Long-Term Care Reforms Live On With Court Ruling

The Affordable Care Act 10 Years In: What Nursing Leaders Should Know

The Patient Protection and Affordable Care Act (PPACA) created dramatic changes in the healthcare payment and delivery systems in the United States. Widely hailed as the largest restructuring of healthcare delivery since the Johnson administration, the PPACA has been reshaping the American healthcare landscape since 2010. While much of the discussion surrounds the original contents of the bill, it is important to consider the changes in the legislation since its enactment 3 years ago. Although these changes can easily be interpreted through a partisan lens, it is critical to consider the evolution of the PPACA as objectively as possible, in order to better understand the potential impact of shifts in policy. The following discussion will attempt to (1) describe the three major changes in the PPACA since its passage in 2010; and (2) reflect on the implications for the overall American healthcare system and orthopaedic surgeons.

Holding on to a huge victory for American health

Arguments in Texas raise questions about the ACA's fate as enrollment holds steady and new state reinsurance waivers are approved.

Pragmatic Trials and Improving Long-Term Care: Recommendations From a National Institutes of Health Conference.

THE EXPERIENCES OF THE “M” FAMILY DESCRIBED BY Ritchie et al in this issue of JAMA are the topic of conversations among many baby boomers coping with aging parents who can no longer manage to live on their own. Although assisted living facilities or continuing care retirement communities are attractive options for individuals who recognize that they are slowing down, such options are paid for out of pocket; those who cannot afford them can either receive unpaid help from family or friends, pay for in-home care of which only a portion may be covered by insurance, or enter a nursing home and spend down to Medicaid—at great cost to the government and taxpayers. Encouraging aging adults to remain in their homes or live with their families would seem desirable from an individual and societal perspective. However, as Ritchie et al explain, the emotional, physical, social, and financial costs of caring for older parents can be high. Many of these costs occur whether the aging parents move in with the adult children or the children supervise care provided elsewhere. The financial costs in particular can be staggering, adding to the emotional stresses of both the parent and the adult child. However, only a small share of elders have high costs. In the United States, for example, 69% of those who live to age 65 years are estimated to need some type of long-term care assistance before they die. Most use only informal, but often substantial, care provided by their relatives and friends. However, while average lifetime long-term care expenditures (excluding informal care) of the individuals who live to age 65 years are projected to be $47 000 (in 2005 dollars), 16% of these individuals will have more than $100 000 (in 2005 dollars) of lifetime expenditures. These individuals receiving high-cost care are especially likely to be in nursing homes for more than 2 years; the average annual cost of nursing home care in 2006 was $72 000. Medicaid pays for more than 40% of all longterm expenditures, but individuals pay for 22% directly, in many cases exhausting their savings and then qualifying for Medicaid. In England, roughly 10% of people at age 65 years are estimated to have lifetime care expenditures of more than £100 000 (equivalent to about $160 000 in July 2011). The wide variation in need for long-term care assistance and the skewed distribution of expenditures (with only a small share of people paying very high costs) show why the financial risk is small but nontrivial. A private insurance market might be expected to thrive in such a situation. Yet it does not—in the United States or any of the other industrialized countries. The primary explanation is that there is great uncertainty surrounding who exactly will need expensive assistance and what those costs will be 20 or 30 years from now. The US Community Living Assistance Services and Supports (CLASS) plan, a voluntary, publicly administered insurance program established by the Affordable Care Act of 2010, was expected to help address this issue, but it appears unlikely to survive US efforts to reduce the budget deficit. With more baby boomers becoming aware of the needs and potentially high costs of family elder care, how to care for the 19% of Americans who by 2030 will be 65 years old and older could be a major focus of the national health care debate. Other industrialized countries have been having such debates for the past 2 decades—in part because higher shares of their population were already aged 64 years or older. For instance, in 2010, more than 20% of the individuals in Japan, Germany, and Italy were aged 65 years and older, as were more than 15% in Sweden, England, Spain, France, and the Netherlands—in the United States that proportion was 13%. These countries are wrestling with the same issues as families in the United States—how to provide quality care to elderly individuals who need assistance with activities of daily living (ADLs) while not impoverishing them and their families. Many countries address the risk of costly longterm care with a social insurance program or a program funded through general revenues to pay for care assistance. The Scandinavian countries rely on taxes raised at the national and local levels; the Netherlands, Germany, and Japan have social insurance programs with mandatory participation. Although the Scandinavian countries have had long-term care assistance programs in place since the 1960s (Sweden since the late 1940s), the programs in the Netherlands, Germany, Spain, and other countries have been implemented only since 1994.

US health reform still faces challenges

Republican presidential candidates united on health care

The Uncertain Future of Nursing Home Post-Acute Care.

With the full implementation of the Affordable Care Act (ACA), January 1, 2014 was supposed to be a day of triumph when millions of Americans would newly have access to health insurance, says Timothy Jost, Washington and Lee University professor of law and Health Affairs Contributing Editor, in the Entry Point feature of the January Health Affairs issue. But with reports of “cancellation” notices, technical failures of the health insurance exchanges, and lack of Medicaid expansion in some states (to name a few setbacks), the new year doesn't appear to have brought the triumph envisioned, Jost writes. Jost points out challenges that existed from the beginning. Instead of creating an entirely new health care financing system, as Medicare and Medicaid had done in the 1960s, the ACA attempted to build on the current system… [The ACA is] heavily dependent on state buy-in, as it retains traditional state administration of the Medicaid program and management of insurance markets. States were asked to expand Medicaid programs dramatically, establish insurance exchanges, and substantially change their insurance regulations. In addition, the ACA depended on cooperation from small and large employers and federal departments as well as bipartisanship in Congress, Jost explains. Looking back to 2010, Jost, who has authored an extensive series of Health Affairs Blog posts chronicling ACA implementation, examines the long series of problems that have undermined ACA implementation, including midterm elections that gave Republicans control of the House. One fundamental challenge was the Supreme Court’s decision that upheld the individual mandate as a tax but "badly undermined the ACA’s coverage expansions by allowing states to opt out of the Medicaid expansion... leaving 11.5 million Americans uninsured.” On October 1, 2013, the first day of the government shutdown, the online federal Marketplace launched only to crash immediately. It took months to resolve some of the new system’s technical difficulties.

Patient-Centered Outcomes Research: Early Evidence From A Burgeoning Field.

The U.S. presidential election of 2016 accentuated the divided perspectives on the Patient Protection and Affordable Care Act of 2010, commonly known as Obamacare. The perspectives included a pledge from then candidate Donald J. Trump to "repeal and replace on day one"; Republican congressional leaders' more temperate suggestions in the first weeks of the Trump administration to "repair" the Affordable Care Act (ACA); and President Trump's February 5, 2017 statement-16 days after inauguration-that a Republican replacement for the ACA may not be ready until late 2017 or 2018. The swirling rhetoric, media attention, and the dizzying rate of U.S. health and payment reforms both within and outside of the ACA makes it difficult for nurses, both United States and globally, to discern which health policy issues are grounded in the ACA and which aspects reflect payer-driven "volume to value" reimbursement changes. Moreover, popular and controversial elements of the ACA-for example, the clause that prohibits insurance carriers to deny coverage to those with preexisting health conditions and the more controversial individual mandate that bears Supreme Court support as a constitutional provision-are paired in ways that might be unclear to those unfamiliar with nuances of insurance rate determination. To support nurses' capacity to maximize their impact on health policy, this overview distills the 906-page ACA into major themes and describes payment reform legislation and initiatives that are external to the ACA. Understanding the political and societal forces that affect health care policy and delivery is necessary for nurses to effectively lead and advocate for the best interests of their patients.

Comments on Mark Seidenfeld’s “Revisiting Congressional Delegation of Interpretive Primacy as Foundation for <i>Chevron</i> Deference”

Background The Avon Breast Health Outreach Program (BHOP) supports community-based organizations to conduct education and outreach to link low-income and uninsured women to routine breast cancer screening and care. Through the Affordable Care Act (ACA), the number of uninsured individuals is expected to decrease as of 2014. While ACA implementation varies by state, BHOP grantees may benefit from understanding the health reform experience in Massachusetts (MA) in 2006 and its impact on the number and proportion of uninsured clients served over time. Objective Describe changes in client volume, health insurance status, and demographics following implementation of health reform in MA to anticipate upcoming impact of ACA on BHOP grantees. Methods Confidential client intake records of continuously funded BHOP grantees from 2004-2012 were analyzed; dataset included females aged 40-64, recruited for breast cancer screening. We compared records for 11,199 clients served by 4 ‘MA’ BHOP programs with 283,720 clients served by 52 ‘control’ agencies funded in the US during the same time period. We examined trends across years in agency-specific rates of health insurance coverage, and client volume adjusting for annual funding. Changes in key demographic characteristics over time were also analyzed. Results The proportion of uninsured MA clients decreased dramatically from 46.6% to 6.2% from 2004-2012, with the biggest decrease occurring in the 3 years following health reform (42.1% to 13.0% from 2006-2009); as compared to only a slight drop among controls from 2004-2012 (69.3% to 67.4%). After adjusting for changes in annual BHOP funding, MA experienced a 74% increase in client volume from 2006-2009, compared with a 15% increase among controls. From 2004-2012, the mean age of clients (53 years) remained stable and similar for MA and controls. The proportion of racial/ethnic minorities served increased considerably in MA, from 62.0% to 77.7%, versus a smaller increase of 60.1% to 63.0% in controls. Likewise, the proportion of clients born outside the US rose from 37.2% to 50.7% in MA, compared with 33.7% to 36.6% among controls. However, the proportion of low-income clients (annual household income &amp;lt;$25,000) decreased overall from 90.4% to 83.1% in MA, and from 83.1% to 79.1% for controls. Conclusion In BHOP, Massachusetts observed a marked decrease (most noticeably in the 3 years following health reform) in the proportion of uninsured clients served, while overall client volume and the proportion of racial/ethnic minorities and foreign-born women increased. Discussion Historically, many BHOP grantees have relied on funding from the CDC’s National Breast and Cervical Cancer Early Detection Program or charity funds to pay for screening services for uninsured clients. As more clients nationally gain access to health insurance, BHOP grantees need to be prepared for the changing landscape and potential increase in client volume, as experienced by MA. Additionally, grantees should plan to update systems that aid in health insurance eligibility determination, assist with enrollment, and strengthen provider partnerships and referral systems that accept multiple types of insurance. Citation Format: Lindsay Senter, Marvin R Aliaga, Yixin Hu, Kelly Morrison Opdyke, Kathryn Gates-Ferris, Marc Hurlbert. Anticipating ACA's impact on breast cancer screening for medically underserved women reached through the Avon Breast Health Outreach Program: Understanding the Massachusetts experience [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-17-01.

Large increases in the need for long-term care (LTC) services are expected as baby boomers age. Little has been published about patient and caregiver preferences for information about LTC. However, our qualitative research findings suggest that potential consumers may find it difficult to obtain accurate and timely information about LTC programs and services. In-person, semistructured interviews were conducted with 47 subjects, including patients (n = 25) within 90 days of their referral to a LTC placement (including NH, assisted living, home care, and community) and their caregivers (n = 22). Interview questions addressed the events that seemed to trigger their need for a LTC referral, the resources they used to become more informed about LTC options and the issues they confronted with the LTC referral process. Qualitative analyses identified a number of patient and informal caregiver-reported barriers to making decisions about LTC services, including insufficient information about LTC programs and community resources, unclear funding requirements and inadequate funding, and difficulty knowing how to plan for LTC or make LTC decisions. A potential solution may be an online LTC Guide designed to provide accurate information about the range of LTC services, with an emphasis on home and community-based services. This Guide was developed to address the gap in comprehensive LTC information identified in the findings of this study.