Lowering both Medicare spending and the rate of Medicare spending growth is important for the nation's fiscal health. Policy makers in search of ways to achieve these reductions have looked at the role that supplemental coverage for Medicare beneficiaries plays in Medicare spending. Supplemental coverage makes health care more affordable for beneficiaries but also makes beneficiaries insensitive to the cost of their care, thereby increasing the demand for care. Ours is the first empirical study to investigate whether supplemental Medicare coverage is associated with higher rates of spending growth over time. We found that supplemental insurance coverage was associated with significantly higher rates of overall spending growth. Specifically, employer-sponsored and self-purchased supplemental coverage were associated with annual total spending growth rates of 7.17 percent and 7.18 percent, respectively, compared to 6.08 percent annual growth for beneficiaries without supplemental coverage. Results for Medicare program spending were more equivocal, however. Our results are consistent with the belief that current trends away from generous employer-sponsored supplemental coverage and efforts to restrict the generosity of supplemental coverage may slow spending growth.

This study assesses the effect of black-white differences in school quality on black-white differences in health in later life resulting from the racial convergence in school quality for cohorts born between 1910 and 1950 in southern states with segregated schools. Using data from the 1984-2007 National Health Interview Surveys linked to race-specific data on school quality, we find that reductions in the black-white gap in school quality led to modest reductions in the black-white gap in disability.

Many demographic, socioeconomic, and behavioral risk factors predict mortality in the United States. However, very few population-based longitudinal studies are able to investigate simultaneously the impact of a variety of social factors on mortality. We investigated the degree to which demographic characteristics, socioeconomic variables and major health risk factors were associated with mortality in a nationally-representative sample of 3617 U.S. adults from 1986 to 2005, using data from the 4 waves of the Americans' Changing Lives study. Cox proportional hazard models with time-varying covariates were employed to predict all-cause mortality verified through the National Death Index and death certificate review. The results revealed that low educational attainment was not associated with mortality when income and health risk behaviors were included in the model. The association of low income with mortality remained after controlling for major behavioral risks. Compared to those in the "normal" weight category, neither overweight nor obesity was significantly associated with the risk of mortality. Among adults age 55 and older at baseline, the risk of mortality was actually reduced for those were overweight (hazard rate ratio = 0.83) and those who were obese (hazard rate ratio = 0.68), controlling for other health risk behaviors and health status. Having a low level of physical activity was a significant risk factor for mortality (hazard rate ratio = 1.58). The results from this national longitudinal study underscore the need for health policies and clinical interventions focusing on the social and behavioral determinants of health, with a particular focus on income security, smoking prevention/cessation, and physical activity.

This paper assesses the effect of payment caps for Medicare home health care on the use of informal care by older adults with functional limitations. We find that individuals exposed to more restrictive payment caps offset reductions in Medicare home health care with increased informal care, although we only observe this effect for lower-income individuals. This suggests that home care payment restrictions may have increased the caregiving burden on some low-income families, but that many higher-income families were able to either forgo the care or finance it privately. Home care payment policies should recognize these effects, balancing costs of the program with the desire to protect families from the burdens associated with providing informal home care.

OBJECTIVE Despite considerable policy interest in the association between perceived public stigmatization of mental illness and use of mental health services, limited empirical evidence, particularly from longitudinal data, documents this relationship. This study used longitudinal data to estimate the association between perceived public stigmatization and subsequent mental health care seeking. METHODS A Web-based survey was used to collect data from a random sample of undergraduate and graduate students at a university at baseline and two years later (N=732). Logistic regression models assessed the association between students' perceived public stigma at baseline and measures of subsequent help seeking for mental health problems (perceived need for help and use of mental health services) at follow-up. RESULTS No significant associations were found between perceived public stigma and help-seeking behavior over the two-year period. CONCLUSIONS In this population of college students, perceived stigma did not appear to pose a substantial barrier to mental health care.

BACKGROUND Cross-sectional studies indicate a high prevalence of mental health problems among college students, but there are fewer longitudinal data on these problems and related help-seeking behavior. METHODS We conducted a baseline web-based survey of students attending a large public university in fall 2005 and a two-year follow-up survey in fall 2007. We used brief screening instruments to measure symptoms of mental disorders (anxiety, depression, eating disorders), as well as self-injury and suicidal ideation. We estimated the persistence of these mental health problems between the two time points, and determined to what extent students with mental health problems perceived a need for or used mental health services (medication or therapy). We conducted logistic regression analyses examining how baseline predictors were associated with mental health and help-seeking two years later. RESULTS Over half of students suffered from at least one mental health problem at baseline or follow-up. Among students with at least one mental health problem at baseline, 60% had at least one mental health problem two years later. Among students with a mental health problem at both time points, fewer than half received treatment between those time points. LIMITATIONS Mental health problems are based on self-report to brief screens, and the sample is from a single university. CONCLUSIONS These findings indicate that mental disorders are prevalent and persistent in a student population. While the majority of students with probable disorders are aware of the need for treatment, most of these students do not receive treatment, even over a two-year period.

Mental illness stigma has been identified by national policy makers as an important barrier to help seeking for mental health. Using a random sample of 5,555 students from a diverse set of 13 universities, we conducted one of the first empirical studies of the association of help-seeking behavior with both perceived public stigma and people's own stigmatizing attitudes (personal stigma). There were three main findings: (a) Perceived public stigma was considerably higher than personal stigma; (b) personal stigma was higher among students with any of the following characteristics: male, younger, Asian, international, more religious, or from a poor family; and (c) personal stigma was significantly and negatively associated with measures of help seeking (perceived need and use of psychotropic medication, therapy, and nonclinical sources of support), whereas perceived stigma was not significantly associated with help seeking. These findings can help inform efforts to reduce the role of stigma as a barrier to help seeking.

This dissertation contains three empirical papers on important health policy issues. The first paper looks at the effect of changes in levels of Medicare home health care services on the informal care use of disabled, older adults. I estimate two-part models of informal care use, where the key independent variable is a measure of Medicare home health payment restrictiveness. Individuals who lived in states with less Medicare home health care services increased their use of informal care, although this effect is only observed among low-income individuals. The second paper assesses the effects of changes in employment incentives on the supply of informal support from adult children to their disabled, older parents. This study focuses on one specific form of informal support, co-residence with a disabled parent. I compare changes in co-residence patterns between 1990 and 2000 across groups of middle aged women whose co-residence patterns were arguably comparable, and who experienced very different changes in employment incentives. Results from difference-in-difference models provide support to the hypothesis that increasing employment incentives reduces the supply of informal support to disabled parents. The third paper looks at the effect of education on health status. This paper builds on the extensive research literature on this topic by measuring health in terms of the number of Quality-Adjusted Life Years experienced by individuals over an extended period of time. This measure captures overall health status over time, which is arguably a more important measure than point-in-time measures of specific health conditions or longevity alone. I use changes in compulsory schooling laws to identify the causal effect of education on health. Instrumental variables models provide evidence that the health returns to education are both statistically significant and substantial.

OBJECTIVE There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. METHODS This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. RESULTS Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. CONCLUSIONS These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes.

OBJECTIVE The authors' purpose in this research was to establish estimates of the prevalence and correlates of nonsuicidal self-injury among university students. PARTICIPANTS The authors recruited participants (N = 2,843) from a random sample of 5,021 undergraduate and graduate students attending a large midwestern public university. METHODS Using an Internet-based survey, the authors measured the prevalence of self-injury and potential risk factors, including depression, anxiety, eating disorders, suicidal thoughts, and negative health behaviors. RESULTS Seven percent of students reported any self-injury over the previous 4 weeks. Factors associated with a significantly higher likelihood (p <.05) of self-injury included cigarette smoking, concurrent depressive and anxiety disorders, and for men, growing up in a family of low socioeconomic status and having symptoms of eating disorders. Only 26% of those who reported self-injury received mental health therapy or medication in the previous year. CONCLUSIONS Students who harm themselves experience high anxiety and distress, yet are unlikely to seek help.

OBJECTIVE This research assesses the association of health services use with subsequent physical health among older Americans, adjusting for the confounding between health care use and prior health. METHOD Longitudinal data are from the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Linear and logistic regressions are used to model the linkages between medical care use and health outcomes, including self-rated health, functional limitations, and mortality. RESULTS There is limited evidence that increased health care use is correlated with improved subsequent health. Increased use of medical care is largely associated with poorer health outcomes. Moreover, there are no significant interaction effects of health care use and baseline health on Activities of Daily Living and Instrumental Activities of Daily Living, despite the existence of a significant but very small interaction effect on self-rated health. CONCLUSIONS The findings have implications for the quality of care delivered by the American health care system.

BACKGROUND University students represent an important population in which to study access to mental health care. Understanding their unmet needs will enhance efforts to prevent and treat mental disorders during a pivotal period in life. OBJECTIVE To quantify mental health service use and estimate how various factors are associated with help-seeking and access in a university student population. DESIGN A Web-based survey was administered to a random sample of 2785 students attending a large, public university with a demographic profile similar to the national student population. Nonresponse bias was accounted for using administrative data and a nonrespondent survey. MEASURES Mental health was measured using the Patient Health Questionnaire screens for depressive and anxiety disorders. Mental health service utilization was measured as having received psychotropic medication or psychotherapy in the past year. RESULTS Of students with positive screens for depression or anxiety, the proportion who did not receive any services ranged from 37% to 84%, depending on the disorder. Predictors of not receiving services included a lack of perceived need, being unaware of services or insurance coverage, skepticism about treatment effectiveness, low socioeconomic background, and being Asian or Pacific Islander. CONCLUSIONS Even in an environment with universal access to free short-term psychotherapy and basic health services, most students with apparent mental disorders did not receive treatment. Initiatives to improve access to mental health care for students have the potential to produce substantial benefits in terms of mental health and related outcomes.

Mental health among university students represents an important and growing public health concern for which epidemiological data are needed. A Web-based survey was administered to a random sample at a large public university with a demographic profile similar to the national student population. Depressive and anxiety disorders were assessed with the Patient Health Questionnaire (R. L. Spitzer, K. Kroenke, J. B. W. Williams, & the Patient Health Questionnaire Primary Care Study Group, 1999). Nonresponse weights were constructed with administrative data and a brief non-respondent survey. The response rate was 56.6% (N = 2,843). The estimated prevalence of any depressive or anxiety disorder was 15.6% for undergraduates and 13.0% for graduate students. Suicidal ideation in the past 4 weeks was reported by 2% of students. Students reporting financial struggles were at higher risk for mental health problems (odds ratios = 1.6-9.0). These findings highlight the need to address mental health in young adult populations, particularly among those of lower socioeconomic status. Campus communities reach over half of young adults and thus represent unique opportunities to address mental health issues in this important age group.