Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Access to outpatient care in Manhattan and Paris: A tale of real change in two world cities

France's system of universal health insurance (UHI) offers more equitable access to outpatient care than the patchwork system in the U.S., which does not have a UHI system. We investigate the degree to which the implementation of the Patient Protection and Affordable Care Act (ACA) has narrowed the gap in access to outpatient care between France and the U.S. To do so, we update a previous comparison of access to outpatient care in Manhattan and Paris as measured by age-adjusted rates of hospital discharge for avoidable hospital conditions (AHCs). We compare these rates immediately before and after the implementation of the ACA in 2014. We find that AHC rates in Manhattan declined by about 25% and are now lower than those in Paris. Despite evidence that access to outpatient care in Manhattan has improved, Manhattanites continue to experience greater residence-based neighborhood inequalities in AHC rates than Parisians. In Paris, there was a 3% increase in AHC rates and neighborhood-level inequalities increased significantly. Our analysis highlights the persistence of access barriers to outpatient care in Manhattan, particularly among racial and ethnic minorities, even following the expansion of health insurance coverage.

The evolution of infant mortality and neighbourhood inequalities in four world cities: 1988-2016

OBJECTIVES

To determine the level of neighbourhood inequalities in infant mortality (IM) rates in the urban core of four world cities and to examine the association between neighbourhood-level income and IM. We compare our findings with those published in 2004 to better understand how these city health systems have evolved.

METHODS

We compare IM rates among and within the four cities using data from four periods: 1988-1992; 1993-1997; 2003-2008 and 2012-2016. Using a maximum-likelihood negative binomial regression model that controls for births, we predict the relationship between neighbourhood-level income and IM.

RESULTS

IM rates have declined in all four cities. Neighbourhood-level income is statistically significant for New York and, for the two most recent periods, in Paris. In contrast, there is no significant relationship between neighbourhood income and IM in London or Tokyo.

CONCLUSIONS

Despite programmes to reduce IM inequalities at national and local levels, these persist in New York. Until the early part of this century, none of the other cities experienced a relationship between neighbourhood income and IM, but growing income inequalities within Paris have changed this situation and it now has geographic inequalities that are comparable to Manhattan.

POLICY IMPLICATIONS

Policy-makers in these cities should focus on better understanding the social and economic factors associated with neighbourhood inequalities in IM.

Public Deliberation about Gene Editing in the Wild

Genetic editing technologies have long been used to modify domesticated nonhuman animals and plants. Recently, attention and funding have also been directed toward projects for modifying nonhuman organisms in the shared environment-that is, in the "wild." Interest in gene editing nonhuman organisms for wild release is motivated by a variety of goals, and such releases hold the possibility of significant, potentially transformative benefit. The technologies also pose risks and are often surrounded by a high uncertainty. Given the stakes, scientists and advisory bodies have called for public engagement in the science, ethics, and governance of gene editing research in nonhuman organisms. Most calls for public engagement lack details about how to design a broad public deliberation, including questions about participation, how to structure the conversations, how to report on the content, and how to link the deliberations to policy. We summarize the key design elements that can improve broad public deliberations about gene editing in the wild.

Regulating Gene Editing in the Wild: Building Regulatory Capacity to Incorporate Deliberative Democracy

The release of genetically engineered organisms into the shared environment raises scientific, ethical, and societal issues. Using some form of democratic deliberation to provide the public with a voice on the policies that govern these technologies is important, but there has not been enough attention to how we should connect public deliberation to the existing regulatory process. Drawing on lessons from previous public deliberative efforts by U.S. federal agencies, we identify several practical issues that will need to be addressed if relevant federal agencies are to undertake public deliberative activities to inform decision-making about gene editing in the wild. We argue that, while agencies may have institutional capacity to undertake public deliberative activities, there may not be sufficient political support for them to do so. Advocates of public deliberation need to make a stronger case to Congress about why federal agencies should be encouraged and supported to conduct public deliberations.

Envisioning Complex Futures: Collective Narratives and Reasoning in Deliberations over Gene Editing in the Wild

The development of technologies for gene editing in the wild has the potential to generate tremendous benefit, but also raises important concerns. Using some form of public deliberation to inform decisions about the use of these technologies is appealing, but public deliberation about them will tend to fall back on various forms of heuristics to account for limited personal experience with these technologies. Deliberations are likely to involve narrative reasoning-or reasoning embedded within stories. These are used to help people discuss risks, processes, and fears that are otherwise difficult to convey. In this article, we identify three forms of collective narrative that are particularly relevant to debates about modifying genes in the wild. Our purpose is not to privilege any particular narrative, but to encourage people involved in deliberations to make these narratives transparent. Doing so can help guard against the way some narratives-referred to here as "crafted narratives"-may be manipulated by powerful elites and concentrated economic interests for their own strategic ends.

Variation in end-of-life care and hospital palliative care among hospitals and local authorities: A preliminary contribution of big data

BACKGROUND

Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use of palliative care.

AIM

Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France.

DESIGN

Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database.

RESULTS

55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84-2.43) and aOR = 2.59 (2.12-3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels.

CONCLUSION

The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.

Unsanitized and Unfair: How COVID-19 Bailout Funds Refuel Inequity in the US Health Care System

CONTEXT

The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19-related medical and financial need. The US health care system is bifurcated into the "haves" and "have nots." The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the "have" hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak.

METHODS

To obtain relief fund data for each hospital in the United States, we started with data from the HHS website. We use the RAND Hospital Data tool to analyze how fund distributions are associated with hospital characteristics.

FINDINGS

Our analysis reveals that the "have" hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the "have nots").

CONCLUSIONS

Despite extreme racial inequities, which COVID-19 exposed early in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the United States, leaving hospitals that predominantly serve low-income people of color with less.

Commentary: Global Comparisons of Physician Associations

The authors reflect on their own work in relation to the articles in this special section on physician organizations, and they make four observations. First, association-government power relations shift after countries introduce universal health insurance, but they are by no means diminished. In France, Germany, and Japan, physicians' economic interests are explicitly considered against broader health system goals, such as providing affordable universal insurance. In low- and middle-income countries (LMICs), physician organizations do not share power in the same way. Second, in higher-income countries, fragmentation may occur along specialty or generalist lines, and some physicians are unionized. Generally speaking, physician influence over reimbursement policy is reduced because of organizational fragmentation. Third, associations develop as legitimate voices for physicians, but their relationship to other professions differs in higher-income countries. Associations in LMICs form coalitions with other health professionals. Finally, although German state physician associations have a key implementation role, in most countries, state and federal policy roles seem relatively defined. Global comparison of the LMICs and other countries suggests power, unity, legitimacy, and federal roles are tied closely to the stage of health system development.

Civic Learning, Science, and Structural Racism

Vaccine hesitancy is a major public health challenge, and racial disparities in the acceptance of vaccines is a particular concern. In this essay, we draw on interviews with mothers of Black male adolescents to offer insights into the reasons for the low rate of vaccination against the human papillomavirus among this group of adolescents. Based on these conversations, we argue that increasing the acceptance of HPV and other vaccines cannot be accomplished merely by providing people with more facts. Instead, we must address the pervasive racial discrimination in the United States that undermines trust in social institutions, including the health care system. In the short term, it may be helpful to increase the number of clinicians of color working in the health system, but more fundamental changes are required. The U.S. must adopt and implement policies that dismantle structural racism if it hopes to produce greater trust and community-oriented thinking on behalf of people who have been exploited for centuries.

Residential Segregation and Publicly Spirited Democracy

Successful deliberations over contentious issues require a publicly spirited citizenry that will encourage elected officials to promote what James Madison called the "permanent and aggregate interests" of the country. Unfortunately, atomizing forces have pulled American society apart, undermining trust and making collective action difficult. Residential segregation is one of those atomizing forces. Residential segregation undermines a commitment to civic virtue because it encourages people to think about fellow citizens as "others" with whom they have little in common. To address this situation, we must start by fixing our neighborhoods and creating local institutions that enhance trust and foster a public-spirited democratic citizenry. For example, our existing educational policies reinforce the disparities associated with residential segregation and have created massive resource inequalities among school districts across the country. A useful first step would be to equalize school district funding to promote a more genuine equality of opportunity.

Civic Learning for a Democracy in Crisis

This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This multiauthored report offers wide-ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people.

Recommendations for Better Civic Learning: Building and Rebuilding Democracy

This is the concluding essay for a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the John S. and James L. Knight Foundation. This essay provides an integrative discussion of various theoretical and practical reform perspectives offered by other essays in the report. It also offers a number of recommendations. It notes that the aim of the special report is not to propose specific reform measures but, rather, to consider larger, more theoretic concerns related to political and economic questions, which are personal and structural-psychological, cultural, and institutional-at the same time. In response, this essay argues that the best relationship between the citizenry and government in a democracy is not one of deference, nor one of contestation, but one that is critically constructive, which in turn is linked to practices of civic learning. To be constructive, citizens need scientific literacy, an understanding of how government and other institutions work, critical thinking abilities, and many open and diverse forums for civic learning to offset the increasingly isolating media "bubbles" that are the only source of information for many. The essay then formulates five recommendations designed to facilitate critically constructive citizenship and civic learning. These are creating a basis for civic participation, acquiring information, talking to each other, designing institutional change, and achieving deliberation.

An Assessment of Healthcare Access and Utilization in the World Trade Center Health Program

OBJECTIVE

Access to healthcare, a national priority, may be better understood through medical surveillance programs like the World Trade Center Health Program (WTCHP).

METHODS

Measures of healthcare access and utilization for 1159 9/11 rescue and recovery workers ("responders") at the Rutgers Clinical Center of Excellence (CCE) were assessed using negative binomial modeling of the Benefits Eligibility Assessment Screening Tool and compared with 174 9/11 responders in the 2017 New York City Community Health Survey (NYCCHS) using z-testing.

RESULTS

Approximately 10.8% of Rutgers CCE respondents lacked at least one aspect of healthcare access. Problems accessing healthcare and basic needs were positively associated with CCE utilization and differed between Rutgers CCE and NYCCHS respondents.

CONCLUSIONS

Some 9/11 responders bridge healthcare access gaps via participation in the WTCHP. Surveillance survey tools may help to identify healthcare disparities.

Inequalities in avoidable hospitalisation in large urban areas: retrospective observational study in the metropolitan area of Milan

OBJECTIVE

Significant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence.

DESIGN

Retrospective observational study.

SETTING

Public and accredited private hospitals in the metropolitan area of Milan. Data obtained from the hospital discharge database of the Italian Health Ministry.

PARTICIPANTS

472 579 patients hospitalised for ambulatory care sensitive conditions and resident in the metropolitan area of Milan from 2005 to 2016.

OUTCOME MEASURE

Age-adjusted rates of avoidable hospitalisations; OR for hospital admissions with ambulatory care sensitive conditions.

METHODS

Age-adjusted rates of avoidable hospitalisations in the metropolitan area of Milan were estimated from 2005 to 2016 using direct standardisation. For the hospitalised population, multilevel logistic regression model with patient random effects was used to identify patients, hospitals and municipalities' characteristics associated with risk of avoidable hospitalisation in the period 2012-2016.

RESULTS

The rate of avoidable hospitalisation in Milan fell steadily between 2005 and 2016 from 16.6 to 10.5 per 1000. Among the hospitalised population, the odds of being hospitalised with an ambulatory care sensitive condition was higher for male (OR 1.42, 95% CI 1.36 to 1.48), older (OR 1.012, 95% CI 1.01 to 1.014), low-educated (elementary school vs degree OR 4.23, 95% CI 3.72 to 4.81) and single (vs married OR 2.08, 95% CI 2.01 to 2.16) patients with comorbidities (OR 1.47, 95% CI 1.38 to 1.56); avoidable admissions were more frequent in public non-teaching hospitals while municipality's characteristics did not appear to be correlated with hospitalisation for ambulatory care sensitive conditions.

CONCLUSIONS

The health system in metropolitan Milan has experienced a reduction in avoidable hospitalisations between 2005 and 2016, quite homogeneously across its 134 municipalities. The study design allowed to explore inequalities among the hospitalised population for which we found specific sociodemographic disadvantages.

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

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.