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

Little, Bert

Committee Co-Chair (if applicable)

Esterhay, Robert

Committee Member

Esterhay, Robert

Committee Member

Jennings, J'Aime

Committee Member

Goldsby, Michael

Committee Member

Ruther, Matthew

Author's Keywords

preventable hospitalization; medicaid expansion; geographic; maps; Kentucky; socioeconomic factors


Objectives: 1) Analyze county level variation in T2DM-PH rates in Kentucky before ACA (2010-2013) and after the ACA (2014-2017). 2) Analyze the relationship between county level socioeconomic factors (income per capita, percentage of uninsured people, percent of urban population, primary care and general preventive offices, population aged 65 and above, median age, household income, percentage in poverty, and unemployment rate ) and county level T2DM-PH rates before (2010-2013) and after (2014-2017) ACA implementation in Kentucky. Method: This research was conducted in two phases: Phase one of this study estimated the county-level PH variation among T2DM patients across eight years (2010-2017), four years (2010-2013) before the Medicaid expansion and the next four years (2014-2017) after the implementation of Medicaid expansion to estimate the ACA impact on health outcomes among T2DM patients in Kentucky. The second phase focused on objective number two, to analyze and compare the socioeconomic factors association with T2DM-PH rates Previ and Post-Medicaid expansion. All county level socioeconomic factors and T2DM-PH rates were extracted from the AHRF data (2010-2017) and merged with Kentucky Hospital Inpatient Discharge Databases (KID) (2010-2017) to estimate and compare the correlations pre- and post-Medicaid expansion. Results: When the overall T2DM-PH rates Pre- and Post-ACA were assessed, a significant reduction (8.38%) in T2DM-PH discharges rates was found in the period of the postexpansion (P = 0.001). However, The spatial statistics analysis revealed significant spatial clustering of counties with similar high rates of T2DM-PH in the southeastern region before and after the expansion. These Counties with cluster type high-high (HH) had high positive z-score, positive Moran’s Index values and p-value2) of the variation in socioeconomic factors. PC1 loaded with wealth variables, whereas PC2 laded with poverty variables. While counties with high PC1 scores were in the northern region of the State, counties with high PC2 were mainly in the southeastern region Pre- and Post-ACA. The regression coefficients show that there is a positive association between PC2 and county level T2DMPH rates in Kentucky. The scaled slope (B) indicates the degree to which the T2DM-PH rate changes with a one-unit change in PC2 Pre-ACA (B=0.972, SE=0313, p=0.002) and Post- ACA (B=1.01, SE=0.218, p=0.001). Conclusion: The Medicaid expansion was associated with reduced T2DM-PH rates at county level in Kentucky. The Medicaid expansion affected the health coverage, but not the economic expansion. Extremely disadvantaged rural counties in southeast Kentucky scored highest on the socioeconomic deprivation profile component (PC2) and was significantly associated with high T2DM-PH rates (p