<p> In response to the increased demand for primary care in the United States&mdash;a byproduct of a growing elderly population and insurance expansion under the Affordable Care Act (ACA)&mdash;the total number and capacities of community health centers (HCs) is expected to grow. While HCs have historically depended on physicians to deliver the majority of their care, more and more, they are shifting to non-physician clinicians, especially nurse practitioners (NPs); yet, little is known about the quality of care delivered by NPs in HCs or about the role state occupational restrictions have on these practitioners or their patients. </p><p> Using quasi-experimental methods and data from the community health center subsample of the National Ambulatory Medical Care Survey (NAMCS), this dissertation explores three distinct, but related, research questions regarding NP-delivered care in HCs&mdash;its effectiveness and comparability to physician care, the extent that tradeoffs in the quantity and quality of care are made, and the real-world risks and benefits of states easing their scope of practice restrictions. Findings, which suggest that NP care is comparable to physician care in most ways and that the quality of NP-delivered care does not significantly vary irrespective of states&rsquo; NP independence status, have important implications for policy and practice.</p>

<p> <b>Objectives:</b> Mothers of low socioeconomic status (SES) and of non-Hispanic black race deliver prematurely more often. The goal of my dissertation was to improve understanding of the mechanism of disproportionate premature birth in low SES women. I tested a psychological and physiological stress explanation of prematurity risk, estimated the effect of the Affordable Care Act (ACA) Medicaid expansion on gestational age (GA), and estimated how the ACA Medicaid expansion effect was influenced by race. <i><b>Data and Methods:</b></i> I developed a conceptual framework of how psychological and physiological stress increase premature birth risk utilizing Appraisal and pathophysiology theory. I generated hypotheses about how financial risk removal would impact GA and tested them utilizing variation in expansions in Medicaid eligibility for pregnant women in three matched state pairs and distribution of the Earned Income Tax Credit (EITC). I utilized data from the Pregnancy Risk Assessment Monitoring System and performed multivariate ordinal regressions. I also used national birth record data and exploited state variation in ACA Medicaid expansion status to estimate the impact on GA in non-Hispanic black and all other mothers using multivariate linear regressions and linear probability models. </p><p> <b>Results:</b> Hypothesis testing based on two of the three Medicaid expansion for pregnant women state pairs and the EITC analyses resulted in significant evidence (one-sided p-values &lt; 0.05) for a direct pathway between psychological stress concerning financial risk, physiological stress, and GA. The ACA Medicaid expansion was associated with an increase in GA for non-Hispanic black mothers (+34 hours), a decrease for all other mothers (&ndash;6 hours), and a 3% decrease (95% CI = &ndash;5% to &ndash;2%) in the incidence of early term or shorter gestation births for non-Hispanic black mothers. </p><p> <b>Conclusions:</b> Decreasing financial risk for low SES women with Medicaid or the EITC is associated with increased GA. The higher premature birth risk in this population is likely the result of a direct pathway involving psychological and physiological stress. Other financial risk removal strategies should be investigated. The ACA Medicaid expansion did not meaningfully influence GA on a weekly scale but did moderately decrease overall preterm birth risk in non-Hispanic black mothers.</p><p>

<p> A review of literature suggests that train derailments are a statistically relevant concern. While not all train derailments involve hazardous materials, those that do release chemicals pose a public health threat. This study challenges the decision-making mainstay tool of the hazardous materials response community &ndash; the <i>Emergency Response Guidebook</i> (ERG) &ndash; and its default strategy of evacuation through quantitative research that evaluates data from train derailments involving the release of hazardous materials. It explores whether there are correlations between a derailment&rsquo;s variables and evacuation, as well as correlations between the number evacuated and the number of those injured or killed. Secondary data on train derailments from the Pipeline Hazardous Material Safety Administration revealed 358 incidents involving the release of 876 substances between October 12, 1989 through August 10, 2016. The resulting data analysis confirms a certain level of predictability between causal factors and worsening outcomes supporting expansion of decision-making tools in the ERG.</p><p>

<p> Waiters who serve alcoholic beverages at the majority of bars and restaurants in the United States are apt to serve alcohol to patrons who are visually intoxicated, notwithstanding laws prohibiting such service. Adverse effects of this practice include patron injuries, deaths, and law violations resulting in fines, incarceration, and lawsuits. Waiters not effectively trained to practice responsible alcohol retailing practices put patrons and others at risk of harm from alcohol related injuries or death. The problem is that the perceptions and attitudes of waiters who serve alcohol regarding self-learning as a strategy to prevent patron intoxication are not known; the purpose of this qualitative case study was to explore these perceptions. The study utilized in-depth semi-structured interviews with 23 waiters who utilized a self-learning tool about preventing patron intoxication. The waiters perceived that this self-learning tool was a good training solution, that it would be beneficial if implemented, that the tool could be used to improve public safety, and that its specific data on patron behavior and BAC levels were helpful. The participants also indicated that there would be challenges to implementing such a tool, including the waiters&rsquo; assertiveness and social aptness. As a whole, the researcher recommended that this tool be implemented across the country to improve waiter knowledge and patron safety. For future research, the researcher recommended that the study be expanded to include the perceptions of waiters across the country, the perceptions of those who underwent this training more than a year ago, and that the learning tool be adapted for different learning styles.</p>

<p><b>Background</b>: Throughout the twentieth century, Brazil developed a Social Health Insurance, providing coverage to formal workers and their dependents. In 1988, the country implemented a health reform adopting a National Health Service model, based on three core principles, universal coverage, open-ended benefit package and striving for health equity. During this transition, formal workers recomposed their privileged access to healthcare through private health insurance, resulting in a two-tier system represented by those with dual coverage&mdash;public and private&mdash;and those who must rely exclusively on the public insurance. Private health insurance coverage has a positive correlation with income, however, between 1998 and 2008 private coverage expanded vigorously among the poor, while remained stable among the rich. The health equity literature in Brazil consistently reports the presence of relevant inequalities in utilization of health services favoring privately insured individuals. A gap in this literature, however, is to determine whether inequalities in utilization of health services remain among insured individuals, i.e., does private insurance improve access regardless of individuals&rsquo; income? </p><p> <b>Methods</b>: The study relies on Andersen&rsquo;s behavioral model as a theoretical framework to analyze data from two rounds (1998 &amp; 2008) of a national household survey, assessing levels of utilization of fourteen dependent variables across income quintiles and calculating concentration indexes as summary measures of inequality. Dependent variable distributions across income are standardized by need using the indirect method. Concentration curves compare the evolution of inequality during that time. Curve dominance is formally tested between survey years. Decomposition analysis identifies the most relevant contributors to inequality. Physician services are analyzed as the probability of having a physician visit and the number of physician visits. Hospital services are analyzed as the number of hospital admissions, the probability of having a hospitalization, and the number of hospital days during the last hospitalization. The latter two variables are broken down according to their financing source, either public (SUS) or private insurance. </p><p> <b>Results</b>: Physician services present very low inequalities, although a statistically significant positive gradient persists in both survey rounds. Poor PHI beneficiaries have an advantage compared to national levels. SUS financed hospitalizations are a rare phenomenon among privately insured individual but strongly concentrated on the poor. Poor PHI beneficiaries utilize private hospital at lower levels than the rich. Compared at a national level, they are at a disadvantage. In 1998, this was not the case, suggesting that insurers may be developing mechanisms to deter hospital utilization among the poor. Premium value and income are the most relevant contributors to inequality in physician and hospital services. </p><p> <b>Conclusions</b>: The Brazilian government (ANS) needs to monitor utilization levels across income and develop policies to increase accountability of PHI products particularly preventing insurers from purposefully pushing their beneficiaries to use SUS hospitals. Greater availability on insurance policies segmented as ambulatory care only and inpatient services only would increase the range of options for consumers that could sort more adequate coverage according to their capacity to pay and healthcare needs. </p>

<p> Advocacy for the counseling profession necessitates a thorough understanding of the factors influencing the hiring and reimbursement of licensed professional counselors. The Patient Protection and Affordable Care Act (ACA) enacted several health care reforms that may influence the utilization of mental health services and the employment of mental health professionals. These reforms included the option for states to expand their Medicaid population (effective January 1, 2014), mental health parity requirements for most insurance plans including Medicaid plans, and increased funding for Federally Qualified Health Centers (FQHCs or health centers). FQHCs, created by Congress in 1989, provide primary care services, including mental health services, to approximately 24 million Americans annually and function as a vital safety net for medically underserved communities and populations. </p><p> The largest source of revenue for FQHCs is Medicaid, and FQHCs receive enhanced reimbursement for services provided to Medicaid patients, known as the Medicaid Prospective Payment System (PPS) rate. Federal law, however, explicitly approves only certain health care professions as billable PPS providers. Licensed clinical social workers (LCSWs), along with psychologists and psychiatrists, are included as billable PPS providers under federal law, but not licensed professional counselors (LPCs). Some states have expanded the list of health care professions able to generate billable PPS encounters at FQHCs to include licensed professional counselors. It is vital for the counseling profession to understand the impact of these reforms and the interplay of federal and state policies related to reimbursement upon the mental health industry. </p><p> The optional Medicaid expansion provision of the ACA created an opportunity for a natural experiment to compare mental health service utilization and employment at FQHCs in Medicaid expansion states versus non-Medicaid expansion states. This quasi-experimental study first tested the causal impact of Medicaid expansion on the number of mental health visits and full-time equivalent (FTE) mental health staff at FQHCs, using state-level data gathered from FQHC reports submitted annually to the Uniform Data System. A count model difference-in-differences analysis strategy compared utilization and employment numbers in 2012-2013 (pre-Medicaid expansion) and 2014-2015 (post-Medicaid expansion) between Medicaid expansion states and non-Medicaid expansion states. Then, a two-sample test of proportions utilizing data from a research-developed employment survey examined the relationship between states approving counselors and states not approving counselors as billable FQHC mental health providers under the enhanced PPS reimbursement and the proportion of LPCs at FQHCs (of the total number of LPCs and LCSWs). </p><p> In both groups of states (Medicaid expansion states and non-Medicaid expansion states), it was evident that there was a substantial increase in the number of mental health visits and FTE mental health staff at FQHCs from 2012 to 2015. Contrary to prediction, the first count model difference-in-differences analysis indicated that non-Medicaid expansion states had a significantly <i> higher</i> rate of change in the number of mental health visits from pre-Medicaid expansion (2012-2013) to post-Medicaid expansion (2014-2015), as compared to Medicaid expansion states (&alpha; = .05, <i>p</i> = .01). Then, contrary to prediction, the second count model difference-in-differences analysis indicated that there was not a significant difference in the rate of change for the number of FTE mental health staff between Medicaid expansion states and non-Medicaid expansion states from pre-Medicaid expansion (2012-2013) to post-Medicaid expansion (2014-2015; &alpha; = .05, <i>p</i> = .13). As predicted, the two-sample test of proportions resulting from the survey responses of 138 FQHCs (60% response rate) indicated that there was a significantly higher proportion of LPCs employed at FQHCs in states approving LPCs as billable FQHC mental health providers under PPS as compared to states not approving LPCs (<i>Z</i> = 4.24, <i>p</i> &lt; .001, Cohen&rsquo;s <i>h</i> = .76). Thus, counselor employment at FQHCs was significantly improved in those states approving counselors as billable PPS providers. It is essential for counselors to understand the impact of federal and state health care policies, such as Medicaid expansion, increased funding of FQHCs, and various Medicaid reimbursement methodologies, to successfully advocate for the profession in the dynamic health care landscape. Counselor educators have a responsibility to convey information to students related to the potential repercussions of billable mental health provider status on their employment opportunities following graduation</p>

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.

<p> According to the Centers for Disease Control (2013), every year an estimated 13 to 20% of children in the United States suffer from mental health disorders. School mental health services developed to address the learning barriers experienced by these children achieve variable rates of success (Adelman &amp; Taylor, 2011; Center for School Mental Health, 2011). Reasons for this variability include lack of integration of these initiatives into comprehensive school reform efforts (Adelman &amp; Taylor, 2011), lack of inclusion of school mental health staff in the school improvement planning process (Nastasi, Varjas &amp; Moore, 2004), and lack of consideration of the local school context in their selection and implementation (Ringeisen, Hendersen &amp; Hoagwood, 2003). A group of 15 school teachers and mental health staff of a small Texas school district conducted this action research study about the status of its school mental health services. Individual interviews of the participants served as the initial basis for group meetings during which participants identified weaknesses in their mental health services, prioritized issues to be addressed, and developed an action plan to be presented to school administrators, and the Board of Education. Consistent with the findings of other research studies on school mental health (Center for School Mental Health, 2011), the three main areas of concern identified by the group included poor role clarification among school personnel responsible for mental health functions, lack of teacher training about mental health disorders and related classroom management strategies, and unclear policies and procedures. The process and outcome of the study support the use of participant action research as a method to aid in the development of locally relevant school mental health programs.</p>

Thesis (Ph.D.)--University of Delaware, 2007. / Principal faculty advisor: Robert Warren, School of Urban Affairs & Public Policy. Includes bibliographical references.