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. / While it is known that over 266,000 Arizonans enrolled in health coverage through the federal Marketplace and Medicaid from October 2013 through May 2014, little analysis has been performed to examine whether enrollment by diverse racial and ethnic groups sufficiently reduced disparities in coverage. We obtained publicly available data from the Census Bureau comparing rates of uninsured by race/ethnicity from 2013 to 2014 in Arizona from the American Community Survey. The uninsured rate in Arizona for the total civilian no institutionalized population dropped from 17% in 2013 to 13.6% in 2014. The uninsured rate in Arizona for whites declined from 15.7% to 12.2%, for African Americans declined from 17.4% to 11.1%, for American Indian/Alaskan Natives declined from 26.9% to 24.1%, for Asian Americans declined from 15.1% to 11.0% and for Hispanic/Latino declined from 27.5% to 22.2%. We conducted interviews with nine community organizations in order to identify barriers that must be addressed moving forward to lessen insurance coverage disparities among various minority groups. Technological literacy and functionality, lack of funding, lack of personnel, physical vastness of many populations, language, and cultural differences were commonly identified as barriers to enrollment. Mistrust of government and confusion regarding the specific provisions within the ACA pertaining to Native individuals were also cited.

acase@tulane.edu / 1 / Yongkang Zhang

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The major legislation, the Patient Protection and Affordable Care Act, is attempting to overhaul the health care system in the United States. Health educators need to understand how this health care policy will impact the profession. Forecasted with change, this study’s goal was to provide preliminary insights into the perceived impact of the Affordable Care Act and changes that could occur within the health education profession as a result of this major health care reform legislation. Seven knowledgeable, experienced, and well-respected leaders of the health education profession participated in this qualitative research study. Semi-structured, exploratory interviews were conducted with six participants and one participant provided written responses to the interview protocol questions. After each interview, a thematic analysis was conducted on the participants’ responses. Five themes emerged from the interviews: (1) a fragmented sick-care system, (2) ACA becomes law: the participants’ reactions, (3) ACA becomes law: the profession’s reactions, (4) impact on the profession, and (5) health education in 2020. The changes the Affordable Care Act is attempting to make to the health care system are no secret. There is potential for health educators to do something they have never been able to do before because of the Affordable Care Act, but action must be taken by these professionals. The positive elements of this legislation need to be protected, strengthened and verified, and further action needs to be taken to assure all critical components for creating a truly reformed health care system are incorporated into future legislation. Future research focused on investigating the impact the Affordable Care Act has on the health education profession should be conducted on a regular basis. As more mandates within the law are enacted over time, the impact on the profession, more than likely, will shift. It is also recommended future research seek to quantify the impact the legislation has on the profession.

Thesis advisor: Marvin Kraus / Thesis advisor: Matt Rutledge / The state of Massachusetts implemented a health care reform in 2006 that induced a number of changes to its health care system. Studies regarding this reform bear a certain degree of predictive power on the national scale because the reform was used as a model for the Affordable Care Act, the highly controversial national health care reform law passed in 2010. Most of the research on health care reform focuses on the costs, not the quality, of health care. I utilized a difference-in-differences statistical design to isolate the impact of the Massachusetts reform on the state's asthma mortality rate, a health care quality indicator. Given certain assumptions, my empirical results indicate that the reform led to a 45.38% reduction in asthma mortality in Massachusetts. Due to the similarity between the Massachusetts and the national health care reform laws, I drew the conclusion that national asthma mortality rates will decrease after 2014 when certain key provisions of the national reform come into play. / Thesis (BA) — Boston College, 2013. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Economics Honors Program. / Discipline: Economics.

Primary care physicians are the first point of contact for patients entering the formal health care system. A shortage of primary care physicians in the United States has left approximately 60 million people without adequate access to a physician, resulting in lowered health care outcomes and excess stress on the health care safety net. Texas has one of the most severe shortages of primary care physicians with more than 5.7 million people living in rural and urban areas considered to be underserved. The state’s rapid population growth, as well as the wide geographic distribution of its residents, makes it particularly vulnerable to health care disparities. Although there is a decisive need, factors like high medical school debt and low anticipated salaries are leading more students to specialize instead of pursue a primary care career. A variety of solutions have been proposed to address this problem including: rethinking the physician reimbursement structure; expanding graduate medical education opportunities for primary care students; and incentivizing primary care with loan repayment. In 2014, the new insurance exchanges created by the Patient Protection and Affordable Care Act will begin operating, giving millions more Texans access to health insurance. The current Texas primary care physician workforce shortage will be exacerbated once the major components of the Patient Protection and Affordable Care Act are fully enacted; therefore, state policymakers must take steps to increase Texas’ primary care physician workforce by making primary care a more attractive and accessible career path for medical students. / text

A key feature of the market for health insurance is selection: a consumer's decision to purchase coverage can affect the costs for producers and the prices faced by other consumers. In three essays, I explore factors that influence consumers to take up insurance coverage, selection in market where a new insurance product was introduced, and the effects of a recent policy to expand coverage among young adults. The first essay examines whether language barriers and network effects can explain disparities in Medicaid participation among low-income immigrants. Using the American Community Survey, I show that linguistic networks facilitate Medicaid enrollment among non-English speaking adults. The identification method follows Bertrand et al. (2000) and employs local variation in the density of immigrant populations and nationwide variation in Medicaid participation among ethnic groups. I also find that the availability of foreign-language Medicaid information online is associated with significantly higher participation. The second essay examines consumer choice in the context of a health insurance exchange. Using data from the Federal Employees Health Benefits program, I examine the extent to which the sudden introduction of high-deductible plans into the system in 2004 may have generated adverse selection. While entry by the newer plan type does not appear to affect premiums of more traditional plan types for federal workers, enrollees in high-deductible plans are more likely to be younger and male. The final essay analyzes one of the earliest coverage-related provisions of the Affordable Care Act to take effect, the extension of health insurance coverage to child dependents up to age 26. Survey data reveal the law resulted in a marked increase in the number of young adults covered by private insurance. Analysis of medical claims data from private health insurance shows a relative decrease in average spending among young adults after the law took effect, implying that the dependent coverage provision brought healthier young adult individuals into the risk pool.

Retail clinics are walk-in clinics designed for convenience and for servicing minor health issues and certain acute conditions. The model began as a way of bringing both convenience and care to areas that have lower levels of access to primary care resources. With the implementation of Affordable Care Act (ACA) in March 2010, populations that were previously uninsured were now required to have access to some level of health insurance. These populations presented a potential new market for retail clinics. This research shows that post implementation of the ACA, retail clinics tend to locate in areas with higher incomes and, generally, greater access to primary care.

The Patient Protection and Affordable Care Act drastically transforms the United States healthcare infrastructure. This law, passed in 2008, will shift financial incentives, payment methods, policies, and, in fact, the very way our physicians practice medicine. Currently, the US ranks 1st in healthcare costs, but 37th in healthcare service in the world. It is estimated that there are between 35-42 million uninsured Americans that ultimately cost 50 billion in taxpayer dollars annually. The 4,033 behemoth of a law sets the groundwork to provide high quality healthcare to all Americans with either insufficient or no insurance. Although it will affect every aspect of healthcare and medicine, this paper will assess the changes being made in primary care. The renewed dedication to family medicine provides the foundation to create a more cost efficient healthcare system and a healthier America. We will review the current state of primary care, assess the provisions enacted by the Patient Protection and Affordable Care Act, and evaluate future goals of family medicine. Ultimately the Affordable Care Act attempts to boost primary care, focus on prevention, and use research-based policies in order to lower healthcare costs and provide accessible healthcare. In order to do so, the United States needs to address the insufficiencies of the previous healthcare system and re-evaluate our healthcare expenditures.

Hospital readmissions are a source of reduced payment as mandated by the Centers for Medicare and Medicaid Services as part of the Affordable Care Act (ACA). The number of dollars used for hospital readmissions has sky rocketed above $17 million for heart failure alone. The changes in the ACA reimbursement guidelines has put stress on many hospitals as they are facing reduced income, increased use of resources, and increased length of stay. This project evaluated the implementation of Project BOOST, its components, and their predictability for hospital readmission. Sample groups were evaluated both pre- and post-implementation of Project BOOST, which included individuals aged 18 and older, who were of Anglo, Hispanic or Native American descent, and living in Northern Arizona. A retrospective chart review was performed and descriptive and predictive statistics were used to analyze obtained data. Patients with cardiovascular disease admitted to the study hospital have high risks for readmission, such as problem medications, polypharmacy, psychological Issues, and principal diagnoses. Integrating elements from Project BOOST significantly decreased 30-day hospital readmissions. Data from this study revealed a statistically significant reduction in 30-day hospital readmission rates from 22% in the pre-intervention period to just 4% in the post-intervention period. Patients who did not receive the risk assessment tool were 14 times more likely to be readmitted to the hospital within 30 days of the index hospitalization.