We have all heard the adage, “the road to hell is paved with good intentions”. Hopefully this will not be the case for the new Patient Protection and Affordable Care Act. The first attempt for health care reform started as far back as President Roosevelt in the New Deal Era.1 Many presidents have tried and have also failed. What was so different about this legislation that allowed it to pass? This paper will discuss what the Patient Protection and Affordable Care Act (PPACA) provides for Americans, as well as the unintended consequences that may happen because of the act. Using the National Scorecard on U.S. Healthcare System Performance6, we will see how the U.S. compares to other countries. Lastly, we will take a look at the newly formed National Prevention Council, and the National Prevention Strategy, and its plan for moving health care from one of sickness to wellness.4
What is the Patient Protection and Affordable Care Act (PPACA)?
The Patient Protection and Affordable Care Act (PPACA) was signed into law in March of 2010. President Obama has done what others before him could not. I do think he borrowed ideas from Hillary Clinton’s, 2006, “Wellness Trust Act (Wellness Trust), Senator Tom Harkin’s, Healthy Lifestyles and Prevention Act of 2007, and his Healthy Workforce Act of 2007, as well as Senator Max Baucus’s, 2009 paper entitled, “Call to Action: Health Reform 2009”. 2 After reading the sincerity of these politicians and their staff, I did gain a more respectful attitude toward their efforts. Before my research, I thought all members of Congress just sat around all day and argued with each other.
If you paid any attention to the presidential debates, you would soon realize the Republicans and the Democrats offer different views on the purpose of the bill and what it means for the people. The Republicans saw this bill as another way for President Obama to “rob from the rich” and “give to the poor”. They felt that his agenda was more about nationalizing healthcare, and moving our country in the direction of socialism. The Republicans mantra was, it was a bad bill that would have “death panels” deciding who should live and who should die. The Democrats position was one that stated everyone would have access to free or affordable healthcare.
A 2009, USA Today article written by Nancy Pelosi and Steny Hoyer proclaimed, “Free mammograms, diabetes tests, and checkups for all”.3 They also stated that prevention would not only make us a healthier nation but would also save money.3 Just listening to these two opposing arguments leaves one with more questions than answers. I am in a conundrum, because I am a fiscal conservative, when it comes to matters of money, and a bleeding heart liberal when it comes to social issues. My research for this paper has enabled me to look at the issues from both sides of the congressional isle.
As stated above, I was left with more questions than answers. My first question was why we needed the Patient Protection and Affordable Care Act. Why fix something that isn’t broken? I thought that everyone had access to some form of healthcare. I was familiar with Medicaid and Medicare. Living in Orlando, I am familiar with the community based centers for the poor, such as Shepard’s Hope and Grace Medical Home. I have worked in an emergency room and have seen the numbers of patients with no insurance, who are never turned away. I personally have had the experience of owning a company with employees, and paying for their group insurance policies. After selling my company I did get a “rude awakening” to how expensive it is to buy private individual insurance, but I bought it anyway, thinking that was my best option. After educating myself, I now realize that what I described above is not optimal or acceptable.
I thought America offered the best healthcare in the world. I was correct with that assumption, but after reading the National Prevention Strategy, I became outraged to discover that the U.S spent over 2.5 trillion dollars on healthcare in 20094, but ranked last, out of 16 industrialized countries, on a measure of mortality amenable to medical care.6 Preventable causes of death have been estimated to be responsible for over 900,000 deaths annually. Tobacco smoking, poor diet, lack of physical exercise and misuse of alcohol are the major causes, representing nearly 40% of the annual mortality rate for the U.S.5 I discovered that out of that 2.5 trillion dollars spent in 2009, 95% was used for treating disease and only 3% was spent on prevention.3 Now the picture is becoming more clear.
There are three big problems, the authors are trying to correct with this legislation. The first is providing greater access to healthcare. The National Scorecard on U.S. Health System Performance, stated that access to health care had eroded since their report in 2006.6 In 2006, there were 61 million uninsured or underinsured adults, in the age range of 19 to 64.6 In 2011, that number grew to 81 million.6
I have always assumed that a large portion of uninsured people, were uninsured by choice. During the recent arguments at the Supreme Court, Justice Alito said “You can get health insurance”. An article in the Washington Post by Donna Dubinsky, brought up a point the Supreme Court did not consider, when talking about access to private insurance. They neglected to consider that the private insurance market doesn’t function as a normal market. In a normal market, if there is demand, there is access. As an individual, wanting to purchase health insurance, you can only get that insurance if the company wants to insure you.7 19% of applications nationwide are denied. Are these people being denied for deadly illnesses? Some, but many are for minor illnesses; it appears, insurers prefer to insure group plans, where they can spread the risk.8 The PPACA tries to fix this broken market.
The PPACA will address this problem in several ways.
• For the 44% of Americans who fall through the cracks, meaning those whose work circumstances do not give them access to employer based insurance, but also make to much money to qualify for Medicaid, will now be able to buy affordable health care coverage through the state exchanges. If their income is below 400% of the Federal Poverty Line (FPL), the government will provide a subsidy to help reduce the cost.9
• For the uninsured whose income is really low; the government has expanded the Medicaid income threshold to 133% of the FPL. This adds an additional 17 million uninsured Americans.9 The current Federal threshold for Medicaid is: 133% FPL of household income for pregnant women and children 6 and younger, 100% FPL for school age children, 75% FPL for the elderly and disabled, and for working parents 25% FPL. An issue arises here, in that Medicaid is jointly funded by Federal Funding (57%) and State Funding (43%). The above federal thresholds are mandatory for all states. Making the new increase to 133% FPL mandatory for all Medicaid eligible Americans, has been ruled illegal by the Supreme Court, and the PPACA cannot force states to contribute to these new levels.
States can now opt out. Why would they want to opt out? Beginning in 2012 the Federal Government will pay 100% of all the “newly eligible” people in Medicaid, with the level reduced to 90% by 2020. Florida and Texas are two states that have opted out. Governor Rick Scott and Governor Rick Perry appear to have a “wait and see” attitude. They both want to see if the additional funding for Medicaid can sustain itself. Currently there are no guarantees in the law that the PPACA level of federal support will be maintained.9 One can understand this “wait and see” attitude since Medicaid spending is now the fastest growing budget item for every state in the country. Many states spend more on their share of Medicaid than they do on K-12.10
Uneven quality of health care is our second problem. It is apparent that discrepancies in life expectancy and health outcomes differ between racial, ethnic and poorly educated populations.1 Hopefully this issue will be corrected by the solutions to healthcare access in the above information. In addition, the PPACA offers consumers protections that will enable everyone to have the chance for quality health care. People with preexisting illnesses will now have access, and pay the same price for health care coverage as everyone else.
There will be no annual or lifetime caps the insurance companies will pay for claims. You will not have to live in fear that your insurance company will rescind your coverage due to severe illnesses.9 Kids up to the age of 26, who are not married, can remain on their parent’s insurance plans.11 This sounds great, but how will we pay for all these new protections? The PPACA has mandated that everyone is required to buy some form of health insurance. This mandate is necessary to help fund the above protections. With this mandate, 30 million more customers will be added to the insurance pool, to offset the financial burdens that insurance companies will shoulder. Without this mandate, the protections will disappear.9
The third and final problem is an effort to gain some control on the price of healthcare while, increasing the level of quality care. The PPACA allows us to move from a nation treating sickness as our primary focus; to one that begins with primary care and prevention.4 President Obama has created the National Prevention Council and the National Prevention Fund to move us in a more positive direction. The council is lead by the Surgeon General and is comprised of 17 heads of departments and agencies across the Federal and State governments. One of the reasons health care has suffered, is because of lack of collaboration between federal and state level departments and agencies. Everyone worked in “silos”; no one shared information or worked on common goals.3 (This is very similar to how our country functioned before 9/11, and was the reason for the creation of Homeland Security).
The National Prevention Council, with input from other agencies, developed the National Prevention Strategy.12 This strategy is positioned to focus efforts on wellness and prevention.12 The strategy addresses the whole patient, and functions under the assumption that health is more than just the absence of disease; it is physical, mental, and social well being.12 The overreaching goal of this strategy is to increase the number of Americans who are healthy at every stage of life. The Council’s approach to meeting this goal was to identify four strategic directions and seven targeted priorities. The strategic directions are:
1. Healthy and Safe Community Environments
2. Clinical and Community Preventive Services
3. Empowered People
4. Elimination of Health Disparities
The seven priorities are:
1. Tobacco Free Living
2. Preventing Drug Abuse and Excessive Alcohol Use
3. Healthy Eating
4. Active Living
5. Injury and Violence Free Living
6. Reproductive and Sexual Health
7. Mental and Emotional Well Being
Recommended approaches are identified for each Strategic direction.12 The seven target priorities were selected, based on the greatest impact, on the largest number of people.12 The National Prevention Strategy is a well thought out plan/document which each healthcare provider would find useful. In my opinion, it is the best part of the entire PPACA, because it is comprehensive, has measures to monitor the success of the programs, and will become more of a living document that will continually be updated with science based solutions. 12
I have presented three glaring problems in today’s health care that the PPACA is intended to correct. I would like to now mention a few extra items in the PPACA that will positively affect issues that were not working well or not implemented at all.
Medicare was one of the first social reforms to health care, created in 1965, which provided health insurance to people 65 and older. The PPACA improves the prescription drug coverage for Medicare. It has also put in place a timeline to slowly eliminate the “donut hole” caused by the prescription drug program. In an effort to move us toward a healthier nation, the PPACA will allow more incentives to participate in prevention. There will be no co-pays for approved preventative test, such as mammograms, and colonoscopies. No co-pays for immunizations. For Medicare patients, there will be free annual wellness visits, as well as a host of preventive screenings. An entire list is on Medicare.gov.13
I would like to mention a couple of the arguments against the PPACA. Funding for Medicaid may become an issue. If the government cannot live up to it’s new financial responsibilities, it is feared that the government will then begin the process of saving dollars by cutting the reimbursement to the providers. Providers will stop taking Medicaid and Medicare patients. This will again create problems for access to healthcare.14
Another argument; will preventative medicine save money? Although the jury is still out on this topic, a review of the literature in Health Economics, suggested that “some preventive measures saved money, but the vast majority did not”.15
In conclusion, my assignment was to read the literature and analyze manuscripts “for” and “against” the Patient Protection and Affordable Care Act. I came into this review with limited knowledge of the facts, and biased against the act, based on the information I was hearing from the media. I am completing this paper with a deep appreciation and respect for the effort, and fight, that President Obama had to endure to achieve. The history of health reform in the U.S. has been tried with multiple failed attempts, dating all the way back to Franklin Roosevelt during the New Deal Era.1 The reason for failure has mostly been political. It is my hope that history does not repeat itself, and that the benefits from this Act will out shine the negatives. I think the PPACA is a huge step forward for America.
I am for the PPACA, and am now empowered with the facts, to help defend its purpose.
1. Gable, L. (2011). The Patient Protection and Affordable Care Act, Public Health, and the Elusive Target of Human Rights. Journal Of Law, Medicine & Ethics. Public Health Reform. Fall 2011.
2. Krauthammer, C. (2009, August 14) Preventive Care Isn’t the Magic Bullet for Health Care Costs. Washington Post. Retrieved from: http://www.washingtonpost.com/wp-dyn/content/article/2009/08/13/AR2009081302898
3. Majette, G. (2011) PPACA and Public Health: Creating a Framework to Focus on Prevention and Wellness and Improve the Public’s Health. Journal of Law, Medicine & Ethics, Public Health Reform, Fall 2011.
4. The National Prevention Strategy, National Prevention Council, June, 16, 2011.
5. Cohen, Joshua T., Neumann, Peter J., Weinstein, Milton C., New England Journal Of Medicine, 2008; 358:661-663. (February, 14, 2008) DOI: 10. 1056/NEJMp0708558
6. The Common Wealth Fund Commission. (2011, October). Why Not the Best? Results from the National Scorecard on U.S. Health System Performance.
7. Dunbinsky, D. (2012, April, 6). What Makes Health Care Different? The Washington Post. Retrieved from: http://www.washingtonpost.com/opinions/the-case-for-obamacare/2012/04/06/gIQAqfgY
8. U.S. Government Accountability Office. (2011, March 16). Data on Application and Coverage Denials. GAOO-11-268.
9. Tate, Nick. (2012). The Affordable Care Act and What It Means For You and Your Healthcare. Obamacare Survival Guide (1st ed.). Florida: Humanix.
10. Coburn, T., Barrasso, T. (2010, April). Bad Medicine: A Check- up On the New Federal Health Law (p.15). United States Senate. 111 Congress.
11. The Affordable Care Act: Patients Bill of Rights and Other Protections.
(2011, April). Families USA.
12. The National Prevention Strategy. (2011, June 16). America’s Plan for Better Health and Wellness. National Prevention Council.
13. Preventative Services Covered Under the Affordable Care Act. HealthCare.gov. Retrieved from: http://www.healthcare.gov/news/factsheets/2010/07/preventative-services-list.html
14. Torrieri, M. (2012, July, 03). How the Medicaid Provision Will Affect Physician Practices. Physicians Practice. Retrieved from: http://physicianspractice.com/blog/how-medicaid-provision-will-physician-practices.
15. Cohen, J., Neumann, P., Weinstein, M. (2008). Does Preventive Care Save Money? Health Economics and the Presidential Candidates. New England Journal Of Medicine. 2008; 358: 661-663. February 14, 2008. DOI: 10.1056/NEJMp0708558.
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