This dissertation consists of three essays on empirical issues in health economics. The first essay considers the selection-efficiency trade-off in competitive health insurance markets, where insurers face incentives to exploit unpriced heterogeneity by selecting low-risk individuals “cream-skimming”). The German Social Health Insurance does not adjust payments to sickness funds for geographic differences in costs, thereby generating incentives for funds to select against relatively more expensive areas, such as West Germany. In an audit study I present funds with fictive applicants from different locations and infer recruitment efforts by measuring callback for letters, emails and phone calls. The findings suggest that sickness funds are less responsive to requests from West German applicants, a result consistent with cream-skimming in this market. The second essay evaluates the impacts of two school nutrition policies, Californias state-wide beverage policy and Los Angeles Unified School Districts food-and-beverage standards of 2004, on adolescent dietary behavior and obesity. Two large datasets on physical measures and food intake facilitate the construction of reliable control groups, including a “synthetic” control unit consisting of unaffected districts that are reweighted to closely resemble Los Angeles in the pre-intervention period. Both policies are found ineffective at reducing the prevalence of overweight or obesity. However, the district policy decreased consumption of its key targets, soda and fried foods. The third essay examines the reliability of self-reported data in empirical analysis. Self-reported data is prone to systematic measurement error that may be constant or change in response to external events. The essay illustrates these issues with data on self-reported and measured overweight/obesity status, and BMI, height and weight z-scores of public school students in California from 2004 to 2006. In the cross-section, the prevalence of overweight/obesity is significantly lower in self-reported data relative to measured data. A district nutrition policy changed the reporting bias differentially in the treatment and control districts, so that program evaluations could find spurious positive or mill impacts of the intervention.

This dissertation presents estimates of the effect of weight on wages in the U.S. Several questions are of interest. Do heavier people earn lower wages? Are the effects of weight on wages evenly distributed over the whole range of wages or are the effects concentrated in the lower, middle or upper part of the wage distribution? Do the effects of weight on wages change over time? This dissertation uses two large data sets, the National Longitudinal Surveys of Youth, NLSY79 and NLSY97, and several regression strategies in an attempt to provide answers to these questions. Differences across gender and race are explored. The key finding is that weight lowers wages for white females. Negative correlations between weight and wages observed for other gender-ethnic groups appear to be due to unobserved heterogeneity. The results also suggested that the weight penalty, if it exists, increases with wages for almost all sub-groups except Black males. Finally, the negative effect of weight appears to have decreased when we compare the weight penalty between two cohorts, NLSY79 cohort and NLSY97 cohort, aged between 19 and 29. More research is needed so that we can gain insights about the causes of these penalties. It also provides incentives for policy makers to come up with policies that will help people attain and maintain a healthy weigh.

This study was exploratory in nature, utilizing a phenomenological collective case study approach. The phenomenon under study was the lived experiences of individuals surrounding employee voice and upward communication. The purpose was to understand CEO behaviors and actions that promote employee voice and upward communication in performance excellence award-winning healthcare organizations. The results suggested the award-winning CEOs facilitated employee voice and upward communication by being approachable, largely achieved through their regular presence throughout their organization. By being consistently visible and available to employees, these CEOs fostered relationships, built trust, and promoted open, upward communication. Leaders in the current case studies created a cultural focus on continuous improvement largely built around transparency of information, and particularly looking for the bad news from their employees. Voice invitation and positive voice response from leaders’ reinforced critical upward feedback as not only welcome, but expected. Findings from the study provided insight into leadership behaviors promoting employee voice and upward communication, which may be valuable to both scholars and practitioners. In-depth descriptions of CEO actions and behaviors address a gap in the current literature and add to the understanding of the phenomenon of employee voice and critical upward feedback.

Rapid growth of the aging population is becoming a global phenomenon. Deterioration of biological functions as a result of the aging process significantly affects daily life and impacts older adults overall quality of life. Aging presents special problems for Chinese-American immigrants. At a minimum, these individuals need to be able to see health care providers as needed. However, medical illiteracy, cultural differences, and lack of transportation and assistance with health care appointments still present barriers for access to health care AHC) for this population. This has not been a well-researched topic. The purposes of this study were to examine AHC of elderly Chinese immigrants and to explore their level of health-related quality of life HRQOL) in the cultural context of the Pacific Northwest. Mixed methods were used to conduct this research. The World Health Organization Quality of Life–Old Module instrument was used to measure Chinese immigrants HRQOL. The demographic data sheet and the questionnaire on access to health care were used to obtain personal background information. The participants were 108 elderly Chinese immigrants recruited from regional communities, with a mean age of 75.3 year and 43 39.8%) of the participants being male. Results showed that the mean HRQOL score was 68.8 on a scale from 0 to 100, indicating that most participants felt their HRQOL was above average. Participants having religious beliefs showed significantly higher HRQOL. Contrary to expectation, participants living alone scored higher in HRQOL than their counterparts who did not live alone. English language difficulty turned out to be the main barrier to access to health care. Ten of the 108 participants provided an additional in-depth interview about their aging experience. Content and theme analysis were used to determine what the participants felt were the most valuable things in their lives, which included physical health, religious belief, happiness, and good family relations. The research results can be applied to nursing practice and education in the care of older adults of different ethnic backgrounds living either in the United States or in Asia. Future research on aging populations could broaden the study sample to compare HRQOL between different races or ethnicities, between immigrants and non-immigrants, and between institutionalized and non-institutionalized adults.

Countless studies have documented the existence of disparities by race and ethnicity in the health care system in the United States. However, not many have sought to explicitly quantify the relative importance of each of the proposed determining factors. This dissertation thus sought to identify the major causes of disparities in health care usage by employing an adaptation of the Blinder/Oaxaca decomposition method originally used in the literature on wage differentials. Specifically, this study sought to investigate the roles that racial differences in patients perceptions of care and expected longevity as they relate to expected gains) might play in the observed disparities in usage. Perceptions of care measures trust and fear/dislike) were used to investigate the importance of the doctor-patient relationship in determining usage disparities through its effect on expected gains. Expected longevity was used as the length of time that someone expects to live would affect how willing they are to invest in anything with payoffs derived in the future. Thus, if expected net payoffs/gains of utilizing health care are positive, the individual would use care. Results show that while expected longevity was found to positively affect whether or not someone utilizes care, it was not a contributing factor to the racial divide in usage. However, when exploring the role of perceptions of care, while the differences in utilization rates between whites and minorities were due mainly to unobserved factors peculiar to each racial/ethnic group, perceptions of care disparities also played a major role in addition to socioeconomic and access factors. These results, while encouraging the need for further analysis into what drives usage disparities by race, point out that the doctor-patient relationship apart from SES and access issues) should also be considered as a possible contributor to racial/ethnic disparities in usage.

This thesis combines three essays on consumer behavior in the health insurance and retirement markets. The first two chapters study the Chilean health insurance system. Here, I estimate price elasticity across health care services and demographic groups using unique data from the Chilean health care market. The results show that consumer response to price variation depends on the type of care required and the demographic background of individuals. These findings provide new evidence on the responsiveness of consumer expenditures to co-payments for different types of health care expenditures. Further, the results allow us to better interpret discrepancies in previous literature. Second, I study the determinants of switching between health insurance plans when a public option is present. Using administrative records and panel data from a national survey. I find that switching depends on labor shocks, health shocks, renewal dates and regulations. Finally, in the third chapter, Justine Hastings and I analyze the Mexican privatized social security market. We examine how people manage or fail to manage) their accounts and the role of mandated information on both investment decisions and strategic firm responses. We find that workers do not pay attention to management fees when selecting accounts. Also, mandated information changes the worker response to fees, but results in their choosing higher cost funds.

Mortality rates for cardiovascular disease (CVD), the leading cause death, varied widely among countries’ populations. Economic freedom has been associated with improved quality of life. The aim of this quantitative study was to examine whether a country’s institutional structures of economic freedom and healthcare financing were associated with the country’s cardiovascular disease mortality. Study population comprised those who died of cardiovascular disease in 153 countries, including the United States. Correlational and regression analyses were conducted using Statistical Analysis Software (SAS). A significant and moderately strong inverse relationship was present between national CVD mortality rates and economic freedom scores. A significant and weak inverse relationship was found between national CVD mortality rate and national government expenditure on health. In addition, a 1% increase in economic freedom worldwide was associated with approximately a 0.7% decrease in annual average CVD mortality rate worldwide and approximately a 2% decrease in the annual CVD mortality rate in the U.S. Populations with high exposure to economic freedom had protective risks for CVD death rates below the global average CVD mortality rate. National Leaders should encourage exposure to economic freedom and increase efforts that reduce CVD mortality rates.

States have historically used Certificate of Need CON) regulations to regulate cost, quality, and access to healthcare services. Federally mandated in 1974, the regulation required the states to review requests for new healthcare construction and services. In theory, community-level planning backed by the state-level CON review and health planning process would prevent unnecessary duplication of services and the accompanying costs Smith-Mellot, 2004). However, none of the published studies have examined the association of CON regulation on volume and outcomes of solid organ transplants. In 1984, the federal mandate ended, and each state was allowed to determine whether or not to maintain its CON programs； more than one-third of the states eliminated them Altman & Ostby, 1991). Currently, 37 states including the District of Columbia have CON programs American Health Planning, 2010). Of those states, 21 include organ transplant as a reviewable, regulated service. Although several studies have investigated whether CON regulation has affected healthcare cost, to date very little has been written about the impact of CON on volume and quality of care； the data that does exist is contradictory. In 1988, investigators studied the effects of CON regulation on mortality and observed that greater regulatory stringency was a positive and significant predictor of hospital mortality rates Shortell & Hughes, 1988). In contrast, DiSesa et al 2006) found no significant difference in risk-adjusted mortality for cardiac surgery patients in states with and without CON regulations. The gap between evidence and decision-making and the large number of states that use CON to regulate healthcare services indicate a need for a study on the quality of healthcare services. Solid organ transplantation is a complex, high-cost treatment that was performed over 27,000 times in 2008. The purpose of this study is to assess the association of solid organ transplant CON regulations using clinically rich data available from the Scientific Registry of Transplant Recipients SRTR). This study tests the hypotheses that states with solid organ transplant CON regulations have fewer transplant centers, higher volumes of heart and kidney transplants per center, lower graft failure rates and lower patient mortality rates per center. In addition, this study assesses these hypotheses using two different transplant procedures heart and kidney). This study provides additional information for transplant centers to use in their strategic decision making. Moreover, with the presence of minimum volume standards for transplant procedures mandated by the Centers for Medicare and Medicaid CMS) now, the policy implications of continuing or repealing CON regulations should be examined.

The purpose of this project was to examine the systemic problem the cost of diabetes causes for the United States workforce and what can be done to lessen its effect. The project first examined data showing the overall cost of diabetes. Using systems theory this project focused on how the government, insurance companies, employers, and employees all pay a part of that cost. It showed how the government, insurance companies, employers, and employees can all benefit by working together to combat diabetes in the workforce. The project then explained the role of leadership in implementing plans to control the cost of diabetes in the workforce.

Over the past three decades, physician-directed managed care tools have been used extensively by health plans to influence physician practice and control health care costs. The success of these tools varies widely as do the specifics of how they are implemented. Organizations involved in implementation of managed care tools are evolving, as are the tools themselves. Gaining insight into physicians views on how managed care tools impact quality of care could help in the development of more effective tools. The purpose of this thesis is to address two questions regarding physicians attitudes towards managed care tools: Do physicians practicing in the same clinics have similar views of managed care tools? Do physicians views of managed care tools differ across practice settings and organizational structures e.g., types of clinics and health plans)? Using the literature on physician job attitudes and sociological and economic theory to guide the investigation, these questions are addressed by looking at the effects of physician, clinic and health plan characteristics on physicians attitudes toward managed care tools. Data for this study come from the PEHP survey of physicians in 15 health plans and 5 major cities nationwide with supplementary health plan information from Interstudy 1997). The data was collected in 1998-99. The initial sample of 4,800 physicians was stratified to be half generalists and half specialists. The overall response rate was 68% and N ＝ 3,459. The first part of the analysis consists of structural equation modeling SEM) to test the new typology of managed care tools. The scales developed in the first part are then used as dependent variables in a hierarchical linear modeling HLM) analysis to explore the role of physicians work setting and health plan affiliation on attitudes toward managed care tools. Results of the SEM indicate that managed care tools can be described and classified in terms of the types of control they exert on physicians. Results of the HLM analysis suggest that physicians practicing in the same clinic and health plans share some similar attitudes toward managed care tools, but the majority of differences are still at the physician level. Physician characteristics included in this study do not explain these differences, leaving open the question of whether the majority of variation is due to real differences in how individual physicians experience managed care tools, or due to measurement error. Future analysis could clarify this issue if clinic associations can be identified more accurately and/or better physician level predictors are developed.