Evaluation of Insurance Coverage and Cancer Stage at Diagnosis Among Low-Income Adults With Renal Cell Carcinoma After Passage of the Patient Protection and Affordable Care Act

IMPORTANCE

The association of the Patient Protection and Affordable Care Act (ACA) with insurance status and cancer stage at diagnosis among patients with renal cell carcinoma (RCC) is unknown.

OBJECTIVE

To test the hypothesis that the ACA may be associated with increased access to care through expansion of insurance, which may vary based on income.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort analysis included patients diagnosed with RCC from January 1, 2010, to December 31, 2016, in the National Cancer Database. Data were analyzed from July 1 to December 31, 2020. The periods from 2010 to 2013 and from 2014 to 2016 were defined as pre- and post-ACA implementation, respectively. Patients were categorized as living in a Medicaid expansion state or not.

EXPOSURES

Implementation of the ACA.

MAIN OUTCOMES AND MEASURES

The absolute percentage change (APC) of insurance coverage was calculated before and after ACA implementation in expansion and nonexpansion states. Secondary outcomes included change in stage at diagnosis, difference in the rate of insurance change, and change in localized disease between expansion and nonexpansion states. Adjusted difference-in-difference modeling was performed.

RESULTS

The cohort included 78 099 patients (64.7% male and 35.3% female; mean [SD] age, 54.66 [6.46] years), of whom 21.2% had low, 46.2% had middle, and 32.6% had high incomes. After ACA implementation, expansion states had a lower proportion of uninsured patients (adjusted difference-in-difference, -1.14% [95% CI, -1.98% to -1.41%]; P = .005). This occurred to the greatest degree among low-income patients through the acquisition of Medicaid (APC, 11.0% [95% CI, 8.6%-13.3%]; P < .001). Implementation of the ACA was also associated with an increase in detection of stage I and II disease (APC, 4.0% [95% CI, 1.6%-6.3%]; P = .001) among low-income patients in expansion states.

CONCLUSIONS AND RELEVANCE

Among patients with RCC, ACA implementation was associated with an increase in insurance coverage status in both expansion and nonexpansion states for all income groups, but to a greater degree in expansion states. The proportion of patients with localized disease increased among low-income patients in both states. These data suggest that ACA implementation is associated with earlier RCC detection among lower-income patients.

Looking back on the ACA, looking forward to bipartisan solutions: a Q&A with Rep Frank Pallone Jr

To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a healthcare thought leader. For the March issue, which marks the 10th anniversary of the Affordable Care Act being signed into law, we turned to Representative Frank Pallone Jr, D-New Jersey, who played a key role in the law's writing and passage.

Why Did the ACA Co-Op Program Fail? Lessons for the Health Reform Debate

The ACA created a new type of nonprofit health insurance entity, the "Consumer Operated and Oriented Plan" ("co-op"). Most of the newly created co-ops soon lost money, and only 4 of the original 23 remain. We interviewed key stakeholders and conducted in-depth case studies of 3 of these co-ops. We discovered that politicians and regulators made it unlikely the program could succeed, that most of the co-ops did not have the management capacity to overcome these political obstacles, and that even those with good managers lacked the needed fiscal resilience. We also considered lessons suggested for those proposing a newly created "public option." The main one is that a successful public option requires a supportive political environment, strong management, and significant fiscal capacity, none of which comes easily. A better route may be a quasi-public option in which the government subcontracts the operation of its newly created plan to a private firm. Although it is uncertain whether federal regulators have the capacity to hold such private for-profit firms accountable, pragmatism suggests that a combination of public-sector regulation and private-sector implementation may be the most direct path toward a US version of affordable universal coverage.

Social Solidarity in Health Care, American-Style

The ACA shifted U.S. health policy from centering on principles of actuarial fairness toward social solidarity. Yet four legal fixtures of the health care system have prevented the achievement of social solidarity: federalism, fiscal pluralism, privatization, and individualism. Future reforms must confront these fixtures to realize social solidarity in health care, American-style.

The Secretary Shall . . . : Implementing the Affordable Care Act's Private Insurance Expansions

The federal bureaucracy played a critical role in implementing most aspects of the Affordable Care Act's private insurance coverage expansion. Through brief case studies, the authors review three dimensions of this role: the development of the Center for Consumer Information and Insurance Oversight, rulemaking in the formulation of the essential health benefits package, and the implementation of the federal website. They relate these to themes in the public administration literature. Politics-both through state decisions and through continuing congressional action (and inaction)-pervaded the implementation process. The challenges of staffing and situating the new bureaucracy effectively changed vertical boundaries within the Department of Health and Human Services, with long-lasting consequences. Finally, the complex design of the policy itself made passage of the legislation easier but implementation much more difficult. Ultimately, however, implementation was remarkably successful, achieving improvements in coverage consistent with the Congressional Budget Office's projections.

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.

The Affordable Care Act in the States: Fragmented Politics, Unstable Policy

Many argue that the frustrated implementation of the 2010 Affordable Care Act (ACA) stems from the unprecedented level of political polarization that has surrounded the legislation. This article draws attention to the law's "institutional DNA" as a source of political struggle in the 50 states. As designed, in the context of US federalism, the law fractured authority in ways that has opened up the possibility of contestation and confusion. The successful implementation of the ACA varies not only across state lines but also across the various components of the law. In particular, opponents of the ACA have experienced their greatest successes when they could take advantage of weak preexisting policy legacies, high levels of institutional fragmentation, and negative public sentiments. As argued in this article, the fragmented patterns of health care politics in the 50 states identified in previous research have largely persisted during the Trump administration. Moreover, while Republicans were unsuccessful at repealing the legislation, the administration has taken advantage of its structural deficiencies to further weaken the legislation's capacity to expand access to affordable, quality health insurance.

The ACA's Choice Problem

The Affordable Care Act (ACA) is in many ways a success. Millions more Americans now have access to health care, and the ACA catalyzed advances in health care delivery reform. Simultaneously, it has reinforced and bolstered a problem at the heart of American health policy and regulation: a love affair with choice. The ACA's insurance reforms doubled down on the particularly American obsession with choice. This article describes three ways in which that doubling down is problematic for the future of US health policy. First, pragmatically, health policy theory predicts that choice among health plans will produce tangible benefits that it does not actually produce. Most people do not like choosing among health plan options, and many people-even if well educated and knowledgeable-do not make good choices. Second, creating the regulatory structures to support these choices built and reinforced a massive market bureaucracy. Finally, and most important, philosophically and sociologically the ACA reinforces the idea that the goal of health regulation should be to preserve choice, even when that choice is empty. This vicious cycle seems likely to persist based on the lead up to the 2020 presidential election.

Association of State Medicaid Expansion With Hospital Community Benefit Spending

IMPORTANCE

Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities.

OBJECTIVE

To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019.

EXPOSURES

State Medicaid expansion between 2011 and 2017.

MAIN OUTCOMES AND MEASURES

Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending.

RESULTS

Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06).

CONCLUSIONS AND RELEVANCE

In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

The Health Resources and Services Administration's Ryan White HIV/AIDS Program in rural areas of the United States: Geographic distribution, provider characteristics, and clinical outcomes

Background

People living with HIV (PLWH) residing in rural areas experience substantial barriers to HIV care, which may contribute to poor HIV health outcomes, including retention in HIV care and viral suppression. The Health Resources and Services Administration’s Ryan White HIV/AIDS Program (HRSA RWHAP) is an important source of HIV medical care and support services in rural areas. The purpose of this analysis was to (1) assess the reach of the RWHAP in rural areas of the United States, (2) compare the characteristics and funded services of RWHAP provider organizations in rural and non-rural areas, and (3) compare the characteristics and clinical outcomes of RWHAP clients accessing medical care and support services in rural and non-rural areas.

Methods and findings

Data for this analysis were abstracted from the 2017 RWHAP Services Report (RSR), the primary source of annual, client-level RWHAP data. Organizations funded to deliver RWHAP any service (“RWHAP providers”) were categorized as rural or non-rural according to the HRSA FORHP’s definition of modified Rural-Urban Commuting Area (RUCA) codes. RWHAP clients were categorized based on their patterns of RWHAP service use as “visited only rural providers,” “visited only non-rural providers,” or “visited rural and non-rural providers.” In 2017, among the 2,113 providers funded by the RWHAP, 6.2% (n = 132) were located in HRSA-designated rural areas. Rural providers were funded to deliver a greater number of service categories per site than non-rural providers (44.7% funded for ≥5 services vs. 34.1% funded for ≥5 services, respectively). Providers in rural areas served fewer clients than providers in non-rural areas; 47.3% of RWHAP providers in rural areas served 1–99 clients, while 29.6% of non-rural providers served 1–99 clients. Retention in care and viral suppression outcomes did not differ on the basis of whether a client accessed services from rural or non-rural providers.

Conclusions

RWHAP providers are a crucial component of HIV care delivery in the rural United States despite evidence of significant barriers to engagement in care for rural PLWH, RWHAP clients who visited rural providers were just as likely to be retained in care and reach viral suppression as their counterparts who visited non-rural providers. The RWHAP, especially in partnership with Rural Health Clinics and federally funded Health Centers, has the infrastructure and expertise necessary to address the HIV epidemic in rural America.

How Patients' Stories Shape Their Votes: The Role of Health Care in the 2018 U.S. Midterm Elections

Reflecting on the 2018 U.S. midterm elections, it is clear that health care coverage once again played an important role. This prompted the authors to look back on their 2016 bike listening tour across the country when they asked people about their views on the Affordable Care Act. Through those conversations, the authors observed that a common thread was the rampant misunderstanding of health insurance coverage and the central role that politicians had in the creation of policy. In this Invited Commentary, the authors explore the results of the 2018 election, particularly in the rural northern areas where they toured in 2016, and the contradictions between what people say they want, what the candidates say they support, and what the facts actually show. They offer suggestions for the role physicians might play with patients in correcting misunderstandings about the health care system and the policies that shape it. Patients do not always make decisions as physicians do. As opposed to evidence and data, they might rely on personal experiences and stories. The authors suggest that physicians might be able to help patients use these stories to inform their decisions, and to help them understand the connection between their personal health care experiences and the votes they cast in elections.

Nobody Knew How Complicated: Constraining The President's Power To (Re)Shape Health Reform

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.

Demand for health insurance: Evidence from the California and Washington ACA exchanges

I estimate demand for health insurance using consumer-level data from the California and Washington ACA exchanges. I use the demand estimates to simulate the impact of policies targeting adverse selection, including subsidies and the individual mandate. I find (1) own-premium elasticities of -7.2 to -10.6 and insurance coverage elasticities of -1.1 to -1.2; (2) limited response to the mandate penalty amount, but significant response to the penalty's existence, suggesting consumers have a "taste for compliance"; (3) mandate repeal slightly increases consumer surplus because the ACA's price-linked subsidies shield most consumers from premium increases resulting from repeal and some consumers are not compelled to purchase insurance against their will; and (4) mandate repeal decreases consumer surplus if ACA subsidies are replaced with vouchers that expose consumers to premium increases. The economic rationale for the mandate depends on the extent of adverse selection and the presence of other policies targeting selection.

Effects of the ACA on Preventive Care Disparities

BACKGROUND

The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care.

OBJECTIVES

We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears.

METHODS

We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA.

RESULTS

After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status.

CONCLUSIONS

Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

The ramifications of recent health policy actions for cardiovascular care of women: Progress, threats, and opportunities

Women's health and well-being are shaped by a combination of healthcare policies that impact the type of health insurance coverage they benefit from, as well as access to preventive, screening, and treatment services. Furthermore, more distal policies, such as those that pertain to housing, education, and employment, as well as social determinants of health, such as issues of socioeconomic status and women's status in society, also impact their cardiac health. Before the passage of the Affordable Care Act in 2010, women were at greater risk of facing barriers to coverage, reflecting gender rating and the higher likelihood of the existence of preexisting health conditions such as a previous pregnancy. The ACA made substantial progress in responding to women's health needs by expanding the numbers of low-income groups eligible for Medicaid (for the 32 states and Washington, DC that expanded the program) and other subsidized healthcare, as well as access to preventive health services. Although health reform efforts to eliminate the ACA failed in 2016, the administration and Congress are using a variety of channels, including the new Tax Cuts and Job Act, to implement policies such as the elimination of the individual insurance mandate, as well as the elimination of premium subsidies, that will likely impact women differentially, potentially undoing the progress that has been achieved over the past decade.

Impact of Enroll America on the Number of Individuals Covered through the Federally Facilitated Marketplace

OBJECTIVE

To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period.

DATA SOURCES/STUDY SETTING

Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local-area demographic, economic, and health services characteristics.

STUDY DESIGN

We used a quasi-experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states.

PRINCIPAL FINDINGS

We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non-Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level.

CONCLUSIONS

Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence-driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act-related coverage.

Statewide Payment and Delivery Reform: Do States Have What It Takes?

States' role in payment as well as coverage will be subject to debate as the administration and the Congress decide how to address the Affordable Care Act (ACA) and otherwise reshape the nation's health policies. Acting as stewards of health care for the entire state population and stimulated by concern about rising costs and federal support under the ACA, the elected and administrative leaders of some states have been using their political influence and authority to improve their state's overall systems of care regardless of who pays the bill. In early 2015 we conducted on-site interviews with key stakeholders in five states to explore their strategies for payment and delivery reform. We found that despite these states' similar goals, differences in their statutory authority and purchasing power, along with their leaders' willingness to use them, significantly influence a state's ability to achieve reform objectives. We caution federal and state policy makers to recognize the reality that state leaders' political desire to exercise stewardship may not be enough to achieve it.

Teaching Health Care Policy: Using Panel Debate to Teach Residents About the Patient Protection and Affordable Care Act

INTRODUCTION

The debate format has been infrequently used in resident education. We used the panel debate format as a tool to improve health care professionals' knowledge of the Patient Protection and Affordable Care Act (PPACA).

METHODS

Six physical medicine and rehabilitation resident physician debaters led a 60-minute panel debate about the PPACA. Outcome measures included a survey of the spectators with validated questions on physician attitudes towards health care reform in the US and open-ended questions regarding Americans' views on the US health care system.

RESULTS

Twenty-nine physician and nonphysician faculty and staff participated as spectators. Responses to the questions on attitudes toward reform of the health care system indicated that zero spectators rated the current US health care system (i.e., the PPACA) as "Excellent," 25% rated it as "Good," 42% "Average," 25% "Poor," and 8% "Failing." Half of the respondents indicated they support a US president who advocates making the US health care system more like those of other countries. The majority of respondents (89%) expressed the idea that the US does not have the best health care system in the world.

DISCUSSION

Approaching a topic as broad as health care reform with the debate format promoted knowledge, reflection, and interaction with both the opposing debaters and audience.

The Medicaid Rebate: Changes in Oncology Drug Prices After the Affordable Care Act

BACKGROUND

Prescription drug spending is a significant component of Medicaid total expenditures. The Affordable Care Act (ACA) includes a provision that increases the Medicaid rebate for both brand-name and generic drugs. This study examines the extent to which oncology drug prices changed after the increase in the Medicaid rebate in 2010.

METHODS

A pre-post study design was used to evaluate the correlation between the Medicaid rebate increase and oncology drug prices after 2010 using 2006-2013 State Drug Utilization Data.

RESULTS

The results show that the average annual price of top-selling cancer drugs in 2006, adjusted for inflation and secular changes in drug prices, have increased by US$154 and US$235 for branded and competitive brand drugs, respectively, following the 2010 ACA; however, generic oncology drug prices showed no significant changes.

CONCLUSIONS

The findings from this study indicate that oncology drug prices have increased after the 2010 ACA, and suggest that pharmaceutical companies may have increased their drug prices to offset increases in Medicaid rebates.

Establishing Successful Patient-Centered Medical Homes in Rural Hawai'i: Three Strategies to Consider

The challenges to healthcare delivery posed by Hawai'i's unique geography, physician shortages, and dispersed population are of particular importance in light of implementing the Affordable Care Act (ACA). This study draws on central goals laid out in the ACA - to decrease costs, increase access, and improve patient outcomes. The use of the Patient-Centered Medical Homes (PCMHs) is a care model that has the potential to meet all three goals. How to identify the most effective way to develop PCMHs in the specific context of Hawai'i is the focus of this study. To provide recommendations for effective PCMH formation, a qualitative review of previously compiled data from the Hawai'i/Pacific Basin Area Health Education Center (AHEC) and phone interviews with six primary care providers throughout the islands were conducted. The results broadly suggest three paths towards the effective implementation of PCMHs in Hawai'i. The first recommendation is to create a PCMH template or business model for physicians in order to ease the complexities of implementing such an elaborate system of care. The second two recommendations actually veer away from PCMH towards general interventions to increase care in rural Hawai'i. Thus, the second recommendation is to create a specific track for becoming a rural practitioner at the John A. Burns School of Medicine (JABSOM) to increase the retention of physicians in underserved areas. And the final recommendation is to increase utilization of telemedicine techniques to overcome physician shortages and geographic challenges by allowing rural physicians to network with specialists on neighbor islands. These three strategies are all possible to accomplish with commitment and could be implemented to benefit the providers and rural population of Hawai'i.

Building the Coverage Continuum: The Role of State Medicaid Directors and Insurance Commissioners

Issue: The Affordable Care Act has expanded coverage to 20 million newly insured individuals, split between state Medicaid programs and commercially insured marketplaces, with limited integration between the two. The seamless continuum of coverage envisioned by the law is central to achieving the full potential of the Affordable Care Act, but it remains an elusive promise. Goals: To examine the historical and cultural differences between state Medicaid agencies and insurance departments that contribute to this lack of coordination. Findings and Conclusions: Historical and cultural differences must be overcome to ensure continuing access to coverage and care. The authors present two opportunities for insurance and Medicaid officials to work together to advance the continuum of coverage: alignment of regulations for insurers participating in both markets and collaboration on efforts to reform the health care delivery system.

The ACA from behind the "Veil of Ignorance"

John Rawls posited that we could determine the nature of justice if we imagined ourselves observing conditions in society from behind a hypothetical "veil of ignorance." Not knowing how or where we would end up-rich, poor, empowered, disabled-we would choose governing principles that did not leave one disadvantaged because of his or her circumstances. Rawls's concepts are implicitly embedded in the Affordable Care Act, which guarantees that vastly more Americans can obtain health insurance. The law effectively closed down the de facto lottery that awarded coverage to most but left out millions of others.

Nursing in the Trump era

Do nurses in the US know what to expect from President Trump? The predominant mood at the moment is one of uncertainty, according to editor-in-chief of the American Journal of Nursing Shawn Kennedy. While presidential candidate Trump had a lot to say about health care, it is far from clear what President Trump will do. One reason for this is that he has been inconsistent in his views. He was pro-choice in 1999, for example, and antiabortion afterwards. Another reason is that the reality of politics may limit his power.

Patient-centered care: turning the rhetoric into reality

Although patient-centered care (PCC) was proclaimed a core health system aim in a 2001 Institute of Medicine report, it remains one of the most-used and least-understood terms in healthcare. We interviewed leaders at 15 Medicare accountable care organizations (ACOs) across the country that have been the most successful in putting patient-centeredness into actual practice to develop an operational definition. The ACOs we spoke with had a 3-pronged practical approach of: 1) patients as partners, 2) proactive customer-service orientation, and 3) care coordination with a whole-person approach. We believe this framework can serve as a guide as the healthcare system moves "from volume to value" and a true partnership becomes increasingly critical both to patients and the healthcare system as a whole.

Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings

OBJECTIVES

To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the immediate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies.

STUDY DESIGN

We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identified reports in the "gray literature" disseminated by government agencies and other organizations.

PRINCIPAL FINDINGS

Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provision, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets.

CONCLUSIONS

The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will provide further insights as to whether the ACA has been successful in achieving its goals.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

Students implement the Affordable Care Act: a model for undergraduate teaching and research in community health and sociology

The implementation of the Affordable Care Act (ACA) provides an opportunity for undergraduate students to observe and experience first-hand changing social policies and their impacts for individuals and communities. This article overviews an action research and teaching project developed at an undergraduate liberal arts university and focused on providing ACA enrollment assistance as a way to support student engagement with community health. The project was oriented around education, enrollment and evaluation activities in the community, and students and faculty together reflected on and analyzed the experiences that came from the research and outreach project. Student learning centered around applying concepts of diversity and political agency to health policy and community health systems. Students reported and faculty observed an unexpected empowerment for students who were able to use their university-learned critical thinking skills to explain complex systems to a wide range of audiences. In addition, because the project was centered at a university with no health professions programs, the project provided students interested in community and public health with the opportunity to reflect on how health and access to health care is conditioned by social context. The structure and pedagogical approaches and implications of the action research and teaching project is presented here as a case study for how to engage undergraduates in questions of community and public health through the lens of health policy and community engagement.

Taming Healthcare Costs: Promise and Pitfalls for Women's Health

When it comes to healthcare, women are often the primary decision makers for their families. Therefore, focusing on women and their health needs can have a profound effect on health reform efforts to control costs and improve quality for all segments of the population. The promise and pitfalls of cost containment reform in Massachusetts can serve as an informative case study for policymakers at the local, state, and federal levels as they attempt to reduce costs while maintaining quality of care. Massachusetts cost containment law, Chapter 224, seeks to control the healthcare cost growth through innovative approaches to increase efficiency and transparency including the adoption of new delivery system models, investments in wellness and prevention programs, and implementation of standard quality and evaluation measures. In this paper, we outline four approaches to delivering on the promise of cost containment reform to maximize women's access to comprehensive, quality healthcare while avoiding the pitfalls of cost containment's adverse impact on women's health.

What Health Care Reform Means for Immigrants: Comparing the Affordable Care Act and Massachusetts Health Reforms

The 2010 Patient Protection and Affordable Care Act (ACA) was passed to provide more affordable health coverage to Americans beginning in 2014. Modeled after the 2006 Massachusetts health care reform, the ACA includes an individual mandate, Medicaid expansion, and health exchanges through which middle-income individuals can purchase coverage from private insurance companies. However, while the ACA provisions exclude all undocumented and some documented immigrants, Massachusetts uses state and hospital funds to extend coverage to these groups. This article examines the ACA reform using the Massachusetts reform as a comparative case study to outline how citizenship status influences individuals' coverage options under both policies. The article then briefly discusses other states that provide coverage to ACA-ineligible immigrants and the implications of uneven ACA implementation for immigrants and citizens nationwide.

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.

Medicare Advantage: what explains its robust health?

The Medicare Advantage (MA) program continues to grow and thrive, despite plan payment cuts imposed through the Affordable Care Act. What explains this surprising outcome (one that is strikingly different than the experience of MA plans in the late 1990s, when payment cuts led to dramatic shrinkage in enrollment and curtailment of plans)? This analysis argues that a combination of factors, including the way payment cuts were imposed, the plan offerings, the characteristics of beneficiaries, and the way they make choices together explain the program's current health. Understanding these factors is important for MA, Medicare, and, more generally, for participants in new payment models.

Accountable Care Organizations: Integrated Care Meets Market Power

Will accountable care organizations (ACOs) deliver high-quality care at lower costs? Or will their potential market power lead to higher prices and lower quality? ACOs appear in various forms and structures with financial and clinical integration at their core; however, the tools to assess their quality and the incentive structures that will determine their success are still evolving. Both market forces and regulatory structures will determine how these outcomes emerge. This introduction reviews the evidence presented in this special issue to tackle this thorny trade-off. In general the evidence is promising, but the full potential of ACOs to improve the health care delivery system is still uncertain. This introductory review concludes that the current consensus is to let ACOs grow, anticipating that they will make a contribution to improve our poor-quality and high-cost delivery system.

The Affordable Care Act versus Medicare for All

Many problems facing the Affordable Care Act would disappear if the nation were instead implementing Medicare for All - the extension of Medicare to every age group. Every American would be automatically covered for life. Premiums would be replaced with a set of Medicare taxes. There would be no patient cost sharing. Individuals would have free choice of doctors. Medicare's single-payer bargaining power would slow price increases and reduce medical cost as a percentage of gross domestic product (GDP). Taxes as a percentage of GDP would rise from below average to average for economically advanced nations. Medicare for All would be phased in by age.