Self-directed supports, as a method of service delivery, have grown from small pilot programs in a handful of states to at least one program in every state. For individuals with intellectual and developmental disabilities (IDD), self-direction presents unique opportunities to engage in self-determined behavior and shape the services upon which they rely. Although the evidence base for self-direction is relatively robust, there is a significant lack of information on how implementation of self-direction is faring on the national level. The purpose of this study is to understand how the political and economic factors within and across states have impacted the implementation of a self-directed service delivery system.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.

Medicaid Disproportionate Share Hospital (DSH) payment is one of the major funds supporting health care providers as they treat low-income patients. However, Medicaid DSH payments have been targeted for major budget cuts in many health policy reforms. This study examines the association between the changes in Medicaid DSH payments resulting from the BBA policy changes and hospital outcomes, in terms of hospital provision of uncompensated care and quality of care. Economic theory of non-profit hospital behavior is used as a conceptual framework, and longitudinal data for California short-term, non-federal general acute care hospitals for 1996-2003 are examined. California was especially affected by DSH changes because it is one of the states with highly concentrated DSH payments and high uninsured rate. Economic theory suggests that hospitals would change their uncompensated care provision as well as quality of care when confronted with a reduction in public payments. Hospital uncompensated care costs and percent of operating costs devoted to uncompensated care are used to measure the provision of hospital uncompensated care. Six AHRQ’s Patient safety indicators (PSIs) and one composite measure are selected to measure hospital quality of care provided for Medicaid and uninsured patients as well as privately insured patients. The key independent variable is Medicaid DSH payments received by individual hospitals. This study also includes control variables such as other governmental financial subsidies, market characteristics, and hospital characteristics. The primary data sources include the detailed hospital annual financial data and Medicaid annual report data at the county level from California Office of Statewide Health Planning and Development, Healthcare Cost and Utilization Project (HCUP) state inpatient data (SID), American Hospital Association Annual Survey, Area Resource File, Interstudy HMO Data and Medicare cost report data. After controlling for different factors, the study findings suggest that not-for-profit hospitals may reduce their provision of uncompensated care in response to reductions of Medicaid DSH payments. The results, however, do not support the hypotheses that for-profit hospitals may reduce uncompensated care by a smaller degree than not-for-profit hospitals for a comparable DSH decline. With respect to quality of care model, the overall study findings do not strongly support there is an association between net Medicaid DSH payments and patient adverse events for both Medicaid/uninsured and privately insured.

The study evaluates the effectiveness of a pregnancy intervention model (PIM) developed to improve first trimester prenatal care utilization in a population of 2,694 low-income Medicaid women. Engagement in prenatal care is critical before prenatal care can occur. Early initiation of prenatal care is important for low income pregnant women at risk for poor birth outcomes and the Medicaid managed care organizations that enroll them. Once identified and enrolled the health plan utilization medical management staff assessed these women for a myriad of high risk and socially detrimental behaviors in order to facilitate, in a sensitive manner, their access to drug treatment or any needed service. Interventions included a real time identification, reporting, incentive model using medical informatics to supplement existing clinical based assessment of high risk pregnant women and nursing care coordination that included outreach, enrollment assistance, support services, interagency coordination, home visits, transportation and medical home assignment. A difference was found in the utilization of first trimester prenatal care visits for all women who conceived after the intervention compared to those who conceived prior to the intervention date. A difference was also noted in the "no prenatal care" category due a decrease in the number of women who did not receive prenatal care. PIM appears to be a cost effective, simple solution to a real world problem. / Graduation date: 2005

Thesis (M.P.H.)--University of Texas Health Science Center at Houston, School of Public Health, 2007. / Source: Masters Abstracts International, Volume: 46-01, page: 0311. Adviser: Osama Mikhail. Includes bibliographical references.

The study sought to identify reasons for non-compliance among a particular medical aid scheme's members and their dependants registered for the asthma disease risk management (DRM) programme. A quantitative descriptive study was undertaken, using postal questionnaires. The research results indicated that most asthma patients were not compliant with the DRM programme because they lacked knowledge about the programme. Asthma patients' compliance with the DRM programme can be enhanced by health providers' and case managers' positive attitudes, better promotion of the programme, and by involving the patients in managing their illnesses. Asthma patients require education about healthy lifestyles, empowering them to successfully manage their condition, preventing asthma attacks and/or hospital admissions. When asthma is well-managed the patients' quality of life and general wellbeing will improve and the medical aid scheme's costs will be contained. / HEALTH STUDIES / MA (HEALTH STUDIES)

The thesis is dealing with financial aspects of the U.S. health care system. The main reasons are excessively high costs and less beneficial outputs of the system compared to other developed countries. The topic is more than up to date especially with regard to the latest changes in American health care and the neverending discussion about the necessity of further reforms aiming especially at fiscal sustainability of the system.The introduction is devoted to a brief description of basic models of health care system. It also introduces the approach of the United States to health care and provides an overview of the structure and participants of American health care. Moreover, the thesis provides details about the latest reform of the system. The main objective of the thesis is analysis of main factors that contributes to high growth of health care costs. Technological development, consolidation of markets and ineffective setting of health care reimbursement are identified as some of the main contributors to high cost in the U.S. health care system.

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.

In 1969, President Richard Nixon declared that the “spiraling costs” of medical care constituted a “crisis.” Medicare and Medicaid had been passed only four years previously, and had dramatically changed the way Americans accessed and paid for medical care. The ensuing three decades ushered in a renewed period of advocacy for health care reform with costs remaining a consistent focus. Proponents for national health insurance framed health as a human right emphasizing equitable access. Those advocating for private health insurance touted the power of the marketplace to contain costs through competition and freedom of choice. Throughout the debates, health reform advocates, insurance industry representatives, medical providers, and legislators repeatedly referred to the “health consumer” as the potential benefactor of such reforms. But this ubiquitous term remained ambiguous. Who exactly was the “health consumer”? The contests over the rhetoric of the health consumer as an identity, its uses and political alignments, were engaged through print, in research, in organized campaigns, and in discrete individual interactions with health insurance and the health care system. These interconnected systems of power informed and were informed by the language used to describe them, in the sense of “structuring structures,” extending to economics and the consumer movement, social movements and civil rights. Thus the ideological orientations of the terms of the debate, focused on the “health consumer,” have shifted often and have continued to be contested in a dialectic relationship. This analysis therefore takes place at those intersections where health consumers as individuals have confronted the private, for-profit sphere by making claims for health consumer rights. The utility and ethical implications of commodification versus rights language have consistently been at the center of these opposing views. This dissertation examines the evolution of the dialectic dynamic of these two approaches to better understand how health consumer rights advocates have confronted challenges to include their voices in health care debates from the 1970s to the late 1980s at the local, state, and national levels. Specific sites include the Office of the Commissioner of Insurance and the Center for Public Representation, both located in Wisconsin, as well as the national grassroots organization Citizen Action and the local chapter Massachusetts Fair Share. Moving beyond binary understandings such as "patients" and "non-patients," or even the "patient/consumer," the health consumer identity blurs distinctions of inclusion and exclusion and dramatically expands the framing of "who counts" in health social movements. The health consumer thereby has remained a locus of contestation and potential rhetorical power that can inform the more political use of the term for making rights claims, as well as the more economic approach that advocates for free market principles. As such, it is readily co-opted in movement/counter-movement shifts in language and political alignment. Such contests and co-optation frame each chapter in this dissertation. Ultimately, health social movements and the dynamic, even equivocal orientation of the “health consumer” identity may play a determinative role in how to move forward with health care policy reform that seeks to provide all Americans with equitable access to wellness, rather than vying to purchase health.

Although women offenders face barriers to successful reentry into their communities, as yet, no research has explored their experiences in accessing health care reentry services. Medicaid enrollment, the process of applying for Medicaid coverage, can be offered as a health care reentry service. Women offenders in jails have shorter sentencing times compared to those in prison, which presents Medicaid enrollment opportunities before release. The Second Chance Act provides the opportunity for reentry services, and the Affordable Care Act provides the opportunity for Medicaid coverage for women offenders. This phenomenological study explored the attitudes of women offenders about Medicaid enrollment and coverage. The conceptual framework for this study was the Andersen's behavioral model. Interviews were conducted with 11 women offenders who were randomly recruited, spoke English, had a minimum of a 6th grade education, and were not on restriction based on jail policy. Data were collected and coded to develop themes for analysis and interpretation. Most participants had an adequate understanding of the purpose of Medicaid coverage and had favorable perceptions of Medicaid enrollment. Barriers to Medicaid enrollment were identified: a lack of language proficiency, denial of coverage, poor health literacy, and a lack of understanding of health information. Facilitators to Medicaid enrollment were identified: providing a translator, being treated with respect as a person to reduce stigma, and assistance with enrollment forms. These findings can contribute to positive social change. Jails have the chance to address these barriers and incorporate the facilitators to make it simpler for women offenders to enroll in Medicaid before released from jail.