This is the concluding essay for a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported ...by the John S. and James L. Knight Foundation. This essay provides an integrative discussion of various theoretical and practical reform perspectives offered by other essays in the report. It also offers a number of recommendations. It notes that the aim of the special report is not to propose specific reform measures but, rather, to consider larger, more theoretic concerns related to political and economic questions, which are personal and structural—psychological, cultural, and institutional—at the same time. In response, this essay argues that the best relationship between the citizenry and government in a democracy is not one of deference, nor one of contestation, but one that is critically constructive, which in turn is linked to practices of civic learning. To be constructive, citizens need scientific literacy, an understanding of how government and other institutions work, critical thinking abilities, and many open and diverse forums for civic learning to offset the increasingly isolating media “bubbles” that are the only source of information for many. The essay then formulates five recommendations designed to facilitate critically constructive citizenship and civic learning. These are creating a basis for civic participation, acquiring information, talking to each other, designing institutional change, and achieving deliberation.
Medicaid waivers for Delivery System Reform Incentive Payment (DSRIP) seek to hold hospitals and other providers accountable for measureable improvements in health care delivery. We explore the ...policy context giving rise to these waivers in six states, with particular attention to the interplay among the financial needs of hospitals; the rise of managed care; and federal interest in replacing an "unconditional" Medicaid funding stream, the upper payment limit, with one rooted in pay-for-performance. Key characteristics of these main DSRIP waivers are compared with a particular focus on the establishment of project menus, performance metrics, and pay-for-performance processes. Concluding sections discuss the potential and limits of the waivers as vehicles for health care reform. The long-term durability and impact of DSRIP remains unclear. But federal and state officials have made considerable headway in planning and otherwise laying the groundwork for it.
The release of genetically engineered organisms into the shared environment raises scientific, ethical, and societal issues. Using some form of democratic deliberation to provide the public with a ...voice on the policies that govern these technologies is important, but there has not been enough attention to how we should connect public deliberation to the existing regulatory process. Drawing on lessons from previous public deliberative efforts by U.S. federal agencies, we identify several practical issues that will need to be addressed if relevant federal agencies are to undertake public deliberative activities to inform decision‐making about gene editing in the wild. We argue that, while agencies may have institutional capacity to undertake public deliberative activities, there may not be sufficient political support for them to do so. Advocates of public deliberation need to make a stronger case to Congress about why federal agencies should be encouraged and supported to conduct public deliberations.
Civic Learning for a Democracy in Crisis Jennings, Bruce; Gusmano, Michael K.; Kaebnick, Gregory E. ...
The Hastings Center report,
January‐February 2021, 2021-Jan, 2021-01-00, 20210101, Letnik:
51, Številka:
S1
Journal Article
Recenzirano
Odprti dostop
This essay introduces a special report from The Hastings Center entitled Democracy in Crisis: Civic Learning and the Reconstruction of Common Purpose, which grew out of a project supported by the ...John S. and James L. Knight Foundation. This multiauthored report offers wide‐ranging assessments of increasing polarization and partisanship in American government and politics, and it proposes constructive responses to this in the provision of objective information, institutional reforms in government and the electoral system, and a reexamination of cultural and political values needed if democracy is to function well in a pluralistic and diverse society. The essays in the special report explore the norms of civic learning and institutions, social movements, and communal innovations that can revitalize civic learning in practice. This introductory essay defines and explains the notion of civic learning, which is a lynchpin connecting many of the essays in the report. Civic learning pertains to the ways in which citizens learn about collective social problems and make decisions about them that reflect the duties and responsibilities of citizenship. Such learning can occur in many social settings in everyday life, and it can also be facilitated through participation in the processes of democratic governance on many levels. Civic learning is not doctrinaire and is compatible with a range of public goals and policies. It is an activity that increases what might be called the democratic capability of a people.
Abstract
Partisan, fractious federalism has strongly shaped the Biden administration’s efforts to reverse Trump’s undermining of the Affordable Care Act (ACA). In June 2021, the U.S. Supreme Court ...sided with Democratic, rather than Republican, state attorneys general to uphold the ACA. This enabled Biden to proceed with legislative and executive initiatives to reinvigorate the program. Biden secured passage of the American Rescue Plan (ARP), which temporarily boosted ACA enrollments. He also successfully pursued several executive initiatives to bolster the program. The victories of Democratic state attorneys general and private litigants in the courts during the Trump presidency often provided the platform for Biden’s success. On balance, the ACA’s vital signs have improved under Biden. But the durability of these gains depends heavily on whether Congress approves Build Back Better legislation that extends ARP benefits, and whether Biden can overcome resistance by Republican states in the courts and otherwise (especially concerning waivers).
Background/Purpose
In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents ...inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.
Methods
We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011–2013 (pre-ACA) and 2014–2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.
Results
Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45–64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.
Conclusions
Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.
Within the American system of shared power among institutions, the executive branch has played an increasingly prominent policy role relative to Congress. The vast administrative discretion wielded ...by the executive branch has elevated the power of the president. Republican and Democratic presidents alike have employed an arsenal of administrative tools to pursue their policy goals: high-level appointments, administrative rule making, executive orders, proclamations, memoranda, guidance documents, directives, dear colleague letters, signing statements, reorganizations, funding decisions, and more. Presidents Obama and Trump employed most of these tools in an effort to shape the implementation and outcomes of the Affordable Care Act (ACA) during its first decade. This article focuses on the Obama and Trump administrations' use of comprehensive waivers to shape ACA implementation. The Obama administration had mixed success using waivers to convince Republican states to expand Medicaid. Compared to Obama, the Trump administration has found it harder to accomplish its policy goals through waivers, but if the courts support the Trump administration's work requirement and 1332 waiver initiatives, it would enable the president to use waivers to achieve an ever broader set of goals, including program retrenchment.
The Patient Protection and Affordable Care Act (ACA) was signed into law by U.S. President Obama in 2010 and fully implemented in 2014. The ACA expanded health insurance by expanding the Medicaid ...program, creating health insurance exchanges (now called “marketplaces”) in which people with incomes between 139% and 400% of the federal poverty level, could purchase subsidized insurance coverage, and by regulating health insurance to eliminate practices such as denying coverage to people with pre‐existing conditions, or basing premiums on health status. We investigate the effects of the ACA's implementation on access to ambulatory health services in New York City by comparing rates of hospitalizations for ambulatory care‐sensitive conditions (ACSC) before and after the full implementation of the law. Although the ACA was associated with a significant decrease in the rate of ACSC in NYC, we find that there continue to be systemic inequalities by gender, race, ethnicity, income, and insurance status. We argue that the broader social and economic inequalities at the national and state levels, including tax and spending policies that have led to increased income and wealth inequalities, help explain why we see persistent inequalities in hospitalizations for ACSC.
摘要
《患者保护与平价医疗法案》(ACA)于2010年由奥巴马总统签署，并于2014年全面实施。ACA通过以下方式扩大健康保险扩大医疗补助计划、创造医疗保险市场（其中收入在联邦贫困线的139%到400%之间的人可以购买有补贴的保险）、通过监管健康保险以消除诸如拒绝向身患疾病的人提供保险或根据健康状况制定保费等做法。通过比较ACA全面实施前后的门诊护理敏感条件(ACSC)住院率，我们调查了ACA的实施对纽约市门诊护理服务获取的影响。尽管ACA与纽约市ACSC住院率的显著下降有关，但我们发现，性别、种族、族群性、收入和保险状况仍然存在系统性不平等。我们论证认为，国家和各州层面的更广泛的社会不平等与经济不平等（包括一系列加剧收入和财富不平等的税收政策和支出政策），有助于解释为何我们在ACSC住院治疗情况中发现持续的不平等。
Resumen
La Ley de Protección al Paciente y Cuidado de Salud Asequible (ACA, por sus siglas en inglés) fue promulgada por el presidente Obama en 2010 e implementada por completo en 2014. La ACA amplió el seguro médico al expandir el programa Medicaid, creando intercambios de seguros médicos (ahora llamados “mercados”) en que las personas con ingresos entre el 139 y el 400 por ciento del nivel federal de pobreza podrían comprar cobertura de seguro subsidiado y al regular el seguro de salud para eliminar prácticas como negar cobertura a personas con condiciones preexistentes o basar las primas en el estado de salud. Investigamos los efectos de la implementación de la ACA en el acceso a los servicios de salud ambulatorios en la ciudad de Nueva York al comparar las tasas de hospitalizaciones por condiciones sensibles a la atención ambulatoria (ACSC) antes y después de la implementación total de la ley. Aunque la ACA se asoció con una disminución significativa en la tasa de ACSC en la ciudad de Nueva York, encontramos que sigue habiendo desigualdades sistémicas por género, raza, etnia, ingresos y estado del seguro. Argumentamos que las desigualdades sociales y económicas más amplias a nivel nacional y estatal, incluidas las políticas de impuestos y gastos que han llevado a mayores desigualdades de ingresos y riqueza, ayudan a explicar por qué vemos desigualdades persistentes en las hospitalizaciones por ACSC.
Key Points
Advocates hoped that the full implementation of the Affordable Care Act would reduce inequalities in access to health care.
We find that, after the implementation of the Affordable Care Act in New York City, there are still large inequalities in hospitalizations for ambulatory care‐sensitive conditions.
Broader social and economic inequalities at the national and state levels help explain why we see persistent inequalities in hospitalizations for ambulatory care sensitive conditions.
Policy Points
Medicaid policymakers have a growing interest in addressing homelessness as a social determinant of health and driver of the potentially avoidable use of expensive medical services.
...Drawing on extensive document reviews and in‐depth interviews in four early‐adopter states, we examined the implementation of Medicaid's Section 1115 demonstration waivers to test strategies to finance tenancy support services for persons experiencing or at risk of homelessness.
Context
The Affordable Care Act extended Medicaid eligibility to large numbers of individuals experiencing or at risk of homelessness. This legislative development and the growing recognition of homelessness as a significant social determinant of health have encouraged advocates and policymakers to seek new ways to use Medicaid to provide housing supports.
Methods
We conducted 28 semistructured interviews with 36 stakeholders in four states. The stakeholders were government administrators, health care providers, nonprofit housing staff, and consultants. We supplemented these interviews with extensive reviews of public documents, media accounts, think‐tank reports, and published literature. We also conducted a systematic inductive qualitative analysis.
Findings
We identified seven challenges to the successful implementation of tenancy support demonstration projects: resolving the housing supply and NIMBY, removing silos between health care and homeless services providers, enrolling and retaining the target populations in Medicaid, contracting with and paying tenancy support providers, recruiting and retaining key workers, ensuring Medicaid's waiver durability, and reducing administrative crowd‐out and waiver burden.
Conclusions
Notwithstanding these challenges, three of the four states have made significant progress in launching their initiatives. At this point, the fourth state has delayed its start‐up to consider alternatives to a Medicaid demonstration waiver to provide tenancy supports. The experience of the four states suggests lessons for Medicaid officials in other jurisdictions that are interested in pursuing tenancy support initiatives. Nevertheless, the limitations of tenancy support waiver programs suggest that federal policymakers should consider allowing states to more directly subsidize housing costs for those experiencing or at risk of homelessness as an optional Medicaid benefit.
Abstract
The authors reflect on their own work in relation to the articles in this special section on physician organizations, and they make four observations. First, association-government power ...relations shift after countries introduce universal health insurance, but they are by no means diminished. In France, Germany, and Japan, physicians' economic interests are explicitly considered against broader health system goals, such as providing affordable universal insurance. In low- and middle-income countries (LMICs), physician organizations do not share power in the same way. Second, in higher-income countries, fragmentation may occur along specialty or generalist lines, and some physicians are unionized. Generally speaking, physician influence over reimbursement policy is reduced because of organizational fragmentation. Third, associations develop as legitimate voices for physicians, but their relationship to other professions differs in higher-income countries. Associations in LMICs form coalitions with other health professionals. Finally, although German state physician associations have a key implementation role, in most countries, state and federal policy roles seem relatively defined. Global comparison of the LMICs and other countries suggests power, unity, legitimacy, and federal roles are tied closely to the stage of health system development.
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