Many of the assumptions underlying health care issues appear to be taken for granted by policy makers, when if fact they ought to be examined for their relevance to today's problems. This research attempts to do so, by analysing the non-economic issues and factors involved in the financing and provision of health care. It will be argued that policy makers commonly have a unidirectional economic perspective in both policy making and in health care system reform directives, a situation which leaves issues such as the health status of the population and of equity in resource allocation to political rhetoric, while in practice, policies deal with the issue of cost reduction. Of major importance is the moral dimension in policies dealing with health and welfare, which is clearly either forgotten or is afforded too little consideration in policy making. This is particularly relevant to the issue of rationing of health care in publicly provided health care systems. While always quietly practised by clinicians in the past, rationing is now required to be overt because demand for health care has outstripped available resources.The substance of the argument comes from the analysis of a very large literature on the broader issues affecting health care policy, such as concepts of social justice, ethics of resource allocation and the physician-patient relationship, all of winch ought to underpin policies for the mechanisms of funding and provision of health care systems.A conceptual diagram of a health care system is offered to provide a framework for the discussion of how the issues are interrelated at micro, meso and macro levels in policymaking. Examples of reforms to health care systems are taken from five OECD countries which share a common social, political and economic heritage: Australia, United Kingdom, New Zealand, Canada and the United States of America.The conclusions ++ / from this research show that theoretical incoherence pervades this most complex of policy areas, allowing the economic imperative to take precedence over the substantive health care issues.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Since the Affordable Care Act (ACA) was signed into law in March of 2010, there have been multiple large survey studies focusing on physicians’ thoughts towards health care policy issues. 1‐6 Unfortunately, there has not been adequate attention paid to medical students’ feelings on reform in the literature. Today’s medical students will enter their practice at a vital time in the ACA’s implementation and will play an integral role in health care reform throughout their careers.7,8 This study is a national project that used a survey tool to demonstrate how well medical students know the details of the ACA and what their feelings are on the legislation. The survey was sent to eight different medical institutions across the country with ten total medical school campuses, using SurveyMonkey to collect results. The institutions were chosen based on their geographic location, mix between private and public institutions, and available investigators at each institution. The survey tool was developed by Tyler Winkelman, MD, from the University of Minnesota after a comprehensive literature review, adaptation of items from his previous survey of medical students in Minnesota performed in 2012, and consultation with physicians and policy experts.9 The survey focuses on student’s opinion of the ACA, knowledge of nine key provisions in the ACA, level of support of key health care policies, feelings towards health care policy education in medical schools, and socio‐demographic information, including political ideology, debt amount and intended specialty. Data analysis was performed using Pearson’s Chi‐square tests and multiple logistic regression models at The University of Minnesota to test for associations between students’ opinion of the ACA and five key predictors: debt, medical school year, political ideology, ACA knowledge, and intended specialty. A total of 2,761 out of 5,340 medical students (52%) responded to the survey, with 63% of students indicating support for the ACA, 75% agreeing that they understand the key ACA provisions, and 56% indicating professional obligation to assist in implementation of the ACA. Students intending to enter surgery or a surgical subspecialty and students who identified themselves as conservative were found to have less support and professional obligation of the ACA when compared to students entering primary care (Internal medicine, family medicine, pediatrics, internal medicine/pediatrics, or emergency medicine) or identifying themselves as liberal or moderate. Students that were most knowledgeable of the ACA were found to more likely support the ACA and indicate professional obligation towards the legislation. In conclusion, our study found that the majority of medical students indicate support for the ACA and feel they have a professional obligation in assisting implementation. The views of the ACA differ based on student’s political ideology, anticipated specialty, and knowledge of key ACA provisions, but overall, there is optimism that this high level of support can lead to advocacy and successful health care reform down the road.

This paper analyzes a 2009 U.S. policy which provided short term federal subsidies for COBRA health insurance premiums. COBRA allows the recently unemployed to continue purchasing health insurance through their employment-based insurance plan for a short time period after they become unemployed. Early analysis found low take-up rates for COBRA insurance due to the exceedingly high cost of full health insurance premiums, especially for those who have just lost a steady employment income. A short term 65 percent federal subsidy for COBRA insurance was implemented as a part of the American Recovery and Reinvestment Act in 2009. Subsidy policy proposed to increase take-up rates of COBRA and to keep national insurance rates from dropping during a time of rising unemployment. This paper finds a 3.09 percentage point increase in insurance rates for the unemployed when subsidies became available in 2009. It also finds that the gains made in 2009 were lost by 2010, suggesting that subsidies may have provided temporary relief but did not represent a long-term solution for many of the unemployed. Demographic analysis within the unemployed population determines that educated, middle to upper income earning men saw the greatest increases in insurance rates during this time. My analysis affirms previous research finding that COBRA eligibility requirements do not allow the majority of the low income, uninsured to receive federal assistance for health insurance through this policy. I also provide a positive analysis for the impact of direct-purchasing federal subsidies on insurance rates.

This thesis takes an innovative approach to examining health care policy by applying the concept of policy drift to the issue of access to abortion across Canada through analyzing three explanations: the structure of Canadian federalism, women’s organizations, and rights litigation. The Supreme Court of Canada ruled that section 251 of the Criminal Code of Canada was unconstitutional in R v. Morgentaler (1988). Section 251 forced women to secure the approval of a panel of medical experts in order to gain legal consent to seek an abortion. As a result of this decision, women are now able to undergo a therapeutic abortion procedure without facing criminal sanctions. However, the issue of equitable access to abortion services across Canada is still unresolved. For example, women living in Prince Edward Island have to travel out of province at their own expense to undergo an abortion procedure. Meanwhile, women in Ontario are able to undergo an abortion procedure at a number of hospitals and private clinics with provincial insurance subsidizing the financial burdens. Abortion is a time-sensitive procedure and different from other health care procedures because it is also gender-sensitive. Findings within this thesis suggest that the model of Canadian federalism contributes to the inability of women’s organizations to gain audience from the federal government and inhibits the courts from assisting in expanding provincial access, which further facilitates policy drift. Recognizing policy drift concerning access to abortion is significant because it is an issue that involves gender equity at its core as well as discussions over what society deems is a right and what society deems is fair.

A concept of "total patient care" was developed in Hong Kong to enhance public hospital services. The development of this concept aimed to resolve two major concerns about patient care delivery. First, for historical reasons, there were differences among public hospitals in their emphases on the scientific medicine and social aspects of caring. Secondly, the health care system was under pressure to change due to rising expectations, in particular to an increasing number of patients requiring complex care in the community. The purposes of this study were (1) to investigate the historical influence on the development of patient services and (2) to examine the determinants affecting the development of new initiatives. The path-finding process to shift care practice from a traditional institutional orientation to a person-centred approach was studied through a focal point of study in all 38 public hospitals, serving a population of 6.3 millions. An analysis of the "successful" examples of the implementation of the concept of total patient care was initially conducted. The subsequent development of a variety of hospital patient care models was traced back to the different origins of patient care orientations through collecting views of hospital stakeholders and the support provided for patients outside the hospitals. A pluralistic approach, which involved site visits, interviews, focus group discussion and survey, was chosen to understand the complexity of historical influence and contemporary determinants in the development of the totality of patient care. A "mapping" method was adopted to analyse the data reflected different levels of concerns. The findings in this study indicated that, technological and financial factors often identified as the more important determinants in development of health care system, might have ignored the historical development of the hospitals and health traditions in the community in the development of totality of patient care. This study suggested that influences of these informal factors, as experienced in a Chinese community, would likely to continue and diffuse the goal of a planned policy. Formalisation of the informal and community involvement in formal hospital settings, through a concept of total patient care, had resulted in the consolidation of some diversified experience in the support of a diversified range of patient needs. The strengthening of a hospital-community linkage was highlighted as a possible solution to bring a full transformation of patient care into a model of totality.

Opioid addiction has reached an all-time high in America, partially because there is no federally approved, affordable, available alternative for chronic pain. This paper examines the role of medical cannabis in the opioid crisis by exploring the effect of medical cannabis laws on opioid prescription rates in an OLS regression. I found that medical cannabis laws produce a statistically significant decrease in opioid prescription rates. I discuss the specific policy components that would allow medical cannabis policy to be most effective nationwide.

The 2010 Patient Protection and Affordable Care Act (PPACA) resulted in providers and health care organizations conforming to new payment models that connect reimbursement to patient outcomes. Primary care providers (PCPs) are tasked to provide new quality provisions as chronic disease management is a key focus to improve outcomes. The purpose of this study was to understand the transition to new payment models and determine whether care is improved. The conceptual framework is grounded in health care access models geared towards the improvement of quality outcomes including the chronic care model (CCM). The research questions were designed to understand providers' perspectives on new metrics to improve quality and the implications on practice workflows and patient outcomes. This phenomenological study consisted of interviews with 9 PCPs directly impacted by health care reform and the implementation of new quality metrics designed to improve patient outcomes. The study analyzed PCPs' perspectives on health care reform and the transition to new quality focused payment models and determined if quality is improved. Collection of data was designed to understand PCPs' challenges in alignment of their medical practices to newly defined provisions of quality expectations. Respondents reported concern with new payment models focused on quality outcomes and reported overall patient care had not improved as a result of alignment of quality initiatives to payment. The implications of positive social change will be an improved understanding of new models of payment intended to maximize reimbursement and address potential challenges with the implementation of quality metrics in order to effectively improve patient outcomes.

The Patient-Centered Medical Home (PCMH) is an emerging model of health care designed to provide a simpler, more effective health care experience. The model places heavy emphasis on the concept of every patient having a "personal physician" who is the point of access for all health care needs and concerns. The personal physician integrates all relevant health care information to provide the patient with a holistic picture of his health. The supposed benefits of the PCMH model include an improved patient experience, increased effectiveness of care, increased efficiency of care, greater access to care, among others. Only now is evidence beginning to emerge to substantiate those clams. As evidence continues to emerge supporting the PCMH model, one area that warrants further study is how those directly involved in health care perceive this model. Here, a survey was developed to assess the following information among a population of pediatric physicians: understanding of the PCMH model, agreement with PCMH principles, interest in moving to a PCMH-based practice, and what issues are perceived as barriers to PCMH integration. Results suggest that there is a high degree of familiarity with the PCMH model and a high level of agreement with PCMH principles in this population, but that agreement does not correlate with interest in moving one’s practice toward the PCMH model. Data further indicate that issues regarding payment and associated expenses for PCMH integration are universally perceived barriers. On the other hand, a lack of evidentiary support and compatibility issues with HIPAA are not perceived as barriers. Other issues, such as human resource needs, were more likely to be perceived as barriers in one subpopulation versus another. These data suggest a disconnect between PCMH familiarity and PCMH interest in pediatric physicians. Further, while some issues are perceived as barriers to all pediatric physicians, some issues are more likely to be perceived as barriers in one physician subpopulation versus another, and these differences must be recognized and addressed to help ensure success of the PCMH movement.

The study explores price transparency in the healthcare system. With the increase in healthcare spending resulting in the advent of high deductible plans, consumers have been exposed to high healthcare cost. Despite being burdened with outrageous and extravagant bills, studies have shown that the consumers are not using price transparency tools to their benefit. The literature review reveals that the major stakeholders in the healthcare industry have never been studied together to understand the research question on ‘Why is there lack of price transparency in the healthcare system?’ moreover, there is no theory to explains this phenomenon. This study undertakes a 360-degree, exhaustive view of all the major stakeholders of the healthcare industry in aims to understand the reasons behind the lack of price transparency in the healthcare system and what is holding the industry back. The study followed a grounded theory methodology approach, utilizing the data from 78 semi-structured interviews. The 78 professionals and executives representing the major stakeholders in the healthcare industry contributed to providing information to uncover the key factors for an opaque healthcare industry. Eighty-five hours of interviews resulted in 1,686 transcribed pages that provided insights and discernment to understanding the complexities and intricacies in the healthcare industry that prevent it from becoming fully transparent. The results provide the richness of data for an emergent theory that explains the actions taken by major stakeholders to reduce healthcare spending based on their intrinsic interests and their perceptions of complexities of the healthcare industry. The study presents practical implications on how a complex industry is slow to evolve and that a change is not possible unless it is deconstructed layer by layer to recognize the root cause. The change has to start from the core by simplifying the complexities that are created over time by the stakeholders who have always looked to optimize their motivations and have had no incentives to make the industry efficient.

The perceived level of self-determination in health care in four First Nations communities in Canada is examined through a multiple case study approach. Twenty-three participants from federal, provincial and First Nations governments as well as health care professionals in the communities of Blood Tribe, Lac La Ronge, Garden Hill and Wasagamack First Nations provided insight into the diversity of perception of self-determination in First Nations health care. The difference in definition between Aboriginal and the federal and provincial governments is a factor in the varying perceptions of the level of control First Nations communities have over their health care system. Participants from the four First Nations communities perceived their level of self-determination over their health care system to be much lower than the level perceived by provincial and federal government participants. The organization and delivery of health care is based on the location of the community, the availability of the human resources, the level of communication, the amount of community resources, and the ability to self-manage. The socio-political history including impact of contact, residential schools, and integration of Aboriginal worldview are factors in the organization and delivery of health care as well as the perceived level of self-determination that the community sees. The duration and intensity of contact influences how health care is organized as the communities become more familiarized with the biomedical model that most Canadians use. Having a holistic health care system that includes acknowledging the socio-political history, culture, language, worldview and traditional medicines is important to the four First Nations communities, but this has not been fully embraced in any of the communities. Despite their differences, all four communities are working toward self-determination that hopefully would result in an ‘ideal’ First Nations health care system which is holistic, cultural, spiritual, and interdisciplinary and ultimately lead to full management of the health care system.