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CHANGING THEU.S. HEALTH CARE SYSTEM

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CHANGING THEU.S. HEALTH CARE SYSTEM

Key Issues in Health ServicesPolicy and Management

4TH EDITION

Gerald F. KominskiEditor

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Cover design by Wiley

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Copyright C 2014 by John Wiley & Sons, Inc. All rights reserved.

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Library of Congress Cataloging-in-Publication DataChanging the U.S. health care system : key issues in health services policy and management /

Gerald F. Kominski, editor. —4th ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-1-118-12891-6 (cloth)—ISBN 978-1-118-41890-1 (pdf)—

ISBN 978-1-118-41640-2 (epub)

I. Kominski, Gerald F.

[DNLM: 1. Health Care Reform—United States. 2. Delivery of Health Care—United States.

3. Health Policy—United States. WA 540 AA1]

RA395.A3

362.10973—dc23

2013013537

Printed in the United States of America

FOURTH EDITION

HB Printing 10 9 8 7 6 5 4 3 2 1

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CONTENTS

Figures and Tables xv

Foreword to the Third Edition xix

Foreword to the Fourth Edition xxi

The Editor xxv

The Authors xxvii

Introduction and Overview xliii

Acknowledgments lvii

PART ONE: ACCESS TO HEALTH CARE 1

1 The Patient Protection and Affordable Care Act of 2010 3

Gerald F. Kominski

Learning Objectives 3

Events Leading to the Enactment of the ACA 4

Major Provisions of the ACA 7

Future Directions 20

v

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vi Contents

Summary 25

Key Terms 26

Discussion Questions 28

2 Improving Access to Care 33

Ronald M. Andersen, Pamela L. Davidson, Sebastian E. Baumeister


Understanding Access to Health Care 34


Summary 63

Key Terms 63


3 Racial and Ethnic Disparities in Health Status 71

Antronette K. Yancey, Roshan Bastani, Beth A. Glenn


Epidemiology of Health Disparities 73

Factors Underlying Chronic Disease-Related Disparities 82


Summary 94

Key Terms 94


4 Racial and Ethnic Disparities in Health Care 103

Arturo Vargas Bustamante, Leo S. Morales, Alexander N. Ortega


Definition of Disparity in Health Care 105

Historical Overview of Disparities in Medical Care 109

Scientific Evidence of Disparities in Health Care 115


Summary 125

Key Terms 126


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Contents vii

5 Multilevel Social Determinants of Health 135

Ninez A. Ponce, Michelle Ko


Policy Frameworks for Social Determinants of Health 137

Mechanisms by Which Social Context Affects Health Care 142


Summary 148

Key Terms 149


6 Public Health Insurance 157

Shana Alex Lavarreda, E. Richard Brown


Medicare, Medicaid, and CHIP 159

Who is Left Out of Public Coverage? 169

Enactment of the Affordable Care Act of 2010: A Political Success Story 179


Summary 183

Key Terms 184


7 Private Health Insurance 191

Nadereh Pourat, Gerald F. Kominski


Evolution of Private Health Insurance 192

Concepts in Private Health Insurance 194

Employment-Based Health Insurance 200

Individually Purchased Health Insurance 207

Significant Trends in Private Health Insurance 208


Summary 216

Key Terms 216


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viii Contents

PART TWO: COST OF HEALTH CARE 223

8 Measuring Health Care Expenditures and Trends 225

Thomas H. Rice


Measuring Health Care Expenditures 226

Trends in Health Care Expenditures 233


Summary 239

Key Terms 242


9 Containing Health Care Costs 245

Thomas H. Rice, Gerald F. Kominski


Framework 246


Summary 264

Key Terms 264


10 Promoting Pharmaceutical Access While Controlling Prices andExpenditures 269

Stuart O. Schweitzer, William S. Comanor


The Problem of Drug Expenditures 271

Interpreting Pharmaceutical Price Data 275

International Price Comparisons 279

Determining Drug Prices 281

Approaches for Containing Pharmaceutical Costs 289

The Link Between Pharmaceutical Expenditures and Research 293

Recent Events Surrounding Pharmaceutical Costs and Access 294


Summary 298

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Contents ix

Note 299

Key Terms 299


PART THREE: QUALITY OF HEALTH CARE 305

11 Measuring Health-Related Quality of Life and Other Outcomes 307

Patricia A. Ganz, Ron D. Hays, Robert M. Kaplan, Mark S. Litwin


Definition, Conceptualization, and Measurement of Quality of Life 310

Contributions From the Literature 318

Comparative Effectiveness Research 328


Summary 332

Key Terms 333


12 Evaluating the Quality of Care 343

Elizabeth A. McGlynn


The Multiple Dimensions of Quality 344

Criteria for Evaluating Quality Measures 345

A Conceptual Framework for Quality Assessment 347

Structure 348

Process 355

Outcomes 365


Summary 372

Key Terms 373


13 Public Release of Information on Quality 381

Elizabeth A. McGlynn, John L. Adams


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x Contents

Public Information on Quality 383

Some Methodological Issues in Performance Reporting 391

What is Known About the Impact of Public Reporting? 402


Summary 406

Key Terms 407


14 Health Care Information Systems 413

Jeff Luck, Leah J. Vriesman, Paul Fu Jr.


Information Systems and Informatics 414

Benefits, Implementation Barriers, and Federal Policy Responses 414

Applications of Information Systems by Health Care Providers 417

Public Health Informatics 434

Applications of Information Systems by Health Plans and Payers 438


Summary 445

Key Terms 445


15 Performance Measurement of Nursing Care 455

Jack Needleman, Ellen T. Kurtzman, Kenneth W. Kizer


Why Measure Nursing Performance? 455

The Scope of Nursing’s Contribution to Inpatient Hospital Care 457

Issues in Constructing Nursing-Sensitive Performance Measures 461

Measuring Nursing Performance 463

Measuring Nursing Performance: The State of the Science 478


Summary 486

Key Terms 487


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Contents xi

PART FOUR: SPECIAL POPULATIONS 493

16 Long-Term Services and Supports for the Elderly Population 495

Steven P. Wallace, Nadereh Pourat, Linda Delp, Kathryn G. Kietzman


Institutional Care 497

Community-Based Services 502

Informal Care 507

Workers in the Long-Term Care System 509


Summary 517

Note 517

Key Terms 517


17 HIV and AIDS in the Twenty-First Century 523

Erin G. Grinshteyn, William E. Cunningham


The Changing Epidemiology and Clinical Treatment of HIV/AIDS 525

Prevention and Education 538

Policy Implications and Research Needs for Management, Planning, and AIDSPolicy 543


Summary 547

Key Terms 548


18 Children’s Health 559

Moira Inkelas, Neal Halfon, David Lee Wood


Special Health Needs of Children 561

Health Service Delivery for U.S. Children 564

Financing Children’s Health Care 569

Improving the Child Health System 576

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xii Contents


Summary 585

Key Terms 586


19 Homeless Persons 593

Lisa Arangua, Lillian Gelberg


A Profile of the Homeless 594

Health Status 597

Mental Illness and Substance Abuse 604

Use of Physical Health Services 606

Use of Mental Health and Substance Abuse Services 608

Barriers to Health Care 609


Summary 612

Key Terms 612


PART FIVE: DIRECTIONS FOR CHANGE 621

20 Changing the Health Care Delivery System 623

Nadereh Pourat, Hector P. Rodriguez


Conceptual Framework: Intervention and Innovations to Correct SystemFailures 625


Summary 642

Key Terms 642


21 Medicare Reform 651

Gerald F. Kominski, Jeanne T. Black, Thomas H. Rice


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Contents xiii

Origin and Philosophy of Medicare 652

Evolution of Medicare 656

Is Medicare Facing a Crisis? 663


Summary 673

Key Terms 674


22 Public Health and Clinical Care 681

Jonathan E. Fielding, Lester Breslow, Steven M. Teutsch


Public Health’s Mission and Scope 682

Prevention In Clinical Care Services 685

Public Health and Provision of Clinical Care Services 689

Direct Medical Service Delivery by Government 691


Summary 699

Key Terms 700


23 Strengthening the Safety Net 703

Dylan H. Roby


Defining the Safety Net 704

Ensuring Access to Care for the Poor, Uninsured, and Underserved 705

Financing the Safety Net 706

Size and Scope of the Safety Net 707

Reducing Costs 715

Improving Quality 716


Summary 719

Key Terms 720


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xiv Contents

24 Ethical Issues in Public Health and Health Services 727

Pauline Vaillancourt Rosenau, Ruth Roemer, Frederick J. Zimmerman


Overarching Public Health Principles: Our Assumptions 730

Ethical Issues in the Allocation of Resources 730

Ethical Issues in Research 737

Ethical Issues in Economic Support 738

Ethical Issues in Management of Health Services 740

Ethical Issues in Delivery of Care 741


Summary 745

Key Terms 746


Index 753

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FIGURES AND TABLES

Figures

2.1 A Behavioral Model of Health Services Use—6th Revision 35

2.2 The Policy Purposes of Access Measures 43

3.1 U.S. Population (2000 Census) and Projections For 2100 72

3.2 Life Expectancy by Race, Ethnicity, and Gender 74

3.3 Years of Potential Life Lost by Race and Ethnicity

(per 100,000) 77

3.4 Limitation of Activity Caused by Chronic Conditions, United

States, 2006. 78

3.5 Theoretical Framework 83

4.1 Institute of Medicine Model of Disparities in Health Care 106

4.2 Factors Related to Health Care Use and their Synergies 106

5.1 WHO CSDH Conceptual Framework 138

5.2 RWJ Commission to Build a Healthier America Framework 140

5.3 Poor or Fair Health by Family Income and Race or Ethnicity 141

6.1 Family Work Status of Uninsured Nonelderly Persons, United

STates, 2010 171

6.2 Family Income of Uninsured Nonelderly Persons, United States,

2010 172

xv

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xvi Figures and Tables

6.3 Family Income of Uninsured Nonelderly Persons, United States,

2010 173

7.1 Trends in Private Insurance Coverage in the United States,

1994–2010, Ages 0–64 193

7.2 Average Annual Premiums for Single and Family Coverage,

1999–2012 202

7.3 Distribution of Health Plan Enrollment for Covered Workers, by

Plan Type, 1988–2012 204

8.1 Distinction Between Accounting and Economic Profits 227

10.1 Share of Personal Health Expenditures, 1960–2010 271

10.2 Rate of Increase of Personal Health Care Components from

Previous Year (Percentage), 1960–2011 272

11.1 Quality-of-Life Publications by Year 308

11.2 Conceptualization of HRQL 312

11.3 Cost-per-QALY Ratios 316

11.4 Framework for Measuring Health Status 320

11.5 Cost Per QALY in DPP 325

11.6 Mean Cumulative QALYs, Years 1 through 3 327

12.1 Conceptual Framework for Quality Assessment 347

14.1 Fields of Biomedical Informatics and Domains of Application 415

14.2 HIT Linkages Between Evidence-Based Medicine and Quality

Improvement 420

17.1 Continuum of Engagement for HIV Care 542

18.1 Where Services can Effect Change in Healthy Development 565

18.2 How Risk-reduction and Health-promotion Strategies Influence

Health Development 584

20.1 Conceptual Framework for Assessing Changes in the Health Care

Delivery System 626

20.2 Joint Principles of the Patient-Centered Medical Home 638

23.1 Payer Mix for NAPH Member Hospitals, 2010 714

Tables

1.1 Summary of Major ACA Regulations Affecting Private

Insurance 15

2.1 Percent of the U.S. Population Under Sixty-five with No Health

Insurance Coverage and Regular Source of Medical Care by Age,

Race or Ethnicity, and Poverty Level 44

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Figures and Tables xvii

2.2 Percent of the U.S. Population with Hospital Admissions, Physician

Visits, and Dental Visits by Poverty Level 46

2.3 Selected Measures of Need by Race or Ethnicity and Poverty

Level 50

2.4 Percent of the U.S. Population with Hospital Admissions, Physician

Visits, and Dental Visits by Race or Ethnicity 52

2.5 Selected Measures of Effectiveness and Efficiency by Race or

Ethnicity and Income 57

3.1 Leading Causes of Death by Ethnicity 75

6.1 Percentage of Nonelderly Population Who are Uninsured, Ages

0–64, United States, Selected Years 170

8.1 Consumer Price Index for Selected Items: United States, Selected

Years, 1980–2011 234

8.2 Annual Change in Consumer Price Index for Selected Items:

United States, Selected Years, 1980–2010 234

8.3 Consumer Price Index for All Items and for Medical Care

Components: United States, Selected Years, 1980–2011 235

8.4 Average Annual Change in Consumer Price Index for All Items

and for Medical Care Components: United States, Selected Years,

1980–2003 236

8.5 Personal Health Care Expenditures, by Selected Types of

Expenditure and Sources of Payment, 2008 237

8.6 Annual Change in Personal Health Care Expenditures, by Selected

Type of Service, United States, 1980–2008 238

8.7 Health Expenditures as a Percentage of Gross Domestic Product:

Selected Countries and Years, 1980–2007 240

9.1 Hospital Payment-To-Cost Ratios, 1990–2009 251

11.1 Conceptual Framework for the Medical Outcomes Study 322

15.1 Comparison of Changes in Top Ten RN Activities During Three

Years of Work Redesign 459

15.2 Nurses’ Time, by Category, 2008 460

15.3 NQF-Endorsed National Voluntary Consensus Standards for

Nursing-Sensitive Care 467

15.4 NQF-Endorsed Recommendations for Research and

Implementation 469

15.5 Pooled Odds Ratios of Patient Outcomes Corresponding to an

Increase of One Registered Nurse Full-time Equivalent Per Patient

Day 480

16.1 Individuals With Impairments Needing Help Carrying Out Routine

Household Activities By Age and Sex, United States, 2010 497

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xviii Figures and Tables

16.2 Characteristics of Selected Direct Care and All Other Occupations,

United States, 2008–2010 511

16.3 Institutionalization Rates by Nativity, Race, and Ethnicity, Age

Sixty-five and Over, United States, 2010 514

17.1 Cumulative AIDS Cases in the United States Through December

2009 527

17.2 Estimated Deaths of Persons with AIDS in the United States,

2006–2008 529

18.1 Public Programs in Child Health Service and Health Need

Domains 570

22.1 Actual Causes of Death in the United States, 2000 683

22.2 Decline of Selected Acute Communicable Disease Cases, United

States, 1920–2000 687

22.3 Death Rates from Major Noncommunicable Diseases, United

States, 1950–2000, selected years 688

22.4 Hospitals, Beds, and Occupancy Rates, According to Type of

Hospital, United States, Selected Years, 1975–2008 692

23.1 Characteristics of Community Health Center Users and the Overall

U.S. Population, 2011 710

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FOREWORD TO THE THIRD EDITION

The book you hold in your hand is a gift. With his wife, Audrey, the

late Samuel J. Tibbitts gave generously to the Department of Health

Services in the UCLA School of Public Health to commission a study of

key issues in health policy and management challenging the U.S. health

care system. The leadership, scholarship, and charity that Sam exhibited

in making this gift typified his life in a number of ways.

Sam changed the health care system in California and the nation,

perhaps as much as anyone else of his generation. After receiving a B.S. in

public health from the University of California, Los Angeles, in 1949 and

anM.S. in public health and hospital administration from the University of

California, Berkeley, in 1950, he pioneered the development of integrated

health care delivery and financing systems. His career course trajectory led

in 1988 to the creation of the nonprofit UniHealth America, where he was

chairman of the board until his death in 1994.

Along the way, Sam founded and chaired both PacifiCare Health

Systems, one of the first major health maintenance organizations, and

AmericanHealth Care Systems, a group of thirty-two hospital systems across

the country that organized thenation’s first preferredprovider system, PPO

Alliance. Both a leader and a scholar, he served as chairman of the board

of trustees of the American Hospital Association and published more than

xix

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xx Foreword to the Third Edition

one hundred articles. Sensing the need to establish a corporate conscience

in a changing health care environment, he was founding chairman of

Guiding Principles for Hospitals, the first program to delineate ethical and

quality principles in the industry.

Even while he entered the twilight of a long and storied career, his

concern for the future of health care remained. For this reason, he invested

in the school that had nurtured him and asked its faculty to address the

challenges that are crucial to the future of health care in the United States:

those relating to cost, quality, and access.

To achieve Sam Tibbitts’s vision, the editors sought to gather, in a

single book, ‘‘a comprehensive, yet readable’’ account of these issues. We

believe that they succeeded remarkably in the first two editions, published

in 1996 and 2001, as well as in their efforts to update those issues in this

new edition. In particular, the addition of four new chapters covering such

issues as disparities in health and health care, the nursing shortage, and

information technology make the volume especially useful in confronting

key issues for the new millennium and beyond.

We commend this volume to you, sharing the hope of Sam and

Audrey Tibbitts that training and discourse shall result, in turn leading to

innovations in policy and management that enable the gift of health to be

shared by all.

Abdelmonem A. Afifi

dean emeritus and professor of biostatistics

UCLA School of Public Health

Linda Rosenstock

dean, UCLA School of Public Health

January 2007

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FOREWORD TO THE FOURTH EDITION

Ourhealth and that of our familymembers and friends has as profound

an impact on the quality of our daily lives as any experience. Given

the importance of health to all our lives, it should come as no surprise

that access to medical care and preventive public health measures are

fundamental rights captured in the Universal Declaration of Human

Rights. Moreover, one hundred countries guarantee or aspire to the right

to medical care services in their constitutions. Yet, despite this widespread

agreement on the importance of health, the United States has struggled.

The United States does not have a constitutional provision guaran-

teeing access to health care services and has been an outlier when it

comes to health care coverage. A recent study of nineteen Organisation

for Economic Co-operation and Development (OECD) countries demon-

strated that the United States had fallen to last place in addressing deaths

amenable to health care. At least as disturbing as the overall health picture

in the United States are the disparities. Men and women with less than

a high school diploma can expect to live nearly a decade less than those

with a bachelor’s degree or higher, and the life-expectancy gap has been

widening. Not only are Americans with less education and lower incomes

more likely to die, but they are more likely to live with a chronic condition

or disability.

xxi

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xxii Foreword to the Fourth Edition

The United States is failing to address preventable conditions

adequately—from cancer to heart disease, from diabetes to infections.

Better population and public health measures could help reduce the hun-

dreds of thousands of deaths linked to preventable causes—overweight

and obesity contributed to 216,000 deaths in one year, physical inactivity

contributed to 191,000 deaths, and tobacco smoking was linked to

467,000. At the same time, medical care that is accessible and affordable

to all, including early interventions, would help reduce the 395,000 deaths

linked to high blood pressure and the 190,000 linked to high blood sugar,

among others.

Public health insurance has been available in most affluent countries

for decades. In 1966, Canada passed the Medical Care Act to ensure all

Canadians had access to acute hospital services, and in 1984 the Canada

Health Act guaranteed access to a wide range of outpatient care. Canada

was hardly the first; social health insurance in Germany began in 1893.

Physician services have been covered in Norway since 1912. The United

Kingdom created its National Health Service to cover medical services

in 1948. Sweden followed suit shortly thereafter in 1955. The spread of

health insurance across the globe is not limited to Europe and Canada;

Chile passed legislation in the 1950s, Japan has had public health insurance

since 1961, and the United Arab Emirates since 1971.

So what happened in the United States? It is not that no one tried to

pass health insurance. In fact, a century ago Theodore Roosevelt made

health insurance a part of his campaign. Health care was debated as an

element for inclusion in FDR’s New Deal in the 1930s, but was ultimately

omitted due to the fear that it would sink Social Security. In 1945, Truman

sought to addhealth insurance to Social Security, but failed. Finally, in 1965

the Johnson administration succeeded in establishing health insurance for

older and poor Americans through Medicare and Medicaid. While there

were multiple subsequent attempts to expand coverage, it took nearly fifty

years to pass a plan for near-universal expansion. Proposals by Nixon for

comprehensive health insurance, which included an employer mandate,

and by Carter for universal care funded by payroll taxes, failed. Clinton’s

initial efforts for universal coverage could not make it through Congress;

an expansion of care for children was all that passed.

This edition of Changing the U.S. Health Care System comes out at an

extraordinary moment in American history. After more than a century

of repeated efforts, the United States is taking a major step closer to

universal health coverage. The Affordable Care Act is expected to cover

twenty-nine million more Americans and improve the coverage of many

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Foreword to the Fourth Edition xxiii

others. With tens of millions of Americans uncovered or poorly covered by

health insurance and with a national debt that many have argued cannot

be addressed without improving the efficiency and effectiveness of U.S.

health care expenditures, the need is urgent.

Leaders in their fields, the contributors to Changing the U.S. Health CareSystem lay out foundational information for the generation who will lead us

at this critical stage and address the issues central to transformingAmerican

health care. The contributors examine crucial questions including: Are

we supporting the social conditions and providing the services needed to

prevent illness and injuries? Once people become sick, do Americans have

access to the care they need? Is the medical care provided affordable to

the individuals and communities receiving it, and to society as a whole?

Are we providing the best quality of care we can? Is the same quality of

medical care accessible to poor and marginalized populations? Each of

these questions is covered from many angles.

In looking at access to care, the book begins with an in-depth look at

the Affordable Care Act, the greatest transformation in access to medical

care the United States has seen in generations. Other chapters investigate

what can be done to extend overall coverage, coverage through private

insurers, as well as coverage through the largest public system,Medicare. In

examining quality, chapters in the book focus on how we can successfully

measure outcomes that will lead to improving quality of life—the ultimate

outcome—and change health care delivery systems. Improving health

care is covered with particular attention to addressing disparities, be they

due to age, ethnicity, social class, or position. Similarly broad and deep

in its attention to costs, the book examines cost trends, the best ways to

measure expenses, approaches to containing costs, and new drivers of

costs, including expansion in pharmaceutical access and the implications

for pricing; it also addresses issues looming large on the horizon, like

long-term care. Importantly, as health care is only half of the equation,

commonly coming into play only after people become sick or injured,

Changing the U.S. Health Care System examines how social conditions shape

health in the first place.

In striving to ensure that we all understand the opportunities and

challenges the United States faces in transforming health and health care,

the contributors to and readers of Changing the U.S. Health Care Systemcould not be taking on a more important task.

Jody Heymann

dean, UCLA Fielding School of Public Health

August 2013

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THE EDITOR

Gerald F. Kominski is a professor of health policy and management and

director of the UCLA Center for Health Policy Research in the UCLA

Fielding School of Public Health. He also currently serves as an asso-

ciate director of the California Medicaid Research Institute (CaMRI), a

multicampus organizational unit that brings together University of Califor-

nia researchers to collaborate with the California Department of Health

Services on issues related to the Medi-Cal program.

Dr. Kominski’s research interests focus on evaluating the costs and

cost-effectiveness of health care programs and interventions, with a special

emphasis on public insurance programs, including Medicare, Medicaid,

andWorkers’ Compensation.He is principal investigator atUCLAof a joint

project with the UC Berkeley Center for Labor Research and Education

to develop and apply the California Simulation of Insurance Markets

(CalSIM) model. CalSIM is currently being used to develop estimates for

the California Health Benefit Exchange Board to determine eligibility and

likely enrollment in the subsidized exchange starting in 2014.

Prior to joining the faculty at UCLA in 1989, Dr. Kominski worked

for three and a half years as a staff member for the agency now known as

the Medicare Payment Advisory Commission (MedPAC), which develops

recommendations for Congress regarding updates to Medicare payment

xxv

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xxvi The Editor

policy. Dr. Kominski is a fellow of Academy Health and a member of the

National Academy of Social Insurance. Dr. Kominski received his PhD

in public policy analysis from the University of Pennsylvania Wharton

School in 1985 and his AB in chemistry from the University of Chicago

in 1978.

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THE AUTHORS

John L. Adams is a senior statistician in the health program at RAND.

His current work focuses on improved quantitative methods in quality

assessment. His interests include statistical methods for profiling managed

care organizations, provider groups, and providers. With Elizabeth McG-

lynn, he has worked on the QA Tools quality measurements system. He

is currently involved in the development of a quality measurement system

for cancer care and the validation of patient self-reports of quality of care.

Ronald M. Andersen is the Wasserman Professor Emeritus in the UCLA

Departments of Health Policy and Management and Sociology. Previously

he chaired the Department of Health Services at UCLA and was professor

at the University of Chicago, serving for ten years as director of the

Center for Health Administration Studies and the Graduate Program in

Health Administration. Dr. Andersen has studied health behavior and

access to medical care for his entire professional career of almost fifty

years. He developed the Behavioral Model of Health Services Use that

has been used extensively nationally and internationally as a framework

for utilization studies including special studies of minorities, low-income

persons, children, women, the elderly, oral health, and the homeless.

xxvii

Kominski f05.tex V2 - 10/17/2013 5:13 P.M. Page xxviii

xxviii The Authors

Lisa Arangua is senior research analyst in the Department of Family

Medicine, David Geffen School of Medicine at UCLA. She has been a

health services researcher and policy analyst for more than a decade. She is

a National WoodrowWilson Public Policy and International Affairs Fellow.

Prior to her appointment at UCLA, she was on the research staff at UCData

Archive and Technical Assistance at the University of California, Berkeley,

where she evaluated health and welfare programs for the state and federal

government. Her professional activities include social justice and health,

epidemiology, clinical trials, women and child/adolescent health, cancer

research, mental health research, illicit drug use and treatment research,

and concurrent behavior change research of severely underserved health

populations. She received her M.P.P. from UCLA in 1999.

Roshan Bastani is professor in the Department of Health Policy and

Management in the Fielding School of Public Health at UCLA. She

is a social and health psychologist and her research interests are in

chronic disease prevention and control among disadvantaged groups, with

a focus on testing the efficacy of patient, community, and health care

system–directed interventions to improve access and reduce disparities.

Dr. Bastani leads a number of research centers, including the UCLA

Kaiser PermanenteCenter forHealth Equity, theUCLA/RANDPrevention

Research Center, and the Center for Cancer Prevention and Control

Research, all of which are focused on addressing health disparities.

Sebastian E. Baumeister, is a senior epidemiologist and a member of the fac-

ulty at the University of Greifswald. As head of the statistics unit of the

Study of Health in Pomerania, a large population-based cohort study, he is

primarily responsible for statistical analyses and consulting. Previously he

worked on other large-scale epidemiological studies, including the Ger-

man Epidemiological Survey of Substance Abuse and the WHO MONICA

Surveys. He teaches graduate courses in epidemiology and biostatistics. He

has published and worked on various research projects in epidemiology,

health care access, health economics, and substance use. Currently, he

is working on consortia investigating the role of genetic background on

social science phenotypes.

Jeanne T. Black received her PhD in health services research from UCLA

and currently is manager of Health Policy Research at Cedars-Sinai Health

System in Los Angeles. Her research interests include the effect of health

reform incentives on academic medical centers and the cross-cultural

Documents

Kominski fﬁrs.tex V1 - 10/22/2013 2:25 P.M. Page ii...Events Leading to the Enactment of the ACA 4 Major Provisions of the ACA 7 Future Directions 20 v. Kominski ftoc.tex V2 - 09/21/2013