Author: Bryan P. White
Original Publication: 12/02/2018-12/23/2018
The Affordable Care Act (ACA) was a sweeping healthcare reform bill passed by President Barrack Obama in 2010 aimed at implementing long term changes in the U.S. healthcare system. This bill consisted of five key provisions including a Medicaid expansion, the creation of health insurance exchanges, prohibiting the denial of insurance to the un-insured, requirements to increase the percentage of insured individuals in the U.S. by 2014, and a combination of penalties and tax incentives to individuals and employers designed to increase overall insured levels. While the ACA has faced many controversial opinions and legal battles since its passing, overall, it has helped increase the insured populace of the U.S. and created a stepping stone for future reforms.
The Patient Protection and Affordable Care Act (PPACA), more commonly known as the Affordable Care Act (ACA) or Obamacare for short, was an expansive healthcare reform bill signed into law by President Barrack Obama on March 23, 2010 during a Democratic majority in the House and Senate. The ACA’s overall goal was to significantly increase the amount of insured American’s through a series of provisions designed to both increase the access and affordability of healthcare (Shi and Singh 2012). These key provisions included a Medicaid expansion allowing individuals within 138% of the federal poverty level to receive Medicaid insurance, the implementation of health insurance exchanges (or “marketplaces”) where individuals could compare various levels of health insurance plans and receive discounted premium costs, limitations for which individuals could be denied insurance (e.g., pre-existing conditions), a requirement that a significant increase in insured individuals be achieved by the year 2014 via significant changes to private insurers, tax incentives for individuals through the Individual Mandate to obtain qualifying minimum insurance, and incentives for employers to offer affordable health insurance to their employees (Kaiser Family Foundation, 2019).
These provisions were implemented to varying degrees in the following ways to increase the overall healthcare coverage of individuals in the U.S, starting with the Medicaid expansion. Medicaid, an already existing U.S. public program that offered medical insurance coverage to low income individuals, was expanded to allow individuals with incomes at or below 138% ($15,415 for a single person) of the poverty level to qualify of Medicaid insurance. This allowed an immediate expansion of healthcare for some of the most affected individuals with the Federal government directly funding most of the State-level costs associated with the expansion. However, this has been one of the most controversial parts of the ACA with a recent Supreme Court decision giving states the option not to refuse Federal funding and not implement the expansion.
American Health Benefit Exchanges, or “healthcare marketplaces”, give individuals and small businesses the option to shop around for different health insurance plans in a regulated marketplace that is implemented by their state. Health insurance plans offered on health exchanges would always meet the minimum requirements described in the Individual Mandate and defer some of the costs of purchasing healthcare plans outside of the exchange through premium subsidies. Most importantly, the healthcare exchanges offered individuals a “one-stop-shop” website where they could easily purchase a healthcare plan as well as request help from representatives to ensure they were not experiencing a barrier to accessing enrolling in a healthcare plan.
Finally, changes to private insurance sought to stabilize the cost of insurance premiums and increase the number of insurable individuals by preventing the denial of health coverage due to pre-existing conditions and raising the age at which young adults can receive insurance through their parent’s plans to the age of 26. Other restrictions included prohibiting lifetime limits on coverage costs, requiring the full coverage of preventative services with no cost-sharing, requiring the review of increases to insurance plan premiums, and a requirement that insurers spend the majority (80%) of revenue from premiums on medical costs or return a rebate to consumers.
Overall, the ACA has largely been successful at changing the healthcare landscape in America since its passing in 2010. However, many challenges remain as the cost of insurance premiums will increase in 2019 largely due to the repeal of the Individual Mandate in 2018 (Kaiser Family Foundation, 2019b). Historically, health insurance in America is a balance between implementing market and social justice principles, and the ACA is no different. While leading on the social justice side, the initial key provisions of the ACA sought to use regulations and policy to effect long-term changes in the U.S. Healthcare system, and that goal has largely been achieved.
Kaiser Family Foundation. (2018a, December 2). Summary of Coverage Provisions in the Patient Protection and Affordable Care Act. Retrieved from: https://www.kff.org/health-costs/issue-brief/summary-of-coverage-provisions-in-the-patient/
Kaiser Family Foundation. (2018b, December 2). How Repeal of the Individual Mandate and Expansion of Loosely Regulated Plans are Affecting 2019 Premiums. Retrieved from: https://www.kff.org/health-reform/issue-brief/how-repeal-of-the-individual-mandate-and-expansion-of-loosely-regulated-plans-are-affecting-2019-premiums/
Shi, L. and Singh, D.A. (2012). Delivering Health Care in America: A Systems Approach. 7th Edition. Sudbury, MA: Jones and Bartlett Publishers.
High Deductible Healthcare Plans (HDHPs) are a new type of healthcare plan that trades the cost of high monthly premiums and low deductibles in favor of low monthly premiums but high deductibles. HDHPs also allow for individuals to save pre-tax money in Health Savings Accounts (HSAs) which creates an incentive for healthcare consumers to take part in increased cost-sharing between consumers and insurance companies. Since HDHPs require more out of pocket expenses to the consumer, they are generally considered to be higher risk than traditional healthcare plans. However, in light of the increased risk to the consumer associated with HDHPs, their adoption has been steadily increasing since 2011. This would suggest these plans offer an attractive healthcare plan system to consumers that are typically only utilizing routine or standard medical procedures that are within the range of out of pocket expense pricing.
High Deductible Health Plans (HDHPs) are healthcare plans that trade the cost of high, monthly premium payments in place of more cost-sharing (consumers pay more per procedure) between the health consumer and insurance company. This results in healthcare plans with high deductibles (the out-of-pocket amount that consumers must pay before insurance begins paying), but low monthly premiums. The economic theory behind HDHPs is that they will discourage unnecessary procedures and offset the cost of procedures to the consumer (increased cost-sharing) instead of the insurance provider, therefore reducing the total amount of medical resources being used. Scenarios where this remains true include procedures that are routine and/or minor, non-emergency services, patients are already aware of their diagnosis, and services that include discounts or other incentives to enroll in an HDHP instead of a normal healthcare plan (Wikipedia 2018).
Although HDHP plans might seem like a poor investment because they limit an individual’s protection against catastrophic medical events, their use has been steadily increasing since 2011. According to a National Center for Health Statistics report, the percentage of adults enrolled in employment-based coverage increased from 26.3% in 2011 to 39.3% in 2016 (Cohen and Zammitti, 2016). This would suggest that for some percentage of healthcare consumers, having a lower cost monthly premium is an acceptable risk for the savings they receive.
High Deductible Healthcare Plans (HDHPs) are a new type of healthcare plan that trade high deductibles for low monthly premiums, as opposed to traditional healthcare plans that tend to have higher monthly premiums and lower total deductibles. While it might seem like the higher risk associated with these plans would curtail use, they have actually been increasing in adoption over the years. If the costs of routine and standard procedures go down, these types of plans might persist as a driving force in the US healthcare delivery system.
Cohen and Zammitti. (2016). High-deductible Health Plans and Financial Barriers to Medical Care: Early Release of Estimates From the National Health Interview Survey, 2016. Retrieved from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERHDHP_Access_0617.pdf
Wikipedia. (2018, December 9). High-deductible health plan. Retrieved from: https://en.m.wikipedia.org/wiki/High-deductible_health_plan
There are two primary forms of modern healthcare payer systems: single-party (a single, national health insurance payer system), and multi-party (multiple, private or government run insurance companies). Traditionally the US healthcare system is a multi-party payer system, but recent efforts including the Affordable Care Act (ACA) in 2010 and other progressive legislative acts like the Medicare For All (M4A) act may shift the healthcare system more towards a single-party payer system. In a broad sense, multi-party payer systems allow for health insurance companies to operate within a free-market economic scenario, whereas single-party payer systems are typically a nationalized system with a single, governmental organization as its the top authority. While allowing a healthcare system to operate under free-market economics has some benefits to healthcare consumers such as the ability to pick and chose from a wide variety of private insurance companies, the lack of standardization of services costs and administrative methods tends to lead to price inflation and a cumbersome payment and reimbursement system. Shifting towards a single-party payer system might help increase overall healthcare demand by standardizing the cost of services and procedures and paying for those costs through taxation. Since healthcare costs are already paid for through taxation, healthcare utilization should also increase under a single-party payer system. The future of payer systems in the US is uncertain due to political disagreement between liberal (pushing towards nationalization) and conservative groups (pushing towards free-market economics.
Currently, the US Healthcare System is based on a multi-party payer system, that is, a healthcare system that relies on multiple private insurance companies to facilitate and finance the costs associated with healthcare in the US (Hussey and Anderson, 2003). However, many of the progressive healthcare reform ideas within the United States and abroad include a shift towards a single-party payer system, a healthcare system where health insurance is provided to all residents of a country and paid for by a single, public authority (Hussey and Anderson, 2003). Under a multi-payer system (current US healthcare protocol), insurance consumers must seek out private insurance companies, either through their employer, health insurance exchanges created under the Affordable Care Act (ACA), or by directly enrolling with an insurance company.
There are several reasons why a shift towards a single-party payer system might help increase the overall health utilization of healthcare services in the US (Blahous, 2018). Prior to the ACA, private insurers could create a multi-tiered cost system where the insured were stratified according to risk, but under the ACA that was limited. Under a single-party payer system, cost based on risk stratification is eliminated and all consumers are covered under the same plan with minimal or zero cost-sharing basis. Additionally, multi-payer systems create a market under which private insurers can implement different payment strategies for different services meaning that the costs of procedures to healthcare consumers will vary from insurer to insurer, and the types of procedures/services that are covered will vary as well. Under a single-party payer system, the costs and types of services are standardized across the entire country and are freely available to all residents. Another drawback of the multi-party payer system is that because of the lack of standardization across insurance companies, this creates a major administrative overhead that ends up increasing overall healthcare costs, the creation of bad debts, and an overall more cumbersome system than a single-party payer system (Shi and Singh, 2012).
Recently, Senator Bernie Sanders (D-VT) has begun work on a healthcare reform bill entitled the “Medicare for All Act (M4A)”, which has three central tenets designed to increase health utilization and health demand (Blahous, 2018). First, the M4A will provide health insurance to all Americans that are currently uninsured. This will effectively set healthcare utilization at 100%, that is, all US persons able to receive federal benefits would now be eligible for healthcare. Second, the M4A would expand the types of healthcare services to include dental, vision, and hearing services as well. This is a major shift in terms of traditional cost-sharing programs for dental insurance as currently 40% of dental costs are paid out of pocket (Blahous, 2018). Third, no cost-sharing requirements for those benefiting from the M4A plan, meaning that healthcare demand would increase as healthcare consumers see financial costs removed as a barrier to healthcare access.
In conclusion, the effectiveness of multi-party payer systems implemented at the national level seems low compared to that of a national, single-party payer system. Under a multi-party system, the health insurance industry itself grows and with it the administrative costs, whereas single-party systems can scale up nationally with minimal changes in administrative needs. Multi-party systems tend to increase barriers to healthcare access, decreasing overall healthcare demand and utilization and ultimately inhibiting health outcomes. The Affordable Care Act (ACA) enacted in 2010 made some steps towards achieving universal healthcare in the US, but its long-term effects will likely be limited as its provisions are steadily repealed by conservative US lawmakers (Goodnough and Pear, 2018). Future efforts, like the Medicare For All (M4A) act created by Senator Bernie Sanders, might pave the way for a single-party payer system in the US, but only under political conditions that favor shifts towards the nationalization of the US healthcare system.
Blahous, C. (2018, July). The Costs of a National Single-Payer Healthcare System. Mercatus Working Paper, Mercatus Center. Arlington, VA: George Mason University.
Goodnough, A., & Pear, R. (2018, December 14). Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional. Retrieved from: https://www.nytimes.com/2018/12/14/health/obamacare-unconstitutional-texas-judge.html
Hussey, P., & Anderson, G. F. (2003). A comparison of single-and multi-payer health insurance systems and options for reform. Health policy, 66(3), 215-228.
Shi, L. and Singh, D.A. (2012). Delivering Health Care in America: A Systems Approach. 7th Edition. Sudbury, MA: Jones and Bartlett Publishers.
Diabetes is a complex set of disease consisting of various states of insulin intolerance resulting in high blood sugar (hyperglycemia) and other complications. Management of blood sugar levels is a primary goal for diabetes treatments and recent studies have shown that improved diet and exercise regimes can confer benefits to each of the different types of diabetic disease states. Under Type 1 Diabetes, a mostly genetic disease with early onset, increased exercise has shown some tendency to stabilize progression of the disease. Pre-diabetes and Type 2 Diabetes show greater improvements with the former potentially having its progression halted before reaching full Type 2 diagnosis, and the latter showing reductions in blood sugar levels reducing blood toxicity of sugar and also slowing progression of the disease. The implementation of health coaches as mid-level healthcare providers may help diabetes patients incorporate diet and exercise regimes into their treatment plans as well as help maintain medication adherence and other aspects of diabetes treatment plans that are difficult for patients to carry out themselves.
Diabetes is a chronic health conditions that affects around 9.4 % of the U.S. population (30.3 million Americans in 2015, CDC Report). Diabetes is a progressive disorder that increases the risk for many other diseases including heart disease, hypertension, kidney disease, vision loss, and the loss of fingers, toes and limbs due to neuropathy (CDC Report). Currently there are several different classifications for people with diabetes; pre-diabetes (meaning elevated blood glucose levels at risk of entering a disease state, Type 1 Diabetes (a genetic disorder affecting roughly 5% of people with diabetes), and Type 2 Diabetes (an acquired condition that might have a genetic component that is mostly related to diet and overall health) (Colberg, 2016). A fourth type, Gestational Diabetes, can also occur in women that have not previously had diabetes during pregnancy (Colberg, 2016).
One of the critical factors in controlling and reducing the negative, progressive effects of diabetes disorders is glycemic control, that is, the control of blood glucose levels (Inzucchi, 2015). Diabetes is characterized by the loss of either the specialized cells in the pancreas (B-cells) that produce insulin (Type 1 Diabetes), a molecule that queues the body’s cells to uptake glucose from the bloodstream to use in cellular respiration, or by the progressive desensitization of cells to the insulin molecule (Type 2 Diabetes). In both cases the overall result is a surplus of blood sugar (hyperglycemia) that causes cardiovascular and organ damage if left uncontrolled (Colberg, 2016).
Recently, many groups have suggested diet and exercise can either prevent the onset of Type 2 diabetes in the case of pre-diabetic conditions, help improve the overall health outcomes of Type 1 diabetics (Chimen, 2012), and directly influence glucose control in Type 2 diabetes (Snowling, 2006). However, one of the challenges with people suffering from diabetes is that high levels of mental health issues are typically comorbid, making it difficult to begin and maintain the exercise and diet regimes needed to help decrease their diabetic symptoms (Lin, 2008). To solve the behavioral challenge of managing diabetes, the utilization of mid-level healthcare professionals known as “health coaches” has begun to rise (Shi and Singh, 2017). Health coaches can act as intermediaries between patients and their doctors, allowing for more frequent contact about a patient’s care plan, but not altering the care plan itself. Health coaches cannot technically give medical advice, but they can help patients maintain their provider care plans and offer diet, nutrient, and exercise advice to chronic care patients (e.g. diabetics) that would benefit to such. Health coaches can also help patients with their other personal struggles that might interfere with their diabetes treatment, such as access to healthcare itself, medication management/adherence (Wolever, 2010), social support structure (Wolever, 2010), transportation, or financial struggles.
Diabetes is a complex disease spectrum that may benefit from simple behavioral changes such as diet and exercise. However, the symptoms and comorbidities associated with the disease make it difficult for individuals to follow through with provider treatment plans and implement healthier lifestyle changes at the same time. This is where mid-level healthcare professionals known as health coaches can help effect change in patients lives through encouraging them to make positive diet and lifestyle changes.
Colberg, S. R., Sigal, R. J., Yardley, J. E., Riddell, M. C., Dunstan, D. W., Dempsey, P. C., Horton, E.S., Castorino, K. and Tate, D. F. (2016). Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care, 39(11), 2065-2079.
Chimen, M., Kennedy, A., Nirantharakumar, K., Pang, T. T., Andrews, R., & Narendran, P. (2012). What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review. Diabetologia, 55(3), 542-551.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., Peters, A.L., Tsapas, A., Wender, R. and Matthews, D.R. (2015). Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care, 38(1), 140-149.
Lin, E. H., Von Korff, M., & WHO WMH survey consortium. (2008). Mental disorders among persons with diabetes—results from the World Mental Health Surveys. Journal of Psychosomatic Research, 65(6), 571-580.
Snowling, N. J., & Hopkins, W. G. (2006). Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes care, 29(11), 2518-2527.
Shi, L. and Singh, D.A. (2017). Delivering Health Care in America: A Systems Approach. 7th Edition. Sudbury, MA: Jones and Bartlett Publishers.
Wolever, R. Q., Dreusicke, M., Fikkan, J., Hawkins, T. V., Yeung, S., Wakefield, J., Duda, L., Flowers, P., Cook, C. and Skinner, E. (2010). Integrative health coaching for patients with type 2 diabetes. The Diabetes Educator, 36(4), 629-639.