The complexity of issues in health care in the United States--specifically insurance coverage, access, affordability, quality of care, and financing--requires effective new models for governing, in which governmental and non-governmental organizations seek to solve problems collaboratively rather than independently. This research explores collaborative governance as a model to form new partnerships among for-profit, nonprofit, and public organizations in an effort to create community-based, locally governed health care entities in Oregon through coordinated care organizations (CCOs). A key question is whether collaboration, through CCOs, brings together government and non-governmental organizations to solve "intractable problems" by establishing new public-private partnerships in Medicaid. The research focuses on the formation of CCOs, including the influence of local, political, institutional, and historical contexts, planning processes, and governance structures. The hypothesis is that conditions, norms, governance structures and processes, and the presence or absence of a combination of these factors, facilitate or impede participation and decision-making, and over time, successful system integration by these new complex organizations. This study developed insights into similarities and differences among CCO governance structures by investigating three CCOs. Findings from the case study suggest that the following key factors influence the collaborative governance process among government and non-governmental organizations within CCOs: prior history of conflict or cooperation; open, transparent, and inclusive processes for stakeholders; face-to-face dialogue, trust building, and shared understanding; and high-functioning governing boards. Results also indicate that maintaining stakeholder participation can be challenging due to time and cost, power imbalances and competing interests among stakeholders, and mistrust and lack of facilitative leadership. The results suggest that collaborative governance is a strategic approach for the allocation of limited resources across public, private, and nonprofit organizations to deliver services to Oregon's Medicaid population. The significance of this study is that it identified starting conditions that facilitate and hinder the ability of CCOs to effectively solve problems through governance mechanisms. Oregon's CCOs offer an example of multiple layers of governing institutions--federal, state, and county--using formal authority to influence a specified set of outcomes, the Triple Aim, in a specific policy domain: provision of health care services for underserved Oregonians. Results of the study can help inform a larger, more fundamental question in public administration about contemporary governance: whether government through collaborative governance can create the "conditions for rule and collective action" through public-private partnerships to achieve policy goals (Stoker, 1998). Further research is needed to better understand whether local community-based organizations such as CCOs offer a sustainable model to address policy issues in other arenas by which there is "more government action and less government involvement" (Agranoff & McGuire, 2003). This study contributes to the theory of collaborative governance and may inform future policy decisions about CCOs in Oregon and, more broadly, ongoing national health care reform efforts.

This study explores the effects of income, insurance, and source of medical care on access to and utilization of health services. Profiles of dental, physician, and hospital services use are developed for more than 3,500 Oregonians. Low income, lack of health insurance, and/or an inappropriate source of medical care are hypothesized to be barriers to access and utilization. Households which face one or more of these barriers are identified as falling into a "Health Policy Gap." The data for this study were drawn from a 1978 random telephone survey of 1249 Oregon households. The survey was commissioned by the State Health Planning and Development Agency in conjunction with the Northwest Oregon Health Systems Agency, the Western Oregon Health Systems Agency, and the Eastern Oregon Health Systems Agency. The questionnaire was developed by the Oregon State University Research Center. Information was collected on use of health services, insurance coverage, income, household structure, health needs, health behaviors, and health satisfaction. A behavioral model of health services utilization was constructed, dividing the independent variables according to their relative mutability or amenity to policy intervention. Income, insurance, and source of care were selected as policy variables, while other variables less under policymakers' control were labelled household characteristics. The latter were assumed to reflect a household's propensity to consume services. They included household structure, health need, residential mobility, and health behaviors. Dependent variables included measures of dental and physician visits, use of the telephone for physician advice, preventive exams, and hospitalization during the past year. Multiple techniques of analysis were employed. Cross-tabular procedures were applied to investigate the interrelationship of income, insurance, and source of care. Multiple linear regression and partial correlation methods were used to select as control variables household characteristics highly correlated to each measure of health services use. Analysis of variance and multiple classification analysis were used to develop profiles of health services use. These last techniques allowed an examination of the relationship of each policy variable and health measure while applying increasing levels of statistical control. The initial bivariate relationship was studied in isolation; it was then studied while controlling for the other policy variables, and finally while controlling for both the other policy variables as well as selected household characteristic variables. Findings support the hypotheses. Income is found to be related to insurance coverage, and insurance coverage to source of medical care, although income is not found to be directly related to source of care. Low income, lack of insurance, and an inappropriate source of medical care depress use across almost all services. However, their relative barrier effects differ by the measure of service examined. After controlling for the effects of household structure, health need, residential mobility, and health behaviors, the greatest disparity in use of dental services remains due to income, in physician services to insurance and income, and in hospital services to insurance. Clear implications arise for policymakers, whether in the public or private sectors. The low income, the uninsured, and those with an inappropriate source of care face real barriers to access. Since the relative magnitude of these barrier effects vary by the health measure examined, neither income, insurance, nor health system delivery strategies can be assumed to evenly enhance use patterns. Their effects must be separately estimated for differing measures of health services. Furthermore, the relationship between these policy variables needs detailed study before large-scale policy interventions are undertaken. Understanding the complexity of these findings for different measures of health services as well as the interrelationship of income, health insurance, and source of care is crucial in designing and implementing more effective and equitable health policies in the future.

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.