US health reform still faces challenges

Holding on to a huge victory for American health

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

EPA-1438 – USA Health System Performance

Long-Term Care Reforms Live On With Court Ruling

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

Back to table of contents Previous article Next article Government NewsFull AccessStates Receive Guidance on Health-Reform WaiversRichard FaustRichard FaustSearch for more papers by this authorPublished Online:15 Apr 2011https://doi.org/10.1176/pn.46.8.psychnews_46_08_10_1AbstractIn March the departments of Health and Human Services (HHS) and Education issued a proposed rule for states applying for waivers from provisions of the Affordable Care Act (ACA). In addition, President Obama has announced his support for bipartisan legislation that would move the timeline for availability of state waivers from 2017 to 2014. In January's State of the Union Address, the president stressed that he was open to new ideas for improving the health care reform law. Echoing this commitment, HHS Secretary Kathleen Sebelius stated in a press release announcing the new rule that "Innovation Waivers empower states to take the lead on implementing the Affordable Care Act." The waivers are designed to give states the latitude to implement their own health care policies, which may differ from those in the ACA as long as they meet specified criteria. The press release lays out the criteria contained in the proposed rule, requiring states to provide coverage that meet these requirements: It must be at least as comprehensive as that offered through health insurance exchanges—new competitive, private health insurance marketplaces. It must be at least as affordable as the cost-sharing protect ions through the exchanges.It must provide coverage to at least as many residents as otherwise would have been covered under the Affordable Care Act.It must not increase the federal deficit.An HHS fact sheet on the proposed rule notes that states receiving waivers would also be required to submit quarterly and annual reports tracking measures in the four areas listed above and that the regulations suggest areas for continued monitoring of the waivers, such as choice of health plans and coverage of individuals with preexisting conditions. The president has thrown his support behind a bipartisan bill to move the start date for implementation of state waivers from 2017 to 2014. The start date is important because many of the provisions of the ACA do not go into effect until 2014. If states can receive wavers at that time, they can continue with any innovations they already have in the works without stopping to switch to implementing the federal requirements. Sens. Ron Wyden (D-Ore.) and Scott Brown (R-Mass.) first introduced the Empowering States to Innovate Act last November. In a press release Wyden stated that "some of the most innovative approaches to health policy have originated at the local level, where lawmakers have a unique insight into their constituents' lives, and the state waiver simply gives states the bandwidth to pursue those kinds of approaches." Brown said that "states shouldn't be forced by the federal government to adopt a one-size-fits-all health care plan." Julie Clements, deputy director for regulatory affairs in APA's Department of Government Relations, stated that "we support the secretary's requirement that any innovative state programs substituting for Affordable Care Act provisions must still satisfy the ACA's goals of coverage, cost-sharing, and comprehensive benefits. These requirements preclude the waiver program from being a means to circumvent the goals of ACA regarding coverage, cost-sharing, and comprehensiveness." APA will likely submit brief comments to the Centers for Medicare and Medicaid Services reiterating support for the goals of ACA and the hope that states that "do innovate will go above and beyond the more positive aspects of the ACA and how it treats mental health." The comment period on the proposed rule is open until May 13.The proposed rule is listed in theFederal Register at <http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2011_register&docid=fr14mr11-23.pdf>. The Empowering States to Innovate Act is posted at <http://thomas.loc.gov/cgi-bin/query/z?c112:H.R.844:>. ISSUES NewArchived

For over four decades, Americans have enjoyed near universal access to treatment for ESRD irrespective of age, lack of qualifying disability, or their ability to pay. However, the health insurance benefits of the Medicare ESRD program do not extend to individuals in earlier stages of CKD, even to

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

The American Dream is a strongly held notion that permeates the American psyche. The subtext of the dream is the assumption of equal opportunity for education and the subsequent career opportunities that presumably follow. Assuming equality of opportunity (a large assumption indeed), potential success is based on individual talent and effort resulting in part in the development of the individualistic societal norms of the ‘self-made man,’ ‘every man for himself,’ and ‘rugged individualism’ ideologies that are predominant in the US today. The archetype of the American Dream is the “self-made man” who, through will and determination gains an education, career success, and material wealth exemplified by home ownership. Human rights language would refer to these as the right to education, work, property, and housing. US constitutional law strongly protects civil and political rights. US federal law has even come to protect some economic, social, and cultural rights such as education as part and parcel of the American Dream. Until the 2010 passage of the Patient Protection and Affordable Care Act (ACA), the right to health has for the most part been excluded from both the notion of the American Dream as well as protection under US federal law. This chapter provides an overview of the historical development of the American Dream, an examination of global health models, and the U.S. model more specifically. It also explores the ACA and the 2012 US Supreme Court ruling as it relates to the international conceptualization of the human right to health, specifically focusing on the human rights principles of accessibility and nondiscrimination and how the ACA may contribute to an expanded notion of the American Dream including the right to health.KeywordsAmerican dreamAffordable care act (ACA)USARight to healthRight to health careAccess to health careNondiscriminationVulnerable populationsHuman rights

The Affordable Care Act (ACA) required that each state set up a health insurance exchange or lose control to the federal government. Because Republicans had supported the concept before it became part of Obamacare, virtually every state was expected to cooperate and implement this core part of the law. However, 34 states refused to participate. This is a stunning miscalculation by the Obama administration. This book tells the story of what happened in the final two states to choose state control and the two that came the closest. The most intense split was not between Republicans and Democrats, but within the Republican Party. Governors were the most important people in the fight over exchanges, but did not always get their way. The Tea Party defeated the most powerful interest groups. State-level and national conservative think tanks were important allies to the Tea Party. The relative power of these groups was shaped by differences in institutional design and procedures, such as whether a state has term limits and the length of legislative sessions. Opposition was more easily overcome in states whose conditions facilitated the development of legislative “pockets of expertise.” This is a dramatic example of opponents using federalism to block national reform and serves as a warning of the challenge of inducing state cooperation in other policy domains such as the environment and education. Understanding the state-level fights over the ACA’s implementation is crucial to understanding the impact of future reforms.

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.

Hobby Lobby, a company that should be merely an individual’s DIY-dream, has become a lawyer’s conundrum. To be precise, this puzzle emerges from the United States Supreme Court (SCOTUS) holding in Burwell v. Hobby Lobby Stores (Hobby Lobby) that the contraceptive mandate in the Patient Protection and Affordable Care Act (ACA) violated the Religious Freedom Restoration Act of 1993 (RFRA) because it substantially burdens the religious beliefs of the three closely held corporations (CHCs) in the case. The Court thus placed Hobby Lobby Stores (Hobby Lobby), Mardel, and Conestoga Wood Specialty Corporation (Conestoga) at the intersection of two of the most thrilling social and legal debates of our times. Upon reading the Court’s decision, the lawyer — as well as the sensible hobby bricoleur — would wonder how far corporate “human” rights can and should go and whether such rights can and should be correlated to responsibilities. They would also consider a twisted variant of the separation of church and state question, and inquire to what extent the state should protect human rights from religious interference. The judgment has important implications for human rights, in particular by weakening the protection of reproductive and healthcare rights, and by posing possible threats to freedom from discrimination based on gender and sexual orientation. While the article engages with some of these consequences, its prime aim is to explore a more basic aspect: the type of entity which can hold and exercise religious views. It is this aspect which we identify as the source of potential socio-legal conflict in the United States. The analysis will compare SCOTUS’ reasoning on corporate form, profit-making objective, and limitations to religious exercise in Hobby Lobby to relevant jurisprudence of the European Convention on Human Rights (ECHR) mechanisms — the European Court of Human Rights (ECtHR) and the European Commission on Human Rights (EComHR). The comparative study therefore will allow us to provide answers to core questions: Whose right and who’s right? In other words, does a corporate right to exercise religion exist and is SCOTUS right in recognizing such protection for for-profit entities or is the ECtHR right in denying it. Looking for inspiration outside the realm of US case law may prove a delicate endeavor, given the different structure of the ECtHR (as a supra-national court overseeing forty-seven sovereign states), and the reticence of certain circles in the US to recognize any comparative value to be gained from foreign judgments. Despite these caveats, the parallel between the two jurisdictions should provide a fuller account of how the interpretations on corporate religious freedom differ, and avenues for alternative interpretation. In terms of structure, a first part of the article summarizes SCOTUS’ treatment in Hobby Lobby of for-profit corporations as ‘persons’ which can exercise freedom of religion under the RFRA, and identifies non-profit organizations with religious or philosophical objectives as exclusive corporate right-holders in the jurisprudence of the ECtHR. We proceed to discuss SCOTUS’ (mis)interpretation and neglect of the legal separation between shareholders and company and the standing requirement in US law, and draw on the insights gained from European practice to outline alternative ways. The second part of the article focuses on SCOTUS’ treatment of state limitations to corporate religious freedom in Hobby Lobby, and on the ECHR mechanisms’ practice of restricting manifestations of religion under the ECHR. The aim here is explore whether cross-fertilization presents potential to mitigate the shortcomings of the two jurisdictions in question. In the third part, the article will unearth some socio-legal consequences brought about by the findings in Hobby Lobby. At a general level, we argue that the exercise of religious freedom by for-profit corporations leads to social polarization, and specifically in relation to the contraceptive mandate in the ACA, we identify a number of societal groups which will disproportionally suffer from the judgment’s nocuous effects.

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.

Enactment of the Patient Protection and Affordable Care Act (ACA) created a dilemma for Republican policy makers at the state level. States could maximize control over decision making and avoid federal intervention by establishing their own health insurance exchanges. Yet GOP leaders feared that creating exchanges would entrench a law they intensely opposed and undermine legal challenges to the ACA. Republicans' calculations were further complicated by uncertainty over the Supreme Court's ruling on the ACA's constitutionality and the outcome of the November 2012 elections. In the first year of operation, only seventeen states and the District of Columbia chose to design and implement their own exchanges; another six partnered with the federal government, and twenty-seven states ceded control to Washington. Out of thirty states with Republican governors in 2013, only four launched their own exchange. Why did many Republican-led states that initially appeared open to establishing exchanges ultimately reverse course? Drawing on interviews with state policy makers and secondary data, we trace the evolution of Republican responses to the exchange dilemma during 2010-13. We explore how exchanges became controversial and explain why so few Republican-led states opted for their own exchange, focusing on the intensifying resistance to Obamacare amid a rightward shift in state politics, partisan polarization, and uncertainty over the ACA's fate.

The US Supreme Court agreed this week to decide whether President Barack Obama’s health reform act, passed in March 2010 ( BMJ 2010;340:c1635, doi:10.1136/bmj.c1635), is constitutional. Members of the Democratic...