Political Perspectives: The Affordable Care Act essay

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Political Perspectives: The Affordable Care Act

9.1 Did It Work?

The U.S. healthcare system is large and complex, so it is no surprise that there are areas that need to be fixed. The Affordable Care Act (ACA) was one of the first major pieces of legislation passed to reform the U.S. healthcare system.

Select and describe one problem that the U.S. healthcare system was facing that the ACA attempted to fix. Were any of the elements of the ACA a new concept/solution to healthcare policy? 650 words and in text citations

9.2: Which Side of the Aisle Is Correct?

The passage of the ACA was heavily partisan along party lines between Republicans and Democrats, with Democrats in full support. Each side of the political spectrum continues to believe that its solutions are better than the other side’s solutions. With such a major piece of legislation, can the solutions be so divided along party lines and still be in the best interests for the country?

Describe one problem that both sides of the political spectrum agree is a problem. Ensure you include why you believe that problem is agreed-upon by both sides. 650 words and in text citations

9.3 Week 9 Journal Entry: Let’s Evaluate the ACA

Value: 100 points

Journal writing provides a non-threatening way to explore different thoughts, ideas and topics without being concerned about audience presentation. The process of writing can facilitate reflection and allow students to express feelings regarding their educational experiences as well as clarify their thinking.

Write about the following in your journal:

It is obvious that the healthcare system is complex and full of problems. Many argue that the ACA was not effective in solving many of the healthcare problems in the United States. Were the healthcare problems that the ACA attempted to address and correct successful? Why or why not? Should policy and resources been applied elsewhere to have better success?

Your journal entry should be four paragraphs long.

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GE N E R ATIONS – Journal of the American Society on Aging By Bruce Chernof, guest editor The Three Spheres of Aging in America: The Affordable Care Act Takes on Long-Term-Care Reform for the 21st Century Aging policy in America has focused on three domains of security for elders: economic security, health security, and functional security. But in the last century, major changes in the economic and health spheres have driven a need to address the third—and newest— sphere of security: physical and cognitive function. A ll public policy, whether supporting public or private goals, is built to solve a specific human or social problem. As a result, the very nature of policy making is by degrees reactive and static, created from a combination of historical facts, current conditions, and future projections. The product from these debates often is built on compromise, with analysis of effectiveness left for future generations. The corridors of public life are filled with challenges and opportunities, big and small, so that once a “solution” is hammered out, attention turns to other press- ing questions of the day. So what does this mean for policy set to address aging issues? Aging policy in the United States across the twentieth century has occurred in fits and starts, more punctuated equilibrium than gentle evolutionary gradualism. Aging policy in the United States has focused on three domains of security for older Americans: economic security, health security, and functional security (see Figure 1, page 46). The twentieth century witnessed major changes in the economic and health spheres of aging, creating the need to address Copyright © 2011 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or distributed in any form without written permission from the publisher: American Society on Aging, 71 Stevenson St., Suite 1450, San Francisco,CA 94105-2938; e-mail: info@asaging.org. the third and newest sphere of security when physical and cognitive function start to fail. Substantial Progress on Two of Three Fronts The passage of the Social Security Act in 1935 squarely addressed the issue of economic security and fundamentally defined and changed the way the country thought about supporting populations as they age. The addition of Supplemental Security Income in 1956 and Social Security Disability Insurance in 1972 further built out the program. Over the latter half of the twentieth century, Spring 2011 • Vol. 35 . No. 1 | 45 GE NER ATIO NS – Journal of the American Society on Aging Figure 1. The Three Spheres of Aging in the United States Income Security Health Security public policy focused on advancing private solutions, including defined contribution plans and retirement savings programs such as 401(k) and 403(b) plans. The passage of Medicare and Medicaid in 1965 addressed policy solutions focusing on health security for older and low-income Americans. Much public policy in recent decades has focused on the development of public–private partnerships to improve the effectiveness and efficiency of these programs through the use of managed-care techniques. A robust set of private sector solutions, such as Medigap and retiree supplemental insurance, has been supported through policy initiatives. 46 | Spring 2011 • Volume 35 . Number 1 Functional Security In the sphere of functional security, a vibrant mix of public and private solutions resulting from a broad policy framework is simply not to be found. Arguably, the first major policy initiative to support functional Pages 45–49 While private long-termcare insurance dates back to the 1970s, these programs have never captured more than 8 percent of the market (Georgetown University, 2007). An attempt to create catastrophic coverage within Medicare was passed in 1988. In less than two years Congress repealed it, largely because elders resented a new tax to cover the cost of the expanded coverage. For Americans older than 65, there is a 70 percent chance that they will require some form of long-term services and supports in their lifetime (Kemper, Komisar, and Alecxih, 2005). On average these services and supports will be required for three years, although the range is quite broad, with roughly 20 percent requiring five or more years (O’Shaughnessy, 2010). The reality is that a significant number of older adults find themselves with chronic In the sphere of functional security, a vibrant mix of public and private solutions resulting from a broad policy framework is simply not to be found. security is the Older Americans Act of 1965, which was visionary but inadequately funded. Almost by default, the Medicaid program through its funding of long-term care (predominately nursing facilities) for the poor has become the significant policy initiative that supports the needs of vulnerable elders. illnesses or some level of functional limitation. Medicare beneficiaries with five or more chronic conditions represent almost 80 percent of all Medicare spending (Anderson, 2010). People with chronic conditions and functional limitations are even more likely to use healthcare services (The ©American Society on Aging Pages 45–49 Lewin Group, 2010). Most elders find themselves completely unprepared and overwhelmed by these health status changes and increasing functional needs: some individuals spend all their resources to pay for health and supportive services, become impoverished, and find themselves completely dependent upon a patchwork of public programs. Ultimately, Medicare and Medicaid bear significant costs for this care. Perception vs. Reality Polling and health services research data have shown time and time again that most people do not understand the strong likelihood that they will need long-term services and supports as they age. Why is this? One reason is that longevity and the demographics of The Affordable Care Act: A Way Toward Aging with Dignity in America illness and death have changed dramatically over the last century. Looking at the top ten causes of death in 1910 compared to 2007, the ratio of acute to chronic conditions is reversed (see Table 1). In 1900, the average life expectancy was 49 years. In 1935, the year Social Security was enacted, it was 62 years. In 1965, when Medicare and Medicaid began, it was 69 years. In 2007, the average life expectancy reached an all-time high of 78 years (Xu et al., 2010). Social Security, Medicare, and Medicaid were all enacted at times when anticipated life expectancy was much shorter and with much less burden of chronic illness. Instead of a few years of support, these programs now provide decades of assistance, a change in demography Table 1. Life Expectancy and Top Ten Causes of Death in 1910 and 2007 1910 2007 Heart disease Heart disease Influenza and pneumonia Cancer Tuberculosis Stroke Diarrhea, enteritis, and ulceration of the intestines Chronic lower respiratory diseases Stroke Accidents Nephritis Alzheimer’s Disease Accidents (excluding motor vehicle) Diabetes Cancer Influenza and pneumonia Premature birth Nephritis Senility Septicemia Source: Centers for Disease Control and Prevention, 2009a; CDC, 2009b. ©American Society on Aging with considerable stress on the trust funds for both Medicare and Social Security. In 2009, prior to the passage of the Patient Protection and Affordable Care Act (ACA), the solvency horizon for the Medicare Trust Fund was approximately eight years and for the Social Security Trust fund less than thirty years (Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2010; Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds, 2010). A looming projection is that by 2030, Medicare and Medicaid will consume one-third of the federal budget (Linden, 2010). Impacts of the Affordable Care Act One important impact of the ACA is that it extends the solvency of the Medicare Trust Fund by an additional twelve years, more than doubling the solvency horizon (Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, 2010). Less pressing but also on the agenda is addressing the Social Security Trust Fund. It is important to recognize that the three spheres of security are interrelated and dependent upon each other to a significant degree. The new health law also provides some important Spring 2011 • Volume 35 . Number 1 | 47 GE NER ATIO NS – Journal of the American Society on Aging opportunities to fundamentally improve the state of public policy and programs in the sphere of functional security. The CLASS Plan The most significant policy advance in the functional security sphere is the Community Living Assistance Services and Supports (CLASS) Plan, which will provide a daily cash benefit that an eligible beneficiary can use to purchase services and supports based on their needs. While the daily cash payment will not be large enough to cover the cost of a nursing home, it will go a long way toward providing for home- and community-based services that could forestall or prevent the need for eventual nursing home placement. According to the Congressional Budget Office, CLASS is projected to save the federal government almost $2 billion in federal Medicaid costs (Congressional Budget Office, 2009). There are likely state-level Medicaid savings as well, because tomorrow’s vulnerable individuals with access to the CLASS benefit will likely spend down more slowly to reach the Medicaid poverty threshold. CLASS fundamentally changes the policy paradigm for vulnerable elders from a povertybased discussion to one that allows for planning and personal responsibility. The CLASS Plan also has the potential to change the way the 48 | Spring 2011 • Volume 35 . Number 1 long-term-care insurance market operates, opening the door for the development of new supplemental and wraparound insurance policies that could work synergistically with CLASS. This would give people more choice than the current all-or-none approach of comprehensive long-termcare insurance. Pages 45–49 Federal Coordinated Health Care Office, informally referred to as the Duals Office, and the Center for Medicare and Medicaid Innovation, also known as the Innovation Center. The Duals Office is tasked with reducing the administrative and legal barriers that prevent financial and programmatic coordination across these two important programs; it will also focus on supporting state-level pilots to test models that should improve care and reduce costs. The Innovation Center is specifically charged with testing an array of new models that could substantially improve the lives of vulnerable Additional opportunities and innovations Also within the ACA are important opportunities to improve healthcare for impoverished elders served through Medicaid. These opportunities include incentives for states to modernize, restructure, and expand home- and communitybased services programs such as the State Most people do not understand Balancing Incentive the strong likelihood that they Payments Program and will need long-term services the Community First and supports as they age. Choice option. Other efforts include extenelders. These models include sion of the Money Follows the Person Demonstration and new different payment systems, such as bundling payments, as flexibility for home- and comwell as specific interventions to munity-based services within improve some of the most Medicaid state plans. Many of these new Medicaid opportuni- intractable problems of the day, such as medication errors and ties may prove challenging for preventable rehospitalizations. interested states to implement Taken together, these because of the recession and their balanced budget mandates, specific policies, as well as many others in the ACA, represent an but they symbolize new opporimportant opportunity to create tunities to create efficiencies a new foundation for long-term within the system. services and supports in the The ACA also created two future. This foundation will only entities within the Centers for prove successful if these policy Medicaid and Medicare: the ©American Society on Aging Pages 45–49 The Affordable Care Act: A Way Toward Aging with Dignity in America changes are implemented in ways that result in a more integrated and person-centered approach, as opposed to the perpetuation of the siloed program models that exist today. Older Americans have far more resources available to them to address economic and health security needs than were available for their grandparents or great-grandparents. Medical advances have added The Challenge of the Century years, even decades, to people’s Over the last century, public lives, but for many, a handful policy has supported and of those years will come with developed important advances significant functional limitaboth in the public and private tions. The ACA provides sectors to help people prepare important opportunities to for their retirement years. build the infrastructure that meets their individual needs. The challenge of this century will be to take on this third sphere of security—to address serious functional needs as we age, in ways that support robust, coordinated public and private solutions. Bruce Chernof, M.D., is president and CEO of The SCAN Foundation, Long Beach, Calif. He is guest editor of this Spring 2011 issue of Generations. References Anderson, G. 2010. “Chronic Care: Making the Case for Ongoing Care.” www.rwjf.org/files/ research/50968chronic.care. chartbook.pdf. Retrieved March 26, 2011. Centers for Disease Control and Prevention (CDC). 2009a. “Leading Causes of Death, 1900−1998.” www.cdc.gov/nchs/data/dvs/ lead1900_98.pdf. Retrieved March 26, 2011. Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 2010. The 2010 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. www.cms. gov/ReportsTrustFunds/down loads/tr2010.pdf. Retrieved March 26, 2011. CDC. 2009b. “Leading Causes of Death.” www.cdc.gov/nchs/fastats/ lcod.htm. Retrieved March 23, 2011. Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds. 2010. The 2010 Annual Report of the Board of Trustees of the Federal Old-Age and Survivors Insurance and Federal Disability Insurance Trust Funds. www.ssa. gov/oact/tr/2010/tr2010.pdf. Retrieved March 26, 2011. ©American Society on Aging Congressional Budget Office. 2009. “H.R. 3962, Affordable Health Care for America Act (November 25, 2009).” www.cbo.gov/costesti mates/health.cfm. Retrieved March 26, 2011. Georgetown University. 2007. “National Spending for Long-Term Care.” http://ltc.georgetown.edu/ pdfs/natspendfeb07.pdf. Retrieved February 17, 2011. Kemper, P., Komisar, H. L., and Alecxih, L. 2005. “Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect?” Inquiry 42(4): 335−50. Linden, M. 2010. “The Math is Clear: Reducing Our Long-Term Federal Budget Deficit Means Enhancing Health Care Reform Now.” www.americanprogress.org/ issues/2010/03/pdf/health_re form_budget_memo.pdf. Retrieved March 26, 2011. O’Shaughnessy, C. V. 2010. “National Spending for LongTerm Services and Supports (LTSS).” www.nhpf.org/library/ details.cfm/2783. Retrieved March 26, 2011. The Lewin Group. 2010. Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look. Final Report for the Office of the Assistant Secretary for Planning & Evaluation, U.S. Department of Health and Human Services. Falls Church, Va.: The Lewin Group. Xu, J., et al. 2007. Deaths: Final Data for 2007. National Vital Statistics Reports. www.cdc.gov/ nchs/data/nvsr/nvsr58/nvsr58_19. pdf. Retrieved March 26, 2011. Spring 2011 • Volume 35 . Number 1 | 49 Copyright of Generations is the property of American Society on Aging and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. ORIGINAL ARTICLE The March to Accountable Care Organizations—How Will Rural Fare? A. Clinton MacKinney, MD, MS;1 Keith J. Mueller, PhD;2 & Timothy D. McBride, PhD3 1 RUPRI Center for Rural Health Policy Analysis, University of Iowa, Iowa City, Iowa 2 Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa 3 George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri Abstract This analysis was funded by a cooperative agreement from the federal Office of Rural Health Policy, Health Resources and Services Administration, DHHS (Grant #1U1C RH03718). The authors thank Sue Nardie for her help in editing this manuscript. For further information, contact: A. Clinton MacKinney, MD, MS, 33291 North 91st Avenue, St. Joseph, MN 56374; e-mail clintmack@cloudnet.com. doi: 10.1111/j.1748-0361.2010.00350.x Purpose: This article describes a strategy for rural providers, communities, and policy makers to support or establish accountable care organizations (ACOs). Methods: ACOs represent a new health care delivery and provider payment system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the literature to describe successful integrated health care organizations that will likely become the first ACOs. Previous research studying rural managed care organizations found rural success stories that can inform the ACO discussion. Findings: Preconditions for success as ACOs include enrolling a minimum number of patients to manage financial risk and implementing medical care policies and programs to improve quality. Rural managed care organizations succeeded because of care management experience, nonprofit status, and strong local leadership focused on improving the health of the population served. Conclusions: Rural provider participation in ACOs will require collaboration among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate programs that motivate their populations to achieve and maintain optimum health status. Policy makers should develop rural-relevant ACO-performance measures and provide necessary technical assistance to rural providers and organizations. Key words accountable care organizations (ACOs), Affordable Care Act (ACA), health care organizations, health care reform, rural physician practices. Accountable care organizations (ACOs) have become one of the hottest new trends in health care. As a new Medicare payment and health care delivery alternative established by the Patient Protection and Affordable Care Act (ACA), ACOs create opportunities for rural health care providers to improve health care quality and control health care costs in their communities. However, despite new opportunities, a bright future for rural providers is c 2010 National Rural Health Association The Journal of Rural Health 27 (2011) 131–137  not assured. Rural providers must remain cautious of urban-based policies and large health care system programs that might disadvantage rural health care delivery. But caution has its limits. Rural stakeholders should proactively participate in ACO development discussions during rule making and implementation of the ACA. Rural pr ...
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