Health Policy & Management Theses and Dissertations

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ADVANCING THE HEALTH OF UNDERSERVED COMMUNITIES ACROSS THE UNITED STATES: OPPORTUNITIES TO IMPROVE HEALTH CENTER QUALITY OF CARE AND PATIENT EXPERIENCE
(2017) Nair, Suma; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
1 in 13 people in the United States receives care at a community health center. As health center services become an increasing percentage of all primary care services delivered in the United States, their success is vital to national efforts to advance health and manage costs. This dissertation presents three studies, addressing critical gaps in our understanding of health center quality and quality improvement opportunities. The first study examined the association between ambulatory care accreditation and 14 clinical quality measures in 1,198 health centers. Results demonstrated that accredited centers achieved higher performance on adult weight screening and follow up, tobacco cessation intervention, and use of lipid-lowering therapy. Universal accreditation could lead to an additional 552,087 patients receiving weight screening and follow up, 157,434 receiving tobacco cessation interventions, and 25,289 receiving lipid-lowering therapy. Findings suggest universal accreditation could contribute to quality gains and facilitate health disparity reduction. The second study used the first nationally representative dataset of health center PEC, to investigate the association between five measures of PEC (access to care, provider communication, office staff interactions, follow up on results and overall provider rating) and patient and health center characteristics. Results demonstrated that PEC ratings varied significantly by race/ethnicity, health and mental health status, education and income levels, and language. Findings highlight PEC improvement opportunities as well as the importance of patient-mix adjustment of PEC ratings in value-based payment. The third study evaluated the association between PEC and health center quality of care. Quality of care metrics included receipt of care, health behaviors, patient activation, and clinical outcomes in health center patients. Results showed that PEC ratings were associated with receipt of care, as well as patient adherence and activation. The findings support the importance of measuring PEC as a key determinant of quality, as well improving PEC as a driver for improvement for other aspects of care quality. All three studies were the first to our knowledge to use nationally representative health center data to examine these dimensions of quality and provide significant contributions towards our understanding of health center quality and related quality improvement and policy implications.
Adverse Childhood Experiences and Preterm Birth: A Systematic Review
(2019) Wiggan, Morgan Lynn; Franzin, Luisa; Shenassa, Edmond; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Adverse childhood Experiences (ACEs) elevate one’s risk for poor health outcomes later in life such as psychiatric disorders, cardiovascular disease, depression, anxiety, obesity, diabetes, poor fetal health, and liver disease (Poulton et al., 2002, Anda et al., 2007, Jimenez et al., 2017, Talbot et al., 2009. While the association between ACEs and negative health outcomes is well established in the literature, only ten studies examine the effect of ACEs on one’s risk for preterm birth (Benedict et al. 1999; Bublitz et al., 2014; Cammack et al., 2019; Christiaens et al. 2015; Jacobs 1998; Gillespie et al. 2017; Grimstad et al. 1998; Leeners et al. 2010; Margerison-Zilko et al., 2016; Noll et al. 2007). Preterm birth accounts for 60% of neonatal deaths and elevates an infant’s risk for poor health outcomes later in life ranging from behavioral issues to heart disease (WHO, 2018) and the rate of preterm birth in the United States has steadily risen since 2015, reaching about 10% in 2018 (CDC, 2018). This systematic review seeks to critically assess and synthesize these ten studies and identify proposed mediators and identify gaps in the literature for future research.
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.
ASSESSING IMPACT OF CANCER AND DEPRESSION ON THE FINANCIAL HEALTH OF MIDDLE AGED AND OLDER AMERICANS
(2023) Omeaku, Nina; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
This dissertation examines the impact of cancer on financial outcomes for individuals aged 50 and older and documents how this relationship varies by sex and race/ethnicity. I then turn to the impact of depression on out-of-pocket medical spending among those with a history of cancer. Findings suggest cancer can have a deleterious effect on the financial outcomes of those who are diagnosed with cancer. Out-of-pocket spending rises in the year of diagnosis, reduced earnings persist beyond diagnosis, and depression increases out-of-pocket spending. I fail to find evidence that the relationship between cancer and financial outcomes is moderated by sex or race-ethnicity.
BARRIERS OF AGING: THE IMPACT OF HOUSING ON U.S. OLDER ADULT HEALTH
(2020) Hall, Quinshay; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Today, millions of older adults aged 65 and older, face the challenges of aging. In the past ten years, the number of people aged 65 and older in the U.S. increased from 37.2 million to 49.2 million, and by 2040 an estimated one in five Americans will be age 65 or older (Administration for Community Living & Administration on Aging, 2018; Urban Institute, 2014). Housing is a significant factor in health outcomes for this population because of their increased time spent in the home, which can put them at an increased risk for home accidents (Newman, 2003). Using the Health and Retirement Study, this study explores the association of assistive features being present in one’s home on health status and provides evidence to identify the housing needs of the older adult population.
Community Living and Health Services Utilization among the Aging Services Network Population
(2017) Gaeta, Raphael; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
By 2050, the number of older adults will increase from 67 million to 111 million, or roughly 28 percent of the total U.S. population. Age is a principal predictor of physical health status as well as functional and cognitive limitation. As the aging population grows, so too will the demand for long-term services and supports (LTSS) and healthcare services. Despite this intersection, LTSS and healthcare systems are highly disconnected. The Aging Services Network, authorized and partially financed by the Older Americans Act (OAA), may play an important role in an emerging trend toward integrating services. Yet, OAA research is lacking. Existing OAA research faces several obstacles, including handling program variation resulting from a decentralized Aging Services Network, identifying non-user comparison groups for OAA study samples, and limited utility of national datasets. Studies often rely on highly descriptive methods, indirect comparisons to the general population of older adults, or state-restricted analysis. This dissertation addresses several gaps in the research. The first study aims to identify factors associated with community tenure and participation among low-income elderly living in subsidized housing. The research is grounded in conceptual frameworks from the World Health Organization. In-depth interviews and focus groups are used to explore these associations among elderly HUD building residents in Prince George's County, Maryland. The second study aims to identify multilevel predictors of OAA Title III services participation. This study develops a conceptual framework based on the Andersen Behavioral Model of Health Services Use, and uses a merged data set from the nationally representative Health and Retirement Study with geographic data and relevant state policies. The third study further examines the relationship between OAA Title III services participation and patterns of healthcare utilization. This dissertation research provides evidence for the importance of OAA Title III services, including for elderly HUD beneficiaries. Findings from multivariate regression analyses provide evidence for (1) county level targeting criteria used to measure LTSS need and direct OAA Title III funding, (2) substantial influence of Medicaid on access to OAA Title III services, and (3) changes in mix of health care services use among OAA Title III services participants over time.
Competition and Consolidation in Medicare Advantage
(2020) Chao, Sandra; DuGoff, Eva H.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Background: Medicare Advantage (MA) serves roughly one in three (24 out of 68 million) Medicare beneficiaries and this number is expected to grow to about half (40 out of 80 million) of Medicare beneficiaries by 2030. Given this expected increase in demand for MA health plans, it is important to assess the relationship between market structure and benefit generosity to ensure that beneficiaries have equal access to high quality plans at low prices.Purpose: The purpose of this research is to assess how policy changes and market structures influence Medicare Advantage plan benefit designs. Data and Methods: This study uses publicly available MA data from the Centers for Medicare & Medicaid Services and the Area Health Resources File. Retrospective cross-sectional analyses examine contract consolidation and reconsolidation from 2012–2020, market competition and supplemental benefits in 2013, and market competition and maximum out-of-pocket limits in 2018. Key Results: Contract consolidations have declined in recent years, likely as a result of a policy that changed the calculation method of the star ratings among consolidated contracts. During the years that contract consolidations peaked, market concentration also increased. We find that the odds of a plan in a nonconcentrated market offering a transportation supplemental benefit is 2.8 times higher than a plan operating in a highly concentrated market, when holding all other predictors constant (p < 0.001). Similarly, plans in nonconcentrated service areas are 2.4 times more likely to offer a hearing benefit (p < 0.001) and 2.3 times more likely to offer a dental benefit (p < 0.001) than plans in highly concentrated markets. Regarding maximum out-of-pocket limits, we find that the odds of a plan in a highly concentrated market having a higher maximum limit is 1.6 times higher than a plan with a nonconcentrated market, when holding all other predictors constant (p = 0.049). Conclusion: MA contract consolidations have declined since 2016 but market concentration continues to increase. Market structure is important because we find that MA market concentration is associated with the offering of supplemental benefits and the level of maximum out-of-pocket limits.
Connecting the Dots Across the Care Continuum: Addressing Behavioral Health in ACO Networks
(2019) Anderson, Andrew; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Accountable Care Organizations (ACOs) represent a shift from traditional fee-for-service payment systems that reward volume to payment models that reward providers for value (e.g. quality improvement and cost reduction). Hospitals that lead or participate in ACOs have the potential to work with other providers to bridge the gap between traditional medical and behavioral health services. The goal of this dissertation was to examine the structures, processes, and outcomes of care for hospitals that lead or participate in ACO networks. The overarching hypothesis was that ACO-affiliated hospitals provide better behavioral health care due to increased care coordination and increased connections to behavioral health providers. This dissertation had three aims: 1) compare the implementation of care coordination strategies between ACO affiliated hospitals and unaffiliated hospitals and examine whether the implementation of care coordination strategies varies by hospital payment model types; 2) compare the use of care coordination strategies between ACO-affiliated hospitals with and without in-network behavioral health providers; and 3) compare rates of follow-up after a hospitalization for mental illness between ACO-affiliated and unaffiliated hospitals. These aims build on each other to illustrate how hospitals that participate in ACOs are improving care coordination and the provision of behavioral health services. There were several meaningful findings. ACO-affiliated hospitals were more likely to use care coordination strategies compared to unaffiliated hospitals. Participation in global capitation and shared savings models was associated with greater use of care coordination strategies. Nearly two-thirds of ACO-affiliated hospitals did not have in-network behavioral health providers. ACO-affiliated hospitals had a significantly higher average unadjusted rates of follow-up after a hospitalization for mental illness at 7 days and 30 days post-discharge compared to unaffiliated hospitals. Hospitals are important components of the care continuum and will play a critical role in improving outcomes for patients with behavioral health conditions. Policy makers should include behavioral health related performance measures tied to performance-based payment arrangements in ACO programs. ACOs can be used as way to bridge behavioral, clinical, and social services to address the unique needs of individuals with behavioral health conditions.
Determinants of Unintended Pregnancy and Modern Family Planning Use
(2017) Kim, Theresa Youngjoo; Boudreaux, Michel H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Unintended pregnancy, defined as a pregnancy that is mistimed or unwanted, is one of the world’s most common negative health outcomes. Furthermore, the United Nations Population Fund has found that 225 million women wish to delay or avoid pregnancy yet do not engage in modern family planning method use. Unintended pregnancy affects both maternal health (by way of nutrient deficiency, reproductive organ deficiency, and mental health) and child health (low birth weight, reduced gestational age, and nursing difficulties). The most life-saving and cost-saving means to prevent unintended pregnancy is to encourage modern family planning use. This dissertation examines family planning and unintended pregnancy in three different national contexts. In these studies, I: 1. Decompose the differences in unintended pregnancy rates for black and Hispanic women compared to white women in the United States; 2. Examine the relationship among indicators of health literacy, health system access, and utilization of modern family planning in Senegal; 3. Evaluate an intervention in Benin designed to increase modern family planning use. My research found that black and Hispanic women had a greater likelihood of unintended pregnancy compared to white women. However, psychosocial and socioeconomic factors contributed to the greater likelihoods of unintended pregnancy among racial and ethnic minorities. Among indicators of health literacy, oral and visual messages were the strongest predictors of health system access and modern family planning use in Senegal. The conclusion of the intervention in Benin found that social diffusion behaviors increased among people in the treatment group, and furthermore, the intervention did reduce unmet need for modern family planning use. These research results, though from different research studies, can imply that increasing access as much as possible to modern family planning use can ultimately prevent unintended pregnancy.
THE EFFECT OF COMMUNITY HEALTH CENTERS ON HEALTH CARE ACCESS, CRIME, AND INTERACTIONS WITH THE MEDICAID PROGRAM
(2022) Marthey, Daniel J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Health centers are community-based clinics that provide services to medically underserved populations. They serve nearly 30 million adults nationwide and more than 90% of patients come from households earning below 200% of the federal poverty level. To date, we know very little about the impact of health centers on measures of social wellbeing.This dissertation estimates the causal impact of the health centers using the staggered expansion of health centers between 2006 and 2020 and advancements in causal inference methods that allow for unbiased identification of treatment effects in the presence of variation in treatment timing and treatment effect heterogeneity. I use the Centers for Medicare and Medicaid Services Provider of Services file to identify the introduction of health centers over time. Measures of primary care access come from the Dartmouth Atlas and the FBI’s UCR Offenses Known and Clearances by Arrest (2005-2016) files are used to measure agency and county level crime rates. Area-by-year covariates are compiled from several sources. The empirical approach uses staggered difference-in-differences where treatment is defined as the year the first health center receives certification in a county-year. Major findings suggest health centers increase annual visits with a primary care clinician by 4.5% within 7 years after certification among Medicare fee-for-service beneficiaries. I find health centers reduce the total crime rate by 7% over the period. Results are robust to several alternative specifications. While results on Medicaid interactions are inconclusive, they suggest declines in crime are largest in counties that experienced a health center opening and Medicaid expansion. My dissertation adds to the literature on the impacts of the Health Center Program’s main objective—increasing access to care. In addition, my findings broaden the literature related to health access programs and crime. The Health Center Program has grown considerably in size and scope since inception, and it is a centerpiece of many policy approaches to reform the US health care system. Findings from my dissertation have important policy implications for health, criminal justice, and social justice reforms.
THE EFFECT OF OWN RACE/ETHNICITY DENSITY ON INSURANCE TAKE-UP BY ASIAN AMERICANS
(2019) Choi, Yoon Sun; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Asian Americans are the fastest growing minority population in the U.S. (Lopez et al., 2017). Since the implementation of the Patient Protection and Affordable Care Act (ACA), Asian Americans have benefitted from insurance coverage increases but continue to experience disparities at the subgroup level (Park et al., 2018). This study investigates the association of own race subgroup density on the take-up of insurance by examining the effect of Asian subgroup concentration that may provide social and knowledge support linkages to available insurance coverage options.
EFFECTS OF MEDICAID STATE PLAN DENTAL BENEFITS ON DENTAL VISITS AMONG NON-ELDERLY ADULTS
(2018) Marthey, Daniel Joseph; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Using the Behavioral Risk Factor Surveillance Survey and optional Health Care Access module, I analyzed dental visits between insurance types and between three levels of Medicaid dental coverage for non-elderly adults in each state defined as no benefits or emergency-only, offering 1-4 services and offering 5 or more service types. I find Medicaid adults are less likely to experience a dental visit compared with adults covered by private insurance. I also find a statistically significant relationship between the level of benefits offered to beneficiaries and the odds of experiencing a dental visit in the previous year. Understanding factors associated with the use of dental services is necessary to adequately address health needs of the Medicaid population and unnecessary emergency room use for non-emergency dental services.
EVALUATING THE QUALITY OF HOME HEALTH CARE FOR INDIVIDUALS WITH COMPLEX MEDICAL NEEDS RECEIVING PRIVATE DUTY NURSING SERVICES IN THE MARYLAND RARE AND EXPENSIVE CASE MANAGEMENT PROGRAM
(2020) Minang, Dyllis Sefeh Mbah; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
OBJECTIVE: To use process and structural measures to evaluate the quality of Private Duty Nursing (PDN) services provided to individuals with complex medical needs in the Rare and Expensive Case Management (REM) program in the state of Maryland. The results will form the basis for recommendations for legislative changes regulating Private Duty Nursing provider agencies. BACKGROUND: Individuals with defined complex medical needs diagnosed before age 21, may receive skilled nursing level of care at home under the Maryland Medicaid REM program. The REM and similar programs have been shown to be cost effective, providing cost-savings to both state Medicaid programs and private insurance companies as the beneficiaries avoid long stays in short-term and/or long-term care facilities. Unfortunately, the quality of care in the REM program is not consistent. Thus, there is a need to evaluate REM program services to understand the reasons for these inconsistencies and make recommendations for fixes to the State and PDN provider agencies. TARGET POPULATION: Individuals with complex medical needs receiving REM program services and PDN provider agencies in the state of Maryland. DATA: Results of audits of client and personnel records of PDN provider agencies performed by the Division of Nursing Services (DONS) in the Maryland Department of Health were reviewed and analyzed. ANALYTICAL METHOD: This was a mixed-methods study, utilizing both qualitative and quantitative methods for data analyses. A descriptive study method with a retrospective analysis was also employed. Frequencies, percentage scores, and means with confidence intervals were generated in Google Sheets and Stata software. Finally, qualitative content analysis was used to analyze the DONS auditors’ comments, to find themes from key words or phrases. RESULTS: The study found major deficiencies in the client and employee records. Out of 99 employees and 30 client records from about 13 PDN provider agencies, 100 % of the records had deficiencies of one kind or the other, the most prevalent being discrepancies between the physician orders and the medication administration records. CONCLUSION: Study findings indicate that improvements to the quality of nursing services to REM program participants can be implemented at provider agencies as well as the executive and legislative levels of state government.
Evaluation methods for a community-centered human subjects protections and research ethics training: Your Rights in Research
(2020) Deane-Polyak, Maya; Roby, Dylan; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Any research project that involves human subjects requires ethical considerations and protections for individuals who enroll as participants. However, because the responsibility of these protections is often entrusted to the researchers, participants may not be aware of, and fully understand the rights to which they are entitled. The proposed training takes a preventative approach to increase awareness of protections available to individuals before they enroll in future research. The training also consists of an evaluation component to assess the extent to which the training program affects Prince George’s County residents’ decision-making ability regarding future research participation. The overarching goal of the project is to equip Prince George’s County residents so that they are able to make informed decisions about research participation that ultimately preserve, optimize, and protect their health and quality of life to the fullest extent possible.
THE EXAMINATION OF NATIONAL-NUTRITION POLICIES ON NONCOMMUNICABLE DISEASE MORTALITY AT VARIOUS STAGES OF ECONOMIC DEVELOPMENT: A CROSS-COUNTRY PERSPECTIVE
(2019) Gupta, Manisha; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The acceleration of economic growth over the past few decades introduces the need to reorient policy to address the needs and challenges for a healthier population. This paper will review the effectiveness of national nutrition policies targeting overweight, healthy diets during pregnancy, infancy and childhood, and noncommunicable diseases (NCDs) across advanced economies and transitional economies. The level of expansion and industrialization of food systems around the world have had a direct impact on nutritional status and health. Considering the magnitude of nationwide public health responses to shifts in mortality have varied over time, this introduces the need to assess the ability for dietary-related policies to successfully reduce NCDs. Results from this analysis can provide a strong rationale as to when interventions will be most effective as well as ways in which we can carry out a timely response in establishing effective policies for countries at different levels of economic development.
EXAMINING NEIGHBORHOOD SOCIOECONOMIC CHARACTERISTICS AND ACCESS TO THE NATIONAL DIABETES PREVENTION PROGRAM: A MARYLAND PERSPECTIVE
(2023) Buchongo, Portia; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Despite substantial federal and state investments made to promote the National Diabetes Prevention Program (NDPP) as a population health strategy for diabetes prevention it remains underutilized. Research has pointed to a variety of factors that have contributed to low uptake of this evidence-based lifestyle change program. However, the role neighborhood socioeconomic disadvantage plays in NDPP access and use has been underexplored. The state of Maryland is an ideal setting to investigate how neighborhood socioeconomic disadvantage impacts various dimensions of NDPP access due to the significant investments in primary care transformation and NDPP. This dissertation examines: (1) the relationship between neighborhood socioeconomic disadvantage and potential access to the NDPP using primary care providers geographic proximity to the NDPP sites in Maryland, (2) the relationship between neighborhood socioeconomic disadvantage and potential access to the NDPP based on geographic proximity of individuals with prediabetes to the nearest NDPP site in Maryland, and (3) the relationship between neighborhood socioeconomic disadvantage and utilization of diabetes prevention intervention such as NDPP, metformin, or both among individuals with prediabetes in Maryland. Findings from this work underscore how targeted statewide public health and health care initiatives can enhance NDPP access and utilization in neighborhoods with higher levels of socioeconomic disadvantage.
EXAMINING THE IMPACTS OF PUBLIC POLICY CHANGES ON IMMIGRANT CHILDREN’S INSURANCE COVERAGE, ACCESS TO CARE, AND HEALTH OUTCOMES
(2022) Chu, Jun; Boudreaux, Michel H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
A large body of evidence shows that public policies that expanding public insurance eligibility to children would lead to improvements in health care access and health outcomes during childhood. Growing up in the US, immigrant children face multifaceted barriers related to “not from here”, including economic constrains, acculturation pressure, immigration status of self and family members. It is unclear if immigrant children may respond to a public policy that expand public insurance eligibility to them. Prior research showed that immigrants would adjust their participation in public programs and health care utilization based on their perceived immigration climate. However, less is known about the impact of a national immigration enforcement program on immigrant children’s health care access and health outcomes. In this study, I examined two public policies: Children’s Health Insurance Program Reauthorization Act of 2009, the public policy that expanded public insurance eligibility to immigrant children under the five-year bar; and Secure Communities, a national immigration enforcement program that linked federal immigration enforcement activities to local authorities. I found that immigrant children in states that adopted CHIPRA’s option experienced a 6.35 percentage points decrease in uninsurance, and 8.1 percentage points increase in public insurance coverage, while estimated changes on private coverage were not statistically significant. I did not observe any statistically significant effects of CHIPRA on immigrant children’s access to care and health outcomes. My estimates suggested that activation of SC significantly decreased immigrant children’s public insurance coverage by 8.2 percentage points, while the estimates on other outcomes were not statistically significant.
Examining the State-Level, and Racial and Ethnic Impact of Cigarette Taxes on Youth Smoking and Cessation
(2022) Shinaba, Muftau; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
The objective of this study is to examine the relationship between per-pack cigarette taxes at the state level and smoking behavior among youth in the United States, based on race and ethnicity. State-level Youth Behavioral Risk Surveys (YRBS) from 2017 and 2019, as well as Tax Burden on Tobacco (TBOT) data, were used to analyze current (past 30-day) cigarette use and quit attempts among high school students, stratified by race/ethnicity and adjusting for age and sex. The findings found that overall odds of cigarette use were lower with higher cigarette taxes across states. The findings look to further evaluate a key tobacco control policy from both an economic and public health perspective.
EXPANDING THE CONCEPTUAL FRAMEWORK OF HEALTH LITERACY TO IMPROVE LONG-TERM SERVICES AND SUPPORTS
(2013) Ruben, Kathleen Ann; Simon-Rusinowitz, Lori; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
Low health literacy is a significant and growing public health problem. It is estimated that 90 million individuals in the U.S. have low health literacy, which is associated with poor health outcomes. Individuals with low health literacy skills may not be able to obtain health information, communicate with health care providers, or make optimal health care decisions. People from all backgrounds can have low health literacy levels, however, the rates are higher in certain groups such as older adults, Medicaid beneficiaries, and minority populations. Due to our rapidly aging and increasingly diverse U.S. population, the problems associated with low health literacy may increase over the next few decades. Studies have examined the relationship between an individual's health literacy level and their own health outcomes. However, few have focused on how the health literacy level of others, such as caregivers and health care professionals, impacts the health outcomes of care recipients. It is important to understand this relationship in terms of elders who depend on others, such as caregivers and family members, for their care. This series of three studies addresses this critical gap in health literacy research. The first two studies examine the need for a health literacy component of a training program for care teams for individuals with dementia in participant-directed programs. The first is an ethnographic pilot study of caregivers in West Virginia's Personal Options Program, and the second is a mixed- methods study of "Decision-Making Partner" preparedness in Arkansas' IndependentChoices Program. The third study examines the effect of the emergency department referral process on repeated utilization of community health centers by low-income, uninsured adults and Medicaid Beneficiaries, as well as the role of Patient Navigators as mediators within the framework of health literacy. This research provides evidence that the health literacy level of others, including caregivers, decision-making partners, and health care providers significantly impacts the ability of older adults to access health services and supports, communicate with healthcare providers, navigate the healthcare system, and manage chronic diseases. Therefore, addressing health literacy is essential for increasing health-related knowledge, improving health outcomes, and decreasing health disparities in long-term care.
Food Insecurity in the District of Columbia: Do Community Gardens Help?
(2021) Sodergren, Cassandra; Roby, Dylan; Wilson, Sacoby; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)
More than 10% of the District of Columbia’s residents have difficulty accessing affordable and healthy food, a number that is now projected to be over 16% because of COVID-19 (Sustainable DC, 2019; Food Security Report, 2020). Wards 7 and 8 experience the highest levels of food insecurity, with one grocery store per 60,000 residents versus other wards with one grocery store per 10,000 residents (Sustainable DC, 2019). Community gardens are sometimes referred to as part of the solution to food insecurity. This study explored if there was an intersection between community gardens and food security in Washington, DC. Through qualitative interviews and an inductive thematic analysis this study concludes that community gardens have a role in food security for those who experience food insecurity. The three core themes that emerged from studying community gardens were food security, relationships, and quality of life.

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