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The Affordable Care Act (ACA) is a mosaic across a spectrum of health policy domains. The law contains hundreds of smaller and mostly unnoticed reforms aimed at nearly every segment of American health policy. Ten years later, these provisions include successes, failures, and mixed bags, which should be considered in any full assessment of the ACA. This article examines 11 from each of these 3 categories, drawn from 9 of the ACA's 10 titles. These mininarratives deepen recognition that the ACA is our best example of comprehensive health reform and defies simplistic judgments., (Copyright © 2020 by Duke University Press.)

Medicaid has become the nation's most important health coverage program, covering more individuals and costing more than Medicare. Because Medicaid finances the health care for society's most challenging cases, it deserves the characterization: "the workhorse of the U.S. health care system." A chief difficulty is that the program is housed within state governments, which means its fiscal fate is tied to the well-being of state economies. State revenues tend to decline just when health care spending and Medicaid spending reach their highest points. States have numerous strategies they employ to reduce the rate of growth in Medicaid spending, though none have strategies to halt relentless cost pressures. The policy challenge today is to survive this difficult period with the least damage to vulnerable individuals, families, and safety net providers.

The author comments on Bruce Vladeck's 2003 article "Universal Health Insurance in the United States: Reflections on the Past, the Present, and the Future" which offers historical-cultural and structural-political explanations for the U.S.' lack of universal health insurance. Topics discussed include Vladeck's historical-cultural explanations for the laggard status of U.S. health insurance coverage that are relevant in 2023 and Vladeck's political-structural explanations.

Policy PointsSince the Surgeon General's report in 2000, multiple stakeholder groups have engaged in advocacy to expand access to oral health coverage, integrate medicine and dentistry, and to improve the dental workforce.Using a stakeholder map across these three policy priorities, we describe how stakeholder groups are shaping the oral health policy landscape in this century. While the stakeholders are numerous, policy has changed little despite invested efforts and resources.To achieve change, multiple movements must coalesce around common goals and messages and a champion must emerge to lead the way. The ongoing COVID‐19 pandemic and political changes due to the 2020 elections can open a window of opportunity to unite stakeholders to achieve comprehensive policy change. [ABSTRACT FROM AUTHOR]

The article focuses on "Statement on the Purpose of the Corporation". Topics include non-profit association The Business Roundtable (TBR's) released statement that feature interests of workers, customers, and "other stakeholders" along with company's shareholders; and use of similar national examination and conversation about the history, experience, and results from health for-profit corporatization and medical care sector.

The article offers information on single-payer health care system and discusses the need of changes in the system of medical care. Topics discussed include single-payer advocates could not make the case to convince voters that the program would be financially sound; former U.S. Presidents Harry Truman and Bill Clinton lost big-time because the opposition overwhelmed advocates; and structure of the U.S. health care financing consists of high payments.

The author reflects on his desire to hear 2016 U.S. presidential candidates address the National Academy of Medicine's (NAM's) 2013 report entitled "U.S. Health in International Perspective: Shorter Lives, Poorer Health" while on the campaign trail. America's public health and medical care system are examined, along with a mortality gap among adults age 50 and older. Political agendas are assessed, as well as health care spending and the views of conservatives and left-wing individuals.

Section 1332 of Title I of the Affordable Care Act offers to state governments the ability to waive significant portions of the ACA, including requirements related to qualified health plans, health benefit exchanges, cost sharing, and refundable tax credits. It permits state governments to obtain funding that otherwise would have gone to residents and businesses through the ACA and to use those funds to establish, beginning in 2017, an alternative health reform framework within statutory limitations. Section 1332 also permits states to apply in a coordinated fashion for waivers from Medicare, Medicaid, the Children's Health Insurance Program, and ‘‘any other federal law relating to the provision of health care items or services.'' This article reviews the statutory provisions and related regulations of this new and unprecedented state waiver authority, as well as the legislative history of section 1332. Finally, it reviews the limited activities thus far by states contemplating use of this provision and considers ways this authority may be considered for use by states in the future. Section 1332 has the potential to instigate a new, varied, and unprecedented array of state health sector innovations from both sides of the political divide over health care reform. [ABSTRACT FROM AUTHOR]

In 2010, the United States adopted its first-ever comprehensive set of health system reforms in the Affordable Care Act (ACA). Implementation of the law, though politically contentious and controversial, has now reached a stage where reversal of most elements of the law is no longer feasible. The controversial portions of the law that expand affordable health insurance coverage to most U.S. citizens and legal residents do not offer any important lessons for the global community. The portions of the law seeking to improve the quality, effectiveness, and efficiency of medical care as delivered in the U.S., hold lessons for the global community as all nations struggle to gain greater value from the societal resources they invest in medical care for their peoples. Health reform is an ongoing process of planning, legislating, implementing, and evaluating system changes. The U.S. set of delivery system reforms has much for reformers around the globe to assess and consider. [ABSTRACT FROM AUTHOR]

Since its passage in April 2006, the Massachusetts health reform law (Chapter 58) has expanded affordable insurance coverage to 355,000 people. Major milestones have been achieved, including establishment of new coverage programs, merger of small- group and nongroup insurance markets, creation of an insurance "Connector," determination of affordability and penalty standards for an individual mandate, and launch of employer responsibility requirements. Key challenges remain, including full implementation of the individual mandate, cost control, and securing of long-term financing. Massachusetts health reform is offering valuable and important lessons for the nation. [ABSTRACT FROM AUTHOR]

Enactment of ambitious health reform laws in Massachusetts and Vermont in 2006 helped instigate a wave of state legislative activities to expand coverage to uninsured people. We identify thirty-nine states that have enacted laws in at least one access category since 2006. At least thirteen states have begun processes to enact comprehensive reforms to cover at least half of their uninsured residents. Key activities involve coverage expansions for uninsured children and for uninsured adults; regulatory changes in small-group and individual insurance markets; and individual and employer mandates. The future extent and durability of this wave are uncertain. [ABSTRACT FROM AUTHOR]

Evaluates the use of anecdotes in making public health policies in the United States. Overlap of careful policy analysis by anecdotes; Details on anecdotes used for bolstering competing values; Identification of neglected policy problems.

The authors reflect on the significance of the reforms contained in the U.S. Affordable Care Act (ACA) and their implications for the U.S. health care system. They explain the plan to extend the guaranteed issue provision of the law which makes the practice of selective medical underwriting illegal. They also discuss issues related to the implementation of the individual shared responsibility provision and Medicaid expansion.

As its 2012 session drew to a close, the Massachusetts legislature passed a much-anticipated cost control bill. The bill sets annual state spending targets, encourages the formation of accountable care organizations, and establishes an independent commission to oversee health care system performance. It is Massachusetts's third law to address health spending since the state's landmark health insurance coverage reforms in 2006. The 2012 legislation is a notable step beyond other recent cost control efforts. Although it lacks strong mechanisms to enforce the new spending goals, it creates a framework for increased regulation if spending trends fail to moderate. Massachusetts's experience provides several lessons for state and federal policy makers. First, implementing near-universal coverage, as is planned under the Affordable Care Act for 2014, will increase pressure on government to begin controlling overall health care spending. Second, introduction of cost control measures takes time: Massachusetts enacted a series of incremental but increasingly strong laws over the past six years that have gradually increased its ability to influence health spending. Finally, the effectiveness of new cost control laws will depend on changes in providers' and insurers' behavior; in Massachusetts, private market activity has had a complementary impact on the pace of health system change. [ABSTRACT FROM AUTHOR]