. Latin@ immigrants face many obstacles to affordable healthcare that push them to disproportionately rely on the primary safety-net for their healthcare needs. This system is mostly funded with public monies that will be significantly reduced when Affordable Care Act is fully implemented. Since undocumented Latin@ immigrants are prohibited from accessing federally funded healthcare, they will be left out of the health care reform. This thesis examines two community-based clinics in the Greater New Orleans area that serve this population, and have developed linguistically and culturally appropriate programs that address its needs. The New Orleans Faith Health Alliance and Common-Ground Health Clinic are cases used to explore the impact that the Affordable Care Act will have in the already unstable safety-net in New Orleans. Through the analysis of other models around the nation, this thesis presents viable recommendations to both clinics and the City of New Orleans Health Department.

About 50% of adults in the United States suffer from at least 1 mental health challenge in their lifetime. Annually, mental health and substance use disorders cost the United States about $800 billion, leaving individuals with unaffordable cost of care and the nation with diminished productivity and revenue. With the Essential Health Benefits and Medicaid expansion under the Patient Protection and Affordable Care Act (PPACA), healthcare resources were created to address gaps in behavioral healthcare. There is a need to understand how the healthcare law has influenced the availability of behavioral health services and access to needed care. This study explored the lived experiences of 10 behavioral health service recipients to identify the benefits and challenges of the PPACA on behavioral health services. Participants from Anne Arundel County, Maryland, were purposefully selected and interviewed face-to-face. Relative advantage, compatibility, and complexity were characteristics of the diffusion of innovation theory used for the exploration of this research. Based on the interpretive phenomenological approach, Nvivo 11 Pro was used for data coding, management, organization, and analysis. There was the shared belief among participants that the PPACA improved their access to adequate and affordable behavioral healthcare. Effective network of care and having health insurance seemed to have improved health outcomes. Findings from this study highlight issues of common interest to healthcare stakeholders while providing reasonable platforms for objectively addressing complex challenges, which tend to undermine the possibility of adopting policies that could yield positive dividends for all parties involved.

African Americans as a group tend to have numerous health issues, and by the time they seek healthcare, the conditions often advance into more serious ailments. Researchers have shown that cultural distrust of the U.S. healthcare system coupled with some discriminatory practices has hindered African Americans seeking care and taking full advantage of the healthcare system. With the introduction of the Patient Protection and Affordable Care Act (ACA), there is some confusion about the application of the law, resulting in many intended beneficiaries misinterpreting it, and not accessing quality healthcare. This interpretive phenomenological study explored how African Americans in the Washington D.C., metropolitan area understand and interpret ACA provisions related to their healthcare needs. A sample of 10 African Americans adults participated in in-depth interviews that generated data for this study. Critical communicative methodology provided a framework for exploring the phenomenon. Study findings highlight the themes of interpreting the ACA to mean having more individual control and responsibility for healthcare decisions and having fewer perceived restrictions acting as barriers to access healthcare. Study results contribute to social change by providing knowledge to those who implement healthcare policy on optimal policy delivery to intended beneficiaries. This knowledge may also apply to other new social policy dissemination, thus ensuring policies reach their intended target populations, facilitating optimal utilization.

<p><strong>Essay in Political Science, C-level, by Camila Alvarez Cea, spring semester 2010.</strong></p><p><strong> </strong></p><p><strong>Tutor: Alf Sundin</strong></p><p><strong>“Reality or a Political Mirage? – A Study of the Swedish Press Views on the Health Insurance Reform in the USA”</strong></p><p> </p><p>The purpose of this essay is partly to examine whether the picture that Swedish press presents of the health insurance reform in the US, which is part of the Patient Protection and Affordable Act bill, will be of crucial importance to the possibilities that the American population has to receive health insurance. The main research question is accordingly: <em>“Does the picture that Swedish press presents of the health insurance reform in the USA, seem like something that will be of radical importance to the possibilities of the population to receive healthcare?”</em> The purpose is also to examine in which model (demand or market) the opinions of the Swedish press fits. This purpose will be answered by using three specific questions asking whether their opinions differ when it comes to three criterions: organization, financing/resources and delivery systems. These criterions come from a model from Milton I. Roemer’s book “National health systems of the world,” which also is the theoretical foundation of this essay.</p><p> </p><p>The methodological approach of this essay is a qualitative text analysis along with an analysis chart, where the three criterions have been examined from the reporting of the four Swedish newspapers chosen for this essay. The conclusions that have been reached from the analysis chart are that the opinions differ greatly within Swedish press, and that the picture that Swedish press presents of the health insurance reform is that it will become easier for the American population to receive health care.</p>

In June 2012, the Supreme Court of the United States decided the fate of the Patient Protection and Affordable Care Act in a case called National Federation of Independent Business v. Sebelius. While initially the decision seemed favorable to supporters of the bill, Chief Justice Roberts’ majority opinion could likely render the bill ineffective in implementation and it creates more Constitutionally confusing precedent than it resolves. Among the questions that now rise to the surface are: will Congress be able to raise the tax to a level where it will become effective? What is now mandatory for states to adopt into their Medicaid programs? Where is the line for the federal government with regards to coercion? What are the definitions of direct and indirect taxes? And, how binding is the Origination Clause of the Constitution?

The Patient Protection and Affordable Care Act (PPACA) represents one of the most significant pieces of legislation in the history of United States healthcare. The PPACA has two main goals: to increase the insured patient population in the US and to reduce the overall cost while improving the quality of healthcare in the US. To accomplish the latter goal, healthcare providers are experiencing a movement toward integrated, team-oriented models that place increasing accountability on the providers and institutions. At the same time, these integrative models emphasize effective preventive care, which is critical in reducing the country’s overall healthcare costs. As more health care institutions and providers across the country adopt the healthcare reform models of the Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) directly under the PPACA, the demand for pharmacists is increasing. In addition, the role of the pharmacist through Medication Therapy Management (MTM) is growing as more public and private sectors adopt MTM and its standards are being used as the medication-related cornerstone for the ACOs. There is a call for lower costs and higher quality outcomes in healthcare, and the pharmacists are increasingly integrated into direct patient care and medication management. The newly integrated responsibilities of the pharmacist are numerous and almost limitless. The roleof pharmacists is expanding, and as many studies suggest, their contributions produce auspicious results.

This qualitative case study examined the perceived effectiveness of executive leadership team processes at a community hospital in the southeastern U.S. in relation to the Value-Based Purchasing (VBP) requirements of the Patient Protection and Affordable Care Act (PPACA) through an analysis of documents and a repository database (http:www.hospitalcompare.hhs.gov) relating to service quality, patient satisfaction, and governmental reimbursements; and, structured interviews. Today, the PPACA or “Obamacare” continues to challenge the executive leadership teams at U.S. hospitals to effectively navigate the intricacies of the legislation in order to remain solvent in a volatile healthcare arena. The Plan-Do-Check-Act (PDCA) model was utilized to guide the theoretical framework for this qualitative case study in terms of process improvement. Hill’s (2010) team leadership model was also applied to examine the perceived effectiveness of the executive leadership team processes in terms of analyzing any change in core measures and patient satisfaction scores from the federal fiscal year (FFY) 2013 and 2014, respectively. The VBP data reflected consistent core measure scores in the 48th percentile and an increase in patient satisfaction scores from the 20th to 33rd percentile. The results revealed that the executive leadership team processes were perceived by the researcher as effective as evidenced by a strong collaboration among administration, the bord, and medical staff in implementing several strategies via a team oriented approach that impacted Medicare patients during the FFY of 2013-2014. This study offers a starting point in terms of generating more understanding of the importance of executive leadership team processes at a community hospital in relation to the VBP requirements of the PPACA which can be studied on a broader scale in the future.

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.

No description available.

Chapter 1 presents the backgrounds and research questions of the dissertation project. Although everyone hopes to die with dignity, a “good death” is often privileged. Inequality in end-of-life care in the United States is striking; older minorities are 3 times more likely to receive intrusive care and experience hospital readmission and less likely to use hospice care and die at home. With the hope to address disparities in end-of-life outcomes, as part of the Affordable Care Act, Medicare expanded its benefit and started to reimburse end-of-life care planning services from 2016. This dissertation examines the roles of health insurance policy and its advocated intervention in ensuring person-centered dying experiences in the United States and the public readiness for establishing a similar end-of-life care policy in China. The second chapter examines whether physician–patient advance care planning (ACP) discussions, the “intervention” embedded in the policy, is effective at prompting end-of-life care planning behaviors and improving end-of-life experiences. I also studied the heterogenous effects by race and ethnicity. I used exit data about 7,282 deceased Medicare-eligible respondents from the Health and Retirement Study (HRS) from 2012 to 2020, a nationally representative biennial survey of U.S. older adults. I conducted latent class analysis to identify different end-of-life experiences and used multinomial logistic regression models to study the relationship between having ACP discussions with doctors and different end-of-life experiences in full and stratified samples by race and ethnicity. Then I used path analyses to test whether completing legal documentation initiated by ACP services explains the effectiveness of the intervention. The results show three types of end-of-life experiences among White, Black, and Hispanic older adults; significant effects of end-of-life care discussions with doctors on uncomfortable dying experiences and extensive use of invasive treatments in the older White population; and the partial mediating role of completion of legal health care documents on the relationship between ACP discussions and end-of-life outcomes. This study identified the limited effectiveness of physician–patient ACP discussions among minority older adults and emphasizes the importance of quality, content (e.g., to cover legal documentation during the conversation), and cultural appropriateness of ACP consultations led by doctors. The third chapter examines the heterogenous intent-to-treat effect of the Medicare policy on older adults’ motivation to plan for care by exploiting policy intervention as a natural experiment. Taking advantage of the longitudinal nature of the HRS, I used core data with 47,982 observations nested in 15,647 individuals across 9 years (2012–2020). I used two quasi-experimental models—interrupted time series analysis and difference-in-difference—to study the care-planning outcomes before and after the policy implementation between older adults eligible or not eligible for Medicare. I studied the heterogenous effects in stratified samples by race and ethnicity, immigration background, and socioeconomic status proxied by education and wealth. I used coarsened exact matching to address the potential bias of the comparison group not being the ideal counterfactual control unit. I found that in the total population, the Medicare policy was associated with a significant increase in the proportion of older adults who completed a living will and designated a durable power of attorney for health care, but not having an ACP conversation. Furthermore, although there were immediate positive policy effects, the increases in ACP outcomes driven by the ACA Medicare benefit expansion were not sustained. Finally, I found no evidence that the ACA Medicare benefit expansion was effective in improving the rates of ACP among Black, Hispanic, Asian, Native American, or non-U.S.-born older adults. I also identified heterogeneous policy effects by socioeconomic status. I discuss promising recommendations for health care policy and practice to improve the participation rate of end-of-life care planning. Chapter 4 explores the feasibility of encouraging physicians to discuss end-of-life care wishes with older patients in China. Knowledge of a medical diagnosis is critical for end-of-life decision making. However, a patient’s right to know their diagnosis is neither guaranteed nor protected by law in China. Doctors typically inform family members of the patient’s illness diagnosis and prognosis and let them decide whether to disclose this information to the patient. This study examined middle-aged and older Chinese adults’ preferences for disclosing their and significant others’ diagnoses and whether sociodemographic, economic, and cultural factors were associated with these preferences. The research team surveyed 571 adults aged 50 or older in Shanghai from 2021 to 2022. The outcome measures are preferences for diagnosis disclosures, including whether and to whom diagnoses should be disclosed. I characterized preference types using latent class analysis and estimated multinomial logistic regression to identify the covariates associated with each preference type. Three latent classes were identified. The transparent group (34%) believed patients, whether self or a significant other, should be informed of their diagnoses. The contradictory group (50%) held conflicting attitudes; they preferred to know their diagnosis but preferred that significant others not be informed of their diagnoses. The avoidant group (16%) preferred not to know their diagnosis or to disclose significant others’ diagnoses to them. Familism attitudes were positively associated with holding contradictory views. Experiences with hospitalization and medical decision-making for family members were associated with holding transparent views. I discuss the importance of illness disclosure for honoring patients’ autonomous decision-making.