Affordable Care Act (ACA) (5)

Why are individuals uninsured?

Insurance is not affordable

Who are the most uninsured groups of people?

Low-income families with at least one worker

Universal Coverage

The goal is to ensure that all people can obtain the health services they need without suffering financial hardships when paying for them

What are the three main components of universal coverage?

- Physical accessibility

- Financial affordability

- Acceptability

Physical accessibility

Patients can access care within a reasonable distance and a reasonable amount of time

Financial affordability

Patients can obtain care where the payment does not cause undue financial hardship

Acceptability

Patients are willing to seek services because of sufficient quality and trust in the system

The United States is the only developed country without...

Universal coverage

The ACA is the most significant overhaul of healthcare policy since the introduction of....

Medicare/Medicaid

Two mechanisms that the ACA used to attempt to increase insurance coverage of the U.S. population

- Expansion of Medicaid eligibility to 138% federal poverty line

- Creation of insurance marketplaces, with those people falling between 100% - 400% federal poverty line qualifying for subsidies

Subsidies

Discounted rates

Individual mandate

- Requirement that Americans had to obtain health insurance or pay a tax penalty

- Reduces adverse selection

Some exemptions to the individual mandate

- Religious

- Those not lawfully present

- Incarcerations

- Members of Native American tribes

- Hardship waivers

- Short coverage gaps

Medicaid expansion through the ACA

- Funds were allocated to expand state Medicaid programs

- States previously focused Medicaid coverage on pregnant women and children

- Expansion was not mandatory and up to each state

- Expansion has significantly improved a variety of health and economic outcomes, as well as racial/ethnic disparities

How many states have expanded their Medicaid programs through the ACA?

41 states, including Washington DC

What has happened in the states that have not accepted the Medicaid expansion?

There are significant gaps in coverage that remain for millions of low-income people

Insurance Marketplace

- The ACA created a website for patients to shop for insurance, compare plans, and identify if they qualify for tax credits to help lower costs

- Available to legal US residents without coverage elsewhere

- Premium costs can only consider five different variables

- There are five major plan categories

What are the 5 variables that insurance companies can consider for premium costs?

- Age

- Geography

- Tobacco use

- Individual vs. family

- Plan category

What are the five major plan catgory forms insurance can take?

Catastrophic (HDHP), bronze, silver, gold, platinum

Tax Credits

- Created for individuals between 100% - 400% FPL

- Designed to close the coverage gap for persons who do not meet Medicaid eligibility but do not make enough to purchase health insurance outright/through an employer

In states that expanded Medicaid, people qualify for either...

- Medicaid up to 138% FPL

- Tax credits on the marketplace for 100% - 400% FPL

In states that did not expand Medicaid...

There are still many people who cannot afford private insurance, but still don't qualify for Medicaid, creating a major coverage gap

How did ACA change the Medicare donut hole?

- incrementally closed the Medicare Part D donut hole

- in the original coverage gap patients were liable for most of the cost of their medication

- now the coverage gap is the same as in the initial coverage phase (25% coinsurance)

Major provisions of ACA

- dependents on insurance

- pre-existing conditions

- preventative services

- contraceptive benefits

- eliminated annual and lifetime limits

Dependents on Insurance

- ACA mandated that insurance must allow dependents to remain on their parents' coverage up until age 26

- Previously, people would lose coverage at 18 years old

- Options for healthcare coverage for the young adults not in full-time employment were limited

What was the "dependents on insurance" mandate aimed to do?

- Get more young and healthy patients covered by insurance, which helps to control costs

- Reduces adverse selection

Pre-existing conditions

- Diagnosis/condition present before an insurance policy goes into effect

- ACA made it illegal to deny an individual insurance coverage or to determine premium costs based on pre-existing conditions

Preventive Services

- ACA mandated that insurance policies must cover preventive health services with no copay or coinsurance

- Better access to preventative care

What does better access to preventive care lead to?

- Healthier population over time

- Less long-term complications of chronic disease (cheaper for companies in the long run)

Adult preventive services

- Screenings for blood pressure

- Cholesterol

- Obesity

- HIV

- Diet counseling

- STI counseling

- Alcohol misuse screening/counseling

- Immunizations

- Tobacco use cessation

Women preventive services

- Screenings for cervical cancer

- Domestic violence

- Gestational diabetes

- BRCA counseling

- Mammography

- Breastfeeding support

- Well-woman visits

Children preventive services

- Screenings for autism

- Developmental issues

- Vision/dental

- Fluoride chemoprevention

- Iron supplementation

Contraceptive benefits

- ACA mandated that insurance policies must cover contraceptives/counseling with no copay or coinsurance

- Previously, contraceptive coverage was erratic based on the insurance policy

Why is access to contraceptives important?

Ultimately reduces costs, improves health, and provides better control over family and economic planning

Contraceptive methods that are fully covered

- Barrier methods (diaphragms & sponges)

- Hormonal methods (birth control pills & vaginal rings)

- Implanted devices (Intrauterine devices, IUDs)

- Emergency contraception (Plan B & ella)

- Tubal ligations

- Instruction in fertility awareness-based methods

- Patient education and counseling

Contraceptive methods that have no mandated coverage

- Drugs to abortions (abortifacients)

- Surgical abortions

- Vasectomies

Annual and Lifetime Limits

- ACA eliminated placing annual/lifetime limits on insurance policies for 'essential health benefits'

- patients had to pay higher premiums to increase their limits

- ACA now has mandated basic services which must be covered without limit in coverage

Policies are used to specify dollar limits up to which insurance companies would provide coverage

- Annual (total amount spent in one year)

- Lifetime (total amount spent during plan enrollment)

ACA mandated basic services which must be covered without limit in coverage

- Ambulatory patient services (outpatient care)

- Emergency services, hospitalizations (surgery)

- Pregnancy, maternity, and newborn care

- Mental health and substance use services

- Prescription drugs

- Rehabilitative and habilitative services and devices

- Laboratory services

- Preventive and wellness services

- Chronic disease management

- Pediatric services

Part D Donut Hole

ACA incrementally closed the Medicare Part D donut hole

Medicare Part D Coverage Gap

- Patients were liable for most of the cost of their medications

- Has now been phased out (patients capped at $2000 out-of-pocket for their drug spend)

Hospital Performance

- ACA created programs to make hospitals more accountable for the quality of care by leveraging Medicare payments

- Hospital performance is required to be made public

- Readmissions Reduction Program

- Hospital-Acquired Condition Reduction Program

Readmissions Reduction Program

- Aims to reduce readmissions for specified conditions

- High re-admissions results in docking of Medicare payments up to 3%

Why are programs based on hospital performance important?

Makes hospitals more accountable for the quality of care

Hospital-Acquired Condition Reduction Program

- Aims to reduce preventable conditions from occurring

- Ex. infections, falls, pressure ulcers, hematomas

- High rates of conditions results in docking of Medicare payments to the lowest-performing 25% hospitals nationally by 1%

Accountable Care Organization (ACOs)

- ACA incentivized opportunities for insurers and providers to use ACO payment models

- Groups of doctors, hospitals, and other health care providers

- Provide coordinated, high-quality care

- Reimbursement includes quality metrics

- Pay for performance payment model

- Earn money based on how well they take care of patients

- Promotes following 'good care' guidelines for conditions

National Federation of Independent Business vs. Sebelius (2012)

- Can the law require citizens to purchase health insurance?

- Decisions upheld (ACA won)

- The individual mandate is within the federal government's taxation power

Burwell vs. Hobby Lobby (2014)

- Can the law require all employers to cover contraceptives?

- Hobby Lobby won (ACA lost)

- Recognize a corporation's claim of religious belief, allowing private corporations the option not to include contraceptive benefits in their group plans

- Insurance company has to use a separate benefit not funded by the company for contraceptives (a whole different insurance card)

King vs. Burwell (2015)

- Are state and federal insurance exchanges the same?

- Decision upheld (ACA won)

- Subsidies regardless of federal vs. state exchange

- Originally in ACA, the states were supposed to create marketplaces -> tried to get the ACA repealed because of this discrepancy

Summary of major changes in the ACA

- Created the health insurance marketplace

- Provided tax credits (subsidies) for people between 100-400% FPL

- Expanded Medicaid coverage for people <138% FPL

- Prohibit coverage denial for pre-existing conditions

- Eliminate annual and lifetime limits on essential coverage

- Provide full coverage of contraceptive methods and counseling

- Closed the Medicare Part D doughnut hole

- Mandate insurance covering free preventative health care

- Tied hospital performance to reimbursement

- Provided incentives for accountable care organizations