Presented to the faculty of the Department of Public Policy and Administration California State University, Sacramento

UNHAPPINESS: THE HIDDEN COST OF NOT HAVING HEALTH INSURANCE COVERAGE A Thesis Presented to the faculty of the Department of Public Policy and Administration California State University, Sacramento Submitted in partial satisfaction of the requirements for the degree of MASTER OF PUBLIC POLICY AND ADMINISTRATION by Ngan Lam Thi Tran SPRING 2013 © 2013 Ngan Lam Thi Tran ALL RIGHTS RESERVED ii UNHAPPINESS: THE HIDDEN COST OF NOT HAVING HEALTH INSURANCE COVERAGE A Thesis by Ngan Lam Thi Tran Approved by: , Committee Chair Robert W Wassmer, Ph.D , Second Reader Edward L Lascher, Jr., Ph.D Date iii Student: Ngan Lam Thi Tran I certify that this student has met the requirements for format contained in the University format manual, and that this thesis is suitable for shelving in the Library and credit is to be awarded for the thesis , Department Chair Robert W Wassmer, PH.D Department of Public Policy and Administration iv _ Date Abstract of UNHAPPINESS: THE HIDDEN COST OF NOT HAVING HEALTH INSURANCE COVERAGE by Ngan Lam Thi Tran Although the United States has the highest health care spending per capita of any industrialized country, there are over 48 million nonelderly Americans lacking health insurance coverage, which translates to more than 18% of the nonelderly being uninsured Currently, governments around the world are pursuing strategies to incorporate well-being measures to advance public policy, yet there are few studies that focus on the effects of health insurance coverage on well-being This study fills the gap by exploring the relationship between well-being, health insurance coverage, health care cost, and Medicaid factors in the United States Data for this study come from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS) 2010 survey The BRFSS houses the world’s largest ongoing telephone health survey system with over 350,000 adults interviewed each year It is designed to measure behavioral risk factors for the adult populations to identify emerging health problems, establish and track health objectives, and develop and evaluate public health policies and programs In addition to the BRFSS data set, this study also uses data on states’ ranking of Medicaid programs from a 2007 report published by the Public Citizen Health Research Group v Controlling for confounding factors, results from a logistic regression analysis indicated that individuals who could not see a doctor due to cost were 40.7% less likely to be satisfied with life Similarly, individuals without health insurance coverage were 9.4% less likely to be happy Moreover, individuals residing in states with a 1-standard-deviation-higher percentage of Medicaid scope of services ranking and Medicaid eligibility ranking have lower odds of being satisfied with life by 6.1% and 2.5%, respectively However, low-income, self-employed, and unemployed individuals residing in states with better Medicaid rankings were found to be happier These findings add to the existing literature by suggesting that health insurance coverage, ability to see a doctor, and residency in states with better Medicaid rankings substantially affect individual well-being These effects held across income categories and health status, which further emphasized their significant influence on happiness Findings from this study have major implications for where policymakers should focus their attention _, Committee Chair Robert W Wassmer, Ph.D _ Date vi ACKNOWLEDGEMENTS I owe my deepest gratitude and appreciation to all those who helped me accomplish my educational goals There are many people I would like to thank for their support and encouragement, without whom this thesis would not have been made possible First and foremost, it is with immeasurable gratitude that I acknowledge the support of my thesis advisor, Professor Rob Wassmer, for imparting to me your knowledge about the wonder of statistical analyses, for your much needed guidance and support to complete this thesis, and for encouraging me to grow Thank you for spending countless hours to mentor me through completion, for responding to my numerous appeals for help, and for your timely and expeditious review I would also like to express my sincere gratitude to my second reader, Professor Ted Lascher - without your guidance, expertise, and spirit of adventure, this thesis would not have been possible Additionally, I am grateful to Professor Mary Kirlin for your continued encouragement, your “it depends” answers that helped me grasp the complexity of public policy issues, and for shaping me into a critical thinker I would like to express my deepest appreciation and thanks to my colleagues and friends at CalPERS, Ray Jacobs, John Maradik-Symkowick, Gayle Pitt, Valerie Wong, Milly RomeroSalas, Brian Covi, and Glenn Stuter, for allowing me to talk incessantly about my thesis, for your encouragement, and for helping me with the final reviews and formatting I am very grateful to my managers at CalPERS, especially Stacie Walker and Kari Yoshizuka, for your ongoing support of my educational goals and for giving me the flexibility in my work schedule to meet the demands of graduate school I am grateful for the friendship of my PPA pals, Jillian Benci-Woodward, George Bravo, Ryan Ong, Angela Marin, Sergio Aguilar, and Katie Cardenas, who watched me struggle through the finish line during the past few years and without whose support this thesis would not have been possible I would be remiss if I did not also acknowledge Ms Aline Bier, whom I am deeply indebted to and grateful for your continued support and encouragement since my undergraduate days at Cal – thank you for your gentle nudges to remind me the importance of higher education vii I am forever indebted to my mother and grandmother for believing in my abilities and encouraging me to attain more than they ever dreamed possible for themselves and the tremendous sacrifices they made to provide me access to a world of educational opportunities and infinite possibilities Without them, I would not be the person I am today To my little brother, even while you struggled you were always encouraging, your love and support mean so much to me To my little cousin, thank you for those delicious home cooked meals that gave me the fuel to power through furious writing sessions and for always encouraging me to keep going Last but definitely not least, I dedicate this thesis to my amazing husband, Eric, without whom I would not have started or finished this program Your inspiration, encouragement, and unconditional love have been instrumental to my educational goals and my love of learning You have always been by my side to witness the highs and lows of my graduate school experience, the lessons, struggles, and joys of learning Thank you from the bottom of my heart for always encouraging me to strive for more, for always challenging me to go further than the limits I have set for myself, and for believing in me You continue to be my true source of love and inspiration viii TABLE OF CONTENTS Page Acknowledgements vii List of Tables xi List of Figures xii Chapter INTRODUCTION……………………………………………………………………… Research Question Affordable Care Act Background Health Care Spending and Health Outcome Disparities in Health Insurance Coverage and Health Care Access Across the U.S 10 The Uninsured Population 13 California’s Uninsured Population and the Projected Impact of the ACA 17 Consequences of the Uninsured 20 Health Care Coverage, Health Care Cost, and Well-Being 22 Organization of Thesis 24 LITERATURE REVIEW 25 Defining Happiness and Measurement Validity 25 Policy Implications of Happiness Research 27 Key Happiness Predictors 31 Health Effect on Happiness and Well-Being 38 Gap in Happiness and Well-Being Literature 41 METHODOLOGY 44 Data Collection 45 ix Regression Model 51 Causal Model Justification 52 Data Sample 55 REGRESSION RESULTS 64 Multicollinearity 65 Heteroskedasticity 66 Ordinary Least Squares Linear Regression 67 Binomial Logistic Regression 72 Overall Model Fit 78 Expectations and Results 79 Interaction Variables 83 CONCLUSION 89 Empirical Findings 90 Research Question Evaluation 95 Policy Implications 99 Limitations of the Study and Future Research 105 Final Thoughts 106 Appendix A Table of Literature Study Methods, Data Sets, Findings, and Significance 108 Appendix B Simple Correlation Coefficients and Significance 116 References 124 x Author, Publication Date, Title Happiness: A 17-Nation Study Dolan, P., Peasgood, T & White, M (2008) Do we really know what makes us happy? A review of the economic literature on the factors associated with subjective well-being Sirgy, J (2012) The Psychology of Quality of Life: Hedonic Well-Being, Life Satisfaction, and Eudaimonia Methodology & Variables Population & Sample Size 1983 Results and Limitations men and women The relationship between marital status and happiness holds in 16 of the 17 nations and the strength of the association does not vary significantly in 14 of the 17 nations NON-REGRESSION BASED STUDIES Meta analysis 19 major national and Disability reduces life satisfaction on a 1-7 scale Review of published cross-national data sets by 0.596 points for those with no past disability, research in that included measures of by 0.521 points after year of disability, 0.447 economics journals SWB points after years and 0.372 after years since 1990 Unemployed have around to 15% lower SWB scores than employed Unemployment reduces the probability of a high life satisfaction score by 19% and a high overall happiness score by 15% Literature Review of Meta-analysis of 104 studies published before Subjective Well1980 focusing on the American elderly Being within Life concluded that objective and subjective measures Domains of health account for 8-14% of the variance in subjective well-being (Okun, Stock, Haring, and Witter 1984) Perception of health status or health satisfaction plus domain satisfaction indicators explain 53% of the variation in respondents’ reported happiness, 68% of the variance in life satisfaction scores, and 63% of the variance in reported satisfaction with overall QOL (Michalos, Zumbo, and Hubley, 2000) 60% of the explained variance in happiness scores was attributable to health satisfaction (George & Landerman, 1984, Larsen, 1978, Michalos et al., 2007) 115 Appendix B: Simple Correlation Coefficients and Significance No Health Insurance Coverage No Health Insurance Coverage Cannot Afford Doctor Cannot Afford Doctor Medicaid Eligibility Medicaid Quality of Care Medicaid Scope Medicaid Reimbursement Medicaid Overall Score 0.3602*** Medicaid Eligibility -0.0577*** -0.0418*** Medicaid Scope -0.0545*** -0.05*** 0.6423*** Medicaid Quality of Care -0.0246*** -0.0114*** 0.1327**** 0.2121*** Medicaid Reimbursement -0.0077*** -0.018*** -0.1484*** -0.0637*** -0.1045*** Medicaid Overall Score -0.0644*** -0.0527*** 0.7889*** 0.7267*** 0.489*** 0.2782*** African American 0.0621*** 0.0698*** -0.0592*** -0.1414*** -0.0453*** -0.0473*** -0.1149*** Asian -0.006*** -0.0091*** 0.0798*** 0.0589*** -0.0084*** -0.0389*** 0.0464*** Native Hawaiian 0.009*** 0.0107*** 0.0175*** 0.0127*** -0.0042*** -0.0041*** 0.0111*** American Indian 0.0471*** 0.03*** -0.0431*** -0.0214*** -0.0312*** 0.0494*** -0.0236*** Other Race 0.0032** 0.0068*** 0.0133*** 0.009*** 0.009*** 0.0212*** 0.0236*** Multi Racial 0.0161*** 0.0262*** 0.0302*** 0.0103*** -0.0193*** -0.0038** 0.0127*** Hispanic 0.1389*** 0.0994*** -0.016*** 0.0104*** -0.0475*** -0.0552*** -0.0488*** Female -0.0189*** 0.0523*** -0.0113*** -0.0187*** 0.0072*** -0.008*** -0.0135*** Age -0.1652*** -0.0119*** -0.0139*** 0.0127*** 0.0026* -0.0054*** 0.0568*** 0.0762*** -0.0023 -0.0072*** -0.0002 -0.0021 -0.005*** Widowed -0.082*** -0.0593*** -0.0218*** -0.0263*** 0.0118*** -0.0054*** -0.019*** Separated 0.0537*** 0.0696*** -0.0022 -0.0188*** 0.0011 -0.0194*** -0.0146*** Never Married 0.1181*** 0.0611*** 0.0345*** 0.0219*** 0.0049*** -0.0267*** 0.0185*** Unmarried Couple 0.0659*** 0.0507*** 0.0267*** 0.0205*** -0.0013 -0.0094*** 0.0181*** Number of children 0.1043*** 0.0917*** -0.0055*** 0.0111*** -0.0127*** 0.0018 -0.0039*** Elementary 0.0674*** 0.0577*** -0.0209*** -0.0229*** 0.0004 -0.0127*** -0.0254*** 116 -0.2205*** Divorced Health Insurance Coverage Cannot Afford Doctor Medicaid Eligibility Medicaid Scope Medicaid Quality of Care Medicaid Reimbursement Medicaid Overall Score Some High School 0.0839*** 0.074*** -0.0407*** -0.0559*** 0.0005 -0.007*** -0.0443*** High School 0.0626*** 0.0319*** -0.0344*** -0.0288*** 0.0262*** 0.0064*** -0.017*** 0.0012 0.022*** -0.0098*** 0.0096*** -0.0089*** 0.0211*** 0.0017 College Graduate -0.131*** -0.1118*** 0.0708*** 0.0557*** -0.0174*** -0.0178*** 0.0465*** Income