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Smithers D, Waitzkin H. Universal health coverage as hegemonic health policy in low- and middle-income countries: A mixed-methods analysis. Soc Sci Med 2022; 302:114961. [PMID: 35527089 DOI: 10.1016/j.socscimed.2022.114961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 02/19/2022] [Accepted: 04/02/2022] [Indexed: 11/24/2022]
Abstract
Universal health coverage (UHC) has become an influential global health policy. This study asked whether and to what extent UHC became a "hegemonic" health policy. The article consists of three parts: a historical timeline of UHC's rise, a bibliometric analysis of UHC in the literature, and a qualitative thematic analysis of how UHC is defined and the thematic content of those definitions. The roots of UHC can be traced to policies enacted by international financial institutions (IFIs) such as the World Bank and International Monetary Fund (IMF) during the latter half of the twentieth century. These policies caused the debt of low- and middle-income countries (LMICs) to rise precipitously and led the same IFIs and other institutions like the World Health Organization to become involved in the development and restructuring of health systems. UHC was presented as the leading method for financing development of health systems. As the bibliometric analysis shows, UHC has come to predominate in the literature around health system reforms. The thematic analysis based on a random selection of papers obtained in the bibliometric component of the study shows that often the term is not defined or only poorly defined. There is wide variation in the definitions, with many papers mentioning concepts such as quality, access, and equity without further clarification. Usually, papers define UHC to include tiering of benefits, with discussions of financing that focus on preventing "catastrophic [individual] expenditures" rather than discussing universal budgeting of a national health care system or national health insurance. We conclude that UHC has become hegemonic within global health policy, to the exclusion of discussions about other approaches to the transformation of health systems that are not predominately based on insurance coverage such as Health Care for All system, a system which provides equal services for the entire population.
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Affiliation(s)
- Daniel Smithers
- Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA.
| | - Howard Waitzkin
- University of New Mexico, Department of Sociology and Health Sciences Center, 801 Encino Place NE, Albuquerque, NM 87102, USA.
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Ruble L, McGrew JH, Snell-Rood C, Adams M, Kleinert H. Adapting COMPASS for youth with ASD to improve transition outcomes using implementation science. Sch Psychol 2019; 34:187-200. [PMID: 30284887 PMCID: PMC6422695 DOI: 10.1037/spq0000281] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Implementation science provides guidance on adapting existing evidence based practices (EBPs) by incorporating implementation concerns from the start. Focus-group methodology was used to understand barriers and facilitators of transition planning and implementation for students with autism spectrum disorder (ASD) who often experience disparate postsecondary outcomes compared to peers. Results were used to modify an evidence-based consultation intervention originally applied to young students with ASD, called the Collaborative Model for Promoting Competence and Success (COMPASS; Ruble, Dalrymple, & McGrew, 2012). Because consultation is a multilevel EBP, two existing implementation science frameworks were used to guide adaptation: the Framework for Evidence Based Implementation and Intervention Practices (Dunst & Trivette, 2012) and the Consolidated Framework for Implementation Research (Damschroder et al., 2009). The purpose of this article is to describe a process of adaptation of COMPASS that may be useful for other implementation science studies of consultation interventions, teacher acceptability, feasibility, and burden, and parent/student satisfaction with the adapted intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Lisa Ruble
- Department of Educational, School, and Counseling Psychology
| | | | | | - Medina Adams
- Department of Educational, School, and Counseling Psychology
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Waitzkin H, Cruz M, Shuey B, Smithers D, Muncy L, Noble M. Military Personnel Who Seek Health and Mental Health Services Outside the Military. Mil Med 2018; 183:e232-e240. [DOI: 10.1093/milmed/usx051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Howard Waitzkin
- Health Sciences Center and Department of Sociology, University of New Mexico, 801 Encino Place NE, Suite C-14, Albuquerque, NM 87102
| | - Mario Cruz
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, MSC09 5030, 1 University of New Mexico, Albuquerque, NM 87131
| | - Bryant Shuey
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, MSC09 5030, 1 University of New Mexico, Albuquerque, NM 87131
| | - Daniel Smithers
- Boston University School of Medicine, 72 East Concord St, Boston, MA 02118
| | - Laura Muncy
- Civilian Medical Resources Network, P.O. Box 2965, Taos, NM 87571
| | - Marylou Noble
- Civilian Medical Resources Network, P.O. Box 2965, Taos, NM 87571
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Stone LC, Boursaw B, Bettez SP, Marley TL, Waitzkin H. Erratum to “Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States” [Health Place 34 (2015) 207–214]. Health Place 2015; 35:155. [DOI: 10.1016/j.healthplace.2015.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Stone LC, Boursaw B, Bettez SP, Larzelere Marley T, Waitzkin H. Place as a predictor of health insurance coverage: A multivariate analysis of counties in the United States. Health Place 2015; 34:207-14. [PMID: 26086690 DOI: 10.1016/j.healthplace.2015.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 12/29/2014] [Accepted: 03/24/2015] [Indexed: 11/26/2022]
Abstract
This study assessed the importance of county characteristics in explaining county-level variations in health insurance coverage. Using public databases from 2008 to 2012, we studied 3112 counties in the United States. Rates of uninsurance ranged widely from 3% to 53%. Multivariate analysis suggested that poverty, unemployment, Republican voting, and percentages of Hispanic and American Indian/Alaskan Native residents in a county were significant predictors of uninsurance rates. The associations between uninsurance rates and both race/ethnicity and poverty varied significantly between metropolitan and non-metropolitan counties. Collaborative actions by the federal, tribal, state, and county governments are needed to promote coverage and access to care.
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Affiliation(s)
- Lisa Cacari Stone
- Public Health Program, Department of Family & Community Medicine, University of New Mexico Health Sciences Center, MSC 095060, 1 University, Albuquerque, NM 87131, United States; Robert Wood Johnson Foundation Center for Health Policy, University of New Mexico Health Sciences Center, MSC 095060, 1 University, Albuquerque, NM 87131, United States; Community Engagement Core, NM CARES Health Disparities Center, University of New Mexico Health Sciences Center, MSC 095060, 1 University, Albuquerque, NM 87131, United States; U.S.-Mexico Border Center of Excellence Consortium, University of New Mexico Health Sciences Center, MSC 095060, 1 University, Albuquerque, NM 87131, United States.
| | - Blake Boursaw
- College of Nursing, University of New Mexico, MSC09 5350, 1 University of New Mexico, Albuquerque, NM 87131, United States.
| | - Sonia P Bettez
- RWJF Center for Health Policy, University of New Mexico, PO Box 90, Corrales, NM 87048-0090, United States.
| | | | - Howard Waitzkin
- Robert Wood Johnson Foundation Center for Health Policy, University of New Mexico Health Sciences Center, MSC 095060, 1 University, Albuquerque, NM 87131, United States; Department of Sociology, University of New Mexico; Department of Internal Medicine, University of Illinois; School of Public Health, University of Puerto Rico, 5406 East Drive, Loves Park, IL 61111, United States.
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Willging CE, Sommerfeld DH, Aarons GA, Waitzkin H. The effects of behavioral health reform on safety-net institutions: a mixed-method assessment in a rural state. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2014; 41:276-91. [PMID: 23307162 PMCID: PMC3987948 DOI: 10.1007/s10488-012-0465-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In July 2005, New Mexico initiated a major reform of publicly-funded behavioral healthcare to reduce cost and bureaucracy. We used a mixed-method approach to examine how this reform impacted the workplaces and employees of service agencies that care for low-income adults in rural and urban areas. Information technology problems and cumbersome processes to enroll patients, procure authorizations, and submit claims led to payment delays that affected the financial status of the agencies, their ability to deliver care, and employee morale. Rural employees experienced lower levels of job satisfaction and organizational commitment and higher levels of turnover intentions under the reform when compared to their urban counterparts.
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Affiliation(s)
- Cathleen E. Willging
- Pacific Institute for Research and Evaluation, Behavioral Health Research Center of the Southwest, 612 Encino Place NE, Albuquerque, NM 87102, USA
| | - David H. Sommerfeld
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812, USA
| | - Gregory A. Aarons
- Department of Psychiatry, University of California, San Diego, 9500 Gilman Drive (0812), La Jolla, CA 92093-0812, USA
| | - Howard Waitzkin
- Department of Sociology, University of New Mexico, MSC 05 3080, 1070 Social Sciences Building, 1915 Roma NE, Room 1103, Albuquerque, NM 87131-0001, USA
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Aarons GA, Fettes DL, Sommerfeld DH, Palinkas LA. Mixed methods for implementation research: application to evidence-based practice implementation and staff turnover in community-based organizations providing child welfare services. CHILD MALTREATMENT 2012; 17:67-79. [PMID: 22146861 PMCID: PMC3841106 DOI: 10.1177/1077559511426908] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Many public sector service systems and provider organizations are in some phase of learning about or implementing evidence-based interventions. Child welfare service systems represent a context where implementation spans system, management, and organizational concerns. Research utilizing mixed methods that combine qualitative and quantitative design, data collection, and analytic approaches are particularly well suited to understanding both the process and outcomes of dissemination and implementation efforts in child welfare systems. This article describes the process of using mixed methods in implementation research and provides an applied example of an examination of factors impacting staff retention during an evidence-based intervention implementation in a statewide child welfare system. The authors integrate qualitative data with previously published quantitative analyses of job autonomy and staff turnover during this statewide implementation project in order to illustrate the utility of mixed method approaches in providing a more comprehensive understanding of opportunities and challenges in implementation research.
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Chuang E, Wells R, Alexander JA. Public managed care and service access in outpatient substance abuse treatment units. J Behav Health Serv Res 2012; 38:444-63. [PMID: 21184286 DOI: 10.1007/s11414-010-9230-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The continued growth of public managed behavioral health care has raised concerns about possible effects on services provided. This study uses a national sample of outpatient substance abuse treatment units surveyed in 2005 to examine associations between public managed care and service access, measured as both the types of services provided and the amount of treatment received by clients. The percentage of clients funded through public managed care versus other types of public funding was positively associated with treatment units' odds of providing some types of resource-intensive services and with the odds of providing transportation to clients, but was negatively associated with the average number of individual therapy sessions clients received over the course of treatment. In general, public managed care does not appear to restrict access to outpatient substance abuse treatment, although states should monitor these contracts to ensure clients receive adequate courses of individual treatment.
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Affiliation(s)
- Emmeline Chuang
- Department of Mental Health Law and Policy, Department of Child and Family Studies, College of Behavioral and Community Studies, 13301 Bruce B Downs Blvd, Tampa, FL 33612-3807, USA.
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Waitzkin H, Yager J, Santos R. Advancing the business creed? The framing of decisions about public sector managed care. SOCIOLOGY OF HEALTH & ILLNESS 2012; 34:31-48. [PMID: 21707659 DOI: 10.1111/j.1467-9566.2011.01360.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Relatively little research has clarified how executives of for-profit healthcare organisations frame their own motivations and behaviour, or how government officials frame their interactions with executives. Because managed care has provided an organisational structure for health services in many countries, we focused our study on executives and government officials who were administering public sector managed care services. Emphasising theoretically the economic versus non-economic motivations that guide economic behaviour, we extended a long-term research project on public sector Medicaid managed care (MMC) in the United States. Our method involved in-depth, structured interviews with chief executive officers of managed care organisations, as well as high-ranking officials of state government. Data analysis involved iterative interpretation of interview data. We found that the rate of profit, which proved relatively low in the MMC programme, occupied a limited place in executives' self-described motivations and in state officials' descriptions of corporation-government interactions. Non-economic motivations included a strong orientation toward corporate social responsibility and a creed in which market processes advanced human wellbeing. Such patterns contradict some of the given wisdom about how corporate executives and government officials construct their reality.
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Affiliation(s)
- Howard Waitzkin
- Department of Sociology, Robert Wood Johnson Foundation Center for Health Policy, University of New Mexico, Albuquerque, New Mexico 87131, USA.
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Weiner BJ, Amick HR, Lund JL, Lee SYD, Hoff TJ. Use of qualitative methods in published health services and management research: a 10-year review. Med Care Res Rev 2011; 68:3-33. [PMID: 20675353 PMCID: PMC3102584 DOI: 10.1177/1077558710372810] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Over the past 10 years, the field of health services and management research has seen renewed interest in the use of qualitative research methods. This article examines the volume and characteristics of qualitative research articles published in nine major health services and management journals between 1998 and 2008. Qualitative research articles comprise 9% of research articles published in these journals. Although the publication rate of qualitative research articles has not kept pace with that of quantitative research articles, citation analysis suggests that qualitative research articles contribute comparably to the field's knowledge base. A wide range of policy and management topics has been examined using qualitative methods. Case study designs, interviews, and documentary sources were the most frequently used methods. Half of qualitative research articles provided little or no detail about key aspects the study's methods. Implications are discussed and recommendations are offered for promoting the publication of qualitative research.
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Affiliation(s)
- Bryan J Weiner
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7411, USA.
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Schillaci MA, Waitzkin H, Carson EA, Romain SJ. Prenatal care utilization for mothers from low-income areas of New Mexico, 1989-1999. PLoS One 2010; 5:e12809. [PMID: 20862298 PMCID: PMC2941446 DOI: 10.1371/journal.pone.0012809] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Accepted: 08/20/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prenatal care is considered to be an important component of primary health care. Our study compared prenatal care utilization and rates of adverse birth outcomes for mothers from low- and higher-income areas of New Mexico between 1989 and 1999. METHODOLOGY/PRINCIPAL FINDINGS Prenatal care indicators included the number of prenatal care visits and the first month of prenatal care. Birth outcome indicators included low birth weight, premature birth, and births linked with death certificates. The results of our study indicated that mothers from low-income areas started their prenatal care significantly later in their pregnancies between 1989 and 1999, and had significantly fewer prenatal visits between 1989 and 1997. For the most part, there were not significant differences in birth outcome indicators between income groupings. CONCLUSIONS/SIGNIFICANCE These findings suggest that while mothers from low-income areas received lower levels of prenatal care, they did not experience a higher level of adverse birth outcomes.
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Affiliation(s)
- Michael A Schillaci
- Department of Social Sciences, University of Toronto Scarborough, Scarborough, Ontario, Canada.
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Kano M, Willging CE, Rylko-Bauer B. Community participation in New Mexico's behavioral health care reform. Med Anthropol Q 2009; 23:277-97. [PMID: 19764315 DOI: 10.1111/j.1548-1387.2009.01060.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In 2005, New Mexico implemented a unique reform in managed behavioral health services that seeks to ensure delivery of consumer-driven, recovery-oriented care to low-income individuals. Distinguishing features of the reform are the Local Collaboratives (LCs), regionally based community organizations designed by state government to represent behavioral health concerns of New Mexico's diverse cultural populations. We examine community response to the LCs, focusing on two broad sets of themes derived from 18 months of ethnographic fieldwork. The first set--structure and function--encompasses several issues: predominance of provider versus consumer voice; insufficient resources to support internal operations; imposition of state administrative demands; and perceived lack of state response to LC efforts. The second set--participation and collaboration--reveals how problems of information flow and other logistical factors impact involvement in LCs and how the construction of "community" introduced under this initiative exacerbates tensions across localities with varied histories and populations.
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Affiliation(s)
- Miria Kano
- Behavioral Health Research Center of the Southwest Pacific Institute for Research and Evaluation, USA
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Willging CE, Waitzkin H, Lamphere L. Transforming administrative and clinical practice in a public behavioral health system: an ethnographic assessment of the context of change. J Health Care Poor Underserved 2009; 20:866-83. [PMID: 19648713 DOI: 10.1353/hpu.0.0177] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In July 2005, New Mexico placed all publicly funded behavioral health services under the management of one private corporation. This reform emphasized the provision of evidence-based, culturally competent services. Methods. Participant observation and semi-structured interviews with 189 administrators, staff, and providers were carried out in 14 behavioral health safety-net institutions (SNIs) during the transition period. Results. New administrative requirements led to substantial paperwork demands, payment problems, and financial stress within SNIs. Personnel at the SNIs often lacked knowledge about and training in evidence-based practices and culturally competent care, and viewed the costs of delivering such services as prohibitive. Discussion. Policymakers must account for the challenges that SNIs face as the reform continues to unfold. The financial stability of SNIs is of critical importance. Efforts are needed to increase training and development opportunities in evidence-based care and cultural competency; SNIs typically lack resources to pursue these opportunities on their own.
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The impact of changing medicaid enrollments on New Mexico's Immunization Program. PLoS One 2008; 3:e3953. [PMID: 19107189 PMCID: PMC2602595 DOI: 10.1371/journal.pone.0003953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 11/18/2008] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Immunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico's immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices. METHODS AND FINDINGS This study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment. CONCLUSIONS New Mexico's improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state's efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.
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Willging CE, Waitzkin H, Nicdao E. Medicaid managed care for mental health services: the survival of safety net institutions in rural settings. QUALITATIVE HEALTH RESEARCH 2008; 18:1231-1246. [PMID: 18689536 DOI: 10.1177/1049732308321742] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.
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Affiliation(s)
- Cathleen E Willging
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA
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