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.     

Can Health Care Reform End Stigma Toward Mental Illness?

This article addresses the destigmatization of mental health through health care reform by incorporating antistigma efforts—a destaining of mental illness—through prevention and early intervention in community-based programs that would be mandated and funded through the auspices of Patient Protection and the Affordable Care Act (ACA). Mental health care policies under the ACA and the Mental Health Parity Act are briefly described, following a definition of mental health stigma and its impacts. Recommendations for statutory mandates in stigma reduction at the community and federal levels and guidelines for mental health/behavioral health providers form the article’s conclusion.     

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.     

The affordable care act and long-term care: comprehensive reform or just tinkering around the edges?

The Patient Protection and Affordable Care Act (ACA) includes several provisions that aim to improve prevailing deficiencies in the nation's long-term care system. But just how effective is the ACA likely to be in addressing these challenges? Will it result in meaningful or marginal reform? This special issue of Journal of Aging & Social Policy seeks to answer these questions. The most prominent long-term care provision is the now-suspended Community Living Assistance Services and Supports Act. Others include incentives and options for expanding home- and community-based care, a number of research and demonstration projects in the areas of chronic care coordination and the dually eligible, and nursing home quality reforms. There are also elements that seek to improve workforce recruitment and retention, in addition to benefit improvements and spending reductions under Medicare. This article reviews the basic problems plaguing the long-term care sector and the provisions within the ACA meant to address them. It also includes a brief overview of issue content.     

The Patient Protection and Affordable Care Act: A Dissenting Opinion

This paper asks whether the Patient Protection and Affordable Care Act achieves its goals of significantly expanding health insurance coverage, while reducing costs and increasing the quality of the care provided. An examination of the early results and current future projections suggests that while PPACA will increase the number of Americans with health insurance, it will fall significantly short of universal coverage. In addition, PPACA fails to control health care costs, and will likely result in higher costs for government, as well as many businesses, and individuals. The author concludes that PPACA is not the most effective vehicle for achieving US health care reform, and that a more market-oriented approach offers a better alternative.     

A 10-foot rope for a 50-yard drop: the CLASS Act in the patient protection and Affordable Care Act

The Community Living Assistance Services and Supports (CLASS) Act, part of the 2010 health care reform, would have paid a daily cash payment toward the costs of long-term care. This article points out that although the CLASS Act may have been sufficient to cover the costs of most home- and community-based services, it was an inadequate response to the most pressing long-term care financing problem facing baby boomers: nursing home care costs. The risk of needing a nursing home is higher than other catastrophic risks. Boomers lack savings to pay those costs. CLASS aimed to encourage people to use home- and community-based services to substitute for nursing home care, but research spanning decades shows there is little substitution effect.     

A Review of: “Dattilio,Frank M. (2010). Cognitive-Behavioral Therapy with Couples and Families: A Comprehensive Guide for Clinicians.”

This conceptual study focuses on health disparities among African Americans in the Arkansas Delta. The author uses an ecosocial perspective to explore several social and individual-level influences upon patients' perceptions of health care quality, including health beliefs and life experiences of discrimination that can lead to not accessing health care systems. The study findings identify community-based strengths that can inform the development of strategies and programs to reduce rural health disparities. The discussion includes the potential implications of the Patient Protection and Affordable Care Act for progress in health care quality and health equality, especially for rural racial/ethnic minorities.     

The Grand Challenge of Reducing Gender and Racial/Ethnic Disparities in Service Access and Needs Among Adults with Alcohol Misuse

This study examined the impact of the Affordable Care Act (ACA) on gender and racial and ethnic disparities in accessing and using behavioral health services among a national sample of adults who reported heavy or binge alcohol use (n = 52,496) and those with alcohol use disorder (AUD; n = 22,966). Difference-in-differences models estimated service-related disparities before (2008–2009) and after (2011–2014) health care reform. A subanalysis was conducted before (2011–2013) and after (2014) full implementation of the ACA. Asian subgroups among respondents with heavy or binge drinking were excluded from substance use disorder (SUD) treatment and unmet need outcome models due to insufficient cell size. Among heavy or binge drinkers, unmet SUD treatment need decreased among Black women and increased among Black men. Mental health (MH) treatment decreased among Asian men, whereas unmet MH treatment need decreased among Hispanic men. MH treatment increased among Hispanic women with AUD. Although there were improvements in service use and access among Black and Hispanic women and Hispanic men, there were setbacks among Black and Asian men. Implications for social workers are discussed.     

Translating collaborative models of mental health care for older adults: using Iowa's experience to inform national efforts

The Patient Protection and Affordable Care Act supports the translation of collaborative models of mental health care, but how the act will affect older adults remains unclear. The authors examined a sample of older Medicare beneficiaries and evaluated how individual characteristics, local service supplies, and other contextual features corresponded with the identification of older persons with psychiatric diagnoses and their access to specialty mental health care providers. Older adults presented a variety of psychiatric disorders, and their access and use of specialty mental health care related to age; sex; diagnosis; supply of mental health, health, and long-term care providers; and whether an older person lived in a rural area. Translation of collaborative models should consider a range of psychiatric conditions, adjust for varying local provider supplies, and consider the challenges in establishing collaborative care within rural areas.     

The Affordable Care Act: Implications for African Americans Living with HIV

This article reviews the Patient Protection and Affordable Care Act (ACA), 2010. It highlights the implications of the ACA for African Americans living with HIV/AIDS. This law is a practical step toward decreasing disproportionate chronic disease in vulnerable communities. Proper implementation of provisions will help the United States catch up to other industrialized nations with well-established public health care programs. Included is a concise table referencing notable provisions that support increased access to treatment, health education, and quality of care for clients. Social workers can use this information to ensure that clients benefit from this legislation.     

Inequitable Access to Health Services for Older Adults with Diabetes: Potential Solutions on a State Level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.     

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.     

Alcohol reinforces both positively and negatively,complicating treatment

The Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act of 2010 require insurance companies to provide parity for mental health and substance use disorders, but these laws, on the books for a decade, aren't being enforced. And insurance companies are taking advantage of this, leaving treatment centers one choice, according to attorney Matthew Lavin: to appeal until they win, and if they don't win, to sue.     

Care coordination for dually eligible medicare-medicaid beneficiaries under the affordable care act

The coordination of Medicare and Medicaid benefits and services for dually eligible enrollees has been a longstanding policy challenge. Several provisions of the Affordable Care Act (ACA) attempt to address this lack of coordination, including the establishment of the Federal Coordinated Health Care Office. This paper reviews the major changes under the ACA directed at care coordination for the dually eligible population and then concludes with a discussion of the continuing legislative and legal challenges in integrating care for the dually eligible.     

The CLASS Act: is it dead or just sleeping?

The Affordable Care Act (ACA) established a voluntary public insurance program for long-term care: the Community Living Assistance Services and Supports (CLASS) Act. In October 2011, the Obama Administration announced that the program would not be implemented because of the high risk of fiscal insolvency. Under the legislative design, adverse selection was a major risk and premiums would have been very high. This article discusses several CLASS Act design and implementation issues, including the design features that led to the decision not to implement the program: the voluntary enrollment, the weak work requirement, the lifetime and cash benefits, and the premium subsidy for low-income workers and students.     

Children’s Mental Disorders and Their Mothers’ Earnings: Implications for the Affordable Care Act of 2010

Children with emotional and behavioral problems (EBP) may have a negative effect on their mothers’ earnings because they require additional time for treatment. On the other hand, children with EBP require additional financial resources, which may increase their mothers’ earnings through an increase in work activities. This study examined the impact of children’s EBP on parental earnings, while accounting for omitted variable bias. This study found significant reductions of single mothers’ wage rate/annual earnings if their children have EBP. Conversely, children’s EBP increased their married mothers’ hourly wage. These results have important implications in terms of public policy such as the Affordable Care Act (ACA) of 2010 in terms of expanding health insurance coverage to children with EBP to have access to appropriate treatment.     

INDIVIDUAL WELFARE WHEN CONSUMERS CAN SHOP FOR HEALTH INSURANCE

The statewide system of health insurance exchanges established by the Affordable Care Act (ACA) of 2010 will allow millions of U.S. citizens to change their health care policies more easily than they can switch automobile or homeowner insurance coverages, because deniability based on prior claim history is illegal. Focusing on this consumer endogeneity of health insurance policy choice, we examine the individual moral hazard welfare implications of a reduction in the price of medical care, which is a potential consequence of the ACA. We show that endogenous policy choice plays a key role in determining the welfare outcome. While moral hazard welfare improvement is not precluded, a distinctly possible outcome is that the consumer revises his/her choice of insurance policy so as to retain some portion of the reduction in expenditure risk caused by the medical care price decrease. In this event, moral hazard welfare loss is higher than it was before the price decrease, although the increased loss is tempered by the endogenous contract choice effect. This result resuscitates an old conventional wisdom. (JEL I11, I13, I30)     

PRICE ADJUSTMENT POLICIES AND FIRM SIZE

A number of U.S. State Departments of Transportation have adopted a price adjustment policy designed to limit cost fluctuations of oil‐based inputs in government procurement. Similar policies are common in defense contracting, and have been used to offset financial losses of health insurance companies in Medicare and the Affordable Care Act. We show that while all bidders submit lower bids after the policy is introduced, the extent of bid reduction diminishes with firm size. Small new firms are able to compete more frequently, promoting auction competition and efficiency. (JEL H4, H57, D44)     

Medicaid Managed Care Programs for High-Risk Older People in Massachusetts

The Commonwealth of Massachusetts has undertaken a major initiative in the development of comprehensive managed health care programs for two sets of high-risk older people: those who are frail and homebound and those who reside in nursing homes. This effort has been coordinated by the state's Department of Public Welfare (DPW; Medical Assistance [Medicaid] Program) and Executive Office of Elder Affairs, and expedited ba a set of Health Care Financy Administration (HCFA) waivers and by the state's revised Nurse Practice Act (MGS Chapter 56). Than act allows nurse-practioners and physician assistants expanded roles as primary providers in home care and nursing home settings. The managed care initiatives have supplemented other efforts (1) to coordinate health and social services for older people, (2) to provide as broad a range as possible of community-based services for older people, and (3) to enroll as many older adults as possible in Health Maintenance Organization (HMO) "Senior Plans" and other similar "Competive Medical Plans."

Though there is still no evidence of the managed care programs' effects, this article summarizes some of the possible risks and benefits of managed care programs for those kinds of populations and presents an agenda of questions that evaluations of managed care programs must address.