Dissertation Title: "Market Dynamics and Health Care for the Uninsured"This dissertation investigates trends in health care for the uninsured and the role of market-level factors in determining their access to and use of care.
The first chapter considers trends in care for the uninsured and in the disparity between uninsured and privately insured nonelderly adults. Using three data sets, I consider trends in access to health care, control of chronic diseases, and acute heart attack care. I find that trends in outcomes for the uninsured have generally been stable from the mid-1990s to the mid-2000s, with fluctuation in some measures over shorter periods within this window. In addition, there is a persistent disparity between the privately insured and uninsured in most measures.
In chapter two, I investigate the effect of the uninsurance rate in a market on access to care for the uninsured and the insured, using a market fixed effects approach. I also consider the role of time-varying market-level factors and instrument for the uninsurance rate using a two-stage residual inclusion approach. I find that the causal effect of the rate of uninsurance in the community on access to care for the uninsured is negative. In contrast, estimates for the insured are small and insignificant. Unlike earlier research, these results imply that there are no spillover effects of uninsurance on access to care for the insured. Thus, policies that expand health insurance coverage may affect access to care for the uninsured but have little effect on access for those who are already insured. The types of institutions that comprise the health care safety net vary in their structure and function, and there is geographic and temporal variation in the availability of and support for different types of safety net providers.
In chapter three, I consider the association between particular types of safety net institutions (specifically, teaching hospitals and federally qualified health centers) and access to and use of care for the uninsured at the market level in both 2003 and in 1996. I find that the presence of teaching hospitals and the presence of health centers are correlated with different aspects of access and use among the uninsured.