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The U.S. spends more money per capita on healthcare when compared to other developed countries. Both state- and federal-level alternatives highlight access to care and cost of care. The ACA has impacted all health policy options. Review Case 5, “Key Features of the Affordable Care Act, by Year,” (
ATTACHMENT INCLUDED
). Then, review alternate scholarly sources (scholarly health policy journals) and discuss the following questions in 250 words:
· Are the key issues of the law highlighted? Provide a rationale.
· What are the key changes to the implementation of the ACA over the years?
· What are some of the debates concerning the ACA? Provide scholarly research.
REFERENCE FOR ARTICLE
McLaughlin, C. P., & McLaughlin, C. D. (2014). Health Policy Analysis: An interdisciplinary approach (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers. Print ISBN: 978128403777
• The tendency of market systems to maximize consumption
Thus we see governments adopting a confusing and seemingly inconsistent
array of measures designed to deal with these concerns. For example,
resources go out to enhance access to services, expanding the supply of
providers and technology, at the same time that other programs seek to
constrain consumption. No wonder professionals caught up in this
maelstrom sometimes feel discouraged. Still, most professionals persevere
and reap the intellectual and personal rewards of their craft. They continue
to balance the interests of their patients and their organizations
successfully.
All of this reflects the Chinese curse: “May you live in interesting
times.”
Case 5 Key Features of the Affordable Care Act, by Year
(Abridged from HealthCare.gov)
The following time line describes the key features of the ACA and the
year of implementation as provided by the HealthCare.gov website
(HealthCare.gov, 2013).
2010
New Consumer Protections
• Putting information for consumers online. The law provides for
sites where consumers can compare health insurance coverage
options and pick the coverage that works for them.
• Prohibiting denying coverage of children based on preexisting
conditions. New rules to prevent insurance companies from
denying coverage to children under the age of 19 due to a
preexisting condition.
• Prohibiting insurance companies from rescinding coverage. In
the past, insurance companies could search for an error, or other
technical mistake, on a customer’s application and use this error
to deny payment for services when he or she got sick. The health
care law makes this illegal.
• Eliminating lifetime limits on insurance coverage. Insurance
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companies are prohibited from imposing lifetime dollar limits on
essential benefits, like hospital stays.
• Regulating annual limits on insurance coverage. Under the law,
insurance companies’ use of annual dollar limits on the amount of
insurance coverage a patient may receive will be restricted for
new plans in the individual market and all group plans. In 2014,
the use of annual dollar limits on essential benefits like hospital
stays will be banned for new plans in the individual market and all
group plans.
• Appealing insurance company decisions. The law provides
consumers with a way to appeal coverage determinations or
claims to their insurance company and establishes an external
review process.
• Establishing consumer assistance programs in the states.
Under the law, states that apply receive federal grants to help set
up or expand independent offices to help consumers navigate the
private health insurance system.
Improving Quality and Lowering Costs
• Providing small business health insurance tax credits. Up to 4
million small businesses are eligible for tax credits to help them
provide insurance benefits to their workers. The first phase of this
provision provides a credit worth up to 35% of the employer’s
contribution to the employees’ health insurance. Small non-profit
organizations may receive up to a 25% credit.
• Offering relief for 4 million seniors who hit the Medicare
prescription drug “donut hole.” An estimated 4 million seniors
will reach the gap in Medicare prescription drug coverage known
as the “donut hole” this year. Each eligible senior will receive a
one-time, tax-free $250 rebate check.
• Providing free preventive care. All new plans must cover certain
preventive services, such as mammograms and colonoscopies,
without charging a deductible, copay, or coinsurance.
• Preventing disease and illness. A new $15 billion Prevention and
Public Health Fund will invest in proven prevention and public
health programs that can help keep Americans healthy—from
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smoking cessation to combating obesity.
• Cracking down on health care fraud. The new law invests new
resources and requires new screening procedures for health care
providers to boost these efforts and reduce fraud and waste in
Medicare, Medicaid, and Children’s Health Insurance Program
(CHIP).
Increasing Access to Affordable Care
• Providing access to insurance for uninsured Americans with
preexisting conditions. The Pre-Existing Condition Insurance
Plan provides new coverage options to individuals who have been
uninsured for at least 6 months because of a preexisting condition.
States have the option of running this program in their state. If a
state chooses not to do so, a plan will be established by the
Department of Health and Human Services in that state.
• Extending coverage for young adults. Young adults will be
allowed to stay on their parents’ plan until they turn 26.
• Expanding coverage for early retirees. To preserve employer
coverage for early retirees until more affordable coverage is
available through the new exchanges by 2014, the new law creates
a $5 billion program to provide needed financial help for
employment-based plans to continue to provide valuable coverage
to people who retire between the ages of 55 and 65, as well as
their spouses and dependents.
• Rebuilding the primary care workforce. There are new
incentives in the law to expand the number of primary care
doctors, nurses, and physician assistants. These include funding
for scholarships and loan repayments for primary care doctors and
nurses working in underserved areas. Doctors and nurses
receiving payments made under any state loan repayment or loan
forgiveness program intended to increase the availability of health
care services in underserved or health professional shortage areas
will not have to pay taxes on those payments.
• Holding insurance companies accountable for unreasonable
rate hikes. The law allows states that have, or plan to implement,
measures that require insurance companies to justify their
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premium increases will be eligible for $250 million in new grants.
Insurance companies with excessive or unjustified premium
exchanges may not be able to participate in the new health
insurance exchanges in 2014.
• Allowing states to cover more people on Medicaid. States will
be able to receive federal matching funds for covering some
additional low-income individuals and families under Medicaid
for whom federal funds were not previously available. This will
make it easier for states that choose to do so to cover more of their
residents.
• Increasing payments for rural health care providers. The law
provides increased payment to rural health care providers to help
them continue to serve their communities.
• Strengthening community health centers. The law includes new
funding to support the construction of and expand services at
community health centers.
2011
Improving Quality and Lowering Costs
• Offering prescription drug discounts. Seniors who reach the
coverage gap will receive a 50% discount when buying Medicare
Part D covered brand-name prescription drugs. Over the next 10
years, seniors will receive additional savings on brand-name and
generic drugs until the coverage gap is closed in 2020.
• Providing free preventive care for seniors. The law provides
certain free preventive services, such as annual wellness visits and
personalized prevention plans, for seniors on Medicare.
• Improving health care quality and efficiency. The law
establishes a new Center for Medicare & Medicaid Innovation
that will begin testing new ways of delivering care to patients.
Additionally, by January 1, 2011, the Department of Health and
Human Services (HHS) will submit a national strategy for quality
improvement in health care, including by these programs.
• Improving care for seniors after they leave the hospital. The
Community Care Transitions Program will help high-risk
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Medicare beneficiaries who are hospitalized avoid unnecessary
readmissions by coordinating care and connecting patients to
services in their communities.
• Introducing new innovations to bring down costs. The
Independent Payment Advisory Board will begin operations to
develop and submit proposals to Congress and the president
aimed at extending the life of the Medicare Trust Fund. The board
is expected to focus on ways to target waste in the system and
recommend ways to reduce costs, improve health outcomes for
patients, and expand access to high-quality care.
Increasing Access to Affordable Care
• Increasing access to services at home and in the community.
The Community First Choice Option allows states to offer home
and community-based services to disabled individuals through
Medicaid rather than institutional care in nursing homes.
Holding Insurance Companies Accountable
• Bringing down health care premiums. The law generally
requires that at least 85% of all premium dollars collected by
insurance companies for large employer plans are spent on health
care services and health care quality improvement. For plans sold
to individuals and small employers, at least 80% of the premium
must be spent on benefits and quality improvement. If insurance
companies do not meet these goals, because their administrative
costs or profits are too high, they must provide rebates to
consumers.
• Addressing overpayments to big insurance companies and
strengthening Medicare Advantage. Today, Medicare pays
Medicare Advantage insurance companies over $1,000 more per
person on average than is spent per person in traditional Medicare.
This results in increased premiums for all Medicare beneficiaries,
including the 77% of beneficiaries who are not currently enrolled
in a Medicare Advantage plan. The law levels the playing field by
gradually eliminating this discrepancy. People enrolled in a
Medicare Advantage plan will still receive all guaranteed
Medicare benefits, and the law provides bonus payments to
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Medicare Advantage plans that provide high-quality care.
2012
Improving Quality and Lowering Costs
• Linking payment to quality outcomes. The law establishes a
hospital value-based purchasing (VBP) program in traditional
Medicare. This program offers financial incentives to hospitals to
improve the quality of care. Hospital performance is required to
be publicly reported, beginning with measures relating to heart
attacks, heart failure, pneumonia, surgical care, health care–
associated infections, and patients’ perception of care.
• Encouraging integrated health systems. The new law provides
incentives for physicians to join together to form ACOs. These
groups allow doctors to better coordinate patient care and improve
the quality, help prevent disease and illness, and reduce
unnecessary hospital admissions. If ACOs provide high-quality
care and reduce costs to the health care system, they can keep
some of the money that they have helped save.
• Reducing paperwork and administrative costs. The new law
will institute a series of changes to standardize billing and requires
health plans to begin adopting and implementing rules for the
secure, confidential, electronic exchange of health information.
• Understanding and fighting health disparities. To help
understand and reduce persistent health disparities, the law
requires any ongoing or new federal health program to collect and
report racial, ethnic, and language data.
Increasing Access to Affordable Care
• Providing new, voluntary options for long-term care
insurance. The law creates a voluntary long-term care insurance
program—called CLASS—to provide cash benefits to adults who
become disabled. [Note: On October 14, 2011, Secretary Sebelius
transmitted a report and letter to Congress stating that the
department does not see a viable path forward for CLASS
implementation at this time.]
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2013
Improving Quality and Lowering Costs
• Improving preventive health coverage. To expand the number
of Americans receiving preventive care, the law provides new
funding to state Medicaid programs that choose to cover
preventive services for patients at little or no cost.
• Expanding authority to bundle payments. The law establishes a
national pilot program to encourage hospitals, doctors, and other
providers to work together to improve the coordination and
quality of patient care. Under payment “bundling,” hospitals,
doctors, and providers are paid a flat rate for an episode of care
rather than the current fragmented system where each service or
test or bundles of items or services are billed separately to
Medicare.
Increasing Access to Affordable Care
• Increasing Medicaid payments for primary care doctors. The
act requires states to pay primary care physicians no less than
100% of Medicare payment rates in 2013 and 2014 for primary
care services. The increase is fully funded by the federal
government.
• Open enrollment in the health insurance marketplace begins.
Individuals and small businesses can buy affordable and qualified
health benefit plans in this new transparent and competitive
insurance marketplace.
2014
New Consumer Protections
• Prohibiting discrimination due to preexisting conditions or
gender. The law prohibit(s) insurance companies from refusing to
sell coverage or renew policies because of an individual’s
preexisting conditions. Also, in the individual and small group
market, the law eliminates the ability of insurance companies to
charge higher rates due to gender or health status.
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• Eliminating annual limits on insurance coverage. The law
prohibits new plans and existing group plans from imposing
annual dollar limits on the amount of coverage an individual may
receive.
• Ensuring coverage for individuals participating in clinical
trials. Insurers will be prohibited from dropping or limiting
coverage because an individual chooses to participate in a clinical
trial. Applies to all clinical trials that treat cancer or other life-
threatening diseases.
Improving Quality and Lowering Costs
• Making care more affordable. Tax credits will become available
for people with income between 100% and 400% of the poverty
line who are not eligible for other affordable coverage. (In 2010,
400% of the poverty line comes out to about $43,000 for an
individual or $88,000 for a family of four.) The tax credit is
advanceable. It is also refundable. Individuals may also qualify
for reduced cost-sharing (copayments, coinsurance, and
deductibles).
• Establishing the health insurance marketplace. If your
employer does not offer insurance, you will be able to buy it
directly in the health insurance marketplace. Individuals and small
businesses can buy affordable and qualified health benefit plans in
this new transparent and competitive insurance marketplace. The
marketplace will offer you a choice of health plans that meet
certain benefits and cost standards.
• Increasing the small business tax credit. In this phase, the credit
is up to 50% of the employer’s contribution to provide health
insurance for employees. There is also up to a 35% credit for
small nonprofit organizations.
Increasing Access to Affordable Care
• Increasing access to Medicaid. Americans who earn less than
133% of the poverty level (approximately $14,000 for an
individual and $29,000 for a family of four) will be eligible to
enroll in Medicaid. States will receive 100% federal funding for
the first 3 years to support this expanded coverage, phasing to
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90% federal funding in subsequent years.
• Promoting individual responsibility. Under the law, most
individuals who can afford it will be required to obtain basic
health insurance coverage or pay a fee to help offset the costs of
caring for uninsured Americans. If affordable coverage is not
available to an individual, he or she will be eligible for an
exemption.
2015
Improving Quality and Lowering Costs
• Paying physicians based on value not volume. Physicians will
see their payments modified so that those who provide higher
value care will receive higher payments than those who provide
lower quality care.
Source: Modified from: Key Features of the Affordable Care Act by Year. U.S. Department of
Health & Human Services. http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html
Discussion Questions
1. The material presented in this case was abridged from a document
provided by the Obama administration on the HealthCare.gov
website. Does it fairly represent the key issues in the law?
2. What do you think was behind the phasing in of the various
provisions of the law? Would you have phased them in differently?
3. How do these provisions represent the three visions of how health
policy should work?
4. How has the implementation of this time line changed over time:
a. After the Supreme Court ruled on the constitutionality of various
provisions of the ACA in 2013,
b. As the Administration experienced problems with the computer
systems it had put in place, and
c. As various groups requested temporary or permanent relief from
the law’s implementation requirements?
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http://www.hhs.gov/healthcare/facts/timeline/timeline-text.html
http://HealthCare.gov
