Healthcare Reform                                                                         1           Healthcare Reform   ...
Healthcare Reform                                                                                                      2  ...
Healthcare Reform                                    Healthcare Reform                                                 3  ...
Healthcare Reform           ·Ending discrimination against Americans with pre-existing conditions (Healthcare             ...
Healthcare Reform                         Strength and Weaknesses of Healthcare Reform                                    ...
Healthcare Reform•   If the secretary estimates for any fiscal year that the aggregate amounts available for              ...
Healthcare ReformIn 2010, President Obama moved to reduce the problems our country faced under the current                ...
Healthcare ReformHere are some alarming statistics by the Center for Disease Control (CDC) the relating chronic           ...
Healthcare Reformpreliminary program is being conducted in hopes of reducing the number of metabolic syndrome             ...
Healthcare ReformFortunately for consumers, The Affordable Care Act calls for employers to take a prospective             ...
Healthcare Reformsuccessful to become part of the state’s healthcare reform initiative. The goals of the program          ...
Healthcare ReformThroughout our entire lives, most, if not all, have dealt with the term “quality” in some shape or       ...
Healthcare ReformUnited States. Their accreditation is known nationwide as the symbol of quality that reflects an         ...
Healthcare Reforminvolves quality bonus payments. Here medical professionals have the chance to gain additional           ...
Healthcare Reform                                                                                                        1...
Healthcare Reform                                                                                                       16...
Healthcare Reform                                                                                                   17    ...
Healthcare Reform  8)Integrating Prevention into Healthcare - Media Centre; Fact Sheet No 172; Retrieved                  ...
Healthcare Reform   16)NCQA, measuring quality, improving healthcare. (n.d.). Retrieved June 4, 2011, from                ...
Healthcare Reform  23)Uygur , C. (2010). Pros & Cons of the Health Care Reform Bill . Retrieved October                   ...
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  1. 1. Healthcare Reform 1 Healthcare Reform CHRONIC DISEASE, PREVENTION & QUALITYShanise Thornton, Melinda Williams and Christopher Owens Keller University Health insurance & Managed Care June 23, 2011
  2. 2. Healthcare Reform 2 AbstractHealthcare reform has a tremendous effect on the economy. This paper will explore the reform aswell as its impact on chronic disease, prevention, and quality. Health care reform is thriving toput American families and small business owners more in control of their own health throughseveral initiatives. There are several strengths and weakness within the reform. Employers withmore than 50 employees must provide health insurance or pay a fine … There are several keyelements under the reform, one of which is Title IV - Prevention of Chronic Disease andImproving Public Health (Health Reform Details). This provision addresses the issues of costsassociated with health care services and is focused on changing the way the services aredelivered. Services will be provided for prevention of manageable illnesses.
  3. 3. Healthcare Reform Healthcare Reform 3 CHRONIC DISEASE, PREVENTION & QUALITYThere has been a lot of criticism geared towards the reform, however change is inevitable. Fordecades, the United States has been concerned with the high cost of medical care. The 2010Healthcare Reform, otherwise known as the Affordable Care Act, consists of many aspects. Wewill explore the reform as well as its impact on chronic disease, prevention, and quality. Overview of the Healthcare Reform InitiativeIn order to gain a better understanding of the Affordable Health Care Act of 2010 also known asthe Health Care Reform, let’s highlight key points of the bill. According to the reform, the mainobjective is to provide affordable, quality health care for all Americans in an attempt to reducethe growth in health care spending (George, 2011). The bill is pushing to create a stablehealthcare budget, to reduce the deficit by more than one hundred billion dollars over the nextten years (Healthcare Reform Details, 2011). The coverage of this reform is expected to expandtowards thirty two million uninsured Americans (Jackson & Nolen, 2010). The health carereform strives to put American families and small business owners in control of their own healthby implementing the following provisions: ·Making health insurance more affordable by the year 2014; providing the largestmiddle class tax cut for health care in our nation’s history. ·Reducing premium costs for countless millions of families and small businessowners who are currently priced out of coverage. ·Setting up a new competitive health insurance market.
  4. 4. Healthcare Reform ·Ending discrimination against Americans with pre-existing conditions (Healthcare 4Reform Details, 2011).The reform will also focus on bridging the gap between the House and Senate bills and it willinclude new provisions to crack down on waste, fraud and also abuse. The reform will reflectmany policies. Some of the key changes that the Reform will tackle are as follows: ·Eliminating the Nebraska FMAP (Federal Medical Assistance Percentage) provision andproviding significant additional Federal financing to all States for the expansion of Medicaid. ·Closing the Medicare prescription drug, in other words the “donut hole” coveragegap by the year 2020. ·Increasing protections for out of pocket costs. ·Increasing the threshold for the excise tax on the most expensive health plans fromtwenty three thousand dollars for a family plan to twenty seven thousand and fifty dollars andstarting it in 2018 for all plans (Healthcare Reform Details, 2011).As you can see, the Health care reform bill has the potential to help the American society withmany changes that will start immediately as well as other changes which will start later. Seniorsthat are affected by the donut hole within the current year shall receive a $250 rebate. However,seniors receiving top shelf prescription brands will receive a fifty percent discount beginninglater in the year. One of the major benefit’s and outcomes that will come from this reform will bethat every citizen is going to be required to have health care which means that the percentage ofindividuals that are healthy will increase.
  5. 5. Healthcare Reform Strength and Weaknesses of Healthcare Reform 5There are strengths and weaknesses of the Healthcare reform for individuals that live within theUnited States which include the following:Strengths- • Prohibits preexisting conditions exclusions periods for children in all new plans (George, 2011). Therefore, if a child has a pre-existing condition he/she will not be denied for care anymore. • Prohibits dropping people from coverage when they get sick in all individual plans (Uygur, 2010). This will allow all adults to be able to receive care without having to pay too much out of pocket or being uncertain if they will be covered. According to Davenport that passed this bill, this reform will also lower overall expenditures in tandem with deficit reduction which is a good strength (Davenport, 2011). The implementation of the bill will not only lower the overall expenditures but it will eliminate lifetime limits and restrict annual limits on benefits on all plans (George, 2011). By ending lifetime limits on care, patients will not have to worry about their care and coverage being dropped mid way through the treatment. • Within this reform it will allow college adults to stay on their parents coverage until the age of 26, which is a positive aspect in certain cases for individuals who have not made it on their own as of yet or who need a little more guidance.Weaknesses- • Include increasing insurance premiums.
  6. 6. Healthcare Reform• If the secretary estimates for any fiscal year that the aggregate amounts available for 6 payment of expenses of the high-risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficits, including reducing benefits, increasing premiums, or establishing waiting list (George, 2011).• Patient’s benefits may reduce which may decrease the quality perceived by some patients and they will have longer waiting times.• Negative effects on the insurance companies.• Negative impact on individuals beginning in 2014; all citizens and legal residents must have insurance. Violators will be subject to a phased-in excise tax penalty for noncompliance which will be a $695 annual fine. However, there are some exceptions for low-income people (Boomers, 2010).• Employers with more than 50 employees must provide health insurance or pay a fine of $2000 per worker each year if any worker receives federal subsidies to purchase health insurance. Fines will be applied to the entire number of employees minus some allowances (Boomers, 2010).Despite the positive and negative aspects that people may think of the bill, the reform is stillseen as being very beneficial. One important element of the reform is Title IV - Prevention ofChronic Disease and Improving Public Health section. Chronic Disease
  7. 7. Healthcare ReformIn 2010, President Obama moved to reduce the problems our country faced under the current 7healthcare system. The Healthcare Reform-Affordable Care Act was signed into policy in theyear 2010. Among the key elements under the reform, is Title IV - Prevention of ChronicDisease and Improving Public Health (Health Reform Details). This provision addresses theissues of costs associated with health care services and is focused on changing the way theservices are delivered. From treating the sick, to helping people live healthier lives by promotingwellness and prevention, reducing the incidences of preventable illness (chronic disease), andempowering families to be accountable for their own health.Under Title IV provision, it is also stated that “investing in preventable diseases saves lives andmoney not just for families but also for businesses and the nation” (Health Reform Details, n.d.).So what is driving up the cost of healthcare? Many would say technology others would sayprescription drugs, and still more may say the aging population. The World Health Organization(2010) states “populations are aging and increasingly, people are living with one or more chroniccondition for decades.” Chronic disease is a defined as a disease or condition that persists for along period of time, it may be progressive, it may contribute to disabilities, and oftentimes it hasbeen linked to deaths. Chronic diseases is usually the results of damaging behaviors such astobacco use, lack of physical activity, and poor eating habits (Medicine Net and Free Dictionary,2011).The most common types of chronic diseases are: heart disease, diabetes, asthma, obesity,hypertension and cancer: One could also conclude that chronic disease is another cost driver ofthe health care system. In fact, seventy percent of deaths are related to chronic diseases. Chronicdisease is the leading cause of death in the United States.
  8. 8. Healthcare ReformHere are some alarming statistics by the Center for Disease Control (CDC) the relating chronic 8diseases: “7 out of 10 deaths among Americans each year from chronic disease” “Heart disease, cancer and stroke account for more than 50% of all deaths each year” “1 in every 3 adults is obese and almost 1 in 5 youths are obese with a Body Mass Index (BMI) > 95th percentile of CDC growth chart” “In 2005, 133 million Americans had at least one chronic disease” “Diabetes continue to be leading cause of kidney failure, amputations and blindness” (Center for Disease Control, et. tal, Mary 2011).As you can see, these figures are startling. In 2009, healthcare expenditures grew at a rate of fourpercent, totaling two point five trillion and accounting for seventeen point six percent of ourgross domestic product or an average of eight thousand eighty six dollars per person withincreases in spending for Medicaid, Medicare, and private insurers (Goldstein, 2011). The rateaffects all spectrums of our country-the consumer, the employer and our government. Even moredisturbing, out of all expenditures that contribute to our nation’s debt (military/defense,education, transportation, etc) fifty one percent of these expenditure costs went towards hospitalcare and physician services; Services such as dental, nursing home care, home health,prescription drugs, government/public health activities, investments, and administration. This isaccording to a briefing done by the Henry J. Kaiser Family Foundation (March 2010) whichsuggests that controlling costs will mean understanding the root cause from which these costswere generated.Chronic disease not only affects healthcare costs in the United States, but is a global issue aswell. Disease management programs and preventive services are becoming more popular asstates and countries seek out ways to lower the costs of providing healthcare. In Japan, a
  9. 9. Healthcare Reformpreliminary program is being conducted in hopes of reducing the number of metabolic syndrome 9patients by twenty five percent between 2008 and 2015. Etsuji Okamot (2007) states, “Japan hasthe highest number of dialysis patients in the world at 194.3 per 100,000 in 2004. Since half ofchronic renal failure results from diabetes and annual cost for dialysis amounts to fifty thousanddollars per year, it would be reasonable to assume that savings can be achieved by preventingdialysis by one patient or by deterring it one year.” For employers, the issues of rising costs,chronic disease and management are causing major concerns in terms of profits and cost-sharing;such that it could also affect the status of the economy. For instance, if employers are spendingmore on health care costs they may decide or even be forced to pass the higher costs to theemployee, reduce the amount of investments, or decrease employment. They may also have todeal with higher taxes in order to finance health care expenditures or increase the amount ofgovernment loans. These issues not only may reduce the competitiveness of the US but may alsodeter consumer spending on goods and services, and alter retirement savings (Sood, Ghosh,Escarse, 2007). The US Department of Health and Human Services (HHS) states employersinsure approximately three-fifths of Americans. Originally the employer sponsored healthinsurance came into play because the contributions for income and payroll taxes were exempt.However as insurance premiums continued to increase, employers began to see a potential threatto their profitability and thus started to institute a change to put more of burden on the employeesuch as: reducing benefits, changing providers, adding high deductible-consumer driven plans(September 2007).
  10. 10. Healthcare ReformFortunately for consumers, The Affordable Care Act calls for employers to take a prospective 10approach to seeking ways to lower costs, improve wellness and quality of care by offeringincentives and giving employee’s an opportunity to be in control of their health outcomes. Management and PreventionConsumers, as well as healthcare workers, see daily the destruction and devastation that chronicdisease and conditions can place on people’s lives. Beyond the emotional and physical pain,there’s also the financial strain that people often bear. In an article by Democratic RepresentativeJim Moran (Va.), he states “chronic diseases such as cancer, heart disease, diabetes, and arthritisare the most prevalent and preventable health problems we face.” He goes on to say thatmillions of Americans, forty million to be exact, “are without health insurance and one-thirdsuffer from chronic disease” (2009). Chronic diseases are preventable and can also be very wellmanaged. The goal of disease management, according to Kongstvedt (2001), is to “reducefrequency and severity of exacerbation of a chronic illness so that readmission costs arereduced.” Many of us are not aware and would be very surprised to hear that Pennsylvania wasranked in the bottom 3rd of states for avoidable chronic disease - hospital related admissions orthat half of our residents have at least one chronic disease that accounts for eighty percent of ourstate’s healthcare costs or that four billion was projected to be unnecessary hospital charges foradmissions that could have been avoided because of a chronic condition (Bricker, Baron, Sheirer,DeWalt, Derrickson, Yunghans, &Gabby, 2010). These statistics were given from a reportpresented by a commission put together among concerned healthcare providers, insurers, nurses,consumers, educators, state government and labor unions to address the issue of controlling thecost associated with chronic disease by implementing a program model to be tried and if
  11. 11. Healthcare Reformsuccessful to become part of the state’s healthcare reform initiative. The goals of the program 11are: • To create a reimbursement program that rewards the use of the “chronic care model” to become team-based, patient-centered, and have quality outcomes… • Promote learning and provide education sessions among constituents. • To improve healthcare resources, utilization, clinical processes. • Reducing the number of re-admissions, avoidable admissions, and ER visits with savings from other cost measures (Bricker et al., 2010)Some positive results from the initial reporting from model, results within the three years forwhich the program has been conducted. For example: practices are finding better ways toimprove processes, better communication with staff as well as patients, disease managementprograms were starting to see positive results in management and less exacerbations. Patientswere more satisfied with care being given, with the education and direction they are receiving,and the better access to services and even thwarted changing of physicians.This program model in Pennsylvania is only one example of what can be done in hopes ofpreventing and managing chronic illnesses. Other resources that are being used and madeavailable are, telephone follow-ups, directing patient to website for educational resources, work-shops and seminar and a host of others will become available as technology advances.Ultimately, it is a way to begin to measure the quality and effectiveness of the programs andservices being provided all in the goal of restructuring healthcare. Quality
  12. 12. Healthcare ReformThroughout our entire lives, most, if not all, have dealt with the term “quality” in some shape or 12form. Whether it was the quality of one’s livelihood, food choice, or even education, we’ve allpartaken in quality in some way. Even though we encountered this concept quite often, we allhave seemingly different various ways of defining the term. When asking a randomPhiladelphian her definition of quality, she responded by stating: “Something that adheres tohigh standards.” Standards are defined as something established by authority or general consentas a model or example. Webster defines quality as a degree of excellence, social status, or even adistinguishing attribute. (Webster, 2011) With all this being stated, we should grasp a clearer andmore concise understanding of quality in regards to healthcare.Quality health care can be described as aspiring for excellent standards of care. This wouldinclude evaluating the suitability of medical treatments and measures to continuously improvepersonal health care in every fields of medicine. For example, accrediting or approvingphysicians, offices, hospitals or other health care providers. This is achieved throughaccreditation or inspection standards that ensure that proper procedures and staffing ratios aremet. The Institute of Medicine also aims to improve the quality of healthcare through thefollowing: safety, timely, effective, efficient, equitable & patient centered. Each concept dealswith the idea of continually improving healthcare.An organization that regulates and sets the standards for accreditation is known as the JointCommission on Accreditation of Healthcare Organizations, also known as (JCAHO). The JointCommission on Accreditation of Healthcare Organizations is an independent nonprofitorganization which accredits more than nineteen thousand healthcare organizations across the
  13. 13. Healthcare ReformUnited States. Their accreditation is known nationwide as the symbol of quality that reflects an 13organizations commitment in meeting high performance standards. (Joint commission, 2011)Another quality measuring organization is The National Committee for Quality Assurance alsoknown as (NCQA).The Affordable Care Act of 2010 lists quality as one of many important elements covered in thenational healthcare reform. In short it aims for quality improvement through establishing nationalpriorities via performance improvement such as quality bonuses payments. Here’s a snippet ofwhat the bill addresses under title IV: • Improving transparency of information on long term care facilities o Nursing home compare Medicare website o Improving staff training o Preventive training • Physician paymentsThe Affordable care Act goes into nursing home transparency by stating in limens term, that thesocial security act has been modified by being required to disclose information pertaining toownership as well as any other disclosure parties involved. Such information includes facilitiesworkers information, I.e. name, position, basic bio of personnel. Also the organizationalstructure, as well as a compliance and ethical program that is effective in the prevention of crimeand administrative violations under this act.In referencing the physician payment section, which is noted as the sunshine provision, it directlyrelates to confidentiality, delayed reporting, reporting, and entities that bill Medicare; it also
  14. 14. Healthcare Reforminvolves quality bonus payments. Here medical professionals have the chance to gain additional 14incentive for reporting particular quality measures. This gives the medical staff to gain from1.5% to 3% their total allowed charges for covered Medicare physician fee schedule services. Toredeem this physician must report at least 80% of their eligible cases.In relation to quality healthcare and chronic disease, Joanne Kenen, a blogger for The NewHealth Dialogue, has managed to give a clear insight on current healthcare issues discussed at apast AARP forum on Capitol Hill.“…Theyll tell you about medical specialists who dontcoordinate with one another. Patients who are sent home from the hospital or rehab withoutadequate information about follow up care and complex medication regimes. They’ll also speakof delays in getting patients the care they need when they need it. In short, a fragmented,disconnected system that seems unaware that its supposed to be all about the patient…” In heropening blog statement, I’ve found her critics all too accurately correct. Just as many othercitizens, I’m too dealing with a family member who’s recently been diagnosed with a chronicdisease. Throughout the past three years, physicians where confused and or unclear on theirpatients diagnoses, and blatantly told use that they had flawed records that which wheresupposed to be beneficial in effectively communicating their patents situation. There’s been tomany times where my loved one was admitted into the ER department to only be held for a fewdays then discharged only to come home with a complex medication schedule, and have thesame situations re occur weeks later. All in all, not one facility has managed to grant my familymember the needed care in which he needs; I believe that because of this three year headache,they’ve managed to turn an acute illness into a chronic one. Regardless of my personalexperiences with the quality of care, far too many others can relate to my story as well.
  15. 15. Healthcare Reform 15The chart above illustrates a survey conducted roughly eleven years ago. It shows familymembers overall quality concerns for vastly ill patients in various settings. Dark bluerepresenting patience’s sent home with hospice care; hospice care refers to providing humaneand compassionate care for people in their last phases of incurable disease so that they may liveas fully and comfortably as possible. The second color code is red which relates to Nursinghomes. Thirdly we have light blue which represents home with home care…I.e. Visiting nursingservices, basically all health and supportive services administrated at home. Last but not least wehave orange which represents hospital services. All in all through analyzing this chart one willnotice the poor quality in not one, but all healthcare settings, these numbers are far too high forany health service group, especially for facilities that are heavily administrated throughaccreditation agencies. These figures portray lack of compassion, communication, andeffectiveness when dealing with direct patient care.
  16. 16. Healthcare Reform 16 ConclusionWith many of its changes that will and have taken place, the Health care reform bill has thepotential to help the American society. Citizens that are affected by the large cost of prescriptiondrugs will have a decreased donut hole to look forward to via rebates and or discounts. Youngadults will be able to remain on their parents’ healthcare coverage up until the age of twenty six.Most importantly, all will have coverage under the reform. This means more patient care thatwill result in higher healthcare revenue, which will result in overall contribution to the nation’sgross domestic production rate. This continues improvement will benefit an entire nation.Through proper education, people can make better decisions, which then leads to prevention ofillnesses such as heart disease, diabetes, asthma, obesity, hypertension and cancer. Now that thechange has come it’s time for us to stand up to sickness and accept health. We must say no toignorance and yes to education. We can do this. We just have to take the steps…
  17. 17. Healthcare Reform 17 References 1)Boomers, BB. (2010, March 21). Obama’s health care reform has passed!. Baby Boomers,Retrieved from 2)Chronic Disease Prevention & Health. National Center for Chronic Disease Prevention &Health. Center for Disease Control and Prevention. Retrieved June 5, 2011;; 3)Chronic Disease are Leading Causes of Death and Disability in the U.S. National Center forChronic Disease Prevention & Health. Center for Disease Control and Prevention. Retrieve June5, 2011; 4)Davenport, Karen . United States. Strengths of the Senate Health Reform Bill. Capitol Hill:AP/Mannul Balce Ceneta, 2010. Web. 30 May 2011.<> 5)George, Miller. Congress. H.R. 3962. D.C.: 111th congress, 2009. Web. 16 May 2011.<>. 6)Goldstein, Amy; US Healthcare Expenditures up Only 4 Percent in 2006; WashingtonPost January 5, 2011; 7)Healthcare Reform Details; Retrieved 5/19/2011 & 5/20/2011 from Healthcare Reform:
  18. 18. Healthcare Reform 8)Integrating Prevention into Healthcare - Media Centre; Fact Sheet No 172; Retrieved 18May 15, 2011; 9) Jackson, J., & Nolen, J. (2010). Health Care Reform Bill Summary: A Look At Whatsin the Bill. Retrieved October 09, 2010 from CBS, 10)Kenen, J. (2009, March 31). QUALITY: What Health Care Reform Can Do for ChronicDisease Care. Retrieved June 2, 2011, from The New Health Dialogue Blog website: 11)Kimbuende, Ranji, Lundy, & Salganicoff (2010). U.S. Health Care Cost: BackgroundBrief. Kaiser Health Policy Education from the Henry J. Kaiser Family Foundation; 12)Kongstvedt, P.R., Essentials of Managed Health Care, 4th ed-Aspen Publishers, Inc.2001; Chapters 13,14, 17; 5th ed-Jones and Barlett, 2007; Chapters 10, 11, 14, 15. 13) Definition of Chronic Disease. Retrieved June 13, 2011. 14)merriam-webster. (2011). In Webster dictionary. Retrieved from 15)Moran, J. (October 2009). The Price of Chronic Disease. The Hill (Vol 16, Issue 114) pg.42.
  19. 19. Healthcare Reform 16)NCQA, measuring quality, improving healthcare. (n.d.). Retrieved June 4, 2011, from 19National Committee for Quality Assurance website: 17)Okamoto, E. (February 2007). Is health a right or an obligation? International Journal ofIntegrated Care (IJIC), (Vol 7). pg 1. 18)Prevention and Managed Care: Opportunities for MCOs, Purchasers of Healthcare, andPublic Health Agencies; CDC MMWR Report; November 17, 1995/Vol 44/No. RR-14; 19)The Common Wealth Fund. (2006, February 22). Retrieved June 12, 2011, from website: imgurl= %2520Snapshots/Experiences%2520with%2520Care/Family%2520Perceptions%2520of %2520Quality%2520of%2520Care%2520at%2520End%2520of%2520Life/Graph %25202.gif&imgrefurl= Snapshots/Experiences-with-Care/Family-Perceptions-of-Quality-of-Care-at-End-of- Life.aspx&usg=__n9Hs0O5tGwmCW41QOuVTiQQzZOE=&h=375&w=500&sz=35&hl=e n&start=0&zoom=1&tbnid=MVY01Js8bnHxzM:&tbnh=147&tbnw=194&ei=Sx35TYLnEaj b0QGg88G0Cw&prev=/search%3Fq%3Dquality%2Bhealthcare%2Bgraph%2Bresults%26hl %3Den%26biw%3D1420%26bih%3D744%26gbv%3D2%26tbm %3Disch&itbs=1&iact=hc&vpx=340&vpy=90&dur=9188&hovh=194&hovw=259&tx=139 &ty=85&page=1&ndsp=26&ved=1t:429,r:1,s:0&biw=1420&bih=744 20)The Free Dictionary. Farlex. Chronic Disease. Retrieved June 13, 2011. 21)The Joint Commision . (n.d. ). Retrieved June 4, 2011, from 22)Sood, Ghosh, Escarse (September 2007). The Effect of Health Care Cost Growth on theU.S. Economy-Final Report. Office of Asst. Secretary for Planning and Evaluation (ASPE); U.S.Dept of Health and Human Services. pgs 12-13.
  20. 20. Healthcare Reform 23)Uygur , C. (2010). Pros & Cons of the Health Care Reform Bill . Retrieved October 2010, 2010 from The young turks, You Tube : 24) Wang, D. (2011). ehow health. Retrieved June 4, 2011, from Ehow website: 24) Wydra, Elizabeth. "The States, Health Care Reform.." Constitutional Accoutability Center vol 2: 1-6. Google Google scholar. . < http:// upload/fck/file/File_storage/The%20States,%20Health%20Care%20Reform,%20and %20the%20Constitution(1).pdf />.