Suzanne A. Celmer-Harter, MA, BS, MT(ASCP)



Taking a Stand Against the ACASuzanne Celmer-Harter, Laura Criddle, LaTraesha Davis, Rebekah WaldronLDR 614-OBDr. John W. Fick, FACHEApril 15, 2017Taking a Stand Against the ACACost, quality, and access are three concerns in healthcare that have been issues for over100 years (Sultz & Young, 2014). Over the past century, there have been many attempts at Healthcare reform in the United States. Unfortunately, when one or two of the three areas is addressed, the other one or two become worse. The Affordable Care Act (ACA) is a landmark piece of legislation that was championed by President Barack Obama. According to Sultz and Young (2014), the ACA is organized under four headings and is intended to address all three of the major healthcare concerns plus some:Providing new consumer protectionsImproving quality and lowering costsIncreasing access to affordable careHolding insurance companies accountableAccording to Showalter (2015), the ACA’s most noted provisions are the following:Expand coverage to 32 million previously uninsuredRequires everyone to have health coverage or pay a penaltyCreate healthcare exchanges (marketplaces) to provide competitive ratesProhibit denial of coverage based on preexisting conditionsCover dependent children until age 26Improve prevention and wellness programsImprove cost-effectiveness of Medicare and MedicaidIn 2008, the Institute for Healthcare Improvement (IHI) developed the Triple Aim. The Triple Aim’s goals are to improve patient experience, improve population health, and reduce per capita cost. McCarthy (2015) states it is fair to assume that the ACA was modeled after the Triple Aim. It is too early to tell if the ACA will achieve the triple aim goals, but thus far, it appears that the ACA has led us in the opposite direction.The ACA has provided coverage to millions of Americans who previously were uninsured which has led to some unanticipated issues that are the opposite of the primary goals of lowering cost, improving access, and improving quality. Due to the increase in the number of newly insured patients, providers find themselves understaffed and overwhelmed. The volume of patients flooding facilities for much-needed care that has not been available to them until now is causing widespread access issues throughout the nation. This influx is causing a decrease in quality as providers struggle to accommodate the mass numbers of patients. Cost is also increasing, as many patients are very ill due to the lack of preventative care because of no insurance coverage in prior years.The triple aim goals are a good benchmark to evaluate the success of the ACA. The evidence thus far is pointing toward the lack of achievement of the ACA. The purpose of this paper is to discuss the cost, quality, and access and why the ACA should be repealed. CostThe Affordable Care Act has provisions, which are supposed to reform the health care in the United States. “ACA intends to reverse incentives that drive up costs, to enact requirements that increase both accountability for and transparency of quality, and by 2019, to increase access by expanding health insurance coverage to an additional 32 million Americans” (Sultz & Young, 2014, p. 56). Review of the literature suggests the ACA falls short of accomplishing these goals, especially related to costs.One of the touted provisions of ACA is that one cannot be excluded from insurance coverage if they have a preexisting condition. The outward appearance of this provision is one that is moral and noble in nature. However, this provision also purports that one can choose not to carry insurance until they are very ill and need expensive medical treatment. Healthy individuals are necessitated in coverage pools to offset the cost of care for people who are sicker and require more medical attention (Jaffe, 2016; Mendoza, 2016). Insured pools composed of sicker patients could lead to increased premiums for all to balance the upsurge in medical expenses (Mendoza, 2016). Even though the ACA has a mandate to require individuals to carry insurance or risk a penalty, unless they qualify for an exemption, many people still choose not to comply. The penalties are modest and not being enforced by criminal prosecution or liens against properties, thus resulting in a lack of compliance with the mandate (Pyles, 2011).The ACA has caused costs and the number of uninsured/underinsured to rise. Since the passage of the Affordable Care Act, the number of uninsured and underinsured individuals has continued to grow, in particular among the sick and poor. Some employers have stopped offering insurance to part-time employees. Most businesses have passed along the increasing expenses of health insurance to employees in the form of shared costs for plans, high deductibles or expensive co-pays. Also, to prevent the purchase of more expensive plans and excessive utilization of medical benefits, the ACA will levy a “Cadillac tax,” delayed until 2020. The tax will “impose a 40 percent annual excise tax on what employers and employees jointly pay above the ACA thresholds” (Mendoza, 2016, p. 522). The Cadillac tax has resulted in employers offering high-deductible plans with large co-pays that employees cannot afford. Some people have to choose to delayed or go without medical care (Hellander, 2015). Finally, insurance premiums on the health insurance marketplace in 38 states increased by 25 percent in 2016 and required high levels of cost-sharing (Jaffe, 2016). The insurance marketplace has tiered plans available; however, even the least expensive plan, the bronze, covers only 60% of medical costs leaving the remaining costs up to the individual to pay (Woolhandler & Himmelstein, 2017). Since the health care reform bill passed, additional ACA-related costs are contributing significantly to major economic hardships of individuals and employers. Another ACA issue concerns the costs of the uninsured. The uninsured utilize emergency departments (EDs) to receive treatment, which comes at a higher price than care in a physician’s office or urgent care facility. EDs are required to accept everyone who presents for treatment, including those who do not have the ability to pay for services. Safety-net hospitals are usually located in poor communities and shoulder the costs of a higher percentage of uncompensated care created by individuals who use EDs as an alternative to primary care. Safety-net hospitals rely on federal Medicaid disproportionate-shared hospital (DSH) payments to provide care, which are scheduled to progressively decrease (Neuhausen et al., 2014). Even though the Affordable Care Act provides coverage to millions of individuals who previously did not have insurance, “the reform will still leave 27 million uninsured in 2025, according to the Congressional Budget Office” (Hellander, 2015, p. 707). Along with rising costs of health care due to inflation, which the ACA does not control, DSH costs will continue to grow due to increased numbers of individuals who now qualify for Medicaid because of the expansion. It is estimated that uncompensated care will increase to between $1.38 billion and $1.54 billion by 2019 (Chokshi, Chang, & Wilson, 2016). Health care in the United States cannot continue to operate and survive under these financial conditions associated with the ACA.QualityThe ACA has several benefits and ensures that the quality of care of individuals in need of immediate care. As a requirement of the ACA, all insurance plans must cover the important ten health benefits. These benefits include direct treatment for individuals that suffer from mental health issues, addiction, and chronic diseases. If these individuals were not offered these services, many patients would end up in the emergency room (Amadeo, 2017). The ACA has made honest efforts to ensure that the quality of care for individuals is consistently within standards set for quality care. However, as with many other situations, the ACA is insufficient in many ways. The quality of care as it relates to the ACA has not reported any substantial research showing that due to the implementation of the ACA, individuals began receiving a higher quality of care. However, the implementation of the ACA has shown there has been an increase in the strain individuals were previously experiencing. Amadeo (2017) reported that between the years 2013 and 2023, pharmaceutical companies would be subjected to paying an extra $84.8 billion in fees. Thus, drug costs could rise. If the amount of drug costs increase, this will ensure that patients’ co-pays and out-of-pocket fees will also increase. In many cases, the costs of prescription drugs are already high; this increase will cause many individuals to become discouraged as it related to going to the doctor and filling prescriptions that the physician gives them because of the increase in cost. Rising costs lowers the quality of care because due to the increased cost, fewer patients are willing to get the care they need leading to less care being given. In 2012, it was recognized that the ACA attempted to change Medicaid into a healthcare program that only assisted with the healthcare needs of the nonelderly population with income 133 percent below the poverty rate. Medicaid was once a program to help individuals in need but has been transformed into a portion of a plan implemented to provide universal healthcare coverage (Goldberg, 2013). Implementing this new policy, of course, helped individuals that were in poverty to have healthcare and ensure that they are healthy individuals. However, what about the individuals who are not considered 133 percent below the poverty rate but are not financially stable enough to receive the healthcare services that they need? In return, the quality of patient care decreases because although the ACA was implemented to help individuals in need with healthcare services, there are still individuals that are not in the best health because they are unable to be cared for adequately due to the changes that the ACA has brought upon them. It is unfortunate that individuals are unable to be given the appropriate care due to being placed into a certain category financially. How can quality care be increased and given when most individuals are not given the tools to receive care at all? It is understood that stipulations and policies must be given for any new laws to be effective. However, people will never be able to receive the quality care that is needed if there are stipulations that are based on finances. There are patients that may not be looked at as below poverty by the government due to their incoming finances. However, their income can be used for many other things. Per the ACA, an individual may not be considered able to receive Medicaid because of their income. However, they are not taking in consideration that in some situations after ensuring that certain bills are paid, and their household is in order, it is not financially possible to take on the responsibility of paying for medical care without some assistance. It is not thought about that any instant financial circumstances can change. Thus, many individuals are experiencing a lack of quality of care and sometimes no healthcare at all. The ACA was implemented with good intentions. However, it is not as effective as it should be as it relates to ensuring that patients are receiving quality care consistently. The ACA should be re-evaluated to fit the needs of individuals that are experiencing health issues.AccessAccess to insurance and healthcare has made the Affordable Healthcare Act difficult to endorse. There are several well-documented issues associated with ACA access. The debut of federally run insurance marketplaces has been laden with difficulties. According to Courlot, Coughlin, and Upadhyay (2014) during the initial launch of Marketplace websites, "consumers encountered error messages and were unable to create accounts or move forward with the online application process" (p. 7). Technical glitches in completing the enrollment process continued even after States attempted to correct them. Other difficulties included failed attempts to log into the marketplace website, account creation difficulties, frozen screens, mistaken identities and much more. Oregon was fraught with problems; they were forced to "hire hundreds of new workers to manually process paper application” (Courlot et al., 2014, p. 3). State-run programs fell short of delivering user-friendly marketplaces. The Affordable Care Act allowed each State to create their own insurance exchange platform if they could remain financially self-sustaining. Four out of 50 States crafted their own platforms which allowed them greater flexibility. Thirty-four States have government-run exchanges; the remaining use federal platforms but run the sites themselves. While federal platforms seem to run smoothly, there are drawbacks: lack of authority over design and layouts, limited ability to integrate processes for financial aid and seamless single door enrollment systems. Efforts to correct these issues are ongoing (Giovannelli & Lucia, 2015).Canceled policies due to noncompliance were noted. President Obama’s pledge that, ‘if you like your insurance plan, you can keep it’ remained true only if the consumer kept the same coverage they had purchased prior to or in 2010 (Hall & Lord, 2014, p. 5). This grandfather clause changed if the insurer made substantial changes to their plans and were unable to meet the ten essential benefits of ACA. Many people lost their healthcare coverage and were forced to purchase insurance through the market exchange. The strain on primary care provider capacity was enormous. According to Dall, West, Chakrabarti, and Iacobucci (2015), “expanded health insurance coverage under the ACA is projected to increase demand for a wide range of medical services” (p. 1). This was not a big surprise as the newly insured “ranged from 7.0 million to 16.4 million” (Blumenthal, Abrams, & Nuzum, 2015, p. 2451). Hofer et al. (2011) “project the demand for primary care physicians will rise by between 4310 and 6940 as a result of the ACA” (as cited in Dall et al., 2015, p. 1). The demand for mental healthcare will far exceed the supply of physicians and other healthcare providers over the ensuing 20 years. “One reason is the significant reduction in resources devoted to mental health services, and the other reason is society’s lack of understanding of intellectual disabilities and disease” (Ray & Norbeck, 2014, para. 4). The Affordable Care Act insured nearly 16 million people living in the United States; yet, it has not provided insurance to all who were promised. A large majority of African-Americans and Latinos remained uninsured due to a few States having rejected Medicaid expansion. Language, literacy and cultural barriers played their part as well. For example, many sites did not take into consideration how many Spanish dialects there were in the United States. Less than half the African-American and Latino respondents could decipher what services were included in the insurance they chose. “In addition, difficulties with the identity verification system (which initially was not multilingual), along with fear of legal reprisals for mixed status families and lack of familiarity with culturally-specific insurance and medical terms, combined to pose a formidable barrier” (Delgado, Henry, & Blair, 2015, p. 17). Minorities were not the only people unable to navigate marketplace websites, others had difficulties as well. Many people gave up and chose to pay the penalty instead. Access to affordable healthcare through the ACA has proven to be a challenge for many people for multiple reasons.ConclusionThe ACA aims to address three majors concerns in healthcare: cost, quality, and access. In order to be successful, all three of the areas must show improvement. Thus far, the ACA is not living up to the hype.Cost is the first area where the ACA is failing. Many of the policies available in the Marketplace are costly, and patients would rather pay the fine for not having insurance. These patients then wait until they are very sick to seek medical attention. These same patients use emergency departments when they do need medical care instead of less costly primary care physicians. ED costs are much higher than those of the family doctor. Due to the increased cost of premiums, employers are passing those cost onto their employees through high premiums and high deductibles. There are absolutely no cost savings that have been realized so far with the ACA.The second area the ACA is failing in is quality. The research shows that the ACA is very costly but has to improve quality. Due to the increased cost of insurance through ACA patients are avoiding medical care until they are very sick. If the premiums and deductibles of the ACA were affordable than patients could seek the preventative and early care that they require improving quality.The final area that the ACA is failing is access. The lack of access started day one with the disastrous launch of the Marketplace and has continued to get worse. Many patients lost their coverage and had to purchase coverage through the Marketplace. Another access issue is the increase in previously uninsured patients has caused a strain on provider capacity. States rejected Medicaid expansion leaving large numbers of minority and less fortunate patients uninsured.As mentioned several times in this paper, the ACA has failed at the triple aim goals and should be repealed immediately. The ACA has not decreased cost it has increased them. There is no evidence that quality of care has improved under the ACA. Finally, the ACA has had the exact opposite effect on access that it was intended to have. It is time to take a stand against the ACA and develop a system that will successfully address cost, quality, and access.ReferencesAmadeo, K. (2017, February 1). 10 Obamacare pros and cons: Is Obamacare worth it? Retrieved from The Balance: , D., Abrams, M., & Nuzum, R. (2015). The affordable care act at 5 years. The New England Journal of Medicine, 372(25), 2451-2458. doi:10.1056/NEJMhpr1503614Chokshi, D. A., Chang, J. E., & Wilson, R. M. (2016). Health reform and the changing safety net in the United States. The New England Journal of Medicine, 375(18), 1790-1796. Retrieved from , B., Coughlin, T. A., & Upadhyay, D. K. (2014). The launch of the affordable care act in selected states: Building aca compliant eligibility and enrollment systems. Retrieved from The Urban Institute: , T., West, T., Chakrabarti, R., & Iacobucci, W. (2015). The Complexities of Physician Supply and Demand: Projections from 2013 to 2025. Retrieved from American Association of Medical Colleges: , G., Henry, M., & Blair, S. (2015). Breaking barriers: Improving health insurance enrollment and access to health care. Retrieved from Alliance For a Just Society: , J., & Lucia, K. (2015, September 17). The experiences of state run marketplaces that use . Retrieved from The Commonwealth Fund: , I. (2013). The affordable care act: Triumphs and tribulations. International Journal of Law and Management, 57(2), 87-97. doi:10.1108/IJLMA-07-2013-0030Hall, M. A., & Lord, R. (2014). Obamacare: What the affordable care act means for patients and physicians. BMJ, 349(g5376), 1-10. Retrieved from 10.1136/bmj.g5376Hellander, I. (2015). The U.S. health care crisis five years after passage of the affordable care act: A data snapshot. International Journal of Health, 45(4), 706-728. doi:10.1177/0020731415595610Jaffe, S. (2016). Clinton versus Trump on health care. The Lancet, 388(10057), 2223. doi:10.1016/S0140-6736(16)32116-XMcCarthy, M. (2015). ACA & the triple aim: Musings of a healthcare actuary. Benefits Quarterly, , R. L. (2016). Which moral hazard? Health care reform under the affordable care act of 2010. Journal of Health Organization and Management, 30(4), 510-529. doi:10.1108/JHOM-03-2015-54Neuhausen, K., Davis, A. C., Needleman, J., Brook, R. H., Zingmond, D., & Roby, D. H. (2014). Disproportionate-share hospital payment reductions may threaten the financial stability of safety-net hospitals. Health Affairs, 33(6), 988-996. doi:10.1377/hlthaff.2013.1222Pyles, J. (2011). Demystifying health reform legislation. Psychiatric Times, 28(3), 26-27, 30-31. Retrieved from , W., & Norbeck, T. (2014, October 21). Affordable care act fails to address physician shortages: Here's how we can better deal with this challenge. Retrieved from Forbes: , J. S. (2015). The law of healthcare administration (7th ed.). Chicago: Health Administration Press.Sultz, H. A., & Young, K. M. (2014). Health Care USA (8 ed.). Burlington, MA: Jones & Bartlett Learning.Woolhandler, S., & Himmelstein, D. U. (2017). The Obama years: Tepid palliation for America's health scourges. American Journal of Public Health, 107(1), 22-24. doi:10.2105/AJPH.2016.303531 ................
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