Strong Start for Mothers and Newborns experiences growing pains in year one

The Strong Start for Mothers and Newborns initiative has experienced “growing pains” in its development, according to a study by the Urban Institute, Health Management Associates, American Institutes for Research, and Briljent. The study evaluates the implementation and impacts of the Strong Start initiative on health care delivery, outcomes, and cost, based on qualitative case studies, participant-level process evaluation, and impact analysis, as well as numerous program monitoring measures. The purpose of the report is to present early findings of the evaluation, summarize the status of the evaluation’s research efforts, and present a plan for the next year of work.


The Strong Start initiative is funded under Section 3021 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) with the goal of improving maternal and infant outcomes for pregnancies covered by Medicaid and the Children’s Health Insurance Program (CHIP). It funds three enhanced prenatal care models: (1) maternity care homes; (2) group prenatal care; and (3) birth centers. The initiative currently supports 27 awardees and 213 provider sites across 30 states, the District of Columbia, and Puerto Rico, serving a target of 80,000 women.

Awardees and sites

Of the 27 Strong Start awardees, 13 are implementing the maternity care home model, 12 are implementing group prenatal care, one is implementing birth center care, and two are implementing more than one model. Of the 213 provider sites, 133 are implementing maternity home care, 42 are implementing group prenatal care, and 38 are offering birth center care. All of these awardees maintain a goal of reducing preterm birth and decrease the rate of low birth rate. Other common goals include decreasing the cost of care, increasing Medicaid and CHIP outreach to inform them of Strong Start, and increasing rates of breastfeeding.

Early observations

Though enrollment in Strong Start was lower than expected during the program’s first year, with slow development of intake and enrollment processes and barriers such as time commitments and transportation identified as possible causes, enrollment is steadily increasing. The study also determined that participants have high levels of emotional and psychosocial needs.Strong Start providers work diligently to address those needs but are constrained by resource limitations and Medicaid- and CHIP-related barriers.

While it is too early to make generalizations about the effects of Strong Start, current data suggests that women served by the program have lower than average Cesarean section rates, higher rates of breastfeeding, and lower rates of preterm deliveries than the country as a whole. Participants also expressed overwhelming satisfaction with their prenatal care, though satisfaction with delivery experiences is somewhat lower

Progress of the study

Much of year one was spent developing foundational documents to set the stage for data gathering. The launch of data collection occurred in the second half of the project year. Year two of evaluation calls for continued data collection and could possibly see the collection and compilation of the first wave of data to be used in the study’s impact analysis.

SCOTUS rules in favor of ACA subsidies for federal Exchange enrollees

In a six to three decision, the U.S. Supreme Court has affirmed the Fourth Circuit and upheld an Internal Revenue Service (IRS) ruling to extend health plan premium tax credits to individuals enrolled in Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) coverage through a federal Health Insurance Exchange (Exchange). Chief Justice John Roberts, writing for the majority, and joined by Justices Kennedy, Ginsburg, Breyer, Sotomayor, and Kagan, found that the ACA phrase “an Exchange established by the state” did not expressly limit tax credits to state Exchanges, as alleged by the petitioners, but was properly viewed as ambiguous and that several other provisions in the ACA would make little sense if tax credits were not available to federal Exchange enrollees (King v. Burwell, June 25, 2015, Roberts, J.).

According to Roberts, “the fundamental cannon of statutory construction [is] that the words of a statute must be read in their context and with a view to their place in the overall statutory scheme.” Reading the words in the context of the ACA’s statutory scheme, Roberts wrote that the majority was compelled “to reject the petitioners’ [limited] interpretation because it would destabilize the individual insurance market in any State with a Federal Exchange, and likely create the very ‘death spirals’ that Congress designed the Act to avoid.”

Roberts granted that the petitioners’ arguments regarding the plain meaning reading of the language “an Exchange established by the state” were strong when viewed alone, however, “the context and structure of the ACA compelled [the Court] to depart from what would otherwise be the most natural reading of the pertinent statutory phrase.”

Justice Scalia, joined by Justices Alito and Thomas, wrote a scathing dissent claiming the majority changed the rules regarding statutory interpretation to save the ACA.


The ACA’s subsidy provisions are the key instrument through which the Act makes coverage affordable to individuals who purchase insurance on an Exchange. The ACA provides for advance payment of premium tax credits for people with incomes between 100 and 400 percent of the federal poverty level (FPL, $11,770-$47,080 for an individual in 2015) and cost-sharing reductions for people with incomes from 100 to 250 percent of the FPL ($11,770-$29,425 per year for an individual in 2015). To illustrate the importance of the subsidy provisions, according to an HHS Assistant Secretary for Planning and Evaluation (ASPE) Issue Brief, in 2015, 87 percent of people who selected a plan in states with a federal Exchange received premium tax credits.

Section 1311 of the ACA is the provision that allows states to set up Exchanges and section 1321 requires the Secretary of HHS to set up federal Exchanges in states that fail to set up Exchanges. Under section 1401 of the ACA, individuals are offered premium assistance through tax credits if they meet certain requirements, including enrollment “through an Exchange established by the State under section 1311.”

Despite the plain language of section 1401, the IRS began issuing tax credits through both federal and state Exchanges in January 2014 (26 C.F.R. Sec. 1.36B-1(k); 77 FR 30377, May 23, 2012) (the “IRS Rule”). The IRS Rule provides that the credits will be available to anyone “enrolled in one or more qualified health plans through an Exchange,” and then adopts by cross-reference an HHS definition of “Exchange” that includes any Exchange, “regardless of whether the Exchange is established and operated by a State…or by HHS” (26 C.F.R. Sec. 1.36B-2; 45 C.F.R. Sec. 155.20).

The petitioners in Kingv. Burwell are Virginia residents who do not want to purchase comprehensive health insurance. Because Virginia has declined to establish a state Exchange, it is served by a federal Exchange. The petitioners claimed that the cost of the least expensive unsubsidized Exchange plan through the federal Exchange would exceed 8 percent of their 2014 income, making them exempt from the ACA tax for failing to comply with the individual mandate. However, if the IRS Rule was correct and premium tax credits were applicable to federal Exchanges, the reduced costs of the policies available to the petitioners would subject them to the minimum coverage penalty. Therefore, if Court upheld the IRS Rule, the petitioners contended they would incur some financial cost because they would be forced to either purchase insurance or pay the individual mandate penalty. The petitioners alleged that the ACA’s statutory language precluded the IRS’s interpretation that the premium tax credits are also available to federal Exchanges.

It was correctly thought that this case would turn on the ACA language that ties the amount of tax credits to a health plan purchased “through an Exchange established by the State.” The petitioners argued that this language is unambiguous and clearly means that persons who purchased their health insurance plan through a federal Exchange do not qualify for tax credits. The government disagreed with the petitioners’ interpretation of the language, arguing that even if the language is unambiguous, the IRS ruling to extend the tax credits to federal Exchange enrollees was reasonable and entitled to deference.

Court Rulings Below

On February 18, 2014, the U.S. District Court for the Eastern District of Virginia dismissed the petitioner’s complaint, finding that the IRS Rule was a permissible exercise of administrative discretion because the ACA as a whole clearly evinced Congress’s intent to make the tax credits available in both state and federal Exchanges (see Subsidies for health coverage through Exchanges within authority of IRS, Health Reform WK-EDGE, February 26, 2014).

On July 22, 2014, a three-judge panel of the Fourth Circuit unanimously affirmed the district court’s ruling that the IRS Rule was a permissible exercise of administrative discretion, finding that the applicable statutory language was ambiguous and subject to multiple interpretations (see Appellate court creates circuit split by upholding IRS Rule, Health Reform WK-EDGE, July 22, 2014).

That same day, however, in Halbig v. Burwell, the U.S. Court of Appeals for the District of Columbia Circuit reached the opposite conclusion, with its three-judge panel ruling 2-1 that the IRS did not have the authority to rewrite the wording of the ACA to suit its intent to allow federal Exchange subsidies (see Federal appeals court axes subsidies for federally-run Health Insurance Exchanges, Health Reform WK-EDGE, July 22, 2014).

The White House then filed a motion for rehearing of the Halbig ruling before a full panel of the D.C. Circuit, which has seven judges appointed by Democratic presidents and four appointed by Republicans (see Halbig panel was wrong; Government seeks rehearing to avoid ‘perverse consequences’, Health Reform WK-EDGE, August 6, 2014). The plaintiffs in Halbig opposed the government’s motion for rehearing by the full D.C. Circuit, claiming that the plaintiffs in King v. Burwell had already petitioned the Supreme Court for review in that factually related case (see Halbig team asks to skip straight to SCOTUS, Health Reform WK-EDGE, August 20, 2014).

The D.C. Circuit granted the government’s motion for a rehearing of the Halbig appeal by the full panel of judges (see Halbig decision on premium subsidies to be reheard by full D.C. Circuit, Health Reform WK-EDGE, September 10, 2014); however, after the Supreme Court agreed to hear King v. Burwell, the D.C. Circuit ordered that Halbig be removed from the oral argument calendar and held in abeyance pending the Supreme Court’s decision in King v. Burwell (see Federal court waits for SCOTUS to rule on health insurance subsidy, Health Reform WK-EDGE, November 19, 2014).

Supreme Court Briefs and Oral Arguments

In their Supreme Court brief, the petitioners argued that there is no legitimate way to construe the phrase “an Exchange established by the State under section 1311” to include one “established by HHS under section 1321.” Therefore, because Congress expressly provided tax credits only for state Exchanges, and not federal Exchanges, the petitioners contended that the Court must give effect to that plain meaning of the ACA. The government’s brief countered that the ACA text, structure, and history demonstrate that tax credits were meant to be available through both state and federal Exchanges.

On Wednesday, March 4, 2015, the U.S. Supreme Court heard oral arguments in the case. As expected, the Justices’ questioning indicated that the Court was split, with the liberal Justices dominating the questioning during petitioner’s portion of the argument, and the conservative Justices becoming more vocal once the government began its argument (see SCOTUS hears King v. Burwell: Kennedy voices constitutional concerns, Roberts doesn’t tip his hand, Health Reform WK-EDGE, March 5, 2015).

Majority Analysis

In its analysis, the majority recognized that the ACA involves three interlocking reforms in the individual health insurance market: (1) it bars preexisting conditions in determining whether to provide coverage (the guaranteed issue requirement) and in setting the premium (the community rating requirement); (2) it requires each person to maintain insurance coverage or make a payment to the IRS; and (3) it gives tax credits to certain people to make insurance more affordable.

In addition to the three interlocking reforms, the ACA required the creation of Exchanges by the states or by federal government if the states declined to do so. If the states declined, the ACA ordered HHS to establish “such Exchange.” According to the majority, the use of the words “such Exchange” indicated that the state and federal Exchanges should be treated the same and that would include the availability of premium tax credits. To rule otherwise would fly in the face of several other ACA provisions, such as the requirement that all Exchanges “distribute fair and impartial information concerning…the availability of premium tax credits.” This provision would not make sense, according to the majority, “if tax credits were not available on Federal Exchanges.”

The majority ultimately decided that the phrase “an Exchange established by the state” was ambiguous. They attributed the ambiguity to Congress (1) writing key parts of the ACA behind closed doors; and (2) passing much of the ACA through the reconciliation process, which limited opportunities for debate and amendment and bypassed the Senate’s normal 60-vote filibuster requirement.

Bearing in mind that statutes must be read in their context and with a view toward the overall statutory scheme, the majority rejected the petitioners’ plain meaning construct because it would destabilize the individual market and likely create “death spirals.” The majority determined that under the petitioners’ reading, the ACA’s three interlocking reforms, particularly the tax credit and coverage reforms, would not work in a meaningful way. The majority noted several studies, including one that predicted that premiums could increase 47 percent and enrollment could decrease by 70 percent. “It is implausible that Congress meant the Act to operate in this manner,” the majority decided.

Roberts concluded by reminding us that “[i]n a democracy, the power to make the law rests with those chosen by the people…A fair reading of legislation demands a fair understanding of the legislative plan. Congress passed the [ACA] to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.”

Dissenting Opinion

In his dissent, Justice Scalia argued that “[u]nder all the usual rules of interpretation…the Government should lose this case. But normal rules of interpretation seem always to yield to the overriding principle of the present Court: The Affordable Care Act must be saved.”

Scalia offered up numerous sections of the ACA that sharply distinguish between the establishment of an Exchange by a state and the federal government and thereby undermine the majority’s interpretation. He also offered seven provisions that refer to the establishment of Exchanges by the states, which he claimed would be nullified by the majority interpretation.

Scalia also attacked the majority claim that the phrase “such Exchange” implies that federal and state Exchanges are same. To highlight what he saw as the majority’s error, Scalia offered Article I, Section 4, Clause 1 of the U.S. Constitution, which states:

The Times, Places and Manner of holding Elections for Senators and Representatives, shall be prescribed in each State by the Legislature thereof; but the Congress may at any time by Law make or alter such Regulations.

According to Scalia, “[j]ust as the [ACA] directs States to establish Exchanges while allowing the Secretary to establish ‘such Exchange’ as a fallback, the Elections Clause directs state legislatures to prescribe election regulations while allowing Congress to make ‘such Regulations’ as a fallback.” Scalia asks “[w]ould anybody refer to an election regulation made by Congress as a ‘regulation prescribed by the state legislature’? Would anybody say that a federal election law and a state election law are in all respects equivalent? Of course not. The word ‘such’ does not help the Court one whit.”

Scalia suggested that “[r]ather than rewriting the law under the pretense of interpreting it, the Court should have left it to Congress to decide what to do about the Act’s limitation of tax credits to state Exchanges.” According to Scalia, the majority opinion changes the rules of statutory interpretation for the sake of the ACA, and thereby “aggrandizes judicial power and encourages congressional lassitude.”

Insurance, physical activity, obesity up; tobacco and skipping care down

Since the Patient Protection and Affordable Care Act (ACA) became law in 2010, there has been a significant decrease in the uninsured rate for Americans of all ages. The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) published an early release of estimates for 15 selected health measures based on data from the 2014 National Health Interview Survey (NHIS). The early release presents estimates from 1997 through 2013 for comparison. NCHS notes that the estimates will be updated as each new quarter of NHIS data becomes available.

Selected health measures

The early release provided estimates on 15 health measures based on data for 111,682 persons. The 15 measures included in the present report are:

Three of these measures (lack of health insurance coverage, leisure-time physical activity, and current cigarette smoking) are directly related to Healthy People 2020 Leading Health Indicators (see Introducing the Healthy People 2020 initiative, Health Law Daily, January 26, 2015).

Health trends

There are some notable trends in the 15 health measures that the early release focuses on. The number of individuals with health insurance coverage has dropped since 2010, when the ACA (P.L. 111-148) was enacted, with a sharper decrease in 2014, which is the first year the ACA’s individual mandate was in effect. NCHS statistician Robin A. Cohen, an author of the study, told Time Magazine that the drop is “pretty sharp.” There were 36 million uninsured Americans in 2014, according to the study, down from a high of 48.6 million in 2010.

The early release also shows an increase of individuals who have a usual place to go for medical care, and a decrease in those who fail to obtain medical care that they need. Vaccination rates have increased slightly since 1997, while obesity rates have steadily risen as well and cigarette smoking has steadily decreased. Alcohol consumption—percentage of adults aged 18 and over who had at least one heavy drinking day in the past year—has mostly stayed the same, though the early release does show more alcohol consumption among women than in the past.

Highlight on Nebraska: 75,000 Nebraskans could have lost subsidies in Supreme Court decision

Approximately 57,000 Nebraskans were at risk to lose their health insurance subsidies depending on the Supreme Court ruling in King v. Burwell, according to an analysis by Families USA published prior to the release of the Court’s decision upholding such subsidies for plans in the federal Health Insurance Marketplace. The analysis determined that, while Nebraskans on the Health Insurance Marketplace currently pay an average premium of $104 per month after the subsidy, if the subsidies were eliminated, monthly premiums would go up to an average of $354.

Loss of subsidies in Nebraska

King v. Burwell threatened to eliminate premium tax credits provided to customers purchasing health insurance from the federal Health Insurance Marketplace, which is used by 34 states including Nebraska, and, in total, 6.4 million risk losing health insurance, according to the analysis.

Families USA used data broken up based on Nebraska’s three congressional districts. It found that, if the Supreme Court decided to eliminate subsidies from the federal Marketplace, 17,000 in Omaha’s District 2 would have lost their subsidies, as well as 16,000 in Lincoln’s District 1 and 19,000 in District 3, which covers central and western Nebraska.


Jessica Herman, the director of research for Omaha’s free-market research organization, the Platte Institute for Economic Research said that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has made health care less affordable. “The end goal should be solutions that make health care more affordable from the get-go,” she said. “Removing costly mandates and allowing people to purchase the plans they want, including those available before the law, should be the first step to overhauling our broken health care system.”

Nebraska Hospital Association spokesman Adrian Sanchez said that eliminating subsidies would also increase the amount of uncompensated care provided by hospitals and doctors, raising health costs for all. He said, “So, obviously, we’re hoping the Supreme Court sides in favor of Burwell, to keep those subsidies intact.”

Update: Since the original writing of this blog post, the Supreme Court on Thursday, June 25, 2015 issued a 6-3 ruling upholding the availability of premium tax subsidies to individuals who purchased insurance through the federal Health Insurance Marketplace, reasoning that, based on the broader structure of the ACA, Congress did not intend to limit the subsidies to state-created Marketplaces.