From February to September of 2001, a significant body of qualitive data was collected to investigate barriers for Hispanic participation in Oregon's managed care Medicaid program. As a means to investigate this topic, comments were solicited from physicians, hospital administrators, social service agencies, and low-income Hispanics through semi-structured focus groups and individual interviews. This methodology presents the reader with a rich enthnohistoric and cultural context to the local issues surrounding Hispanic under-participation in Oregon's managed care Medicaid program. Finally, through an analytical framework of critical medical anthropology, connections are drawn from local barriers to state and corporate policies. / Graduation date: 2002

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.

Originally, the focus of this project was to be a policy analysis and survey of the new procedures and regulations established by the state of Oregon for the protection and management of nursing home residents' Personal Incidental Funds (PIF). The analysis was to be divided into four phases, according to a pre-planned timetable. The last phase was to be a field survey of the policy's impact upon nursing homes and adult service workers. The timetable was synchronized with that of the Congregate Care Consultant from the Public Welfare Division's (PWD) Adult Services Unit, whose responsibility it was to develop and write a new policy for the state. Although the PIF is a miniscule segment of the total policy which the state of Oregon has developed for nursing facilities, it is submitted here as representative of public policy formulation in that area.