The Administrative Presidency, Waivers, and the Affordable Care Act

Within the American system of shared power among institutions, the executive branch has played an increasingly prominent policy role relative to Congress. The vast administrative discretion wielded by the executive branch has elevated the power of the president. Republican and Democratic presidents alike have employed an arsenal of administrative tools to pursue their policy goals: high-level appointments, administrative rule making, executive orders, proclamations, memoranda, guidance documents, directives, dear colleague letters, signing statements, reorganizations, funding decisions, and more. Presidents Obama and Trump employed most of these tools in an effort to shape the implementation and outcomes of the Affordable Care Act (ACA) during its first decade. This article focuses on the Obama and Trump administrations' use of comprehensive waivers to shape ACA implementation. The Obama administration had mixed success using waivers to convince Republican states to expand Medicaid. Compared to Obama, the Trump administration has found it harder to accomplish its policy goals through waivers, but if the courts support the Trump administration's work requirement and 1332 waiver initiatives, it would enable the president to use waivers to achieve an ever broader set of goals, including program retrenchment.

Putting The Pieces Together Again: American States and the End of the ACA's Shared Responsibility Payment

The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's "shared responsibility payment," which penalized those who failed to comply with the requirement to purchase health insurance. In this article the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states-Maryland, Connecticut, Hawaii, and Washington-formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.

Aging, Pensions and Long-term Care: What, Why, Who, How? Comment on "Financing Long-term Care: Lessons From Japan"

Japan has been aging faster than other industrialized nations, and its experience offers useful lessons to others. Japan has been willing to expand its welfare state with a long-term care (LTC) insurance to finance home care and nursing home care for frail elderly. As Ikegami shows, it created new facilities and expanded specialized staffing for home care, developed a country-wide assessment system and shifted responsibilities between the central and local authorities over that assessment and the determination of co-payments for LTC. Faced with rapid growth in demand for LTC, the government felt the need for new cost control measures. The Japanese experience illustrates that new social policies take time to develop. There is often a need to adjust. But there are also other lessons. The main one is that there is no direct relation between the degree of population aging and total health spending. While aging requires adjustments in the organization of care, and expanding LTC for frail elderly, international studies show there is no need to worry about the 'unaffordability' of aging. In this commentary, we have framed four "What, Why, Who, and How" questions about LTC to (re-)define the borderlines between public and private responsibilities for the range of activities for which some (but certainly not all) frail elderly as well as many non-elderly require support in daily life.

Infant Mortality in Moscow: the Perils of Progress in Russia's World City

This paper examines changes in infant mortality (IM) in Moscow, Russia's largest and most affluent city. Along with some remarkable improvements in Moscow's health system over the period between 2000 and 2014, the overall IM rate for Moscow's residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow's 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

Disparities in Access to Revascularization: Evidence from New York

Purpose: To quantify and compare citywide disparities in the performance of coronary revascularization procedures in New York residents diagnosed with ischemic heart disease (IHD) by the characteristics of the patients and their neighborhood of residence in 2000–2002 and 2011–2013.

Methods: We identify the number of hospitalizations for patients with diagnoses of IHD and/or congestive heart failure (CHF) and the number of revascularization procedures performed on the population 45 years and older, relying on hospital administrative data for New York City, by area of residence, from the Statewide Planning and Research Cooperative System (SPARCS). We conduct multiple logistic regressions to analyze the factors associated with revascularization for hospitalized patients admitted with IHD and CHF over the two time periods.

Results: Despite any decline in population health status, both the age-adjusted rates of inpatient hospital discharges for acute myocardial infarction, for IHD and for CHF, decreased as did the rates of revascularization procedures. Racial and ethnic disparities were much smaller in the later period than those documented earlier. However, there were persistent gender, insurance status, and neighborhood-level disparities in the treatment of heart disease.

Conclusions: With the declines in rates of heart disease, our findings point to the need for more clinical and population-based research to improve the understanding of why race/ethnicity, gender, insurance status, and neighborhood-level disparities persist in the treatment of heart disease.

Disparities in Statin Use in New York City: Implications for Health Reform

Heart disease is the leading cause of death in the USA, and there is an extensive literature describing disparities in the treatment of the disease. Cholesterol-lowering medications are an effective strategy for reducing the risk of cardiovascular diseases for many patients, but some who are prescribed these medications fail to take them. We examine data from the 2014 New York City Community Health Survey to investigate the factors that influence why patients are not compliant in following the prescribed regimen. We focus on adults age 45 and older who report that they are diagnosed with elevated cholesterol levels and were told by a health professional they needed to take cholesterol-lowering medication. We find that evident disparities: individuals with low incomes, those who rely on emergency departments for their healthcare, have not received medical care within the past year, are depressed, and identify as black non-Hispanic and Hispanic are less likely to adhere to a cholesterol-lowering medication program. Although Medicare beneficiaries are less likely to take cholesterol-lowering medication than those with private insurance, those who were on Medicaid or were uninsured did not report lower rates of adherence.

The state of aging policy and politics in the Trump era

The surprise election of President Donald J. Trump to the presidency of the United States marks a singular turning point in the American republic-not only because of his idiosyncratic approach to the office, but also because the Republican Party now holds the presidency and both houses of Congress, presenting a historic opportunity for change. The role of older Americans has been critical in both shaping and reacting to this political moment. Their political orientations and behaviors have shaped it through their electoral support for Republican candidates, but they also stand as highly invested stakeholders in the policy decisions made by the very officials they elected and as beneficiaries of the programs that Republicans have targeted. This article draws on the content of this issue to explore the ways in which Trump administration policies are likely to significantly undermine the social safety net for near-elderly and older Americans with respect to long-term care, housing, health care, and retirement. It also draws on issue content to speculate on the ways that these policy changes might shape politics and political behavior. We conclude that the response of older voters in the 2018 midterm elections to efforts by the Trump administration and its Republican allies in Congress to draw back on the federal government's commitment to programs and policies affecting them will shape the direction of aging policy and politics in the years to come.

Breakthrough Cancer Treatments Raise Difficult Questions

The approval of a first-of-its kind cancer therapy creates new challenges related to safety, access, and costs.

Undermining the ACA through the executive branch and federalism: what the Trump administration's approach to health reform means for older Americans

The ACA has survived multiple existential threats in the legislative and judicial branches, including dozens of congressional attempts at repeal and two major Supreme Court cases. Even as it seems that the ACA is here to stay, what the law accomplishes is far from settled. The Trump administration is using executive powers to weaken the law, in many cases using the same powers that President Obama used to strengthen the effects of the reform. States have responded by seeking flexibility to pursue reforms, such as work requirements, that could not pass Congress and that were not allowed by the Obama administration. There is no indication that the ACA is imploding as President Trump has predicted and seems to desire, although these changes have a real and substantial impact on the lives of many Americans, including the near-elderly in unique ways.

Delhi's health system exceptionalism: inadequate progress for a global capital city

OBJECTIVES

India has proclaimed commitment to the goal of Universal Health Coverage and Delhi, the National Capital Territory, has increased investment in public health and other health services over the past decade. The research investigates whether Delhi's increased investment in health over this period is associated with a reduction in premature deaths, after the age of 1 year, which could have been avoided with better access to effective health care interventions (amenable mortality).

STUDY DESIGN

A population-based study of changes in amenable mortality (AM) in Delhi over the 2003-2013 period.

METHODS

To calculate AM, a list of International Classification of Disease (ICD) codes from the published literature was relied upon. In defining AM in India, an upper age limit of 69 years was adopted, rather than the more common limit of 74 years. Population estimates and vital statistics were downloaded from the Delhi Statistical Handbook. Deaths by cause and age, including medical certification, are from the Vital Statistics site of the Delhi Government. To age-adjust these data, the direct method was employed, using weights derived from the 2010 United Nations world standard population.

RESULTS

The research found that, between 2004 and 2013, the age-adjusted rate of AM rose from 0.87 to 1.09. The leading causes of death in both years were septicemia and tuberculosis. Maternal mortality is well above the global level for middle-income countries.

CONCLUSION

Recent investments in public health and health care and the capacity to leverage them to improve access to effective care have not been sufficient to overcome the crushing poverty and inequalities within Delhi. Large and growing numbers of residents die prematurely each year due to causes that are amenable to public health and health care interventions.

An Examination Of Medicaid Delivery System Reform Incentive Payment Initiatives Under Way In Six States

Medicaid waivers for Delivery System Reform Incentive Payment (DSRIP) seek to hold hospitals and other providers accountable for measureable improvements in health care delivery. We explore the policy context giving rise to these waivers in six states, with particular attention to the interplay among the financial needs of hospitals; the rise of managed care; and federal interest in replacing an "unconditional" Medicaid funding stream, the upper payment limit, with one rooted in pay-for-performance. Key characteristics of these main DSRIP waivers are compared with a particular focus on the establishment of project menus, performance metrics, and pay-for-performance processes. Concluding sections discuss the potential and limits of the waivers as vehicles for health care reform. The long-term durability and impact of DSRIP remains unclear. But federal and state officials have made considerable headway in planning and otherwise laying the groundwork for it.