The purpose of this study was to examine three state-sponsored health insurance programs targeted at small businesses and identify the political and economic factors that contributed to their success. I evaluated the success of each states program using three criteria: reducing the number of uninsured, program participation, and providing portability. In my analysis, I examined factors which may have played a role in the varying levels of success that were observed. I found that the success of a program depended largely on two factors: economic conditions within the state and the quality of the program. / Department of Political Science

This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.

In 1969, President Richard Nixon declared that the “spiraling costs” of medical care constituted a “crisis.” Medicare and Medicaid had been passed only four years previously, and had dramatically changed the way Americans accessed and paid for medical care. The ensuing three decades ushered in a renewed period of advocacy for health care reform with costs remaining a consistent focus. Proponents for national health insurance framed health as a human right emphasizing equitable access. Those advocating for private health insurance touted the power of the marketplace to contain costs through competition and freedom of choice. Throughout the debates, health reform advocates, insurance industry representatives, medical providers, and legislators repeatedly referred to the “health consumer” as the potential benefactor of such reforms. But this ubiquitous term remained ambiguous. Who exactly was the “health consumer”? The contests over the rhetoric of the health consumer as an identity, its uses and political alignments, were engaged through print, in research, in organized campaigns, and in discrete individual interactions with health insurance and the health care system. These interconnected systems of power informed and were informed by the language used to describe them, in the sense of “structuring structures,” extending to economics and the consumer movement, social movements and civil rights. Thus the ideological orientations of the terms of the debate, focused on the “health consumer,” have shifted often and have continued to be contested in a dialectic relationship. This analysis therefore takes place at those intersections where health consumers as individuals have confronted the private, for-profit sphere by making claims for health consumer rights. The utility and ethical implications of commodification versus rights language have consistently been at the center of these opposing views. This dissertation examines the evolution of the dialectic dynamic of these two approaches to better understand how health consumer rights advocates have confronted challenges to include their voices in health care debates from the 1970s to the late 1980s at the local, state, and national levels. Specific sites include the Office of the Commissioner of Insurance and the Center for Public Representation, both located in Wisconsin, as well as the national grassroots organization Citizen Action and the local chapter Massachusetts Fair Share. Moving beyond binary understandings such as "patients" and "non-patients," or even the "patient/consumer," the health consumer identity blurs distinctions of inclusion and exclusion and dramatically expands the framing of "who counts" in health social movements. The health consumer thereby has remained a locus of contestation and potential rhetorical power that can inform the more political use of the term for making rights claims, as well as the more economic approach that advocates for free market principles. As such, it is readily co-opted in movement/counter-movement shifts in language and political alignment. Such contests and co-optation frame each chapter in this dissertation. Ultimately, health social movements and the dynamic, even equivocal orientation of the “health consumer” identity may play a determinative role in how to move forward with health care policy reform that seeks to provide all Americans with equitable access to wellness, rather than vying to purchase health.

This study collects the views of 38 health policy leaders, answering one open-ended question in a 1-hour interview: What state-level reforms do you believe are necessary to implement a feasible model of universal health insurance in Oregon? Interviewees represented seven groups: state officials, insurers, purchasers, hospitals, physicians, public interest, and experts. About 370 coded arguments in the interview transcripts were condensed into 95 categorical topics. A code outline was constructed to present a dialogue among stakeholders in one comprehensive narrative. Topical sections include the cost imperative, politics, model systems, insurance, purchasing, delivery system, practice management, and finance. Summary results show the prevalence of group attention to each topic, group affinities, and proximity correlations of different arguments mentioned by individuals. The most common arguments related to problems of low-value care and delivery system reform. There was a generally felt imperative to control costs. Regarding universal health insurance, stakeholders were split between two main alternatives. One model, favored mostly by insurer and purchaser groups, supported the state-sponsored individual mandate. This plan, embodied in the current Oregon Action Plan to implement universal health insurance, involved managed competition for insurers and clinical governance over professional practice. A separate set of arguments, favored mostly by expert and physician groups, emphasized the need for a unified public system, or utility model, possibly with centralized funds and regional global budgets. The ability of the individual mandate plan to control costs or manage quality appears doubtful, which strengthens opposition. The utility model is more likely to work at cost control and governance, but it disrupts the status quo and its details are vague, which strengthens opposition. Neither model is endorsed by a majority of the stakeholders, and political success for either one alone is not promising. Possibly, a close analysis of the two models could find a way to combine them and generate unified support.

University of Macau / Faculty of Social Sciences and Humanities / Department of Government and Public Administration

Given the general poor state of health care and the devastating effect of user fee, the National Health Insurance Scheme (NHIS) was instituted as a health financing policy with the main purpose to ensure universal access for all Nigerians. However, since NHIS became operational in 2005, only members of scheme are able to access health care both in the public and in private sectors, representing about 3% of Nigerian population. The thesis therefore examines the design and implementation policy of NHIS in Oyo state, Nigeria. Key design issues conceptual framework guides the analysis of data. The framework identifies three health interrelated financing functions namely revenue collection, risk pooling and purchasing. Data was collected from the NHIS officials, employees of the Health Maintenance Organisations (HMOs) and the Health Care Providers (HCPs) using key informant interview. In addition, in-depth interview and semi structure questionnaire were used to gather data from the enrolees and the nonenrolees. Empirical findings show that NHIS is fragmented given the existence of several programmes. In addition, there is no risk pooling neither redistribution of funds in the scheme. Revenue generated through contributions from the enrolees was not sufficient to fund health care services received by the beneficiaries because of the small percentage of the Nigerian population that the scheme covers. Further findings indicate that enrolled federal civil servants have not commenced monthly contribution to the NHIS. They pay 10% as co-pay in every consultation while federal government as an employer subsidised by 90%. Majority (76.8%) of the respondents agreed that they were financially protected from catastrophic spending. However, the overall benefit package was rated moderate because of exclusion of some priority and essential health care needs. Although above half (57%) of the respondents concurred that HMOs are accessible, in the overall, (47.6%) of the respondents were not satisfied with their services. In the case of the HCPs, majority (61.9%) of the respondents claimed that there is no excessive waiting time for consultation. Furthermore, (64.3%) rated their interpersonal relationship with the HCPs to be good. However, more than half of the respondents (54%) disagreed on availability of prescribed drugs in NHIS accredited health facilities. For the nonenrolees, findings show that most of the respondents (72.9%) were willing to enrol, but significant proportion (47.5%) indicated financial constraint as impediment to enrolment. / Sociology / D. Phil. (Sociology)