Laboratories of Health: Determinants of State Health Policies for Vulnerable Populations and Impacts on Access to Care Open Access

Johnston, Emily Morrison (2016)

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The federalist structure of the United States government creates challenges and opportunities for ensuring access to health care for all Americans. States can customize health policies within federal standards, resulting in variations in policies, access, and health outcomes across states. This dissertation relies on quasi-experimental state policy variation to examine the effect of public opinion on state public health insurance eligibility policies and the impact of state contraception coverage mandates on unintended births. In Chapter One, I develop and test a theory of the role of public opinion, measured as state resident ideology, on eligibility expansions for children in Medicaid and the State Children's Health Insurance Program (CHIP) from 1997-2010. I find that increases in liberal state resident ideology lead to expanded eligibility for children, even after controlling for state demographic characteristics, fiscal capacity, Medicaid financing, and party control of state government. In Chapter Two, I apply the same methods to parental eligibility levels. I then estimate the effect of ideology on the type of program implemented by a state. I find that liberal ideology leads to increased eligibility for parents, and that the effect is larger for parents than for children. Liberal state resident ideology also reduces the likelihood of no expansion and increases the likelihood of the most generous programs: Medicaid without premiums and Medicaid with full benefits. In Chapter Three, I test the effects of state-level prescription contraception insurance mandates 1996-2012 on pregnancy prevention efforts, problems getting birth control, and unintended births. Mandates decrease the likelihood of unintended birth for individuals and reduce the number of unintended births in a state. These results suggest that the Affordable Care Act (ACA) contraceptive coverage mandate, which is more comprehensive than prior state mandates, may significantly reduce unintended births in the United States. Together, this research finds that state flexibility in program design has allowed for the translation of the tastes and preferences of state residents into health policy. In turn, these policies have significantly impacted the health of state residents. State variation in health policies will continue as states leverage new opportunities for flexibility offered by the ACA.

Table of Contents

1. Chapter 1: Translating Ideology into Health: Public Opinion and Public Health Insurance Expansions for Children

a. Background. 1

b. Conceptual Framework. 4

c. Study Design. 9

d. Results. 17

e. Discussion. 23

f. Tables & Figures. 29

2. Chapter 2: Deserving or Deviant? The Role of Public Opinion in Public Health Insurance Eligibility and Program Design for Parents

a. Background. 36

b. Conceptual Framework. 40

c. Study Design. 41

d. Results. 48

e. Discussion. 51

f. Tables & Figures. 56

3. Chapter 3: State Prescription Contraception Insurance Mandates: Effects on Pregnancy Prevention Efforts, Problems Getting Birth Control, and Unintended Births

a. Introduction. 64

b. Background. 68

c. Conceptual Framework. 73

d. Study Design. 75

e. Results. 84

f. Discussion. 86

g. Tables & Figures. 93

4. References. 102

5. Appendix A: Chapter 1 Sensitivity Analysis. 121

6. Appendix B: Chapter 2 Sensitivity Analysis. 131

7. Appendix C: Chapter 3 Sensitivity Analysis. 143

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