county, county government, health, health care, network, public administration, governance, complexity, resource dependency, uninsured, underinsured, safety-net


Contemporary health care systems in the United States are not equitable. Indeed, as the literature indicates, there are substantial differences in the variety and scope of service delivery based on age, income, and other socio-economic indicators. The recent passage of health care reform in the United States illustrates that Americans are seeking to bring balance and equity to health care. However, as learned in this study, county governments across the country have been working in their communities to ensure some balance and equity, by making a safety net available for those citizens who are unable to access health care. Perhaps this is because health care quickly becomes a local government problem. In this current economic climate, county governments are being pinched between declining revenues and rising demands for services (Eaton, 2009; Phaup, 2009). The Orange County Primary Care Access Network is one example studied here that provides clear evidence of how organizations can work together to develop and maintain a sustainable health care safety net for the underinsured and uninsured. This study is the first of its kind to examine county government influences, environmental pressures, and community resources in the context of health care network performance. The methodological research question for this study is what determinants (exogenous constructs) contribute to a health care network and its performance (endogenous construct) within the framework of county government participation? Further, is the model supported by the data and can prediction, direction, and strength of relationships among the variables be identified? The simple answer is yes. For this study, the responses from 123 counties were analyzed with a variety of statistical techniques, culminating in structural equation modeling. The outcome of these analyses provided a reasonable explanation for the variation among the variables leading to network performance improvement in meeting the health care needs of uninsured and underinsured people. These quantitative data were also supported in their results with the inclusion of a case study analysis of a particular health care safety-net, the Orange County Primary Care Access Network in Orange County, Florida. Ultimately, this study learned three valuable lessons that can be used by county government decision-makers and health care providers alike. First, county involvement in community based health care networks results in a benefit that reverberates during economic stress- the leveraging of resources. Second, public-private initiatives are fundamental to reducing disparities in health care access. Third, health care networks improve access to health care for uninsured and underinsured people. Ultimately, county government participation is the largest predictor of network performance in this study.


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Graduation Date



Feldheim, Mary Ann


Doctor of Philosophy (Ph.D.)


College of Health and Public Affairs


Public Administration

Degree Program

Public Affairs








Release Date

August 2010

Length of Campus-only Access


Access Status

Doctoral Dissertation (Open Access)