As roads and bridges across the country continue to age and deteriorate, governments at all levels are struggling to pay for maintenance and upkeep -- not to mention investments in much-needed upgrades and new projects. Since the federal Highway Trust Fund was established in the late s, total combined highway and transit spending as a share of gross domestic product has fallen by about 25 percent, according to the federal National Surface Transportation Infrastructure Financing Commission. John Schroer, the transportation commissioner from Tennessee, delivered.
The ACA is much more than just a health insurance law. For those who earn too much to qualify for Medicaid but earn no more than four times the standard threshold that indicates poverty — e.
Although these are associations of providers, their use is being stimulated by public and private insurers.
The Affordable Care Act encourages the formation of such organizations as part of the Medicare programme but they are also being used, selectively, by other payers. ACOs are required to have primary care providers but often also include hospitals and specialists. Most are based in large metropolitan areas and most are sponsored by physician-led groups.
They work with insurers to develop reimbursement schemes that provide incentives to provide efficient, high-quality care to the population that they serve.
Under the Medicare Shared Savings Program that was established by the Affordable Care Act, ACOs receive financial rewards if they are able to both provide high-quality care and control costs. To determine these financial awards, the performance of the ACOs is compared against benchmark costs.
These costs are initially based on the mean Medicare inpatient and outpatient expenditures — in the three years before the formation of the ACO — for each beneficiary assigned to the ACO.
The benchmark costs are updated annually.
Each ACO must achieve quality standards in four overall areas: Experiences with regard to the organization of integrated care and bundled payments — both positive and negative — are accumulating quickly. Concerns about ACOs ACOs face several challenges in providing high-quality cost—effective care in a fee-for-service setting.
First, because ACOs generally rely on highly integrated systems, the consolidation of providers could lead to monopolistic pricing power that could raise costs.
Second, there are concerns that, as a result of the financial incentives available, ACOs will put so much pressure on providers that quality could suffer.
Finally, there is little evidence that independent providers who are linked together mainly through reimbursement incentives will be able to provide the same quality and continuity of care as health maintenance organizations that oversee the entire patient-care process.
Early experiences with the ACOs have been mixed.
One model that received a great deal of attention was the Pioneer ACO Model, which included 32 ACOs from across the country — including some of those serving both Medicare and privately insured patients. In their first year, 18 of the 32 ACOs generated savings but the others generated losses.
The indicators of quality were generally good. It also requires the organization of several regulatory functions that apply to the private insurance market.
An exchange typically provides several insurance plans that offer a minimum list of essential benefits, flat rate — community-rated — premiums that are not based on health status, and tax subsidies for individuals on relatively low incomes.
Further components often include the quality rating of plans, enforcement of insurance mandates, compensation payments to insurers with high-cost enrolees and regulatory oversight.
Under the Affordable Care Act, states have received important latitude in how they set up their exchanges. By January17 states had opted to develop and manage their own exchanges, 27 states had decided to rely entirely on a federal exchange and the remaining states were developing an exchange jointly with the federal government.
The idea behind exchanges is not new; similar systems have been operational in Switzerland sincein the Netherlands and the state of Massachusetts since One feature that distinguishes the exchanges in the United States of America from some of those in Europe is that, in the former, premiums can vary by age and smoking status.
In the exchanges, premiums may be age-related but the highest age-based premium may be no more than threefold higher than the lowest.
The latter restriction means that the youngest people on an exchange cross-subsidize the older ones — because older people who are not yet eligible for Medicare spend about five times as much on health care as people in their mids.
There is a fear that too many young, healthy residents will choose to pay the penalty and remain uninsured rather than pay the high premiums needed to cover the costs of care of older individuals. Although the charging of higher premiums to self-declared smokers is generally supported by the public, the low-income groups who have the higher prevalences of smoking are also those least able to pay high premiums.
It also seems likely that many smokers will falsely declare themselves to be non-smokers to obtain cheaper insurance. Some states have therefore decided not to allow self-declared smokers to be charged higher premiums than self-declared non-smokers.
Data from the exchanges in the Netherlands, Switzerland and the state of Massachusetts indicate that, when used alone, exchanges may not be enough to control costs and that reforms in the purchasing market are also needed. The ACA-related change from experience rating to community rating introduces a major shift away from a private actuarial insurance market and should lead to a financial redistribution, at any point in time, from those who are healthier towards those who have a history of costly illness.
Many uninsured individuals who do not receive health-care coverage from an employer and who are not poor enough to qualify for Medicaid — or are not otherwise waived from the requirement — are required to purchase private insurance through one of the new exchanges.
Otherwise, most such individuals will be required to pay a penalty — although there are some groups exempted from this requirement. It has been estimated that about 31 million residents — undocumented workers, those exempted from mandated coverage because it would be unaffordable, those living in states that chose not to expand Medicaid eligibility, and those individuals and families who choose to pay a penalty rather than purchase health insurance coverage — will remain uninsured in It was originally estimated that, inapproximately 21 million residents would remain uninsured — compared with an estimated 56 million had the ACA not gone into effect.Jan 06, · At the end of , we asked what you felt was the greatest challenge facing the United States in the coming year.
Over a thousand readers responded, and while their answers varied widely, a few common themes emerged. The United States, by contrast, leans toward a worldwide system, but there is an important exception—taxes on actively earned foreign income are deferred until the income is repatriated to the.
Start studying Part 2 Amer. History Unit 4. Learn vocabulary, terms, and more with flashcards, games, and other study tools. C. Tax breaks and decreases D. Reducing military spending. Which pair is not one of the many challenges facing the United States?
A. Terrorism and global warming. "The Challenges of Tax Collection in Developing Economies (with Special Reference to India)" ().LLM Theses and This paper gives an overview of the Indian tax system and discusses the challenges in tax collection faced by developing economies using India as a model.
United States Taxes and Tax Policy, () (Quoting Adam Smith. Best States. Healthiest 10 Problems With the Income Tax.
It makes Congressmen powerful and lobbyists rich and creates a tax system with more loopholes than Swiss cheese.
It's very. Board of Governors of the Federal Reserve System. The Federal Reserve, the central bank of the United States, provides the nation with a safe, flexible, and stable monetary and financial system.
Long-term fiscal challenges facing the United States.
Chairman Ben S. Bernanke. Before the Committee on the Budget, U.S. Senate.