Medicare and the affordable care act

The recently enacted Patient Protection and Affordable Care Act made modest changes to improve Medicare and obtained a substantial share of funding for the Act's broader reforms from future spending reductions in the program. Drug benefits and preventive services were improved. While painful, the spending reductions will have only moderate impacts on beneficiaries and should help achieve the goals of health care reform: encouraging better primary and preventive care, making providers conscious of finding ways to increase the productivity of care delivered and changing the relative levels of payment across certain providers. Additional costs to beneficiaries will arise from changes in private plan payments and increasing income-related premiums.     

Medicaid home- and community-based services: impact of the affordable care act

The Affordable care Act (ACA) legislation of 2010 has three important voluntary provisions for the expansion of home- and community-based services (HCBS) under Medicaid: A state can choose to (1) offer a community first choice option to provide attendant care services and supports; (2) amend its state plan to provide an optional HCBS benefit; and (3) rebalance its spending on long term services and supports to increase the proportion that is community-based. The first and third provisions offer states enhanced federal matching rates as an incentive. Although the new provisions are valuable, the law does not set minimum standards for access to HCBS, and the new financial incentives are limited especially for the many states facing serious budget problems. Wide variations in access to HCBS can be expected to continue, while HCBS will continue to compete for funding with mandated institutional services.     

Nursing homes and the affordable care act: a cease fire in the ongoing struggle over quality reform

Most provisions in the Affordable Care Act that affect nursing homes originated in two earlier attempts at reform, both of which failed multiple times in prior Congressional sessions: the Elder Justice Act and the Nursing Home Transparency and Improvement Act. Both of these earlier efforts focused on improving quality and reducing elder abuse in nursing homes by strengthening oversight and enforcement penalties, expanding staff training, and increasing the information on nursing home quality available to consumers and regulators. Each bill addressed problems that were serious, widespread, and had persisted for years, but each failed to pass on its own. The Affordable Care Act, with its own momentum, became the vehicle for their passage. However, the reasons the bills failed in these earlier efforts suggest implementation challenges now that they have ridden into law on the coattails of the more general effort to reform the health care sector.     

Managing risk under the children act 1989: Diversion in child care?

The idea of diversion has dominated the theory and practice of juvenile justice for some time. Developments in child care practice in the 1980s mirror those which produced diversion. Diversion provides an alternative conceptual framework within which the changes to child care law introduced by the Children Act 1989 can be analysed, particularly the interrelation of s.1(5), the so-called non-intervention principle, and Part III, which establishes the duty of local authorities to provide services for children in need. These provisions and current child care practices may be seen to promote four distinct forms of diversion: (1) diversion from court; (2) diversion from care or residential provision; (3) diversion from procedures; and (4) diversion from social work. Examining the law and practice in terms of diversion focuses on the potential gains and losses resulting from the Children Act's emphasis on partnership, planning and bureaucracy without presuming that losses will be compensated for by the provision of services. It also suggests the need to consider child care in terms of net widening and tariff raising.     

A care coordination program for substance-exposed newborns

The Vulnerable Infants Program of Rhode Island (VIP-RI) was established as a care coordination program to promote permanency for substance-exposed newborns in the child welfare system. Goals of VIP-RI were to optimize parents' opportunities for reunification and increase the efficacy of social service systems involved with families affected by perinatal substance use. Findings from VIP-RI's final four years show that by 12 months, 86% of substance-exposed newborns had identified permanent placements and 77% were placed with biological parents or relatives.     

Health care innovations for homeless families: Emerging opportunities under Medicaid and the Affordable Care Act

Prior to the Patient Protection and Affordable Care Act of 2010 (the ACA), the US health care system left many low-income families facing limited access to medical care, struggling with high-health costs, or lacking health insurance altogether. The ACA aims to increase access to care, improve the quality of care, and lower total health care costs. While the ACA can benefit all individuals and families, it has significant potential for expanding and improving services for those experiencing homelessness. This paper describes specific opportunities under the ACA and Medicaid that can be used to strengthen services for homeless families and provides examples of efforts under way. It also offers guidance for how homeless service agencies can effect change in their respective states. The examples described here are promising approaches to strengthening homeless services. Pursuing these ideas for homeless families will require initiative, creativity, and perseverance, but recent progress is encouraging.     

Outcomes of a model care coordination program for adults with mental illness under guardianship/conservatorship

Adults with serious and persistent mental illnesses, such as schizophrenia, schizoaffective disorder, and bipolar disorder, who are under guardianship/conservatorship, may experience health care, social, financial, and housing concerns, which can be addressed by care coordination programs. In such programs, providers assist with communication across service sectors, assistance with monitoring of psychiatric care, and support with practical needs. Such programs are understudied in the context of guardianship/conservatorship. Through a review of electronic records for 217 consumers who were enrolled in a model program continuously for 3 years or more, we examined trends before and after enrollment in a model care coordination program for adults with serious and persistent mental illnesses under guardianship/conservatorship. We sought to describe the number of days and rates of hospitalization, emergency room visits, and arrests before and after receiving program services. Comparing utilization among consumers three years pre- to three years post-enrollment, we identified statistically significant reductions in hospitalizations and imprisonment, but no change in state hospitalizations. We also saw some (non-significant) reduction in emergency room visits. Findings provide preliminary evidence of effectiveness of the model program; future efforts could expand its reach to more adults with serious and persistent mental illnesses.     

Expanding the focus of health insurance education for Medicare beneficiaries

Health insurance education plays an important role in helping consumers make informed decisions about their need for supplemental coverage. This article reviews findings on the knowledge of Medicare beneficiaries about their health insurance coverage. Then, current health insurance education programs are examined with regard to their ability to meet the needs of a competition-based public policy. Barriers outside the control of individuals that impede the growth of the long-term care insurance market are identified and the need for an alternative, broader form of health insurance education is suggested. Changes in the scope and content of health insurance education are proposed that would educate the elderly to their own needs as well as the larger policy issues. An expanded model of education based on the concept of the Swedish study circle is discussed to illustrate the possibility of combining individual knowledge and public debate about complex social issues.     

Partial strikes under the railway labor act: The need for a doctrine of unprotected concerted activity

In light of use by airline unions of partial-strike tactics, such as concerted refusals to bid for overtime work and so-called ” CHAOS” tactics involving unannounced refusals to fly after passengers have been ticketed and are ready to board, the authors examine whether the Railway Labor Act (RLA) should be interpreted to permit employers to discipline employees for engaging in such tactics, or whether these are a protected form of economic pressure. Although in many respects bargaining duties and economic weapons under the RLA are read consonant with precedents under the National Labor Relations Act (NLRA) (which governs all industries other than rail and air transport), there are a few decisions suggesting that during the period when self-help may be resorted to, employees can engage in partial strike activities as long as they violate no court order but are subject to permanent replacement in limited circumstances. These decisions, the authors submit, fail to take account of Supreme Court decsions since the 1930s that some economic pressures by unions, such as slowdowns and sitins, may not violate the labor laws but nor are they protected by those laws so as to immunize partial strikers from employer discipline. These decisions are not based on unique features of the NLRA. Rather, they give recognition to the background assumptions of Congress that employers may act to protect their property interests as long as they do not run afoul of NLRA or RLA protections and that employees who engage in partial-strike activities are subject to employer discipline even where not strictly necessary to maintain operations. Moreover, these tactics skew the bargaining process by giving employees an essentially risk-free gambit to pressure their economic position through planned disruption of carrier operations. Professor Estreicher is also labor and employment counsel to O’Melveny & Myers, LLP. The views expressed herein are the authors’ and should not be attributed to any organization. Hannah Breshin and Tom Jerman of O’Melveny & Myers, assisted the authors with this article. We also thank Professor Herbert Northrup for his helpful comments.     

Challenges to care coordination posed by the use of multiple health IT applications

Coordinating care for hospitalized patients requires the use of multiple sources of information. Using a macroergonomic framework (i.e. the work system model), we conducted interviews and observations of care managers involved in care coordination across transitions of care. When information is distributed across multiple health IT applications, care managers experience a range of challenges, including organizational barriers, technology design problems, skills and knowledge issues, and task performance demands (i.e. issues related to individual information processing and management and sharing of information). These challenges can be used as a checklist to evaluate the proposed IT infrastructure that will allow the integration of multiple health IT applications and, therefore, support coordination across transitions of care.     

Developing family-based care: complexities in implementing the UN Guidelines for the Alternative Care of Children

In response to immense challenges facing children in out-of-home care in all parts of the world, there is a growing international trend towards the development of family-based placements for children in out-of-home care, away from large-scale institutions. This development of family-based care within a range of care options is recommended within the international Guidelines for the Alternative Care of Children (the Guidelines), which were welcomed unanimously by the United Nations General Assembly in 2009. This paper offers an overview of these guidelines’ key principles, and considers the complexities that arise in efforts towards their implementation. Drawing on the literature, supported by research that informed Moving forward (the implementation handbook on the Guidelines) and illustrated by practice examples from across global regions, the authors examine three fundamental challenges in States’ efforts to implement the Guidelines’ ‘suitability’ principle, namely: de-institutionalising the care system; financing suitable family-based care and supporting the suitability of kinship care. The paper critically reflects on de-institutionalised systems and practices, and the cross-cultural assumptions about suitable foster and kinship care that emerge in efforts towards de-institutionalisation; it aims to spark new thinking on strategic ways in which alternative care is planned and delivered, to impact on future practice.     

社会化养老趋势下家庭照料的作用及支持体系研究

文章以上海为例探讨在当前我国社会化养老初级阶段,家庭照料的重要作用,指出社会化养老服务体系不是替代家庭养老功能,而是应该维持家庭的照顾能力,帮助和支持家庭更好地履行养老责任。最后,文章从政策制定及法律保障、医保梯度支付、居家养老服务提供、支持家庭照料者几个方面构建鼓励家庭成员承担老年照料的支持体系。     

Conquering the enemy within: The case for reform of the Landrum-Griffin act

The Labor Management Reporting and Disclosure Act (LMRDA) requires unions to file financial reports with the Department of Labor (DOL) and make these reports available to members to provide them information necessary to govern their unions. For most of the time since the LMRDA's enactment, LM-2 reports were poorly designed and inaccessible to members and the public. However, in 2002 DOL made LM- 2 forms available online and proposed rulemaking to substantially reform union reporting requirements. I identify major problems with the law's current reporting requirements, briefly critique DOL's proposed rulemaking, and suggest additional steps to improve LMRDA financial reporting. This article is based on testimony delivered to the House Committee on Education and the Workforce in 2002.     

统筹城乡视角下中部地区多元城镇化模式研究

当前,虽然我国各地区城镇化迅猛发展．但各区域发展仍不平衡,中部地区发展缓慢．而城镇化滞后是制约中部崛起的主要原因之一。2007年．武汉城市圈和长株潭城市群获批全国资源节约型和环境友好型社会建设综合配套改革试验区,在此背景下．从统筹城乡的视角出发,研究适合中部地区的城镇化发展模式．促进中部地区城镇化快速健康发展．对于统筹中部地区城乡发展．促进中部崛起．缩小全国区域差距具有重要意义．     

Promoting rights or avoiding litigation? The introduction of the human rights act 1998 into adult social care in England

Rights to social care in England have traditionally been highly restricted. By placing positive obligations on social care agencies and practitioners to make provision for vulnerable adults, the incorporation of the European Convention on Human Rights into UK law through the Human Rights Act 1998 promised to extend their reach. Yet transforming a set of largely procedural rights into something more substantive requires the active intervention of social care practitioners. This article firstly examines the fit between human rights and the policy and operational contexts of social care before exploring the views of social workers included in a recent interview study. Whilst the findings point to a willingness on the part of some to advocate on behalf of vulnerable adults, they also highlight the extent to which individualistic beliefs about dependency and responsibility reinforce the dominant construction of citizenship rights under the current government as contingent upon the fulfilment of responsibilities. Treating the Human Rights Act as a weapon of litigation, the article concludes, simply reinforces defensive practice. Progressive change is best supported by fostering a human rights culture in social care which, in turn, depends upon challenging social workers’ assumptions about the nature of dependency, responsibility and rights.