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Open Access Publications from the University of California

Scholarly Works (15 results)

  • Thesis
  • Peer Reviewed
UCLA Electronic Theses and Dissertations (2016)

Objective: This dissertation explores the relationship between welfare reform and the health of single mothers with less than a high school diploma or GED (LESMS) by addressing six research questions: (1) what impact did welfare reform have on the health insurance coverage of LESMS, (2) what impact did welfare reform have on the annual medical provider contact of LESMS, (3) what impact did welfare reform have on the health outcomes of LESMS, (4) what impact did welfare reform have on the federal disability receipt of LESMS, (5) how has the relationship between welfare reform and these outcomes changed over time, and (6) does state-level variation in welfare reform policy stringency impact the relationships between welfare reform and these outcomes? Data: The data source was the Survey of Income and Program Participation, 1992, 1993, 1996, 2004 and 2008 panels. Methods: A difference-in-differences study design that exploited differences in welfare eligibility by marital status was used to identify the effect of welfare reform. The treatment group was LESMS and the comparison group was similarly educated married mothers (LEMMS). The primary statistical model was a state level fixed-effects ordinary least squares regression model, controlling for public health insurance generosity, state unemployment, federal and state earned income tax credits and individual-level demographics, with robust standard errors. Sensitivity analyses with linear time trends, sampling weights, an alternative comparison group and alternative statistical model specifications (logit and negative binomial regression models) were conducted. Results: This dissertation found a transient negative relationship between welfare reform and having no health insurance coverage, among LESMS. Welfare reform was also found to be consistently negatively associated with Medicaid coverage and consistently positively associated with private health insurance coverage over time, among LESMS. Welfare reform was also found to have a transient, positive and statistically significant impact on the annual medical provider contact of LESMS.

Welfare reform increased self-reported disability among LESMS but not federal disability receipt. There was no evidence that the magnitude of the relationship between welfare reform and any of these outcomes grew over time. There was also no relationship between welfare reform policy stringency and any outcome.

    Cover page: Welfare Reform & the Health of Single Mothers
    • Article
    • Peer Reviewed
    UCLA Previously Published Works (2019)
      • Article
      • Peer Reviewed
      UCLA Previously Published Works (2020)
      Purpose: There is some evidence that self-employment may improve measures of cardiovascular and general health among the general population; however, no studies have examined this relationship among Non-Hispanic Blacks (NHBs). Studying the health implications of self-employment among NHBs is important because of the disparities that persist in both cardiovascular health and self-employment rates between NHBs and other racial/ethnic subgroups. Methods: A pooled cross-sectional analysis of data from the Behavioral Risk Factor Surveillance System (2000 to 2014) was used to explore the association between self-employment and the following self-reported outcomes: "no exercise," fruit consumption, vegetable consumption, days of alcohol consumption, fair or poor health, hypertension, poor mental health days, and poor physical health days among the total population of NHBs and across gender/income subgroups. Results: We find favorable associations between self-employment and several measures of cardiovascular health (increased fruit and vegetable consumption, reduced reports of "no exercise," and reduced reports of hypertension) and positive associations between self-employment, poor mental health days, and days of alcohol consumption among the total population. The nature of these associations varies across gender/income subgroup. Conclusions: Given the disparities between racial/ethnic subgroups with respect to adverse cardiovascular outcomes and the well-documented roles of exercise and blood pressure control in limiting cardiovascular disease, it is important to probe the relationship between self-employment and health among NHBs further.
        Cover page: Exploring the Relationship Between Self-Employment and Health Among Blacks
        • Article
        • Peer Reviewed
        UCLA Previously Published Works (2019)

        Background

        The minimum wage creates both winners (through wage increases) and-potentially-losers (through job losses). Research on the health effects of minimum wage policies has been sparse, particularly across gender and among racial/ethnic minorities. We test the impact of minimum wage increases on health outcomes, health behaviors and access to healthcare across gender and race/ethnicity.

        Methods

        Using 1993-2014 data from the Behavioral Risk Factor Surveillance System, variables for access to healthcare (insurance coverage, missed care due to cost), health behavior (exercise, fruit, vegetable and alcohol consumption) and health outcomes (self-reported fair/poor health, hypertension, poor physical health days, poor mental health days, unhealthy days) were regressed on the product of the ratio of the 1-year lagged minimum wage to the state median wage and the national median wage, using Linear Probability Models and Poisson Regression Models for dichotomous and count outcomes, respectively. Regressions (total population, gender-stratified, race/ethnicity stratified (white, black, Latino), gender/race/ethnicity stratified and total population with interaction terms for race/ethnicity/gender) controlled for state-level ecologic variables, individual-level demographics and fixed-effects (state and year). Results were adjusted for complex survey design and Bonferroni corrections were applied to p-values such that the level of statistical significance for a given outcome category was 0.05 divided by the number of outcomes in that category.

        Results

        Minimum wage increases were positively associated with access to care among white men, black women and Latino women but negatively associated with access to care among white women and black men. With respect to dietary quality, minimum wage increases were associated with improvements, mixed results and negative impacts among white, Latino and black men, respectively. With respect to health outcomes, minimum wage increases were associated with positive, negative and mixed impacts among white women, white men and Latino men, respectively.

        Conclusions

        While there is enthusiasm for minimum wage increases in the public health community, such increases may have to be paired with deliberate strategies to protect workers that might be vulnerable to economic dislocation. Such strategies may include more robust unemployment insurance or increased access to job training for displaced workers.
          Cover page: Examining the association of changes in minimum wage with health across race/ethnicity and gender in the United States
          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2016)
          Studies have shown that in the wake of welfare reform there has been a drop in the health insurance coverage and health care utilization of low-income mothers. Using data from 20 telephone interviews, this study explored the health insurance and health care experiences of current and former welfare participants living in Los Angeles County. This study found that half of these women had been uninsured at some point. Many of these lapses in health insurance coverage were linked to employment transitions and lack of knowledge regarding eligibility for different safety net programs. This study also found that satisfaction with access to health care was high among the insured respondents; however, barriers to care remained for many individuals, including appointment scheduling issues, limited scope of health insurance coverage, narrow provider networks, lack of care continuity, and perceived low quality of care. Better linkages between social programs assisting with health insurance coverage and improved knowledge among program clients may reduce health insurance cycling in this group. New rules for Medicaid managed care, currently being considered by the Centers for Medicare and Medicaid Services, have the potential to improve access to health care and the quality of care for these individuals.
            Cover page: Experiences with Health Insurance and Health Care in the Context of Welfare Reform
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2023)
            We investigated the impact of State-level Earned Income Tax Credit (SEITC) generosity on HIV risk behavior among single mothers with low education. We merged individual-level data from the Behavioral Risk Factor Surveillance System (2002-2018) with state-level data from the University of Kentucky Center for Poverty Research and conducted a multi-state, multi-year difference-in-differences (DID) analysis. We found that a refundable SEITC ≥ 10% of the Federal Earned Income Tax Credit was associated with 21% relative risk reduction in reporting any high-risk behavior for HIV in the last year, relative to no SEITC. We also found that a 10-percentage point increase in SEITC generosity was associated with 38% relative risk reduction in reporting any high-risk HIV behavior in the last year. SEITC policy may be an important strategy to reduce the burden of HIV infections among women with low socioeconomic status, particularly single mothers.
              Cover page: Evidence for the Role of State-Level Economic Policy in HIV Risk Reduction: State Earned Income Tax Credit Generosity and HIV Risk Behavior Among Single MothersCreative Commons 'BY' version 4.0 license
              • Article
              • Peer Reviewed
              UCLA Previously Published Works (2021)

              Background

              To determine if requiring Dual Eligible Special Need Plans (D-SNPs) to receive approval from the National Committee of Quality Assurance and contract with state Medicaid agencies impacts healthcare utilization.

              Methods

              We use a Multiple Interrupted Time Series to examine the association of D-SNP regulations with dichotomized measures of emergency room (ER) and hospital utilization. Our treatment group is elderly D-SNP enrollees. Our comparison group is near-elderly (ages 60-64) beneficiaries enrolled in Medicaid Managed Care plans (N = 360,405). We use segmented regression models to estimate changes in the time-trend and slope of the outcomes associated with D-SNP regulations, during the post-implementation (2012-2015) period, relative to the pre-implementation (2010-2011) period. Models include a treatment-status indicator, a monthly time-trend, indicators and splines for the post-period and the interactions between these variables. We conduct the following sensitivity analyses: (1) Re-estimating models stratified by state (2) Estimating models including interactions of D-SNP implementation variables with comorbidity count to assess for differential D-SNP regulation effects across comorbidity level. (3) Re-estimating the models stratifying by race/ethnicity and (4) Including a transition period (2012-2013) in the model.

              Results

              We do not find any statistically significant changes in ER or hospital utilization associated with D-SNP regulation implementation in the broad D-SNP population or among specific racial/ethnic groups; however, we do find a reduction in hospitalizations associated with D-SNP regulations in New Jersey (DD level = - 3.37%; p = 0.02)/(DD slope = - 0.23%; p = 0.01) and among individuals with higher, relative to lower levels of co-morbidity (DDD slope = - 0.06%; p = 0.01).

              Conclusions

              These findings suggest that the impact of D-SNP regulations varies by state. Additionally, D-SNP regulations may be particularly effective in reducing hospital utilization among beneficiaries with high levels of co-morbidity.
                • Article
                • Peer Reviewed
                UCLA Previously Published Works (2024)

                Background

                Sub-optimal HbA1c control is a driver of disparities in diabetes outcomes among Hispanic patients. Differences in medication adherence may underlie racial/ethnic differences in HbA1c level.

                Objective

                To examine the relationship between medication adherence and disparities in HbA1c level among Hispanic patients, relative to other racial/ethnic groups, obtaining care in the University of California Health System (UC Health).

                Design

                This study used clinical, administrative, and prescription dispensing data (January-December 2021) derived from the electronic health records of 5 Academic Medical Centers in UC Health, and linear regression models (LRMs) to conduct a cross-sectional analysis of the association between medication adherence, race/ethnicity, and HbA1c level. Adjusted LRMs were run with and without the measure of medication adherence to assess this relationship.

                Participants

                Patients with a UC Health primary care physician (PCP), with ≥ 1 PCP visit within the last 3 years, ages 18-75, reporting Asian, Hispanic, or White race/ethnicity, and who had ≥ 2 encounters with an ICD diagnosis of diabetes or had a prescription for a diabetes medication within the last 2 years, as of 12/31/21 (N = 27, 542; Asian = 6253, Hispanic = 7216, White = 14,073).

                Main measures

                Our measure of medication adherence was the proportion of days covered (PDC) for diabetes medications in 2021. Our outcome was the most recent HbA1c value.

                Key results

                In the LRM excluding the PDC, Hispanic ethnicity was positively associated with HbA1c level (β = 0.31, p =  < 0.001). In the LRM model including PDC, PDC was negatively associated with HbA1c level (β =  - 0.18, p =  < 0.001). However, the positive relationship between Hispanic ethnicity and HbA1c level did not change (β = 0.31, p =  < 0.001).

                Conclusions

                The findings of this study suggest that the relationship between Hispanic ethnicity, HbA1c level, and factors outside of medication adherence should be explored among primary care patients receiving care in Academic Medical Centers.
                  Cover page: Exploring the Relationship Between Medication Adherence and Diabetes Disparities among Hispanic Patients in a Large Health System
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2022)

                  Objective

                  To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM).

                  Data sources and study setting

                  Cohort of adults (18-64) with T2DM, an annual household income Study designWe employed a linear regression Difference-In-Differences (DID) approach with a matched comparison group. To assess for differential DHP effects across adherent versus non-adherent patients, we ran a Difference-in-Difference-in-Differences (DDD) analysis by including an interaction term that included indicators for DHP exposure status and time, and low versus high baseline medication adherence.

                  Data collection

                  The analytic data set is limited to employer groups that purchased the DHP and standard benefit plans from UnitedHealthcare, had internal pharmacy contracts; complete pharmacy claims data, and sufficient medical claims and lab data to identify employees and their dependents with T2DM.

                  Principal findings

                  Our DID analysis did not show improved medication adherence associated with employer DHP adoption. However, the DDD model suggested a difference between DHP-exposed and comparison beneficiaries when comparing the relative effect on individuals who were adherent versus non-adherent at baseline, as suggested by the significant three-way interaction term (10.2,p = 0.028). This effect was driven by the 8.2 percentage point increase in medication adherence for the DHP subsample that was non-adherent at baseline.

                  Conclusions

                  The DHP may benefit low-income patients with low baseline medication adherence. Value-based insurance design may be an important strategy for mitigating income disparities in T2DM outcomes.
                    Cover page: The diabetes health plan and medication adherence among individuals with low incomes
                    • Article
                    • Peer Reviewed
                    UCLA Previously Published Works (2024)
                    Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. Methods: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. Results: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.
                      Cover page: An Effectiveness Study of a Primary Care-embedded Clinical Pharmacist-Led Intervention Among Patients With Diabetes and Medicaid Coverage
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