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Is health care a right or an entitlement? This question persists in the ongoing political, legal, and social turbulence surrounding efforts toward accessible and affordable health care in the United States.

The analysis is drawn from a review of the literature and interviewing a subject matter expert employed by a health maintenance organization in Michigan.

Since the early 1900s, federal legislation has been proposed to establish some type of health care structure that could sufficiently address the varying health care needs of Americans. These multiple attempts toward national health care reform invoke the inquiry of the federal government’s role and function to facilitate access to and management of health care. The passage of the Patient Protection and Affordable Care Act (PPACA) amplifies the conditions and consequences of implementing health care reform effectively.

For college students, the complexities of both the health care and higher education systems can be overwhelming, especially for those students who may already be struggling to pay for and/or finance their schooling and satisfy academic requirements to matriculate while simultaneously striving to maintain a reasonable level of health to complete their education. College students are but one of many vulnerable populations in the United States impacted by the complicated policies and procedures of accessing, delivering, funding, and paying for health care.

This study aims to examine the effect of the Patient Protection and Affordable Care Act (PPACA) on for-profit hospitals in the USA.

The study uses the event study methodology to examine the stock market’s reaction to the passage of the PPACA.

The results of the analysis do not show a negative effect; on the contrary, the stock prices of for-profit hospitals increased, on average, by 6%. The cumulative abnormal returns were 5.64% with a generalized z-value of 3.851 with a significance level of 0.001 (two-tailed test). This translates into an average gain of $230,537,096 for the four days (dates) that a positive step was taken in making the Affordable Care Act (ACA) a law of the country.

Because the study suggests that for-profit hospitals will be profitable under the PPACA, one could expect to see growth or, at the minimum, expansion in for-profit hospitals under the Act. Furthermore, and consistent with the principles of marketing, one would expect all the for-profit hospitals, at this nascent stage of the ACA, to pull resources together to promote the benefits of having the ACA.

To the best of the author’s knowledge, this is the first study to examine the effect of the PPACA on the operations of for-profit hospitals.

Purpose – Medicaid funding for long-term services and supports (LTSS) is a key avenue for community access for people with disabilities and others. Between 1997 and 2009, the boundaries of community access were redrawn and redefined with the introduction of a series of 13 bills to change how Medicaid requires states to fund LTSS. Although they did not successfully pass into law, their presence is felt in the language of the Community First Choice (CFC) Option, part of the Patient Protection and Affordable Care Act (PPACA) of 2010. This chapter documents and analyzes the changes in the concept of community access as reflected across these bills and the CFC.

Methodology – The text of these 13 bills and the CFC were compared with attention to structure, order, and meaning. Documents were hand coded and electronically searched. Codes were entered into atlas.ti for comparison and analysis.

Findings – Four significant changes in the conceptualization of community access emerged: (1) who deserves access to community, (2) what community access entails, (3) why people deserve access to community, and (4) how community access should be organized. With the exception of the reasons why people deserve access to community, the expanded concept of community access illustrated across these bills is reflected in the text of CFC.

Originality/value of the chapter – This chapter contributes to the limited literature that documents and analyzes the historical development of community access across policy documents. In addition, it highlights the relevance of incremental analysis to understanding social change through the legislative process.

The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics (RHCs) are responding to the ACO model. This research examines RHC managers’ perceived benefits and barriers for implementing ACOs from an organizational ecology perspective.

A survey was conducted in spring of 2012 covering the present RHC network working infrastructures – (1) Organizational social network; (2) organizational care delivery structure; (3) ACO knowledge, perceived benefits, and perceived barriers; (4) quality and disease management programs; and (5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of 91 responses were received.

RHC managers’ personal perceptions on ACO’s benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis.

The study is primarily focused in the Southeastern region of the United States. The generalizability is limited to this region. The predictors of RHCs’ participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act.

RHCs are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.

The purpose of this paper is to make readers aware of the extensiveness of healthcare fraud in the USA and how it involves and affects the government, healthcare providers, insurance companies, patients and the public. In addition, recommendations are made that may help control this pervasive type of fraud.

A range of different journal publications, information from government health institutions and law enforcement websites, healthcare fraud cases and healthcare laws are used as a basis to provide information about how fraudsters are committing healthcare fraud and how to prevent this fraud from occurring.

Despite increased funding and prosecution efforts by the government, healthcare fraud continues to be a major threat to the US economy and public. While healthcare fraud will never be eradicated, specific efforts can be deployed to help rein in these complex fraud schemes.

The paper provides a useful resource of information on healthcare fraud for healthcare providers, insurance companies, patients and the public that may help combat healthcare fraud and prevent financial losses.

Every dollar saved from combating fraud could be used to improve access to more or better health services and can, thereby, save lives.

This paper provides recommendations regarding healthcare fraud that could help prevent this large drain on the US economy.

Bundled payments for care are an efficient mechanism to align payer, provider, and patient incentives in the provision of health care services for an episode of care. In this chapter, we use agency theory to examine the evolution of bundled payment programs in private and public payer arrangements, and postulate future directions for bundled payment development as a key component in the provision and payment of health care services.

Population, community, and public health notions are addressed separately in the Patient Protection and Affordable Care Act (ACA), have different foci and stakeholders, build on different frameworks to achieve their aims, and apply different measures to determine the long-term impact of interventions. This paper attempts to clarify each concept and proposes a method of evaluating each of these sets of health-related activities based on the benefits that accrue to the respective stakeholders.

In addition to indicating how to affect change and improvements in health, the ecological model of health also provides insight into how the benefits from health-related activities may or may not flow back to the entities sponsoring health interventions. By clearly defining each of the concepts and examining the methods and metrics being used to select activities and measure benefits, a valuation model is developed that measures the financial impact on the targeted population as well as the sponsoring institution.

Defining, measuring, and evaluating are important to bring clarity to how individual organizations can contribute to the overall health of the population, as well as the limits of any single organization in doing so. Collective and upstream action will be required to improve the population’s health, but identifying and justifying the role of each participating organization is a challenge that still lacks an overarching vision that can be explained and measured to the satisfaction of all stakeholders.

Decision makers must justify how resources are committed in an era of scarcity and limited financial means. Moreover, methods must be in place to measure the impact of potential collaborations. The proposed valuation framework lays out the natural incentives, the responses to those incentives, and how to select initiatives that maximize value from the perspective of the various stakeholders.

Personnel costs typically account for 60% or more of total operating expenses in health systems, and as such beome a necessary focus in most if not all substantive health reform adaptations. This study sought to assess whether strategic alignment of the human resource (HR) and learning functions was associated with greater adaptive capacity in U.S. health systems.

Data were gathered using a survey that was distributed electronically to chief human resource officers from two U.S.-based associations. The survey included questions about organizational structure, strategic human resource management, strategic learning, and organizational response to health reform.

Significant correlations were found between strategic alignment of HR and HR’s involvement in responses related to cost control (r=0.46, p<0.01); quality improvement (r=0.45, p<0.01), and patient access (r=0.39, p<0.01). However, no significant relationships were found between strategic alignment of organizational learning and HR involvement with these responses.

Results suggest that HR structure may affect an organization’s capacity for adaptive response. Top-management teams in health systems should consider positioning HR as part of the core leadership team, with a reporting relationship that allows HR to maximally participate in formulating and implementing organizational adaptation.

Purpose – Health information technology (HIT) has been lauded as a foundation upon which the development of an integral solution to cost and quality problems facing many nations is predicated. Countries throughout the world have taken differing approaches in their efforts to advance that foundation through policy, financial, and cultural systems that come to support or hinder adoption. As we explore potential opportunities to learn from the experience of others, we pause to consider the environmental, regulatory, financial, and social dynamics that define the US context.

Design/methodology/approach – This chapter outlines the framework for a comparative approach through four dimensions – environmental, regulation, financial, and social – through which comparative HIT studies should be explored.

Findings – With such markedly different contexts in which their HIT is embedded, it is important to not simply look at other countries as a yardstick upon which we compare our failures and successes. Rather, we must look critically at these examples understanding that the dynamics at play in each context have created opportunities and obligations that have come to define each country's implementation.

Originality/value – The need for a common framework through which scholars can explore comparative HIT systems, while remaining grounded in the US context is an important aspect of effective knowledge translation in adoption.