Research Portfolio

I am a health policy researcher seeking to build a research program focused on improving the mental health and quality of life for low-income Americans. Throughout my doctoral training, I have used quasi-experimental methods in large administrative datasets (e.g., Medicaid enrollment and claims) and nationally representative survey data to achieve these goals. My research makes two key contributions: understanding how to redesign public programs to improve health outcomes and how to expand access to prescription drugs. Together, this body of work has produced 14 papers (5 first author and 9 co-authored) and addresses critical gaps in the literature. My dissertation, Public insurance, access to care, and mental health among low-income Americans, is chaired by Meredith Rosenthal, with Nicole Maestas, Haiden Huskamp, and Alex McDowell.

How to Redesign Public Health Insurance Programs to Improve Health Outcomes

My first major area of research generates evidence that informs the redesign of public health insurance programs to help expand access to high-quality care and improve health outcomes among low-income individuals. Specifically, I explore utilization of newly covered benefits for gender-affirming care among Medicaid enrollees and take-up of a subsidy program for dual-eligible Medicare and Medicaid enrollees.

Utilization of Newly Covered Benefits among Medicaid Enrollees

Job market paper: The Impact of Medicaid Coverage of Gender-affirming Care on Surgery and Hormone Use and Adverse Mental Health Outcomes (with P. Liu, K. Ranganathan, M.B. Landrum, V. Fung, and A. McDowell). Draft available on request.

Transgender adults experience elevated rates of mental illness and suicidality. Yet, they face persistent barriers to care. In first-author work published in the American Journal of Preventive Medicine, I analyzed nationally representative KFF survey data and found high unmet mental health need among transgender adults, driven largely by cost. Gender-affirming care, including hormone therapy and surgery, can improve quality of life and mental health, but coverage varies across payers and states. Nine state Medicaid programs began covering this care between 2016 and 2021. My job market paper is the first research to identify transgender adults in national Medicaid claims data and evaluate these policy changes. Using national Medicaid enrollment and claims data from 2016–2021, I estimate how state Medicaid decisions to cover gender-affirming care affect both service use and mental health outcomes. I constructed a national dataset of state Medicaid coverage policies for gender-affirming care by reviewing statutes, regulations, provider manuals, and agency guidance. I then identified transgender adults in claims using a validated diagnosis-based algorithm and use an event study and difference-in-differences approach that leverages the staggered coverage adoption. Difference-in-differences inference under staggered adoption, heterogeneous treatment effects, and small cluster counts remains an active methodological frontier, so I use modern estimators and inference procedures where possible. I find that coverage increases use of gender-affirming surgery among transgender enrollees by 0.41 percentage points, a 158% relative increase from baseline, and that Medicaid coverage of gender-affirming care decreases adverse mental health outcomes in some states.

My ongoing work will estimate the effects of gender-affirming services on transgender adolescents, including spillovers onto other family members’ mental health. Beyond gender-affirming care, I plan to extend this design to other newly covered, high-cost benefits that states adopt differentially (e.g., Medicaid coverage of GLP-1s for obesity).

Eligibility and Program Enrollment among Dual-eligible Enrollees

I have developed deep knowledge of the policies that underlie the intersection of Medicaid and Medicare for low-income adults. Dual-eligible beneficiaries are among the sickest and poorest enrollees in public insurance, and policymakers are interested in ways to improve their health insurance plan selection to achieve comprehensive coverage and reduce costs. In first-author work published in Health Affairs, I used the Medicare Current Beneficiary Survey (MCBS) to identify low-income Medicare beneficiaries who are eligible for the Medicare Savings Program, which pays beneficiary premiums and cost-sharing for low-income adults. I found that a third of eligible beneficiaries did not enroll in the program, and these beneficiaries reported more cost barriers to care than those enrolled in the subsidy program. Our results informed recent CMS policy changes to streamline enrollment in the Medicare Savings Program and increase the number of beneficiaries who are automatically enrolled; I discussed the findings on Health Affairs’ A Health Podyssey. Related co-authored work with the MGH Mongan Institute team examines state expansions of Medicare Savings Program eligibility (Health Services Research) and Medicaid retention after the transition to Medicare (JAMA Network Open).

Additionally, despite the fact that two thirds of Medicaid enrollees age 50–64 are eligible via the Affordable Care Act expansion, there is limited evidence about how Medicaid coverage gains impact outcomes at the transition to Medicare. In ongoing work supported by the Commonwealth Fund, I am assessing how Medicaid coverage might impact health outcomes among older adults as they age into Medicare eligibility, to produce estimates that can contextualize the effects of upcoming Medicaid cuts for older, low-income adults.

Access to Prescription Drugs

Working papers: Pharmacy Closures and Medication Adherence Among Medicaid Enrollees with Serious Mental Illness and Prevalence of Mail-order Prescription Drug Fills among Medicaid and Medicare Enrollees Overall and by Drug Type (both with P. Kakani and N. Maestas). Drafts available on request.

In my second major domain of research, I investigate prescription drug access and its relationship to health outcomes. I am currently examining how community pharmacy closures affect access to prescription drugs for Medicaid beneficiaries. Closures have risen over the past decade, and prior work links them to reduced cardiovascular and anticonvulsant adherence in commercially insured populations. However, pharmacy closures may have a disproportionate impact on Medicaid and Medicare enrollees, as previous studies have found closures are more likely to occur in low-income neighborhoods. In a separate, first-author analysis, I link 2021 Medicaid and Medicare prescription fills to pharmacy characteristics data, and I find that a larger share of Medicaid prescription fills occur via chain pharmacies while fewer occur via mail-order compared to Medicare beneficiaries. This may suggest that Medicaid enrollees have fewer substitution options when a pharmacy closes.

Medicaid enrollees with serious mental illness may be particularly impacted by pharmacy closures, as medication disruption is linked to relapse, hospitalization, and suicide. However, no research has examined the effect of pharmacy closures on the care received by this population. To address this gap in the literature, I estimate the effect of pharmacy closures on prescription drug access and behavioral health care use among enrollees with serious mental illness using a stacked difference-in-differences design and national Medicaid claims from 2016–2021. To do this, I construct a national dataset of pharmacy closures, linking NPI records to monthly Medicaid claims to identify each pharmacy’s last Medicaid fill. I find that closures reduce antipsychotic and mood stabilizer fills and days supplied among individuals with schizophrenia and bipolar disorder, with the largest disruption in the closure month and recovery within a year. Closures also increase outpatient mental health use and transiently raise inpatient admissions in the month after closure, while emergency department use is unchanged.

Looking forward, given the large shocks to the mental health provider landscape through digital health companies (e.g., telepsychiatry, direct-to-consumer prescription services, and virtual provider networks), I plan to use state variation to answer questions about access and quality of mental health care. I also plan to assess how prior authorization and formulary rules for mental health and substance use drugs affect access and outcomes across state Medicaid programs since the ACA.

Grant Funding

In a faculty position or postdoctoral fellowship, I would apply for K01 or R01 grants (NIMH, NIDA, NIA, or an institutional K12 program) to advance key threads in my research portfolio such as assessing Medicaid provision of pharmacy services with a focus on mental health and substance-use disorder treatment. In addition to NIH grant prospects, I have a broad array of foundation relationships from my prior non-profit sector work and have begun conversations about possible opportunities to support my portfolio. Using those contacts and working with Professor Vicki Fung, I helped write and acquire a grant from the Commonwealth Fund to study how Medicaid enrollees transition to Medicare for which I currently serve as project director. I would also seek foundation support to pursue work assessing access to mental health services among LGBTQ adults (e.g., American Foundation for Suicide Prevention).