Evaluating Access to Care and Health Outcomes in Public and Private Insurance

Abstract

The objective of this dissertation is to evaluate whether changes in insurance coverage and provider decision making are associated with changes in the use of health care services and health outcomes. Paper 1: Due to the high rates of maternal morbidity and mortality in the United States, preconception insurance has been identified as critical for addressing risk factors for poor pregnancy outcomes. Using the Pregnancy Risk Assessment Monitoring Survey (2009-2017) and an index measuring state Medicaid program generosity, we find that recent Medicaid expansions for childless adults were associated with increases in insurance coverage in the month before pregnancy. In addition, increased Medicaid generosity was associated with increases in early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high school degree or less. Paper 2: Prescription drugs are critical for managing complex physical and mental health conditions for over 10 million disabled Medicaid beneficiaries. However, some state Medicaid programs limit the number of prescription drugs beneficiaries can fill monthly (i.e., “drug cap policies”), which may limit access. Using difference-in-differences methods and Medicaid Analytic eXtract claims data (2007-2012), we find that three-drug monthly limits in Arkansas and Texas were associated with declines in prescription drug use, including drugs to treat mental health conditions, and increases in inpatient admissions among young, disabled adults. However, the drug cap policies were not associated with any significant changes in total prescription drug spending. Paper 3: Advanced Maternal Age (AMA), often defined as age 35 or older on the expected delivery date, is a frequently applied designation in clinical obstetrics to identify women at higher risk of pregnancy complications. Using a regression discontinuity design and administrative claims data for a large commercial insurer (2008-2019), we find that the AMA designation is associated with increases in visits with maternal fetal medicine specialists, total ultrasounds, detailed ultrasounds, antenatal surveillance, and aneuploidy screening but no changes in delivery-related practices. In addition, the AMA designation was associated with substantial declines in perinatal mortality.