Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity.

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

Financial Performance of Health Insurers: State-Run Versus Federal-Run Exchanges.

Many insurers incurred financial losses in individual markets for health insurance during 2014, the first year of Affordable Care Act mandated changes. This analysis looks at key financial ratios of insurers to compare profitability in 2014 and 2013, identify factors driving financial performance, and contrast the financial performance of health insurers operating in state-run exchanges versus the federal exchange. Overall, the median loss of sampled insurers was -3.9%, no greater than their loss in 2013. Reduced administrative costs offset increases in medical losses. Insurers performed better in states with state-run exchanges than insurers in states using the federal exchange in 2014. Medical loss ratios are the underlying driver more than administrative costs in the difference in performance between states with federal versus state-run exchanges. Policy makers looking to improve the financial performance of the individual market should focus on features that differentiate the markets associated with state-run versus federal exchanges.

A five-year assessment of the affordable care act: market forces still trump the common good in U.S. Health care.

The Affordable Care Act (ACA) was enacted in 2010 as the signature domestic achievement of the Obama presidency. It was intended to contain costs and achieve near-universal access to affordable health care of improved quality. Now, five years later, it is time to assess its track record. This article compares the goals and claims of the ACA with its actual experience in the areas of access, costs, affordability, and quality of care. Based on the evidence, one has to conclude that containment of health care costs is nowhere in sight, that more than 37 million Americans will still be uninsured when the ACA is fully implemented in 2019, that many more millions will be underinsured, and that profiteering will still dominate the culture of U.S. health care. More fundamental reform will be needed. The country still needs to confront the challenge that our for-profit health insurance industry, together with enormous bureaucratic waste and widespread investor ownership throughout our market-based system, are themselves barriers to health care reform. Here we consider the lessons we can take away from the ACA's first five years and lay out the economic, social/political, and moral arguments for replacing it with single-payer national health insurance.

Patient perceptions of asthma-related financial burden: public vs. private health insurance in the United States.

BACKGROUND: Given the complexity of the health insurance market in the United States and the confusion that often stems from these complexities, patient perception about the value of health insurance in managing chronic disease is important to understand. OBJECTIVE: To examine differences between public and private health insurance in perceptions of financial burden with managing asthma, outcomes, and factors that explain these perceptions. METHODS: Secondary analysis was performed using baseline data from a randomized clinical trial that were collected through telephone interviews with 219 African American women seeking services for asthma and reporting perceptions of financial burden with asthma management. Path analysis with multigroup models and multiple variable regression analyses were used to examine associations. RESULTS: For public (P < .001) and private (P < .01) coverage, being married and more educated were indirectly associated with greater perceptions of financial burden through different explanatory pathways. When adjusted for multiple morbidities, asthma control, income, and out-of-pocket expenses, those with private insurance used fewer inpatient (P < .05) and emergency department (P < .001) services compared with those with public insurance. When also adjusted for health insurance, greater financial burden was associated with more urgent office visits (P < .001) and lower quality of life (P < .001). CONCLUSION: African American women who perceive asthma as a financial burden regardless of health insurance report more urgent health care visits and lower quality of life. Burden may be present despite having and being able to generate economic resources and health insurance. Further policy efforts are indicated and special attention should focus on type of coverage.

Beyond interests and institutions: US health policy reform and the surprising silence of big business.

Interest-based arguments do not provide satisfying explanations for the surprising reticence of major US employers to take a more active role in the debate surrounding the 2010 Patient Protection and Affordable Care Act (ACA). Through focused comparison with the Bismarckian systems of France and Germany, on the one hand, and with the 1950s and 1960s in the United States, on the other, this article concludes that while institutional elements do account for some of the observed behavior of big business, a necessary complement to this is a fuller understanding of the historically determined legitimating ideology of US firms. From the era of the "corporate commonwealth," US business inherited the principles of private welfare provision and of resistance to any expansion of government control. Once complementary, these principles are now mutually exclusive: employer-provided health insurance increasingly is possible only at the cost of ever-increasing government subsidy and regulation. Paralyzed by the uncertainty that followed from this clash of legitimate ideas, major employers found themselves unable to take a coherent and unified stand for or against the law. As a consequence, they failed either to oppose it successfully or to secure modifications to it that would have been useful to them.

Hospital reimbursement incentives: is there a more effective option?--Part II.

As discussed in Part I of this article, hospital executives in Canada, Germany, and the United States manage their facilities' resources to maximize the incentives inherent in their respective reimbursement system and thereby increase their bottom line. It was also discussed that an additional supply of available hospitals, physicians, and other services will generate increased utilization. Part II discusses how the Patient Protection and Affordable Care Act of 2010 will eventually fail since it neither controls prices nor utilization (e.g., imaging, procedures, ambulatory surgery, discretionary spending). This article concludes with the discussion of the German multipayer approach with universal access and global budgets that might well be a model for U.S. healthcare in the future. Although the German healthcare system has a number of shortfalls, its paradigm could offer the most appropriate compromise when selecting the economic incentives to reduce the percentage of the U.S. gross domestic product expenditure for healthcare from 17.4% to roughly 12.0%.

Ditching the single-payer system in the national health service: how the English Department of Health is learning the wrong lessons from the United States.

Reforms to the British National Health Service introduce major changes to how health care will be delivered. The core elements include the creation of new purchaser organizations, Clinical Commissioning Groups, which unlike their predecessors will be able to recruit and reject general practices and their patients without geographical restriction. The Clinical Commissioning Groups are to transition from statutory bodies to freestanding organizations, with most of their functions privatized and an increasingly privatized system of provision, In this paper, we explore the likely consequences of these proposals, drawing in particular on the experience of managed care organizations in the United States, whose approach has influenced the English proposals extensively. We argue that the wrong lessons are being learned and the English reforms are likely to fundamentally undermine the principles on which the British National Health Service was founded.

Increase in federal match associated with significant gains in coverage for children through Medicaid and CHIP.

As the number of children living in poverty has increased steadily over the past decade, Medicaid and the Children's Health Insurance Program (CHIP) have enrolled millions of additional youths. Federal and state governments jointly finance both programs, with the federal portion determined by the Federal Medical Assistance Percentage, commonly known as the "federal match." The federal government has used intermittent increases in the federal match as a way to provide fiscal relief to states during economic downturns. The most recent broad increase ended in June 2011, but the precise impact on Medicaid and CHIP enrollment for children is not known. No previous study has evaluated the association of the federal match with children's enrollment in state Medicaid or CHIP programs in the context of other state factors. To shed light on the degree to which public coverage for children varies with differences in the federal match, we examined publicly available data from all fifty states from 1999 to 2009. We found that a ten-percentage-point increase in the federal match was associated with a 1.9 percent increase in Medicaid and CHIP enrollment, equivalent to approximately 500,000 children. This association persisted when adjusted for multiple state-level factors, including the proportion of children living in poverty. This analysis underscores the central role of the federal match in supporting expansion of Medicaid and CHIP coverage for children.

Designing health insurance exchanges: key decisions.

A cornerstone of health care reform is the establishment of state-level insurance exchanges where individuals and small businesses can purchase health insurance in an online marketplace. States are required to develop an exchange by 2014, or participate in a federal one. The exchanges will help people without employer-sponsored insurance find and choose a health plan to meet their needs. This Issue Brief reviews the experience of Massachusetts in developing a health insurance exchange and offers policymakers guidance on key features and likely consumer responses.