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Chapter 1 presents the backgrounds and research questions of the dissertation project. Although everyone hopes to die with dignity, a “good death” is often privileged. Inequality in end-of-life care in the United States is striking; older minorities are 3 times more likely to receive intrusive care and experience hospital readmission and less likely to use hospice care and die at home. With the hope to address disparities in end-of-life outcomes, as part of the Affordable Care Act, Medicare expanded its benefit and started to reimburse end-of-life care planning services from 2016. This dissertation examines the roles of health insurance policy and its advocated intervention in ensuring person-centered dying experiences in the United States and the public readiness for establishing a similar end-of-life care policy in China. The second chapter examines whether physician–patient advance care planning (ACP) discussions, the “intervention” embedded in the policy, is effective at prompting end-of-life care planning behaviors and improving end-of-life experiences. I also studied the heterogenous effects by race and ethnicity. I used exit data about 7,282 deceased Medicare-eligible respondents from the Health and Retirement Study (HRS) from 2012 to 2020, a nationally representative biennial survey of U.S. older adults. I conducted latent class analysis to identify different end-of-life experiences and used multinomial logistic regression models to study the relationship between having ACP discussions with doctors and different end-of-life experiences in full and stratified samples by race and ethnicity. Then I used path analyses to test whether completing legal documentation initiated by ACP services explains the effectiveness of the intervention. The results show three types of end-of-life experiences among White, Black, and Hispanic older adults; significant effects of end-of-life care discussions with doctors on uncomfortable dying experiences and extensive use of invasive treatments in the older White population; and the partial mediating role of completion of legal health care documents on the relationship between ACP discussions and end-of-life outcomes. This study identified the limited effectiveness of physician–patient ACP discussions among minority older adults and emphasizes the importance of quality, content (e.g., to cover legal documentation during the conversation), and cultural appropriateness of ACP consultations led by doctors. The third chapter examines the heterogenous intent-to-treat effect of the Medicare policy on older adults’ motivation to plan for care by exploiting policy intervention as a natural experiment. Taking advantage of the longitudinal nature of the HRS, I used core data with 47,982 observations nested in 15,647 individuals across 9 years (2012–2020). I used two quasi-experimental models—interrupted time series analysis and difference-in-difference—to study the care-planning outcomes before and after the policy implementation between older adults eligible or not eligible for Medicare. I studied the heterogenous effects in stratified samples by race and ethnicity, immigration background, and socioeconomic status proxied by education and wealth. I used coarsened exact matching to address the potential bias of the comparison group not being the ideal counterfactual control unit. I found that in the total population, the Medicare policy was associated with a significant increase in the proportion of older adults who completed a living will and designated a durable power of attorney for health care, but not having an ACP conversation. Furthermore, although there were immediate positive policy effects, the increases in ACP outcomes driven by the ACA Medicare benefit expansion were not sustained. Finally, I found no evidence that the ACA Medicare benefit expansion was effective in improving the rates of ACP among Black, Hispanic, Asian, Native American, or non-U.S.-born older adults. I also identified heterogeneous policy effects by socioeconomic status. I discuss promising recommendations for health care policy and practice to improve the participation rate of end-of-life care planning. Chapter 4 explores the feasibility of encouraging physicians to discuss end-of-life care wishes with older patients in China. Knowledge of a medical diagnosis is critical for end-of-life decision making. However, a patient’s right to know their diagnosis is neither guaranteed nor protected by law in China. Doctors typically inform family members of the patient’s illness diagnosis and prognosis and let them decide whether to disclose this information to the patient. This study examined middle-aged and older Chinese adults’ preferences for disclosing their and significant others’ diagnoses and whether sociodemographic, economic, and cultural factors were associated with these preferences. The research team surveyed 571 adults aged 50 or older in Shanghai from 2021 to 2022. The outcome measures are preferences for diagnosis disclosures, including whether and to whom diagnoses should be disclosed. I characterized preference types using latent class analysis and estimated multinomial logistic regression to identify the covariates associated with each preference type. Three latent classes were identified. The transparent group (34%) believed patients, whether self or a significant other, should be informed of their diagnoses. The contradictory group (50%) held conflicting attitudes; they preferred to know their diagnosis but preferred that significant others not be informed of their diagnoses. The avoidant group (16%) preferred not to know their diagnosis or to disclose significant others’ diagnoses to them. Familism attitudes were positively associated with holding contradictory views. Experiences with hospitalization and medical decision-making for family members were associated with holding transparent views. I discuss the importance of illness disclosure for honoring patients’ autonomous decision-making.

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On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. This reform, it is argued, is projected to increase insurance coverage of pre-existing conditions, to expand access to insurance for more than 30 million Americans, and to increase estimated National medical spending while lowering projected Medicare spending. This thesis sought to investigate and analyze the perceptions of senior citizens in Central Florida about PPACA and their perceived effects on the healthcare quality provided to them under this law. Four sections of PPACA bill, thought to specifically pertain to the elderly, were selected for this study; respondents were asked their opinions regarding PPACA's aspects of: (1) the reform on preventive healthcare services; (2) Medicare Part D (prescription drugs); (3) Medicare; and (4) Medicaid. This thesis employed both qualitative and quantitative methodologies; data were collected and analyzed with findings presented and discussed.

<p>The dissertation is consisted of two essays on Affordable Care Act Marketplace plan pricing. These two essays are the two chapters of the dissertation respectively.  </p> <p>First essay studies the effect of Medicaid expansion on ACA Marketplace plan premium. The Affordable Care Act (ACA) aims to mitigate Americans’ uninsured crisis by expanding Medicaid and establishing the ACA Marketplace. The Medicaid expansion has a profound impact on Marketplace plan premiums. On the one hand, it lowers the premiums because the expansion drives out the people with lower income from Marketplace plans, resulting in a pool with a lower risk score for these plans. On the other hand, the Medicaid expansion may shrink the pool size of Marketplace plans, resulting in a riskier pool and a higher Marketplace plan premium. Integrating data from multiple sources, we study how these two competing effects vary across markets with different demographics. We find that the premium-reduction effect is less pronounced in more wealthy markets, while the premium-increase effect is less pronounced in more populous markets. We further find that the Medicaid expansion overall decreased the Marketplace premiums, with more reduction for Silver plans than Bronze plans. We also explore how the Medicaid expansion can lower Marketplace premiums indirectly through the change of the market structure. We finally show the heterogeneity of the net impact of the Medicaid expansion on Marketplace premiums across markets. Our results offer important policy and managerial implications.</p> <p>The second essay explores the effect of insurer competition on marketplace plan premiums. ACA Marketplace is a new market opportunity for insurers that grant them access to a new group of customers who were not insured before. Previous studies utilize ACA marketplace data and find that additional insurers on the market are associated with a premium decrease in Marketplaces for a benchmark plan. However, the impact of the insurer entry on the premium is not the same for all plans. Using data from 2014 to 2017, we empirically examine the effect of insurer entry on the premium on Marketplace. Our study first confirms the finding that the premium of the second-lowest Silver plans decreases in the number of insurers. We further find evidence of different price trends across plans of different quality levels with additional insurers on the market. When more insurers are on the market, the premium increases for higher-end plans and decreases for lower-end plans. Our analysis shows that intensified competition may exaggerate price discrimination in certain segments while alleviate price discrimination in other markets. The results offer important managerial implications. </p>

This dissertation examines the effects of physician ownership of hospitals on the quality of patient-centric care in the U.S. The health care sector in the U.S. is becoming more aligned with markets and in turn, with consumers’ preferences. In consumer driven service industries, consumer satisfaction is considered a key criterion to judge quality. In the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction surveys, physician-owned hospitals (POHs) get more top 5-Star ratings than other hospitals. However, it is not known whether higher perceived patient satisfaction is because of better inpatient experience or due to better health related outcomes. Ratings also do not clarify variations between specialty and general service POHs. The study compares the quality of care in POHs with that in other major forms of hospitals (corporate-owned, and not-for-profit). The Affordable Care Act (ACA) regulated physician ownership of hospitals due to concerns that physicians’ profit motive might negatively affect the quality of care. This non-experimental study used bivariate and multivariate analyses to examine variation in the quality of care among types of hospitals in 2017 and 2018 using patient satisfaction and clinical outcomes as indicators of quality. This study used two samples, a full and a restricted sample. Full sample compared all POHs (specialty and general service) with other hospitals. Restricted sample included only general service hospitals. Patients in POHs were found to have higher perceived satisfaction, and viewed providers’ practices more favorably in the full sample. In the restricted sample, however, not-for-profit (NFP) hospitals provided relatively better care. Corporate-owned hospitals had lowest patient satisfaction and poorest outcomes. Results indicate POHs are competitive with not-for-profit hospitals on patient satisfaction dimension of quality care. Multivariate analyses suggest that the effects of physician ownership go away when mediation by providers’ practices is considered. NFP hospitals, however, continue to provide better overall value of care. The results do not support reconsideration of the ACA restrictions on POHs. Patient satisfaction may be contingent upon patient-centric practices than type of hospital, but hospital ownership may affect preference for some practices over others. Outcomes may not matter when patients’ perceptions measure quality. / Ph. D. / The health care sector is becoming more closely linked to markets, and consumer experience and satisfaction, like any other consumer services industry due to growing influence of for-profit hospitals and hospital forms. Physician-owned hospitals are a relatively new form of hospitals in the U.S. Along with more traditional not-for-profit and corporate-owned hospitals; physician-owned hospitals compete for patients and patient dollars. Many physician-owned hospitals are specialty and surgical hospitals, in addition to general service hospitals. According to federal government surveys, patients usually perceive medical care provided by physician-owned hospitals to be of superior quality to that of other kinds of hospital. However, physician-owned hospitals are a type of for-profit hospital, and it is not clearly known if general service physician owned hospitals provide similar care as specialty hospitals. This research compared possible quality differences between specialty and general service physician-owned hospitals as well as with corporate-owned and not-for-profit hospitals. The results indicate that patients’ perceptions of quality of care are not consistent for physician-owned specialty and general service hospitals; the higher patient perception ratings for physician-owned hospitals reflect the better performance of specialty hospitals. In comparison with other hospitals, not-for-profit hospitals seem to provide better quality of care (tapped by both patient satisfaction and clinical outcomes) than for-profit hospitals. Corporate-owned hospitals were found to have lowest quality of care. Patients should consider tradeoffs between having better inpatient experiences and better outcomes of care.

Cette thèse inscrite dans la tradition intellectuelle de l’American Political Development analyse les liens dialectiques entre l’entrepreneuriat des présidents des États-Unis sur la question de l’assurance maladie, l’essor du système de santé américain contemporain et son produit le plus récent, le Patient Protection and Affordable Care Act (2010). Il s’agit d’analyser les influences réciproques entre un exécutif qui subit de très fortes contraintes institutionnelles dans ce champ précis des politiques publiques et un système de santé dont les fondements et les contours sont en perpétuelle mutation. Les réformes de santé, de par leur nature transversale et polémique, leur complexité mais aussi leur poids dans l'économie américaine, agissent directement sur les équilibres de la gouvernance publique. Elles doivent être considérées comme un laboratoire et un accélérateur d’innovations pour la présidence, dans un système politique où sa sphère d’action est limitée, tant par les freins et des contre-pouvoirs que par l’influence d’autres entrepreneurs politiques dotés d’une légitimité d’action égale voir supérieure à se saisir de la question épineuse de la santé. L’adoption du PPACA, sa promulgation par un président démocrate après un siècle de rendez-vous manqués avec les réformes ambitieuses de l’assurance maladie, ainsi que sa mise en œuvre compliquée, offrent un cas d’étude de premier plan sur les évolutions de l'exécutif étasunien et sur la normalisation d’un entrepreneuriat présidentiel hétérodoxe. / This dissertation which falls within the intellectual tradition of American Political Development explores the dialectical links between the entrepreneurship of US presidents on health care reform, the development of the American health care system and its latest product, the Patient Protection and Affordable Care Act (PPACA), which was signed into law in 2010. This work analyses the mutual forces of influence at work between a deeply constrained executive in this particular field of public policy and a health care system whose foundations and contours are in constant mutation. Given its controversial nature, its complexity and its weight in the US economy, health care reform directly affects the dynamics of public governance. Health care reform must therefore be considered as a laboratory and an accelerator of innovations for the presidency, in a political system in which its sphere of action is limited, as much by checks and balances as by the influence of other entrepreneurs who enjoy equivalent if not greater legitimacy than the executive branch to take action on the thorny issue of health care. The passage of the PPACA, the fact that it was signed into law by a democratic president after a century of failed attempts at ambitious reform as well as its arduous implementation, are a picture perfect case study on the evolutions of the presidential institution and on the routinization of heterodox presidential entrepreneurship.

The Patient-Centered Medical Home (PCMH) is an innovative, team-based health care model that was applied during the implementation of the Affordable Care Act (ACA). However, the competencies for PCMH health care social worker team members are not identified within this model. Thus, the purpose of this phenomenological study focused on identifying the core competencies that will enable social workers to perform competently in PCMHs. This study also explored the roles and training needs as related to improving the competence of social workers. Sandberg’s and Parry’s conceptualization of the competency model was used as the theoretical framework. Data were acquired through interviews with 10 PCMH social workers. These data were then inductively coded and analyzed using a modified Moustakas method. Key findings indicated that these social workers believed that improvements in competencies may include training and knowledge with mental health and physical health knowledge which consist of diagnoses, interventions, medications, symptoms, and terminology. It was also noted that knowledge of evidence-based practices for mental health interventions and patient-centered, team-based principles were essential to ACA policy implementation. The positive social change implications of this study include recommendations to health care leadership, educational institutions, and other PCMH providers to develop competency-based training for social workers. Recommendations are also put forth to adapt social work curriculum to ensure the effective implementation of the principles of the ACA policy and to improve social work practice in PCMH health care settings.

This research focuses on obesity and other major risk factors for chronic diseases such as Type II Diabetes Mellitus, Heart Disease, and Stroke. Worksite wellness programs have been successful in this realm of health promotion and disease prevention for heart disease and stroke, but their effectiveness in treating diabetes has been uncertain partially due to poor patient compliance, lack of stress reduction strategies, poor diet and lack of persuasive health education on the risk of being obese. Published peer-reviewed articles were reviewed, coded and analyzed to determine best practices, using a modified systematic review approach. The findings from these studies yield results that were used to develop a new employer-sponsored wellness program that is in accordance with the recently passed Affordable Care Act. / Includes bibliography. / Thesis (M.S.)--Florida Atlantic University, 2014. / FAU Electronic Theses and Dissertations Collection

The Diploma work "Health care reform in the United States of America" is the sequel of the Bachelor work of 2008 called "The liberal health care system of the United States of America". The work is focused on the financial means and changes which has been effective since singing The Patient Protection and Affordable Care Act (acronym PPACA) into the United States law on 23rd March 2010 by the democratic president Barack Obama. The special attention is drawn to permanently increasing health care costs and defrauding of money within the social heath care program Medicare that is designated for seniors 65 and over as well as handicapped people. This work deals with Massachusetts Mandatory Health Insurance Program of 2006, which has been used like a model for the new federal law PPACA. The practical part presents the particular changes brought by the new law, including their impact on the chosen social groups -- the uninsured, the employers, the families and their kids, the seniors and the people with "pre-existing conditions". Since the Health care reform is the political issue as well, at the end there are mentioned some pros and cons opinions.