Development of the Palliative Care Law and Policy GPS to Assess National Policies in Palliative Care.

Background: State policy-making to address disparities in access to and quality of palliative care is increasing. Yet, there is no mechanism to systematically assess palliative care policies nationally. Methods: We describe the development of the Palliative Care Law and Policy GPS by the Center to Advance Palliative Care and the Yale Solomon Center for Health Law and Policy. The GPS is an online, searchable repository of national palliative care policies. We developed the GPS by conducting a systematic search of Lexis+, LegiScan, and state health departments for palliative care-related statutes and proposed legislation, categorizing policies into workforce, payment, quality/standards, clinical skill-building, public awareness, telehealth, and pediatric palliative care, and creating an interactive website. Conclusions and Implications: The GPS is a critical tool that can advance palliative care research, practice, and policy. Next steps include the expansion of data from 2010 onward as well as gathering state-level regulations and partially automating search and updating functions.

The Mifepristone Case and the Legitimacy of the FDA.

This Viewpoint discusses a recent federal court decision that invaliated the Food and Drug Administration's (FDA) approval of mifepristone, a drug used to end pregnancies and manage miscarriage when used with misoprostol, and how that decision challenges the legitimacy and independence of the FDA.

Cost-Free Preventive Care Under the ACA Faces Legal Challenge.

This Viewpoint examines the recent decision by a federal district court that undercuts the Affordable Care Act's mandate for cost-free coverage of preventive services, including contraception, some vaccinations, many screenings, and preexposure prophylaxis for HIV, among others.

INTRODUCTION: Medical-Legal Partnerships: Equity, Evolution, and Evaluation.

The COVID-19 pandemic laid bare systemic inequities shaped by social determinants of health (SDoH). Public health agencies, legislators, health systems, and community organizations took notice, and there is currently unprecedented interest in identifying and implementing programs to address SDoH. This special issue focuses on the role of medical-legal partnerships (MLPs) in addressing SDoH and racial and social inequities, as well as the need to support these efforts with evidence-based research, data, and meaningful partnerships and funding.

The Synergy of Legal and Medical Palliative Care: Challenges and Opportunities in Palliative MLP and the Yale Experience.

Palliative care and medical-legal partnership are complementary disciplines dedicated to integrating care to treat the whole patient and intervening before a legal or medical issue is at a crisis point. In this paper, we discuss the founding and operations of the Yale Palliative Medical Legal Partnership, give examples of typical cases, explain special considerations in this area of law, and propose areas for further research.

Targeting Health-Related Social Risks in the Clinical Setting: New Policy Momentum and Practice Considerations.

The federal government is funding a sea change in health care by investing in interventions targeting social determinants of health, which are significant contributors to illness and health inequity. This funding power has encouraged states, professional and accreditation organizations, health care entities, and providers to focus heavily on social determinants. We examine how this shift in focus affects clinical practice in the fields of oncology and emergency medicine, and highlight potential areas of reform.

Understanding the Role of Law in Reducing Firearm Injury through Clinical Interventions.

Firearm injury in the United States is a public health crisis in which physicians are uniquely situated to intervene. However, their ability to mitigate harm is limited by a complex array of laws and regulations that shape their role in firearm injury prevention. This piece uses four clinical scenarios to illustrate how these laws and regulations impact physician practice, including patient counseling, injury reporting, and the use of court orders and involuntary holds. Unintended consequences on clinical practice of laws intended to reduce firearm injury are also discussed. Lessons drawn from these cases suggest that physicians require more nuanced education on this topic, and that policymakers should consult front-line healthcare providers when designing firearm policies.

Gun Violence in Court.

Litigation cannot solve a public health crisis. But litigation can be an effective complementary tool to regulation by increasing the salience of a public health issue, eliciting closely guarded information to move public opinion, and prompting legislative action. From tobacco to opioids, litigants have successfully turned to courts for monetary relief, to initiate systemic change, and to hold industry accountableFor years, litigators have been trying to push firearm suits into their own litigation moment. But litigation against the gun industry poses special challenges. Not only has the regulatory regime failed to prevent a public safety hazard, Congress has consistently underfunded and understaffed the relevant regulatory actors. And in 2005 it legislatively immunized the gun industry from suit with the Protection of Lawful Commerce in Arms Act (PLCAA).This paper surveys the field of litigation in response to gun violence, tracking the limited successes of victims and stakeholders suing the gun industry. We find that victories remain confined to individual actors and unlike high-impact public litigations in other areas, aggregate class actions and major public litigation led by state attorneys general are noticeably absent in the firearm context.

Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients.

Importance: Trauma is a leading cause of death and disability for patients of all ages, many of whom are also among the most likely to be uninsured. Passage of the Patient Protection and Affordable Care Act was intended to improve access to care through improvements in insurance. However, despite nationally reported changes in the payer mix of patients, the extent of the law's impact on insurance coverage among trauma patients is unknown, as is its success in improving trauma outcomes and promoting increased access to rehabilitation. Objective: To use rigorous quasi-experimental regression techniques to assess the extent of changes in insurance coverage, outcomes, and discharge to rehabilitation among adult trauma patients before and after Medicaid expansion and implementation of the remainder of the Patient Protection and Affordable Care Act. Design, Setting, and Participants: Quasi-experimental, difference-in-difference analysis assessed adult trauma patients aged 19 to 64 years in 5 Medicaid expansion (Colorado, Illinois, Minnesota, New Jersey, and New Mexico) and 4 nonexpansion (Florida, Nebraska, North Carolina, and Texas) states. Interventions/Exposure: Policy implementation in January 2014. Main Outcomes and Measures: Changes in insurance coverage, outcomes (mortality, morbidity, failure to rescue, and length of stay), and discharge to rehabilitation. Results: A total of 283 878 patients from Medicaid expansion states and 285 851 patients from nonexpansion states were included (mean age [SD], 41.9 [14.1] years; 206 698 [36.3%] women). Adults with injuries in expansion states experienced a 13.7 percentage point decline in uninsured individuals (95% CI, 14.1-13.3; baseline: 22.7%) after Medicaid expansion compared with nonexpansion states. This coincided with a 7.4 percentage point increase in discharge to rehabilitation (95% CI, 7.0-7.8; baseline: 14.7%) that persisted across inpatient rehabilitation facilities (4.5 percentage points), home health agencies (2.9 percentage points), and skilled nursing facilities (1.0 percentage points). There was also a 2.6 percentage point drop in failure to rescue and a 0.84-day increase in average length of stay. Rehabilitation changes were most pronounced among patients eligible for rehabilitation coverage under the 2-midnight (8.4 percentage points) and 60% (10.2 percentage points) Medicaid payment rules. Medicaid expansion increased rehabilitation access for patients with the most severe injuries and conditions requiring postdischarge care (eg, pelvic fracture). It mitigated race/ethnicity-, age-, and sex-based disparities in which patients use rehabilitation. Conclusions and relevance: This multistate assessment demonstrated significant changes in insurance coverage and discharge to rehabilitation among adult trauma patients that were greater in Medicaid expansion than nonexpansion states. By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and functional outcomes for more than 60 000 additional adult trauma patients nationally in expansion states.

Impact of Affordable Care Act Insurance Expansion on Pre-Hospital Access to Care: Changes in Adult Perforated Appendix Admission Rates after Medicaid Expansion and the Dependent Coverage Provision.

BACKGROUND: The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care. STUDY DESIGN: We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims. RESULTS: Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups. CONCLUSIONS: Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations.

Medical-Legal Partnership: Lessons from Five Diverse MLPs in New Haven, Connecticut.

This article examines five different Medical-Legal Partnerships (MLPs) associated with Yale Law School in New Haven, Connecticut to illustrate how MLP addresses the social determinants of poor health. These MLPs address varied and distinct health and legal needs of unique patient populations, including: 1) children; 2) immigrants; 3) formerly incarcerated individuals; 4) patients with cancer in palliative care; and 5) veterans. The article charts a research agenda to create the evidence base for quality and evaluation metrics, capacity building, sustainability, and best practices; it also focuses specifically on a research agenda that identifies the value of the lawyers in MLP. Such a focus on the "L" has been lacking and is overdue.

What Is Federalism in Healthcare For?

The Affordable Care Act (ACA) offers a window into modern American federalism--and modern American nationalism--in action. The ACA's federalism is defined not by separation between state and federal, but rather by a national structure that invites state-led implementation. As it turns out, that structure was only a starting point for a remarkably dynamic and adaptive implementation process that has generated new state-federal arrangements. States move back and forth between different structural models vis-a-vis the federal government; internal state politics produce different state choices; states copy, compete, and cooperate with each other; and negotiation with federal counterparts is a near constant. These characteristics have endured through the change in presidential administration. This Article presents the results of a study that tracked the details of the ACA's federalism-related implementation from 2012 to 2017. Among the questions that motivated the project: Does the ACA actually effectuate "federalism," and what are federalism's key attributes when entwined with national statutory implementation? A federal law on the scale of the ACA presented a rare opportunity to investigate implementation from a statute's very beginning and to provide the concrete detail often wanting in federalism scholarship. The findings deconstruct assumptions about federalism made by theorists of all stripes, from formalist to modern. Federalism's commonly invoked attributes--including autonomy, cooperation, experimentation, and variation--have not been dependent on any particular architecture of either state-federal separation or entanglement, even though theorists typically call on "federalism" to produce them. Instead, these attributes have been generated in ACA implementation across virtually every kind of governance model--that is, regardless whether states expand Medicaid; get waivers; or operate their own insurance exchanges or let the federal government do it for them. This makes it extraordinarily challenging to measure which structural arrangements are most "federalist," especially because the various federalism attributes are not always present together. The study also uncovers major theoretical difficulties when it comes to healthcare: Without a clear conception of the U.S. healthcare system's goals, how can we know which structural arrangements serve it best, much less whether they are working? If healthcare federalism is a mechanism to produce particular policy outcomes, we should determine whether locating a particular facet of healthcare design in the states versus the federal government positively affects, for example, healthcare cost, access, or quality. If, instead, healthcare federalism serves structural aims regardless of policy ends--for instance, reserving power to states in the interest of sovereignty or checks and balances--we should examine whether it does in fact accomplish those goals, and we should justify why those goals outweigh the moral concerns that animate health policy. The ACA did not cause this conceptual confusion, but it retained and built on a fragmented healthcare landscape that already was riddled with structural and moral compromises. This does not mean that federalism is an empty concept or that it does not exist in the ACA. Federalism scholars tend to argue for particular structural arrangements based on prior goals and values. The ACA's architecture challenges whether any of these goals and values are unique to federalism or any particular expression of it. At the same time, the ACA's implementation is clearly a story about state leverage, intrastate democracy, and state policy autonomy within, not apart from, a national statutory scheme. Its implementation illustrates how federalism is a proxy for many ideas and challenges us to ask what we are really fighting over, or seeking, when we invoke the concept in healthcare and beyond.

Treatment Innovation in Orthopedic Surgery: A Case Study from Hospital for Special Surgery.

Excessive prescribing of pain medications after surgery has contributed to the epidemic of opioid misuse and diversion in the United States. Pain specialists may be particularly well situated to address these issues. We describe an attempt to reverse the trend at an orthopedic surgical hospital by implementing a peri-operative assessment and treatment service which minimizes preoperative opioid use, when necessary implements addiction treatment, and encourages early tapering from opioids.

Pain and Addiction in Specialty and Primary Care: The Bookends of a Crisis.

Specialists and primary care physicians play an integral role in treating the twin epidemics of pain and addiction. But inadequate access to specialists causes much of the treatment burden to fall on primary physicians. This article chronicles the differences between treatment contexts for both pain and addiction - in the specialty and primary care contexts - and derives a series of reforms that would empower primary care physicians and better leverage specialists.

Civil Litigation and the Opioid Epidemic: The Role of Courts in a National Health Crisis.

The devastating impact of the national opioid epidemic has given rise to hundreds of lawsuits. This article details the extremely broad range of legal claims, compares the opioid cases to other public health litigation efforts, including tobacco, and describes the special mechanism - a multidistrict litigation - through which more than 700 opioid-related cases have been consolidated thus far, with settlement almost certain to follow.