Date of Award
Spring 2024
Document Type
Dissertation
Degree Name
Doctor of Philosophy (PhD)
Department
Public Health
First Advisor
Schlesinger, Mark
Abstract
Public insurance programs play a crucial role in providing affordable coverage to older adults in the U.S. With the U.S. population rapidly aging, providing and financing long-term care is one of the most pressing policy concerns. Since the 1980s, state Medicaid programs have begun deploying tools such as HCBS Section 1915(c) waiver programs and managed long-term services and supports (MLTSS) programs (wherein states contract with private managed care plans who deliver LTSS) in the hopes of managing costs and expanding HCBS services. At the same time, there is a need to further understand if and how health systems tailor treatment based on insurance coverage (such as Medicare). In this dissertation, I study the impact of public insurance coverage and cost containment tools on shaping care and treatment decisions for older adults. In Paper 1, I conduct a systems-level analysis to understand the role of HCBS 1915(c) waivers and MLTSS programs in restructuring LTSS financing and expanding HCBS access, using state-level LTSS data. I find that not only do states with higher levels of HCBS have more waiver participants, but they are also spending more per participant. Next, I model the adoption and diffusion of MLTSS programs across states, and find that Medicaid generosity, rather than neighboring state decisions, are a stronger predictor of policy adoption. I also study the impact of MLTSS programs on LTSS expenditures, and find through a difference-in-differences regression design that MLTSS programs appear to be associated with increased spending on HCBS, with inconclusive evidence of if this is in replacement of spending towards institutional care. In Paper 2, I continue examining the impacts of MLTSS programs, this time focusing on its impacts at the population level. Using The Health and Retirement Study data from 2004-2018 and a staggered difference-in-differences design, I study how MLTSS plans impact the use of nursing home, HCBS, and acute care for older adults. I find that the shift to MLTSS led to a 2.5 percentage point increase in home care use, a 3-percentage point decrease in informal care use, and no change in nursing home occupancy or acute care utilization. I also find suggestive evidence that the amount of home care individuals living in MLTSS states receive is substantially (27%) lower. In Paper 3, I shift my focus to Medicare, and examine whether health systems tailor their treatment or discharge decisions to otherwise similar patients based on Medicare coverage. Using a regression discontinuity design, I find that patients with trauma who are eligible for Medicare at age 65 years are admitted to the hospital for a shorter amount of time and are more likely to be discharged to a nursing home or other inpatient setting than those just below age 65. However, there was a limited impact on treatment patterns during hospital admission, with negligible detectable effects on health and no effect on mortality. Taken together, the findings from this dissertation suggest that cost containment tools are somewhat successful in achieving their objectives, and that rather than simply impacting access to treatment, changes in health insurance coverage can shape how patients are steered through our fragmented health system.
Recommended Citation
Bhaumik, Deepon, "Older and Growing Wiser? Evaluating How Public Insurance Programs Have Restructured the Delivery of Care to Older Adults" (2024). Yale Graduate School of Arts and Sciences Dissertations. 1481.
https://elischolar.library.yale.edu/gsas_dissertations/1481
