Affordable Care Act Discussion Response to discussion The Affordable Care Act (ACA) was enacted in 2010 and included many provisions to help reform health

Affordable Care Act Discussion Response to discussion The Affordable Care Act (ACA) was enacted in 2010 and included many provisions to
help reform health care coverage, and it also outlined key provisions regarding cost
containment, wellness and prevention, tax changes, as well as changes to Medicaid
and Medicare. In Primary Care, the Medicare provision related to providing high-need
Medicare enrollees with primary care options in their home impacts my organization
(Knickman & Elbel, 2019). As a nurse, if I feel that a patient needs more care, typically
when they have multiple chronic and complex medical conditions, I can refer them to
home-based medicine, where a team of NP’s, RN’s and other support staff are able to
provide primary care to these patients in their homes. This provision also states that
providers share in savings if this program can reduce or prevent hospital admissions,
improve outcomes, or increase patient satisfaction (Knickman & Elbel, 2019). I think this
is a successful provision of the ACA, as it does attempt to provide care that is cost
effective by caring for the patient in the home and trying to prevent costlier care related
to hospital visits or admissions.
Another major provision in the ACA requires coverage or preventative services, and it
removed cost-sharing for preventative services in Medicare and Medicaid – as many
patients were previously paying a portion of the preventative services costs (Knickman
& Elbel, 2019). In primary care, preventative visits, screenings and tests are done often.
With increased health care coverage provided by the ACA, and more patients coming in
for preventative care, as well as for other services, is likely one of the causes of the
physician shortage and burnout in primary care (Manchikanti, Helm Ii, Benyamin, &
Hirsch, 2017). On one hand, I think it is important that every patient has health care
coverage and access to preventative medicine, but there did not seem to be
considerations for the current and upcoming primary care physician shortage and
potential burden on the health care system.
Lastly, under the wellness and prevention provision, it is stated that employers can offer
rewards to employees for participating in a wellness program through work that meets
certain standards (Knickman & Elbel, 2019). At my organization we have a large
wellness program, and it was actually built into our contract that if we participate in
wellness programs we can save money on our office co-pays for certain medical visits.
The ACA was created to increase the number of people with health insurance, improve
the quality of that care, and reduce health care costs (Manchikanti et al., 2017). While
the ACA was successful in enrolling previously uninsured people, approximately 20
million, this was mainly due to Medicaid expansion, as approximately 13 million of those
new enrollees qualified for Medicaid, and not through private or employer based
insurance (Manchikanti et al., 2017). However, when the ACA was enacted, around 6
million people lost their insurance because their employers could not afford to adhere to
the new regulations (Manchikanti et al., 2017).
There are also issues relating to cost and the ACA. There are many arguments that
state the ACA has not been working for the middle class. This population does not
qualify for Medicaid based on income, but is often burdened with high deductible plans
and large co-pays, which increases health care costs for them (Manchikanti et al.,
2017). This population also does not benefit from tax credits, and has a difficult time
affording health care coverage in the private market (Knickman & Elbel, 2019). I do
think it is difficult to define if the ACA is working or not. There are parts of it that are
working, like increasing the number of people who have the ability to get health
insurance, but there does seem to be parts that are not working, like increasing costs
for consumers.
References
Knickman, J.R., & Elbel, B (Eds). (2019). Jonas & Kovner’s Health care delivery in the
United States (12th ed). Springer Publishing. Retrieved from
https://www.springerpub.com/media/springer-downloads/9780826172723/Health-CareDelivery-in-the-United-States-12E_Major-Provisions-of-the-ACA.pdf
Manchikanti, L., Helm Ii, S., Benyamin, R. M., & Hirsch, J. A. (2017). A Critical Analysis
of Obamacare: Affordable Care or Insurance for Many and Coverage for Few?. Pain
physician, 20(3), 111–
138.https://www.painphysicianjournal.com/current/pdf?article=NDMwMg%3D%3D&jour
nal=104
The Affordable Care Act (ACA) is the most complicated piece of federal legislation
affecting the U.S. health system since the passing of the original Medicare and
Medicaid programs in the 1960s (Jonas & Kovner, n.d.). The ACA law was passed in
2010 to help increase the number of people covered by health insurance. Part of the
original law required all states to expand their Medicaid programs, which was then
amended in 2012 to allow states to voluntarily expand the program.
There are many provisions of the ACA. One that impacts my organization is
Improving Quality/Health System Performance. The goal of this provision was to
establish a hospital value-based purchasing program in Medicare. Hospitals are now
paid based on quality measure performance (Jonas & Kovner, n.d.). Another provision
is cost containment, specifically potentially preventable readmissions. The goal of this
provision was to reduce Medicare payments that would otherwise be made to hospitals
by paying a percentage for preventable hospital readmissions. Another provision under
cost containment is a 1% reduction in Medicare payments to hospitals for hospitalacquired conditions (Jonas & Kovner, n.d.).
All of these provisions affect my facility. We use the Hospital Consumer
Assessment of Healthcare Providers and Systems survey (HCAHPS) to show our
patient satisfaction scores. We previously obtained this information from Press Ganey,
but now have moved to NRC Health. These scores are linked to reimbursement
penalties for hospitals that fail to meet patient satisfaction metrics (Strate, 2018). Scores
are used to compare hospitals to other hospitals and to identify areas that need
improvement. Poor survey results could result in hospitals getting fewer
reimbursements (Strate, 2018). We collect this data every month and make sure that
our scores are meeting our goal.
We are also faced with financial penalties for both high re-admission rates as
well as hospital-acquired conditions (falls, infections, etc.). Hospitals with a high
readmission rate or high occurrence of hospital-acquired conditions will have a 1%
reduction in their Medicaid payment or possibly more (Strate, 2018). We also pull data
on our potentially preventable readmissions along with our hospital-acquired conditions
(i.e., falls, MRSA, CDiff, hip infections) monthly. Some of this is reportable to the state.
We keep a close eye on this data.
Is the ACA working? That’s a good question. According to Emanuel (2019), from
2010-2017, the ACA reduced health care by $2.3 trillion. This reduction was done while
creating health care coverage to more than 20 million uninsured Americans. The
problem is it’s hard for Americans to see this reduction, and there are reasons why.
First, employers are putting the cost of health insurance onto the employees.
Employees’ health premiums have gone up way more than employers. The next reason
is that drug prices are rising, and Americans copays are becoming higher and higher.
The last reason is that more Americans have high deductible health plans (Emanuel,
2019). The question as to whether the ACA is working is not black and white. It did help
previously uninsured Americans get health insurance, and it has reduced health care
spending by $2.3 trillion. The issue is that is has created a primary care physician
shortage; it has cost the American people more due to increased premiums for
insurance, and it has created high deductible health plans. This question cannot be
answered with a yes or no. It is much more complex than that.
Resources
Emanuel, E. J. (2019, March 22). Name the much-criticized federal program that has
saved the U.S. $2.3 trillion. Hint: it starts with Affordable. In STAT News. Retrieved
from https://www.statnews.com/2019/03/22/affordable-care-act-controls-costs/
Jonas & Kovner. (n.d.). Major provisions of the Patient Protection and Affordable Care
Act of 2010. Retrieved from https://www.springerpub.com/media/springerdownloads/9780826172723/Health-Care-Delivery-in-the-United-States-12E_MajorProvisions-of-the-ACA.pdf
Strate, C. (2018, March 20). How does patient satisfaction impact reimbursement?.
In Access. Retrieved from https://www.accessefm.com/blog/how-does-patientsatisfaction-impact-reimbursement
Compare and contrast the major provisions of the ACA and their impact in your
organization (if currently unemployed, describe the major provisions that impact
you).
In 2010, former President Obama signed into action a health care reform bill, the
Affordable Care Act (ACA), which is also known to most as Obama Care. ACA will
require most U.S citizens and legal residents to have health insurance, those without
coverage will have to pay a tax penalty of the greater $695 per year up to a max of
three times that amount, $2085 per family or a 2.5% of their household income.
Medicaid was expanded to all individuals under the age of 65 with incomes up to 133%
of the federal poverty level. One mandate was to establish a grant program that
supports the delivery of evidence and community-based prevention and wellness
services that were aimed at strengthening prevention activities, reducing chronic
disease rates, and addressed health disparities, especially in rural areas. For skilled
nursing facilities they required SNF under Medicare and nursing facilities under
Medicaid to disclose information regarding ownership, accountability requirements, and
expenditures. Standardized information is to be published on their website so Medicare
enrollees can compare the different facilities (Jonas & Kovner, n.d).
At my facility, we deal a lot with Medicare and Medicaid residents. I have noticed that
depending on type of insurance, depends on the type of services, medications, and
testing they are able to receive. If a resident has Medicare, or facility pays for
everything, if they need a lab test done asap and it is after our corresponding clinics lab
hours it would need to be sent to our local hospital after hours lab. If we have to do this
it will cost our facility $700, whereas if it went to the clinic it would be $300. When this
happens the company or physician will prolong the testing until it is able to be sent to
the clinic during business hours. Medications is a major issue with our facility. I had one
resident who was on paliperidone, an anti-psychotic medication for schizophrenia,
because he was on Medicare and we would have to pay for it, he received his injection
for it 2 weeks late because we had to battle our corporate office to get them to pay for
this medication for him. Even though he had Medicaid as secondary insurance we were
not able to bill Medicaid and he had to wait for authorization from our facility to receive
it. As for our corporations insurance plans, I do not receive their insurance plan due to
being a veteran, but I have seen a co-worker fight with the corporation to drop her
children and her current insurance plan that she buys through work because of the high
expense of it. She has to provide proof that she has a different insurance plan before
they will allow her to drop her plan through the company.
Evaluate whether or not the ACA is working (be sure to include facts from the
references included in this week’s content or additional resources rather than
opinion).
According to Obamacare pros and cons (2020), the biggest benefit of ACA is that it
slowed down the rise of health costs, this was done partly by providing insurance for
millions and making preventative care free. It required all insurance plans to cover 10
essential health benefits, which included treatment for mental health, addiction, and
chronic diseases. Individuals were no longer able to be denied coverage due to preexisting conditions. It eliminated lifetime and annual coverage limits. Children are able
to stay on their parents plans until they are 26 years old. States were required to set up
insurance exchanges or use a federal government exchange, which made it easier for
individuals to shop for their plans. Individuals that earned up to 400% of the poverty
level were able to receive tax credits on their premiums. Medicaid was expanded to
138% of the poverty level, which provided coverage to childless adults for the first time.
It eliminated the Medicare “doughnut hole” gap in coverage by 2020. Businesses with
over 50 workers must provide insurance, but they receive tax credits to help with the
costs. The congressional budget office originally estimated the ACA would reduce the
budget deficit by $143 billion by 2022. This would theoretically be accomplished in 3
days. First, it would reduce the government’s health care costs. Second, it raises taxes
on some businesses and higher income families. Third, it would shift the cost burdens to
health care providers and pharmaceutical companies. CBO has since revised these
estimates.
According to Obamacare pros and cons (2020), the cons of ACA are that 3-5 million
people lost employment-based insurance. Many businesses found it more cost effective
to pay the penalty and let employees buy their plan on the exchanges. Other small
businesses find they get better plans through exchanges that are ran by the state. 30
million individuals never had company plans and relied on private insurance plans.
Many insurance companies cancelled their plans because they did not cover the 10
essential benefits. Increased coverage raised overall health care costs in a short term
because many people started receiving preventive care and testing for conditions that
had been ignored for many years. People were taxed because they did not purchase
insurance. The number of individuals with insurance was estimated to drop by 4 million
in 2019, which could cost millions of dollars. In 2013 the ACA raised the income tax for
people whose incomes were above $200,000 for individuals and $250,000 for couples.
The rate was increased to 2.35%. These individuals would also pay an additional 3.8%
Medicare tax on investment income. The ability to deduct medical expenses increased
from 7.5% to 10% of their income. Rebates close the “doughnut hole” in Medicare D,
but prices for medications continue to increase, and for many the out-of-pocket expense
continue to rise. In 2022, insurance companies will be assessed a 40% excise tax on
“Cadillac” type health plans. Under the current definitions, these are the plans with an
annual premium over $10,200 for individuals and $27,500 for families. Many of these
plans are for high-risk pools, which include older workers or more dangerous jobs. Most
of the tax will be passed on to companies and employees, this will raise premiums and
deductibles and possibly lowering wages.
References:
Amadeo, K. (2020, April 8). Pros and Cons of Obamacare. Retrieved
from https://www.thebalance.com/obamacare-pros-and-cons-3306059
Jonas & Kovner. (n.d.). Major provisions of the Patient Protection and Affordable Care
Act of 2010. Retrieved from https://www.springerpub.com/media/springer-
downloads/9780826172723/Health-Care-Delivery-in-the-United-States-12E_MajorProvisions-of-the-ACA.pdf

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