This article mentions the objectives of the Affordable Care Act which is a turning point in U.S. public health policy. It was revised and extended multiple times in the federal legal framework of the United States healthcare system.
The Patient Protection and Affordable Care Act (PPACA) also known as the Affordable Care Act (ACA) or Obamacare act was passed by President Barack Obama in March 2010 in the 11th congress. It was first enacted as a comprehensive health care reform law on March 23, 2010.
Medical developments and new technologies allow Americans to live longer and better lives for the past few decades. The Patient Protection and Affordable Care Act is a law that is dependable with the AAFP standard and gives importance to health care as a basic human right. It is accessible to healthcare in the United States. The act presents the basic legal health protection from birth to retirement that until now has been absent.
The policymakers of the United States are actively engaged in a discussion about how to make changes to federal laws that depend on health care analysis in America, including the Affordable Care Act (or “Obamacare”). This debate is centred in Washington, D.C., but it is also a part of the conversation in the state, city halls, and local communities. Presently, the ACA is concerned with facilitating most people and providing them health care coverage. This law affects American citizens in a variety of ways.
After fully applied, the Act will cut more than half of uninsured Americans. The law will give health insurance coverage for about 94% of the American residents, will reduce the uninsured by 31 million people, and will increase Medicaid registration by 15 million beneficiaries. Nearly 24 million people are likely to remain without coverage.
History of health care reforms
In the United States, health care reform has a long and complex history. Reforms were often presented but were not able to be applied. Therefore, the two reforms were passed through the federal government in 2010. The first was known as the Patient Protection and Affordable Care Act (PPACA) and the second one was named the Health Care and Education Reconciliation Act which revised the PPACA and became a part of the law on March 30, 2010.
In addition, the PPACA was designed to introduce new agencies and to work for Medicare and Medicaid innovation. It was planned to establish research reform ideas through different major projects.
Efforts of national reforms in the United States
From 1965 to the present, the efforts that were done in health reforms are as under:
In 1965 President Lyndon Johnson passed legislation for Medicare and was designed to provide services for hospitals and supplemental medical insurance for senior citizens. The law also introduced Medicaid, which allowed the Federal government to set programs for the poor.
The Consolidated Omnibus Budget Reconciliation Act was passed in 1985 to give health insurance coverage to some employees after retirement. Other health care reforms were made in 1996 and the name of the Act was Health Insurance Portability and Accountability Act (HIPAA) was designed to give insurance coverage protection to the employees and their families after changing or losing jobs. The Act also made it work for the health insurance companies to cover preexisting conditions.
In 1997 The Balanced Budget Act introduced the State Children’s Health Insurance Program (SCHIP) along with the Medicare health program. It was proposed to manage Medicare services and give health insurance to the children of those families who are below the federal poverty line. Due to congressional concern, in 2000 another law was passed to cut the three named programs like Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA). In 2003, The Medicare Prescription Drug, Improvement, and Modernization Act (also recognized as the Medicare Modernization Act or MMA) were introduced to provide Medicare coverage for prescription drugs. It also brought changes in three suggested parts of the Medicare law.
In 2010, President Barack Obama introduced the Patient Protection and Affordable Care Act (PPACA or ACA). The ACA is responsible to improve the quality and performance of the health system. They mainly deal with the effectiveness of medical treatments, work to develop medical malpractice and decrease medical errors, and improve payment systems for effectiveness.
They also coordinate between Medicare and Medicaid for the patient’s care. They give the option to state “health homes” for Medicaid if necessary for patients with chronic conditions. Similarly, they collect data and address health inequalities among populations based on gender, ethnicity, geographic location, and language.
The Medicare Access and CHIP Reauthorization Act (MACRA) was introduced in 2015 to extend the SCIP and to bring changes in the Medicare Part B services. In 2017, under the oath of President Donald Trump, the American Health Care Act was introduced but did not get a reasonable number of votes in the Senate. This act was initially designed to reverse the Patient Protection and Affordable Care Act. Thus Donald Trump signs Executive Order 13813 that permits insurance companies to sell short term plans at low cost, give coverage to purchase association health plans, and develop health savings accounts.
The aims and objectives of the Act
The Act has 10 separate legislative titles and has several key aims. The first and most important aim is to achieve universal coverage through combined responsibility between government and employers. The second aim of the act is to improve the equality, quality, and affordability of health insurance management. The third aim is to progress in healthcare standards and to give fineness to a diverse patient population. A fourth aim is to reinforce primary healthcare access and to bring longer-term changes in the access to receive primary and preventive health care. The last aim is to create strategic investments in the community’s health, through clinical preventive care and public investments.
Women’s preventive health care under the affordable care act
Under this act, women’s preventive health care services must be covered with no cost-sharing. These include mammograms, screenings for cervical cancer and other prenatal care etc. However, the law identifies the need to provide unique health needs of women throughout their life.
Adolescent health care sheet
ACA has created several data sheets on different health topics. This sheet also includes federal data for adolescents in each state. The rights and all provided health care facilities for adolescents are mentioned in detail in this datasheet.
Accessibility of primary health care to medically underserved populations
Generally, it is estimated that 60 million individuals are not underserved medically due to the shortage of primary healthcare professionals and elevated health risks. To decrease this shortage, the Act works for the development of community health centres and the National Health Service Corps. These extensions are likely to serve the double number of patients, increasing the total number of health patients from 20 million in 2010 to around 40 million by 2015.
Improvement of the public’s health and training of health professionals
To protect the American community, to organize primary health care in medically underserved communities, and to increase clinical preventive health services, the Affordable Care Act generates direct public health services.
In addition, the Act offers for the development of a national prevention plan and generates the Public Health Trust Fund to finance the community that will make sure the public health. According to FY 2010, the total amount of $15 billion was fixed for the Act that offers additional funding for prevention activities and continues annually.
The health care facilities for the targeted specific subpopulations, mainly the area of Indian health care, receive focused attention aiming to develop the performance of the healthcare sub population’s health and healthcare programs. The act also presents some programs for some specific centres like school-based health centres, tobacco termination programs for Medicaid-enrolled pregnant ladies and oral healthcare prevention programs.
The Act also allows primary health care training for new health professionals and establishes teaching health centres for health professionals. These changes are not funded officially by the Act.
Long-term health care
The Act provides long-term care to those people who are seriously ill and need community-based care. It gives protection to the spouses of those needy patients. It also presents a long-term care insurance program on a volunteer basis.
Health insurance market reforms
The act set some rules for the health insurance reforms and implemented the most significant health insurance. According to the market insurance reforms, the new rules related to medicine will be implemented in all states. In which the Insurers will be forbidden from negating coverage or setting charges based on health status, medical condition, genetic information or other health-related factors. Payments will vary by family structure, age, geographical status, tobacco use, participation in a health promotion program and so on.
Medicaid eligibility to lower salary people
The Patient Protection and Affordable Care Act increased eligibility for Medicaid to lower salary personnel and accept federal responsibility for their health care prevention. It provides higher federal support for the Health Insurance of children. It also streamlines Medicaid and CHIP enrollment, develops Medicaid services, offers new options for long-term support and services, provides options for dual-eligible community members, and enhances Medicaid quality for patients.
According to the Act, the state is responsible to protect the children, parents and childless adults who are not authorized to Medicare and have family incomes up to 133% FPL will become entitled to Medicaid. The act makes sure that the enrollment process of Medicaid will be simplified and eligible people can enrol themselves through state-run websites. In addition, the hospitals will provide Medicaid services to all Medicaid eligibility categories. Likewise, the states may offer community-based attendant services and will provide care to Medicaid beneficiaries with any disability who would otherwise need care in a hospital and nursing facilities, or are considered as mentally retarded.
Prevention of chronic disease and improving public health
To improve the nation’s health care system, promote health system and disease prevention. The act makes it clear that the prevention council will be supported through the prevention and public health security fund. Therefore, the barriers will be removed from clinical preventive services. Its priority is to Increase healthy communities and provide them affordable care to make the 21st-century public health organization support this goal.
They also present some prominent measures for updating disease prevention and public health systems, for the operation and expansion of school-based health clinics, for delivering Medicare coverage, for support and innovation of public health programs to create a healthier community.
Individuals who are having an income that is below the line of the federal poverty level are eligible to get federal subsidies and can purchase policies on an ACA exchange. But it is important that they are not already receiving the coverage of Medicare, Medicaid the Children health insurance plans or any other types of public support health coverage, and are not able to receive any reasonable coverage through their own business or any member of the family. Those families who are below the federal poverty level are not qualified to have these subsidies.
In addition, legal residents whose household income is below 100% FPL, and are not eligible for Medicaid are worthy of subsidies if they get all other eligibility criteria. For married people, it is a must to file taxes jointly to collect subsidies. Whereas, enrollees must have proof of legal residency to obtain eligibility criteria for ACA aid.
The ACA plans subsidies to those families who are having 400% of the federal poverty level (FPL), but the Kaiser Foundation considers this distribution as “discontinuity of treatment” at 400% FPL, which is also known as the “subsidy cliff”. After-subsidy aid for the second-lowest-cost, below the cliff, is 9.86% of income in 2019.
The amount of subsidy is sufficient for the second-lowest-cost silver plan (SCLSP). This percentage depends on the percentage of the federal poverty level (FPL) for the family and varies a little from year to year. In 2019, its range was 2.08% of income to 9.86% of income. The availability of the subsidy can be used for any specific plan, but not terrible plans.
ACA executed multiple programs to help and reduce the troubles to insurers that approached with its many changes. However, during multiple risk management programs, some most prominent are as under:
This program was a temporary risk management program. Its main purpose was to encourage hesitant insurers and make them part of the ACA insurance market from 2014 to 2016. During the period of 2014 to 2016, The aim of the Department of Health and Human Services was to cover some of the damages for insurers whose expectations were worse than they planned. Loss-making insurers would collect payments paid for in part by profit-making insurers. Similarly, the task of risk corridors was also to generate the Medicare prescription drug benefit.
This act, 2014 specified that during this exchange plan, no funds would be used for the benefit of the risk corridor itself. The purpose of this plan was only to specify the insurer to the DHHS, who will pay insurers from “general government revenues”.
In addition, due to the result of this program, several insurers sued the government of the United States to recover their funds.
The temporary reinsurance program was also available from 2014 to 2016. It was meant to streamline payments by reducing the inducements for insurers. It was also designed to raise premiums due to worries about higher-risk enrollees.
This plan involves Risk funds transfer plans with lower-risk enrollees to higher-risk enrollees. It was designed to facilitate insurers in terms of value and efficiency rather than by catching healthier enrollees. In all these three risk management programs, only risk adjustment was permanent while the other two plans were for a specific time period.
Delivery system reforms
The Act includes delivery system reforms that are proposed to reduce costs and improve quality. These are planned to improve hospital conditions and improve their quality, smooth the system of bundled payments and work for accountable care organizations etc.
Health care quality enterprises offer incentives and work to decrease hospital infections, make electronic medical records up to date and provide the best quality services for health care.
Medicare transition from fee for service to bundled payment is mandatory. In every payment system, it was required to be paid to a hospital and a group of physicians in a flawless care system, rather than deliver separate payments to individual service providers.
Accountable care organizations
Accountable care organization, also abbreviated as ACO, is a team of doctors, hospitals and other required staff that was organized to give care to Medicare patients. They were permitted to use fees for service billing and they got bonuses from the government for providing quality services and for reduction and prevention of chronic diseases.
The famous study of 2014 estimated that ACA prevented almost 50,000 patient deaths from 2010 to 3013. According to an estimation presented by Himmelstein and Woolhandler in January 2017, the ACA’s Medicaid services would cause an estimated 43,956 deaths annually.
A recent study of 2021 showed a noteworthy decline in mortality rates in those states that have Medicaid expansion programs rather than those states that did not offer them. The study reported that states decisions’ not to develop Medicaid caused around 15,600 additional deaths from 2014 to 2017.
State Roles in Execution of the Act
States play various roles and have some important responsibilities under the ACA. It is the responsibility of the state to implement new health insurance by developing Medicaid programs by Jan. 1, 2014. Moreover, states may implement the essential provision and keep an eye on the federal government in taking necessary steps to implement the act. For instance, the state forms a temporary high-risk pool and generates and manages health benefit exchanges.
Trauma centre program
The affordable act also creates a new trauma centre to support the emergency department and increases the volume of the trauma centre. It provided the funds to research emergency medicine and improve programs to design, evaluate and implement advanced systems for emergency care.
The changes were made every year in the ACA. The amendments in the legislation and the decision of the budget can affect its implementation. Modifications in the healthcare services and amendments in the political environment make it possible that the changes will remain in the years to come.
In short, the ACA has some pros and cons. In its benefits, more Americans have health insurance services, which would be more affordable for many citizens. Similarly, people with poor health conditions can no longer be left without coverage. There would not be any time limit for care coverage and the prescription drug cost would be below.
However, there are some problems with implementing the ACA. Due to the rise of the premium, many people have to pay a higher premium even for those who already had health insurance. New taxes were passed to help with the ACA, which is a load on the poor citizens.
The ACA website initially had a lot of technical problems and people faced difficulties enrolling and signing up on the website. However, this problem was removed with the passage of time, still many people complained that it is hard to sign up on the website.