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 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.