The Affordable Care Acts 1332 Waiver: An Avenue for Short-run Adjustment, Innovative Change, or Political Acceptance?

Although the Congress repeatedly failed to repeal and replace the Affordable Care Act (ACA) in 2017, ACA policies have changed extensively over the past year. December's tax bill eliminated the financial penalties enforcing the individual mandate, starting in 2019. The Trump administration used its executive powers to slash ACA advertising spending and shrink the ACA enrollment period, and it ceased making cost-sharing reduction payments to insurers. These changes did not appear to have a big impact on ACA's 2018 enrollments, which were only slightly below the previous year's total, but there has been a decline in the number of participating insurers, and premiums increased in many rating areas.It is still too early to know the longer-term effects of these changes, much less anticipate future developments. They do, however, suggest that states are implementing the ACA in a dynamic, uncertain environment even after the act escaped wholesale replacement. To deal with these and future changes, or to modify policies that would make state ACA programs more effective, or more to their political liking, state governments may turn to the ACA's Section 1332 State Innovation Waivers. The 1332 waivers are not the only way in which states can modify ACA policies, and their role has been limited to date. But the waivers have potential as a means for widespread policy change, and that potential may grow. As of this writing, there are bipartisan proposals in the Congress to expand the authority under the ACA's section 1332 provision to foster even more state innovation.This paper discusses the 1332 waiver — its origins, powers and limitations, and uses thus far — and how it may be used to address major challenges facing the ACA. We note, for example, a shift in the purposes of planned 1332 applications before and after the 2016 elections, a shift that suggests a new and challenging function for waivers — not simply to allow states to adopt different pathways to common policy goals, but to respond effectively and quickly to rapid changes in healthcare markets. We discuss the practicality and implications of this shift along with ways in which 1332 waivers may be used to serve other purposes, including how they may be used in combination with other waivers and instruments to bring about comprehensive reforms in the delivery of healthcare. We also discuss the prospects for 1332 waivers in the coming years, their potential roles in adapting the ACA to changing and diverse circumstances, and ways in which the waiver process may be improved

Microstructural Characterization of Mg-Al Spinel Powders

Mg-Al spinel powders have been prepared by thermal decomposition of a mixture of: A-aluminium and magnesium nitrates; B-aluminium and magnesium hydroxides; and C-aluminium hydroxide and magnesium oxalate. The initial and the final powders were both characterized by specific surface area measurements, mercury intrusion porosimetry, X-ray diffraction, and scanning electron microscopy. The results showed that the preparation process sharply influences the final microstructure of the spinel powders. In particular while the shape and particle dimensions of the samples prepared by mixture of aluminium and magnesium nitrates are mainly influenced by crushing process, the preparation via mixed magnesium and aluminium hydroxides precipitation permits use of spinel formation temperatures as low as 350°C. Characteristically this powder is very uniform and consists of small particle sizes (0.1 micrometers)

World Cities Project: New York, Paris, London, Tokyo Fact Sheet

The World Cities Project (WCP) originated as a joint research project between the International Longevity Center-USA and New York University's Robert F. Wagner Graduate School of Public Service. It has since grown to include the active involvement of the ILC-France, ILC-Japan, and ILC-UK. Also the City of Paris Department of Health and Social Affairs, the London Regional Office of the British National Health Service, the Tokyo Metropolitan Government Bureau of Health and Social Welfare, and the New York City Department of Aging and Department of Health have provided important support to the project. The project compares health, social services, and quality of life for persons aged 65 and over in the four largest urban agglomerations in the countries belonging to the Organization for Economic Cooperation and Development (OECD): New York, Paris, Tokyo and London.Although these four cities have been the subject of numerous studies in the fields of architecture and urban planning, there have been few comparative studies of health and social services. Additionally, the WCP introduces a spatial perspective to more conventional economic and demographic analyses of population aging and longevity issues. Most comparative analyses of health systems focus on national averages that mask important variations within smaller jurisdictions. In contrast, the WCP relates smaller, more comparable units providing notable advantages for cross-national learning

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