Dissertation Title:  "Stretching the Safety Net: Child Participation in Public Insurance and the State of Community Health Centers"

Non-participation by children eligible for public insurance programs in the United States has been a persistent dilemma for policymakers. Paper One begins by developing a participation model to determine differences between children who enrolled in Medicaid and CHIP and children who did not. The analyses utilize data from the 1998 Ohio Family Health Survey (OFHS) and find that children in poorer health and those who resided in counties with higher levels of expenditures on outreach were also more likely to enroll. Half of all parents with uninsured but eligible children reported that they were unaware of their child's eligibility and very few indicated that the reason for non-enrollment was related to pride or to hassles regarding the enrollment process. Findings from this study demonstrate a substantial need to increase awareness about program eligibility and to identify subgroups that would benefit from targeted outreach strategies. A recent report on the health care safety net by the Institute of Medicine recommends the monitoring of community health centers (CHCs) because of the many fiscal and operating challenges they currently face.

Paper Two and Paper Three respond to this recommendation. Paper Two uses data from the Bureau of Primary Health Care (BPHC) to analyze recent payor-mix changes and to assess the financial health of CHCs from 1996 to 1999. Results show that many individual CHCs have been subject to fluctuations in uninsured and Medicaid users. Troubling is the finding that more than half of all CHCs reported a deficit in 1997, 1998 and 1999. Paper Three formalizes an examination of CHC integration activity to determine whether strategic adaptation or institutional theory best explains the present organizational behavior of CHCs. Data obtained from multiple case studies show that CHC integration activity was substantial, varied and consistent with the organizational behavior model of strategic adaptation. Together with Paper Two, the results of Paper Three provide clear evidence that monitoring of CHC financial health and their organization behavior should continue.