The purpose of this paper is to discuss the importance of providing increased access to primary care and the expected impact of the 2010 Affordable Care Act on the delivery of primary care in the United States, extending current trends through the year 2023. Addressed topics will include a brief overview of the Affordable Care Act, current state of primary care and the impact of the Affordable Care Act upon primary care patients, providers and payers. The Affordable Care Act
In March 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA) into law. This law makes preventive care, including primary care, family planning and other services more accessible and affordable for many Americans.
According to the Center on Budget an Policy Priorities , the ACA would expand health care coverage to 32 million citizens who are currently uninsured. Expanded coverage of Medicaid and Medicare allows for increased inclusion of individuals who previously were not eligible for state and federal health insurance programs. The Medicaid expansion is 100% federally funded for the first three years (2014-2016) and at least 90% federally funded through 2022 and beyond (CBO, 2013).
Included in the law is health insurance reform that makes illegal preexisting condition clauses in health insurance coverage and provides coverage for young adults under a family health insurance plan.
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The uninsured and self employed would be able to purchase health insurance through state-based “exchanges”. Subsidies would be available to those who cannot afford to purchase insurance if they meet income requirements. Primary Care in the United States
In the United States medical practice was not regulated until the 20th Century. Medical care was provided by a “doctor” who may or may not have been trained at a medical school. Many doctors received no formal training, learning as apprentices. These early practitioners provided a multitude of medical services to an entire family including delivering babies, setting fractures, surgeries, diagnosing and dispensing medications. Through organizations such as the American Medical Association the practice of medicine became regulated.
These early pioneers were the early practitioners of primary care. Influenced by American ideals and desire for technology and wealth, the number of medical students choosing a path in primary care diminished in favor of specialty practice such as surgery, cardiology, radiology, etc. For several years there has been a decline in the United States primary care workforce. Primary care providers include general practitioners, general internal medicine practitioners, family physicians, physician assistants and nurse practitioners.
The United States healthcare system has been facing a decline in its primary care Affordable Care Act and Primary Care 4
workforce, infrastructure and access to primary care services for several years. According to research (Petterson,2013) a number of factors, including poor reimbursements to primary care providers, low comparative income, and poor quality of work life due to high patient loads, have contributed to more providers choosing to train and practice in specialty medicine. This trend has led to a shortage of primary care providers across the country, likely contributing to fragmented care, inappropriate use of specialists, and less emphasis on prevention. Patients
People who have access to a regular primary care physician are more likely than those who do not, to receive recommended preventive services and timely care for medical conditions before they become more serious and more costly to treat by visiting the emergency room instead of a primary care provider (Abrams, 2011). Patients are more likely to adhere to physician recommendations when seen by a primary care provider. Among low-income patients, access to primary care is associated with better preventive care, better management of chronic conditions, and reduced mortality.
Preventing illness is as much a part of primary care as is the diagnosis and treatment of health conditions. The Affordable Care Act provides positive incentives to encourage people to obtain preventive primary care services. Through provisions in the act, applying to Medicare and Medicaid beneficiaries, as well as the privately insured, the law eliminates coinsurance, deductibles, and co payments for approved preventive services Affordable Care Act and Primary Care 5
and tests, such as blood-pressure and cancer screenings, mammograms and Pap tests, and immunizations.
Studies have shown full coverage of preventive services with no patient cost, increases use of preventive screening services over time (Abrams, 2011). In a study of low-income patients, researchers found that even small incremental changes in co-payments had a substantial impact on the affordability and utilization of care. Included in the ACA is the concept of a patient “medical home.”
This is a primary care site that provides patients with timely access to care, including availability of appointments after regular office hours with patients to manage health conditions and prevent complications, coordinates all care, and engages in continuous quality improvement (Abrams, 2011). Primary care providers will be the coordinators of the medical home. These medical homes will also ensure greater coordination between the primary care site and local emergency departments. Primary Care Providers
With the ACA the total number of primary care office visits is expected to increase from the 462 million visits in 2008, to 565 million in 2015. Also expected is the need for an additional 52,000 primary care providers by 2025 due to insurance coverage expansion (Hofer, 2011).
The ACA will entice primary care providers to accept more of the newly covered by increasing Medicare and Medicaid payments for primary care services. There are two Affordable Care Act and Primary Care 6
provisions in the ACA that augment payments to primary care providers, one provides a bonus to providers whom participate in Medicare, the second increases reimbursements for Medicaid participation. The goal of these financial incentives is to stabilize and expand the existing primary care workforce. The Affordable Care Act invests an estimated $3.5 billion in the primary care provider bonus program from 2011 to 2016. As a result, Medicaid primary care physicians are estimated to gain an additional $8.3 billion in reimbursement between 2013 and 2019 (Abrams, 2011).
To address this growing shortage of primary care providers, the Affordable Care Act provides support of education and training for primary care providers and community health centers. The Affordable Care Act includes $1.5 billion authorized over 2011 to 2015 for the National Health Service Corps to provide scholarships and loan forgiveness for primary care physicians, nurse practitioners, and physician assistants practicing in health professional shortage areas (Abrams, 2011).
Other provisions that offer financial support for training new primary care physicians include more favorable loan repayment requirements for the federally supported Primary Care Loan Program and a loan repayment program for pediatric sub specialists and child or adolescent mental or behavioral health providers working in underserved areas. The necessary midlevel primary care practitioner is recognized through scholarships, loans, and loan repayment programs, as well as through the creation and expansion of training opportunities.
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The Affordable Care Act brings an unprecedented level of scrutiny and transparency to health insurance companies. The concept of an insurance exchange is a major component of the federal Affordable Care Act. An important component of the federal law is that individuals must have health insurance with federal subsidies to help them pay for it.
To improve access and protect patient rights, ACA introduces new commercial insurance standards, such as the removal of medical underwriting, elimination of lifetime limits, prohibition of pre-existing condition exclusions, and removal of cost-sharing for preventive services. Insurance plans will be required to cover essential health benefits which are defined under the ACA (Rosenbaum, 2011). Insurance companies expect significant changes in enrollment, demographics, and plan types.
Economic, behavioral, political, and strategic influences are expected to shape the changing insurance coverage landscape, according to a Department of Health and Human Services Report. Implications for insurance industry stakeholders are considerable, due to being regulated by state and federal government. Insurance companies and insurance trade publications are stating they will be forced to raise premiums due to ACA requirements, fess and taxes forced upon them ( DHHS,2013).
The ACA imposes an annual fee or excise tax on most businesses that provide health insurance, starting in 2014. The fee will be raised proportionately each year among Affordable Care Act and Primary Care 8
insurance providers based on their share of the health insurance market (DHHS, 2013). Certain insurers are exempt from federal excise tax, including public charities and social welfare organizations. In addition, nonprofit insurers that receive more than 80 percent of their gross revenue from government programs that target low-income individuals, seniors, and people with disabilities (including Medicare, Medicaid, and the Children’s Health Insurance Program) are not subject to the tax.
Supply and demand will determine how the excise tax is ultimately split between insurance companies and purchasers. Insurers have recently turned in strong financial results and thus are well positioned to bear some of the tax (DHHS, 2013). It is speculated they will pass a portion on to consumers. The Joint Committee on Taxation estimates that premiums subject to the fee will be 2 to 2½ percent higher than they would otherwise be.
The Congressional Budget Office estimates that ACA will slightly reduce premiums for employer-sponsored health insurance in the near future. For employers with more than 50 workers, CBO estimates that the law will reduce average premiums by up to 3 percent in 2016. For small employers, the estimated change in premiums ranges from an increase of 1 percent to a reduction of 2 percent .
It is important to note that the health insurance industry will gain millions of new enrollees in the next few years as a result of ACA. Insurance plans providing preventative health coverage will benefit financially by providing less expensive care for treatable Affordable Care Act and Primary Care 9
chronic conditions and early diagnosis on other medical conditions. Summary With the oncoming implementation of the Affordable Care Act the benefits of the plan encourage the active role of the primary care provider. The uninsured patient now has access to health care that will afford him a better quality of life and address the financial implications of a poorly managed health care system in the United States. The ACA provides a means to entice more into the field of primary care.
While it is in the early stages of scrutiny, the health insurance industry is a growing industry and is positioned to be profitable as a result of ACA, even with increased regulation. Conclusion
With the implementation of the Affordable Care Act, the United States is positioned to provide a more sustainable and stronger health care system, due in part to the primary care provisions provided with the ACA. The health care system outlined would provide expanded service for patients, improve
outcomes and quality and reduce future health care spending for the nation.
Abrams, M., Nuzum, R., Mika, S. and Lawlor, G. (2011, January). Realizing Health Reform’s Potential. The Commonwealth Fund. 1, 1-8. http://www.commonwealthfund.org/Publications/Issue-Briefs/2011/Jan/Strengthen-Primary-Care.aspx
Center on Budget and Policy Priorities. (2013, July). Status of the ACA Medicaid Expansion After Supreme Court Ruling. Retrieved from http://www.cbpp.org
Congressional Budget Office. (2013). CBO’s Estimate of the Net Budgetary Impact of the Affordable care Act’s Health Insurance Coverage Provisions Has Not Changed Much Over Time. (CBO Publication No. 144176). Washington, D.C. U.S. Government Printing Office. http://www.cbo.gov/publication/44176.
Department of Health and Human Services. (2013, February). Health Insurance Premium Increases in the Individual Market Since the Passage of the Affordable Care Act.
(DHHS. Research Brief). Washington, D.C. http://aspe.hhs.gov/health/reports/2013/RateIncreaseIndvMkt/rb.cfm
Hofer, A., Abraham, J., Moscovice, I. (2011, March). Expansion of Coverage under the Patient Protection and Affordable Care Act and Primary Care Utilization. Milbank Quarterly. 89(1): 69-89. http://www.milbank.org/publications/the-milbank-quarterly
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).
Petterson, S., Liaw, W., Phillips, R., Rabin, D., Meyers, D. and Bazemore, A. (2013). Projecting US Primary Care Physician Workforce Needs: 2010-2025. Annuals of
Medicine. 6, 503-509. http://annfammed.org/content/10/6/503.full
Rosenbaum, Sara. (2013, February). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports. 126, 130-135. http://www.publichealthreports.org/