This example helps demonstrate that the success of engagement may depend on the institutional setting within which decisions are made. Legislative rules and procedures are paramount. The trajectory of click through legislation in Minnesota provides another illustration, as a law was adopted through an omnibus budget bill in after a stand-alone proposal was unsuccessful in For ACA supporters, one potential lesson is that embedding policy changes within omnibus tax, budget, or health care bills provides two key advantages.
First, omnibus bills have a greater likelihood of passage. Second, the discussions surrounding omnibus initiatives are an especially propitious setting for an elite-level engagement strategy. It is easier to link policies to broader principles such as cost containment and tax reduction when those issues are already under consideration, and that context might facilitate the sort of compromise that allows progress to occur. This dynamic can occur in non-budgetary and non-legislative settings, including bureaucratic amendments to a state's insurance code.
The e-commerce example offers other useful lessons for ACA supporters. In both contexts, the salience of these alternatives varies. Some prominent features of the ACA, such as the Medicaid expansion and health insurance marketplaces, are freighted with enough political baggage that engagement may not always lead immediately to policy change. Developments in Arkansas, where low-income uninsured individuals enroll in exchange-sponsored health plans instead of Medicaid, nonetheless illustrate the strategy's potential.
In contrast, the law's regulatory changes to the health insurance market and the delivery of health care services may prove especially amenable to engagement. Looking ahead, significant uncertainty remains over state implementation of the ACA. There are open questions about whether and how states will expand Medicaid as well as ongoing governance decisions affecting the operation of health insurance marketplaces. According to John E.
As a result, they have been linked to everything from the establishment of a single-payer system in Vermont to the expansion of the Arkansas model McDonough Thus, the waivers might facilitate the diffusion of a new round of health care policy innovations. The comprehensive nature of the waivers—and the fact that they can be merged with waivers associated with Medicare and Medicaid reform—makes engagement particularly appealing.
An engagement strategy will not be a panacea for the partisan polarization that characterizes responses to the ACA, and we do not expect it to lead to a rapid about-face in public attitudes. However, it offers a viable alternative to the framing strategy that has dominated discussions of the ACA and is represented by the quotation from Secretary Burwell with which this article began. The framing process can occasionally lead to policy change over the long term Baumgartner, De Boef, and Boydstun , but most discussions of framing effects emphasize ephemeral changes in individual attitudes Jacobs and Mettler Under certain conditions, many of which appear relevant to the diffusion of the ACA, an engagement strategy offers an approach that is more responsive to the elites who make the actual decisions that will determine the future course of health care reform in the United States.
In addition to its promise as a political strategy for ACA supporters, elite-level engagement deserves a more prominent place in academic studies of policy change and its causes. Existing research on framing effects illuminates the psychological bases of political attitudes, but there is ample reason to question whether subtle shifts in rhetoric are sufficient to cause well-informed elites to endorse policies that they had previously opposed.
The recent trajectory of the e-commerce debate, in contrast, suggests that engagement can occasionally spur previously reluctant state officials to endorse change. Many questions remain about the institutional and political contexts in which engagement is most likely to succeed, and these questions offer numerous fruitful avenues for future research. For example, the potential impact of an engagement-based rhetorical strategy on policy change offers two valuable lessons for policy diffusion scholars.
Existing diffusion research tends to focus on various political, economic, and demographic correlates of adoption over which state leaders have little to no control. These background conditions and many others are undoubtedly influential, but it is equally important to recognize the dynamic nature of the policy process. The strategic and tactical choices that are made by institutionally critical actors such as governors and legislative leaders may help explain why a policy innovation either takes root in a seemingly inhospitable environment or fails to gain enactment under what seem to be favorable conditions.
To be sure, rhetoric alone is rarely sufficient to explain policy change. The policy-making context might increase or decrease the power of a specific rhetorical strategy, as when the growing scope and scale of electronic commerce enhanced the size of the potential tax cuts that a change in policy would facilitate. However, diffusion scholars must be more attentive to the rhetorical and other strategic choices made by the individuals with the power to decide a policy's fate. Like policy innovations, the strategies themselves may diffuse through media coverage, advocacy organizations, or other means.
Understanding whether and how advocates in late-adopting states learn about and employ rhetorical claims that proved successful in early adopters therefore has the potential to illuminate the impact of various diffusion mechanisms. At its core, policy diffusion scholarship investigates whether the existence of a given program in one jurisdiction affects the likelihood that it will be adopted elsewhere.
Most studies in this research tradition emphasize the adoption decision, but the second lesson of the preceding analysis is that the impact of external developments may be felt during the earlier stages of the policy process Karch In the electronic commerce example, the rhetorical strategy of linking policy change to tax policy spread from one state to another as advocates viewed it as a way to try to convince unsupportive state officials to change their views. The geographic spread of this engagement approach suggests that the impact of diffusion can influence the nature of the political agenda and the portrayal of existing policy alternatives in ways that precede, but ultimately may affect, decisions concerning final passage.
This insight has implications for both the future trajectory of the ACA and future research on the forces that facilitate or hinder the spread of innovative policies. The US Census Bureau publishes an annual report that estimates e-commerce activity in key sectors of the economy.
The list of nineteen states can be found at trustfile. When the customer makes a purchase, the affiliate earns a referral fee or percentage of the sale. For one example, see affiliate-program. Of the fifty-three members of the Democratic caucus who voted, forty-eight supported the Marketplace Fairness Act; only twenty-one of forty-three Republicans voted for it. An event history analysis of the fourteen adoptions that occurred through confirms that, all else equal, Republican-led states are less likely to adopt a click through law.
The results of this analysis are available on request. This comparison should not be taken too far, however, since many ardent opponents of e-commerce taxation come from states that lack a sales tax Alaska, Delaware, Montana, New Hampshire, and Oregon. There is a common misperception that the law prevents state and local governments from taxing online sales, but it does not Lunder and Pettit The widespread reach of the SSTP and the gubernatorial letter should be interpreted as evidence of state officials' efforts to grapple with a new issue.
It does not imply that more than forty states supported collecting sales taxes on online purchases.
This justification supplemented, rather than supplanted, the fairness frame. The entire letter can be viewed at www. The growth of electronic commerce makes this argument more appealing than it was a decade ago, since it implies that the resulting tax cuts will be larger. Indeed, a recent analysis of the US Senate finds that both partisan affiliation and state revenue foregone were significant predictors of Senators' votes on the Marketplace Fairness Act of Karch and Rosenthal In this sense, the engagement strategy is rendered more effective by the rising economic costs of maintaining a suboptimal tax policy.
Sign In or Create an Account. Research Article April 01 Framing, Engagement, and Policy Change: Aaron Rosenthal Aaron Rosenthal. J Health Polit Policy Law 42 2: Standard View Views Icon Views. Abstract Supporters of the Patient Protection and Affordable Care Act ACA sometimes speculate that public attitudes toward the law will shift if proponents succeed in focusing attention on its more popular components, but the scholarly literature on framing effects provides ample reason to question their assertion.
Interview with interest group official, October 9, The House version passed by voice vote, while the Senate version passed on a 96—2 vote. Interview with elected official, August 25, Interview with state representative, October 2, Amazon and the States: From Gulf to Bridge? Framing Debates over State Lotteries. Testing Theories of American Politics: Elites, Interest Groups, and Average Citizens. Who Deserves Health Care? Why Public Opinion Changes: The Implications for Health and Health Policy. Issue Framing and Engagement: Rhetorical Strategy in Public Policy Debates.
A Change of Mind or a Change of Focus? A Theory of Choice Reversals in Politics. Framing Opposition to Gay and Lesbian Rights. Intergovernmental Finance in the New Global Economy: Volume 42, Issue 2. Opinion Change and Policy Change. Sales Taxes and Electronic Commerce: Framing, Engagement, and Policy Change. Implications for the ACA. Previous Article Next Article. Citing articles via Google Scholar. Email alerts Latest Issue.
Subscribe to Article Alert. Ideas, Institutions, and Political Actors. Lessons for the Affordable Care Act. Expanding Medicaid, Expanding the Electorate: Related Topics policy diffusion health care reform rhetorical strategies. Duke University Press W. This site uses cookies. By continuing to use our website, you are agreeing to our privacy policy. Your request to send this item has been completed. Citations are based on reference standards.
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Your rating has been recorded. Write a review Rate this item: Preview this item Preview this item. Health Policy Innovations and Lessons Author: English View all editions and formats Summary: This book examines the landmark Patient Protection and Affordable Care Act ACA from the perspective that health policy innovation is translational research directed at improving health.
The Affordable Care Act as a National Experiment: Health Policy Innovations - Google Книги
EMTALA ensures access to care for the uninsured, but ED visits are expensive and tend to result in people flowing back into the hospital for reasons that could have been avoided with adequate primary and specialty care. A major goal of the ACA was to extend health insurance coverage to 32 million uninsured people in the United States.
The ACA had two major components: The ACA eliminated the concept of categorical eligibility and replaced it with standard eligibility criteria of percent of the federal poverty level. In , the Supreme Court ruled that the federal government could not force the states to expand Medicaid coverage. For the individual and small-group markets, the ACA established health insurance exchanges in states to allow individuals and small groups to buy standard insurance policies with income-based subsidies from percent up to percent of the federal poverty level KFF, b.
The ACA eliminated medical underwriting and imposed a legal mandate to purchase health insurance with a penalty for those who did not comply. Before the ACA, insurance companies used medical underwriting to determine whether to offer a person coverage, at what price, and with what exclusions or limits based on the person's health status; the purpose was to ensure a healthy risk pool by requiring people to pay premiums that reflected their expected medical costs.
Because of medical underwriting in the individual and small-group markets, people who were sick often paid higher premiums or were denied coverage. The ACA's individual mandate, in contrast, was designed to compel healthier people to purchase insurance so as to balance the risk pool and lower premiums for everyone. States could establish their own health insurance exchanges or use the one created by the federal government. However, access to care except for increases in insurance coverage did not show improvement until the time period between and June KFF, c.
The health-care delivery system in the United States consists of an array of clinicians, hospitals and other health-care facilities, insurance plans, and purchasers of health-care services, all operating in various configurations of groups, networks, and independent practices IOM, The health-care delivery system has historically been organized around the concept of fee-for-service medicine.
Under the fee-for-service payment model, patients or their insurers pay physicians and hospitals for any covered services delivered on a per-unit basis without particular regard for price, patient outcomes, or quality. Because provider revenues increase as more services are provided—and insured and some uninsured patients do not bear the full cost of the additional services—the fee-for-service model creates incentives to increase utilization of health-care services, which in many cases lead to overutilization of physician and hospital visits.
In some segments of the market, health plans have been designed around alternative incentive structures by using a concept of fixed payment for a set of services. Often called managed care, these plans aim to reduce overutilization of hospital and physician services through such arrangements as full-risk capitation payment models which involve sharing of financial risk among all participants and place providers at risk not only for their own financial performance but also for the performance of other providers in the network , some forms of bundled payment in which a single payment covers a hospital stay or all services related to a specific diagnosis or procedure , and a more modest approach called pay-for-value an incentive structure that includes bonuses or penalties that are based on cost and quality metrics.
Pay-for-value managed-care arrangements are used in Medicare Advantage, Medicaid managed care, and some commercial health insurance plans. In the Medicare program, around 30 percent of beneficiaries are enrolled in Medicare Advantage plans in which Medicare makes payments to private insurers that are responsible for delivering the Medicare benefit package, and payment arrangements between plans and providers are determined contractually and are thus difficult to describe because they are proprietary KFF, a.
In sharp contrast with Medicare, managed-care enrollment has greatly expanded during the past two decades, rising from just over one-half of all beneficiaries enrolled in managed care in to 77 percent in KFF, Medicaid-managed care plans cover a broad array of Medicaid benefits, including acute, primary, and specialty care and in some states, behavioral health and LTSS CMS, Although the fee-for-service model remains the most common payment form in the private health insurance market, private insurers have integrated aspects of the managed-care model into broader efforts to address the incentive problems created by the fee-for-service payment structure, such as utilization management and performance metrics for providers.
If managed care is defined by the use of capitated payments to providers that are responsible for the total cost of care, then very few people are covered by managed care KFF, b. If, however, anything other than unconstrained fee-for-service is defined as managed care, most people who are covered by private health insurance are enrolled in some form of managed care. Managed care in any form usually involves restricting the set of providers from whom patients might obtain covered care to so-called in-network providers. Insurers can adjust network breadth to limit patient access to preferred hospitals and physicians.
Figure illustrates that dramatic shift over time. In , 73 percent of employees enrolled in health plans had conventional fee-for-service coverage; by , fewer than 1 percent had unconstrained fee-for-service coverage. The figure also shows the dramatic growth in HDHPs since Distribution of health plan enrollment of covered workers, by plan type, — A portion of the change in plan type enrollment for is likely attributable more The ACA included payment-reform provisions to incentivize the adoption of more effective care-delivery models Abrams et al.
The new models involve some combination of shared risk among providers to enhance collaboration and coordination of care so as to reduce avoidable hospitalizations, ED visits, and other forms of expensive or unnecessary care. To protect against stinting, quality metrics are often used to evaluate provider performance. Beyond payment models, the ACA encouraged perhaps unintentionally the narrowing of provider networks and reshaped the delivery of long-term services and supports, all of which have implications for the ways in which people who have disabilities receive care and for the documentation of that care in the medical record.
We discuss each in turn. The payment, contractually determined in advance, is intended to encourage better coordination among the various providers involved in a given patient's care. Some 7, post-acute care providers, hospitals, and physician organizations have signed up to participate in bundled-payment demonstrations Abrams et al.
Early evidence suggests that bundled payments can reduce medical costs and improve patient satisfaction CMS, The ACA also incentivized the development of alternative delivery models, such as accountable care organizations. Those involve collaboration among physicians, hospitals, and other health-care entities in a shared-risk arrangement. The alternative delivery models were intended to encourage provider organizations to address patient health needs better, to reduce the amount of hospital and ED care, and to meet quality goals.
Their effectiveness and their effects on clinical practice, however, are still matters of considerable debate Schulman and Richman, ; Song and Fisher, The primary goal of the PCMH is to keep people ambulatory in the community, in addition to aligning provider financial incentives with the best interests of patients. The PCMH is not a physical home but rather a care delivery system in which each patient's care is coordinated through his or her primary care physician PCP.
The PCP manages and coordinates care with the goals of having each patient receive the necessary care when and where he or she needs it, and in a manner that the patient can understand and that is consistent with and respectful of the patient's preferences, needs, and values Blumenthal et al. In patient-centered models, there is greater potential for providers to identify people who have comorbidities and to coordinate their care. Visits for both ambulatory care sensitive and non-ambulatory care sensitive conditions were reduced; this suggests that steps taken by practices to attain PCMH recognition might decrease some of the demand for outpatient ED care van Hasselt et al.
NCQA also noted that PCMH recognition is associated with fewer inpatient hospitalizations and lower utilization of both specialist and emergency services Harbrecht and Latts, ; Raskas et al. Money was offered to physician practices to meet compliance with health information technology or so-called meaningful use criteria or face penalties in Medicare reimbursement. EMRs offer the promise of aggregating records from many providers into a single, legible medical record as long as all providers seen by a patient participate in the same EMR system; interoperability among systems is imperfect.
The HITECH Act offers the promise of a more complete medical record that details the full history of care provided to a patient who applies for disability benefits. The change in provider network size is another indicator of how the ACA has transformed the care that people get. So-called narrow networks existed before the implementation of the ACA, but they have grown more common as a result of it.
The Affordable Care Act as a National Experiment : Health Policy Innovations and Lessons
Many consumer protection measures, such as the prohibition of medical underwriting, have made it difficult for many insurers to rely on traditional strategies to keep costs low. Other elements of the law, such as the availability of the online marketplace where consumers can compare premiums, have made it possible for insurers to compete with each other. Plans that have narrow networks might benefit consumers by lowering premiums. Negotiations between insurers and providers on network participation might encourage more efficient delivery of care.
And the ability to contract selectively might allow insurers to attract a small group of providers that meet raised standards of quality and potentially would result in care of higher value Health Affairs, But narrow networks also pose risks to consumers. For example, if a network gets too narrow, it will jeopardize the ability of consumers to obtain needed care in a timely manner.
That can also happen if the network contains an unsatisfactory mix or insufficient number of providers. Network limitations can have the additional effect of turning away sicker patients who have more health needs and thus changing the risk pool.
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One study notes that consumer advocates argue that narrow networks adversely affect access to care, especially for patients who have chronic illnesses. They claim that insurers structure the networks strategically to discourage the higher-cost patients from enrolling. Patients who have high needs will then have to go outside the network and possibly outside the EMR system and as a result tend to incur high expenses and receive surprise medical bills EBRI, Their medical documentation is also more likely to be missing elements. The ACA included several provisions aimed at improving deficiencies in the nation's long-term care system to ensure that people can receive LTSS in their home or the community KFF, a.
In addition, in states that accepted the Medicaid expansion, funds were made available to pay for home- and community-based attendant services in connection with matching by the federal government KFF, a. Nonetheless, Wiener has argued that despite the growing need for HCBS, not enough progress had been made in improving the financing of long-term care. A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use KFF, c found that health insurance coverage has expanded overall, access to and use of care have increased, self-reported health status has improved, and flow of federal health-care resources into expansion states has risen.
One study by Barakat et al. It did not, however, detect a substantial change in top diagnoses or in the overall rate of ED visits and hospitalizations. The authors argued that there appeared to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization. In contrast, Sommers et al. Wherry and Miller observed an increase in office visits to physicians but also an increase in overnight hospital stays after the Medicaid expansion. There is consensus among studies on the effects of the ACA on utilization of preventive services.
Similarly, Wherry and Miller found that Medicaid expansion under the ACA led to higher rates of preventive services, which resulted in more diagnoses of diabetes and high cholesterol.
Several studies have specifically identified ACA-related improvements in health-care utilization by people who had chronic conditions. They found improvements in multiple measures: A related study by Sommers et al. They echoed the findings in the report by suggesting that regular care for chronic conditions increased substantially after Medicaid expansion.
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The findings of those two studies were consistent with the findings of an earlier study by Sommers et al. Although evidence suggests that on average people who had chronic conditions experienced an increase in access to regular care for those conditions, coverage effects vary among diseases Baicker et al. Because of the many design features that are common to the ACA, the Massachusetts health-care reform of , and the Oregon Medicaid lottery of , the experiences of Massachusetts and Oregon are informative about potential effects, and in particular long-term effects, of the ACA on utilization.
A study by Cole et al. It found no effect of Medicaid coverage on diagnoses or on the use of medication for blood pressure and high cholesterol, but Cole et al. The Oregon Medicaid study Baicker et al. The evidence on cancer care is also mixed. One study of the Massachusetts health-care reform did not find any changes in breast-cancer stage at diagnosis Keating et al.