What the Evolution of 1332 Waivers Tells Us about Their Innovative Potential.

Section 1332 of the Affordable Care Act (ACA) provides states unprecedented flexibility to alter federal health policy. The authors analyze state waiver activity from 2019 to 2023, applying a comparative approach to understand waivers proposed by Georgia, Colorado, Washington, Oregon, and Nevada. Much of the waiver activity during this period focused on reinsurance programs. During the Trump administration, the most innovative waiver application was from Georgia, which sought to restructure and decentralize its individual market, moving away from the framework established by the ACA. While the Biden administration suspended Georgia's efforts, Democratic-led states have focused implementing waiver programs supporting and expanding on the ACA. This has included adopting public-option insurance plans offered by private insurers and expanding eligibility for qualified health plans for previously ineligible groups. The authors' analysis offers insights into contemporary health politics, policy durability, and the role of the administrative presidency.

An Imperfect Space: Logistical Considerations in School-Based Health Centers.

BACKGROUND: From a range of perspectives, scholars have demonstrated the value of school-based health centers (SBHCs) in recent decades, but few studies have examined the logistics of establishing SBHCs. METHODS: Semi-structured interviews were conducted with 9 hospital and 6 school employees involved in a network of SBHCs. After common themes were identified, cluster analysis was performed. Finally, quotes were identified within each thematic cluster for further qualitative analysis. RESULTS: The most prominent themes were (1) differences in physical space (between schools and clinical settings), (2) collaboration and communication, and (3) privacy and compliance. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: This study points to several high yield considerations for the practice of SBHCs. First, we identified three distinct needs: (1) clear funding streams for construction costs for health services on school grounds, (2) improved understanding of SBHC space needs, and (3) blueprints for collaborating within SBHCs. Second, this study points to a future in which new-build and renovated schools should include space for SBHCs. CONCLUSIONS: This qualitative thematic analysis provides a picture of health and educational professionals engaged in creative, collaborative, and adaptive work to meet children's health care needs within SBHCs, but also highlights the challenges of navigating physical space, compliance, and collaboration within SBHCs.

Social Determinants of Health as a Lens for Understanding Local News Reporting.

While scholars have long examined media bias, few studies have systematically examined how media represents health within American urban neighborhoods. Drawing on a qualitative analysis of 10 years of news articles of one Ohio neighborhood, the authors apply a social determinants of health (SDOH) lens to the coverage of one urban newspaper. The study's aim is to understand what a SDOH approach might tell us about local and ongoing coverage of historically challenged neighborhoods. Findings reinforce those of previous studies from health communication and media studies which document a disproportionate emphasis on crime, but also push the conversation further to show how the health aspects of housing and food instability, unemployment, and non-crime safety concerns, are often elided in news coverage. The authors argue that the SDOH lens affords journalists a framework for ensuring that their reporting adequately captures the drivers of poor health in American urban neighborhoods.

Building trust in American hospital-community development projects: a scoping review.

Although it has become increasingly common for hospitals to engage in development projects aimed at improving the social determinants of health in surrounding communities, scholarly literature examining the establishment of trust between hospitals and communities is sparse. Because of an extensive and complex history of abuse suffered by marginalized populations at the hands of medical institutions, trust building is critical to the pursuit of equitable health outcomes in these communities. A scoping review was conducted to assess the current base of knowledge for building trust between hospital systems and community members. The review identified only 13 relevant articles addressing this topic, centered on six key themes: with whom to form partnerships; how to form partnerships; conceptualizing and defining trust; questions about investment and hiring; effective communication with communities; and, understanding communities.

Primary Care in Cuba: Considerations for the U.S.

In 2017, we traveled to Cuba to learn about the nation's approach to health care. Despite being a developing nation, Cuba boasts health care indicators that are comparable to those of the United States and other developed nations. Emphasizing prevention and proactive care, the Cuban health care system provides lessons to inform future U.S. health care reform efforts in order to contain medical costs while providing quality care. Visiting with Cuban health care professionals over the course of eight days, and interviewing American physicians who were trained in Cuba but practice in the U.S., this paper provides an overview of key differences in primary health care in Cuba and primary care practice in the U.S. Our work has three main themes: how Cuban medicine approaches primary health care, the importance of medical curriculum in establishing these priorities, and the prioritization of the clinical encounter over technologically-advanced interventions.

Should Hospital Emergency Departments Be Used as Revenue Streams Despite Needs to Curb Overutilization?

This case asks how a hospital should balance patients' health needs with its financial bottom line regarding emergency department utilization. Should hospitals engage in proactive population health initiatives if they result in decreased revenue from their emergency departments? Which values should guide their thinking about this question? Drawing upon emerging legal and moral consensus about hospitals' obligations to their surrounding communities, this commentary argues that treating emergency departments purely as revenue streams violates both legal and moral standards.

Hospitals and substance use disorder services in the time of the opioid epidemic.

OBJECTIVE: To test whether the opioid epidemic increased hospitals' offerings of substance use services. DATA SOURCES/STUDY SETTING: This study employs data from the 2010 and 2015 American Hospital Association Annual Survey. STUDY DESIGN: A multilevel, cross-sectional design was utilized to examine associations between county-level overdose rates and hospital substance use services. DATA COLLECTION/EXTRACTION METHODS: The analytic sample consisted of 3365 acute care hospitals that answered pertinent survey questions. PRINCIPAL FINDINGS: In 2010, 334 hospitals offered inpatient opioid services and 588 hospitals offered outpatient services, compared to 327 and 577, respectively, in 2015, indicating that more hospitals dropped services than added them as overdose rates increased. Factors other than growing need weigh more heavily in hospitals' determination to offer substance use services, including resources, mission, and the presence of psychiatric facilities within their communities. Importantly, hospitals that employ medical home models had greater odds of offering outpatient substance abuse services in 2015 OR, 95 percent CI (1.54; 1.23-1.93; P < 0.0001). CONCLUSIONS: Hospitals are either not willing or equipped to increase substance use services in response to growing need.

Why Don't Hospitals Prioritize Substance Abuse in Their Community Benefit Programming?

The goal of this study was to understand whether Appalachian Ohio hospitals prioritized substance abuse in their IRS-mandated community health needs assessments (CHNAs) and if not, what factors were important in this decision. Analysis of CHNA reports from all 28 hospitals in the region supplemented interview data from in-depth phone interviews, with 17 participants tasked with overseeing CHNAs at 21 hospitals. The CHNA reports show that hospitals in this region prioritize substance abuse and mental health less often than access to care and obesity. Interviews suggest 4 reasons: lack of resources, risk aversion, concern about hospital expertise, and stigma related to substance abuse. Hospitals are playing a larger role in public health as a result of CHNA requirements but resist taking on challenging problems such as substance abuse. The report concludes by summarizing concrete steps to ensure that community benefit efforts address pressing health problems. The implications of this study are manifest in concrete recommendations for encouraging hospitals to address pressing health problems in their community benefit efforts.

How U.S. children's hospitals define population health: a qualitative, interview-based study.

BACKGROUND: The literature suggests that although adult hospitals are establishing population health programs around the country, there is considerable definitional ambiguity regarding whether interventions are aimed at the social determinants of health or the management of existing patient populations. U.S. children's hospitals also undertake population health programs, but less is known about how they define population health. The purpose of this study is to understand how U.S. children's hospitals define population health, and how institutions are adjusting to new preventive health care models. METHODS: We conducted semi-structured interviews with key stakeholders at ten hospitals with the highest amount of staff time dedicated to population health activities as reported in the 2016 Children's Hospital Association's population health survey. Using a semi-structured interview guide, we interviewed representatives from each hospital. Verbatim interview notes were coded and analyzed using the data analysis software Dedoose. Data analysis followed a modified constructivist grounded theory approach. RESULTS: Our results suggest that even population health innovators employ a variety of approaches that span both population health management and public health. We present further evidence that U.S. children's hospitals are actively debating the definition and focus of population health. CONCLUSIONS: Definitional debates are ongoing even within children's hospitals that are dedicating significant resources to population health. Increased clarity on the conceptual boundaries between population health and population health management could help preserve the theoretical differences between the two concepts, especially insofar as they mark two quite different long-term visions for health care. Without agreement about the meaning of population health within and among institutions, hospitals will not be able to know whether projects aimed at addressing the social determinants of health are likely to improve the health of populations.

What Challenges Do Nonprofit Hospitals Face in Taking on Community Health Needs Assessments? A Qualitative Study From Appalachian Ohio.

PURPOSE: The purpose of this study is to understand the experiences of Appalachian hospitals in undertaking Community Health Needs Assessments (CHNAs). Of particular interest is whether new requirements to undertake regular evaluation and public health programming pose challenges for rural, Appalachian hospitals. METHODS: Using a sample of nonprofit hospitals in Appalachian Ohio, we conducted in-depth qualitative interviews with hospital administrators overseeing community benefit activities and external consultants hired to complete assessments. Following a grounded theory approach, we coded interviews to ascertain major themes. FINDINGS: Our findings suggest that there are several challenges faced by nonprofit hospitals that may relate to their status as rural hospitals. In particular, we found that these hospitals struggle to hire staff to oversee CHNAs, often lack the material resources to address needs identified in reports, and seek more concrete guidelines from the IRS on carrying out these new activities in their communities. CONCLUSIONS: The results from these interviews suggest that there is significant support for new CHNA activities in Appalachian Ohio, but challenges remain to translate these efforts into improved health outcomes in this region. Because rural Appalachia, in particular, faces significant health disparities and a relative lack of health care providers, there is a potential for hospitals to take on an important role in public and preventive health if initial challenges are addressed.

Assessment of acquired mucociliary clearance defects using micro-optical coherence tomography.

BACKGROUND: Dehydration of airway surface liquid (ASL) disrupts normal mucociliary clearance (MCC) in sinonasal epithelium, which may lead to chronic rhinosinusitis (CRS). Abnormal chloride (Cl- ) transport is one such mechanism that contributes to this disorder and can be acquired secondary to environmental perturbations, such as hypoxia at the tissue surface. The objective of this study was to assess the technological feasibility of the novel micro-optical coherence tomography (µOCT) imaging technique for investigating acquired MCC defects in cultured human sinonasal epithelial (HSNE) cells. METHODS: Primary HSNE cell cultures were subjected to a 1% oxygen environment for 12 hours to induce acquired cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. Ion transport characteristics were assessed with pharmacologic manipulation in Ussing chambers. ASL, periciliary fluid (PCL), and ciliary beat frequency (CBF) were evaluated using µOCT. RESULTS: Amiloride-sensitive transport (ΔISC ) was greater in cultures exposed to hypoxia (hypoxia: -13.2 ± 0.6 µA/cm2 ; control: -6.5 ± 0.1 µA/cm2 ; p < 0.01), whereas CFTR-mediated anion transport was significantly diminished (hypoxia: 28.6 ± 0.3 µA/cm2 ; control: 36.2 ± 1.6 µA/cm2 ; p < 0.01), consistent with acquired CFTR dysfunction and sodium hyperabsorption. Hypoxia diminished all markers of airway surface function microanatomy as observed with µOCT, including ASL (hypoxia: 5.0 ± 0.4 µm; control: 9.0 ± 0.9 µm; p < 0.01) and PCL depth (hypoxia: 2.5 ± 0.1 µm; control: 4.8 ± 0.3 µm; p < 0.01), and CBF (hypoxia: 8.7 ± 0.3 Hz; control: 10.2 ± 0.3 Hz; p < 0.01). CONCLUSION: Hypoxia-induced defects in epithelial anion transport in HSNE led to predictable effects on markers of MCC measured with novel µOCT imaging. This imaging method represents a technological leap forward and is feasible for assessing acquired defects impacting the airway surface.

The impact of the Affordable Care Act on hospital-led community health evaluation in the U.S. Appalachian Ohio region.

In recent years, policy developments in the United States have dramatically changed how nonprofit hospitals interact with surrounding communities. However, despite the importance of these changes encoded in Internal Revenue Service regulations, little is known about how these requirements have affected how nonprofit hospitals are approaching community health evaluation. We present qualitative findings from interviews with hospital employees and consultants overseeing preliminary rounds of community health needs assessments, as required by the Affordable Care Act. The sample comes from the Appalachian region of Ohio, an area targeted because of significant health challenges. Our findings suggest that the Affordable Care Act has led hospitals to formalize their processes, focus on developing an evidence base, cultivate local partnerships, and reflect on the role of the hospital in public health.

Where do uncertainties reside within environmental risk assessments? Testing UnISERA, a guide for uncertainty assessment.

A means for identifying and prioritising the treatment of uncertainty (UnISERA) in environmental risk assessments (ERAs) is tested, using three risk domains where ERA is an established requirement and one in which ERA practice is emerging. UnISERA's development draws on 19 expert elicitations across genetically modified higher plants, particulate matter, and agricultural pesticide release and is stress tested here for engineered nanomaterials (ENM). We are concerned with the severity of uncertainty; its nature; and its location across four accepted stages of ERAs. Using an established uncertainty scale, the risk characterisation stage of ERA harbours the highest severity level of uncertainty, associated with estimating, aggregating and evaluating expressions of risk. Combined epistemic and aleatory uncertainty is the dominant nature of uncertainty. The dominant location of uncertainty is associated with data in problem formulation, exposure assessment and effects assessment. Testing UnISERA produced agreements of 55%, 90%, and 80% for the severity level, nature and location dimensions of uncertainty between the combined case studies and the ENM stress test. UnISERA enables environmental risk analysts to prioritise risk assessment phases, groups of tasks, or individual ERA tasks and it can direct them towards established methods for uncertainty treatment.

A Qualitative, Interview-Based Study of the Health Policy Fellowship's Osteopathic Identity.

CONTEXT: Since 1993, the Health Policy Fellowship (HPF) has trained osteopathic professionals in health policy and leadership. Although almost 250 fellows have graduated from the program, many of whom have assumed leadership roles within the osteopathic medical profession, the HPF has, to the authors' knowledge, never been subjected to scholarly analysis. OBJECTIVE: To understand the HPF's professional significance as a health policy and leadership training program that has enrolled mostly osteopathic physicians. METHODS: Semistructured interviews were conducted with graduates supplemented by interviews with other professionals involved with the HPF. Using an inductive grounded theory approach, we coded interviews for major themes. RESULTS: Forty-three interviews were conducted, 38 of which were with graduates of the program and 5 of which were with HPF staff. The data suggest that although the content of the HPF is applicable to all medical professionals, the program's language and structure are designed to accommodate specific needs of osteopathic professionals. Specifically, the language of the fellowship emphasizes the "high ground" (considering multiple perspectives on an issue), and the structure of the fellowship allows fellows to continue in their jobs but travel to several COMs and to Washington, DC, throughout the year. CONCLUSION: Closer examination of the HPF helped convey the relevance of this program, and perhaps programs like it, for a minority medical profession still finding its voice within the policy climate of US health care.

When Hospitals Join the Community: Practical Considerations and Ethical Frameworks.

Written from the perspective of hospitals, this article examines, in theory and in practice, challenges associated with hospitals' efforts to engage in neighborhood development more fully with the communities that neighbor them. Increasingly, these efforts include significant investments in housing, safety, and educational initiatives. These investments stretch the traditional expertise of medical practitioners and administrators and raise ethical and political questions about how best to engage and work with communities. After first describing the contexts within which hospital-community relationships arise, we examine ethical and political considerations likely to bear on the success of these projects. We conclude with recommendations to hospitals for operating within communities in a way that is consistent with hospitals' ethical commitments.

Evangelical Protestants and the ACA: An Opening for Community-Based Primary Care?

Evangelical Protestants make up the largest religious subgroup in the United States, and previous research has shown that Evangelical churches are disproportionately active in community engagement and efforts toward social change. Although Evangelical Protestant perspectives have been considered with regard to persistent socioeconomic stratification and racial discrimination, less focus has been given to how churches interpret poor health outcomes within the United States. In particular, this research addresses how enduring health disparities are understood within the larger discussion of healthcare reform. Due to the similarity of approaches favored by participants in this study and community-based philosophy, a suggestion is made for future health policy dialogue. Although Evangelical Protestants have been most likely to reject all aspects of the Affordable Care Act, in many ways the findings of this study suggest the potential for successful future health policy collaboration. In particular, community-based primary care might appeal to Evangelicals and health professionals in the ongoing effort to improve population health and the quality of healthcare in the United States.

Maximizing the Patient-Centered Medical Home (PCMH) by Choosing Words Wisely.

BACKGROUND: Culture is transmitted through language and reflects a group's values, yet much of the current language used to describe the new patient-centered medical home (PCMH) is a carryover from the traditional, physician-centric model of care. This language creates a subtle yet powerful force that can perpetuate the status quo, despite transformation efforts. This article describes new terminology that some innovative primary care practices are using to support the transformational culture of the PCMH. METHODS: Data come from the Agency for Healthcare Research and Quality-funded Working Conference for PCMH Innovation 2013, which convened 10 innovative practices and interdisciplinary content experts to discuss innovative practice redesign. Session and interview transcripts were analyzed using a grounded theory approach to identify patterns and explore their significance. RESULTS: Language innovations are used by 5 practices. Carefully selected terms facilitate creative reimagining of traditional roles and spaces through connotations that highlight practice goals. Participants felt that the language used was important for reinforcing substantive changes. CONCLUSIONS: Reworking well-established vernacular requires openness to change. True transformation does not, however, occur through a simple relabeling of old concepts. New terminology must represent values to which practices genuinely aspire, although caution is advised when using language to support cultural and clinical change.

The Politics of Native American Health Care and the Affordable Care Act.

This article examines an important but largely overlooked dimension of the Patient Protection and Affordable Care Act (ACA), namely, its significance for Native American health care. The author maintains that reading the ACA against the politics of Native American health care policy shows that, depending on their regional needs and particular contexts, many Native Americans are well-placed to benefit from recent Obama-era reforms. At the same time, the kinds of options made available by the ACA constitute a departure from the service-based (as opposed to insurance-based) Indian Health Service (IHS). Accordingly, the author argues that ACA reforms--private marketplaces, Medicaid expansion, and accommodations for Native Americans--are best read as potential "supplements" to an underfunded IHS. Whether or not Native Americans opt to explore options under the ACA will depend in the long run on the quality of the IHS in the post-ACA era. Beyond understanding the ACA in relation to IHS funding, the author explores how Native American politics interacts with the key tenets of Obama-era health care reform--especially "affordability"--which is critical for understanding what is required from and appropriate to future Native American health care policy making.

Medicaid in Ohio: The Politics of Expansion, Reauthorization, and Reform.

When, in 2012, the US Supreme Court held that Medicaid expansion sanctioned by the Affordable Care Act (ACA) was essentially optional for states, it ushered in a newly contentious state politics. States led by Republican governors and legislatures opposed to the ACA had to decide whether to accept extensive federal funding to expand Medicaid for citizens in their states who were earning up to 138 percent of the federal poverty level. This Report from the States focuses on Ohio, whose Republican governor successfully navigated the rancorous politics of Medicaid to expand the state's program in 2014. Working at odds with his own party and gaining praise from traditional political opponents for his leadership on the issue, John Kasich circumvented the state legislature, turning to the Controlling Board to bring about initial expansion. In the wake of Kasich's landslide reelection in 2014, the politics of expansion and reauthorization have given way to a pervasive discourse of "reform." In this next phase Kasich has endorsed policy positions (e.g., cost sharing, a focus on "personal responsibility") that reunite him with his party's more traditional view of Medicaid while continuing to emphasize the importance of expansion.

Osteopathic medical students' understanding of the Patient Protection and Affordable Care Act: a first step toward a policy-informed curriculum.

CONTEXT: Current osteopathic medical students will play an important role in implementing, modifying, and advocating for or against the Patient Protection and Affordable Care Act (ACA) of 2010. Accordingly, medical educators will need to address curricular gaps specific to the ACA and medical practice. Research that gauges osteopathic medical students' level of understanding of the ACA is needed to inform an evidence-based curriculum. OBJECTIVE: To assess first- and second-year osteopathic medical students' beliefs about the ACA. METHODS: In this descriptive cross-sectional survey-based study, first- and second-year students were recruited because their responses would be indicative of what, if any, information about the ACA was being covered in the preclinical curriculum. A 30-item survey was distributed in November 2013, after the health insurance exchanges launched on October 1, 2013. RESULTS: A total of 239 first- and second-year osteopathic medical students completed the survey. One hundred ten students (46%) disagreed and 103 (43.1%) agreed that the ACA would provide health insurance coverage for all US citizens. The ACA was predicted to lead to lower wages and fewer jobs (73 students [30.5%]), as well as small business bankruptcy because of employees' health insurance costs (96 [40.2%]). Regarding Medicare recipients, 113 students (47.3%) did not know whether these individuals would be required to buy insurance through the health insurance exchanges. The majority of students knew that the ACA would require US citizens to pay a penalty if they did not have health insurance (198 [82.8%]) and understood that not everyone would be required to purchase health insurance through health insurance exchanges (137 [57.3%]). Although students took note of certain clinical benefits for patients offered by the ACA, they remained concerned about the ACA's impact on their professional prospects, particularly in the area of primary care. CONCLUSION: These findings build on the existing literature that emphasize the need for incorporating into the osteopathic medical curriculum knowledge of the dynamics of health care policy and reform and for creating opportunities for students to follow health policy developments as they evolve in real time.