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Affordable Care Act
Definition/Introduction
The Patient Protection and Affordable Care Act is an American law passed in March of 2010. Its primary goal is to achieve universal health insurance coverage by facilitating cooperation among employers, citizens, and the government. Its other objectives are to make healthcare more affordable while simultaneously increasing healthcare quality and reducing unnecessary spending. To this end, the Act puts specific emphasis on primary and preventative care. The Act requires that all US citizens and legal residents purchase health insurance to increase the pool of healthy individuals enrolled. This "individual mandate" spreads around the associated risk while subsidizing coverage for the economically disadvantaged. It potentially includes an expansion of Medicaid, at the discretion of the state governments. Additionally, the Act promotes the creation of state health insurance "Exchanges" that allow employers and individuals to select health insurance options that are eligible for federal subsidies in accordance with state and federal regulations. Subsidized plans that meet these requirements are called "qualified health benefit plans." To achieve universal coverage, the Act also bars insurance companies from refusing coverage to those under 19 years of age with pre-existing conditions, prohibits cost ceilings on essential health benefits, and allows children less than 26 years of age to stay on their parents' health insurance plans. In an effort to more thoroughly integrate employers into the program and promote preventative care, the Act incentivizes the creation of "wellness programs" in the workplace by offering discounts, rebates, and waivers towards the cost of insurance.[1][2]
Issues of Concern
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Issues of Concern
Relevant concerns about the Patient Protection and Affordable Care Act include is constitutionality, affordability, and efficaciousness. Critics of the Act insist that its "individual mandate" requiring citizens and legal residents to buy health insurance forces them to purchase a product they do not want, a power that does not fall under the federal government's ability to regulate interstate commerce under the Commerce Clause (Article I, Section 8, Clause 3) of the U.S. Constitution. Another concern is that since the Act is a federal law, ensuring that the states are enforcing it would require the federal government to override state law enforcement in violation of the U.S. Constitution's 10th Amendment protection of states' rights. This, in turn, would require the states to voluntarily enforce the Act's provisions, leading proponents of the Act to fear that it will be improperly or incompletely enforced. Regulation that could potentially be ignored by state governments include prohibitions on discrimination against people with pre-existing conditions, excessive waiting periods, and requirements for internal and external impartial appeal procedures implemented when coverage is denied.[1] Other concerns include the possibility that the Act might disrupt existing healthcare coverage, force employers to curtail or abandon coverage for their employees, overwhelm healthcare providers with new patients, reduce the quality of provided services, and increase health care costs, though proponents of the law say that these concerns are exaggerated.[3][4]
Clinical Significance
The Patient Protection and Affordable Care Act has significant clinical implications for various branches of medicine. For instance, critics of the Act insist that it has been shown to increase costs and reduce the quality of end of life care received by cancer patients, thereby adversely affecting patients receiving hospice care.[5] However, its proponents insist that the Act's Medicaid expansion component has increased access to care for diabetics, patients suffering from trauma, and patients requiring emergency surgery.[6][7][8] Also, data suggested reductions in inpatient hospitalizations due to Medicaid expansions covering ambulatory care under the Affordable Care Act, thereby producing cost savings for the US health care system.[9][8] Another component of the Affordable Care Act, Dependent Care Provision, has increased insurance coverage in young adults with cancer.[10]
Nursing, Allied Health, and Interprofessional Team Interventions
The Patient Protection and Affordable Care Act has had a particularly unique impact on the conduct of physicians as well as auxiliary health care providers like nurses. Proponents of the Act say its linking Medicare payments to readmission rates disincentivized readmissions and thereby encouraged physicians to develop leadership skills to increase the quality of care.[11] Proponents of the Act also believe that it helped public health nurses to integrate primary care with broader public health, prioritize preventative health care, and coordinate care more efficiently with other providers.[12] The ACA also accounts for new payment methodologies, based on outcomes, replacing traditional "fee for service" payments. Therefore mandating hospitals to implement new programs by creating "care coordinators"- paid nurses who make sure that patients are getting appropriate follow-up care, thereby optimizing hospital reimbursement. These new implementations also require complex data reporting, need for sophisticated information technologies; thus, institutions have to be prepared to adapt to the new healthcare trends. On the other hand, health care providers have to work in conjunction with other hospital interprofessional teams and subspecialties to get through this cultural transformation to better acclimate to the new methodologies. Due to changes in reimbursements, increasing regulations, need for expensive electronic medical record systems (EMRs), individual physician practices are having a tougher time and eventually either bought or merged into larger groups and hospital-owned practices.
References
Rosenbaum S. The Patient Protection and Affordable Care Act: implications for public health policy and practice. Public health reports (Washington, D.C. : 1974). 2011 Jan-Feb:126(1):130-5 [PubMed PMID: 21337939]
Borelli MC, Bujanda M, Maier K. The Affordable Care Act Insurance Reforms: Where Are We Now, and What's Next? Clinical diabetes : a publication of the American Diabetes Association. 2016 Jan:34(1):58-64. doi: 10.2337/diaclin.34.1.58. Epub [PubMed PMID: 26807011]
Reisman M, The Affordable Care Act, Five Years Later: Policies, Progress, and Politics. P [PubMed PMID: 26417176]
Manchikanti L, Helm Ii S, Benyamin RM, Hirsch JA. A Critical Analysis of Obamacare: Affordable Care or Insurance for Many and Coverage for Few? Pain physician. 2017 Mar:20(3):111-138 [PubMed PMID: 28339427]
Parikh RB,Wright AA, The Affordable Care Act and End-of-Life Care for Patients With Cancer. Cancer journal (Sudbury, Mass.). 2017 May/Jun; [PubMed PMID: 28537965]
Zerhouni YA,Scott JW,Ta C,Hsu PC,Crandall M,Gale SC,Schoenfeld AJ,Bottiggi AJ,Cornwell EE 3rd,Eastman A,Davis JK,Joseph B,Robinson BRH,Shafi S,White CQ,Williams BH,Haut ER,Haider AH, Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis. The journal of trauma and acute care surgery. 2019 Aug; [PubMed PMID: 31095067]
Level 1 (high-level) evidenceZogg CK, Payró Chew F, Scott JW, Wolf LL, Tsai TC, Najjar P, Olufajo OA, Schneider EB, Haut ER, Haider AH, Canner JK. Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients. JAMA surgery. 2016 Dec 21:151(12):e163609. doi: 10.1001/jamasurg.2016.3609. Epub 2016 Dec 21 [PubMed PMID: 27760245]
Lee J, Callaghan T, Ory M, Zhao H, Bolin JN. The Impact of Medicaid Expansion on Diabetes Management. Diabetes care. 2020 May:43(5):1094-1101. doi: 10.2337/dc19-1173. Epub 2019 Oct 24 [PubMed PMID: 31649097]
Wen H,Johnston KJ,Allen L,Waters TM, Medicaid Expansion Associated With Reductions In Preventable Hospitalizations. Health affairs (Project Hope). 2019 Nov [PubMed PMID: 31682506]
Barnes JM, Brown DS, Harris JK, King AA, Johnson KJ. Impact of the affordable care act dependent coverage provision on young adult cancer patient insurance coverage by sociodemographic and economic characteristics. Cancer causes & control : CCC. 2020 Jan:31(1):33-42. doi: 10.1007/s10552-019-01246-3. Epub 2019 Nov 6 [PubMed PMID: 31696421]
Sterbenz JM,Chung KC, The Affordable Care Act and Its Effects on Physician Leadership: A Qualitative Systematic Review. Quality management in health care. 2017 Oct/Dec; [PubMed PMID: 28991812]
Level 2 (mid-level) evidenceEdmonds JK, Campbell LA, Gilder RE. Public Health Nursing Practice in the Affordable Care Act Era: A National Survey. Public health nursing (Boston, Mass.). 2017 Jan:34(1):50-58. doi: 10.1111/phn.12286. Epub 2016 Jul 21 [PubMed PMID: 27444260]
Level 3 (low-level) evidence