Implementing the Affordable Care Act: The Promise and Limits of Health Care Reform

The Obama administration has confronted a formidable array of obstacles in implementing the Affordable Care Act (ACA). The ACA has overcome those obstacles to substantially expand access to health insurance, though significant problems with its approach have emerged. What does the ACA's performance to date tell us about the possibilities and limits of health care reform in the United States? I identify key challenges in ACA implementation-the inherently disruptive nature of reform, partisan polarization, the limits of "near universal" coverage, complexity, and divided public opinion-and analyze how these issues have shaped its evolution. The article concludes by exploring the political and policy challenges that lie ahead for the ACA

Unraveling from Within? The Affordable Care Act and Self-Undermining Policy Feedbacks

The 2010 Patient Protection and Affordable Care Act (ACA) passed through Congress on partisan lines and with only lukewarm public support. The Obama administration and Congressional Democrats, though, had reason to expect that the ACA’s political fortunes would substantially improve as the acrimonious debate over its enactment faded and millions of Americans came to receive significant benefits from health care reform. But 5 years after its passage, the ACA’s political foundations remain shaky. We suggest that one reason for the ACA’s unsettled fate is the role of policy feedbacks that undermine public support for and opponents’ acceptance of the program. The ACA experience highlights how policy feedbacks can vary widely in their political impact, and suggests that some policies are in fact self-undermining. We also emphasize the crucial role of partisan polarization as a mediating factor in shaping policy feedbacks

The US health care system: On a road to nowhere?

THIS ARTICLE REVIEWS THE CURRENT STATE AND FUTURE PROSPECTS of the health care system in the United States. The 1990s were a decade of reform and change in US medical care, with the debate over the Clinton plan for universal insurance and, after its defeat, the spread of managed care. In particular, managed care had a profound impact on the delivery of medical services, transforming traditional insurance arrangements. However, after all of the changes, the United States appears to be no closer to solving the problems that have characterized its health care system for the past 3 decades. Over 40 million Americans lack health insurance, universal coverage is nowhere in sight, and medical care costs are rising again after a period of moderation. It is doubtful that incremental health reforms will significantly ameliorate these problems

From HMOs to ACOs: The Quest for the Holy Grail in U.S. Health Policy

The United States has been singularly unsuccessful at controlling health care spending. During the past four decades, American policymakers and analysts have embraced an ever changing array of panaceas to control costs, including managed care, consumer-directed health care, and most recently, delivery system reform and value-based purchasing. Past panaceas have gone through a cycle of excessive hope followed by disappointment at their failure to rein in medical care spending. We argue that accountable care organizations, medical homes, and similar ideas in vogue today could repeat this pattern. We explain why the United States persistently pursues health policy fads--despite their poor record--and how the promotion of panaceas obscures critical debate about controlling health care costs. Americans spend too much time on the quest for the "holy grail"--a reform that will decisively curtail spending while simultaneously improving quality of care--and too little time learning from the experiences of others. Reliable cost control does not, contrary to conventional wisdom, require fundamental delivery system reform or an end to fee-for-service payment. It does require the U.S. to emulate the lessons of other nations that have been more successful at limiting spending through budgeting, system wide fee schedules, and concentrated purchasing

The Politics of Paying for Health Reform: Zombies, Payroll Taxes, and the Holy Grail

Outlines the political and institutional contexts for efforts to finance universal health coverage. Analyzes the political feasibility and consequences of various funding options and their implications for cost control. Includes international comparisons

Significance of Medicare and Medicaid Programs for the Practice of Medicine

The 1965 legislation that established Medicare and Medicaid declared that the Federal Government would not interfere in clinical medicine. Despite the original intent, Medicare and Medicaid have had tremendous influence on medical practice. In this article, we focus on four policy areas that illustrate the influence of CMS (and its predecessor agencies) on medical practice. We discuss the implications of the relationship between CMS and clinical medicine and how this relationship has changed over time. We conclude with thoughts about potential future efforts at CMS

Repression of Sex4 and Like Sex Four2 Orthologs in Potato Increases Tuber Starch Bound Phosphate With Concomitant Alterations in Starch Physical Properties

To examine the roles of starch phosphatases in potatoes, transgenic lines were produced where orthologs of SEX4 and LIKE SEX FOUR2 (LSF2) were repressed using RNAi constructs. Although repression of either SEX4 or LSF2 inhibited leaf starch degradation, it had no effect on cold-induced sweetening in tubers. Starch amounts were unchanged in the tubers, but the amount of phosphate bound to the starch was significantly increased in all the lines, with phosphate bound at the C6 position of the glucosyl units increased in lines repressed in StSEX4 and in the C3 position in lines repressed in StLSF2 expression. This was accompanied by a reduction in starch granule size and an alteration in the constituent glucan chain lengths within the starch molecule, although no obvious alteration in granule morphology was observed. Starch from the transgenic lines contained fewer chains with a degree of polymerization (DP) of less than 17 and more with a DP between 17 and 38. There were also changes in the physical properties of the starches. Rapid viscoanalysis demonstrated that both the holding strength and the final viscosity of the high phosphate starches were increased indicating that the starches have increased swelling power due to an enhanced capacity for hydration

Sex-dependent associations between maternal prenatal cortisol and child callous-unemotional traits: findings from the Wirral Child Health and Development Study

Elevated maternal glucocorticoids during pregnancy may impact on fetal development in a sex-dependent way, leading to increased amygdala activation and increased risk for internalising disorders in females. Based on evidence implicating reduced amygdala activation in callous-unemotional (CU) traits, we predicted that elevated maternal cortisol in pregnancy would be associated with lower CU traits and elevated anxious-depressed symptoms, only in girls. Participants were 225 members of a stratified subsample within an epidemiological longitudinal cohort (WCHADS). Salivary cortisol was measured over two days at 32 weeks gestation (on waking, 30-min post-waking and during the evening) and the log of the area under the curve (LogAUC) was calculated as an index of diurnal cortisol. Mothers reported on child CU traits and anxious-depressed symptoms at 2.5, 3.5 and 5.0 years of age. As predicted there was a sex of child by cortisol interaction (p < .001) whereby elevated maternal cortisol was associated with lower child CU traits, explaining 25% of the variance, in girls, but not in boys. This effect remained when controlling for relevant confounders and anxious-depressed symptoms. By contrast, elevated maternal cortisol did not predict higher anxious-depressed symptoms in girls. The study adds to growing evidence for sex-dependent effects of elevated maternal cortisol during pregnancy on early child psychopathology, consistent with mediation by elevated amygdala activation. The conditions under which, in girls, this is associated with heightened responsiveness to others' distress characteristic of low CU traits, or with increased affective symptoms, require further study