Right-wing conspiracy? Socialist plot? The origins of the Patient Protection and Affordable Care Act.

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA). Did the ACA signify a government takeover of the health care system, a first step on the road to socialism, as conservative critics charged? Or was it, rather, a sellout to the right wing, as liberal single-payer advocates proclaimed? The ACA's key provisions, the employer mandate and the individual mandate, were Republican policy ideas, and its fundamental principles were nearly identical to the Health Equity and Access Reform Today Act of 1993 (HEART), a bill promoted by Republican senators to deflect support for President Bill Clinton's Health Security plan. Yet the ACA was also a policy legacy of the Clinton administration in important ways that rarely are acknowledged, notably Medicaid expansion and insurance company regulation. Although the ACA departed from the liberal vision of a single-payer plan and adhered closely to the objectives of those who believed that the health care system should encourage the free market, it included provisions that will make coverage more affordable, reliable, and accessible.

Institutions, interest groups, and ideology: an agenda for the sociology of health care reform.

A central sociological premise is that health care systems are organizations that are embedded within larger institutions, which have been shaped by historical precedents and operate within a specific cultural context. Although bound by policy legacies, embedded constituencies, and path dependent processes, health care systems are not rigid, static, and impervious to change. The success of health care reform in 2010 has shown that existing regimes do have the capacity to respond to new needs in ways that transcend their institutional and ideological limits. For the United States the question is how health care reform will reconfigure the existing network of public and private benefits and the power relationships between the numerous constituencies surrounding them. This article considers how institutions, interest groups, and ideology have affected the organization of the health care system in the United States as well as in other nations. It then discusses issues for future research in the aftermath of the 2009-10 health care reform debate.

The effect of licensure type on the policies, practices, and resident composition of Florida assisted living facilities.

PURPOSE: Most assisted living facility (ALF) residents are White widows in their mid- to late 80s who need assistance with activities of daily living (ADLs) because of frailty or cognitive decline. Yet, ALFs also serve younger individuals with physical disabilities, traumatic brain injury, or serious mental illness. We compare Florida ALFs with different licensure profiles by admission-discharge policies and resident population characteristics. DESIGN AND METHODS: We use state administrative data and facility survey data from the Florida Study of Assisted Living (FSAL) to classify ALFs by licensure type and to determine how licensure influences ALF policies, practices, and resident population profiles. RESULTS: Standard-licensed traditional ALFs primarily serve elderly White women with physical care needs and typically retain residents when their physical health deteriorates. Some ALFs that hold specialty licenses (extended congregate care and limited nursing services) offer extra physical care services and serve an older, more physically frail population with greater physical and cognitive challenges. ALFs with limited mental health (LMH) licenses serve clientele who are more racially and ethnically diverse, younger, and more likely to be men and single. LMH facilities also have a significant proportion of frail elder residents who live alongside these younger residents, including some who exhibit behavioral problems. LMH facilities also employ discharge policies that make it more difficult for frail elderly residents to age in place. IMPLICATIONS: These differences by facility type raise important quality of life issues for both the frail elderly individuals and assisted living residents who do not fit the conventional demographic profile.

The salience of social relationships for resident well-being in assisted living.

OBJECTIVES: We examined how organizational characteristics, transition experiences, and social relationships impact three subjective measures of well-being among assisted living residents: life satisfaction, quality of life, and perception that assisted living feels like home. METHODS: Data were from 384 assisted living residents interviewed for the Florida Study of Assisted Living. Using ordinary least squares and logistic regression we estimated associations between resident well-being and organizational characteristics, transition experiences, and social relationships, controlling for gender, age, education, and physical functioning. RESULTS: To varying degrees depending on the measure used, higher resident well-being was associated with facility size, facility acceptance of payment from Florida's low income program, and resident perceptions of adequate privacy. Non-kin room sharing reduced life satisfaction, whereas food quality positively affected all measures of well-being. The most consistent findings concerned internal social relationships. Residents with high scores on internal social relationship measures reported more positive well-being across all measures than residents with low scores on the same measures. DISCUSSION: Individuals have the capacity to form new support networks following a move to assisted living, and relationships formed become more salient to their well-being than the continuation of past relationships or the physical characteristics of the immediate surroundings.

Why the United States has no national health insurance: stakeholder mobilization against the welfare state, 1945--1996.

The United States is the only western industrialized nation that fails to provide universal coverage and the only nation where health care for the majority of the population is financed by for-profit, minimally regulated private insurance companies. These arrangements leave one-sixth of the population uninsured at any given time, and they leave others at risk of losing insurance as a result of normal life course events. Political theorists of the welfare state usually attribute the failure of national health insurance in the United States to broader forces of American political development, but they ignore the distinctive character of the health care financing arrangements that do exist. Medical sociologists emphasize the way that physicians parlayed their professional expertise into legal, institutional, and economic power but not the way this power was asserted in the political arena. This paper proposes a theory of stakeholder mobilization as the primary obstacle to national health insurance. The evidence supports the argument that powerful stakeholder groups, first the American Medical Association, then organizations of insurance companies and employer groups, have been able to defeat every effort to enact national health insurance across an entire century because they had superior resources and an organizational structure that closely mirrored the federated arrangements of the American state. The exception occurred when the AFL-CIO, with its national leadership, state federations and union locals, mobilized on behalf of Medicare.

Reinventing long-term care: the effect of policy changes on trends in nursing home reimbursement and resident characteristics--Florida, 1989-1997.

PURPOSE: This study investigated how changes in Medicare and Medicaid policies affected skilled nursing facility (SNF) revenue streams and resident characteristics in Florida during the 1990s. DESIGN AND METHODS: We used a series of ordinary least squares (OLS) regression models to analyze state-provided administrative data and Online Survey Certification and Reporting (OSCAR) data for all Florida SNFs. RESULTS: We found that Florida SNFs responded differently to the growing gap in reimbursement between Medicaid and other payers, depending on their profit status. As the reimbursement gap grew, for-profit SNFs maximized their revenues by admitting fewer Medicaid paying residents, whereas nonprofit facilities increased their percentage of Medicaid admissions. IMPLICATIONS: Changes in patterns of reimbursement altered the composition of Florida SNF residents in terms of age, physical status, length of stay, and place of discharge.

Why are older Floridians exceptional?

Why do older Floridians have higher utilization of health care and live longer than other older Americans? Higher health care use among Florida's older residents is likely related to housing patterns, marital status, health insurance coverage, and ethnic composition. Lower mortality is unlikely a result of lifestyle factors or labor-force participation rates but may be associated with usage of preventive health care services. These indicators suggest that attention needs to be paid to health behavior and social support networks.