Category Archives: Supreme Court Health Reform Ruling

Jul 25 2012
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After Growing Up Without Health Insurance, "Relieved" by the Supreme Court Health Reform Ruling

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Michelle Scott recently graduated from Rowan University and is an intern at RWJF, working with The Future of Nursing: Campaign for Action.

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I’m 22 and uninsured. I’ve only had health insurance for the four years I went to college, and now that I’ve just graduated, I no longer have that luxury. I survived the first 18 years of my life without it, but thanks to the Affordable Care Act, I don’t have to live without it for the rest of my life.

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The day I received my college health insurance card in the mail, that flimsy piece of laminated paper with my name on it, I vividly remember thinking, “Wow. I’m allowed to be sick.” During my time at college I never got sick, nor injured in a serious accident of any kind where I actually needed medical attention. There was a brief period where I thought I smashed my hip and orbital bone in a skateboard incident my senior year of college, but after sitting on the ground at the skate park for a minute, and contemplating whether my family could afford to patch me up, I decided to walk it off. From my very early childhood, that’s how I learned to treat any kind of issue: Walk it off, or rest up until you can walk it off.

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Jul 20 2012
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How the Supreme Court's Health Reform Ruling May Affect the Latino Population

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Gabriel R. Sanchez, PhD, is an associate professor of political science at the University of New Mexico, assistant director of the RWJF Center for Health Policy at the University of New Mexico, and director of Research for Latino Decisions.

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The Supreme Court decision regarding the constitutionally of the signature policy victory of the Obama administration has been the most anticipated and hotly debated decision of the Court in recent memory. In the spirit of a prior Human Capital blog post I wrote back in November, I wanted to take advantage of the opportunity to participate in this series by providing a perspective on how this decision will likely impact the Latino population.  I have been analyzing public opinion toward health care reform for some time now, and draw on some of this data to provide a few examples. I focus my attention here on some of the more intriguing relationships to emphasize the complexity of Latino’s views of this historic policy.

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Latinos had a lot at stake in this decision, as the Affordable Care Act (ACA) is projected to expand insurance to 9 million Latinos. It is therefore not surprising that support for health care reform, and the ACA in particular, has been higher among Latinos when compared to non-Latinos. In fact, since Latino Decisions started collecting data in October 2011, on average 51 percent of Latinos have supported the ACA. Conversely, as reflected in the figure below, the percentage of Latino voters who want to repeal the law has been lower than what other polls have shown for the non-Latino population over this time period.

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Jul 19 2012
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Cautiously Optimistic about the Affordable Care Act - If Older Americans and Their Advocates Speak Out as It Is Implemented

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Margaret P. Moss, PhD, JD, RN, FAAN, is associate professor, Yale School of Nursing and an alumna of the RWJF Health Policy Fellows program (2008 – 2009).

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As I reflect upon the monumental decision by the Supreme Court to uphold the Affordable Care Act, I can’t help but be awed by how the branches of government are alive and well and operating just as they were designed to work.  But as I filter what this decision will mean for the groups I am most closely tied with professionally and personally, I am struck at how the ‘system’—public and private—has largely let them down.

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My professional focus has been in aging, and in particular American Indian aging.  My profession is nursing, with a background in law.  I am optimistic that these groups, both patient and provider, will be lifted and solidified by the spirit of this law.  But I am cautious that the letter of the law must be handled with an eye toward impact, unintended consequences, short-term pilot and demonstration projects, and authorized but unfunded rules.

There can be no question that there are provisions in the Act that no-one would dispute are positive.  The most cited are: 1) no more pre-existing condition exclusions, 2) the ability to keep adult children under parents’ plans until after college age, and 3) widening the net for coverage to include those now uninsured. The opposing point being moot now with the Supreme Court’s decision, we must look forward and responsibly carry out the law before us.  Unfortunately, the devil, as they say, is in the details.

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Jul 17 2012
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Make What the Supreme Court Upheld a Reality by Empowering All Providers

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Matthew D. McHugh, PhD, JD, MPH, RN, CRNP, is an assistant professor of nursing at the Center for Health Outcomes & Policy Research, University of Pennsylvania School of Nursing, and an RWJF Nurse Faculty Scholar.

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By upholding the Affordable Care Act, the Supreme Court’s landmark ruling has allowed health reform to continue to move forward. But the promise and potential of health reform depends on having a robust, well-trained workforce that can meet the demands of a changing health care system, an aging population, and newly insured Americans with increasingly complex health care needs.

More than ever, the recommendations from the Institute of Medicine’s (IOM’s) report The Future of Nursing: Leading Change, Advancing Health will be critical to achieving the goals of health reform. For example, this defining moment provides an opportunity to redefine roles to take advantage of the fullest extent of all providers’ capabilities to improve health system efficiency and meet the health care needs of the population.

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The first recommendation from the IOM report is that nurses should practice to the full extent of their education and training. Many of the Affordable Care Act’s provisions rely on the health care workforce, particularly the primary care workforce, working in new and expanded roles.  Whether it is implementing new models of integrated care, providing much needed care to previously uninsured Americans, or delivering guaranteed preventive services and essential benefits, meeting the coming demand for primary care will require “all hands on deck”—every provider working at their fullest capacity. Although advanced practice nurses are one way to grow the primary care workforce, their ability to fully participate has been limited by legal barriers that restrict them from practicing up to the level they have been trained and often requiring physician oversight.

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Jul 16 2012
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The Affordable Care Act and Its Juncture between Health Care and Health

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Sara Rosenbaum, JD, is the Harold and Jane Hirsh Professor at George Washington University, School of Public Health and Health Services, Department of Health Policy.  Rosenbaum received an RWJF Investigator Award in Health Policy Research in 2000, and is on the board of the RWJF Health Policy Fellows program.

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In affirming the constitutionality of the Affordable Care Act, the United States Supreme Court assured the legal survival, not just of thousands of discrete legislative provisions, but also the big ideas embedded in the Act.  One of the biggest is its emphasis on strengthening the juncture between health care and health, an opportunity whose potential is only beginning to be explored.  The most publicly visible aspect of this emphasis is the Act’s expansion of coverage for clinical preventive services without cost-sharing across the principal health insurance markets recognized under the Act: Medicare; employer-sponsored health plans, state regulated individual and small group markets (including the new Exchange market) and the Medicaid “benchmark plan” market that will  serve newly eligible beneficiaries. (Ironically, the Act leaves out of this expanded clinical preventive coverage design the health plan market serving traditional Medicaid beneficiaries; other than a state option to expand coverage at slightly favorable federal financing rates, the law does not require expanded clinical preventive benefits for the very poorest beneficiaries. Although family planning services are a required benefit for all beneficiaries of childbearing age, services such as screening colonoscopies and adult immunizations remain optional for the traditional coverage group).

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But the opportunities to bridge the health/health care divide go well beyond the important, threshold question of coverage design.   The biggest opportunities are those that are intended to change the way that two of the principal players in the health care system—physicians and hospitals—envision their role in society and position themselves in communities.  In the case of physicians, the Act incentivizes formation of accountable care organizations (ACOs), entities that assume responsibility not simply for health care of a defined group of patients (like any practice network) but for the health of the population they serve.   ACOs are expected to move beyond improvements in the quality of clinical services they furnish and to reach into their communities through greater involvement in community health improvement activities.   Similarly, the Act expands and strengthens the community benefit obligations of the nation’s nonprofit hospitals seeking federal tax-exempt status, upping their responsibilities related to community health improvement planning, and incentivizing investment in community health improvements and community building.

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Jul 13 2012
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I Hope This Ruling Will Stimulate a Stronger Sense of Urgency to Reduce and Ultimately Eliminate Health Disparities

This post is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Janice Phillips, PhD, RN, FAAN, is associate professor, adult health and gerontological nursing at Rush University College of Nursing and an RWJF Health Policy Fellow (2010 – 2011).

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I am deeply encouraged by the recent Supreme Court Health ruling on health reform. I consider this a major step toward ensuring that the countless numbers of patients, underserved communities and even personal friends who I have worked with will now have a better chance of getting the health care they deserve.

Far too many of them have suffered from chronic health conditions and related complications, in part due to a lack of preventive services and a lack of timely access to the health care they need.

My in-depth exposure to health reform occurred during my tenure as an RWJF Health Policy Fellow working in the office of Senator John D Rockefeller IV (W.Va.). It was there that I was introduced to the complexities and the comprehensive nature of the Affordable Care Act.

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That experience left me to wonder how best to educate underserved communities and those who are most in need.  My desire in moving forward is that communities that stand to benefit the most are educated and empowered to take full advantage of the extended coverage and protections in the Affordable Care Act.

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Jul 12 2012
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How the Affordable Care Act Would Have Helped My Father

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Susan B. Hassmiller, PhD, RN, FAAN, is the Robert Wood Johnson Foundation Senior Adviser for Nursing and Director, Future of Nursing: Campaign for Action. This post also appears on Off the Charts, the blog of the American Journal of Nursing.

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When I heard that the Supreme Court upheld the Affordable Care Act, I immediately thought of my father.  He suffered mightily at the end of his life. Plagued with multiple chronic illnesses, he spent his last year in and out of hospitals.  He received good hospital care, but his health deteriorated every time he left. He simply couldn’t keep track of a growing list of prescriptions, tests and doctor visits.  My father accidentally skipped antibiotics, which led to infections, which landed him back in the hospital. He accidentally skipped blood tests, which landed him back in the hospital. It seemed that every time he came home, he’d land back in the hospital. I lived thousands of miles away and couldn’t be the advocate that he needed.

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What he needed was transitional care – he needed a nurse to meet with him during a hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. He needed a nurse to identify reasons for his instability, design a care plan that addressed them and coordinate various care providers and services. He needed a nurse to check up on him at home.  Transitional care would have eased his suffering and enabled him to live better.

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Jul 9 2012
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It is Time to Engage in Conversations with People Who Have Ideas We Don't Like

This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act.  Andru Ziwasimon Zeller, MD, is co-founder of the Casa de Salud family medical office and the Community Coalition for Health Care Access in Albuquerque, and a 2010 RWJF Community Health Leader.

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I’m a doctor and supporter of health care for all and happy that we as a nation have achieved almost universal health care.  The Affordable Care Act has flaws and areas of disagreement.  It was forged from 100 years of argument and compromise, bringing together liberal universal health care with conservative personal responsibility

I don’t love every detail of the law but I love that we as a nation, through the leadership of President Barack Obama, have removed a massive injustice in our society which has contributed significantly to stress, disease, death, medical debt and household bankruptcy.  These have been “silent killers" since those affected tend to keep their suffering to themselves.  Many of us have born witness to that suffering.  I am so glad it is coming to an end.

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Yet I feel the fear and anger of those in our nation who oppose this new law and see in it an assault on individual freedom, a government invasion of health care, and a grand plan to destroy what is perceived to be our founding principles.

I resonate emotionally with the first point—no one likes to be told what to do.  Seat belts, car insurance, driver’s license to vote, passport to travel, taxes, and now health insurance?  Why not let the hospitals eat that cost?  Or drop it on the county health fund?  Is this a slippery slope to dreaded socialism or an evolution towards health and personal accountability?

Facts are hard to come by.  Trust is next to impossible.  We are a nation of belief against belief in search of the ultimate political power to create a singular vision of the future—Republican vs. Democrat, and who knows what either of those really mean.  This battle, more than anything, is the greatest threat to the vision and political prowess of our founding fathers.  Democracy is conversation, compromise and decision-making for solutions that help us take care of each other and improve our place in this world.

This is our democracy in action.  I give thanks that we fight the ‘war’ between liberals and conservatives with words and election ballots.

The decline of our schools, health care system, manufacturing, and prestige internationally stems from and contributes to our inability to care for each other.  We are squandering our resources, fighting for control instead of forging a better society.  This criticism is not about “hating” America.  I’m saying that we Americans are wasting the equity that all of our forebears gave us.  All of them.  Native Americans and all of the immigrants who come to these shores by force, or hope for a better future.  This hope and equity are not owned by any one segment of our society, they are our shared birthright as Americans.  

It is time we each take a deep breath, do an internal inventory of our emotional tenor, and start to engage in perhaps stressful, but important conversations with people who have ideas that we don’t like.  Passion is a beautiful thing when it can be restrained by reason and respect.  Let’s embrace this challenge as a nation, hear what we each have to offer, and live better lives together.

Read more about Ziwasimon Zeller’s work, visit the Casa de Salud website, and learn about the Robert Wood Johnson Foundation Community Health Leaders.

Jul 6 2012
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A Tale of Two Emergency Rooms

This post is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Julia Lynch, PhD, is an associate professor at the University of Pennsylvania. Lynch is a recipient of a 2006 RWJF Investigator Award in Health Policy Research at the University of Pennsylvania and an alumna of the RWJF Scholars in Health Policy Research program (2003-2005).

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The first emergency room is one you know: the ED in your nearest inner-city or rural hospital. There you’ll find trauma cases, heart failures, emergency appendectomies, heroic rescues by doctors and nurses working through the night, just like on TV. But also, waiting in chairs (lots of chairs), the frequent fliers, the preventable complications of asthma and diabetes, the people awaiting primary care in the worst possible medical environment for it. These are America’s emergency rooms.

And then there are Italian emergency rooms. As an expat living in Italy, I’ve navigated hundreds of miles of red tape to get a car registered, a telephone line installed, a tax ID number. I’ve paid notaries hundred upon hundreds of Euro for the stamps and forms needed to make the transactions of daily life (renting an apartment, selling a car) legal. Just imagine the emergency room. Better yet, don’t. I’ll tell you about it.

Some years ago, just after my husband and I had moved to Italy for my research, he cut his finger while preparing dinner. It looked bad, but it was Saturday night, and the one doctor we knew of who accepted our weird Belgian insurance policy for expats wasn’t in his office. So when the cut failed to stop bleeding overnight, we reluctantly made our way to the city hospital, asked for directions to the pronto soccorso (literally “immediate aid”), and prepared ourselves for a very long wait.

In the area to which the hospital greeter had directed us, we found a closed door, and three empty chairs in the hallway. After some confused wandering around, we knocked on the door, and once again asked for directions to the elusive ER waiting room. A doctor poked his head out, pointed to the three chairs, and said he’d be with us as soon as he finished patching up a motorcycle accident.

How long would that take, we wondered? And how many heart attacks, asthma attacks, and gunshot wounds would come in while we were waiting?

But the remaining chair in the hallway remained empty; and within ten minutes, the very same doctor who had answered our knock glued my husband’s finger back together and sent us on our way. Minimal wait, one doctor, no paperwork, and no charge—despite the fact that neither of us had an Italian National Health Service (NHS) card. Our Belgian insurance policy would not be billed. The doctor explained proudly that Italy’s NHS looked after everyone, even visitors.

And that’s not all: we didn’t know at the time that there is a designated doctor for every quartiere (neighborhood) in Italy, called the guardia medica, on call for minor nighttime emergencies. The doctors of the guardia medica, which I’ve also since had the occasion to call, are paid by the Italian state. They make house calls, with a little black bag and everything. The doctor for our quartiere could have glued my husband up on a Saturday night, in the comfort of our own home, again at no charge.

I know you must be thinking “But all this must be terribly expensive!” It’s true. Since our visit to the Italian ER, many patients of the NHS have been subjected to new out-of-pocket charges for medicines and specialist visits, and lines have grown longer in emergency departments as regional health budgets have come under pressure. But primary and emergency care is still free at the point of service. And Italy still spends considerably less than its neighbors do on health care: $2,870 per capita in 2008, compared to $3,129 in the UK, $3,696 in France, $4,063 in the Netherlands—and $7,538 in the U.S. Even so, income disparities in both access to care and health outcomes remain small in Italy, and most readers of this blog will know that Italy outperforms the U.S. on virtually every indicator of health and well-being.

Where does this tale of two emergency rooms leave us? The Affordable Care Act (ACA) brings us nowhere near a National Health Service on the Italian or British model. And not even the most ardent advocates of cost-effective medicine can imagine a way, under the ACA, to reduce our health care budget by 60 percent to bring us in line with what Italy spends on a per capita basis.

What the ACA does do is bring us one step closer to being able to say -- as that Italian ER doctor could -- that our health care system “looks after everyone.” It may even bring us nearer to the day when the waiting rooms of our emergency departments aren’t packed with patients seeking primary care, and care for complications resulting from a lack of primary care. Perhaps even a day when our emergency departments look a little more like three empty chairs in a hallway.

Jul 5 2012
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The Supreme Court Upholds Health Reform. What Will it Mean to Voters?

This post is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Hahrie Han, PhD, is an associate professor of political science at Wellesley College. She was an RWJF Scholar in Health Policy Research from 2009-2011.

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The Supreme Court’s decision to uphold the Affordable Care Act is unlikely to change anyone’s mind, but its political legacy may lie in its ability to energize the base of each party.

From a policy standpoint, there is no doubt that the Supreme Court’s decision to uphold the health reform law has vast implications for millions of Americans. The political impact of the decision, however, remains unclear. Will it help Obama in 2012 by affirming the centerpiece of his legislative record? Will it hurt him by firing up the Tea Partiers in opposition? Or, will it have little to no impact on the 2012 election?

Initial polling results from the Kaiser Family Foundation show that people’s views on the law have not changed as a result of the Supreme Court’s decision. People who opposed the law in the past are still opposed to it and people who supported it still support it.

What has changed, according to Kaiser, is the intensity of partisan support for the law. In May, only 31 percent of Democrats reported having “very favorable” views of the ACA. In the days after the Supreme Court’s ruling, that number had jumped 16 percentage points to 47 percent. (Republicans remained consistent in their dislike for the law, with 64 percent reporting “very unfavorable” views.)

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This surge in Democratic enthusiasm could make an electoral difference in our polarized political climate. Elections in polarized times are often about turnout more than persuasion. An election that is about persuasion is won or lost on a candidate’s ability to persuade the undecided voter to support his or her side. An election that is about turnout hinges not on the undecided voter but instead on the candidate’s ability to turn out the partisan base. When elections are very polarized, as this year’s presidential election is, the undecided voter is an ever-narrowing slice of the population. Turning out the partisan base thus becomes that much more important.

The question is how stable rising Democratic enthusiasm for the law is. Republican opposition to the law has been very stable and research shows that people are more likely to take political action to fight against laws they do not like (threats) as opposed to supporting laws they do (opportunities). The Supreme Court’s decision seems only to have reinforced Republican opposition to Obama. Will it also solidify Democratic support for Obama?

The Obama campaign’s ability to capitalize on this surge in enthusiasm may depend on its ability to organize its supporters using the venerated organizing machine it built in 2008. As I have argued in my work, people are motivated to take political action when they are personally invested. To connect people’s personal lives to the Supreme Court decision, the Obama campaign would need to rebuild the personal relationships and neighborhood teams that were the secret to its success in 2008.

Political scientist Gerald Rosenberg has argued that the major legacy of the Supreme Court’s decision in Roe v. Wade was not to make legal abortions more widely available to women, but instead to spur a political backlash that polarized the debate over reproductive rights and is still felt today.

Time will tell if the legacy of this decision by the high Court lies in its impact on improving the health of millions of Americans, spurring political backlash, or both.

Learn more about the Robert Wood Johnson Foundation Scholars in Health Policy Research program.