Future Directions for the National Healthcare Quality and Disparities Reports
Table of Contents
Our nation devotes extensive resources to health care and expects high-quality, high-value care for its investment. Three influential Institute of Medicine (IOM) studies—To Err Is Human: Building a Safer Health System (IOM, 2000), Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001a), and Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (IOM, 2003b)—provide evidence-based narratives for the necessity of addressing quality and eliminating disparities in health care in the United States. Evidence continues to mount confirming widespread variation in the quality of care by geographic area, by health care delivery site, and by population (AHRQ, 2009a,b; Fisher et al., 2009; HHS, 2009c).
An oft-cited maxim in quality improvement is that "efforts to improve quality require efforts to measure it" (Casalino, 2000, p. 520). One such effort is the annual publication of the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR) by the Agency for Healthcare Research and Quality (AHRQ), of the U.S. Department of Health and Human Services (HHS). These congressionally mandated reports track U.S. trends in health care performance, identify gaps in quality, and assess the degree of disparities in care.1 Although the authorizing legislation indicates that the primary audience for the NHQR and NHDR is the U.S. Congress, over time, the NHQR, NHDR, and their associated products have grown in scope and have come to be read by a broader audience than the originally intended one of legislative policy makers. AHRQ has asked the IOM to review these reports and provide a vision for their future direction that will enhance their role not only in documenting but also in advancing the state of health care quality and promoting equity.
Study Charge and Approach
Soon after the U.S. Congress passed the Healthcare Research and Quality Act of 1999,2 which required the annual production of both reports, AHRQ contracted with the IOM to develop a vision for the NHQR and NHDR and to establish the reports' content and presentation. That request led to the publication of two IOM consensus reports: Envisioning the National Healthcare Quality Report (IOM, 2001b) and Guidance for the National Health-care Disparities Report (IOM, 2002a). A summary of the IOM's previous recommendations for the national healthcare reports is presented in Appendix A.
AHRQ has published the NHQR and NHDR since 2003. In late 2008, after five years of producing both reports and in recognition of the changing landscape of health care delivery and quality measurement, AHRQ returned to the IOM to seek additional external guidance on the next generation of reports. In response to AHRQ's request, the IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports was formed to revisit previous IOM guidance pertaining to the NHQR and NHDR, examine the evolution of these reports and their related products, provide an updated assessment of how these reports and their related products can best fulfill their purpose, and establish priority areas in health care quality and disparities. The committee's statement of task is presented in Box 1-1.
National Reporting on the State of Quality and Disparities
The NHQR and NHDR monitor the health care performance of the nation rather than the health of the nation. The ultimate goal of health care is to improve an individual's health (physical or mental well-being). Two HHS publications that complement AHRQ's national healthcare reports by focusing more directly on the health status of Americans are: Health, United States (HHS, 2009b), which is an annual chartbook of U.S. health statistics, and Healthy People 2010 and Healthy People 2020, which present U.S. health and health care indicators with targets set for achievement by 2010 and 2020, respectively (HHS, 2000,2009a).
Overview of Progress
AHRQ's national healthcare reports have helped raise awareness of the state of the nation's health care and identify where gaps in quality and equitable care exist across different types of care (i.e., preventive care, acute treatment, chronic condition management), care for specific conditions (e.g., diabetes, heart disease), in specific health care settings (e.g., hospital, long-term care, ambulatory), and for specific population groups (e.g., race, income, age). The NHQR and NHDR highlight performance in the health care system in delivering health care that is safe, timely, effective, and patient-centered.3
The 2008 NHQR states that quality of health care in the United States has improved for a majority of the individual measures it tracks (of the 46 core measures that AHRQ reports on in the print version of the NHQR, 87 percent showed improvement, and of the expanded set of 190 measures tracked, 69 percent showed improvement),4,5 but concludes with the message that the overall quality of health care in the United States is suboptimal, and the pace of improvement is slow. Among performance measures that AHRQ tracks, the median annual rate of change is low (1.8 percent for the 46 core measures featured in the print reports and 1.4 percent for an expanded set of 190 measures that AHRQ monitors [AHRQ, 2009b]).
Because rates of change in quality measures diminish as high performance levels are achieved and because there is no standard or ideal rate of quality improvement, gaps between the level of health care people receive and what is recommended provide a more telling picture of the state of the nation's health care quality than just historic rates of change. The 2008 NHQR documents that quality achievement varies widely across different measures—from 96 percent of hospitalized heart attack patients receiving recommended care6 to only 15 percent of dialysis patients being registered on a waiting list for kidney transplantation (AHRQ, 2009b).
Across all the process of care quality measures tracked in the NHQR, patients received the recommended care less than 60 percent of the time.7 Other studies have documented similar shortcomings in the delivery of recommended care. Figure 1-1 illustrates the findings from several studies looking across 12 selected communities; less than 60 percent of adults received recommended health care regardless of the type of care or its function (Asch et al., 2006; Kerr et al., 2004; McGlynn et al., 2003).
When overall national performance rates are improving, disparities in receipt of care among population groups often remain evident (AHRQ, 2009a). Moreover, disparities even exist in geographic areas noted as having the highest performance on quality of care measures, so there is "no simple story" to explain patterns of disparities across different regions, health plans, or by type of care (Baicker, 2004, p. 33; Trivedi et al., 2006). Knowing whether disparities exist depends on the availability of descriptive population data to allow stratification of performance measurement data. The NHQR and NHDR primarily use the same set of quality measures, and the NHDR shows when differences exist in national performance levels for various sociodemographic groups. Too often in quality measurement, however, these more detailed population descriptors are not available, but they are essential for use in analysis and subsequent planning of interventions to reach affected populations. For example, Aetna, Inc. Health Plan found disparities in the quality of care received even among its insured minority populations, "when they paid attention to this issue, and began collecting race and ethnicity data" (Betancourt et al., 2006, p. 3). Armed with such information, Aetna sought to integrate disparities reduction into quality improvement efforts.
Other health care quality reports also find overall performance on quality measures is less than optimal and that disparities continue to persist, although they may look at different topics and sets of measures (for example, Byers, 2010; Cantor et al., 2007; The Commonwealth Fund Commission on a High Performance Health System, 2008; IOM, 2000, 2001a, 2002b, 2003a,b, 2004a,b, 2005, 2006, 2007; Kaiser Family Foundation, 2009; McCarthy et al., 2009; NCQA, 2008, 2009; President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998; Rowe et al., 2010; Schuster et al., 2005). Despite progress being made in many areas, the United States still has far to go before the entire population receives the level of care it expects, desires, and deserves.
Box 1-1. Statement of Task for the IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports
The Institute of Medicine (IOM) will form a consensus committee to review and synthesize current evidence to establish priority areas in health care quality and disparities for a combined update of the 2001 IOM report Envisioning the National Healthcare Quality Report and the 2002 IOM report Guidance for the National Healthcare Disparities Report. Previous recommendations regarding questions and objectives to be addressed relevant to quality of care and disparities will be evaluated and updated and new ones considered. The update's final findings and recommendations will address important questions evaluating quality and disparities in health care and will result in insight and guidance to the Agency for Healthcare Research and Quality (AHRQ) on ways of improving the National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR). The committee will take note of recommendations that are estimated to be a reach for the current resources of AHRQ.
In addition, a separate subcommittee of experts will report to the committee on the lack of standardization of collection of race and ethnicity data at the federal, state, local, and private sector levels due to the fact that the federal government has yet to issue comprehensive, definitive guidelines for the collection and disclosure of race and ethnicity data in health care quality improvement. The subcommittee will focus on defining a standard set of race, ethnicity, and language categories and methods for obtaining this information to serve as a standard for those entities wishing to assess and report on quality of care across these categories. The subcommittee will carry out an appropriate level of detailed, in-depth analysis and description, which can be issued as a stand-alone report and summarized in the final overall report by the committee.a
aThe subcommittee's focus was on a specific data issue relevant to identifying disparities. Its report Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement was released on August 31, 2009, and can be accessed at http://www.nap.edu/catalog.php?record_id=12696.
Reporting as One Aspect for Quality Improvement
In testimony to the Future Directions committee, AHRQ staff observed that the primary utility of the national healthcare reports is to raise awareness of the level of health care quality and the existence of disparities (Moy, 2009). In response, the IOM Future Directions committee considered how such awareness could more readily be translated into action, given that health care delivery tends to be a local enterprise, and to examine the relationship of national or more localized reporting to quality improvement.
The Strategic Framework Board (SFB), which was formed in 1999 to design a national quality measurement and reporting strategy, provides one schematic showing relationships among quality improvement activities. The SFB schematic illustrates how measurement and reporting should be integrally tied to other elements of quality improvement, including establishment of national goals, building a strong evidence base for measures and interventions, and widespread adoption in the field (Figure 1-2) (McGlynn, 2003). The SFB stressed that stronger linkages between these activities would "increase the likelihood that measurement and reporting can drive change"(McGlynn, 2003, p. I-6) and that it is essential to think about how collected "information should be packaged and made available to maximize utility for decisions" (McGlynn, 2003, p. I-5).
To make collective strides toward improved health care delivery, a national quality improvement effort requires standardization of measurement tools; harmonization of measures for reporting purposes; implementation of interventions and public reporting on performance; and setting priorities and performance goals through collaborative processes (Smith Moore et al., 2007). Recent efforts by the National Priorities Partnership (NPP), convened by the National Quality Forum,8 have achieved a consensus among numerous private and public sector stakeholders, including some federal agencies (including AHRQ, the Centers for Medicare and Medicaid Services, and the Centers for Disease Control and Prevention, among others) on national priority areas for quality improvement action. The NPP has identified 6 priority areas for health care with 27 specific goals, all of which address "four major challenges—eliminating harm, eradicating disparities, reducing disease burden, and removing waste—that are important to every American" (NPP, 2008, p. 8). The Future Directions committee's task includes recommending priority areas for quality improvement and disparities in the context of national reporting, and these six NPP priority areas, along with earlier IOM advice on priority areas, are further reviewed in Chapter 2.
Key Issues Addressed by the Committee
Throughout much of the period of the Future Directions committee's deliberations, the nation considered expanding insurance coverage and investments in quality monitoring.9,10 With trillions of dollars already being spent on health care, monitoring the state of health care quality improvement and the degree of disparities is essential. The committee acknowledges the tremendous effort that AHRQ and its data partners have made in bringing forth the national healthcare reports and related products to document the state of U.S. health care. The following discussion focuses on improving AHRQ's current products so that the products might ultimately set a direction for progress and drive change among stakeholders.
The committee sought input from experts through testimony, interviews, and commissioned papers to determine how best to enhance the usefulness of the NHQR and NHDR in contributing to the overall advancement of health care quality and equity. The committee heard from a variety of individuals and organizations that these reports relay a lot of facts for specific conditions, populations, and measures. Most often, stakeholders found the NHQR and NHDR to be useful sources for quotable information in bringing attention to specific quality issues that their state, institution, or organization might examine. As examples, health services researchers use data from the reports in articles they produce or presentations they give, and advocacy groups educate their members and funders about access and utilization gaps in recommended care.
Generally, however, observers thought that the NHQR and NHDR could be improved in numerous ways that would make them more influential in promoting change in the U.S. health care system, in addition to being a source of technical data on past trends. In view of the slow progress in improving quality or reducing disparities, the committee approached its task with the overall aim of improving the actionability of the national healthcare reports and their related products.
Several key themes for improving the NHQR and NHDR emerged from the committee's research, including the need for AHRQ to:
- Identify the most important opportunities for concerted national action.
- Develop measures and data sources to support monitoring of "high-impact" areas (e.g., those showing the greatest net health benefit; those showing greatest opportunity for increasing value and equity if the gaps between current achievement and desired performance levels were closed).
- Increase understanding of the content and visibility of the national healthcare reports in both print and Web-based forms.
Issues raised in assessing the national healthcare reports, as well as potential solutions, identified through the committee's outreach and deliberations are featured in Table 1-1. The topics identified in that table and the committee's recommendations will be taken up in subsequent chapters of this report.
Limitations of the Study
For many of the issues addressed in this report by the Future Directions committee, no specific evidence base of peer-reviewed articles exists. For that reason, the committee's recommendations are generally based on the expert consensus of committee members in consultation with other experts in the fields of performance measurement and communications. Whenever possible, connections between the committee's decisions and those of other prominent groups are identified.
Organization of the Report
This introductory chapter has described the context for this report, including the committee's charge, as well as issues and potential solutions related to the national healthcare reports, and the limitations of the study. In subsequent chapters, the committee makes recommendations to AHRQ for modifying future editions of the NHQR and NHDR, identifying priority areas and developing a process for the selection of measures to evaluate progress, strengthening data resources for quality measurement and disparities identification, and providing for additional resources to fulfill the recommended changes.
- Chapter 2–Re-envisioning the NHQR and NHDR. Chapter 2 examines legislative guidance on the purpose of the national healthcare reports and the intended audience of Congress. In addition, the chapter discusses a vision for the NHQR and NHDR that is more forward-looking and action-oriented by tying the reports to national priorities and a national quality improvement strategy. In accordance with its charge, the committee identifies a set of national priority areas to help guide measure selection for the reports.
- Chapter 3–Updating the Framework for the NHQR and NHDR. Chapter 3 presents an updated frame-work that has evolved from previous IOM guidance. The chapter provides a rationale for the four new components of the framework (i.e., access, efficiency, care coordination, and capabilities of health systems infrastructure). The framework is to be used by AHRQ as a tool to categorize measures and thereby ensure balance in its overall portfolio of measures (e.g., included in State Snapshots not just the reports). Core measures featured in the reports, however, should meet more stringent tests—applicability to priority areas and having the highest potential to improve population health compared to other candidate measures. Equity and value are highlighted as crosscutting dimensions of the framework and serve as criteria in the process for ranking measures as well as distinct data elements for inclusion in the national healthcare reports.
- Chapter 4–Adopting a More Quantitative and Transparent Measure Selection Process. Chapter 4 reviews AHRQ's current measure selection process and makes a case for a more transparent and quantitatively based measure selection and ranking process. The chapter includes discussion of the applicability of parameters such as clinically preventable burden, cost-effectiveness, and net health benefit. The committee's recommendation process can also help prioritize areas for measure and data source development as well as retirement of measures.
- Chapter 5–Enhancing Data Resources. Chapter 5 examines the ways in which AHRQ can play a role in establishing needed content for the nation's health care data infrastructure by suggesting areas for measure and data source development, and by defining areas where data enhancement is desirable. Criteria are set for use of subnational data to inform quality improvement efforts when national data are not yet available in key areas. Further, the chapter examines the need for analyses that stratify health care quality measures by sociodemographic factors and for standardization of race, ethnicity, and language need data to foster their collection and the ability to compare findings for subgroups across settings.
- Chapter 6–Improving Presentation of Information. Chapter 6 highlights issues pertaining to the presentation of data in the NHQR, NHDR, and related products, with a focus on setting benchmarks to illustrate the best levels of performance that have been achieved. It expands on ways to improve specific products by telling a more complete quality improvement story and by drawing stronger parallels between the NHQR and NHDR so that disparities reduction is not seen as a separate activity from quality improvement.
- Chapter 7–Implementing Recommended Changes. Chapter 7 reviews the major tasks recommended by the committee and identifies areas in which AHRQ would need additional resources to support the recommended changes.
The Future Directions committee offers a vision for future editions of the NHQR and NHDR. Both data and analyses in the reports must focus on promoting improvements in the U.S. health care system and what various stakeholders can do to positively affect desired outcomes. The national healthcare reports alone will not transform the quality of health care in the United States. By refocusing national attention on areas with potential for the greatest health impact, presenting data to identify the best levels of achievement and accountable actors, stimulating measure and data development, and identifying evidence-based policies and practices, the reports should stimulate greater progress on closing quality gaps and eliminating disparities.
AHRQ (Agency for Healthcare Research and Quality). 2009a. National Healthcare Disparities Report, 2009. Rockville, MD: Agency for Healthcare Research and Quality.
—. 2009b. National Healthcare Quality Report, 2008. Rockville, MD: Agency for Healthcare Research and Quality.
Asch, S. M., E. A. Kerr, J. Keesey, J. L. Adams, C. M. Setodji, S. Malik, and E. A. McGlynn. 2006. Who is at greatest risk for receiving poor-quality health care? New England Journal of Medicine 354(11):1147-1156.
Baicker, K., A. Chandra, J. S. Skinner, and J. E. Wennberg. 2004. Who you are and where you live: How race and geography affect the treatment of Medicare beneficiaries. Health Affairs Supplement Web Exclusive: VAR:33-44.
Betancourt, J. R., J. S. Weissman, and the Disparities Solutions Center and Institute for Health Policy. 2006. Aetna's Program in Health Care Disparities: The diabetes pilot program. Boston, MA: Massachusetts General Hospital.
Byers, T. E. 2010. Two decades of declining cancer mortality: Progress with disparity. Annual Review of Public Health 31(1):121-132.
Cantor, J. C., C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy. 2007. Aiming higher: Results from a state scorecard on health system performance. Washington, DC: The Commonwealth Fund.
Casalino, L. P. 2000. The unintended consequences of measuring quality on the quality of medical care. New England Journal of Medicine 342(7):519-520.
The Commonwealth Fund Commission on a High Performance Health System. 2008. Why not the best? Results from the national scorecard on U.S. health system performance, 2008. New York: The Commonwealth Fund.
Fisher, E. S., J. Bynum, and J. Skinner. 2009. The policy implications of variations in Medicare spending growth. Hanover, NH: The Dartmouth Institute for Health Policy and Clinical Practice.
HHS (U.S. Department of Health and Human Services). 2000. Healthy People 2010: Understanding and improving health. Washington, DC: U.S. Department of Health and Human Services.
—. 2009a. Developing Healthy People 2020. http://www.healthypeople.gov/hp2020/default.asp (accessed February 4, 2010).
—. 2009b. Health, United States, 2008. http://www.cdc.gov/nchs/hus.htm (accessed November 10, 2009).
—. 2009c. Hospital Compare—a quality tool provided by Medicare. http://www.hospitalcompare.hhs.gov/ (accessed December 8, 2009).
IOM (Institute of Medicine). 2000. To err is human: Building a safer health system. Washington, DC: National Academy Press.
—. 2001a. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
—. 2001b. Envisioning the National Healthcare Quality Report. Washington, DC: National Academy Press.
—. 2002a. Guidance for the National Healthcare Disparities Report. Washington, DC: The National Academies Press.
—. 2002b. Fostering rapid advances in health care: Learning from system demonstrations. Washington, DC: The National Academies Press.
—. 2003a. Priority areas for national action: Transforming health care quality. Washington, DC: The National Academies Press.
—. 2003b. Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: The National Academies Press.
—. 2004a. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: The National Academies Press.
—. 2004b. Patient safety: Achieving a new standard for care. Washington, DC: The National Academies Press.
—. 2005. Quality through collaboration: The future of rural health care. Washington, DC: The National Academies Press.
—. 2006. Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington, DC: The National Academies Press.
—. 2007. Preventing medication errors. Washington, DC: The National Academies Press.
Kaiser Family Foundation. 2009. Putting women's health care disparities on the map: Examining racial and ethnic disparities at the state level. Menlo Park, CA: Kaiser Family Foundation.
Kerr, E. A., E. A. McGlynn, J. Adams, J. Keesey, and S. M. Asch. 2004. Profiling the quality of care in twelve communities: Results from the CQI study. Health Affairs 23(3):247-256.
McCarthy, D., S. K. H. How, C. Schoen, J. C. Cantor, and D. Belloff. 2009. Aiming higher: Results from a state scorecard on health system performance, 2009. New York, NY: The Commonwealth Fund.
McGlynn, E. A. 2003. Introduction and overview of the conceptual framework for a national quality measurement and reporting system. Medical Care 41(1 Suppl):I1-I7.
McGlynn, E. A., S. M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. A. Kerr. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348(26):2635-2645.
Moy, E. 2009. Lessons learned in de eloping NHQR and NHDR. Agency for Healthcare Research and Quality. Presentation to the IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports, February 9, 2009. Washington, DC. PowerPoint Presentation.
NCQA (National Committee for Quality Assurance). 2008. The state of health care quality report 2008. Washington, DC: National Committee for Quality Assurance.
—. 2009. The state of health care quality report 2009: Value, variation and vulnerable populations. Washington, DC: National Committee for Quality Assurance.
NPP (National Priorities Partnership). 2008. National priorities and goals: Aligning our efforts to transform America's healthcare. Washington, DC: National Quality Forum.
President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. 1998. Quality first: Better health care for all Americans. http://www.hcqualitycommission.gov/ (accessed September 4, 2009).
Rowe, V. L., F. A. Weaver, J. S. Lane, and D. A. Etzioni. 2010. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006. Journal of Vascular Surgery 51(4 Suppl):21S-26S.
Schuster, M. A., E. A. McGlynn, and R. H. Brook. 2005. How good is the quality of health care in the United States? The Milbank Quarterly 83(4):843-895.
Smith Moore, T., M. D. Francis, and J. M. Corrigan. 2007. Health care quality in the 21st century. Clinical & Experimental Rheumatology 25(6 Suppl 47):3-5.
Trivedi, A. N., A. M. Zaslavsky, E. C. Schneider, and J. Z. Ayanian. 2006. Relationship between quality of care and racial disparities in Medicare health plans. Journal of the American Medical Association 296(16):1998-2004.
1 The 2008 NHQR and NHDR, as well as links to previous and subsequent editions of these reports, are available on AHRQ's Web site: http://www.ahrq.gov/qual/qrdr08.htm.
2 Healthcare Research and Quality Act of , 1999, Public Law 106-129 § 902(g) and 913(b)(2), 106th Cong., 1st sess. (November 19, 1999).
3 These attributes—safe, timely, effective, and patient-centered—are four of six aims for health care systems' quality outlined by the IOM in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century.
4 Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, September 22, 2009.
5 A misprint in the 2008 NHQR in Figure H.1 (p. 3), states that the NHQR reports on 45 rather than the correct number of 46 measures. Core measures denote a smaller group of measures that AHRQ has selected as having the greatest importance and scientific soundness; the AHRQ core measures are not the same as the core measures used by the Centers for Medicare and Medicaid Services (CMS) or The Joint Commission.
6 Based on all payers, 95.8 percent of hospitalized heart attack patients received aspirin within 24 hours of heart attack and at discharge, beta blocker within 24 hours of attack and at discharge, ACE inhibitor or ARB treatment, and smoking cessation counseling for those that smoke.
7 Personal communication, Ernest Moy, Agency for Healthcare Research and Quality, August 10, 2009.
8The NPP consisted of 28 members when the initial priorities and goals were established in 2008; it has since grown and now consists of 32 members (http://www.nationalprioritiespartnership.org/Partners.aspx).
9National Health Care Quality Act, Bill S.966, 111th Cong., 1st sess. (May 4, 2009); American Recovery and Reinvestment Act of 2009, Public Law 111-5, 111th Cong., 1st sess. (January 6, 2009); Medicare Improvements for Patients and Providers Act of 2009, Public Law 110-275, 110th Cong., 2d sess. (July 15, 2008); Children's Health Insurance Program Reauthorization Act, Public Law 111-3, 111th Cong., 1st Sess. (January 6, 2009); Affordable Health Care for America Act, HR 3962, 111th Cong., 1st sess. (October 29, 2009); Patient Protection and Affordable Care Act, HR 3590, 111th Cong., 1st sess. (December 24, 2009).
10 This IOM report was written during the health reform debate of 2009 and 2010. In March 2010, the Patient Protection and Affordable Care Act was signed into law [Patient Protection and Affordable
Page originally created September 2012