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3.
Am J Law Med ; 45(2-3): 106-129, 2019 May.
Artículo en Inglés | MEDLINE | ID: mdl-31722633

RESUMEN

Beginning on inauguration day, President Trump has attempted an executive repeal of the Affordable Care Act. In doing so, he has tested the limits of presidential power. He has challenged the force of institutional and non-institutional constraints. And, ironically, he has helped boost public support for the ACA's central features. The first two sections of this article respectively consider the use of the President's tools to advance and to subvert health reform. The final two sections consider the forces constraining the administration's attempted executive repeal. I argue that the most important institutional constraint, thus far, is found in multifaceted actions by states - and not only blue states. I also highlight the force of public voices. Personal stories, public opinion, and 2018 election results - bolstered by presidential messaging - reflect growing support for government-grounded options and statutory coverage protections. Indeed, in a polarized time, "refine and revise" seems poised to supplant "repeal and replace" as the conservative focus countering liberal pressure for a common option grounded in Medicare.


Asunto(s)
Personal Administrativo , Reforma de la Atención de Salud/legislación & jurisprudencia , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Política , Gobierno Federal , Financiación Gubernamental/legislación & jurisprudencia , Financiación Gubernamental/organización & administración , Regulación Gubernamental , Reforma de la Atención de Salud/historia , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Reembolso de Seguro de Salud/legislación & jurisprudencia , Jurisprudencia , Medicaid/legislación & jurisprudencia , Medicaid/organización & administración , Medicare/legislación & jurisprudencia , Medicare/organización & administración , Patient Protection and Affordable Care Act/organización & administración , Cobertura de Afecciones Preexistentes , Opinión Pública , Gobierno Estatal , Estados Unidos
5.
Am J Occup Ther ; 73(5): 7305090010p1-7305090010p6, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31484018

RESUMEN

Passage of the Patient Protection and Affordable Care Act in 2010 mandated reform of the United States' existing primary care system. As part of this reform, advanced practice models, including the Patient-Centered Medical Home model, expanded, with the goal of increasing the use of interprofessional teams. Integrating occupational therapy was promoted as an opportunity to enhance the value of care provided in these redesigned primary care practices. However, occupational therapy's presence in primary care is still extremely limited.


Asunto(s)
Terapia Ocupacional , Humanos , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Atención Dirigida al Paciente/organización & administración , Atención Primaria de Salud , Estados Unidos
6.
Surgery ; 166(5): 820-828, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31402131

RESUMEN

BACKGROUND: Obesity disproportionately affects vulnerable populations. Bariatric surgery is an effective long-term treatment for obesity-related complications; however, bariatric surgical rates are lower among racial minorities and low-income and publicly insured patients. The Affordable Care Act's Medicaid expansion improved access to health insurance, but its impact on bariatric surgical disparities has not been evaluated. We sought to determine the impact of the Affordable Care Act's Medicaid expansion on disparate utilization rates of bariatric surgery. METHODS: A total of 47,974 nonelderly adult bariatric surgical patients (ages 18-64 years) were identified in 2 Medicaid-expansion states (Kentucky and Maryland) versus 2 nonexpansion control states (Florida and North Carolina) between 2012 and 2015 using the Healthcare Cost and Utilization Project's State Inpatient Database. Poisson interrupted time series were conducted to determine the adjusted incidence rates of bariatric surgery by insurance (Medicaid/uninsured versus privately insured), income (high income versus low income), and race (African American versus white). The difference in the counts of bariatric surgery were then calculated to measure the gap in bariatric surgery rates. RESULTS: The adjusted incidence rate of bariatric surgery among Medicaid or uninsured and low-income patients increased by 15.8% and 5.1% per quarter, respectively, after the Affordable Care Act in expansion states (P < .001). No marginal change was seen in privately insured and high-income patients in expansion states. The adjusted incidence rates increased among African American and white patients, but these rates did not change significantly before and after the Affordable Care Act in expansion states. CONCLUSION: The gap in bariatric surgery rates by insurance and income was reduced after the Affordable Care Act's Medicaid expansion, but racial disparities persisted. Future research should track these trends and identify factors to reduce racial disparity in bariatric surgery.


Asunto(s)
Cirugía Bariátrica/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Obesidad Mórbida/cirugía , Aceptación de la Atención de Salud/estadística & datos numéricos , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Poblaciones Vulnerables/estadística & datos numéricos , Adolescente , Adulto , Afroamericanos/estadística & datos numéricos , Cirugía Bariátrica/economía , Cirugía Bariátrica/legislación & jurisprudencia , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Humanos , Masculino , Medicaid/economía , Medicaid/legislación & jurisprudencia , Medicaid/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Grupos Minoritarios/estadística & datos numéricos , Obesidad Mórbida/economía , Patient Protection and Affordable Care Act/economía , Patient Protection and Affordable Care Act/estadística & datos numéricos , Estudios Retrospectivos , Factores Socioeconómicos , Estados Unidos , Adulto Joven
9.
Health Serv Res ; 54(4): 739-751, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31070263

RESUMEN

OBJECTIVE: To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey. STUDY DESIGN: Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups. FINDINGS: In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group). CONCLUSIONS: Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.


Asunto(s)
Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Necesidades y Demandas de Servicios de Salud/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricos , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Adulto , Factores de Edad , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Masculino , Medicaid/estadística & datos numéricos , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Alta del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores Sexuales , Factores Socioeconómicos , Estados Unidos , Adulto Joven
12.
Health Serv Res ; 54(4): 839-850, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-30941767

RESUMEN

OBJECTIVES: To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing. DATA SOURCES: Twenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012. STUDY DESIGN: Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA. FINDINGS: Model-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10 000) and the 2011 cost-sharing change (range: 1.1-34/10 000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm. CONCLUSIONS: Screening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.


Asunto(s)
Algoritmos , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/diagnóstico , Seguro de Costos Compartidos/estadística & datos numéricos , Detección Precoz del Cáncer/estadística & datos numéricos , Anciano , Colonoscopía/economía , Seguro de Costos Compartidos/economía , Detección Precoz del Cáncer/economía , Reacciones Falso Positivas , Femenino , Humanos , Reembolso de Seguro de Salud , Masculino , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Estados Unidos
13.
Albany Law Rev ; 82(2): 533-54, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30990590

RESUMEN

The Affordable Care Act (ACA) has been subject to considerable volatility, with perhaps the greatest blow being the rescission, as part of the 2017 Tax Cuts and Jobs Act, of the penalty for its individual mandate to have health insurance coverage. As a New Republic article noted, "we will now find out whether or not an individual mandate really is essential to health reform. And that will settle an old intra-Democratic fight that has been dormant for a decade." The author, Joel Dodge, noted that in the face of Republican efforts to repeal the ACA, "Obamacare defenders (myself included) rebutted these attacks by doubling down on the argument that the law's entire structure would collapse without a mandate." Yet, following the mandate's repeal, Dodge admitted: The mandate was also never much of a mandate to begin with. The Obama administration gave numerous exemptions from the mandate for hardship and other life circumstances. And at just $695 or 2.5 percent of household income, the mandate's penalty for going without insurance costs far less than the cost of actually buying insurance. In contrast, in Massachusetts, the state that pioneered health care reform, the penalty for going uninsured, when one is deemed to be able to afford coverage, is "50 per cent of the minimum insurance premium for creditable coverage available through the commonwealth health insurance connector for which the individual would have qualified during the previous year." As one national policy magazine noted, after the individual mandate was repealed, many Democratic legislators expressed support for enacting it in their states, but those efforts mostly faltered: "Health policy experts attribute the waning enthusiasm to the unpopularity of the individual mandate." This article traces the origin of the individual mandate, chronicles the efforts of some states to enact their own mandates, and concludes by questioning whether the mandate is either necessary or politic.


Asunto(s)
Reforma de la Atención de Salud/legislación & jurisprudencia , Cobertura del Seguro/legislación & jurisprudencia , Seguro de Salud/legislación & jurisprudencia , Programas Obligatorios/legislación & jurisprudencia , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Gobierno Estatal , Humanos , Estados Unidos
14.
Inquiry ; 56: 46958019841514, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31018737

RESUMEN

This policy brief examines preventive services state legislation trends in the United States during uncertainty regarding the Affordable Care Act (ACA), which requires certain coverage of 4 evidence-based preventive services categories without additional patient costs under §2713. We used a legal mapping approach to search for and analyze state legislation related to preventive services proposed or enacted over a 25-month period of ACA uncertainty. We screened 1231 bills and coded the 76 screened-in bills. Next, we determined their characteristics and examined trends. Bills originated in 28 states, and 69.7% were not enacted. Only 3.9% contained requirements contingent on ACA modifications. About 56.6% referenced services covered by §2713, but usually not entire §2713 categories. Bills also mentioned preventive services in general (53.9%) and services outside §2713's scope (21.1%). About 55.3% applied to private insurance, and 75.0% only to one patient group. Bills generally promoted access, and 51.3% specifically prohibited cost-sharing. But 26.3% of the bills limited access to preventive services. State-level legislation targets preventive services, usually expanding, but sometimes limiting, access. Most bills single out specific services without fully incorporating evidence-based recommendations. State legislation may therefore promote access to preventive services but can favor certain services, deviate from experts' recommendations, and increase nationwide variability. State legislation can function as an important lever for access to preventive services across patient groups. This may be especially important during uncertainty about federal policy. However, the design of state-level proposals is critical for maximizing access to preventive services.


Asunto(s)
Reforma de la Atención de Salud/legislación & jurisprudencia , Accesibilidad a los Servicios de Salud , Servicios Preventivos de Salud/normas , Incertidumbre , Humanos , Cobertura del Seguro/tendencias , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Servicios Preventivos de Salud/legislación & jurisprudencia , Servicios Preventivos de Salud/estadística & datos numéricos , Gobierno Estatal
15.
Inquiry ; 56: 46958019836060, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30895826

RESUMEN

Reinsurance, an insurance product designed to protect health insurers against the financial risk of covering high-cost enrollees, has attracted bipartisan policy interest as a mechanism to stabilize individual health insurance markets. Three states-Alaska, Minnesota, and Oregon-have implemented state-based reinsurance programs under the Affordable Care Act's 1332 State Innovation Waivers, and reinsurance waivers have been approved though not yet enacted in Maine, Maryland, New Jersey, and Wisconsin. In this article, we estimate the costs of implementing national and state-based reinsurance programs using health spending data from the 2007-2016 Medical Expenditure Panel Survey and state demographic and health insurance coverage data from the 2015-2017 Current Population Survey Annual Social and Economic Supplement. We project that a reinsurance program with an 80% payment rate for expenditures between $40,000 and $250,000 would cost $30.1 billion from 2020-2022. We observed considerable variation in reinsurance programs and estimated costs between the 4 states we examined: California, Florida, Illinois, and Texas. Our projections provide updated estimates of the costs of implementing federal reinsurance programs for the individual health insurance market.


Asunto(s)
Costos y Análisis de Costo/economía , Intercambios de Seguro Médico/economía , Aseguradoras/economía , Seguro de Salud/economía , Gobierno Estatal , Adolescente , Adulto , Niño , Preescolar , Gastos en Salud , Humanos , Lactante , Recién Nacido , Persona de Mediana Edad , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Ajuste de Riesgo , Prorrateo de Riesgo Financiero , Estados Unidos , Adulto Joven
16.
Health Mark Q ; 36(2): 107-119, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30848997

RESUMEN

The 2010 Affordable Care Act (ACA) resulted in the creation of state-based marketplaces (SBMs) and federally facilitated marketplaces (FFMs), and provided financial assistance to a portion of those eligible to enroll. This study looks at how choosing to create a SBM rather than a FFM, and the financial assistance provided to some, influenced enrollments rates as signals of support for the ACA in the eyes of those eligible to enroll. The findings show that the enrollment behavior of those most strongly in support of the ACA legislation was influenced by those external signals of support for the ACA.


Asunto(s)
Intercambios de Seguro Médico/economía , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Patient Protection and Affordable Care Act , Afroamericanos/estadística & datos numéricos , Determinación de la Elegibilidad/estadística & datos numéricos , Humanos , Modelos Estadísticos , Patient Protection and Affordable Care Act/economía , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Estados Unidos
18.
PLoS Med ; 16(2): e1002752, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30807584

RESUMEN

In this month's Editorial, PLOS Medicine Academic Editor Zirui Song and his colleague Adrianna McIntyre discuss outcomes and possible futures for the United States Affordable Care Act as it nears the ten year mark.


Asunto(s)
Patient Protection and Affordable Care Act/legislación & jurisprudencia , Patient Protection and Affordable Care Act/tendencias , Opinión Pública , Predicción , Humanos , Estados Unidos/epidemiología
19.
Am J Health Promot ; 33(2): 166-169, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30739464

RESUMEN

A recent District Court decision held that the Affordable Care Act (ACA), absent a tax penalty relating to the individual mandate, was unconstitutional. This follows on a Circuit Court decision that the ACA wellness provisions should be nullified. This editorial reviews the similarities and differences between the rulings and asks if a reasonable person would believe that offering financial incentives aimed at supporting a modicum of effort at self-care is rational. One survey of employers and health care consumers indicates 91 percent of those surveyed agree that wellness programs are a perk that helps employees improve health and, interestingly, the same percent agree these programs are sponsored by employers to cut costs. Where some may view the cost containment objectives of employee wellness as dubious, it's a minority view. Still, some minorities should and do carry inordinate sway in public health such as the small percent of those living with chronic conditions who are unwilling to participate in a healthy living program that is associated with their receiving full benefits. Are incentives a worthwhile strategy if they fail to motivate those who would benefit most from health improvement?


Asunto(s)
Planes de Asistencia Médica para Empleados/organización & administración , Promoción de la Salud/organización & administración , Impuestos/legislación & jurisprudencia , Planes de Asistencia Médica para Empleados/normas , Promoción de la Salud/normas , Humanos , Motivación , Patient Protection and Affordable Care Act/legislación & jurisprudencia , Estados Unidos
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