• Capitol

Health Policy and the Affordable Care Act

Ezekiel Emanuel, MD, PhD

This course will explore the many problems of the American health care system and discuss the specific ways that the Affordable Care Act will impact access, quality, costs, as well as medical innovation.

The Patient Protection and Affordable Care Act

President Barack Obama signed the Affordable Care Act (ACA) into law March 2010.  It may be one of the most ambitious and consequential pieces of legislation in U.S. history.  Ezekiel Emanuel and Peter Orszag argue,

"The ACA not only will extend health care coverage to millions of Americans but also will enact many policies specifically aimed at reducing the amount we are spending on health care and, by changing the delivery system, reducing the rate of growth in health care costs over time. Indeed, one of the essential aspects of the legislation is that unlike previous efforts, it does not rely on just one policy for effective cost control. Instead, it puts into place virtually every cost-control reform proposed by physicians, economists, and health policy experts and includes the means for these reforms to be assessed quickly and scaled up if they're successful. By enacting a broad portfolio of changes, the ACA provides the best assurance that effective change will occur."  (N Engl J Med 2010; 363:601-603)

Faculty are engaged in an ongoing analysis of the impact of the ACA on patients, caregivers, and across virtually every sector of healthcare.

Moving Forward with Wellness Incentives Under the Affordable Care Act

Health care payers in the United States and abroad have used wellness incentives as a tool to improve health and reduce costs. In Germany, public insurers operate many such programs. Participation nearly doubled between 2004 and 2008, reaching one-quarter of the publicly insured population. An evaluation of one large wellness program there found that it reduced costs. However, population-level survey data also suggest that individuals with low incomes or poor health are less likely to enroll. In the United States, the Affordable Care Act raised the maximum allowed size of wellness incentives, which could lead to wide differences in insurance premiums between users and nonusers of programs, and may risk reintroducing a form of medical underwriting. The German experience confirms the cost-saving potential of programs, but also suggests that they should be evaluated rigorously to ensure they do not disadvantage those with health problems or low incomes.  [H. Schmidt, S. Stock, and T. Doran, Moving Forward with Wellness Incentives Under the Affordable Care Act: Lessons from Germany, The Commonwealth Fund, May 2012.]

Comparative Effectiveness and Safety of Hospital-Based Pediatric Palliative Care

With funding from the Agency for Healthcare Research and Quality (RO1 HS018425), this study, led by Chris Feudnter, measures the rates of use of palliative care-related pharmaceuticals (PCRPs) among hospitalized children with life-threatening complex chronic conditions; analyze variation among hospitals in the usage of PCRPs; and compares PCRP-treatment-associated outcomes and adverse events among hospitalized children with life-threatening complex chronic conditions, measuring the differences in outcomes and adverse events among patients who did and who did not receive PCRPs in specific clinical scenarios.

CLAIM (Comprehensive Longitudinal Advanced Illness Management)

Growing evidence has identified numerous problems in the care of seriously ill patients with cancer. Many patients, and their families, experience unnecessary burdens and suffering, and receive treatments that are costly and ineffective. Although some benefit from hospice, many more continue to seek aggressive life-sustaining treatment until very late in the course of illness, and are not eligible for hospice. CLAIM (Comprehensive Longitudinal Advanced Illness Management) is a $4.3 million project funded by the Centers for Medicare and Medicaid Services to provide a comprehensive set of palliative care services to patients who are not yet ready to enroll in hospice. CLAIM is directed by David Casarett.

The Work of Care for Children and Young Adults with Complex Chronic Conditions

For children and young adults living with complex chronic conditions, medical advances continue to reduce the risk of illness and death. These advances, however, also create new challenges for parents caring for these children. Treatment plans for families need to take into consideration the complexity and work load of the care for children and young adults with complex chronic conditions. The policy goal of this project, which is directed by Chris Feudtner, is to inform models of care for children with complex chronic conditions that better manage the work of care and yield improved outcomes for children and their families.

Does Having a Dysfunctional Personality Hurt Your Career? Axis II Personality Disorders & Labor Market Outcomes

Despite recent interest in how psychiatric disorders affect work outcomes, little is known about the role of personality disorders (PDs), which are poorly understood yet prevalent (15%) and impairing. We used nationally representative data for 12,457 men and 16,061 women to examine associations of PDs with any employment, full-time employment, chronic unemployment, being fired or laid off, and having trouble with a boss or co-worker. Antisocial, paranoid, and obsessive-compulsive PDs demonstrated the broadest patterns of associations with adverse outcomes. Findings suggest that PDs may have implications for the productivity of co-workers as well as that of the disordered employees themselves.