California’s elderly population over age 85 is estimated to grow 361% by the year 2050. Many of these elders are frail and highly dependent on caregivers making them more likely to need nursing home care. A 1998 United States Government Accountability Office report identified poor quality of care in California nursing homes. This report spurred multiple Assembly Bills in California designed to increase nursing home nurse staffing, change the state’s Medi-Cal reimbursement methodology, or both. The legislation culminated in Assembly Bill (AB) 1629, signed into law in September 2004, which included the Long-Term Care Reimbursement Act. This legislation changed the state’s Medi-Cal reimbursement from a prospective, flat rate to a prospective, cost-based methodology and was designed in part to increase nursing home nurse staffing. It is estimated that this methodology change moved California from the bottom 10% of Medicaid nursing home reimbursement rates nationwide to the top 25%. This study analyzed the effect of AB 1629 on a panel of 567 free-standing nursing homes that were in continuous operation between the years 2002–2007. Resource Dependence Theory was used to construct the conceptual framework. Ordinary least squares (OLS) and first differencing with instrumental variable estimation procedures were used to test five hypotheses concerning Medi-Cal resource dependence, bed size, competition (including assisted living facilities and home health agencies), resource munificence, and slack resources. Both a 15 and 25 mile fixed radius were used as alternative market definitions instead of counties. The OLS results supported that case-mix adjusted licensed vocational nurse (LVN) and total nurse staffing hours per resident day increased overall. Nursing homes with the highest Medi-Cal dependence increased only increased NA staffing more than nursing homes with the lowest Medi-Cal dependence post AB 1629. The fixed effects with instrumental variable estimation procedure provided marginal support that nursing homes with more home health agency competition, in a 15 mile market, had higher LVN staffing. This estimation procedure also supported that nursing homes with more slack resources (post AB 1629) increased nurse aide and total nurse staffing while nursing homes located in markets with a greater percentage of residents over the age of 85 had more nurse aide staffing.

A conflict and challenge exists between the quality of care and life experienced by the obese elderly patient who remains in the acute care hospital waiting for admission to a nursing home and the nursing home leader’s and organization’s best interests. Obese elderly patients who remain in an acute care hospital waiting for admission to a nursing home often have their urgent medical needs addressed, but fail to receive care that improves their quality of life (Healthcare Association of Hawaii, 2008, 2009). The purpose of the qualitative, phenomenological study was to explore if and how nursing home leaders’ lived experiences regarding obese elderly patients influenced their attitudes and behaviors and to explore if any connection existed between the nursing home leaders’ attitudes and behaviors and their admission decisions. According to nursing home leaders, accommodation of the obese elderly patient’s needs is priority when making admission decisions. Accessibility and availability of size appropriate equipment and supplies, adequate staffing ratios and obesity-related staff training, and reimbursements that cover the cost of care are among the barriers to admitting obese elderly patients to nursing homes. Strategies to overcoming these barriers will require health-care stakeholders, including long term and acute care leaders, lawmakers, vendors, and public and private insurance providers, to work together to find solutions. Eliminating the barriers to admission should increase the number of obese elderly patients admitted to nursing homes, lower health care costs, and improve the obese elderly patient’s quality of life.

The goal of my research is to explore ways to improve the welfare of populations that are targeted by public programs. In particular, my thesis consists of three chapters on health insurance and education. The first chapter looks at Medicaid take-up decisions among poor children. Medicaid is public health insurance that is available to low income individuals, and it is provided freely by the government. However, there is a puzzling observation that many low-income children are uninsured despite their eligibility for Medicaid. As one possible explanation, I propose that the low level of access to health care that Medicaid provides can explain incomplete take-up. Existing literature suggests that the low level of Medicaid fee payments to physicians reduces their willingness to see Medicaid patients, creating an access-to-care problem for these patients. Using variation in the timing of the changes in Medicaid payments across states, I find that improving Medicaid generosity increases the take-up rate and reduces the uninsured rate among poor children. These findings provide a partial explanation for why Medicaid-eligible children in poverty remain uninsured. While my first chapter focuses on traditional means-tested public health insurance which targets mainly low income families, the second chapter explores the issues with a more recent intervention that extends beyond low income families. In recent years, several states have allowed young adults as old as 30 to remain covered under their parents employer-provided health insurance. For those who qualify for these benefits, the expansion of parental coverage partially reduces the value of being employed by a firm that provides health insurance since adult children can now get health insurance through another channel. We employ quasi-experimental variation in the timing and generosity of states eligibility rules to identify the effect of the policy change on young adults labor market choices. Our results suggest that the expansion of parental coverage increases the group coverage rate and reduces labor supply among young adults, particularly in full-time employment. The third chapter analyzes the effect of educational tracking by decomposing it into the separate roles of peer effects and coursework. The practice of tracking often results not only in grouping students by different ability, but also in providing different types of coursework for students. For instance, the advanced track may have both higher achieving peers and higher level coursework. Using detailed panel data from the San Diego Unified School district, I find that having high achieving peer is beneficial, while I do not find convincing evidence that taking more advanced math coursework predicts students test score.

In 2006, the Brazilian Health Council approved a National Health Policy for the Black Population. The Policy is striking because it promotes the image of a biologically and culturally discrete black population in a nation where racial classification has historically been relatively fluid and ambiguous. It transforms established patterns of racialization by collapsing “brown” pardo) and “black” preto) Brazilian Census categories into a single “black population” populacao negra) to be considered a special-needs group by the public health apparatus. This construction resembles the United States dominant mode of racialization based on hypodescent and represents a significant departure from hegemonic portrayals of Brazil as a racially mixed nation. Furthermore, the Policy challenges national ideologies of racial and cultural unity by affirming the existence of an essential black body with specific health concerns, as well as an essential Afro-Brazilian culture that materializes in recommendations for culturally competent health care. As such, the Policy constitutes an important site for new negotiations of racial and cultural identity in Brazil. In this dissertation, I explore the political and social implications of treating racial and ethnic groups differently within Brazilian health care. I examine how the re-definition and medicalization of racial and cultural identities unfolds in public clinics, temples of Afro-Brazilian religion, and social movements based in Sao Luis and Sao Paulo, Brazil. Through an analysis of ethnographic data that I collected over twenty-four months, I assess the impact of recent developments in race-conscious health policy on Brazilians lived experiences of race, ethnicity, and health disparities. I argue that the new Policy, and its associated health programs, signals the emergence of a new biopolitical paradigm in which the Brazilian state formalizes citizens racial and ethnic differences in order to address inequalities among them. I also show that many aspects of these programs, which incorporate global discourses and concepts related to health equity, fail to resonate with Brazilian citizens notions about race and health. Consequently, patients and healthcare providers often resist the new measures. The result is a disjuncture between policy and practice that ultimately hinders Brazils efforts to reduce health inequalities among its citizens.

This dissertation examines university employees’ access to public health benefits in the state of Michigan, following the 2004 passage of a constitutional amendment banning gay marriage. Proposition 04-02 was interpreted by Michigan courts to mean that under traditional eligibility schemes, public employers could no longer offer health benefits to the same-sex domestic partners (or the children of same-sex domestic partners) of employees. How Michigan’s research universities responded to this change in public policy illustrates the complex array of moral and strategic concerns undergirding the issue of health benefits for gay and lesbian faculty and staff. This multiple case study is derived from an institutional logics methodology. Drawing from a multitude of sources, including interviews, secondary data collection and document analysis, it reveals four contested logics at work behind institutional decision-making. Presented in order of magnitude, these are: market logics, compliance logics, political logics and diversity logics. The recognition that LGBT faculty and staff are essential to institutional competitiveness and recruitment initiatives emerges as an important consideration. Against the backdrop of retrenchment and fiscal austerity particular to public higher education, cost containment plays a variable role, first as a material and later as a cultural consideration. These findings, and others, provide insight into the implications of the broader fight over the institution of marriage and the movement for gay civil rights for public higher education. Elaborating upon this empirical platform, the study develops a new rubric for evaluating the fairness of work-family policy in higher education. Harnessing the Human Capabilities approach from political philosophy it evaluates the organizational adaptations of Michigan’s higher educational institutions to the new regulatory environment. This research offers several contributions to the field: a substantive analysis of access to health benefits for same-sex partners and family members, and its importance to recruitment and retention in higher education； the identification of an evolving definition of diversity in which sexual orientation plays an increasingly important role； a deeper understanding of the tension between material and cultural considerations in institutional decision-making； and a powerful new theoretical construct for the normative evaluation of public policy and organizational change in higher education.

The quality of nursing home care remains a serious challenge. The Centers for Medicare & Medicaid Services and the nursing home industry have heralded culture change not only as a means to improve quality of life, but also quality of care. Unfortunately, there is a lack of empirical data regarding the effects of culture change on quality-of-care outcomes in nursing home residents. This cross-sectional causal-comparative study addressed the need for empirical data based on information from a sample of nursing homes (N ＝ 97) in an East North Central and Southern Mountain state. Utilizing the Artifacts of Culture Change instrument, the researcher assigned participants to three groups (medical, hybrid, or social model of care), and used the quality measures to assess quality-of-care outcomes. Based on social ecology theory, it was expected that nursing homes using culture change as their operating model would have higher residents. quality-of-care outcomes than nursing homes using a medical model of care. The data collected suggest that there was no difference in residents. quality-of-care outcomes between nursing homes operating under a medical model of care and those operating under a social model of care when the aggregate quality measures were examined. However, when considered separately, the study found that residents in nursing homes operating under a social model of care were less restrained ( p ＝ .01, 95% CI [.0091, .1971], effect size ＝ .07) and spent less time in bed or chair (p ＝ .03, 95% CI [-.0078, .1996], effect size ＝ .05) at the .05 level of significance, and had fewer high-risk pressure ulcers (p ＝ .10, 95% CI [-.0230, .1343], effect size ＝ .08) at the .10 level of significance than residents who received care from nursing homes operating under the medical model. Results should be cautiously interpreted because the exploratory study experienced limited statistical power and results may have been spurious. In conclusion, the study provides tentative support that culture change can be used as a means to enhance some quality-of-care outcomes in nursing home residents.

The study of strategic management pursues a continual understanding of the factors that influence an organization’s adaptation to innovation and change. The U.S. health care industry is one in which hospital managers face countless issues that require the organization to seek strategic decisions that provide a sustainable, competitive advantage. Frustrated with hospitals’ historical unwillingness to adopt ambulatory surgery centers (ASCs), physician specialists established strategic alliances among themselves or with well-funded surgery center companies to reduce the (a) cost, (b) complexity, (c) time, and (d) risk involved in the development of these facilities. Based on competition with their referring physicians and physicians’ acceptance of strategic alliances with ambulatory surgery center management companies, hospital managers reacted. The framework for the study was a cross-sectional, one-time assessment of managerial attitudes and perceptions utilizing a survey instrument from a population of hospital executives and senior managers regarding their willingness to adopt physician strategic alliances (PSAs) in ASCs. Review of the literature enabled identification of influential factors and offered support to the chosen framework within which answers to the research questions were pursued. The research questions tested various hypotheses regarding hospital decision makers’ perceptions of the (a) need, (b) relative value, (c) complexity, and (d) risk of innovation with physician strategic alliances in ambulatory surgery centers. As a result of this study, the data indicate that hospital senior managers’ willingness to recommend PSAs in ASCs may be dependent on their perception of need and relative value but may not be dependent on their perception of organizational complexity or risk.

References to accountability are common throughout public administration literature. However, a clear model to assess accountability in government programs is not fully developed. This research fills this gap and provides policymakers with a tool they can use to assess accountability in both public and contracted programs and enables them to make more informed contracting-out decisions. In addition, the Integrated Accountability Framework introduced in this research will serve as a guideline for how public administrators can improve accountability in the programs they administer and oversee. For the public and private health care programs analyzed in this study, the findings indicate that the publicly delivered programs provided more accountability to the vulnerable populations served than the contracted-out health care programs.

Background. The Centers for Medicare and Medicaid Services, CMS) implements National Coverage Decisions NCD) to expand access or eliminate regional reimbursement differences. Policymakers may estimate clinical and economic consequences through short term pilots or demonstration projects. Objective. Examined whether short term outcomes mirror longer term outcomes for a CMS NCD for Deep Brain Stimulation DBS) in Parkinsons disease PD). Methods. This observational study examined the inpatient clinical and economic outcomes associated with a CMS NCD for DBS in PD using Health Care Utilization Project HCUP) retrospective data from 1999 through 2007. The Healthcare Utilization Project HCUP) data, is supported by CMS. HCUP is the largest collection of all-payer, uniform, state-based inpatient surgery administrative data and covers the years of interest. Short-term cross-sectional analysis examined 12 months pre NCD January 1, 1999 to March 31, 2003)； and 12 months post NCD April 1, 2003 to March 30,2004). Long-term, cross-sectional analysis examined the three years, three months prior to the the short term pre period January 1, 1999 to March 31, 2002)； and the three years, nine months after the short term post period April 1 2004 to December 31, 2007). Results. A patient who had DBS surgery in the 12 months post NCD is more likely to be discharged to long or short term care rather than home OR 3.671, p＝0.0249)； is associated with longer lengths of stay 0.2888, p＝0.0001)； and is positively associated with the log of total charges 0.19985, p＝0.0240). A patient who has DBS surgery more than 12 months post NCD compared surgery more than 12 months pre NCD, was less likely to have complications OR 0.376, 0.0004) , was associated with a shorter length of stay -0.2857, p＝0.0093), and is positively associated with the log of total charges 0.33875, p&lt；0.001). Conclusions. These results suggest that after the benefit expansion, outcomes worsened in the short term, and improved in the long term. Policymakers may benefit from a longer term view when forecasting before—or interpreting outcomes after—a benefit design change. Differences in populations served may cause temporary or long term shifts in health outcomes and resource utilization.

This dissertation deals with consumer demand, asymmetric information, and insurer pricing in health insurance markets. The first chapter considers the role of imperfectly competitive insurers. Imperfect competition is a pervasive feature of many health insurance markets. In Medicare Supplement insurance Medigap), two firms control nearly three- fourths of the market and premiums exceed claims by thirty percent. Rather than harming consumers, adverse selection actually restrains markups, resulting in a seven percent increase of total surplus. However, a low price elasticity and consumers brand preferences incentivize firms to engage in substantial marketing of their products and price above cost. Policies limiting marketing by insurers could reduce premiums significantly. I conclude that the strategic behavior of insurers facing relatively inelastic demand is far more important than adverse selection in explaining poor market performance. The second chapter further analyzes demand for Medicare Supplement Insurance, focusing on the relationship between the characteristics of consumers who purchase an insurance products and contract characteristics, including price. The parameter values estimated imply the coexistence of adverse and advantageous selection. While healthier consumers are more likely to purchase insurance, relatively sicker consumers are willing to pay higher prices conditional on purchase. While selection is a prevalent feature of this market, the estimates of moral hazard are smaller in magnitude and statistically insignificant. The final chapter, joint with Keith Ericson, considers a relatively new environment in which consumers purchase insurance: the individual insurance exchange. We describe Massachusetts exchange. The determination of minimum credible coverage has substantial effects on this market: more than 60% of consumers choose the lowest tier of plan quality, and the lowest-priced policy in each region receives a substantial increase in enrollment. We identify substantial heterogeneity in consumer price sensitivity using a regression discontinuity design. We test for adverse selection based on use of plan features prescription drug coverage) and tenure in plan. We find that young women a category more likely to use drugs) are more likely to choose plans with prescription drug coverage. While we find large differentials in tenure by age, we find relatively small differentials in tenure based on generosity of plan chosen.