My dissertation examines issues of accessibility, innovation and cost, and the role of public policy in the United States health care system. Chapter 1 explores the effects of Medicaid and State Children's Health Insurance Program (SCHIP) pregnancy eligibility expansions occurring from 1992 to 2005 on public and private health insurance coverage, prenatal care, and health outcomes. Recent public health insurance expansions for pregnancy have extended eligibility to women with family incomes over twice the federal poverty level. However, pregnancy program expansions have received little attention in the literature, due in part to a lack of pregnancy health insurance data.
I use two novel sources of data to study the impacts of pregnancy eligibility expansions. The Centers for Disease Control- Pregnancy Risk Assessment Monitoring System (PRAMS) and California Birth Cohort birth certificate data are rich sources of birth data with detailed information on pregnancy health insurance coverage, prenatal care use, and infant and maternal health outcomes. My estimation of event study models shows that public coverage follows an upward trend following eligibility expansions, and that this coincides with smaller but imprecisely measured decreases in private health insurance. Simulated instrumental variables regression results imply public health insurance take-up rates between 14 and 19 percent. However, the private coverage estimates imply that an imprecisely measured but significant portion of the increase in public coverage comes from women who previously would only have private health insurance during pregnancy. Public eligibility expansions increase participation in the WIC program, but there is little evidence that program expansions improve overall prenatal care utilization or health outcomes.
Chapter 2 (joint work with Christopher R. Knittel) explores how changes in pharmaceutical patent policy and the structure of health insurance and pharmaceutical markets have affected the use of prescription drugs. The Hatch Waxman Act of 1984 considerably lowered the barriers to entry for generic drug manufacturers. Following the Act, branded drugs coming off patent lost considerable market share to cheaper generic competition. At the same time, brand manufacturers have increasingly used marketing to promote use of newer branded therapies to patients and physicians. Health insurers have responded to increasing drug costs by imposing cost-sharing measures to encourage use of generic therapies over more expensive new branded drugs.
In this chapter, we use generic entry as a natural experiment to study how the opposing forces of more restrictive prescription drug plans and increasing pharmaceutical marketing have affected prescription drug utilization patterns. We study the effects of generic entry using case studies and event study models that exploit the differential timing of generic entry across drug molecules. Our analysis examines drugs treating hypertension, high blood pressure, type 2 diabetes and depression using price and utilization data from the Medical Expenditure Panel Survey. We find that utilization of drug molecules starts decreasing in the two years prior to generic entry and continues to decrease in the years following generic entry, despite the decrease in prices offered by generic versions of a drug. We find that this decrease coincides with the market entry and increased utilization of branded reformulations and other branded drugs from the same manufacturer of the drug going off patent. Finally, we find similar utilization patterns across individuals with more and less restrictive health plans, suggesting that cost-sharing and formulary restrictions have little effect on the utilization of new patented products.
|Advisor:||Hoynes, Hilary W., Miller, Douglas L.|
|Commitee:||Huff Stevens, Ann, Page, Marianne E.|
|School:||University of California, Davis|
|School Location:||United States -- California|
|Source:||DAI-A 70/11, Dissertation Abstracts International|
|Subjects:||Economics, Economic theory|
|Keywords:||Health insurance, Medicaid, Patent policy, Pharmaceuticals, SCHIP, State Children's Health Insurance Program|
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