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

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

Inequalities in avoidable hospitalisation in large urban areas: retrospective observational study in the metropolitan area of Milan

Significant inequalities in access to healthcare system exist between residents of world megacities, even if they have different healthcare systems. The aim of this study was to estimate avoidable hospitalisations in the metropolitan area of Milan (Italy) and explore inequalities in access to healthcare between patients and across their areas of residence

Cities and Health: A Response to the Recent Commentaries

We are grateful to our many colleagues who took the time to respond to our analysis of Shanghai’s declining “avoidable mortality.”1 The range of their perspectives across 5 recent commentaries reassures us that the topic is worthy of sustained study. Indeed, the presumption behind our comparative research on healthcare in world cities 2 is that the city is a strategic unit of analysis for understanding the health sector and that world cities share a host of important characteristics

Reduce Avoidable Hospitalisations: A Policy to Increase Value from Health Care Expenditures

An interdisciplinary examination of rates of avoidable hospitalizations in France and England to evaluate access to primary care and identify the extent to which these countries may be able to reduce hospital costs by investing in disease management and primary care

Needed: Global Collaboration for Comparative Research on Cities and Health

Over half of the world’s population lives in cities and United Nations (UN) demographers project an increase of 2.5 billion more urban dwellers by 2050. Yet there is too little systematic comparative research on the practice of urban health policy and management (HPAM), particularly in the megacities of middle-income and developing nations. We make a case for creating a global database on cities, population health and healthcare systems. The expenses involved in data collection would be difficult to justify without some review of previous work, some agreement on indicators worth measuring, conceptual and methodological considerations to guide the construction of the global database, and a set of research questions and hypotheses to test. We, therefore, address these issues in a manner that we hope will stimulate further discussion and collaboration

Shanghai rising: health improvements as measured by avoidable mortality since 2000

Over the past two decades, Shanghai, the largest megacity in China, has been coping with unprecedented growth of its economy and population while overcoming previous underinvestment in the health system by the central and local governments. We study the evolution of Shanghai’s healthcare system by analyzing “Avoidable Mortality” (AM) – deaths amenable to public health and healthcare interventions, as previously defined in the literature. Based on analysis of mortality data, by cause of death, from the Shanghai Municipal Center for Disease Control and Prevention, we analyze trends over the period 2000–10 and compare Shanghai’s experience to other mega-city regions – New York, London and Paris. Population health status attributable to public health and healthcare interventions improved dramatically for Shanghai’s population with permanent residency status. The age-adjusted rate of AM, per 1,000 population, dropped from 0.72 to 0.50. The rate of decrease in age-adjusted AM in Shanghai (30%) was comparable to New York City (30%) and Paris (25%), but lower than London (42%). Shanghai’s establishment of the Municipal Center for Disease Control and Prevention and its upgrading of public health and health services are likely to have contributed to the large decrease in the number and rate of avoidable deaths, which suggests that investments in public health infrastructure and increasing access to health services in megacities – both in China and worldwide – can produce significant mortality declines. Future analysis in Shanghai should investigate inequalities in avoidable deaths and the extent to which these gains have benefitted the significant population of urban migrants who do not have permanent residency status

The Role of Formal Policy To Promote Informed Consent of Psychotropic Medications For Youth in Child Welfare Custody: a National Examination

Active participation of youth and surrogate decision-makers in providing informed consent and assent for mental health treatment is critical. However, the procedural elements of an informed consent process, particularly for youth in child welfare custody, are not well defined. Given calls for psychotropic medication oversight for youth in child welfare custody, this study proposes a taxonomy for the procedural elements of informed consent policies based upon formal and informal child welfare policies and then examines whether enacted state formal policies across the United States endorsed these elements. A sequential multi-method study design included: (1) semi-structured interviews with key informants (n = 58) primarily from state child welfare agencies to identify a taxonomy of procedural elements for informed consent of psychotropic medications and then (2) a legislative review of the 50 states and D.C. to characterize whether formal policies endorsed each procedural element through February 2022. Key informants reported five procedural elements in policy, including how to: (1) gather social and medical history, (2) prescribe the medication, (3) authorize its use through consent and youth assent, (4) notify relevant stakeholders, and (5) routinely review the consenting decision. Twenty-three states endorsed relevant legislation; however, only two states specified all five procedural elements. Additionally, the content of a procedural element, when included, varied substantively across policies. Further research and expert consensus are needed to set best practices and guide policymakers in setting policies to advance transparency and accountability for informed consent of mental health treatment among youth in child welfare custody