United States Health Care Reform Progress to Date and Next Steps

IMPORTANCE The Affordable Care Act is the most important health care legislation enacted in the United States since the creation of Medicare and Medicaid in 1965. The law implemented comprehensive reforms designed to improve the accessibility, affordability, and quality of health care. OBJECTIVES To review the factors influencing the decision to pursue health reform, summarize evidence on the effects of the law to date, recommend actions that could improve the health care system, and identify general lessons for public policy from the Affordable Care Act. EVIDENCE Analysis of publicly available data, data obtained from government agencies, and published research findings. The period examined extends from 1963 to early 2016. FINDINGS The Affordable Care Act has made significant progress toward solving long-standing challenges facing the US health care system related to access, affordability, and quality of care. Since the Affordable Care Act became law, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, primarily because of the law’s reforms. Research has documented accompanying improvements in access to care (for example, an estimated reduction in the share of nonelderly adults unable to afford care of 5.5 percentage points), financial security (for example, an estimated reduction in debts sent to collection of $600-$1000 per person gaining Medicaid coverage), and health (for example, an estimated reduction in the share of nonelderly adults reporting fair or poor health of 3.4 percentage points). The law has also begun the process of transforming health care payment systems, with an estimated 30% of traditional Medicare payments now flowing through alternative payment models like bundled payments or accountable care organizations. These and related reforms have contributed to a sustained period of slow growth in per-enrollee health care spending and improvements in health care quality. Despite this progress, major opportunities to improve the health care system remain. CONCLUSIONS AND RELEVANCE Policy makers should build on progress made by the Affordable Care Act by continuing to implement the Health Insurance Marketplaces and delivery system reform, increasing federal financial assistance for Marketplace enrollees, introducing a public plan option in areas lacking individual market competition, and taking actions to reduce prescription drug costs. Although partisanship and special interest opposition remain, experience with the Affordable Care Act demonstrates that positive change is achievable on some of the nation’s most complex challenges

Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies

Background RCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design. Methods A comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model. Results Fifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively). Conclusion Results of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs

Interests, trust and security in US-Jordanian nuclear relations

This article explores the relationship between Jordan and the United States (US) in the field of nuclear energy cooperation. Since 2010 the Jordanian government has accelerated its plans for a nuclear energy program and has engaged with multiple partners around the world in order to agree terms for cooperation in technology exchange, monitoring, and the construction of infrastructure. Bilateral negotiations between the US and Jordan for a "123" nuclear cooperation agreement were underway by early 2008, but were suspended in 2011 without an agreement being reached. Jordanian nuclear energy policy has been spurred by energy security considerations (as it currently imports 97 percent of its energy needs) and the discovery of up to 120,000 tonnes of uranium ore in Jordan. At the same time, the US is primarily interested in management of nuclear technology proliferation. This work considers the perceptions of self and other in Jordanian and US policymaking in order to understand why bilateral cooperation has not materialized and what this means for nuclear proliferation in Jordan. This study finds that the US–Jordanian negotiations have been impeded by contradictory objectives and perceptions, and a "123" agreement is not likely in the short to medium term, but that development of Jordan’s nuclear energy program will likely continue regardless

Time to First-Line ART Failure and Time to Second-Line ART Switch in the IeDEA Pediatric Cohort

BACKGROUND: Globally, 49% of the estimated 1.8 million children living with HIV are accessing antiretroviral therapy (ART). There are limited data concerning long-term durability of first-line ART regimens and time to transition to second-line. METHODS: Children initiating their first ART regimen between 2 and 14 years of age and enrolled in one of 208 sites in 30 Asia-Pacific and African countries participating in the Pediatric International Epidemiology Databases to Evaluate AIDS consortium were included in this analysis. Outcomes of interest were: first-line ART failure (clinical, immunologic, or virologic), change to second-line, and attrition (death or loss to program ). Cumulative incidence was computed for first-line failure and second-line initiation, with attrition as a competing event. RESULTS: In 27,031 children, median age at ART initiation was 6.7 years. Median baseline CD4% for children ≤5 years of age was 13.2% and CD4 count for those >5 years was 258 cells per microliter. Almost all (94.4%) initiated a nonnucleoside reverse transcriptase inhibitor; 5.3% a protease inhibitor, and 0.3% a triple nucleoside reverse transcriptase inhibitor-based regimen. At 1 year, 7.7% had failed and 14.4% had experienced attrition; by 5 years, the cumulative incidence was 25.9% and 29.4%, respectively. At 1 year after ART failure, 13.7% had transitioned to second-line and 11.2% had experienced attrition; by 5 years, the cumulative incidence was 31.6% and 25.9%, respectively. CONCLUSIONS: High rates of first-line failure and attrition were identified in children within 5 years after ART initiation. Of children meeting failure criteria, only one-third were transitioned to second-line ART within 5 years

Doing more with less: Teacher professional learning communities in resource-constrained primary schools in rural China.

Teacher professional learning communities provide environments in which teachers engage in regular research and collaboration. They have been found effective as a means for connecting professional learning to the day-to-day realities faced by teachers in the classroom. In this article, the authors draw on survey data collected in primary schools serving 71 villages in rural Gansu Province as well as transcripts from in-depth interviews with 30 teachers. Findings indicate that professional learning communities penetrate to some of China’s most resource-constrained schools but that their nature and development are shaped by institutional supports, principal leadership, and teachers’ own initiative

Putting it into perspective: Mathematics in the undergraduate science curriculum

Mathematics and science are tightly interwoven, yet they are often treated as distinct disciplines in the educational context. This study details the development, implementation and outcomes of a teaching intervention that highlights the links between mathematics and science, in the form of a first-year interdisciplinary course. A mixed method study using surveys and focus groups was employed to investigate undergraduate science students' perceptions of their experiences. Findings reveal that students bring strong beliefs about the nature of mathematics and science from secondary school, which can impact significanly on the success of interdisciplinary science-mathematics courese at the teritary level. Despite this, a range of beneficial outcomes can arise from such courses when they are delivered within a framework of analysing real-world issues. However, students with weak mathematical skills derived little benefit from an interdisciplinary approach and are likely to disengage from learning, in comparision with students who enter university with a solid foundation in mathematics

(Re)Storying Obama: An Examination of Recently Published Informational Texts

American publishers have published numerous children’s books about Barack Obama over the past several years; most take the form of informational biographies. This article reports on a research project aimed at how these books incorporate sociohistorical narratives, particularly those related to the civil rights movement. Though the features of the books might cause the reader to presume political neutrality, the books link readers to distinct Discourses (Gee, 1996), suggesting particular ideologies. In this article, we identified the following differences: (1) specific happenings from Obama’s life were included in some texts while omitted in others; (2) when the events were included, how they were framed differed; and (3) the narrative constructions of the events varied. We use the differences amongst these texts to argue for the importance of critical literacy in elementary classrooms

'A foundation-hatched black elite’: Obama, the US establishment and foreign policy

US foreign policy has a largely unacknowledged racial dimension due to the racial characteristics of the US foreign policy establishment, and in shared mindsets in a soon-to-be ‘majority-minority’ nation. White Anglo-Saxon Protestant (WASP) racial-ethnic and class factors produce managed change through socialisation in an attenuated meritocratic order, adapting to challenges to elite dominance by incorporating rising talent, without altering broader patterns of power. The greatest success of such a system would be the assimilation of the most elite minority individuals, even as the bulk of those groups’ members continue to experience discrimination. Such success would be compounded by election to the highest office of a minority US president extolling the virtues of post-racial politics. President Barack Obama represents a ‘Wasp-ified’ black elite, assimilated into the extant structures of power that remain wedded to a more secular, non-biologically-racial, version of Anglo-Saxonism or, more broadly, liberal internationalism. Hence, it should occasion little surprise that there has been so little change in US foreign policies during Obama’s two-term presidency

Self-Transforming Configuration Based on Atmospheric-Adaptive Materials for Solid Oxide Cells

Solid oxide cells (SOC) with a symmetrical configuration have been focused due to the practical benefits of such configurations, such as minimized compatibility issues, a simple fabrication process and reduced cost compared to SOCs with the asymmetrical configuration. However, the performance of SOCs using a single type of electrode material (symmetrical configuration) is lower than the performance of those using the dissimilar electrode materials (asymmetrical configuration). Therefore, to achieve a high-performance cell, we design a &apos;self-transforming cell&apos; with the asymmetric configuration using only materials of the single type, one based on atmospheric adaptive materials. Atmospheric-adaptive perovskite Pr0.5Ba0.5Mn0.85Co0.15O3-delta (PBMCo) was used for the so-called self-transforming cell electrodes, which changed to layered perovskite and metal in the fuel atmosphere and retained its original structure in the air atmosphere. In fuel cell mods, the self-transforming cell shows excellent electrochemical performance of 1.10Wcm(-2) at 800 degrees C and good stability for 100 h without any catalyst. In electrolysis mode, the moderate current densities of -0.42A cm(-2) for 3 vol.% H2O and -0.62 A cm(-2) for 10 vol.% H2O, respectively, were observed at a cell voltage of 1.3V at 800 degrees C. In the reversible cycling test, the transforming cell maintains the constant voltages for 30 h at +/- 0.2A cm(-2) under 10 vol. % H2O