Women’s Health and the Affordable Care Act: High Hopes Versus Harsh Realities?

Our population-based survey of 1078 randomly sampled US women, aged 18 to 55 years, sought to characterize their understanding of and attitudes toward the Affordable Care Act (ACA). Most women, especially socially disadvantaged groups, had negative or uncertain attitudes toward the ACA and limited understanding of its health benefits, including its relevance for their own health service coverage and utilization. Our findings are important for continued research, policy, and practice, with implications for whether, when, and how improved coverage will translate to improved access and outcomes for US women.Women’s health clinicians, researchers, and policymakers are hopeful that expanding health care coverage under the Patient Protection and Affordable Care Act (ACA)1 will improve the health of US women. By requiring coverage, increasing access to affordable health plans, incentivizing utilization of high-value services, establishing benefit mandates, and reducing cost sharing, the ACA is expected to improve health outcomes and reduce health disparities for women. Since ACA implementation began, however, it has become clear that the public’s participation in its programs and benefits is compromised by widespread confusion.2–6 Recognizing that the ACA can only have an impact on women’s health (individual and population) if women are aware of available benefits and act upon them,7–9 we conducted a study to examine women’s understanding of and attitudes toward the ACA. Specifically, we sought to determine (1) whether women were aware and approved of the ACA and the women’s health benefits attributable to it, (2) whether women expected their coverage of women’s health services and subsequent service utilization to change as a result of the ACA, and (3) whether women’s awareness and attitudes differed across sociodemographic groups.     

Health Care Reform and Young Adults' Access to Sexual Health Care: An Exploration of Potential Confidentiality Implications of the Affordable Care Act

One provision of the 2010 Affordable Care Act is extension of dependent coverage for young adults aged up to 26 years on their parent’s private insurance plan. This change, meant to increase insurance coverage for young adults, might yield unintended consequences.Confidentiality concerns may be triggered by coverage through parental insurance, particularly regarding sexual health. The existing literature and our original research suggest that actual or perceived limits to confidentiality could influence the decisions of young adults about whether, and where, to seek care for sexual health issues.Further research is needed on the scope and outcomes of these concerns. Possible remedial actions include enhanced policies to protect confidentiality in billing and mechanisms to communicate confidentiality protections to young adults.ON MARCH 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law, effecting the most significant change to the US health care system since the creation of the Medicare and Medicaid programs in 1965.1 All components of the health sector are affected: the legislation includes expansions of public coverage, new subsidies for private coverage, health insurance exchanges, insurance coverage requirements and mandates, and strategies to increase the efficiency of health care delivery and rein in health care costs. Such sweeping reforms bring a host of intended changes and potential unforeseen ramifications. One provision of the ACA expands access to dependent coverage for young adults on their parent’s health insurance up to age 26 years, regardless of marital, employment, or educational status, effective September 2010. Previously, the maximum age varied by state, with eligibility for dependent coverage often linked to factors such as educational enrollment status. The government Web site describes the intended benefits of this provision: “By allowing children to stay on their parent''s plan, the Affordable Care Act makes it easier and more affordable for young adults to get health insurance coverage.”2Young adults aged 19 to 26 years have the highest uninsured rate of any age group in the country; 30% were without coverage in 2009.3 The high rate reflects many contributing factors. Young adults are more likely than other working-aged adults to be unemployed; if working, they are more likely to be newly employed, employed in entry-level jobs, and working in part-time positions without access to employer coverage. Furthermore, most young adults do not meet the traditional categorical eligibility requirements for the Medicaid program—the parent of a child younger than 19 years or an aged or disabled individual—and so young adults, even those with very low incomes, seldom qualify for public coverage. The subsequent low levels of insurance result in limited access to care and high levels of unmet need for care.4By expanding access to health insurance coverage, the ACA addresses two Healthy People 2020 goals5: attaining a higher proportion of individuals with insurance and reducing the proportion of individuals who are unable to obtain or who delay obtaining necessary medical care. This provision of the ACA has already shown significant success in expanding health insurance coverage for young adults. The percentage of young people with health insurance increased by 3.8 points from the first quarter of 2010 to the first quarter of 2011, far outstripping gains in other age groups.6 However, the reliance on expanding dependent coverage to address the high levels of uninsured young adults contains the potential for unintended consequences, because concerns about confidentiality could disrupt access to care.     

The Affordable Care Act and Emergency Care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.The Affordable Care Act (ACA) focuses on improving access and quality by expanding insurance coverage, using payment reform strategies, and increasing quality reporting.1 In the ACA, hospital-based emergency departments (EDs) are referenced as places to be avoided and reduced; no new payment models focus on ED care, and there are no plans to broadly address ED-specific quality through new measurement programs.Promoting value in ED care needs to be a greater focus for policymakers as the ACA is implemented. Emergency departments play a central role in health care delivery as the staging area for the ill and injured, and as an always-available resource for unscheduled care. Emergency department physicians constitute less than 5% of the US physician workforce, yet manage 28% of acute care encounters.2 Historically, the need for EDs arose from increases in vehicular trauma that accompanied the expansion of the Interstate Highway System in the 1960s.3 However, EDs also quickly became providers of low acuity unscheduled care as well.4 The Emergency Medical Treatment and Active Labor Act legislation passed in 1986 institutionalized EDs as provider of last resort for all, regardless of their ability to pay. Emergency departments have replaced the community physician’s office as the primary source for hospital admissions and provide a safety net for the uninsured, underinsured, and medically disenfranchised.5,6Several elements of the ACA—the insurance expansion, patient-centered medical homes, accountable care organizations, and bundled payments—will directly affect both demand for ED care and expectations for its role in providing coordinated care. We explore these effects and suggest some practical ways that EDs can be better integrated into these efforts.     

Determinants of Receipt of Recommended Preventive Services: Implications for the Affordable Care Act

Objectives. We examined preventive care use by nonelderly adults (aged 18–64 years) before the Affordable Care Act (ACA) and considered the contributions of insurance coverage and other factors to service use patterns.Methods. We used data from the 2005–2010 Medical Expenditure Panel Survey to measure the receipt of 8 recommended preventive services. We examined gaps in receipt of services for adults with incomes below 400% of the federal poverty level compared with higher incomes. We then used a regression-based decomposition analysis to consider factors that explain the gaps in service use by income.Results. There were large income-related disparities in preventive care receipt for nonelderly adults. Differences in insurance coverage explain 25% to 40% of the disparities in preventive service use by income, but education, age, and health status are also important drivers.Conclusions. Expanding coverage to lower-income adults through the ACA is expected to increase their preventive care use. However, the importance of education, age, and health status in explaining income-related gaps in service use indicates that the ACA cannot address all barriers to preventive care and additional interventions may be necessary.The benefits of many preventive health care services are well-established.1 In the case of immunization, for instance, those who receive the recommended services are likely to avoid a variety of life-threatening diseases while promoting herd immunity and protecting individuals who are unable to be immunized.2 Those appropriately screened for cancer are likely to receive more timely diagnosis and treatment, which ultimately leads to better outcomes.3 Furthermore, early detection of heart disease, diabetes, and other chronic conditions can lead to the promotion of healthier lifestyles and better management of the diseases.4 Despite this evidence, many studies have shown the use of preventive services, including cholesterol checks, Papanicolaou (Pap) tests, mammograms, colon cancer screenings, and flu vaccines to be below recommended levels.5–9In recent years, the growing prevalence of obesity and chronic conditions and the evidence that modifiable behaviors are among the leading causes of death have led to a renewed emphasis on promoting health and wellness as opposed to treating disease.10,11 This emphasis on prevention was particularly evident in the national conversation leading up to the passage of the Affordable Care Act (ACA) in March 2010. Increasing access to preventive care was one motivation for expanding coverage to the uninsured, and was the explicit goal of an additional provision in the ACA requiring private insurers to cover recommended preventive services without any cost-sharing obligations to consumers. The effects of these ACA policies on preventive service use will depend on the extent to which preventive services are currently underused and whether expanding coverage will increase the receipt of these services.We examined the receipt of 8 preventive services by nonelderly adults in the years before the ACA (2005–2010), thus providing recent evidence on the extent of underuse of a variety of important services. Previous studies have found that lower rates of service use are generally associated with more limited education, low incomes, and a lack of insurance coverage12–14; we concentrated on the disparities in service use between the lower-income adults most likely to benefit from the ACA coverage expansion and their higher-income counterparts. Using a regression-based decomposition analysis, we identified the roles of insurance coverage, education, and other factors in explaining these income-related disparities. The results provide important insights on the potential of ACA efforts to increase the use of preventive care through coverage expansion as well as on the limitations of such efforts.Our conceptual framework relies on human capital models, which suggest that the demand for medical care is derived from the demand for health.15,16 According to such models, critical factors that are expected to affect the demand for health and medical care include age, health status, education, and rate of time preference. In some cases, the effects of these factors on demand for preventive care may be distinct from their effects on demand for treatment. In the case of age, for example, the demand for treatment, or curative care, is expected to increase with age as an individual’s health depreciates, whereas investment in preventive medical care is expected to decrease with age as the payoff period for avoiding future illness shortens.13,17 This reflects a more general distinction between investment and consumption considerations in the demand for preventive care, which is also relevant with respect to the role of health status. From a consumption perspective, those in poor health are more likely to use preventive services, but healthy individuals and those who are future-oriented are also more likely to invest in health and preventive care.18,19 Lastly, although the effect of education on the demand for health and health care is theoretically ambiguous,15 considerable empirical evidence finds a positive relationship between education and prevention activities.13,20–22Another critical consideration is the influence of insurance coverage on the demand for medical care. The direct effect of insurance is to lower the out-of-pocket cost of medical care and thus increase the demand for services. The RAND health insurance experiment provides the most rigorous evidence that this is the case,23 but many other studies provide empirical evidence that having health insurance is associated with increased utilization of medical care.24–27 The possibility exists, however, that because insurance coverage protects against the financial costs of adverse health events, it may reduce the incentive to invest in preventive care.17 Despite this potential for “ex ante moral hazard,” most empirical evidence finds that those with insurance coverage use more preventive care, including blood pressure screenings, mammograms, and other cancer screenings.28–30 Furthermore, those with more generous coverage and lower cost-sharing exhibit higher rates of preventive service use.31–33The ACA includes several components that expand coverage and reduce cost-sharing and thus have the potential to increase the receipt of recommended preventive care. The ACA includes an optional expansion of Medicaid for those with incomes less than 138% of the federal poverty level (FPL) and federal subsidies to purchase coverage in the new health insurance exchanges for those with incomes up to 400% of the FPL. The law also includes penalties for not having health insurance coverage and enhanced enrollment and outreach efforts. When fully implemented, the ACA is expected to significantly expand coverage, particularly among adults with incomes less than 400% of the FPL.34 Many of those becoming newly insured under the ACA are expected to experience improved access to recommended preventive services, given that these services will be included at no or low cost in exchange plans and under most Medicaid plans.In addition to the broader coverage expansions included in the ACA, the law includes new requirements for private health insurance coverage of a set preventive services rated “A” or “B” by the US Preventive Services Task Force.35 After September 2010, many private health plans were required to cover the specified services, and to do so at no cost to members. Although coverage for some of the ACA-mandated services is already relatively common, other services, such as diet and tobacco counseling, are likely to see expanded coverage under the law.36 Furthermore, with the notable exception of mammograms, few of the mandated services are currently required to be covered by private plans under state laws.37     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.Methods. We used 2003–2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.Results. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states—from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.Conclusions. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

Uninsured Veterans Who Will Need to Obtain Insurance Coverage Under the Patient Protection and Affordable Care Act

Objectives. We examined the number and clinical needs of uninsured veterans, including those who will be eligible for the Medicaid expansion and health insurance exchanges in 2014.Methods. We analyzed weighted data for 8710 veterans from the 2010 National Survey of Veterans, classifying it by veterans’ age, income, household size, and insurance status.Results. Of 22 million veterans, about 7%, or more than 1.5 million, were uninsured and will need to obtain coverage by enrolling in US Department of Veterans Affairs (VA) care or the Medicaid expansion or by participating in the health insurance exchanges. Of those uninsured, 55%, or more than 800 000, are likely eligible for the Medicaid expansion if states implement it. Compared with veterans with any health coverage, those who were uninsured were younger and more likely to be single, Black, and low income and to have been deployed to Iraq and Afghanistan.Conclusions. The Patient Protection and Affordable Care Act is likely to have a considerable impact on uninsured veterans, which may have implications for the VA, the Medicaid expansion, and the health insurance exchanges.The Patient Protection and Affordable Care Act (ACA)1 represents one of the most significant overhauls of the US health care system and is expected to affect millions of uninsured people across the country. Military veterans constitute a particularly important segment of the population because of their service to the country, access to US Department of Veterans Affairs (VA) health care, and other special benefits after their service. However, little has been written on the potential impact of the ACA on the health and health care of veterans.2 Although the VA operates an integrated national health care system that offers free or low-cost services to eligible veterans, many veterans are not enrolled in VA health care, and some are ineligible. Enrollment in VA health care satisfies the ACA’s requirement for insurance coverage, but eligibility for VA health care is determined on the basis of a complex system of priorities, mostly based on service-connected disability, income, and age, and it generally requires a military service discharge that is other than dishonorable (i.e., honorable, general).One study estimated that only 13% (3.6 million) of veterans report receiving some or all of their health care at the VA, and the vast majority (> 20 million) receive no health care from the VA.3 Most veterans thus rely on non-VA health care and are covered by various private or other public forms of health insurance, including Medicare and Medicaid. A small, albeit important, minority of veterans have no health insurance coverage. Estimates based on data from 1987 to 2004 showed that 7.7% of veterans were uninsured (including having no VA coverage), which equates to nearly 1.8 million veterans and represents 4.7% of all uninsured US residents.4Lack of health insurance coverage is an important problem because it can hinder access to effective health care, including needed medical visits, preventive care, and other services, and it can ultimately lead to poor health, premature mortality, and high medical costs.5,6 Being uninsured is a growing problem in the United States that the ACA addresses by requiring virtually all legal US residents to have health insurance. The ACA includes various provisions to help US residents, including veterans, accomplish this.One major provision that is optional for states to implement is the expansion of Medicaid coverage to all individuals aged 18 to 65 years with incomes at or below 138% of the federal poverty level. Although not all states will implement this expansion, and the number of participating states is currently unknown, many poor, uninsured adults will be able to obtain Medicaid coverage in states that implement the Medicaid expansion. Uninsured adults who have incomes above the Medicaid expansion limit or who live in states that do not implement the Medicaid expansion will have to purchase health insurance and may participate in the health insurance exchanges.A second major provision of the ACA is the creation of health insurance exchanges in each state whereby individuals may purchase competitive health insurance plans that are eligible for federal subsidies, but those subsidies are only available to those with income above the federal poverty level. Both of these major ACA provisions are planned for implementation in 2014 and will introduce a variety of coverage options for US residents, including veterans.There has been little study of uninsured veterans and no study of the potential impact of the ACA on veterans in general. Moreover, most data that exist on veterans are based on VA data, which only contain information about veterans who use VA health services and do not include information about those who are uninsured or not covered by VA health care. However, 1 population-based study7 has provided some evidence that a substantial number of veterans are uninsured (particularly those younger than 65 years) and that many uninsured veterans are in poor health, often forego needed health care because of costs, and have equal or worse access to health care than other uninsured adults in the general population. As the country moves toward a new era of health care with the ACA and continues to engage in conflicts in the Middle East, the impact of the ACA on the health care of veterans needs to be considered.We used a recent nationally representative survey of veterans to (1) describe the proportion and characteristics of veterans who are currently uninsured because they will likely be required to obtain coverage under the ACA; (2) determine, among those who are uninsured, who will likely be eligible for the Medicaid expansion; and (3) compare the sociodemographic and health characteristics of those who are uninsured and likely eligible for Medicaid expansion (LEME), those who are uninsured and not LEME, and those who currently have health insurance coverage. The results provide information about the number and health characteristics of veterans who will likely be affected by different provisions of the ACA and inform planning efforts for the VA and states that implement the Medicaid expansion and health insurance exchanges.     

Local Health Departments as Essential Community Providers for Health Benefits Exchange Plans

The Affordable Care Act requires health plans’ networks to include “essential community providers” (ECPs). Local health departments (LHDs) can be ECPs, typically for tuberculosis and sexually transmitted disease–related services or family planning. An ECP status may be controversial if it jeopardizes core population health services or competes with community partners. Some LHDs already bill for ECP services, but independent billing functions could exceed projected revenue. Thus, LHDs may wish to investigate contractual arrangements as alternatives to billing multiple issuers.The Affordable Care Act requires health plan issuers to include some essential community providers (ECPs) in their networks to qualify for participation in health benefit exchanges. Essential community providers are entities that help meet the needs of historically underserved areas and populations1; the classification includes federally qualified health centers, critical access hospitals, Ryan White grantees for HIV/AIDS services, and entities that provide services related to tuberculosis and sexually transmitted diseases (STDs), among others. Qualified health plans are required to contract with at least 20% of the ECPs in their service areas and with at least 1 in each service category, or document that doing so is not feasible.2 The rationale for requiring inclusion of ECPs is to ensure continuity of service for newly insured individuals who had received services from ECPs, and to support the health care safety net after Affordable Care Act implementation increases access to third-party coverage.2 The following brief review points to opportunities, challenges, and controversies that the ECP option raises for local health departments (LHDs).     

Older Jail Inmates and Community Acute Care Use

Objectives. We examined older jail inmates’ predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release.Methods. We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use.Results. We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89).Conclusions. The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.Jail has become a critical site for linking medically vulnerable older adults to community health care. Approximately 12 million Americans pass through jails each year and nearly all return to the community within 6 months where many struggle to access nonemergency medical care. Between 1996 and 2008 the number of “older” or “geriatric” inmates (aged 55 years or older) increased 278% compared with a 53% growth in the overall jail population.1,2 Now, approximately 550 000 older adults spend time in jail each year, comprising 10% of all inmates. Yet little is known about their health care and social service needs.Reducing acute care use (hospitalizations and emergency department [ED] use) and improving insurance access for former inmates is a priority in the Affordable Care Act (ACA).3 Although most inmates are without health insurance,4 those with insurance demonstrate reduced recidivism and better access to mental health and substance abuse treatment when released.5–7 The ACA expands Medicaid eligibility for low-income adults and allows eligible inmates to apply for coverage while in jail.3,8 As most persons passing through jails will be eligible for Medicaid in states participating in the expansion, an estimated 4 to 6 million jail inmates will gain new coverage by the end of 2014 through outreach and patient navigator assistance.9For community-dwelling older adults, health and social factors beyond insurance drive community acute care use, such as functional impairment, uncontrolled symptoms, and housing instability.10–12 This may also be true for older former inmates, many of whom experience “accelerated aging” because of high rates of disability and chronic disease at relatively young ages.13 Therefore, we conducted a study of older jail inmates to describe predetainment acute care use and anticipated plans for using acute care after release, and to assess the factors associated with use.     

The Curious Case of Cuba

As health professionals in the United States consider how to focus health care and coverage to ensure better, more equitable patient and population health outcomes, the experience of Cuba’s National Health System over the last 5 decades may provide useful insights. Although mutual awareness has been limited by long-term political hostilities between the United States and Cuban governments, the history and details of the Cuban health system indicate that their health system merits attention as an example of a national integrated approach resulting in improved health status. More extensive analysis of the principles, practices, and outcomes in Cuba is warranted to inform health system transformation in the United States, despite differences in political-social systems and available resources.There is a growing awareness in the United States that major changes in health care’s conceptualization, organization, and delivery are needed if the country is to bring soaring medical costs under control and create a population health status commensurate with current evidence and technology.1 The realities that 25 years of the approximate 30-year gain in life span in the 20th century are because of public health actions rather than clinical care2; that risk factors for chronic disease such as tobacco use, inappropriate diet, lack of exercise, and drug misuse are not easily addressed in clinical settings3,4; that many societal influences not traditionally included in medicine’s purview can profoundly affect population health5,6; and that the United States is lagging behind other industrialized nations in population health outcomes6 strongly suggest that a different approach is warranted.Efforts in this direction have begun. A major impetus is the Patient Protection and Affordable Care Act (PPACA), which became law in March 2010. It includes significant funding for public health over the next decade, emphasis on prevention and wellness strategies, and incentives to develop partnerships among clinical and public health entities, governmental and nongovernmental alike, to improve health.7 We suggest that lessons for maximizing the potential of the ACA and other significant efforts to improve our population’s health status can be found in the experience of Cuba, despite differences in our political-social systems and available resources.More than 50 years of political enmity separating Cuba and the United States, complicated by a United States embargo prohibiting normal trade in food, medicines and medical equipment, and official programs aiming at regime change on the island, have made it difficult for Cuba’s National Health System (NHS) and its outcomes to be thoughtfully considered by the United States media, the public, or policymakers. During the same decades, however, strategies were developed in Cuba that have resulted in consistent improvement in the population’s health status, to the extent that today the country’s health indicators resemble those of industrialized nations. In the words of Cooper et al.:

In virtually every critical area of public health and medicine facing poor countries Cuba has achieved undeniable success; these include most prominently – creating a high quality primary care network and an unequaled public health system, educating a skilled work force, sustaining a local biomedical research infrastructure, controlling infectious diseases, achieving a decline in non-communicable diseases, and meeting the emergency health needs of less developed countries.8^(p818)

In this article, we do not advocate the United States adopt the Cuban system: the cultural, political, and socioeconomic differences are too great, and clearly each nation must find its own path to health. However, we may draw from the principles and practices in Cuba to good end, and in particular we suggest the Accountable Care Community (ACC) concept as a viable model to apply such insights in our capitalist context.9 In this light, we describe Cuba’s health care conceptualization, delivery, and associated outcomes, and analyze how Cuban approaches to health might be tailored to our environment to improve both health care effectiveness and population health status.     

Whether Health Departments Should Provide Clinical Services After the Implementation of the Affordable Care Act

I have described a decision support tool that may facilitate local decisions regarding the provision and billing of clinical services. I created a 2 by 2 matrix of health professional shortage and Medicaid expansion availability as of July 2015. I found that health departments in 93% of US counties may still need to provide clinical services despite the institution of the Affordable Care Act. Local context and market conditions should guide health departments’ decision to act as safety net providers.Because more individuals have health insurance coverage as a result of the Affordable Care Act, health departments grapple with the question of whether to continue to provide clinical services such as maternal and child health, oral health, and HIV/AIDS treatment and, if so, whether to seek reimbursement from third party payers.1 In fact, a 2012 Institute of Medicine report states,

As clinical care provision in a community no longer requires financing by public health departments, public health departments should work with other public and private providers to develop adequate alternative capacity in a community’s clinical care delivery.2^(p68)

The decision to provide clinical services and pursue reimbursement is complex,3 and that complexity will likely increase as reimbursement moves to new models such as accountable care organizations. Health departments must decide whether it makes sense to provide clinical services on the basis of local context and, if so, whether to seek reimbursement.4 As of 2013, a minority of local health departments provided clinical services such as maternal and child health, oral health, and HIV/AIDS treatment,5 although a 2014 report showed that, of those who do, the majority bill some form of third party payment.6 I tested a simple decision support tool that might be used to facilitate local decision-making.     

Latino Population Growth and Hospital Uncompensated Care in California

Objectives. We examined the association between the size and growth of Latino populations and hospitals’ uncompensated care in California.Methods. Our sample consisted of general acute care hospitals in California operating during 2000 and 2010 (n = 251). We merged California hospital data with US Census data for each hospital service area. We used spatial analysis, multivariate regression, and fixed-effect models.Results. We found a significant association between the growth of California’s Latino population and hospitals’ uncompensated care in the unadjusted regression. This association was still significant after we controlled for hospital and community population characteristics. After we added market characteristics into the final model, this relationship became nonsignificant.Conclusions. Our findings suggest that systematic support is needed in areas with rapid Latino population growth to control hospitals’ uncompensated care, especially if Latinos are excluded from or do not respond to the insurance options made available through the Affordable Care Act. Improving availability of resources for hospitals and providers in areas with high Latino population growth could help alleviate financial pressures.Uncompensated hospital care for the uninsured and underinsured imposes a significant financial burden on the US health care system. The American Hospital Association reported that uncompensated care rose to $45.9 billion in 2012, which accounted for 6.1% of total hospital expenses that year.1 This problem affects hospitals’ financial stability and ability to recoup losses from reduced payments, which in turn can hurt their ability to care for the local population, operate emergency department and specialty services to meet patient needs, and maintain optimal nurse staffing ratios.2–4Hospitals have typically responded to increased uncompensated care by increasing prices for paying patients5; however, Medicaid and Medicare payments have been reduced, and it has become more difficult to shift costs to private payers. Uncompensated care also affects all levels of government, which provide subsidies to offset these losses through other programs.6 The largest source of federal funding for uncompensated care—Medicaid Disproportionate Share Hospital (DSH) payments—totaled $11.4 billion in 2012.7 Despite these mechanisms that indirectly subsidize hospitals’ provision of uncompensated care, hospital closures have been linked to uncompensated care.8Hospital administrators, policymakers, and advocates for the uninsured hoped that the Patient Protection and Affordable Care Act (ACA) would provide health insurance to many of the almost 50 million previously uninsured Americans and thereby significantly reduce uncompensated care. The Supreme Court’s decision on the ACA allows states to opt out of the mostly federally funded Medicaid expansion, which will likely lower the projected numbers of Americans who obtain coverage and potentially undermine the predicted decreases in future uncompensated care by hospitals.9 Existing policy efforts focus on decreasing hospital payments to reduce health care spending,10 and DSH payments are being reduced in anticipation of increases in insurance coverage in all states.11 These recent health policy developments have brought the problem of uncompensated hospital care into a new focus, generating increasing interest in understanding what factors affect hospitals’ financial stress.Some have suggested that immigrants use large amounts of uncompensated care,12 potentially implicating the Latino population—the nation’s largest immigrant group13—in rising uncompensated care. However, hospital uncompensated care may also decrease because of Latinos’ low health care utilization14–21 and expenditures,22–25 which have been described in the context of the healthy immigrant effect (i.e., Latino immigrants are usually younger and healthier than Latinos born in the United States)26 and other factors (e.g., fewer available health care resources, lack of linguistically appropriate care, discrimination in health care settings, and fear of deportation among undocumented Latinos).27,28 Empirical evidence for the potential impact of changing Latino demographics on hospitals’ uncompensated care is limited at best. A study of Oregon state data found weak evidence of an association between the size of the Latino population and hospital uncompensated care.27 A nonsignificant relationship might have reflected Latinos’ immigrant status, limited health care access, and unwillingness or inability to seek health care.California’s hospitals account for more than 10% of uncompensated care nationally.29 California has the largest Latino population of any state, as well as the largest growth rate in its Latino population.29 In 2012, 44.5% of California''s uninsured population was Latino.30 Among the uninsured Latino population in the state, more than 1 million will remain uninsured, even after the ACA’s coverage expansions.31,32 Although some are able to temporarily access emergency Medicaid services for significant, emergent health issues, the majority are uninsured and require help from local indigent care programs, hospital charity care, federally qualified health centers, or other safety net providers. Hence, California, because of its high number (7 million) and percentage (20%) of uninsured residents prior to the ACA,33 offers an excellent setting to study the impact of the Latino population on the uninsured rate, uncompensated care need, and local safety net providers.We examined the association between Latino population growth rates and hospitals’ uncompensated care in California between 2000 and 2010. These growth rates not only reflected the marginal increases in uncompensated care and Latino population estimates, but also took into account baseline levels of these variables. Because growth rates are considered to be better than the level measures for predicting future population growth trends,34 our findings could have important policy implications regarding the allocation of health care resources.     

State Politics and the Creation of Health Insurance Exchanges

Health insurance exchanges are a key component of the Affordable Care Act. Each exchange faces the challenge of minimizing friction with existing policies, coordinating churn between programs, and maximizing take-up. State-run exchanges would likely be better positioned to address these issues than a federally run exchange, yet only one third of states chose this path. Policymakers must ensure that their exchange—whether state or federally run—succeeds. Whether this happens will greatly depend on the political dynamics in each state.ONE OF THE MOST IMPORTANT components of the Patient Protection and Affordable Care Act of 2010 (ACA)1 is the creation of health insurance exchanges. Exchanges will be online marketplaces through which individuals and small businesses will shop for health insurance. The goal of an exchange is to expand coverage for previously uninsured populations while increasing transparency in the health insurance marketplace by enabling consumers to compare plans in a standardized way. The exchange will also be the mechanism through which qualifying individuals receive subsidies from the federal government to purchase private insurance coverage. It is estimated that 24 million people will receive insurance through an exchange by 2016.2 Every state will have an exchange, although states have had to decide whether to create the exchange themselves or cede control to the federal government. Public opinion is divided over the ACA as a whole, yet exchanges were not expected to be controversial in their own right. Republicans endorsed organized marketplaces for insurance in the past and even supported state insurance exchanges during the legislative battles over the ACA.3 A November 2012 Associated Press poll found that 63% of Americans preferred a state-run exchange; 32% favored federal control. Among Republican respondents, 81% preferred state control.4 However, after 3 years of contentious debates, only 17 states and the District of Columbia chose to create an exchange themselves. Six chose to partner with the federal government, and the remaining 27 states chose to allow the federal government to develop and run their exchange.5 States can take control of their exchanges at any point in the future. However, a state that inherits a federal structure will have lost the opportunity to make decisions that will dramatically affect both what the exchange strives to accomplish and whether it succeeds. This includes shaping whether the exchange is run inside government or as a nonprofit organization, the role of the exchange in determining what plans can be sold, how the exchange is financed, the role of insurance agents and brokers, and whether interest group representatives sit on the board of directors.The ACA was written with the assumption that states would take the initiative to create their own exchange. The law gives the Department of Health and Human Services authority to fund the creation of state-run exchanges and provide subsidies through state-based exchanges but includes no specific authorization to provide subsidies through a federally run exchange.1 Neither did the department receive resources to create federally run exchanges. It has had to divert this money from other parts of its budget.Opponents offer several reasons for being cautious about creating a state exchange. For example, state policymakers have complained that federal guidelines have taken too long to develop and that creating an exchange commits them to restrictions of which they are not yet aware.6 Second, frustration over lack of federal guidance is compounded by a fear of hidden costs. Opponents worry that exchanges will be more expensive than expected and that states will ultimately be burdened by these additional costs.7 Finally, some argue that states would not have much control anyway and would function as a vendor for the federal government.8Although we believe that the benefits of state-run exchanges outweigh these concerns, it may be that there is no single answer to the question of whether a state should have created its own exchange. A state exchange would stand no chance of success if run by leaders who were uncommitted or even belligerent toward the idea. That only 17 states chose to create an exchange should not necessarily be viewed as a failure for the administration of President Barack Obama. This may be the ideal outcome. Every state will have an exchange, and early adopter states will benefit from flexibility and grant money when they design their own exchange. These states will serve as a natural experiment through which the rest of the country can observe the advantages and disadvantages of each model.     

How the Affordable Care Act and Mental Health Parity and Addiction Equity Act Greatly Expand Coverage of Behavioral Health Care

The Patient Protection and Affordable Care Act (ACA) will expand coverage of mental health and substance use disorder benefits and federal parity protections to over 60 million Americans. The key to this expansion is the essential health benefit provision in the ACA that requires coverage of mental health and substance use disorder services at parity with general medical benefits. Other ACA provisions that should improve access to treatment include requirements on network adequacy, dependent coverage up to age 26, preventive services, and prohibitions on annual and lifetime limits and preexisting exclusions. The ACA offers states flexibility in expanding Medicaid (primarily to childless adults, not generally eligible previously) to cover supportive services needed by those with significant behavioral health conditions in addition to basic benefits at parity. Through these various new requirements, the ACA in conjunction with Mental Health Parity and Addiction Equity Act (MHPAEA) will expand coverage of behavioral health care by historic proportions.     

State Medicaid Expansion,Community Interventions,and Health Care Disparities in a United States–Mexico Border Community

Objectives. We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona’s Medicaid program in 2001 and multiple community-level programs and policies.Methods. We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively.Results. In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P < .001 for all outcomes). Improvements in access to and use of health care were most pronounced among residents with less than a high school education, which reduced or eliminated educational disparities in health care.Conclusions. Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.Mexican Americans and other Latinos suffer from a high burden of chronic disease.1,2 For example, 79% of Mexican American adults and 78% of all Latino adults are overweight or obese compared with 67% of non-Hispanic Whites, and half of Latinos born in 2000 will develop diabetes in their lifetimes compared with less than one third of non-Hispanic Whites.1,2 Identifying effective programs and policies to improve the health of Mexican Americans and other Latinos is a top public health priority, both to reduce health disparities and because even small improvements can yield large health and economic benefits at the population level.Poor access, use, and quality of health care services may contribute to high rates of chronic disease among Mexican Americans and other Latinos. Latinos are less likely than are other racial/ethnic groups to have health insurance, attend regular medical checkups, have a usual source of care, or be regularly screened for several forms of cancer and other chronic conditions.3–8 Latinos are also more likely to delay needed care, have chronic conditions that go undiagnosed or are diagnosed at later stages, have negative outcomes related to their chronic conditions, and be unsatisfied with their providers.4,9,10 Health care access and use is even poorer among Mexican Americans than most other Latino subgroups.4Latinos face numerous social, economic, and structural barriers to health care. As a group, Latinos have low income, high poverty rates, and poor educational attainment, factors consistently found to affect health and health care.11–13 One third of Latinos are immigrants and 41% of Latino immigrants speak English less than very well, factors that can lead to linguistic and cultural barriers to health care.13,14 Many immigrants, including 6 million who are undocumented, are ineligible for public health insurance programs that subsidize health care for other low-income populations.15–17One potential way to reduce health care disparities faced by low-income and minority populations, including Latinos, is through public policy. The Affordable Care Act (ACA) includes several provisions expected to curb uninsurance and increase access to and use of health care services among medically underserved populations, including an individual mandate requiring most Americans to have health insurance; public health insurance exchanges that can be used to buy affordable, high-quality, and often subsidized insurance; and expanded eligibility for Medicaid to include individuals with incomes up to 138% of the federal poverty level (FPL) as set by the US Department of Health and Human Services.18 It is important to understand whether the ACA and other policy- and community-level interventions can effectively reduce health care disparities that Latinos and other low-income and minority populations face.     

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.Lack of health insurance is associated with lower rates of preventive care, delays in necessary care, forgone care, medical bankruptcy, and increased mortality.1–5 The Affordable Care Act (ACA; Pub L No. 111–148) expanded Medicaid insurance for people with low incomes (< 138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.6–8Some have suggested that Medicaid’s low reimbursement rates discourage physician acceptance of Medicaid patients, limiting access to care and resulting in poor health outcomes.9,10 Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.11–13 However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.14,15The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured16,17 may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.We used the nationally representative National Health and Nutrition Examination Survey (NHANES) to compare outpatient physician visit frequency among the uninsured and comparable persons with Medicaid coverage. We also assessed whether individuals with major chronic conditions had been previously diagnosed with the condition, and whether it was under control.     

A Window of Opportunity: Maximizing the Effectiveness of New HCV Regimens in the United States With the Expansion of the Affordable Care Act

Patients with chronic HCV have predictable overlapping comorbidities that reduce access to care. The Affordable Care Act (ACA) presents an opportunity to focus on the benefits of the medical home model for integrated chronic disease management.New, highly effective HCV treatment regimens in combination with the medical home model could reduce disease prevalence. We sought to address challenges posed by comorbidities in patients with chronic HCV infection and limitations within our health care system, and recommend solutions to maximize the public benefit from ACA and the new drug regimen.Over 180 million people worldwide have HCV-related chronic liver disease, with an estimated yearly incidence of 17 000 and prevalence of 3.2 million people in the United States alone.1,2 Years of undetected infection and untreated disease might culminate in hepatic fibrosis, cirrhosis, hepatocellular carcinoma, and liver transplantation, accompanied by increased morbidity and mortality. Approximately 20% of chronically infected adults develop cirrhosis within 20 years.3,4Each stage of disease incurs increasing human and economic costs, with medical treatment of infected patients in the United States estimated as high as $9 billion in 2012.5–7 Curing HCV infection, measured by a sustained virological response (negative HCV-RNA PCR) 24 weeks after the end of therapy (SVR 24), reduces mortality and the risk of hepatocellular carcinoma.8,9 Regrettably, the reach of curative therapy has been limited by the efficacy and tolerability of past regimens.A radical shift in standard therapy for HCV infection is occurring in which new regimens exceed 90% cure rates, eliminate injectable interferon and its attendant adverse effects, reduce dosing frequency and pill burden potentially to 1 pill daily, and reduce treatment duration to as short as 3 months. Currently, an interferon-free regimen exists for the treatment of genotype 1. It combines sofosbuvir with simeprevir. Because the efficacy trial combined drugs from separate manufacturers, the regimen is not explicitly supported by either drug label.10 There are multiple regimens with high efficacy in genotype 1 without interferon that are expected to be approved by fall 2014.11For the past decade, treatment has consisted of peginterferon (pegINF) α-2a/2b plus ribavirin, administered up to 12 months, which has clinical trial efficacy rates among genotype 1 treatment-naive patients that range from 41% to 55%.12–14 In 2012, the efficacy of regimens for genotype 1, estimated to comprise more than 70% of HCV-infected patients in the United States, modestly improved when 2 new protease inhibitors, boceprevir15 and telaprevir15 were approved. However, both of these medications must be administered in addition to the standard regimen of interferon and ribavirin, add significant toxicity, and are unlikely to continue to play a significant role in future treatment regimens.In 2013, the US Food and Drug Administration approved 2 novel HCV drugs: simeprevir,16 an NS3/4A protease inhibitor, and sofosbuvir,17 an oral nucleotide inhibitor of HCV polymerase. Sofosbuvir enables the first all-oral, interferon-free regimen approved for the cure of chronic HCV infection, though an indication for an interferon-free regimen for genotype 1 is not yet available. Treatment with sofosbuvir plus pegylated interferon plus ribavirin yields cure in an unprecedented 89% of genotype 1 patients in only 3 months.17 In the near-term, other novel antiviral agents are expected to become available that will enable interferon-free regimens for genotype 1. Already, phase 2 trials have shown that sofosbuvir in combination with ledipasvir and ribavirin, without interferon, achieves 100% cure rates in genotype 1 patients without cirrhosis, with an excellent safety profile.18This dramatic improvement in HCV treatment has the potential to substantially reduce the public health burden of chronic liver disease as earlier therapy yielded low efficacy, was long in duration, and had burdensome side effects that deterred both physicians and patients. Better treatment regimens could lead to more screening, more diagnoses, stronger adherence, more cures, and ultimately reduce HCV-associated cirrhosis and liver cancer, liver transplantation, mortality, and lower health care system costs associated with chronic HCV infection.Maximizing the public health benefit from this therapeutic innovation will require addressing the barriers that US patients with chronic HCV face when attempting to access treatment. Most people in the United States with chronic HCV live in areas of high poverty, lack health insurance or rely on public insurance19 and have a history of injection drug use.20 With multiple medical and behavioral health co-morbidities, patients with HCV face a fragmented health care delivery system.Historically, the chasm between clinical trial HCV cure rates (efficacy) and cure rates in the community (effectiveness) has been considerable.21,22 The specific efficacy-effectiveness gap in curative HCV therapy has been modeled to suggest that even a substantial improvement in the efficacy of a curative regimen alone is unlikely to move the effectiveness bar very far.23 One model suggests that if the new antiviral treatments consistently resulted in an 80% response rate and half of all HCV-infected patients were treated, then incidence of cirrhosis would decline by 15%.24 Consequently, to move beyond treatment efficacy to improved cure rate, greater attention must be given to the social determinants of health, consistent access to care, as well as patient and provider acceptance of treatment therapy.25,26A key component of the efficacy-effectiveness gap is the readiness of the health care system to identify patients, address comorbidities, safely and effectively administer a curative regimen, reduce the risk of reinfection, and measure population-level progress. Fortunately, the Affordable Care Act (ACA)27 represents a timely opportunity to engage HCV infected patients in care and achieve a higher community-level cure rate.