventive services were associated with increased utilization of flu shot, but Medicaid expansion was not associated with increased utilization of preventive services or many changes in disparities in preventive service utilization among vulnerable populations. Finally, I found that primary care, especially ongoing primary care, was strongly associated with a decrease in the odds of having any hospitalization and potentially preventable hospitalizations. Results suggest that increased access alone will not increase utilization rates and reduce health disparities, but rather, a focus on education of what coverage options are available through the ACA, the importance of ongoing primary care, and how to navigate the healthcare system once insured could increase utilization of preventive care, especially in vulnerable populations.