Dimensions of Disadvantage: Normative and Empirical Analysis of the Effect of Public Insurance on Low-Income Children and Families

Abstract

This dissertation considers some challenges to delivering effective and equitable health care to disadvantaged children and families in the United States. Chapter one examines whether expanded access to health insurance following the enactment of the Children’s Health Insurance Program (CHIP) in 1997 reduced the prevalence of economic hardships (food insecurity, problems affording housing) and postponed medical care. In difference-in-differences analysis, I find that relative to a comparison group of families that missed the eligibility cutoffs, families that gained eligibility under CHIP did not experience changes in food or housing problems, but were significantly less likely to postpone medical care. These findings suggest that while public insurance for families with children likely improves access to care, it does not significantly reduce other forms of hardship. Chapter two provides an ethical argument for subsidizing health insurance for low income families – a central component of the 2010 Affordable Care Act (ACA). I argue subsidies are a vehicle for promoting equality of opportunity: specifically, subsidies ensure access to specific “basic opportunities” (such as the ability to attend college) when out-of-pocket spending on insurance would have otherwise crowded out those opportunities. Subsidies thus make a modest, but important, contribution to mitigating the negative effect of health spending on social mobility and financial security, even if they fall short of comprehensive income protection. I raise and respond to some potential concerns about inequities created by this system, and conclude with implications for evaluating the subsidies under the ACA. Chapter three investigates whether diffusion of long-acting stimulants, a medication for Attention-Deficit/Hyperactivity Disorder (ADHD), narrowed racial/ethnic disparities among diagnosed children in the Florida Medicaid program. In longitudinal analysis, we found that minorities were substantially less likely than whites to use medications overall, but minority medication users were equally likely to switch to long-acting medications after market introduction. The increase in prescribed days was comparable for white and black medication users, but lower for Hispanics. Geography and provider setting helped explain overall medication utilization disparities, but adherence disparities were not explained by any of the covariates. We recommend targeting interventions to increase medication adherence to high-volume, minorityserving providers.