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The Politics of Healthcare Quality The Politics of Healthcare Quality The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Scott, Kirstin W. 2015. The Politics of Healthcare Quality. Doctoral dissertation, Harvard University, Graduate School of Arts & Sciences. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:17467364 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA The Politics of Healthcare Quality A dissertation presented by Kirstin Woody Scott to The Committee on Higher Degrees in Health Policy in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the subject of Health Policy Harvard University Cambridge, Massachusetts April 2015 i @ 2015 Kirstin Woody Scott All rights reserved. ii Dissertation Advisor: Professor Robert Blendon Kirstin Woody Scott The Politics of Healthcare Quality Abstract Improving the quality of care provided by the U.S. healthcare system is an important societal goal. Policymakers who wish to operationalize this goal must navigate an increasingly polarized health policymaking environment. In this dissertation, I examine three stakeholders who can influence this environment: the public, state governors, and health care providers. In Chapter 1, I explore attitudes of and experiences with health care quality among Democrats and Republicans. Relying on a national survey of 1,508 American adults, I find that regardless of having a recent medical issue, Democrats express greater concerns about national quality of care problems relative to Republicans. At the same time, I find no difference in their personal experiences with quality of care received while hospitalized or with healthcare providers. In Chapter 2, I examine how gubernatorial candidates treat health policy in the 2012 and 2014 elections given the states’ increasing role in ACA implementation, which can collectively impact the quality of care provided nationally. After generating a novel database of all gubernatorial candidates’ campaign websites, I summarize the presence of healthcare content, framing of health system problems, and issue engagement with the ACA and its key coverage provisions in these two elections. I find the majority of gubernatorial candidates discuss health policy but are selective in their focus. Republicans, who are more likely than Democrats to express their views specifically regarding the ACA (which they nearly all refer to as “Obamacare”), won the majority of these 47 gubernatorial seats. Winning candidates from both parties discussed the iii Medicaid expansion decision of their state, with some expressing intentions to reverse course relative to their current expansion status. In Chapter 3, I examine a trend expected to grow under the ACA: hospital-physician integration. Using national hospital and Medicare data from 2003- 2012, I document the rise of hospital employment of physicians and examine whether or not this yields improvements in mortality, readmission rates, length of stay or patient satisfaction. Though I find that a plurality of hospitals now enter into employment relationships with physicians, this study provides no evidence that these changes are associated with improvements in quality of care. iv Table of Contents Abstract .......................................................................................................................................... iii Acknowledgements ........................................................................................................................ vi Chapter 1 - Sick of Healthcare Politics? ......................................................................................... 1 1.1. INTRODUCTION ............................................................................................................... 2 1.2. METHODS .......................................................................................................................... 4 1.3. RESULTS .......................................................................................................................... 11 1.4. DISCUSSION .................................................................................................................... 29 1.5. CONCLUSION .................................................................................................................. 32 Chapter 2 - Health Care in the 2012 and 2014 Gubernatorial Elections ...................................... 32 2.1. INTRODUCTION ............................................................................................................. 34 2.2. MOTIVATION AND THEORETICAL FRAMEWORK ................................................. 35 2.3. RESEARCH QUESTIONS ............................................................................................... 43 2.4. METHODS ........................................................................................................................ 46 2.5. RESULTS .......................................................................................................................... 54 2.5.1. Results Part I - 2012 Election ..................................................................................... 54 2.5.2. Results Part II - 2014 Election .................................................................................... 64 2.6. DISCUSSION .................................................................................................................... 86 2.7. CONCLUSION .................................................................................................................. 92 Chapter 3 - Changes in Hospital-Physician Affiliations and Impact on Quality of Care ............. 93 3.1. INTRODUCTION ............................................................................................................. 94 3.2. METHODS ........................................................................................................................ 96 3.3. RESULTS ........................................................................................................................ 107 3.4. DISCUSSION .................................................................................................................. 120 3.5. CONCLUSION ................................................................................................................ 123 References ................................................................................................................................... 124 Appendix ..................................................................................................................................... 135 v Acknowledgements The date of my dissertation defense – 17th April 2015 – marked the 1,688th day that I had the privilege of being a part of this PhD program. I could easily fill this entire document with words of gratitude to all those who have supported me in this quest. First, I thank God for the opportunity to be a student at this University. The Harvard experience has shaped me in profound ways and I am eternally grateful for the people – and powerful ideas – that I have had the privilege to cross paths with and encounter over these past 5 years. I am committed to striving each day to make the most of the opportunity I have had here. I am also thankful for my family for their unconditional love and support for everything I have ever done, including this program. Mom, Dad, Gav, Sara, Sienna, Tyler, Papa and Momma Bear, Jeff and Sara – I am so thankful for you all. I am also grateful to Grandma Woody – who we lost while I was in this program – for showing me the value of being a little feisty and stubborn for things we believe in. For my husband and best friend, John, there are no words to express how precious and invaluable your grace, kindness, patience and belief in me has been throughout this journey. Only you can fully appreciate the peaks and valleys that we have endured throughout this quest; I am grateful for the ways we have grown throughout it. Thank you for making me laugh often and much. When I entered this program, I was blessed to find a family in my peers and their loved ones, especially my cohort (Daria, Emily, David, Rebecca, Portia, Jacob, Craig, Portia, Paula, Daniel, and Alison). Each of them, as well as my Political Analysis family (Emma, Mary, Loren, Ali, Joe, Alecia, Beth, Mike, Sara, Ricky and alumni such as Molly) have graciously opened up their homes and lives to me, and I am thankful for the joy they have added to my life. These vi individuals, and other dear friends in this program such as Zirui (and Katie), Hummy, and Aaron (and Katherine), add to my hope for the future of health care as their brilliance, competence and devotion to moving the needle in a positive direction are truly second to none. I will always cherish the memories we have from Story Time, Political Analysis retreats, AcademyHealth 90210 style condos, Café Crema chats and more. Also, my running shoes have been faithful friends to me over the years and have afforded me much time to reflect upon the challenges in health care, politics and global health. Through their accompaniment, I have learned about the value of endurance. I am especially grateful to members of the 2am running club who have inspired me while on the trails
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