Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Esterhay, Robert

Committee Co-Chair (if applicable)

Little, Bert

Committee Member

Little, Bert

Committee Member

Mills, Michael

Committee Member

Kulasekera, Karunarathna

Author's Keywords

Adverse Selection; ACA; Risk Adjustment


In 2014 the Patient Protection and Affordable Care Act (ACA) implemented a risk adjustment program to stabilize premiums and neutralize premiums in the individual health insurance marketplace. This dissertation will examine the impact of the ACA risk adjustment program on adverse selection for one insurer during 2014. This study utilized enrollment and claims data for one insurer and employs graphical analysis to test for adverse selection. Previous studies have been unable to utilize actual insurer data to test for adverse selection in under the ACA risk adjustment program. Until the implementation of the ACA, insurers relied on underwriting methods to avoid being adversely selected. The ACA has removed the underwriting model by requiring insurers to move to a community rated model for pricing plans. This approach, along with risk adjustment was intended, by the Department of Health and Human Services (HHS), to attract insurers to participate in the individual health insurance marketplaces. Unfortunately, not all states enjoyed a large contingent of participating insurers which consequently had a dramatic financial impact on certain insurers being adversely selected. This dissertation discusses the potential drivers of adverse selection. In addition, the study examines potential improvements to help balance the risk pool and move toward the intended goal of risk adjustment.

Included in

Public Health Commons