Author ORCID Identifier
https://orcid.org/0000-0003-1939-7311
Defense Date
2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy
Department
Healthcare Policy & Research
First Advisor
Andrew Barnes
Second Advisor
Alex Krist
Third Advisor
Roy Sabo
Fourth Advisor
Anika Hines
Fifth Advisor
Chethan Bachireddy
Abstract
Health and health equity encompass not only healthcare but individual level material circumstances like food and housing, neighborhood level conditions like local consequences of residential segregation, and state and federal policies like Medicaid expansion. However, we are just beginning to understand how state level health insurance policy changes operate in the relationship between material circumstances, healthcare use, and health outcomes. This work focuses on newly enrolled Virginia Medicaid expansion members by using both claims data and survey data collected at the point individuals enrolled in Medicaid expansion and a year after Medicaid coverage.
Paper 1 asks if newly enrolled Medicaid expansion members who experience food or housing insecurity at the time of enrollment use primary care less frequently in the subsequent 12 months of Medicaid coverage compared to newly enrolled individuals who are not experiencing food or housing insecurity at the time of enrollment. Food and housing insecurity increase the prevalence of chronic conditions which may increase the demand for primary care and subsequent utilization, particularly in this sample of Medicaid expansion members who have no co-pays or premiums. However, individuals experiencing food and housing insecurity may have decreased primary care utilization because of increased barriers to care. Using data from the Virginia Department of Medical Assistance Services, we find that experiencing food insecurity at the time of enrollment in Medicaid expansion is associated with significantly decreased primary care utilization during the first year of coverage. Importantly, this association is significant among individuals living in disproportionately low-income neighborhoods, urban, and suburban neighborhoods. These findings suggest that other barriers, besides the monetary cost of primary care, exist for individuals experiencing food insecurity and the efficacy of interventions to address these barriers need to consider the local context.
Paper 2 investigates the following question: how does Medicaid expansion improve material circumstances? We offer three potential pathways in which Medicaid could reduce worry about affording food or paying for housing: 1) an increase in primary care utilization and subsequent improvements in health and functional job limitations, 2) reductions in economic constraints through decreased medical bills and healthcare expenditures, and 3) a decrease in worry about paying for catastrophic healthcare costs. To answer this question, individuals were surveyed within the first several months of Virginia Medicaid expansion (January – May 2019) and asked about their experiences in the year prior to their enrollment. Individuals who remained enrolled in Medicaid for 12 months were resurveyed about a year later (July 2020- June 2021) and were asked about their experiences during their first year of Medicaid coverage. We find that Medicaid expansion is associated with improvements across all three pathways. Critically, improvements in mental health, reductions in medical bills, and reductions in anticipated healthcare costs are associated with reductions in worry about paying for food or housing costs after a year of coverage. These findings suggest that Medicaid expansion operates through several different pathways to improve material circumstances, worry about affording food and paying for housing costs, that impact health.
Rights
© The Author
Is Part Of
VCU University Archives
Is Part Of
VCU Theses and Dissertations
Date of Submission
5-5-2024