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The Affordable Care Act (ACA) was designed with multiple goals in mind, including a reduction in social disparities in health care and health status. This was to be accomplished through some novel provisions and a significant infusion of resources into long-standing public programs with an existing track record related to health equity. In this article, we discuss seven ACA provisions with regard to their intended and realized impact on social inequalities in health, focusing primarily on socioeconomic and racial/ethnic disparities. Arriving at its 10th anniversary, there is significant evidence that the ACA has reduced social disparities in key health care outcomes, including insurance coverage, health care access, and the use of primary care. In addition, the ACA has had a significant impact on the volume/range of services offered and the financial security of community health centers, and through section 1557, the ACA broadened the civil rights landscape in which the health care system operates. Less clear is how the ACA has contributed to improved health outcomes and health equity. Extant evidence suggests that the part of the ACA that has had the greatest impact on social disparities in health outcomes-including preterm births and mortality-is the Medicaid expansion., (Copyright © 2020 by Duke University Press.)

This paper discusses Republican efforts to repeal the 2010 Patient Protection and Affordable Care Act (ACA) over President Trump's first year in office (2017) and their impact on near-elderly Americans (50-64 years old). We describe how the ACA's provisions for strengthening health care coverage were particularly advantageous for near-elderly Americans: The law shored up employer-sponsored health care, expanded Medicaid, and-most important-created conditions for a strong individual health insurance market. We then describe Republican efforts to undermine the ACA in the years immediately following its passage, followed by detailed discussion of Republican proposals to repeal and replace the ACA during 2017. We conclude by discussing factors informing the fate of Republican legislation in this area, the potential consequences of the legislation that ultimately passed, and the prospects for future attempts to repeal and replace the ACA through the legislative process.

What health insurance should cover and pay for represents one of the most complex questions in national health policy. Israel shares with the US reliance on a regulated insurance market and we compare the approaches of the two countries regarding determining health benefits. Based on review and analysis of literature, laws and policy in the United States and Israel. The Israeli experience consists of selection of a starting point for defining coverage; calculating the expected cost of covered benefits; and creating a mechanism for updating covered benefits within a defined budget. In implementing the Affordable Care Act, the US rejected a comprehensive and detailed approach to essential health benefits. Instead, federal regulators established broadly worded minimum standards that can be supplemented through more stringent state laws and insurer discretion. Notwithstanding differences between the two systems, the elements of the Israeli approach to coverage, which has stood the test of time, may provide a basis for the United States as it renews its health reform debate and considers delegating decisions about coverage to the states. Israel can learn to emulate the more forceful regulation of supplemental and private insurance that characterizes health policy in the United States.

ISSUE: The Affordable Care Act enhanced Medicaid's role as a health care purchaser by expanding eligibility and broadening the range of tools and strategies available to states. All states have embraced delivery and payment reform as basic elements of their programs. GOAL: To examine the effects of reducing the size and scope of Medicaid under legislation to repeal the ACA. FINDINGS AND CONCLUSIONS: Were the ACA's Medicaid expansion to be eliminated and were federal Medicaid funding to experience major reductions through block grants or per capita caps, the effects on system transformation would be significant. Over 70 percent of Medicaid spending is driven by enrollment in a program that covers 74 million people; on a per capita basis Medicaid costs less than Medicare or commercial insurance. States would need to absorb major financial losses by reducing the number of people served, reducing the scope of services covered, introducing higher cost-sharing, or further reducing already low payments. Far from improving quality and efficiency, these changes would cause the number of uninsured to rise while depriving health care providers and health plans of the resources needed to care for patients and invest in the tools that are essential to system transformation

Through a combination of three needs-based public programs--Medicaid, the Children's Health Insurance Program, and tax credits for purchasing private plans in the new marketplaces--the Affordable Care Act can potentially ensure continuous coverage for many low- and moderate-income Americans. At the same time, half of individuals with incomes at less than twice the poverty level will experience a form of "churning" in their coverage; as changes occur in their life or work circumstances, they will need to switch among these three coverage sources. For many, churning will entail not only changes in covered benefits and cost-sharing, but also in care, owing to differences in provider networks. Strategies for mitigating churning's effects are complex and require time to implement. For the short term, however, the experiences of 17 states with policies aimed at smoothing transitions between health plans offer lessons for ensuring care continuity.

Part of states' roles in administering the new health insurance marketplaces is to certify the health plans available for purchase. This analysis focuses on how state-based and state partnership marketplaces are using their flexibility in setting certification standards to shape plan design in the individual market. It focuses on three aspects of certification: provider networks; inclusion of essential community providers; and benefit substitution, which allows plans to offer benefits that differ from a state's benchmark plan. A review of documents collected from 18 states and the District of Columbia finds that 13 states go beyond the minimum federal requirements with respect to provider network standards, four states specify additional standards for including essential community providers, and five states and Washington, D.C., bar benefit substitution. These interstate variations in plan design reflect the challenges policymakers face in balancing health care affordability, benefit coverage, and access to care through the marketplace plans.

Health insurance exchanges are the centerpiece of the private health insurance reforms included in the Patient Protection and Affordable Care Act. As of May 2012, 13 states, together with the District of Columbia, had taken legal action to establish exchanges, through legislation or executive order. State implementing laws are essential to the translation of broad federal policies into specific state and market practices. Overall, the laws in the 14 jurisdictions vary, but they tend to show a common approach of according exchanges much flexibility in how they will operate and what standards they will apply to the insurance products sold. In all states, these "threshold policies" will be followed by policy decisions, expressed through regulations, guidelines, and health plan contracting and performance standards.

In establishing minimum coverage standards for health insurance plans, the Affordable Care Act includes an "essential health benefits" statute that directs the U.S. Secretary of Health and Human Services not to make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life. This issue brief examines how this statute will help Americans with disabilities, who currently are subject to discrimination by insurers based on health status and health care need. The authors also discuss the complex issues involved in implementing the essential benefits provision and offer recommendations to federal policymakers for ensuring that people with disabilities receive the full insurance benefits to which they are entitled.

The Affordable Care Act will extend health insurance coverage by both expanding Medicaid eligibility and offering premium subsidies for the purchase of private health insurance through state health insurance exchanges. But by definition, eligibility for these programs is sensitive to income and can change over time with fluctuating income and changes in family composition. The law specifies no minimum enrollment period, and subsidy levels will also change as income rises and falls. Using national survey data, we estimate that within six months, more than 35 percent of all adults with family incomes below 200 percent of the federal poverty level will experience a shift in eligibility from Medicaid to an insurance exchange, or the reverse; within a year, 50 percent, or 28 million, will. To minimize the effect on continuity and quality of care, states and the federal government should adopt strategies to reduce the frequency of coverage transitions and to mitigate the disruptions caused by those transitions. Options include establishing a minimum guaranteed eligibility period and "dually certifying" some plans to serve both Medicaid and exchange enrollees.

One of the most challenging aspects of health care improvement and reform is ensuring that individuals, particularly those who are vulnerable and low income, have access to care. Just as challenging is the imperative to ensure that the care accessed is of the highest quality possible. The Institute of Medicine (IOM) report, Crossing the Quality Chasm, identified the primary goal of any high-quality heath care system: The ability to furnish the right care, in the right setting, at the right time. This aim must also be the primary goal of Medicaid in regard to providing access to high-quality care for women throughout the reproductive cycle. Nationwide, Medicaid is a large purchaser of maternity care; in 2006, the program paid for 43% of all births and maternity costs represented 29% of all hospital charges to Medicaid. Under current federal law, state Medicaid agencies have to fulfill several obligations related to assessing, ensuring, and improving the quality of care, particularly for enrollees who receive services through managed care arrangements. The main purpose of this article is to analyze and describe the role of Medicaid in facilitating access to care for pregnant women and ensuring high-quality maternity care that is affordable. It first summarizes the federal Medicaid requirements regarding eligibility, coverage of benefits, financing, and service delivery, with a special emphasis on existing quality provisions. Then, it discusses current issues and recommends several Medicaid reforms, particularly in the area of quality assessment and improvement. All reforms, including Medicaid reforms, should seek to support the IOM-identified aims. Much of the emphasis in Medicaid policy development has been focused on access to care and great need for reform remains in the area of quality assurance and improvement, and disparity reduction because the program can play a significant role in this regard as well. More broadly, health care reform may provide an opportunity to revisit key issues around access to and quality of maternity care, including the benefit package, the content of services covered in the package, the frequency with which these services should be furnished, and the development of meaningful measures to capture whether women of childbearing age, including pregnant women, regardless of insurance status, indeed receive efficient, timely, effective, safe, accessible, and woman-centered maternity care., (Copyright 2010 Jacobs Institute of Women)

This policy brief examines Medicaid's assurance of medical transportation in the context of medically necessary but non-emergency health care. Reviewing the origins and evolution of the assurance and presenting the results of a 2009 survey of state Medicaid programs, the results of this analysis underscore Medicaid's unique capacity to not only finance medically necessary health care but also the services and supports that enable access to health care by low income persons since Medicaid covers non-emergency medical transportation. This ability to both finance health care and enable its use moves to the forefront as Congress considers whether to assist low income persons in health reform through Medicaid expansions or via subsidies for traditional health insurance, which typically does not provide comparable transportation coverage.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

This article examines health insurance coverage among women of reproductive age and considers how national health insurance reform may affect access to high-quality, timely, and affordable preconception and interconception care. A focus on preconception and interconception care increasingly is understood as essential, not only to the health of women, but to that of infants as well, and thus, as a key part of a comprehensive infant health strategy. After a brief overview that examines the relationship between preconception and interconception health care and health insurance reform, the article examines the current state of health insurance coverage among women of childbearing age and the underlying causes of uninsurance and underinsurance in this population group. The article then sets forth a proposed health insurance reform taxonomy in the context of health and health care generally, and preconception and interconception health care in particular. It is the underlying assumption of this article that preconception and interconception care can serve as bellwethers of the extent to which health reform achieves preventive results. Such results include coverage reforms that not only put acute treatments within financial reach, but that also help finance interventions that can help to achieve population-wide preventive results, in this case, long-term improvement in the health of both women and children.

Contained in the Deficit Reduction Act of 2005 is a provision that could greatly affect Medicaid's signature child health coverage standard, embodied since 1967 in the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. Whether the core child health and developmental principles that have been EPSDT's touchstone for four decades will continue to guide Medicaid depends on whether and how these principles will be incorporated into states' coverage reforms.

National attention on issues of public health preparedness necessarily brings into sharp focus the question of how to assure adequate, community-wide health care financing for preventive, acute care, and long-term medical care responses to public health threats. In the U.S., public and private health insurance represents the principal means by which medical care is financed. Beyond the threshold challenge of the many persons without any, or a stable form of, coverage lie challenges related to the structure and characteristics of health insurance itself, particularly the commercial industry and its newly emerging market of consumer-driven health plans. States vary significantly in how they approach the regulation of insurance and in their willingness to support various types of insurance markets. This variation is attributable to the size and robustness of the insurance market, the political environment, and regulatory tradition and custom. Reconciling health insurance markets with public health-related health care financing needs arising from public health threats should be viewed as a major dimension of national health reform.

A group of 13 panelists were brought together by the Journal and the Massachusetts Medical Society to discuss the U.S. health policy and debate whether it has actually managed to cover the entire American population. Results suggested that the medical community is quite dissatisfied and need health care reforms.

The article discusses the Medicaid coverage gap created by the U.S. Supreme Court's landmark decision in National Federation of Independent Business v. Sebelius. Topics covered include the effect of the decision on the nation's poorest working-age adults, the various options for closing the gap, and the Affordable Care Act's pluralistic approach to insurance coverage.

In 2017, Medicaid faced a near-death experience, the third of its 53-year history. Its survival and resilience is a testament not just to its size but to the multiple, vital roles Medicaid plays in the health care system, and its ability to adapt to emerging population health needs. It can take an existential threat to make these indispensable qualities clear. [ABSTRACT FROM AUTHOR]

The article talks about the misconception about poor working-age adults in the U.S. and their health care, including the national attitude toward the poor. Topics discussed include the health care reforms brought by the Affordable Care Act's (ACA); the efforts to remove Medicaid expansion in several U.S. states; and the need to improve government assistance to health care of the poor.

As 2017 ended, Medicaid's entitlement structure--and the funding base on which this structure rests--remained intact. During the Trump administration's first year, this largest and most unique form of US health insurance faced an existential threat under three distinct waves of legislative attack as part of the efforts to repeal the Affordable Care Act (ACA). The first two waves would have preserved the ACA's transformative change by maintaining the eligibility category created by health reform for working-age low-income adults. But the price exacted for this concession was enormous: loss of the very federal funding on which the ability to provide coverage rests. The third wave would have gone further, not only destroying Medicaid's open-ended funding structure but also stripping states of the option to extend federally- financed assistance to all poor working-age adults. The effort to effectively end Medicaid as we know it failed for both political and policy reasons, but the existential threat continues in Congress, the executive branch, and the courts. [ABSTRACT FROM AUTHOR]

The author discusses the importance of health centers which were established as an Office of Economic Opportunity demonstration program in the U.S. He states the enactment of the Public Health Service Act in 1975 to be part of the U.S. health care system, and the importance of the centers to the poorest communities in the U.S.

An essay is presented on health care reform in America, the U.S. federal Medicaid statute, and private health insurance in the country. The nation's Patient Protection and Affordable Care Act is mentioned in relation to Medicaid coverage for poor adults, as well as employer-sponsored and government health insurance. Social contracts are mentioned, along with the U.S. Supreme Court case National Federation of Independent Business v. Sebelius which deals with the expansion of Medicaid.

Thirty-eight percent of US children depend on publicly financed health insurance, reflecting both its expansion and the steady erosion of employment-based coverage. Continued funding for the Children's Health Insurance Program (CHIP) is an immediate priority. But broader reforms aimed at improving the quality of coverage for all insured children, with a special emphasis on children living in low-income families, are also essential. This means addressing the “family glitch,” which bars premium subsidies for children whose parents have access to affordable self-only employer-sponsored benefits. It also means addressing the quality of health plans sold in the individual and small-group markets—whether or not purchased through the state and federal exchanges—that are governed by the “essential health benefit” standard of the Affordable Care Act (ACA). In this article we examine trends in coverage and the role of Medicaid and CHIP. We also consider how the ACA has shaped child health financing, and we discuss critical issues in the broader insurance market and the need to ensure plan quality, including the scope of coverage, use of a pediatric medical necessity standard that emphasizes growth and development, the structure of pediatric provider networks, and attention to the quality of pediatric health care. [ABSTRACT FROM AUTHOR]

This installment of Law and the Public's Health provides an overview of the Patient Protection and Affordable Care Act, signed into law on March 23, 2010. The Act represents a watershed in U.S. public health policy. When fully implemented, its insurance reforms are expected to lead to coverage of 94% of the population, and its health-care provisions lay the groundwork for the fundamental transformation of the health-care system. [ABSTRACT FROM AUTHOR]

The article discusses the implications of comparative effectiveness research (CER) for public health policy and practice in the U.S. As reported, the implementation of CER is anticipated by the Patient Protection and Affordable Care Act (PPACA) as a matter of formal federal policy and practice in the country. One of the most controversial issues is the use of cost information in CER.