Affordable Care Act (ACA) was passed and implemented to expand insurance coverage, reduce health care cost, and improve the quality of care. The purpose of this dissertation study was to investigate whether the ACA insurance expansion correlates with the number of visits made to emergency departments (EDs). The quasi-experimental design interrupted time series was utilized in the analysis. The ED visits were compared using MANOVA to determine the relationship between ED visits and ACA and canonical correlation analysis to assess the strength of the relationship and the extent to which independent variables could predict the dependent variable. The hypothesis was that the ACA will reduce the uninsured, increase the insured, and reduce the ED visits. The relationship between number of ED visits and the ACA will present whether the uninsured patients contributed significantly to the ED overcrowding. Analysis of secondary data from four EDs (H1, H2, H3, and H4) in the Chicago area showed that 484,742 visits were made, and 2,801 were excluded due to unknown payer type. Medicaid patients recorded the largest number of visits (181,226) while the uninsured patients recorded the least number of visits (56,572). The ED visits decreased by 6% from 2012 to 2013 (pre-ACA) and increased by 4% from 2013 to 2105 (post-ACA). The ACA implementation increased the people with insurance who visited the EDs by 11%. The results demonstrated a strong relationship between ACA and ED visits. The correlation of the variables (hospital and year) and ED visits demonstrated that the hospital could explain 97% of the Medicaid visits and 87% of uninsured while the year could predict 82.6% of the uninsured visits and 52.5% of Medicaid visits.

The U.S. Department of Health and Human Services has declared the misuse of opioid prescription drugs as a public health emergency. The Affordable Care Act’s Medicaid expansion expanded the number of people with insurance and increased the demand for services related to substance abuse treatment. In the first part of this study, the researcher examines whether the Medicaid expansion reduced the likelihood of treatment delay. The second part of this study explores whether the length of stay for opioid use disorder treatment is significantly different in states that adopted Medicaid expansion versus states that did not. In both studies, the researcher analyzes administrative data from the Substance Abuse and Mental Health Services Administration to discover any treatment delays associated with the opioid treatments for the states that adopted the expansion versus the states that did not, and to determine whether there was a difference in the length of stay in the states that adopted the Medicaid versus the states that did not. A difference-in-difference approach is used in both studies to compare the states which adopted an optional Medicaid expansion to those non-adoption states. The evidence suggests that demand for opioid treatment services increased in expansion states as there is a decreased probability of obtaining treatment on the first day for initial requests for outpatient treatment. In addition, evidence suggests that Medicaid expansion increased the likelihood of staying longer in outpatient facilities, but not inpatient facilities. / Business Administration/Risk Management and Insurance

Objectives: Few research studies have analyzed college students' attitudes of health reform caused by the Affordable Care Act (ACA). Specifically, no studies exist looking at undergraduate and graduate social work students' views on current health reform. The study will ask two questions: (1) What do Social Work students know about the components and potential impacts of the ACA, and (2) Are there any characteristics of students associated with their level of knowledge or attitudes about the Act? Methods: A 53-item survey questionnaire inquiring knowledge, attitudes, and perceptions related to health reform and the Affordable Care Act was dispersed to a convenience sample of 105 undergraduate and graduate social work students from the University of Central Florida School of Social Work in January-February 2014. Results: Students had favorable views on how the health reform will be funded and how health reform could support specific social issues such as acknowledging the need for reform and believing health care should be a basic right. There were fewer clear trends in students' attitudes about reform implementation and knowledge of specific ACA provisions. There were no significant associations between student's knowledge of the ACA and their insurance status or political affiliation. Conclusions: Students' beliefs on health reform are inconsistent. Ethnicity was the only demographic characteristic that affected students' views. This study advocates the need for more in-depth health policy education within the social work program curriculum.

Community engagement in health assessment enables researchers to better understand and prioritize community needs. The value of community engagement is increasingly documented; however, few studies engage youth. Research and assessments are often done for youth, but not with youth. Youth bring a unique contextual lens to community issues; without engagement, the likelihood that resultant efforts would be accepted by or appropriate for youth decreases. This dissertation explores opportunities and methodological approaches for, and contributions and feasibility of engaging youth in non-profit hospital community health needs assessments (CHNAs) mandated through the Affordable Care Act. This study has three specific aims, utilizing multiple methodological approaches: • Aim 1: Assess the current level of youth engagement, and prevalence of youth-focused priority areas in Massachusetts CHNAs. CHNAs were reviewed and analyzed using the Community Health Improvement Data Sharing System’s community engagement template. • Aim 2: Compare assessment results of focus groups and participatory photo mapping (PPM) in documenting youth observations of Boston community conditions. Three focus groups and PPM processes engaged 46 high-school age youth. Data were qualitatively compared, with attention to youth-identified community assets, concerns, and recommendations. • Aim 3: Compare youth results with existing CHNAs and identify potential contributions of youth engagement. Using the social determinants of health framework, youth recommendations were compared to Boston hospital community health improvement (CHI) publications to observe the convergence and divergence of priorities. While all MA hospitals minimally complied with required CHNA community engagement criteria, there was no standard practice or approach. 20% of CHNAs engaged youth, primarily through focus groups; yet, 80% of CHNAs that identified priorities included youth-focused priorities. Youth-driven results focused upon social determinants of health factors; furthermore, PPM results provided more detailed and granular CHI recommendations. Youth-identified CHI recommendations complemented those identified by hospitals, indicating that youth engagement can potentially strengthen CHI priorities and identify salient strategies for addressing youth health, specifically. Findings can be extrapolated to the many institutions conducting assessments, including health departments and Community Action Agencies. Findings will be disseminated through a series of practice briefs that make recommendations to hospitals, assessment practitioners, and youth organizations to consider for future efforts.

In 2001, The Institute of Medicine published its recommendations for bringing high quality care to all people of the United Sates. That solution involved fulfilling criteria expressed in the acronym, STEEEP. Care must be: Safe, Timely, Effective, Efficient, Equitable and Patient Centered (Institute of Medicine 2001). While improvements were made in terms of infant mortality, longevity, and deaths amenable to quality care, healthcare in the United States has remained fragmented with much work yet to be done. This leaves many uninsured individuals without access to affordable healthcare. Despite the implementation of policies such as the Affordable Care Act and the American Rescue Plan, which have expanded Medicaid and given access to many, it still falls short. Approximately 24.9 million people remain uninsured. The rising costs of healthcare in the U.S. have led to both insured and uninsured patients being exposed to medical debt, lower health status, and limited access to care. Safety net clinics, such as free clinics, have become essential for many uninsured individuals who rely on them to receive medical care. Free clinics are an example of safety nets that give medical access to the uninsured. These clinics have positive results on health outcomes and help to lower healthcare expenditures, particularly in emergency room visits. Studies have shown that uninsured individuals are more likely to use emergency services, which results in higher healthcare costs. Free clinics provide preventative care and early interventions that can help prevent costly emergency visits and hospitalizations. Moreover, free clinics serve as a place for volunteers to grow their skills and become better providers of medicine. Volunteers include physicians, nurses, medical students, and other healthcare professionals who dedicate their time and expertise to help those in need. Volunteers at free clinics are provided with a unique opportunity to enhance their skills by working with a diverse patient population that often has complex medical conditions. Free clinics are essential safety nets that provide medical access to the uninsured and underserved communities. Without these clinics, many uninsured individuals would be left without access to care, leading to poor health outcomes and higher healthcare costs. The importance of free clinics cannot be overstated, and unless there is a change in the current healthcare system, free clinics should be given the place they deserve, including more volunteer and funding support. As the U.S. healthcare system continues to evolve, it is critical to recognize the value of free clinics and the role they play in ensuring access to care for all individuals, regardless of their insurance status.

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This dissertation studies the impact of Medicaid expansion on the liability insurance industry. Within the three chapters, the first two chapters focus on the medical liability insurance industry, and the third chapter focuses on the auto insurance industry. Chapter 1, “Medicaid Expansion and Medical Liability Costs”, examines the impact of health insurance expansion on medical liability costs using the case of the Affordable Care Act’s (ACA) Medicaid expansion. Medicaid expansion has increased the demand for medical services, but in doing so it may also have increased physicians’ liability in medical practice. By studying malpractice costs to insurers, medical practitioners, and hospitals in the U.S. for the period 2010–2018, we find insurers operating in states with Medicaid expansion experienced significantly higher medical liability costs than those in non-expansion states. While insurers in expansion states did increase premiums, the increase was not enough to fully offset rising costs. Moreover, we find that tort reforms did not mitigate ACA-induced malpractice liability costs. We show this is because Medicaid expansion increased malpractice costs mainly by increasing claim frequency while tort reforms generally focus on reducing claim severity. We further find little evidence that hospitals paid higher malpractice insurance premiums, self-insurance, or incurred higher out-of-pocket medical liability losses after Medicaid expansion. Taken together, our results imply that it is medical practitioners and malpractice insurers who bear the rising medical liability costs. Chapter 2, “Medicaid Expansion and Medical Liability Insurance Prices” extends the first chapter to study the impact of Medicaid expansion on medical liability insurance prices for three specialties, internal medicine, general surgery, and obstetrics-gynecology (OB-GYN). As Medicaid expansion increased medical liability costs to insurers, they may react by increasing medical malpractice insurance prices. By studying counties in expansion states and non-expansion states and bordering counties with different Medicaid expansion status over the years from 2010-2018, we find that Medicaid expansion leads to significantly higher medical liability insurance prices two years after the expansion on average and the impact is strongest for internal medicine and general medicine but less so for OB-GYN. Our finding suggests that the expansion of health insurance could increase liability costs to medical practitioners. Auto insurance provides coverage of healthcare for injured drivers even for those without traditional health insurance coverage. The expansion of public health insurance provides low-income injured drivers with an additional source of coverage for medical bills. This may change drivers’ incentives for using auto insurance and the ultimate payments made by auto insurers. In Chapter 3, “Public Health Insurance Expansion and Auto Insurance: The Case of Medicaid Expansion”, we first use a simple theoretical model to illustrate how obtaining public health insurance mitigates the incentive of insured drivers to engage in claims buildup. We then empirically test how the Affordable Care Act (ACA)’s Medicaid expansion changed the medical costs covered by auto insurance. By studying private passenger auto insurers in expansion states and non-expansion states between 2010 and 2018, we find that Medicaid expansion led to significantly lower auto insurance losses and premiums. We further show that the results were driven by the decreasing losses and premiums for third-party liability insurers but not in the states with no-fault insurance. / Business Administration/Risk Management and Insurance

Jana Leichterová Conservative Criticism of Obamacare and its Transformation in the Context of Donald Trump Running for President Abstract The thesis deals with the debate over the health care reforms in the United States. It focuses specifically on the debate over the Affordable Care Act, also known as Obamacare, a health care reform initiated by President Barack Obama that was signed into law in March 2010. The goal of the thesis is to identify the main arguments of the conservative criticism of the Affordable Care Act, and to determine whether the debate transformed with the emergence of Donald Trump onto the political scene. The thesis provides historical context of the three main approaches to the health care policies in the United States throughout the 20th century: the Social Security path of strong government in the 1930s, the mixed "American way" with government providing social benefits to citizens through private institutions in the 1970s, and the approach of unregulated free market since the 1980s. Obama's health care originates in the urge for a national solution of the high number of uninsured citizens (more than 50 million in 2009) and rising cost of health care. The reform has three essential pillars: 1. the reform of the health insurance market that unifies the diverse state approaches and...

This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure. This is a quantitative study of archival data that examines Merger and Acquisition (M&A) activity using currently established healthcare quality and financial performance metrics. The research seeks to explicate the relationship between M&A activity and M&A experience in the healthcare industry as it relates to initiatives aimed at improving the quality and decreasing the cost of healthcare. The Affordable Care Act (ACA) legislation appears to be contributing to a trend toward M&A consolidation; by illuminating how this trend potentially impacts healthcare quality and cost reduction initiatives, this study’s contribution is both useful and practical. The units of analysis are Medicare reporting hospitals, hospital systems, and related healthcare providers that have or have not experienced an M&A or multiple M&As. The study shows a statistically significant improvement in quality each year from 2006–2014, which is reflected in higher scores for the four quality metrics measured. M&A activity, as measured by acquisition status and acquirer experience, did not appear to influence these quality metrics, with the exception of the heart failure measure, which showed a statistically significant positive influence of acquirer experience across all specifications. M&A activity’s possible effects on hospital financial performance was assessed through operating-cost-to-charge and capital-cost-to-charge ratios (CCRs). The operating CCR appears to be positively influenced by both acquisition status and acquirer experience, while the capital CCR was positively influenced only by acquirer experience. A positive influence is reflected in a decreasing ratio. Results on quality improvement over time, both before and after the ACA, suggest that the ACA itself may not be the driver for quality improvement. Similarly, decreases in OCCR occurred consistently and statistically significantly over time, both pre- and post-ACA, while CCCR showed statistically significant decreases in 2006–2008, 2013, and 2014. These results appear to support the notion that the trend was ongoing before the ACA was enacted and gave these measures high-profile exposure.