Following the Money: The ACA's Fiscal-Political Economy and Lessons for Future Health Care Reform.

It is no exaggeration to say that American health policy is frequently subordinated to budgetary policies and procedures. The Affordable Care Act (ACA) was undeniably ambitious, reaching health care services and underlying health as well as health insurance. Yet fiscal politics determined the ACA's design and guided its implementation, as well as sometimes assisting and sometimes constraining efforts to repeal or replace it. In particular, the ACA's vulnerability to litigation has been the price its drafters paid in exchange for fiscal-political acceptability. Future health care reformers should consider whether the nation is well served by perpetuating such an artificial relationship between financial commitments and health returns.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND: Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities. STUDY DESIGN: From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series. RESULTS: The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion. CONCLUSIONS: Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.

The Affordable Care Act in the United States and HIV Disease: Past, Present, and Future.

From its beginning, the AIDS epidemic crystallized some of the major flaws of the American health care system. Most private health insurance was associated with employment, and job loss meant insurance loss. Private insurers refused new coverage for people with HIV infection. Medicaid, an important program for uninsured people with low income, was limited to only those in certain categories (eg, pregnant women or children), and although people who had progressed to AIDS were categorized as eligible (ie, "disabled"), those with early stage HIV disease were not. The Patient Protection and Affordable Care Act is a landmark change in health care law in general and for people with HIV infection in particular. Its provisions offer dramatic improvements in health coverage, although a Supreme Court ruling that limited the expansion of Medicaid poses ongoing problems in some states. This article summarizes a presentation by Timothy M. Westmoreland, JD, at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Washington, DC, in May 2015.

The Supreme Court's surprising decision on the Medicaid expansion: how will the federal government and states proceed?

In National Federation of Independent Business v. Sebelius, the US Supreme Court upheld the constitutionality of the requirement that all Americans have affordable health insurance coverage. But in an unprecedented move, seven justices first declared the mandatory Medicaid eligibility expansion unconstitutional. Then five justices, led by Chief Justice John Roberts, prevented the outright elimination of the expansion by fashioning a remedy that simply limited the federal government's enforcement powers over its provisions and allowed states not to proceed with expanding Medicaid without losing all of their federal Medicaid funding. The Court's approach raises two fundamental issues: First, does the Court's holding also affect the existing Medicaid program or numerous other Affordable Care Act Medicaid amendments establishing minimum Medicaid program requirements? And second, does the health and human services secretary have the flexibility to modify the pace or scope of the expansion as a negotiating strategy with the states? The answers to these questions are key because of the foundational role played by Medicaid in health reform.

Redeeming hollow promises: the case for mandatory spending on health care for American Indians and Alaska Natives.

The reliance on discretionary spending for American Indian/ Alaska Native health care has produced a system that is insufficient and unreliable and is associated with ongoing health disparities. Moreover, the gap between mandatory spending on a Medicare beneficiary and discretionary spending on an American Indian/Alaska Native beneficiary has grown dramatically, thus compounding the problem. The budget classification for American Indian/Alaska Native health services should be changed, and health care delivery to this population should be designated as mandatory spending. If a correct structure is in place, mandatory spending is more likely to provide adequate funding that keeps pace with changes in costs and need.

Health policy roundtable--policy by numbers: the role of budget estimates and scoring in health care reform.

The purpose of this roundtable is to explore the imperfect art of estimating the budget costs of health insurance proposals-called scoring when done by government agencies. The panel addresses the complexities involved in generating these estimates, which usually depend on many untested and untestable assumptions. For example, the Medicare prescription drug "donut hole" was invented so that policymakers could achieve budget targets. These budget scores play a critical role in the design of health policies, as well as in the reform proposals put forth by candidates in an election. The roundtable discusses how policymakers can and do use health policy estimates and budget scores.