Evaluating the Impacts of Federal Social Programs on Older Adults in the United States of America: Three Essays in Health Economics

Abstract

Federal social insurance and safety net programs are integral to the well-being of older adults in the United States. As such, this dissertation focuses on evaluating the impacts of changes to or differences within two of these programs, Medicare and the Supplemental Nutrition Assistance Program, on the senior population. In Chapter 1, I examine the effects of Medicare’s Hospital Acquired Condition Reduction Program (HACRP), a part of the Affordable Care Act (ACA). According to final rules announced in 2013, the HACRP reduces Medicare payments by 1% for hospitals in the lowest performance quartile in hospital-acquired condition (HAC) measures. Using 2009-2015 fee-for-service Medicare claims data for those 65 and older, I employed an interrupted time-series design to evaluate changes in HAC rates, percentage of HACs coded as present on admission (POA), and 30-day mortality. I estimated models with linear splines to test for changes before the ACA, after the ACA, and after the announcement of HACRP rules. In my results, I found that, while the HACRP was associated with an decline in the rates of targeted HACs and an increase in POA coding, it was not similarly associated with any change in 30-day mortality. This suggests that the HACRP may not have led to the true downstream clinical improvements it intended. In Chapters 2 and 3, I switch to focusing on the Supplemental Nutrition Assistance Program (SNAP). Over the past two decades, food insecurity, including reduction in diet quality with or without reduced food intake, has been increasing among seniors (those aged 60 or older, as defined by SNAP). Even though many older adults are eligible for SNAP, they have historically been under-enrolled, compared to the general eligible population. In response, federal and state governments have implemented policies aimed at influencing eligibility and enrollment both among seniors (age 60+) and among Supplemental Security Income (SSI) beneficiaries, many of whom are older. In Chapter 2, I examine some of these specific state policies, including broad-based categorical eligibility (BBCE), offering a standard medical deduction (SMD), using an SSI combined application project, and requiring applicant fingerprinting. Using 2002-2018 Health and Retirement Study (HRS) data, I employed a difference-in-differences framework with two-way fixed effects to assess these policies’ impact on eligibility and enrollment amongst seniors and older SSI beneficiaries. I found that, while BBCE and SMD were associated with increased estimated eligibility, no program significantly impacted enrollment. This surprising result indicates that new, innovative programs are needed to encourage SNAP participation amongst seniors and/or SSI beneficiaries moving forward. In Chapter 3, I exploit geographic variation in average meal cost (leading to geographic differences in SNAP benefits’ purchasing power or real dollar value) to examine SNAP’s impact on older adult beneficiaries’ food security, health outcomes, and healthcare affordability or utilization. Using 2010-2018 HRS data combined with county-level average meal cost data, I modeled changes to these outcomes in response to purchasing power differences, both concurrently and approximately two years later. I found that increases in SNAP purchasing power were associated with significant improvements in food security and self-reported physical health both concurrently and over time and decreases in not receiving needed medical care concurrently. This suggests that increasing the real dollar value of older adults’ SNAP benefits may not only improve food security but also boost health and improve healthcare accessibility in the long term.