The Affordable Care Act (ACA) was passed into law in 2010 by President Barack Obama. Provisions of the health care act were intended to extend coverage to millions of Americans that were uninsured, lower health care costs, improve efficiency of the health care system, and to eliminate denial of coverage to Americans based on pre-existing conditions (Health Insurance.org). This paper will outline the impact the ACA has had on health care organization and finance, explain how the ACA has incorporated social determinants of health into health policy, and outline the proposed changes to the ACA under our current administration.
The Affordable Care Act encourages health care providers to form new organizational arrangements. According to Blumenthal, Abrams, & Nuzum (2018) these arrangements are called Accountable Care Organizations (ACO) which are intended to promote integration and coordination of ambulatory, inpatient, and postacute care services and to take responsibility for the cost and quality of care for a defined population of Medicare beneficiaries (p. 2451). An incentive for physicians who create these organizations falls under the Medicare Shared Savings Program (MSSP) when providers improve or maintain the quality of care, they can share part of the savings they achieve (Blumenthal, Abrams, & Nuzum, 2018).
With the expansion of the ACA in 2014, millions of Americans were able to get health insurance through the expansion of Medicaid which increased health care costs to 5.3% from 2.9% (Weiner, Marks, & Pauly, 2017). According to Abramowitz & O' Hara (2015) the ACA sets maximum limits on how much consumers with health insurance coverage can be required to pay out-of-pocket annually for their medical care based on their income beginning in 2014 (p. 197). In 2013, it was estimated that provider's uncompensated care costs were between $74.9 billion and $84.9 billion. The amount of uncompensated costs, were offset by government payments designed to cover the costs (Coughlin, Holahan, Caswell, & McGrath, 2014). According to Coughlin, Holahan, Caswell, & McGrath (2014) Medicaid and Medicare were the largest sources of such government payments, providing $13.5 billion and $8.0 billion, respectively. Anticipating fewer uninsured people and lower levels of uncompensated care, the Affordable Care Act reduces certain Medicare and Medicaid payments. In states that have not adopted the Medicaid expansion, cuts in government funding could pose challenges to some providers (Coughlin, Holahan, Caswell, & McGrath, 2014).
Social determinants of health (SDH) are the conditions in which people are born, grow, live, and age (Leong & Roberts, 2013). Leong & Roberts (2013) go on to state Racism, poverty, unsafe neighborhoods, and lack of education are some of the many SDH that create health inequity through effects such as elevated stress levels, higher rate of uninsured patients, and less access to healthy foods. The ACA incorporated SDH into health policy with a two-pronged approach. First, it encourages action at an individual level with funding for public information campaigns that educate people in the community on how to make healthier diet choices with the creation of an Internet portal that allows individuals to track their own health. However, Leong & Roberts (2013) recognize a downfall stating the ACA fails to recognize that many low-income neighborhoods are food deserts, where fresh fruits and vegetables are scarce and processed and shelf-stable foods are more abundant, which can lead to poor nutritional health. The ACA SDH is addressing the average American as opposed to the especially disadvantaged population (Leong & Roberts, 2013).
Second, the ACA created The Community Transformation Grants to serve as a tool to improve the holistic well-being of marginalized communities (Coughlin, Holahan, Caswell, & McGrath, 2014). The guidelines for this grant call for neighborhood safety as well as an underlying foundation to increase healthy living. However, all cities have populations that are more susceptible to SDH than others and these grants are not created equal for all states (Leong & Roberts, 2013). The Community Transformation Grants recognize SDH nationally, however, according to Leong & Roberts (2013) these relatively small grants are not standard for all states and their communities; instead, communities with the resources to apply for the grants are not guaranteed to have a winning application. Which then leads one to believe that community responsibility to reduce SDH under the ACA only stretches so far.
Prior to President Trump being sworn into office he stated he wanted to repeal and replace the ACA. He has been successful at making changes that will affect millions of Americans. According to Winfield (2018) The ACA created two subsidies to help low-income consumers afford marketplace plans: premium tax credits and cost-sharing reductions (CSR) to assist with deductibles and other out-of-pocket costs. In 2017, the Trump administration ended funding of the subsidies. Winfield goes on to state To offset the end of CSR reimbursements, most insurance companies raised premiums on silver plans, the only marketplace plans that offered cost-sharing reductions. According to Jaffe (2017) the ACA also forbids insurers from denying coverage to people with a history of health problems. According to PBS News Hour (2018) Trump signed an executive order aimed at giving people who buy their own insurance easier access to different types of health plans that were limited under the ACA rules (Analysis: What you need to know about Trump's changes to the health law). According to Winfield (2018) This executive order will attract healthier people seeking to pay less for insurance due to the fact that they offer less benefits but they will have to pay more out-of-pocket while at the same time decreasing the number of Americans sharing the insurance costs of other enrollees making premiums increase (p. 23). Additionally, Trump's executive order will allow insurance companies to deny coverage to Americans with pre-existing conditions (PBS News Hour, 2018).
The Trump administration also changed the 2018 annual open enrollment period, cutting it down to six weeks when enrollees previously had twelve and making it harder for people to buy insurance after the six-week open enrollment period closed (Rovner, 2018). It was stated by Rovner (2018) that, under Trump's administration, the new rules would reduce the number of people who game the system' by waiting until they need care to sign up for coverage (This ACA timeline illustrates how the health law has been changed since Trump took office). Rovner (2018) also outlines an additional change made under Trump's administration the advertising budget will be cut 90% for the coming enrollment season and programs that provide help to people signing up will be cut by 41%. Officials tell reporters that the programs are ineffective and people are already aware of the health law logistics, something public opinion polls suggests is not the case.
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