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Introduction
Finite resources are a reality for programs that provide access to healthcare, whether government-run, private insurance, or community-based safety net programs. Within the scope of those finite resources and informed by their hierarchy of values, policymakers must make a variety of allocation decisions, including who can be served and with what level of service. These resource allocation and policy decisions affect access to care for all people through costs for members and breadth of coverage. A variety of factors influence resource allocation and priority-setting decisions in healthcare, including economic factors and values – principles or judgments of what is important in life (Ahn et al., 2012; Docherty et al., 2012; Keren and Littlejohns, 2012; Kieslich, 2012; Littlejohns et al., 2012; Maluka, 2011). In healthcare organizations, values are often codified in a mission statement, but the extent to which allocation decisions shaping healthcare services are consistent with those stated organizational values remains unclear.
This project aimed to describe resource allocation and policy decisions affecting access to care for the uninsured in the USA and to examine the relationship between organizational values and those decisions. Community access programs (CAPs) served as an interesting laboratory to examine these questions because CAPs shared characteristics of health provider organizations, public health organizations, and insurance companies. They provided an accessible forum to examine the understudied relationship between values and decisions. A focus on practical implementation of decision making and the factors affecting them will allow future work to avoid making unrealistic behavioral assumptions about how program managers make important decisions. Additionally, the description of how healthcare decisions are actually made can be matched with literature that describes how healthcare resource decisions ought to be made (Clark and Weale, 2012; Daniels and Sabin, 2002; Gibson et al., 2004; Oddo, 2001; Slosar, 2004) in order to provide a normative grounding for future decisions.
Background
CAPs were a part of the safety net health system in nearly every state across the USA at the time data were collected for this project, which occurred between the passage and implementation of the Affordable Care Act (ACA) that aimed to reform the US healthcare system to dramatically reduce the number of uninsured individuals (Blewett et al., 2008). In absence of federal...