The fate of the Affordable Care Act (ACA) is yet again held in the balance by the Supreme Court. The King v. Burwell case calls into question the legality of subsidies for individuals purchasing insurance on federal exchanges: the text of the law specifically mentions only state-run exchanges in relation to subsidies. If the Supreme Court rules in the plaintiff's favor, subsidies for insurance purchased on federal exchanges would end unless Congress moves forward with a technical clarification to allow it, which this Republican Congress seems unlikely to do. Thus, while many states — even those with federally run and partnership exchanges — have invested years of resources to prepare for the implementation of the ACA, a central component of the bill could be reserved. Given this development, state innovation and the use of the 1332 waivers to be submitted in 2016 appear that much more important. The article by Ashley Fox and Nathan Blanchet about Vermont's attempts to move forward with a single-payer approach is particularly timely. “The Little State That Couldn't Could? The Politics of ‘Single-Payer’ Health Coverage in Vermont” helps prompt important questions about how much discretion states have to shape reform in their own vision, and what help — legally, financially, and technically — states need from the federal government.
The next two research articles in this issue remind us that two major health policy questions continue to loom: end-of-life and long-term-care (LTC) reforms. In “Do Advance Directives Direct?” Susan Shapiro takes an in-depth look at end-of-life cases in one major hospital setting among patients with an advance directive. Although previous literature reveals that advance directives are rarely used, Shapiro's work helps us understand how patients and providers attempt to navigate the difficult world of end-of-life care and how even the best directives often provide only a minimal guide to the questions facing surrogates at the time of decision making. Importantly, she grapples with options for how end-of-life policy might improve. In “An Assessment of State-Led Reform of Long-Term Services and Supports,” Mary Naylor, Ellen Kurtzman, Eddie Miller, Pamela Nadash, and Peter Fitzgerald review key state-led long-term care reforms to assess the pros and cons of the major approaches based on a number of important indicators. This is a useful framework for a systematic review of the options facing state policy makers in another complex policy area.
We have three additional special sections in this issue. The Report on Health Reform Implementation features an essay set providing two opposing views on the King v. Burwell decision currently residing with the Supreme Court. Given the huge implications of this case — if subsidies under the federally run exchanges are deemed illegal, some 5 million Americans could lose their health care coverage — the court's decision could not be more important. We are fortunate to have two particularly relevant and timely essays on this topic written by some of the issue's major players: “King v. Burwell: Desperately Seeking Ambiguity in Clear Statutory Text,” by Jonathan Adler and Michael Cannon, two prominent advocates for the plaintiffs; and “Three Words and the Future of the Affordable Care Act,” by the University of Michigan's Nicholas Bagley, one of the most visible and articulate critics of the case. In our Report from the States section, we have Laura Olson's article, “The ACA Medicaid Expansion Waiver in the Keystone State: Do the Medically Uninsured ‘Got a Friend in Pennsylvania’?,” which looks at Pennsylvania's waiver proposal to the Department of Health and Human Services (HHS) to expand Medicaid under the ACA. This article explains many of the unique components of this proposal — work requirements, incentives for health behaviors — and why these components were rejected by HHS. It is useful for developing an understanding of how Republican-controlled states are framing and developing policy designs to expand Medicaid under their ideological perspective. Finally, in the In Memoriam section, JHPPL remembers Daniel Schaffer. With “Politics, Policy, Law, and Friendship: Celebrating Daniel C. Schaffer, 1938–2013,” Daniel Fox honors the important work of his longtime friend and colleague.