affordable care act

pubhlth

Which of the four main problems of the health care system does the ACA cover?

Main four problems:

1. cost of care

2. access to coverage and care

3. quality and accountability

4. racial and economic disparities

Answer: Access to coverage and care

However, the ACA addresses the other problems in small or indirect ways

• total and per capita spending on health is unsustainable

Large numbers of Americans are uninsured

nonelderly unisured = 25.6 million in 2022 = 9.6% of US population

What was the ACA designed to expand?

insurance access

Groups that faced barriers to insurance coverage before the ACA:

• young adults

  • excluded from parents insurance after 19 years old (22 if student)

• people with pre-existing conditions

  • could be denied insurance if they had a health condition prior to the start of a new insurance plan

• childless adults

  • not eligible for medicaid, no matter the income level

• very sick individuals

  • could face limits on coverage → limits on annual or lifetime coverage

ACA successfully decreased the uninsured rate

affording care is challenging, esp for working class and historically disenfranchised individuals

ex. americans putting off medical treatment in 2019 because of costs

Why was the ACA an unfulfilled promise?

political and legal challenges have diminished the ACA, especially its ability to provide access to coverage for low-income individuals

components of the ACA

• built on the existing models of coverage (ex romneycare in massachusetts and obamacare)

ACA reformed health insurance industry but left fundamental structure in place

ACA does not (and never meant to)… (3 items)

• create single payer or government sponsored care

• eliminate health insurance companies

• make people change doctors or other health care providers

the ACA created hundreds of regulations and administrative rules by various agencies within the department of health and human services

• ex. center for consumer information and insurance oversight

• centers for medicare and medicaid services

• health services resources administration

• food and drug administration

• centers for disease control and prevention

ACA TITLES

1. quality, affordable health care for all americans (most controversial)

2. the role of public programs (most controversial)

3. improving the quality and efficiency of health care (component of PH importance)

4. prevention of chronic disease and improving public health (component of PH importance)

5. health care workforce

6. transparency and program integrity

7. improving access to innovative medical therapies

8. community living assistance services and supports

9. revenue provisions

10. strengthening quality affordable care

ACA TITLE 1: quality, affordable health care for all americans

• employer mandates

  • most americans insurance via employer-sponsored plans (50%)

  • dependents can stay on parents’ insurance until 26 years old

  • penalties for companies with 50+ employees who don’t provide insurance

  • tax credits for companies with less than 50 employees who provide insurance

• insurance industry reforms (designed to end insurance company efforts to avoid adverse selection)

  • guaranteed issue (cannot exclude people with pre-existing conditions

  • no rescission (cannot kick sick people off of their plans)

  • no annual or lifetime caps to care

  • adverse selection: insurance companies acceptance of applicants who are at greater risk of poor health

    • individuals have an ‘adverse’ effect on insurance companies b/c insurance premiums are calculated on the basis of policy holders being in average (good) health

• individual mandate

  • everyone must have health insurance or pay a penalty

    • exceptions: financial hardship, those who don’t pay SS for religious reasons, indigenous tribes, undocumented immigrants, uninsured for period of less than 3 months

  • requiring everyone to have health insurance offsets the additional costs health insurance companies feared incurring due to mandated health insurance reforms (recission, etc.)

  • gov assistance in affording health insurance through new “marketplace” for purchasing publicly subsidized private insurance and expansion of public programs

    • insurance marketplaces (exchanges) are for people to purchase insurance; individuals and small employee groups can purchase private insurance plans through insurance exchanges

      • three types of marketplaces (exchanges):

        • state, federal, state/fed partnership

      • subsidies and tax credits available to offset costs

        • for individuals making up to 400% of federal poverty level (62,000/year for an individual in 2025)

• insurance subsidies for low-income persons through exchanges

  • subsidies and tax credits available to offset costs

    • for individuals making up to 400% of federal poverty level (62,000/year for an individual in 2025)

ACA TITLE 2: role of public programs

• medicaid

  • expansion of medicaid is central component of ACA

  • pre-ACA: childless adults not eligible for medicaid despite income level; and amount of coverage based on “category”

  • post-ACA: medicaid will cover everyone under the 133% of FPL ($20815 for individual; $42760 for family of 4 in 2025)

• indian health service

• community health centers

Other MAJOR FEATURES of ACA

• essential health benefits package

  • set of 10 categories of services health insurance plans must cover

  • includes: outpatient care, hospitalization, emergency services, maternity and newborn care, pediatric care, mental health and addiction treatment, prescription drugs, rehab services and devices, laboratory services, clinical preventive services (ex vaccinations)

• limit on annual out-of-pocket spending

  • caps on the amount people pay in deductibles, copayments, and coinsurance annually

    • in 2024: individual plan = 9450; family plan = 18900

What did the ACA address in regards to public health?

• insurance plans must cover evidence-based preventive services

  • ex. immunizations, smoking cessation counseling, cancer screening

• creation of prevention and public health fund

  • nation’s first dedicated federal funding for prevention

• created national prevention, health promotion, and public health council

  • promote healthy policies and establish a national prevention and health promotion strategy

challenges to ACA

• controversial and politically divisive

• national federation of independent business v. sebelius (2012)

  • penalties imposed enforcing individual mandate are a tax and are allowable under government’s authority

  • ruled that medicaid expansion provision as unconstitutional

    • threatened states with the loss of their ecisting medicaid funding if they declined to comply with the expansion

  • allowed states to choose whether or not to expand medicaid

• king v. burwell (2015)

  • scotus ruled that people were eligible for subsidies and tax credits whether they bought their insurance via a state or federal insurance exchange

• dozens of votes to repeal

ACA today

• successful in reducing the number of uninsured americans

  • ~30 million individuals gained insurance following implementation of ACA because..

    • medicaid expansion

    • private insurance market subsidies

    • stay on parents’ plan till 26

• majority of states expanded medicaid coverage

  • 41 states adopted medicaid expansion (including dc)

  • 10 states have not adopted expansion

millions more could be covered if more state expanded medicaid coverage

uninsured individuals include…

• low-income on medicaid non-expansion states

• those unable to afford marketplace coverage

• undocumented immigrants

• documented, low-income immigrants in the US less than 5 years

How Trump weakened the ACA…

• eliminated individual mandate

  • no federal penalty for not having health insurance

• supported work requirements for medicaid beneficiaries

• ended subsidies to insurers participating in exchanges

  • payments meant to motivate insurance companies to be in exchanges and keep premiums down

• assistance to navigate exchanges cut

  • cut federal funding for navigators

  • no advertising for open enrollment

most americans support ACA provisions, regardless of political affiliation

tax credits supported by both parties

marketplace coverage meant to insure those with incomes just above those on medicaid

differences between medicaid and medicare

ACA expanding healthcare coverage (shortened ver)