Browsing by Author "Taylor, Donald Hugh"

Health insurance coverage is associated with better access to health care and better health outcomes at every age. The United States does not provide universal health insurance, and most people pay for private insurance that is linked to their job. Individuals whose jobs do not provide insurance have three choices: to remain uninsured, to buy their own insurance, or, in some cases, apply for public health insurance. Select populations in the US may be eligible for public health insurance coverage through Medicare and Medicaid. Medicare provides essentially universal insurance coverage for adults over 65, and, although enrollment is required, there is no application to determine eligibility. Alternately, Medicaid is a means-tested program with a stringent application process and recertification requirements, and take-up rates vary greatly across the US. In some states, individuals who do not have insurance through their employer can apply for and enroll in Medicaid. Individuals with Medicare coverage can also apply for Medicaid. Individuals who are “dually eligible” for Medicare and Medicaid, represent a uniquely vulnerable population due to their age, income, health, and life course exposures to marginalization, poverty, and other risk factors.Medicaid provides an essential health safety net for people in the United States living in poverty, particularly for individuals with high health care needs and costs. Many adults over 65 will need Medicaid to cover health and long-term care costs, yet the process by which older adults gain access to Medicaid is complex and burdensome. Chapter 1 includes the results of a qualitative study of Medicaid enrollment among residents of a skilled nursing facility (SNF). In interviews with caregivers and staff at the Department of Social Services (DSS) in a large, urban county in North Carolina, I find that family members are often applying their aging relatives, and that these applicants have difficulty navigating the Medicaid application process. In addition, I find that prior exposure to institutional care settings facilitates knowledge about Medicaid eligibility and enrollment criteria. Finally, all respondents commented on the costs associated with SNF care. In particular, respondents with higher incomes noted the long process of becoming eligible, while lower income respondents noted the inevitability of running out of funds. This qualitative study illustrates the distinct ways that older adults, marginalized due to their health and socioeconomic status, engage with social welfare programs in the US. Building on the results from Chapter 1, in Chapter 2 I employ an intersectional, life course approach to assess predictors of Medicaid enrollment in later life. In Chapter 1 I hypothesize that, for institutionalized individuals, having living kin facilitates Medicaid enrollment. In addition, I hypothesize that individuals who have experienced health events requiring a skilled nursing facility (SNF) or other institutional care stay, as well as individuals who have low incomes are more likely to enroll in Medicaid as older adults. Using data from 10 waves of the Health and Retirement Survey I test each hypothesis, accounting for other dimensions of social and health disparities. Alternate to my expectations, individuals without living kin are more likely to enroll in Medicaid than those with living family members. Results from discrete-time logit models confirm the second hypothesis, that individuals who have had a short-term SNF stay are more likely to enroll in Medicaid over a two-year period. In addition, as expected from both interviews and Medicaid policy, income is the single greatest predictor of enrollment in late life. Enrollment odds, though, are distinctly racialized and gendered: Black and Hispanic individuals are more likely to enroll than whites, women are at a greater risk than men, and women of color are at the highest risk. In addition, having a higher income is less protective for marginalized racial and ethnic groups than for white populations. In the third chapter, I examine late life health as an outcome of structural, state-level variations in Medicaid policy. Although every US state is required to provide some form of Medicaid coverage to “Aged, Blind, and Disabled” adults, each state establishes distinct requirements and benefits. In this study I use 10 waves of restricted data from the Health and Retirement Survey (HRS) to examine late life consequences of state-level Medicaid generosity. Using multistate life tables, this study demonstrates that Medicaid generosity is associated with more years dually covered by Medicare and Medicaid. In addition, I demonstrate that racial and gender marginalization, low income, and specific late life health risks contribute to inequitable health and mortality outcomes in late life.

Many factors affect responsiveness of elected policy makers to public opinion. While a full understanding of this topic is not possible without decades of careful research, this dissertation examines a few important areas. In particular, I look at the effects of party competition on legislator responsiveness, the dynamics of interest group politics and the ability of some voters to obtain disproportionate representation, and the nuances of how to interpret public opinion itself for a specific policy.

The first two chapters, on party competition and interest groups, make use of secondary data generated by the government, other scholars, and various relevant organizations. The chapters employ data on the behaviors and characteristics of members of Congress, election results, campaign finance data, and population and demographic information. Using appropriate econometric models, I find in chapter 1 that significant competition between the two major parties does serve to increase responsiveness to the public at the level of the individual legislator, with effects at the aggregate level being somewhat weaker. In recent years, it is difficult to estimate these effects because of the generally high levels of party competition and low variance across district.

Using similar data and methods, the exploratory analysis in chapter 2 suggests a relationship between unorganized groups of voters and the positions their elected officials take, independent of party, district average public opinion, and organized interest group contributions. The results also suggest that context matters a great deal in determining which groups will be influential.

Chapter 3 examines the nature of public opinion itself, using the Affordable Care Act as a case study. I conducted a survey experiment to assess how the distribution of opinions on the Affordable Care Act might change in response to priming different design features of the law. My findings indicate that opinion on the ACA is malleable and depends on what pieces of the law people think about at the time of response. In the real world, this implies that which parts of the ACA are highlighted and how it is discussed publicly will affect its future. Policy pork, as defined in the chapter, can build up support, but wedge provisions in the law can serve to entrench the opposition further. These implications can also be applied to other complex, highly visible reform bills.

A final concluding chapter attempts to apply these findings, as well as other political science research, to the case of the Medicare Access and CHIP Reauthorization Act (MACRA). Based on my assessment of the political context of this act, which was hailed as a permanent resolution to a longstanding debate over Medicare provider payments, I argue that the debate is not actually over, and that group interests, the design of the law, and broader contextual factors will ensure the debate continues.