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Political Perspectives: The Affordable Care Act 9.1 Did It Work? The U.S. healthcare system is large and complex, so it is no surprise that there are areas that need to be fixed. The Affordable Care Act (ACA) was one of the first major pieces of legislation passed to reform the U.S. healthcare system. Select and describe one problem that the U.S. healthcare system was facing that the ACA attempted to fix. Were any of the elements of the ACA a new concept/solution to healthcare policy? 650 words and in text citations 9.2: Which Side of the Aisle Is Correct? The passage of the ACA was heavily partisan along party lines between Republicans and Democrats, with Democrats in full support. Each side of the political spectrum continues to believe that its solutions are better than the other side’s solutions. With such a major piece of legislation, can the solutions be so divided along party lines and still be in the best interests for the country? Describe one problem that both sides of the political spectrum agree is a problem. Ensure you include why you believe that problem is agreed-upon by both sides. 650 words and in text citations 9.3 Week 9 Journal Entry: Let’s Evaluate the ACA Value: 100 points Journal writing provides a non-threatening way to explore different thoughts, ideas and topics without being concerned about audience presentation. The process of writing can facilitate reflection and allow students to express feelings regarding their educational experiences as well as clarify their thinking. Write about the following in your journal: It is obvious that the healthcare system is complex and full of problems. Many argue that the ACA was not effective in solving many of the healthcare problems in the United States. Were the healthcare problems that the ACA attempted to address and correct successful? Why or why not? Should policy and resources been applied elsewhere to have better success? Your journal entry should be four paragraphs long.
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GE N E R ATIONS – Journal of the American Society on Aging
By Bruce Chernof, guest editor
The Three Spheres of Aging in
America: The Affordable Care Act
Takes on Long-Term-Care
Reform for the 21st Century
Aging policy in America has focused on three domains
of security for elders: economic security, health
security, and functional security. But in the last century,
major changes in the economic and health spheres
have driven a need to address the third—and newest—
sphere of security: physical and cognitive function.
A
ll public policy, whether
supporting public or
private goals, is built to solve a
specific human or social
problem. As a result, the very
nature of policy making is by
degrees reactive and static,
created from a combination of
historical facts, current conditions, and future projections.
The product from these debates
often is built on compromise,
with analysis of effectiveness
left for future generations. The
corridors of public life are filled
with challenges and opportunities, big and small, so that once
a “solution” is hammered out,
attention turns to other press-
ing questions of the day. So
what does this mean for policy
set to address aging issues?
Aging policy in the United
States across the twentieth
century has occurred in fits and
starts, more punctuated
equilibrium than gentle
evolutionary gradualism. Aging
policy in the United States has
focused on three domains of
security for older Americans:
economic security, health
security, and functional security (see Figure 1, page 46). The
twentieth century witnessed
major changes in the economic
and health spheres of aging,
creating the need to address
Copyright © 2011 American Society on Aging; all rights reserved. This article may not be duplicated,
reprinted or distributed in any form without written permission from the publisher: American Society on Aging,
71 Stevenson St., Suite 1450, San Francisco,CA 94105-2938; e-mail: [email protected]
the third and newest sphere
of security when physical and
cognitive function start to fail.
Substantial Progress on
Two of Three Fronts
The passage of the Social
Security Act in 1935 squarely
addressed the issue of economic security and fundamentally
defined and changed the way
the country thought about
supporting populations as they
age. The addition of Supplemental Security Income in 1956
and Social Security Disability
Insurance in 1972 further built
out the program. Over the latter
half of the twentieth century,
Spring 2011 • Vol. 35 . No. 1 | 45
GE NER ATIO NS – Journal of the American Society on Aging
Figure 1. The Three Spheres of Aging in the United States
Income Security
Health Security
public policy focused on
advancing private solutions,
including defined contribution
plans and retirement savings
programs such as 401(k) and
403(b) plans.
The passage of Medicare
and Medicaid in 1965 addressed
policy solutions focusing on
health security for older and
low-income Americans. Much
public policy in recent decades
has focused on the development of public–private partnerships to improve the effectiveness and efficiency of these
programs through the use of
managed-care techniques. A
robust set of private sector
solutions, such as Medigap and
retiree supplemental insurance,
has been supported through
policy initiatives.
46 | Spring 2011 • Volume 35 . Number 1
Functional Security
In the sphere of functional
security, a vibrant mix of public
and private solutions resulting
from a broad policy framework is simply not to be found.
Arguably, the first major policy
initiative to support functional
Pages 45–49
While private long-termcare insurance dates back to the
1970s, these programs have
never captured more than 8
percent of the market (Georgetown University, 2007). An
attempt to create catastrophic
coverage within Medicare was
passed in 1988. In less than two
years Congress repealed it,
largely because elders resented
a new tax to cover the cost of
the expanded coverage.
For Americans older than
65, there is a 70 percent chance
that they will require some
form of long-term services and
supports in their lifetime
(Kemper, Komisar, and Alecxih,
2005). On average these
services and supports will be
required for three years,
although the range is quite
broad, with roughly 20 percent
requiring five or more years
(O’Shaughnessy, 2010).
The reality is that a significant number of older adults
find themselves with chronic
In the sphere of functional security, a vibrant mix of
public and private solutions resulting from a broad
policy framework is simply not to be found.
security is the Older Americans
Act of 1965, which was visionary but inadequately funded.
Almost by default, the Medicaid
program through its funding of
long-term care (predominately
nursing facilities) for the poor
has become the significant
policy initiative that supports
the needs of vulnerable elders.
illnesses or some level of
functional limitation. Medicare
beneficiaries with five or more
chronic conditions represent
almost 80 percent of all Medicare spending (Anderson,
2010). People with chronic
conditions and functional
limitations are even more likely
to use healthcare services (The
©American Society on Aging
Pages 45–49
Lewin Group, 2010). Most
elders find themselves completely unprepared and overwhelmed by these health status
changes and increasing functional needs: some individuals
spend all their resources to pay
for health and supportive
services, become impoverished,
and find themselves completely
dependent upon a patchwork of
public programs. Ultimately,
Medicare and Medicaid bear
significant costs for this care.
Perception vs. Reality
Polling and health services
research data have shown time
and time again that most
people do not understand the
strong likelihood that they will
need long-term services and
supports as they age. Why is
this? One reason is that longevity and the demographics of
The Affordable Care Act: A Way Toward Aging with Dignity in America
illness and death have changed
dramatically over the last
century. Looking at the top
ten causes of death in 1910
compared to 2007, the ratio of
acute to chronic conditions is
reversed (see Table 1). In 1900,
the average life expectancy
was 49 years. In 1935, the year
Social Security was enacted,
it was 62 years. In 1965, when
Medicare and Medicaid began,
it was 69 years. In 2007, the
average life expectancy
reached an all-time high of
78 years (Xu et al., 2010).
Social Security, Medicare,
and Medicaid were all enacted
at times when anticipated life
expectancy was much shorter
and with much less burden of
chronic illness. Instead of a few
years of support, these programs
now provide decades of assistance, a change in demography
Table 1. Life Expectancy and Top Ten Causes of Death
in 1910 and 2007
1910
2007
Heart disease
Heart disease
Influenza and pneumonia
Cancer
Tuberculosis
Stroke
Diarrhea, enteritis,
and ulceration of the intestines
Chronic lower respiratory
diseases
Stroke
Accidents
Nephritis
Alzheimer’s Disease
Accidents
(excluding motor vehicle)
Diabetes
Cancer
Influenza and pneumonia
Premature birth
Nephritis
Senility
Septicemia
Source: Centers for Disease Control and Prevention, 2009a; CDC, 2009b.
©American Society on Aging
with considerable stress on the
trust funds for both Medicare
and Social Security. In 2009,
prior to the passage of the
Patient Protection and
Affordable Care Act (ACA),
the solvency horizon for the
Medicare Trust Fund was
approximately eight years and
for the Social Security Trust
fund less than thirty years
(Boards of Trustees of the
Federal Hospital Insurance and
Federal Supplementary Medical
Insurance Trust Funds, 2010;
Board of Trustees of the Federal
Old-Age and Survivors Insurance and Federal Disability
Insurance Trust Funds, 2010).
A looming projection is that by
2030, Medicare and Medicaid
will consume one-third of the
federal budget (Linden, 2010).
Impacts of the
Affordable Care Act
One important impact of the
ACA is that it extends the
solvency of the Medicare Trust
Fund by an additional twelve
years, more than doubling the
solvency horizon (Boards of
Trustees of the Federal Hospital Insurance and Federal
Supplementary Medical
Insurance Trust Funds, 2010).
Less pressing but also on the
agenda is addressing the Social
Security Trust Fund. It is
important to recognize that the
three spheres of security are
interrelated and dependent
upon each other to a significant
degree. The new health law
also provides some important
Spring 2011 • Volume 35 . Number 1 | 47
GE NER ATIO NS – Journal of the American Society on Aging
opportunities to fundamentally
improve the state of public
policy and programs in the
sphere of functional security.
The CLASS Plan
The most significant policy
advance in the functional
security sphere is the Community Living Assistance Services
and Supports (CLASS) Plan,
which will provide a daily cash
benefit that an eligible beneficiary can use to purchase
services and supports based on
their needs. While the daily
cash payment will not be large
enough to cover the cost of a
nursing home, it will go a long
way toward providing for
home- and community-based
services that could forestall or
prevent the need for eventual
nursing home placement.
According to the Congressional Budget Office, CLASS is
projected to save the federal
government almost $2 billion in
federal Medicaid costs (Congressional Budget Office, 2009).
There are likely state-level
Medicaid savings as well,
because tomorrow’s vulnerable
individuals with access to the
CLASS benefit will likely spend
down more slowly to reach the
Medicaid poverty threshold.
CLASS fundamentally changes
the policy paradigm for vulnerable elders from a povertybased discussion to one that
allows for planning and personal responsibility.
The CLASS Plan also has the
potential to change the way the
48 | Spring 2011 • Volume 35 . Number 1
long-term-care insurance
market operates, opening the
door for the development of
new supplemental and wraparound insurance policies that
could work synergistically
with CLASS. This would give
people more choice than the
current all-or-none approach
of comprehensive long-termcare insurance.
Pages 45–49
Federal Coordinated Health
Care Office, informally referred
to as the Duals Office, and the
Center for Medicare and
Medicaid Innovation, also
known as the Innovation
Center. The Duals Office
is tasked with reducing the
administrative and legal
barriers that prevent financial
and programmatic coordination
across these two important
programs; it will also focus on
supporting state-level pilots to
test models that should improve care and reduce costs.
The Innovation Center is
specifically charged with
testing an array of new models
that could substantially improve the lives of vulnerable
Additional opportunities
and innovations
Also within the ACA are important opportunities to improve
healthcare for impoverished
elders served through Medicaid.
These opportunities include
incentives for states to modernize, restructure, and expand
home- and communitybased services programs such as the State Most people do not understand
Balancing Incentive
the strong likelihood that they
Payments Program and
will need long-term services
the Community First
and supports as they age.
Choice option. Other
efforts include extenelders. These models include
sion of the Money Follows the
Person Demonstration and new different payment systems,
such as bundling payments, as
flexibility for home- and comwell as specific interventions to
munity-based services within
improve some of the most
Medicaid state plans. Many of
these new Medicaid opportuni- intractable problems of the day,
such as medication errors and
ties may prove challenging for
preventable rehospitalizations.
interested states to implement
Taken together, these
because of the recession and
their balanced budget mandates, specific policies, as well as many
others in the ACA, represent an
but they symbolize new opporimportant opportunity to create
tunities to create efficiencies
a new foundation for long-term
within the system.
services and supports in the
The ACA also created two
future. This foundation will only
entities within the Centers for
prove successful if these policy
Medicaid and Medicare: the
©American Society on Aging
Pages 45–49
The Affordable Care Act: A Way Toward Aging with Dignity in America
changes are implemented in
ways that result in a more
integrated and person-centered
approach, as opposed to the
perpetuation of the siloed
program models that exist today.
Older Americans have far more
resources available to them to
address economic and health
security needs than were
available for their grandparents or great-grandparents.
Medical advances have added
The Challenge of the Century years, even decades, to people’s
Over the last century, public
lives, but for many, a handful
policy has supported and
of those years will come with
developed important advances significant functional limitaboth in the public and private
tions. The ACA provides
sectors to help people prepare important opportunities to
for their retirement years.
build the infrastructure that
meets their individual needs.
The challenge of this century
will be to take on this third
sphere of security—to address
serious functional needs as
we age, in ways that support
robust, coordinated public
and private solutions.
Bruce Chernof, M.D., is president
and CEO of The SCAN Foundation,
Long Beach, Calif. He is guest
editor of this Spring 2011 issue of
Generations.
References
Anderson, G. 2010. “Chronic Care:
Making the Case for Ongoing
Care.” www.rwjf.org/files/
research/50968chronic.care.
chartbook.pdf. Retrieved March
26, 2011.
Centers for Disease Control and
Prevention (CDC). 2009a. “Leading Causes of Death, 1900−1998.”
www.cdc.gov/nchs/data/dvs/
lead1900_98.pdf. Retrieved March
26, 2011.
Boards of Trustees of the Federal
Hospital Insurance and Federal
Supplementary Medical Insurance
Trust Funds. 2010. The 2010 Annual
Report of the Boards of Trustees of
the Federal Hospital Insurance and
Federal Supplementary Medical
Insurance Trust Funds. www.cms.
gov/ReportsTrustFunds/down
loads/tr2010.pdf. Retrieved March
26, 2011.
CDC. 2009b. “Leading Causes of
Death.” www.cdc.gov/nchs/fastats/
lcod.htm. Retrieved March 23,
2011.
Board of Trustees of the Federal
Old-Age and Survivors Insurance
and Federal Disability Insurance
Trust Funds. 2010. The 2010 Annual
Report of the Board of Trustees of
the Federal Old-Age and Survivors
Insurance and Federal Disability
Insurance Trust Funds. www.ssa.
gov/oact/tr/2010/tr2010.pdf.
Retrieved March 26, 2011.
©American Society on Aging
Congressional Budget Office. 2009.
“H.R. 3962, Affordable Health Care
for America Act (November 25,
2009).” www.cbo.gov/costesti
mates/health.cfm. Retrieved
March 26, 2011.
Georgetown University. 2007.
“National Spending for Long-Term
Care.” http://ltc.georgetown.edu/
pdfs/natspendfeb07.pdf. Retrieved
February 17, 2011.
Kemper, P., Komisar, H. L., and
Alecxih, L. 2005. “Long-Term Care
Over an Uncertain Future: What
Can Current Retirees Expect?”
Inquiry 42(4): 335−50.
Linden, M. 2010. “The Math is
Clear: Reducing Our Long-Term
Federal Budget Deficit Means
Enhancing Health Care Reform
Now.” www.americanprogress.org/
issues/2010/03/pdf/health_re
form_budget_memo.pdf. Retrieved
March 26, 2011.
O’Shaughnessy, C. V. 2010.
“National Spending for LongTerm Services and Supports
(LTSS).” www.nhpf.org/library/
details.cfm/2783. Retrieved
March 26, 2011.
The Lewin Group. 2010. Individuals Living in the Community with
Chronic Conditions and Functional
Limitations: A Closer Look. Final
Report for the Office of the
Assistant Secretary for Planning &
Evaluation, U.S. Department of
Health and Human Services. Falls
Church, Va.: The Lewin Group.
Xu, J., et al. 2007. Deaths: Final
Data for 2007. National Vital
Statistics Reports. www.cdc.gov/
nchs/data/nvsr/nvsr58/nvsr58_19.
pdf. Retrieved March 26, 2011.
Spring 2011 • Volume 35 . Number 1 | 49
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ORIGINAL ARTICLE
The March to Accountable Care Organizations—How Will
Rural Fare?
A. Clinton MacKinney, MD, MS;1 Keith J. Mueller, PhD;2 & Timothy D. McBride, PhD3
1 RUPRI Center for Rural Health Policy Analysis, University of Iowa, Iowa City, Iowa
2 Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
3 George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri
Abstract
This analysis was funded by a cooperative
agreement from the federal Office of Rural
Health Policy, Health Resources and Services
Administration, DHHS (Grant #1U1C RH03718).
The authors thank Sue Nardie for her help in
editing this manuscript. For further information,
contact: A. Clinton MacKinney, MD, MS, 33291
North 91st Avenue, St. Joseph, MN 56374;
e-mail [email protected]
doi: 10.1111/j.1748-0361.2010.00350.x
Purpose: This article describes a strategy for rural providers, communities, and
policy makers to support or establish accountable care organizations (ACOs).
Methods: ACOs represent a new health care delivery and provider payment
system designed to improve clinical quality and control costs. The Patient Protection and Affordable Care Act (ACA) makes contracts with ACOs a permanent option under Medicare. This article explores ACA implications, using the
literature to describe successful integrated health care organizations that will
likely become the first ACOs. Previous research studying rural managed care
organizations found rural success stories that can inform the ACO discussion.
Findings: Preconditions for success as ACOs include enrolling a minimum
number of patients to manage financial risk and implementing medical care
policies and programs to improve quality. Rural managed care organizations
succeeded because of care management experience, nonprofit status, and
strong local leadership focused on improving the health of the population
served.
Conclusions: Rural provider participation in ACOs will require collaboration
among rural providers and with larger, often urban, health care systems. Rural providers should strengthen their negotiation capacities by developing rural
provider networks, understanding large health system motivations, and adopting best practices in clinical management. Rural communities should generate
programs that motivate their populations to achieve and maintain optimum
health status. Policy makers should develop rural-relevant ACO-performance
measures and provide necessary technical assistance to rural providers and
organizations.
Key words accountable care organizations (ACOs), Affordable Care Act
(ACA), health care organizations, health care reform, rural physician practices.
Accountable care organizations (ACOs) have become one
of the hottest new trends in health care. As a new Medicare payment and health care delivery alternative established by the Patient Protection and Affordable Care
Act (ACA), ACOs create opportunities for rural health
care providers to improve health care quality and control
health care costs in their communities. However, despite
new opportunities, a bright future for rural providers is
c 2010 National Rural Health Association
The Journal of Rural Health 27 (2011) 131–137
not assured. Rural providers must remain cautious of
urban-based policies and large health care system programs that might disadvantage rural health care delivery. But caution has its limits. Rural stakeholders should
proactively participate in ACO development discussions
during rule making and implementation of the ACA. Rural pr …
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