Theses and Dissertations from UMD
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New submissions to the thesis/dissertation collections are added automatically as they are received from the Graduate School. Currently, the Graduate School deposits all theses and dissertations from a given semester after the official graduation date. This means that there may be up to a 4 month delay in the appearance of a give thesis/dissertation in DRUM
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Item THE EFFECTS OF MEDICAID COVERAGE FOR ABORTION(2024) Kim, Taehyun; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In this dissertation, I examine the causal impact of Medicaid abortion coverage on abortion utilization, births, economic, and maternal health outcomes. I do so by leveraging benefit changes in Illinois, Maine, and West Virginia. Major findings suggest Medicaid abortion coverage increases the abortion rate and decreases birth rates, although the effects differ by state. I also found that Medicaid abortion coverage increases individual wage income and decreases the poverty rate among females of reproductive age. I did not find evidence that introducing Medicaid abortion coverage increased educational attainment or decreased maternal morbidity. The findings have important policy implications for the wellbeing of people capable of pregnancy.Item Essays in Labor and Health Economics(2022) Hou, Claire; Hellerstein, Judith; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Chapter 1 investigates the impact of the opioid crisis on the foster care system, motivated by a growing literature suggesting that the opioid crisis has negatively impacted children. This paper builds on prior work by separately identifying the causal effects of parental illicit opioid use and prescription opioid (PO) misuse on foster care entry and caseload after 2010. Two baseline opioid supply measures from 2000, at the onset of the opioid crisis, instrument for post-2010 changes in opioid overdose death rates among adults of prime parenting age. Using county-level mortality data and administrative foster care records, I find that moving from the 10th to the 90th percentile of change in the illicit opioid death rate leads to a 1.1 (2.4) standard deviations larger percent growth in foster care entry (caseload). In contrast, a 10th to 90th percentile difference in the change in PO misuse does not significantly affect total entry or caseload. Female illicit opioid use has larger effects than male illicit opioid use. Effects are similar across child age at the time of removal. Illicit opioid use has similar effects across all placement settings, whereas PO misuse only increases entry to kinship care. Chapter 2 studies how an expansion of public health insurance affects self-employment dynamics. I investigate this question in the context of the Affordable Care Act (ACA) Medicaid expansion, which made Medicaid available to all non-elderly adults with family income up to 138% of the federal poverty level. By increasing access to health insurance outside of wage employment, expanding Medicaid eligibility could (i) induce some wage workers to become self-employed, and (ii) increase persistence in self-employment for the currently self-employed. Using the 2003-2016 CPS-ASEC linked to respondents' earnings histories from tax returns, I estimate the effect of expanding Medicaid eligibility on the probability of self-employment, wage employment to self-employment transition, and self-employment persistence among childless adults, the group that saw the largest increase in Medicaid eligibility as a result of the expansion. Using difference-in-differences that takes into account pre-ACA cross-county variation in population shares of "at-risk" groups and triple differences, I find suggestive evidence that the expansion of Medicaid eligibility may have increased persistence in self-employment for those with a relatively high valuation of health insurance, but no effects on wage employment to self-employment transitions or self-employment rates. Chapter 3 (with Katharine Abraham, John Haltiwanger, Kristin Sandusky, and James Spletzer) examines the role of self-employment in older workers' transitions to retirement. Self-employment rates rise with age, especially past the age of 50. Using unique integrated survey and administrative data, we find the share of the employed who are primarily self-employed more than doubles from age 47-52 to 65-70 – rising from under 10% to more than 20%. This growth reflects the differential patterns by age of all of the transitions among wage and salary employment, self-employment and non-employment. There is a sharp decline in the likelihood that workers switch from self-employment to wage and salary employment with age, but not the reverse. The share of wage and salary workers who transition to non-employment each year rises more rapidly with age between 53-58 and 65-70 than is the case for the self-employed. Just as important, there is a much sharper decline with age in the pace of transitions from non-employment to wage and salary employment than in the pace of transitions from non-employment to self-employment. The interaction of these changing transition rates, as opposed to simply their individual effects, plays a large role in accounting for the increase in the self-employment rate with age. We investigate how education, cumulative earnings over the prior 20 years, and earnings volatility over the prior 20 years affect these changing transition dynamics by age. We find, for example, that wage and salary workers who are more educated and have higher cumulative earnings are more likely to move to self-employment and less likely to move to non-employment, with both of these effects larger at older ages.Item 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.Item 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.Item 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.Item The Effect of Medicaid Disease Management Programs on Medicaid Expenditures(2011) Kranker, Keith; Duggan, Mark; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Disease Management (DM) programs for Medicaid patients with chronic diseases have become very popular, with a majority of states having introduced some type of DM program in the last decade. These programs provide interventions designed to assist patients and their health care providers appropriately manage their chronic health condition(s) according to established clinical guidelines. Cost-containment has been a key justification for the creation of DM programs, despite mixed evidence that DM actually saves money for the Medicaid program or for society as a whole. While most studies on the impact of DM focus on estimating the impact of a single DM program, Chapter 2 estimates the average, national impact of state Medicaid DM programs by linking a detailed survey of state Medicaid programs to the nationally representative Medical Panel Expenditure Survey. Difference-in-difference models are used to test the hypothesis that medical expenditures change after a DM program is implemented, exploiting variation in the timing at which state Medicaid programs implemented DM programs. DM coverage also varies within states over time due to variation in program eligibility by disease, insurance category, and/or county of residence. Although the models estimate the effect of DM imprecisely, point estimates are stable across multiple specifications and indicate that DM programs for common chronic diseases may decrease total medical expenditures, potentially by 10 percent or more. Chapter 3 evaluates one DM program in the state of Georgia using a proprietary data set. By exploiting a natural experiment that delayed the introduction of high-intensity services for several thousand high and moderate risk patients, the research identifies the causal impacts of the program's interventions on total Medicaid expenditures, categories of health care utilization, and other indicators. These patients are observationally similar to those who received interventions at the beginning of the program. For example, I find the interventions lowered health costs and hospital utilization, after controlling for unobservable individual characteristics. Health expenditures were lowered about 4.4 percent for patients with positive expenditures. Heterogeneous treatment effect analysis indicates that the savings were largest at the most expensive tail of the distribution.Item Essays in Health Economics(2009) Hayford, Tamara Beth; Duggan, Mark; Economics; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Health care expenditures have risen dramatically in the last several decades. Various agents have responded by reforming their practices in an effort to protect their budgets. My dissertation studies the implications of two of these changes on both quality and expenditure dimensions. The first chapter introduces and briefly discusses these topics. The second chapter discusses the implications of hospital mergers. A large body of research has examined their financial consequences, while little has analyzed the effect on patient health and experiences. This chapter aims to fill this gap, utilizing 17 years of hospital discharge data to study the impact of 40 California hospital mergers on changes in treatment choices and health outcomes. I use an empirical strategy that is based on geography of residence to enable a market level analysis. My findings indicate that hospital mergers result in increased utilization of intensive treatments for heart disease, such as bypass surgery and angioplasty. This result could be driven by increased access to intensive procedures as well as a change in hospital treatment practices. I also find evidence of a small increase in inpatient mortality which could be driven by an increase in average travel time to the nearest facility offering cardiac services. In chapter three, co-authored with Mark Duggan, we analyze the implications of a widespread Medicaid reform: contracting out health care treatment of Medicaid recipients to managed care organizations. State governments rapidly shifted Medicaid enrollees into managed care during the 1990s, perhaps partly as a response to increasing Medicaid expenditures. This reform has not previously been studied at the national level. We use state-level aggregate administrative data for the years 1991-2003 in conjunction with a unique data set on mandatory managed care enrollment policies to estimate the average national impact. Results suggest that this policy may have increased the expense of the Medicaid program, particularly for HMO-style insurance plans. We extend our analysis to investigate the impact of these policies on enrollment decisions. Using CPS data, we find mixed responses to mandatory managed care policies, though all changes in take-up were small and did not appear to increase uninsurance rates.