Essays on Health and Vulnerable Populations

Abstract

This dissertation examines the impact of enacting barriers to care among vulnerable populations. In the first paper I measure the effect of a large increase in the deductible on patients with pre-existing diabetes and hyperlipidemia. I find that a $1,000 exogenous deductible increase does not affect the health of the average patient. When I divide patients on the basis of their underlying disease severity, I find that among diabetics with initial glycemic control the deductible change causes a 2.3 percentage point, or a 19% increase relative to the mean in the probability of having a high HbA1c value (>7.5%). Among patients with stable baseline cholesterol, the deductible change causes a 0.5 percentage point, or 12.5%, increase relative to the mean in the probability of having a high LDL cholesterol value (>160 mg/dl). This is driven by the differential impact of the deductible increase on primary care use, and in short-term reductions of high value prescription drugs. In the second paper I examine how cost-sharing in medical care affects the full range of services patients use by leveraging changes in copays for two million patients with employer sponsored insurance. I find that compared to other groups, patients that live in low-income areas have a higher-elasticity and lower demand for medical services that are high-value. When PCP copays increase, patients from low-income areas experience a stronger decline in the use of downstream services such as referrals to specialists, laboratory tests, physical therapy, and radiation services. In the third paper we investigate adverse selection among Special vs. Open Enrollment Period members in the Marketplaces. We find SEP members are more likely to be hospitalized for discretionary and non-discretionary services. We also test the impact of increased paperwork requirements and find that it caused a differential reduction among SEP members in the rates of predictable inpatient care but did not affect rates of non-predictable care. When compared to OEP members, the policy caused SEP members to increase monthly inpatient spending by $29.72. This increase was offset by reduced spending on prescription drugs, emergency department, and outpatient care and thus had no impact on total costs.