affordable care act essay

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Summary of the Affordable Care Act

Published: Apr 25, 2013

Note: President Trump and Republicans in Congress have pledged to repeal and replace the Affordable Care Act, and unsuccessfully advocated several proposals to do so in Congress in 2017. Compare those plans  here .  As part of the Tax Cuts and Jobs Act of 2017, Congress eliminated the Affordable Care Act’s tax penalty for most people who are not covered by health insurance effective in 2019.  On Dec. 14, 2018, a federal judge in Texas ruled that this change to the law’s individual mandate made the entire law itself unconstitutional, though that decision has no effect as the case works its way through the appeals process.

On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act, into law. The following summary of the law as originally enacted focuses on provisions to expand coverage, control health care costs, and improve health care delivery system.

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Open Access

The US Affordable Care Act: Reflections and directions at the close of a decade

Affiliation PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts, United States of America

* E-mail: [email protected]

Affiliations Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America

• Adrianna McIntyre, 

Published: February 26, 2019

• https://doi.org/10.1371/journal.pmed.1002752
• Reader Comments

Citation: McIntyre A, Song Z (2019) The US Affordable Care Act: Reflections and directions at the close of a decade. PLoS Med 16(2): e1002752. https://doi.org/10.1371/journal.pmed.1002752

Copyright: © 2019 McIntyre, Song. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was supported in part by a grant from the Office of the Director, National Institutes of Health (NIH Director’s Early Independence Award, 1DP5OD024564, to ZS). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: ZS is a member of the Editorial Board of PLOS Medicine.

Provenance: Commissioned, not externally peer reviewed.

Nearly nine years after its passage, the Affordable Care Act (ACA) remains at the forefront of public policy debate. The law is persistently contentious as a matter of public opinion, but represents a historic achievement in United States healthcare reform. While it was incremental in many respects—health insurance plans for the vast majority of Americans were relatively unchanged—the ACA left an indelible mark on the healthcare system through its expansion of insurance coverage and efforts to improve the healthcare delivery system. In the past decade, the country has witnessed a substantial decline in the number of uninsured individuals, while other elements of the law have sought to make inroads into affecting the cost and quality of care [ 1 ]. Yet looking forward, the ACA continues to face challenges that make its abiding impact and legacy uncertain.

What the ACA did for insurance expansion

The ACA expanded insurance coverage in two principal ways. First, it created health insurance marketplaces at the state level on the premise of competition and choice; individuals could compare similar coverage options and choose among competing plans. The health law also provided low-income individuals and households up to 400% of the federal poverty line with subsidies to help them purchase insurance. Second, the ACA expanded eligibility for the Medicaid program to individuals and families with incomes up to 138% of the federal poverty line—about US$35,000 for a family of four. Since the law’s implementation in 2010, the number of uninsured people in the country has fallen by about 20 million [ 2 ].

The ACA reshaped private insurance in other important ways. It established new minimum federal consumer protections; of note, insurers were prohibited from discriminating on the basis of health status—they could not turn people away or charge higher premiums due to pre-existing medical conditions. A set of 10 “essential health benefits” was defined. Annual and lifetime limits on covered health benefits were abolished. The law’s dependent coverage provision enabled children up to age 26 to stay on their parents’ insurance, benefiting between 2 and 3 million young people [ 3 ].

Expansions in health insurance were aided by complementary policies that encouraged people to enroll in coverage. Federal tax credits that reduced the financial burden of monthly premiums—and, in some cases, reduced cost-sharing—made plans on the marketplaces more appealing to low-income consumers. The subsidies functioned as a carrot that was balanced by a stick: the ACA’s individual mandate required people to get covered or else pay a tax penalty. However, the Tax Cuts and Jobs Act effectively eliminated this policy by lowering the penalty for not having health insurance to US$0 beginning in 2019.

When it launched in 2014, this type of regulated individual market was new terrain for most insurers. They were responsible for projecting the likely healthcare costs of people who would elect to take up coverage, with limited experience to guide these estimates. To assuage insurers’ concerns about enrolling unexpectedly sick (and expensive) populations, the ACA implemented federal protections through three programs: risk corridors, reinsurance, and risk adjustment. The first two were temporary; they expired after three years but gave insurers an opportunity to find their footing and price their products accurately. Risk adjustment is a permanent program, intended to mitigate against insurers selecting healthier enrollees and avoiding sicker populations.

Challenges to the ACA

The law has endured numerous legislative challenges following its passage. The House of Representatives advanced over 50 bills to repeal the ACA in whole or in part, with the Senate voting on a subset of them [ 4 ]. These started out as largely symbolic—a presidential veto was virtually guaranteed while President Obama was in office—but began to pose an existential threat to the ACA under a unified Republican government that held power during the first two years of the Trump administration. The narrow 49-to-51 vote defeat of the last prominent repeal effort in the summer of 2017 illustrated the tenuous grounds upon which the law sat in the previous Congress. However, its survival was also a testament to its legislative durability; the political challenge of withdrawing health benefits shared across different constituencies has thus far been insurmountable, despite lukewarm public opinion on the law.

Proponents of the ACA have identified some regulatory actions by the Trump administration as unilateral efforts to undermine the law. For example, terminating funding for cost-sharing reductions, which are supplemental subsidies available to some low-income enrollees, led to fears about destabilizing the markets and increasing the ranks of the uninsured. Cutting resources allocated to enrollment outreach and education have raised similar concerns. Recent changes to insurance regulations will likely make plans that bypass the ACA’s consumer protections more common. Moreover, the administration has made it easier for states to modify their Medicaid programs in ways that could lower enrollment (by requiring nondisabled beneficiaries to work in order to qualify for benefits, for example). Its proponents have championed these changes as efforts to promote consumer choice and state innovation.

Other serious threats to the law’s sustainability have come from the courts. A landmark 2012 Supreme Court decision scaled back the Medicaid expansion from a nationwide mandate to a state option. To date, 14 states have declined to expand their Medicaid programs (although this number has gradually decreased in recent years). Another challenge sought to roll back subsidies on the ACA marketplaces. Still other litigation concerning regulations related to contraceptive coverage is ongoing. Perhaps the ACA’s greatest lingering existential threat comes from a late-2018 district court ruling in Texas. The judge in this case ruled that the zeroed-out mandate is unconstitutional—and, moreover, that the mandate is not severable from the rest of the ACA, meaning that the rest of the law would need to fall with it. The case is now within the appeals process and could end up before the Supreme Court.

Looking forward: 2019 and beyond

The prospects for near-term repeal have diminished with Democrats taking control of the House of Representatives, but the ACA has not receded from the public debate. On the contrary, healthcare ranked among voters’ most important issues in the 2018 midterms. The administration and new Congress will need to decide whether to leave the law alone or modify it. Additionally, attempts to weaken the law through regulatory channels will be subject to increased scrutiny now that Democrats have more congressional oversight.

Opportunities for bipartisan legislation to stabilize the law appear slim. The leading Republican and Democrat of the Senate Health, Education, Labor, and Pensions Committee coauthored a modest marketplace stabilization bill in 2017 that would have provided funding for cost-sharing reductions, increased funding for enrollment outreach and assistance, and made other minor tweaks to the law. However, Democrats may be reticent to revive that bill, as insurers in many states addressed the cost-sharing reductions issue in a way that made insurance more affordable for subsidized enrollees. A more ambitious stabilization bill was introduced by House Democrats in 2018, which would increase the availability of marketplace subsidies by lifting the income cap (currently at 400% of poverty), reverse certain regulations by the current administration, and provide more funding for consumer outreach and assistance. The prospects of this bill are dim without support from across the political aisle.

Perhaps more fundamental for the future direction of health policy, public opinion on the role of government in healthcare is evolving. In 2013, 42% of Americans believed that it is the responsibility of the government to ensure that all Americans have coverage; that number rose to 60% in 2017 [ 5 ]. Support for “Medicare for All” proposals has also climbed in recent surveys, though these opinions have been malleable to follow-up questions. These public opinion trends suggest that a growing share of Americans may be receptive to proposals that move the ACA in a more progressive direction.

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• 2. Martinez M., Zammitti E. and Cohen R. (2018). Health Insurance Coverage : Early Release of Estimates From the National Health Interview Survey , January–June 2018 . National Health Interview Survey Early Release Program. [online] Division of Health Interview Statistics, National Center for Health Statistics. Available from: https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201811.pdf [Accessed 17 Jan. 2019].
• 3. Uberoi N., Finegold K. and Gee E. (2016). Health Insurance Coverage and the Affordable Care Act , 2010–2016 . [online] Washington, DC: Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Available from: https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf [Accessed 17 Jan. 2019].

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The impact of the Affordable Care Act on patient coverage and access to care: perspectives from FQHC administrators in Arizona, California and Texas

Angelo ercia.

1 Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PT UK

2 Cievert, an Evergreen Life Company, Evergreen Business Centre, Clowes St, Manchester, M3 5NA UK

Associated Data

The dataset analysed in this study are not publicly available due to potentially identifiable information about the key informants based on their full transcripts. De-identified data can be requested from the corresponding author upon reasonable request.

The Affordable Care Act (ACA) enabled millions of people to gain coverage that was expected to improve access to healthcare services. However, it is unclear the extent of the policy’s impact on Federally Qualified Health Centers (FQHC) and the patients they served. This study sought to understand FQHC administrators’ views on the ACA’s impact on their patient population and organization. It specifically explores FQHC administrators’ perspective on 1) patients’ experience with gaining coverage 2) their ability to meet patients’ healthcare needs.

Twenty-two semi-structured interviews were conducted with administrators from FQHCs in urban counties in 2 Medicaid-expanded states (Arizona and California) and 1 non-expanded state (Texas). An inductive thematic analysis approach was used to analyze the interview data.

All FQHC administrators reported uninsured patients were more likely to gain coverage from Medicaid than from private health insurance. Insured patients generally experienced an improvement in accessing healthcare services but depended on their plan’s covered services, FQHCs’ capacity to meet demand, and specialist providers’ willingness to accept their coverage type.

Gaining coverage helped improved newly insured patients’ access to care, but limitations remained. Additional policies are required to better address the gaps in the depth of covered services in Medicaid and the most affordable PHI plans and capacity of providers to meet demand to ensure beneficiaries can fully access the health care services they need.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06961-9.

The Patient Protection and Affordable Care Act (ACA) of 2010 was a comprehensive national health care reform aimed to expand health insurance coverage and improve access to care in the United States (US). The ACA enabled people to gain coverage by 1) expanding the publicly funded Medicaid program to cover adults with annual incomes up to 138% of the federal poverty level; 2) establishing the Health Insurance Marketplace for individuals and small businesses, allowing them to purchase private health insurance (PHI); and 3) enforcing an individual mandate that required eligible people to have federally approved health insurance coverage [ 1 – 4 ].

While the policy was passed in 2010, the provisions to expand coverage took effect in 2014 and their implementation varied from state to state. Some states did not expand the Medicaid program because of the Supreme Court’s 2012 ruling that made it an option [ 2 ]. As of 2020, 39 states, including the District of Columbia (D.C.), opted to expand Medicaid while 12 states decided against implementing the expansion [ 5 ]. Despite the inconsistent implementation of coverage expansion across the nation, the ACA enabled millions of uninsured people to gain coverage. An estimated 10.8 million low-income uninsured individuals enrolled in Medicaid in 2014 [ 6 ] and this increased to 12.2 million people by 2015 [ 2 ]. The Health and Human Services estimated that 11.7 million people in 2014 enrolled in a PHI plan [ 6 , 7 ]. The National Health Interview Survey estimated the rate of uninsured people dropped to 9% by 2015 [ 8 ]. Several studies [ 9 – 11 ] have highlighted the different decline of uninsurance between Medicaid expanded and non-expanded states-- the former experiencing a larger decline in their uninsurance rates.

It was expected the ACA’s coverage expansion would improve access to care [ 12 ]. However, inconclusive evidence from several studies suggests it is unclear whether it has been realized, particularly among newly insured patients. For example, Shartzer et al. [ 7 ] suggest that access to care improved between 2013 and 2015 among nonelderly adults. Key informants (e.g., Medicaid and marketplace officials, assisters and advocates) interviewed in 4 Medicaid-expanded states (Colorado, Connecticut, Kentucky, and Washington) in 2016 believed Medicaid patients generally had good access to care, but acknowledged that limitations remained [ 13 ]. Wherry and Miller’s [ 14 ] findings suggest the evidence supporting improvements in access to care in Medicaid-expanded states was also inconsistent.

Furthermore, there is limited understanding of the ACA’s coverage expansion effect on newly insured low-income patients’ access to care served by Federally Qualified Health Centers (FQHCs). FQHCs are an integral part of the US’s safety net system as it provides primary care services to millions of vulnerable and underserved populations [ 10 – 12 ]. It has been estimated that FQHCs served one in 11 people in the nation [ 15 ]. The ACA’s coverage expansion was expected to enable many uninsured patients served by FQHCs to gain coverage from Medicaid and help them have better access to care. However, few studies have explored this topic. Findings have suggested that newly insured FQHC patients may have continued to experience limitations in accessing care. For example, some studies found that FQHCs in Medicaid-expanded states experienced an increase in their visit rates compared to non-expanded states [ 16 , 17 ]. Angier et al. [ 18 ] also found FQHCs in five expanded states (California, Minnesota, Ohio, Oregon and Washington) experienced a 32% increase or 71 more visits per month among Medicaid patients. These findings suggest the immediate rise in demand may have challenged FQHCs to meet higher demand for care, particularly in sites that had limited capacity prior to the ACA taking effect. Some studies [ 13 , 19 ] also have found that improvements in accessing care depended on primary and secondary care providers’ willingness to accept certain coverage type. Newly insured patients, particularly with Medicaid, could not always get care from their chosen provider, as it was not widely accepted [ 19 , 20 ]. Therefore, this study aimed to gain insights from FQHC administrators in Medicaid expanded and non-expanded states on the impact introduced by the ACA on their patient population and organization. Specific objectives were to investigate 1) administrators’ views on patients’ experience with gaining coverage and 2) administrators’ views on their ability to meet patients’ healthcare needs.

This study conducted semi-structured interviews with key informants that included executive directors and mid-level managers from selected FQHCs in urban counties of Arizona (AZ), California (CA), and Texas (TX). The study selected administrators from FQHCs in Medicaid-expanded states and a non-expanded state to understand their experiences with the ACA’s coverage expansion. California was selected because it expanded Medicaid and TX was selected because it did not expand the program. Arizona was included because it was a state that reluctantly expanded Medicaid. These three states were also selected because of similar characteristics of being Border States in the lower part of the US and continued increase in population growth [ 21 ]. Convenience sampling was used to select all FQHCs. AE initially identified FQHCs within a selected area comprised of urban counties in the three states from his pre-exiting professional network, as this provided a point of contact. A web search was then conducted to identify other FQHC sites in the area outside AE’s network. An FQHC was selected if they were classified as a Health Resources and Services Administration grantee and a community health center. At least one selected FQHC site had a large patient population (over 50,000) and a small patient population (under 50,000) in each selected area. This study used some data collected for AE’s PhD thesis [ 22 ] and received ethical approval from the University of Edinburgh School of Social and Political Science.

Participants and recruitment

Key informants were selected to be interviewed if they held an executive director and mid-level manager position in the selected FQHCs. Executive directors were selected given their oversight of the strategic and financial management of their respective organizations [ 23 ]. They supported mid-level managers to oversee the impact of the ACA on their programs and patients. Mid-level managers were selected given their unique role of managing social structures and organizational strategic plans, while also managing day-to-day activities on their site [ 24 ]. The selected managers also supervised clinical services, patient outreach, and registration of health insurance plans, which were affected by the ACA. Convenience sampling was used to recruit participants through the primary author’s pre-existing professional networks, web searches, and social media. AE communicated with all the participants through email, which included inviting them to take part and scheduling the interview. The snowballing approach was also used to identify other participants suitable for the study. Participants that either declined or did not respond to the invitation were replaced by someone with a similar background in the organisation.

Data collection

AE conducted all the interviews and took place during the selected timeframe of the study from July and September 2014. The majority of the interviews were conducted in the administrators’ office or in a meeting room within their FQHC. One interview was conducted on the telephone and another occurred in a public meeting space. Most of the interviews were completed individually. One interview was conducted with two participants from the same organization because of convenience. Participants completed a written consent form at the start of the interview and were aware that their participation was voluntary, with no compensation. The interview lasted for 60 minutes, conducted in English, and was guided by a topic guide (see Supplementary A ). The design of the topic guide was primarily informed by the research question and current literature. As there is a gap in knowledge in the ACA’s direct impact on primary care providers, particularly among FQHCs’ patient population and organization, most of the questions in the guide aimed to explore these topics. The topic guide included questions that explored administrators’ perspectives on the impact of the ACA on their uninsured patients’ ability to gain coverage, their ability to meet patients’ healthcare needs, and challenges and opportunities with coverage expansion. The interviews were all audio recorded and then transcribed verbatim by the primary author.

Data analysis

AE reviewed several transcripts and inductively coded the interviews to develop an initial coding framework guided by the research question. Several meetings took place with AE and two other members of the research team to discuss the suitability of the framework. Multiple meetings took place to discuss the coding process and the outcome of taking a constant comparative approach. NVivo 10 software was used to conduct this process. The coded data was then thematically analyzed [ 25 ] and presented to the research team to discuss emerging themes. The team met several times to discuss the themes as related to the research question until consensus was reached.

Ten FQHCs in two Medicaid expanded-states (AZ, CA) and one non-expanded state (TX) were selected to be part of this study. Four FQHCs were selected in AZ, 4 in CA, and 2 in TX. Twenty-two interviews were conducted and at least one executive director and one manager were interviewed in each site. There were instances that 2 executive directors and 2 managers were interviewed in some sites because of their availability. A total of 11 executive directors and 11 managers were interviewed (see Table  1 ). All FQHCs were in areas comprised of urban counties and offered similar comprehensive primary care services, dental care, mental health, health education, enabling and outreach services. All sites had a central site and multiple satellite sites. The patient volume served at all sites varied. At least one FQHC in each state served over 90,000 patients, and at least one FQHC served less than 50,000 patients.

Interviews conducted

Administrator views on FQHC patients’ ability to gain coverage

All the interviewed FQHC administrators had positive views on expanding Medicaid to cover more low-income uninsured adults. Arizonan and Californian administrators were particularly positive about Medicaid expansion, as their state enacted the provision.

“I think the biggest impact of the Affordable Care Act so far has been the dramatic increase in the number of patients that we see who has Medi-Cal [California’s Medicaid program].” (CA Director 2)

Most administrators from AZ and CA estimated that the program’s expansion increased their sites’ newly insured Medicaid patients by 10 to 15%. However, directors and managers believed the increase was determined by the proportion of uninsured patients in their community that met the new eligibility criteria for Medicaid. Some FQHCs served communities with high uninsured populations that were eligible for Medicaid under the expanded eligibility criteria. Other FQHCs served communities with high immigrant and undocumented populations that were ineligible for Medicaid because of their immigration status. Arizona director 3 described their site as experiencing a 10% increase of newly insured Medicaid patients. However, they continued to serve a high proportion of uninsured patients who were ineligible for Medicaid because of their immigration status. Several other administrators in AZ, CA, and TX acknowledged that patients’ immigration status was a major barrier to gaining Medicaid. Therefore, FQHC administrators continued to depend on unrestricted locally funded programs to help subsidize the cost of care for these patients.

All Texan administrators believed their state’s decision to not expand Medicaid was a missed opportunity for their FQHC. They believed expanding the program would have enabled many of their low-income uninsured patients to gain coverage from Medicaid and reduce the proportion of patients without coverage they served. It would have also enabled their organization to generate more revenue that could help expand their capacity and resources to meet demand for care. While TX has yet to adopt Medicaid expansion, most directors believed their state would expand the program eventually in some form that best meets the needs of their population.

“Texas has said that they are not going to expand Medicaid, but I don’t think that means they are not going to do anything, right? They are going to do something, they just gotta figure out what works for Texas … it just probably won’t look like how the Feds (US Federal government) originally designed it. [It] will look like something Texas designed.” (TX Director 2)

All Arizonan and Californian administrators acknowledged their uptake of newly insured patients with PHI was minimal. Texan FQHCs experienced a higher uptake of patients with PHI compared to AZ and CA FQHCs, but administrators did not view this as significant. Two Texan directors from the same FQHC stated 1% of their patients had PHI prior to the ACA and only increased to 5% after the enactment of the ACA.

All administrators from the three states acknowledged PHI remained unaffordable for many of their low-income patients. Patients with annual incomes slightly surpassing the Medicaid income eligibility risked not being able to afford the monthly premium and out-of-pocket expenses of a marketplace PHI plan even with Federal government subsidies. Most of the managers also believed the patients that could purchase a marketplace PHI plan would experience financial hardship in maintaining their plan.

“I think most our patients are making the decision whether they want to buy groceries or go to the doctor. And they don’t have the money for even an inexpensive insurance program … it’s like these people not only live pay check to pay check … They were already coming to see us with no money.” (TX Manager 1)

All administrators from the three states believed low-income FQHC patients that purchased a PHI plan selected the most affordable plan (known as the bronze plan). These plans had limited provider networks and high out-of-pocket expenses, thus limiting beneficiaries’ access to care. AZ Director 2 stated, “generally the well visits are covered but if [they] end up needing acute care [their] insurance may not pay much at all . .. maybe [their] deductible is $2,500 before [their] insurance really kicks in”. Several directors and managers were also concerned that their low-income patients with PHI were underinsured, a problem that seemed to grow under the ACA. TX Manager 2 believed these plans give their patients a sense of “ falsehood of being insured when really, they [can’t afford] insurance”.

Challenges of newly insured patients to access primary care services from FQHCs

All the administrators in the three states viewed the Medicaid program as an effective form of coverage for their low-income patients. It enabled beneficiaries to access preventative and primary care services with no, or limited, out-of-pocket expenses. However, Arizonan and Californian administrators were concerned that fewer non-FQHC primary care providers (PCPs) (e.g., private providers) accepted new Medicaid patients to establish care with them. Therefore, it restricted new Medicaid patients’ choice of PCPs and, to an extent, caused them to rely on establishing care with an FQHC. This caused FQHCs to see an increase in serving more insured patients. Most managers in AZ and CA believed the rapid gains of newly insured patients, particularly with Medicaid, further increased their demand and affected access to care. CA Manager 2 believed, “[taking] a large group of people who formerly didn’t have any health insurance coverage and [are given] coverage overnight. .. these people have all these pent up health care needs. .. now they are flooding the system, they have an ‘[insurance] card’ so they think they should get everything in today and rightfully so” . Managers from other FQHCs also believed newly insured patients had many neglected health conditions that were not treated when they were uninsured. Many patients required multiple treatments and referrals. According to CA manager 4, “ it’s not like [a patient] comes in here today and get a flu shot. .. [they] get so many referrals, [they need] so much help” .

The rapid rise of serving newly insured Medicaid patients with co-morbidities that needed multiple treatment caused many patients in AZ and CA to experience longer waits for an appointment. CA Manager 1 stated “ someone might attempt to schedule an appointment to establish care, and for those type of appointments it can take as long as three months ”. Directors and managers from TX did not associate the increase in demand they continued to experience after the ACA took effect because of the limited impact of coverage expansion. They believed local events such as recent rises in migration into their city more likely contributed to the increased number of patients seeking care from them.

All administrators from the three states believed they would continue to struggle to meet demand unless they expanded their capacity, something that had proven difficult because of limited financial resources and workforce shortages. This limited capacity stopped some FQHCs accepting new patients, which directly affected patients’ ability to establish care with them. TX Director 3 acknowledged limited capacity meant, “ the [staff] have to explain to patients that [they] are not accepting new patients. They give them the number for the two other FQHCs [that] are accepting new patients and until we get the new site, that’s the best we can do” .

Challenges of newly insured patients’ access to secondary care services

Most of the administrators discussed struggling to refer their newly insured patients to secondary care because of the large volume of need. CA Manager 4, in agreement with the perspectives of the other administrators in AZ and TX, stated:

“When they come to us (patients), they [need] four or five referrals. .. they need to see a cardiologist, they need to see a gastroenterologist. They have so much going on and I don’t think we were expecting that.”

This study found that some newly insured patients’ coverage plan restricted their ability to access secondary care. All administrators from the three states acknowledged that referring Medicaid patients to specialists pre-ACA was a challenge, as not all specialists accepted the coverage. Most Arizonan and Californian administrators also believed specialists became more selective about the type of coverage they accepted after the ACA took effect. Some administrators described that there were only a handful of secondary care providers in their region willing to accept patients with Medicaid. Some directors aimed to form partnerships with local specialists to serve their patients, but this did not guarantee patients access to timely secondary care. The majority of administrators in the three states also struggled to refer patients with the most affordable PHI plan (bronze plan) to specialists, as these plans had a very narrow network of specialist providers willing to accept the coverage and high out-of-pocket expenses. AZ Director 2 stated,

“ We worry that they (patients) are going to need specialty care and it’s not going to be available. .. the network is going to be so narrow that it’ll be challenging to find them specialty providers” .

Constant shortages of specialists across regions further challenged patients’ ability to access secondary care services because of long waiting times. AZ Director 1 stated, “If you need a rheumatology referral, we are talking [a] three or four months [wait]” . A Californian manager acknowledged that many of their local specialists were also reaching maximum capacity. The manager described that there was a 6 month waiting period for physical therapy referrals in the county general hospital. Sometimes patients were referred to specialists outside their county because of lack of appointment availability. This was a barrier for many FQHC patients, as it required them to take time off from work and potentially travel long distances.

The ACA’s multi-faceted approach to expanding coverage enabled millions of people in the US to gain coverage in a short period of time [ 26 , 27 ]. However, this study found that administrators believed Medicaid expansion was the key element in providing coverage to low-income uninsured patients served by FQHCs in urban counties of AZ and CA. The absence of Medicaid expansion in TX placed many low-income patients of FQHCs at risk of remaining uninsured as marketplace PHI plans remained unaffordable. Moreover, all the administrators believed Medicaid was the most appropriate form of coverage for their low-income patients because of its comprehensive coverage for primary care services and limited or no out-of-pocket expenses. Health care professionals from small private practices, FQHCs, free/low-cost clinics, and hospital-based practices in other states such as Michigan also had this view [ 28 ].

The findings of this study and others [ 13 , 28 ] suggests newly insured Medicaid patients experienced an improvement in accessing care under the ACA. However, this study highlights exceptions as some newly insured continued to experience limitations with accessing care and, sometimes, contributed to the growing problem of underinsurance. For example, some private PCPs in AZ and CA did not accept newly insured Medicaid patients to establish care with them. Some newly insured Medicaid patients, therefore, had limited choice of PCPs and, to an extent, relied on establishing care with FQHCs when no other providers would accept them. This is supported in Boccuti et al. [ 29 ] analysis of a nationwide survey of primary care providers, as they found that only 45% of non-paediatric PCPs accepted new Medicaid patients- a proportion much lower compared to accepting patients with Medicare (72%) or private insurance (80%). Other studies [ 4 , 30 – 32 ] also found that compared to privately insured patients, more Medicaid patients struggled to get appointments with primary care providers. A contrasting viewpoint comes from Polsky et al. [ 26 ] which found the ACA’s temporary introduction of higher payment rates for PCPs serving Medicaid patients improved patients’ ability to get an appointment in 10 states. It was unclear, however, whether PCPs would continue accepting new Medicaid patients and offer appointments after the temporary payment increase ended.

Besides the challenges with establishing care with private PCPs, administrators believed newly insured patients with Medicaid and the most affordable PHI plan experienced difficulties in accessing secondary care services. Most administrators in AZ, CA, and TX acknowledged the challenge of referring their Medicaid patients to secondary care, both before and after the enactment of the ACA. However, they observed that newly insured patients with Medicaid or marketplace PHI plan continue to struggle to access secondary care services given the very narrow network of specialists willing to accept their coverage. Out-of-pocket expenses of affordable PHI plan were also high and unaffordable. These findings have been found by other studies [ 13 , 24 , 33 – 35 ] and suggest that gaining insurance did not necessarily protect newly insured FQHC patients from becoming underinsured.

Although the depth of covered services of Medicaid and certain PHI plans influenced newly insured patients’ ability to access care, the study findings also suggest the capacity of healthcare providers to provide care was a significant factor. All FQHC administrators in the three states acknowledged their organization struggled to meet demand because of their limited capacity even before the ACA took effect. Arizonan and Californian administrators believed coverage expansion further exacerbated this problem, as they served more newly insured Medicaid patients that sought care for multiple untreated health conditions. Many newly insured patients had comorbidities that required extensive treatment and referrals to secondary care services. The analysis of the Community Health Applied Research Network database that composed of 17 FQHCs in nine states also found demand increased under the ACA because of serving new young patients with chronic physical and/or mental health conditions requiring multiple primary and secondary treatments [ 27 ]. The high demand prior to and after the implementation of the ACA with constant limited capacity, thus made it more difficult for these primary care providers to meet the needs of newly insured patients.

The limited capacity of secondary care providers affected their ability to meet demand for care, particularly in regions with high specialist provider shortages. This was not unique to AZ, CA, and TX, as Goold et al. [ 28 ] found specialist shortages occurred in rural and urban areas across Michigan. Nakamura et al. [ 36 ] also suggest that access to specialty care depended on the availability of specialists in the region. Administers in this study believed it caused patients to experience longer waiting period for appointments, travel farther distances to receive care, or could not access secondary care altogether. As a result, it reduced FQHCs’ ability to effectively care for their patients and contributed to the rise in patients developing unmet medical needs that required additional services, including emergency services [ 37 ].

Policy implication and limitation of the study

This study adds to the literature insights from FQHC administrators on their experience with the ACA’s impact on their patient population and organization. It expands knowledge in understanding how the design of the ACA in expanding coverage and improving access to care translated into practice among FQHCs and the patients they served.

A key finding in the study identified the covered services of Medicaid and certain private insurance plans (e.g., bronze plan) were limited and not all providers accepted them. This caused patients with the coverage type to continue experiencing barriers in accessing primary and secondary care services, particularly in areas that had few providers. It underscores the need for additional policies in these plans to be widely accepted as to prevent patients from having health insurance coverage but unable to establish care with a provider or access to affordable health care services. This issue is a nationwide problem, as scholars and policymakers in other states have identified the need to address it. The state of Michigan considered setting up local incentives for providers to encourage acceptance of all forms of coverage [ 12 ]. Colorado policy makers considered increasing reimbursement rates for providers that accepted Medicaid [ 13 ]. Kentucky and Washington policymakers considered allowing more primary and secondary care providers to join the provider network that offers services to Medicaid patients [ 13 ]. Improving the network of secondary care providers that accept Medicaid and all forms of marketplace PHI plan is also imperative to minimize unmet needs and exacerbating patients’ health conditions that cannot be treated from primary care alone. While local and state level policies may be an effective initial step in addressing this problem, a comprehensive national approach could better address this issue that could minimize different practices across states.

Newly insured patients’ ability to access primary healthcare services relied on FQHCs’ capacity. Our findings suggest that many of the FQHCs were challenged to effectively meet the needs of their patients when they reach their maximum capacity. Expanding capacity to meet higher demand was also a struggle for most FQHCs as this was a lengthy process that could be affected by external factors such as availability of funding and access to the healthcare workforce. This was not a unique problem in this study as [ 13 ] found that FQHCs in Colorado, Connecticut, Kentucky, and Washington also had the same issue. Furthermore, Artiga et al. [ 13 ] found hiring more primary care providers became more challenging under the ACA because of intense competition among all healthcare providers to hire more of them. FQHCs in Colorado also struggled to recruit and retain clinical staff because of their inability to provide competitive salaries that the private sectors could offer [ 13 ]. Policy makers need to consider a strategy in which FQHC providers can hire and retain more healthcare professionals to expand their capacity without the financial competition from private providers. Otherwise, FQHCs will continue to struggle to recruit for more personnel and will remain in a constant state of trying to keep up with demand.

This study has several limitations that should be considered. First, the interviews were conducted with FQHC administrators working in urban counties in AZ, CA, and TX. Their experiences and perspectives differ from those of FQHCs in other parts of the state and country, particularly in rural areas. Second, the perspectives of the administrators reflected the beginning of the ACA’s implementation of coverage expansion. California expanded Medicaid in October 2013 and Arizona expanded in January 2014, thus the views of administrators reflected their experiences during the early stages of the policy implementation and several months thereafter. The study also focused on understanding the views of executive directors and mid-level managers. While this provided unique insights into the impact of the ACA’s coverage expansion on FQHCs, these insights do not reflect the experiences of patients and wider staff members—particularly clinicians. Third, these states are along the border of Mexico, thus exposing them to unique factors caused by migration and immigration policies. Many of the administrators in AZ, CA, and TX acknowledged the immediate impact of state- and federal-level immigration policies. Remaining well-informed of current immigration policies was important, given their impact on the organization and patient population. Last, Texas was the only state selected that did not expand Medicaid in the sample. Therefore, the perspective of administrators from the state may be unique and does not reflect other non-expanded states’ experiences to be used exclusively as a comparison to Medicaid-expanded states.

This study presents FQHC administrators’ views on the ACA’s impact on their patient population and organization. The findings suggest the ACA’s coverage expansion provided the opportunity for uninsured low-income FQHC patients to gain coverage. However, uninsured FQHC patients living in Medicaid expanded states (AZ and CA) were more likely to gain coverage than those living in the non-expanded state (TX). PHI from the marketplace remained unaffordable for most uninsured FQHC patients. While gaining coverage from Medicaid and the most affordable PHI plan enabled newly insured patients to experience an improvement in accessing care, gaps remained in the depth of covered services and willingness of all providers to accept them. Additional policies are needed to expand covered services of these coverage types and extend capacities of FQHCs to better meet higher demand for care.

Acknowledgements

The author would like to thank the members of the research team, Dr. Mark Hellowell and Dr. Sarah Hill from the University of Edinburgh School of Social and Political Science. Dr. Hellowell and Dr. Hill contributed to the design of the study and interpretation of the data as they were the author’s PhD supervisors.

The author would also like to thank the key informants that took part in the interview from the selected FQHCs in Arizona, California and Texas. Their willingness to share the perspective enabled this study to further explore the impact of the ACA on these providers and their patients.

Abbreviations

Author’s contributions.

AE conceptualized the study, study design, data collection, analysis of results and interpretation of the findings. AE also drafted and completed the manuscript revisions. The author read and approved the final manuscript.

This study was not funded by any funder.

Availability of data and materials

Declarations.

The study was approved by School of Social and Political Science of The University of Edinburgh. Written informed consent was obtained from all participants to participate. All methods performed in this study meets BMC Health Services Research ethics and consent guidelines.

Not applicable.

The author declare that he has no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Home — Essay Samples — Nursing & Health — Health Care — Affordable Care Act

Essays on Affordable Care Act

Brief description of affordable care act.

The Affordable Care Act, also known as Obamacare, is a comprehensive healthcare reform law enacted in 2010. It aims to expand healthcare coverage, control healthcare costs, and improve the quality of care. The ACA has had a significant impact on the healthcare system in the United States, making it a crucial topic for discussion and analysis.

Importance of Writing Essays on This Topic

Essays on the Affordable Care Act are important for both academic and personal exploration. They provide an opportunity to understand the complexities of healthcare policy, analyze its impact on various stakeholders, and evaluate the effectiveness of the ACA in achieving its goals. Writing on this topic also allows individuals to engage with current healthcare issues and contribute to informed public discourse.

Tips on Choosing a Good Topic

• Consider the impact of the ACA on specific demographics or healthcare providers.
• Analyze the political and economic implications of the ACA.
• Evaluate the effectiveness of the ACA in addressing healthcare disparities.

Essay Topics

• The impact of the Affordable Care Act on access to healthcare for low-income individuals.
• The role of the Affordable Care Act in reducing healthcare costs for small businesses.
• A critical analysis of the individual mandate in the Affordable Care Act.
• The influence of the Affordable Care Act on insurance coverage for pre-existing conditions.
• The ethical implications of the Affordable Care Act's contraceptive coverage mandate.
• An argumentative essay on the effectiveness of Medicaid expansion under the Affordable Care Act.
• Reflective essay on personal experiences with the Affordable Care Act.
• The Affordable Care Act and its impact on mental health services.
• Comparing the Affordable Care Act with healthcare systems in other countries.
• The future of the Affordable Care Act under changing political landscapes.

Concluding Thought

Exploring the Affordable Care Act through essay writing offers a valuable opportunity to delve into the complexities of healthcare policy and its real-world impact. By engaging with this topic, individuals can contribute to meaningful discussions and develop a deeper understanding of the challenges and opportunities within the healthcare system.

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• What Is the Affordable Care Act?
• Understanding the ACA
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Affordable Care Act (ACA): What It Is, Key Features, and Updates

Investopedia / Zoe Hansen

What Is the Affordable Care Act (ACA)?

The Affordable Care Act (ACA) is the comprehensive healthcare reform signed into law by then-President Barack Obama in March 2010. Formally known as the Patient Protection and Affordable Care Act and commonly referred to as Obamacare, the law includes a list of healthcare policies intended to expand access to health insurance to millions of uninsured Americans.

The law expanded Medicaid eligibility, created health insurance exchanges, mandated that Americans purchase or otherwise obtain health insurance, and prohibited insurance companies from denying coverage due to preexisting conditions .

Key Takeaways

• The Affordable Care Act was signed into law in March 2010 and is commonly known as Obamacare.
• The ACA was designed to extend health coverage to millions of uninsured Americans.
• The ACA expanded Medicaid eligibility, created a Health Insurance Marketplace, and prevented insurance companies from denying coverage due to preexisting conditions.
• The Affordable Care Act requires insurers to cover a list of essential health benefits.

Understanding the Affordable Care Act (ACA)

The ACA was designed to reform the health insurance industry and help reduce the cost of health insurance coverage for individuals who qualify. The law includes premium tax credits and cost-sharing reductions to help lower expenses for lower-income individuals and families.

The ACA requires most insurance plans, including those sold on the Health Insurance Marketplace , to cover a list of preventive services at no cost to policyholders that include checkups, patient counseling, immunizations, and numerous health screenings.

All ACA-compliant health insurance plans must cover specific “essential health benefits,” such as emergency services, family planning, maternity care, hospitalization, prescription medications, mental health services, and pediatric care.

The law allows states to extend Medicaid coverage to a wider range of people. As of September 2022, 39 states and the District of Columbia had exercised that option.

Every year, there is an open enrollment period on the Health Insurance Marketplace during which people can buy or switch insurance plans. Enrollment outside of the open season is allowed only for those whose circumstances change, such as marrying, divorcing, becoming a parent, or losing a job that provided health insurance coverage.

The Inflation Reduction Act of 2022 extends the expanded ACA for three years, through 2025, for people who need financial assistance. It also allows Medicare to negotiate the cost of prescription drugs and place an annual cap of $2,000 on the cost of drugs. The ACA extension is expected to cost an estimated $64 billion.

Key Features of the Affordable Care Act

Provisions included in the ACA expand access to insurance, increase consumer protections, emphasize prevention and wellness, improve quality and system performance, expand the health workforce, and curb rising healthcare costs.

Expand Access to Insurance

The ACA requires employers to cover their workers and provides tax credits to certain small businesses that cover specified costs of health insurance for their employees. It created state- or multistate-based insurance exchanges to help individuals and small businesses purchase insurance. 

The law expanded Medicaid coverage for low-income individuals and allows young adults to remain on parents’ policies until age 26.

Part of the ACA until 2017 was the individual mandate, a provision requiring all Americans to have healthcare coverage, either from an employer or through the ACA or another source, or face tax penalties.

Increase Consumer Insurance Protections

The ACA prohibits lifetime monetary caps on insurance coverage, limits the use of annual caps, and establishes state rate reviews for insurance premium increases. It prohibits insurance plans from excluding coverage for children with preexisting conditions and canceling or rescinding coverage.

Prevention and Wellness

The Prevention and Public Health Fund, established under the ACA, provides grants to states for prevention activities, such as disease screenings and immunizations, and the National Prevention, Health Promotion, and Public Health Council addresses tobacco use, physical inactivity, and poor nutrition.

The ACA requires insurance plans to cover preventive care such as immunizations; preventive care for children; screening for certain adults for conditions such as high blood pressure, high cholesterol, diabetes, and cancer; and a public education campaign for oral health.

Improve Health Quality and Curb Costs

The ACA requested investments in health information technology. It addressed guidelines to reduce medical errors and create payment mechanisms to improve efficiency and results and improve care coordination among providers.

The law requires oversight of health insurance premiums and practices, reducing healthcare fraud and uncompensated care to foster comparison shopping in insurance exchanges to increase competition and price transparency.

Pros and Cons of the Affordable Care Act

Expands healthcare availability to more citizens

Prevents insurers from making unreasonable rate increases

Individuals with preexisting health conditions cannot be denied

Coverage for additional screenings, immunizations, and preventive care

Those already insured saw an increase in premiums

Taxes were created to help supplement the ACA, including taxes on medical equipment and pharmaceutical sales

The enrollment period is limited for new enrollees

Many businesses curtailed employee hours to avoid providing medical insurance

Updates to the Affordable Care Act

With his election in 2016, then-President Donald Trump launched efforts to repeal and replace the ACA, stating that the United States should delay “the implementation of any provision or requirement of the [Patient Protection and Affordable Care] Act that would impose a fiscal burden on any State.”

In December 2017, the Tax Cuts and Jobs Act (TCJA) removed the penalty for individuals not having health insurance and substantially scaled back the outreach program to help Americans sign up for the ACA, cutting the enrollment period in half. By 2018, the number of Americans covered under the ACA had dropped to 13.8 million from 17.4 million in 2015, according to a report from the Kaiser Family Foundation, a healthcare research organization.

In 2021, President Biden signed an executive order to focus on the “rules and other policies that limit Americans’ access to health care,” prompting federal agencies to examine five areas, including preexisting conditions, policies undermining the Health Insurance Marketplace, enrollment roadblocks, and affordability. COVID-19 relief legislation, the American Rescue Plan Act (ARPA) , extended eligibility for ACA health insurance subsidies to those buying their health coverage on the Marketplace with incomes over 400% of poverty.

With the passage of the Inflation Reduction Act , signed into law by Biden on Aug. 16, 2022, financial assistance was extended for people enrolled in the ACA through 2025 instead of 2022. It also expands eligibility, allowing more middle-class citizens to receive premium assistance. The legislation passed in both the House of Representatives and the Senate.

What are common arguments for and against the Affordable Care Act (ACA)?

Opponents argue that the Affordable Care Act (ACA) hurts small businesses that are required to provide insurance, raises healthcare costs, and creates a reliance on government services by individuals.

Proponents state that those with health insurance get medical attention quickly and live a healthier lifestyle. They contend that the healthcare system will operate more efficiently when commercial insurers and their customers do not need to fund the uninsured.

When does the yearly enrollment period on the Marketplace begin?

The Health Insurance Marketplace is available for new enrollment on Nov. 1, and information is available on the government website .

How many citizens use the Health Insurance Marketplace?

As of 2021, more than 13 million citizens are enrolled in coverage offered by the ACA’s Marketplace.

The Patient Protection and Affordable Care Act (ACA) was passed in 2010 and is commonly known as Obamacare. It extended healthcare coverage to millions of previously uninsured Americans. The ACA launched the Health Insurance Marketplace, through which eligible people may find and buy health insurance policies.

All ACA-compliant health insurance plans, including those sold through the Marketplace, must cover several essential health benefits. The ACA has continued to evolve through three presidencies.

HealthCare.gov, Health Insurance Marketplace. “ Affordable Care Act (ACA) .”

HealthCare.gov, Health Insurance Marketplace. “ Preventive Care Benefits for Adults .”

HealthCare.gov, Health Insurance Marketplace. “ What Marketplace Health Insurance Plans Cover .”

Kaiser Family Foundation. “ Status of Medicaid Expansion Decisions: Interactive Map .”

HealthCare.gov, Health Insurance Marketplace. “ Enroll in or Change 2022 Plans—Only with a Special Enrollment Period .”

Senate Democratic Caucus. “ Summary: The Inflation Reduction Act of 2022 .”

Congress.gov, U.S. Congress. “ H.R.5376—Inflation Reduction Act of 2022: Actions .”

National Conference of State Legislatures. “ The Affordable Care Act .”

HealthCare.gov, Health Insurance Marketplace. “ Fee .”

Federal Register. “ Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal .”

Kaiser Family Foundation. “ Data Note: Changes in Enrollment in the Individual Health Insurance Market Through Early 2019 .”

The White House. “ Fact Sheet: President Biden to Sign Executive Orders Strengthening Americans’ Access to Quality, Affordable Health Care .”

U.S. Department of Health and Human Services Archives. “ All-Time High: 13.6 Million People Signed Up for Health Coverage on the ACA Insurance Marketplaces with a Month of Open Enrollment Left to Go .”

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About the Affordable Care Act

The Patient Protection and Affordable Care Act, referred to as the Affordable Care Act or “ACA” for short, is the comprehensive health care reform law enacted in March 2010.

The law has 3 primary goals:

• Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the  federal poverty level  (FPL). 
• Expand the Medicaid program  to cover all adults with income below 138% of the FPL. Not all states have expanded their Medicaid programs.
• Support innovative medical care delivery methods designed to lower the costs of health care generally.

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For the first time, more Americans say 2010 health care law has had a positive than negative impact on U.S.

While the future of the Affordable Care Act is in question , the public increasingly thinks the law has had a positive impact on the country. Today, more Americans say the 2010 health care overhaul has had a mostly positive than mostly negative effect on the country (44% versus 35%), while 14% say it has not had much effect.

Overall support for the health care law also has grown since last year. Currently, 56% of the public approves of the law while 38% disapproves, according to a new national survey by Pew Research Center, conducted Nov. 29-Dec. 4. The law drew majority approval for the first time in February , when 54% expressed support for it.

As recently as April 2016, more Americans thought the law had had a negative impact on the country (44%) than said it had a positive effect (39%). Since 2013, the share of Americans saying the law has had a positive effect on the country has increased 20 percentage points, from 24% to 44%.

In addition, the share saying the law has had a positive personal effect has ticked up over the past year. Today, about as many say its effect on them and their families has been mostly positive (28%) as say mostly negative (24%); nearly half (48%) say it has not had much personal effect. In April 2016, somewhat more said the law had impacted them negatively (31%) than positively (23%); 45% said it had not much of an effect.

Much of the increase in positive views of the impact of the Affordable Care Act – and support for the law – has come among Democrats. Two-thirds (67%) of Democrats and Democratic-leaning independents now say the law has had a positive effect on the country.

That is up only modestly from last year (62%), but in September 2013, shortly before the rollout of the law’s health insurance exchanges, only 38% of Democrats and Democratic leaners said it was having a positive effect.

Opinions among Republicans and Republican leaners have shown less change. Currently 64% say the law has had negative impact on the country. Over the past four years, majorities of Republicans have consistently said the law is having a negative effect on the country.

As in the past, fewer Republicans and Democrats express positive or negative opinions about how the health care law has affected them than how it has affected the country. Currently, about half in each party say it has not had much of an effect on them and their families.

However, Democrats increasingly say they have been affected positively by the health care law. In the new poll, 43% say the law has had a positive effect on them and their families, up from 28% four years ago. Only 10% say it has had a negative effect, about the same share as in 2013 (12%).

Among Republicans, more say the health care law has had a negative than positive effect on them and their families (43% vs. 7%). The share of Republicans saying the law has had a negative personal effect is somewhat lower than it was in April of last year (51%).

Most approve of health care law

Throughout the seven-year history of the health care law, opinions about it have tended to be more negative than positive – or, less frequently, divided. But in February, for the first time, a majority of the public approved of the law.

That remains the case today, with 56% approving of the law. While that is little changed since February, support has jumped 12 percentage points since April 2016 (44%).

Since then, there has been a sharp rise in the share of Democrats and Democratic-leaning independents who approve of the health care law (from 71% then to 85% today). By contrast, there has been very little change in views among Republicans (13% approved of the law then, 14% today).

In addition, there continue to be demographic differences in opinions about the law. By about two-to-one, women are more likely to say they approve (61%) than disapprove (31%) of the law. Men are more divided: Half approve, while 45% disapprove.

Adults ages 65 and older are now more likely to approve (51%) than disapprove (41%) of the law. Still, they remain less likely than younger adults to support it: For example, about two-thirds of those younger than 30 (66%) approve. The share of young adults who approve of the law is little changed from February (65%), but as recently as October 2016, only about half of those younger than 30 (51%) approved.

While Republicans and Republican leaners are widely opposed to the health care law, those without a college degree are somewhat more likely to approve of it than those with a college degree or more education (20% versus 12%). By contrast, Democrats with at least a college degree express stronger approval for the law than those without a degree (93% vs. 81%).

Note: See full topline results and methodology .

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Affordable Care Act Essay Example

Type of paper: Essay

Topic: Health , Insurance , Health Care , Medicine , People , Obama , America , Family

Words: 1200

Published: 10/25/2021

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Introduction

Affordable Care Act was enacted after President Barack Obama signed it on 23rd March 2010. The law introduced wide-ranging health insurance reforms that made consumers in charge of their health care decisions. The objective of The Affordable Care Act is to make health care affordable, accessible and of a better quality. The law applies to all the divisions of society including families, senior citizens, businesses, and taxpayers. Those citizens who were not insured previously or those citizens who were insured but their policy did not provide them proper coverage and security are also included in the parameter of the Affordable Act. Affordable care act ensures that American citizens are being provided with better health security. The act put forward comprehensive health reforms that expand coverage period, minimize health care costs, hold insurance companies accountable and enhance the quality of health care received by Americans (Rosenbaum). The affordable care act is a compilation of two separate legislations; the patient protection and affordable care act and the health care and education reconciliation act of 2010. These two acts expands medical coverage to millions of low – income Americans and improves the quality of Medicaid and the children health insurance program (CHIP)

Key Features of the Act

Coverage: The act discards the pre - existing conditions that were previously required for children. Now any child under 19 years is eligible for the health care plans and benefits without any limitations. An adult under 26 is eligible for insurance coverage under parent health care plan (Blumenthal and Collins). Furthermore, health care insurance could not be canceled now just on the basis of honest mistake, and people are granted the right for reconsidering the denial of payment ( Curbing Insurance Cancellations). Cost: significant cost reduction measures have been taken, and new reforms were introduced year over year in this regard. Insurance companies are required to justify publicly and put forward the reason for any price increases. Additionally, previously put limitations of lifetime coverage are banned for all new health insurance plans. Care: Under the reforms of the Affordable Care Act, people can now choose the primary care doctor from their network of the plan. Also, there were previously barriers on emergency services put by the insurance companies under which people were not allowed the emergency care outside their health plan network. These barriers are now removed, and people can seek emergency care at any hospital outside their network.

ObamaCare Benefits: the ACA Makes Health Insurance More Affordable and More Available (Benefits Of ObamaCare: Advantage of ObamaCare)

The Affordable Care Acts Provisions Summary • Eligibility: Minimum income eligibility level has been reduced across the country to ensure that all the deserving American citizens receive best health care facility. • Financing: all the financing of eligible adults will be done by the Federal Government. The financing will be done from the start of year 2014. • Information technology systems and data: designs have been prepared for policy structure and financial structure to provide all the states with the immediate investment required for information technology systems. It is done to ensure that all the Medicaid systems are operational at the launch date January1st, 2014. • Coordination with Affordable insurance exchanges: according to this system, now the families and individuals can apply for coverage through a single application. A single process is implemented to determine the eligibility for all insurance affordability programs. • Benefits: newly eligible people for Medicaid will be given the benchmark benefit. This benefit includes the minimum essential benefits provided by the Affordable insurance exchanges. • Community-based long-term services and support: this provision improves the funding and ensures that people receive services and support in their communities on a long-term basis. • The quality of care and delivery system: This system improves the quality and delivery of care and reduces costs at the same time. • Prevention: To promote prevention and public health and support the efforts made at local and federal level. The act has authorized heavy investments in primary care workforce to promote prevention (Koh and Sebelius)

• Children’s Health Insurance Program: This provision extends the Children’s health Insurance Program (CHIP) from financial year 2015.

• Dual Eligible: A new office will be created within Medicare and Medicaid centers to deal with individuals who are eligible for both the services i.e. Medicare and Medicaid.

• Program Transparency: this provision promotes the transparency in Medicaid policies and establishes opportunities for public involvement in the development.

• Program Integrity: These provisions deal with those individuals who are terminated from Medicaid or whose Medicaid payments are pending due to ongoing investigations or allegations of fraud. It also includes guidelines on prevention of inappropriate payments and false claims. In 2014, federal website HealthCare.gov was facing technical problems due to which many consumers got frustrated as a result of long waits and gave up enrolling. However, in 2015 the problems were solved, and the enrollment process is now much smoother. As a result, up till 2015, more than 10 million people have enrolled themselves for health insurance in different US states under The Affordable Care Act (Armour). The other side of the picture is that Obama Care plans promised that The Affordable Care Act would lower the insurance premiums by average $2500 per family. Despite such promise, according to an analysis conducted by PricewaterhouseCoopers, insurance premiums have increased by 7.5% in 2015 (Ramlet). If the rates continue to increase at such a pace, it will likely to limit the American citizen’s accessibility to health care facilities in upcoming years. It is estimated that over the next decade, uninsured Americans may increase by 10%.

Works Cited

Benefits Of ObamaCare: Advantage of ObamaCare. 2014. 28 April 2015 <http://obamacarefacts.com/benefitsofobamacare/>. Curbing Insurance Cancellations. 26 February 2015. Web, 20 April 2015 <http://www.hhs.gov/healthcare/rights/appeal/curbing-insurance-cancellations.html>. Armour, Stephanie. "Affordable Care Act Enrollment Near 10 Million." 4 February 2015. wsj. Web. 20 April 2015 <http://www.wsj.com/articles/affordable-care-act-enrollment-near-10-million-1423070147>. Blumenthal, David and Sara R. Collins. "Health Care Coverage under the Affordable Care Act — A Progress Report." The New England Journal of Medicine (2014): 275-281. PRint. Koh, Howard K. and Kathleen G. Sebelius. "Promoting Prevention through the Affordable Care Act." The New England Journal of Medicine (2010): 1296-1299. Print. Lau, Josephine S., Josephine S. Lau and W. John Boscardin. "Young Adults' Health Care Utilization and Expenditures Prior to the Affordable Care Act." Journal of Adolescent Health (2014): 663–671. Print. Ramlet, Michael. "A 10-Year Prediction for the Affordable Care Act." 29 August 2014. nationaljournal. Web. 20 April 2015 <http://www.nationaljournal.com/next-america/perspectives/a-10-year-prediction-for-the-affordable-care-act-20140829>. Rosenbaum, Sara. "The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice." PublicHealth Reports (2011): 130–135. Print.

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Affordable Care Act: A Critical Analysis

Economic concerns, actual availability of health care, consistency of implementation.

The Affordable Care Act (ACA) covers almost a thousand pages and represents a radical attempt to review the medical insurance and health care system in the United States. From the early stages, even before its adoption and implementation, the law had generated a lot of discussion and concern on the part of both the population and the congressmen. The ACA envisaged several unpopular policies, including requiring US citizens to purchase health insurance as well as stricter requirements for employers and insurance companies.

The implementation of the law has encountered a multitude of practical challenges, economic difficulties, and, accordingly, criticism. Initiating the repeal of the law was one of Donald Trump’s key campaign promises. However, the new President, as well as his proponents, have faced the necessity to offer a practical alternative and have so far not taken decisive steps to abolish the ACA. This paper elaborates on economic concerns, the actual availability of medical care, and the consistency of public policies about the current state of health care and nursing practices.

The draft law provided that the implementation of all measures would require significant expenditures from the state budget. Nevertheless, the Congressional Budget Office predicted that the prolonged nature of the reform and its long-term benefits would ultimately lead to positive fiscal tendencies. Over time, it emerged that the ACA is potentially fraught with other economic challenges. For example, the law has reduced competition in the market of insurance services (Moffit, 2016). Moreover, “the employer mandate, which requires firms with 50 or more full-time workers to offer federally approved levels of insurance coverage or pay a tax penalty,” has resulted in job cuts (Moffit, 2016, para. 53). Employers are now more cautious when recruiting staff due to increased demands.

There is no doubt that the requirements of the ACA in respect of employers and insurance companies increase the availability of insurance and provide variability of choice for ordinary citizens. At the same time, from an economic point of view, they interfere quite strongly with the system of market competition. One of the main objectives of the Presidential Executive Order on ACA update was to promote free competition (US President, 2017). Thus, there is a certain contradiction between the social protection of poor and uninsured citizens and maintaining a free market economy. The ACA unambiguously chooses in favor of citizens, for which Republicans and other conservatives have repeatedly criticized.

It should be noted that all these measures were aimed at improving access to traditionally expensive medical care in the United States and at increasing the range of services covered by insurance. Unfortunately, “the ‘typical family’ pays about 35 percent of their income for health care” (Moffit, 2016, para. 10). The individual obligation to purchase insurance that would cover all the necessary provisions, however, proved to be a partly unpopular measure even among the population.

At the same time, the number of insured citizens has severely increased. The researchers note that if the implementation of the law is canceled, the number of uninsured people may double and become even more than in the period before Barack Obama’s reform (Blumberg et al., 2016). It may be admitted that the primary goal of the law to increase the share of the insured population is being fulfilled, and that is the greatest virtue of the ACA.

However, it should be stipulated that medical care is still expensive, and insurance does not cover all necessary treatment. In addition, insurance premiums are steadily increasing: “for 27-year-olds, premiums in 11 states more than doubled” and “for 50-year-olds, there was a premium increase of 50 percent or more in 13 states” (Moffit, 2016, para. 43). Thus, the number of insured individuals has increased, which is indeed the merit of the ACA, but health services have not become much more accessible by themselves.

It should be noted that the health care reform system is currently in a highly unstable political situation. Republicans initially had a negative view of the ACA, and after winning the 2016 elections, they thoughtfully planned to cut back on funding for the implementation of the law (Wilensky, 2017). However, they encountered the need to ensure “that 20 million newly insured individuals retain coverage,” which was extremely challenging (Wilensky, 2017, p. 21).

Executive measures by Donald Trump to sabotage the law began in 2017 but were not radical (Bryan, 2017). Meanwhile, the main challenges related to the implementation of the law and the initial reasons for its adoption were not overcome either by the Republicans or the new President.

It should be noted here that the extended ten-year implementation period of the ACA is its merit, given the ability of business, government, and population to adapt to new realities. However, given the change of authorities and the polar attitude to the law, this quality severely affects the consistency of its implementation. Researchers note that strong deviations from the original course can lead to extremely harmful consequences (Blumberg et al., 2016). Thus, the longevity of the provided measures has a negative side as well.

It can be concluded that the ACA has begun to fulfill its primary goal of increasing the share of the insured population in the US and supporting poor citizens. At the same time, the law imposes high requirements on employers and insurance companies, which has an impact on the economic situation. Its long-term implementation, on the one hand, allows the state to adapt to new circumstances and, on the other hand, makes it dependent on the political conditions.

Blumberg, L. J., Buettgens, M., & Holahan, J. (2016). Implications of Partial Repeal of the ACA through Reconciliation . Urban Institute . Web.

Bryan, B. (2017). Trump just took a big step to unravel Obamacare . Business Insider. Web.

Moffit, R. (2016). Year six of the Affordable Care Act: Obamacare’s mounting problems . The Heritage Foundation . Web.

US President. (2017). Presidential executive order promoting healthcare choice and competition across the United States. Washington, DC: White House.

Wilensky, G. R. (2017). The future of the ACA and health care policy in the United States. Jama, 317 (1), 21-22.

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Affordable Care Act, Essay Example

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Affordable Care Act may put those at disadvantages who take good care of their health and currently qualify for lower rates. Thus, Affordable Care Act does reduce the incentive to maintain healthy lifestyles for some by eliminating financial reward. Affordable Care Act could also be seen as a form of progressive tax on businesses and high-income individuals. While Affordable Care Act is not perfect and it may lead to fewer choices in health plans for individuals, it may lower the insurance industry costs in the long-term through standardization. It is possible that the government may then force the insurance industry to further lower insurance costs for an average American.

Affordable Care Act seems to be an attempt at making healthcare a basic right of everyone in America, just like education though it does exclude undocumented residents. It is also a noble attempt to prevent discrimination against those with pre-existing conditions because certain health conditions mean disastrous financial consequences for many low-income Americans. One can also expect for average healthcare costs to come down because now government would be able to bargain with drug manufacturers and insurance agencies on behalf of Americans. But the healthcare costs could go up to because the Affordable Care Act is quite generous towards the elderly. This is unnecessary because elderly population already benefits from Medicare and Medicaid and there is no need to put additional burden on the rest of the population.

But like any other regulation, there may be some abuses. For e.g. the law does exclude those with very little income and it is possible that more self-employed people will severely understate their income. In addition, many small businesses may intentionally hire 25 or fewer people to qualify for generous federal tax credits for businesses with 25 or fewer employees.

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Biden Administration Restores Health Protections for Gay and Transgender People

The Health and Human Services Department finalized a rule prohibiting discrimination based on sexual orientation and gender identity, reversing a Trump-era policy.

By Noah Weiland

Reporting from Washington

The Biden administration announced expansive new protections on Friday for gay and transgender medical patients, prohibiting federally funded health providers and insurers from discriminating on the basis of sexual orientation and gender identity.

The new rule reverses a policy instituted by the Trump administration and helps to fulfill part of President Biden’s vow to restore civil rights protections for L.G.B.T.Q. people that were eliminated by his predecessor.

“Today’s rule is a giant step forward for this country toward a more equitable and inclusive health care system, and means that Americans across the country now have a clear way to act on their rights against discrimination when they go to the doctor, talk with their health plan or engage with health programs run by H.H.S.,” Xavier Becerra, the health and human services secretary, said in a statement.

The rule overhauls federal policy in an area that has become a political flashpoint, with more than 20 Republican-led states banning or restricting gender-affirming care for minors in recent years, and it is likely to draw legal challenges. Even the history of the rule illustrates the political sensitivities at play: It has now taken three different forms under three successive presidents.

The Affordable Care Act, passed in 2010, established a sweeping set of civil rights protections in the U.S. health system through what is known as Section 1557. It prohibits discrimination against patients based on race, color, national origin, sex, age or disability in “any health program or activity” that receives federal funds, covering a broad swath of the U.S. health system.

In 2016, the Obama administration issued a less expansive version of the rule the Biden administration finalized on Friday, requiring health providers to provide medically appropriate treatment for transgender patients. Officials at the time argued that the Affordable Care Act’s protections against discrimination included gender identity. The Obama rule became tied up in litigation, and the Trump administration declined to enforce it.

Conservative opponents of the rule have argued that the policy could effectively coerce doctors into performing medical services that they might have objected to, including on religious grounds. The Trump administration in 2020 formally narrowed the legal definition of sex discrimination to not include protections for transgender people.

The rule finalized by the Biden administration on Friday states that it preserves religious exemptions and “does not require or mandate the provision of any particular medical service.”

“Section 1557 prohibits discrimination on certain prohibited bases, and does not interfere with individualized clinical judgment about the appropriate course of care for a patient,” the rule says.

After the Supreme Court ruled in 2020 that the Civil Rights Act of 1964’s prohibition on discrimination based on sex also applied to discrimination based on sexual orientation and gender identity, the Biden administration began to reverse the Trump administration policy.

Republican officials continued to work to preserve the Trump-era rule. In 2022, after the Biden administration issued a proposed version of the rule it finalized on Friday, a group of Republican attorneys general wrote to Mr. Becerra , suggesting they could sue if the Health and Human Services Department pursued the policy.

The rule proposal drew intense scrutiny from advocates and opponents. The Health and Human Services Department said on Friday that it had garnered more than 85,000 comments.

Groups that pushed for the reversal of the Trump-era rule hailed the Biden administration’s decision on Friday. “Countless Americans can now find solace in knowing that they cannot be turned away from health care they need just because of who they are or who they love,” said Kelley Robinson, the president of the Human Rights Campaign.

Noah Weiland writes about health care for The Times. More about Noah Weiland

Policy A: Affordable Care Act Essay

Introduction.

According to the background of the Affordable Care Act, this paper would analyze the effect of policy A that raises the age for which young adults could stay on their parent’s employer-sponsored health plan. Section 1 would review the background and young adults’ coverage of the ACA. Thus, section 2 and section 3 would give some potential benefits and concerns of policy A, respectively. Finally, section 4 would analyze the effects of policy A based on experimental results, using descriptive statistics and the Difference-in-differences method.

Coverages of the ACA

There are four main coverages in ACA legislation. Employer-Sponosred Coverage will be discussed in more detail below. Other coverages are through social programs, such as Medicaid, which is supported by the federal government. In this case, medical care is provided to people with incomes below the official poverty line. Finally, subsidized marketplaces can also provide coverage. Their responsibility extends to people with moderate income.

Employer-Sponsored Health Insurance and Young Adults in the ACA

Employer-sponsored health coverage refers to the health insurance for employee obtained by employer. In the U.S., it is normally Affordable Care Act that requires the employers insure their employee’s minimum essential health coverage with at least 50 full-time employees or full-time equivalents (Edward G., Craig A., Elonda C., & Emily M., 2010). Meanwhile, the ACA also protects the minimum essential health coverage of employees’ family. Plans and issuers of plans could not remove adult children from their parents’ coverage until they reach the age of 26, whatever married or unmarried. Once the young adults reach 26 and age out of their parents’ coverage, they could choose to enroll in any other employer plan that they are eligible.

From private perspective, policy A that raises the age for which young adults can stay on their parents’ employer-sponsored health plan from age 26 to age 27 might provide at least the following benefits:

• The young adults could have less concerns about the situation that they out of the minimum health coverage due to unemployment if graduating from school. Staying on their parents’ employer-sponsored health plan, they could obtain the required health coverage, even through they were not enrolled in the other employer health plan.
• On the other hand, policy A could also lower the financial risk of young adults or the family with a young adult. According to the statistics of Center for Medicare & Medicaid Services (CMS), almost one in six young adults suffer a chronic illness (cancer, diabetes or asthma etc.). Moreover, around half of uninsured young adults report those health problems. If staying on their parents’ employer-sponsored health insurance, those young adults or their family could face less financial risk due to physical problems.

Heath Insurance Premiums

From social perspective, the largest benefit of policy A is the efficient addition of health insurance coverage. Based on the statistics of CMS, almost 30% of young adults are not included in any health insurance. With the highest uninsured rate among any age group, uninsured young adults who are age at 20 to 30 represent over 20% of total population uninsured. The implementation of policy A could efficiently raise the health coverage in the U.S.

The implementation of policy A would also affect the employment decisions of both employee and employer as the following:

• The employers are required to offer the health insurance to their employees. If policy A has been implemented, they would afford a larger administration costs for their employees. Employers might choose to employ less labor with a consideration of costs. Thus, policy A might affect the demand in labor market.
• On the other hand, employees and potential employees would have less incentive to enter the labor market for a job with a more comprehensive social welfare. Thus, the supply of labor would also decrease.

Unemployment Rates

Therefore, the labor market would reach a new equilibrium in which less population would be employed with a higher welfare in the aspect of the whole society. Moreover, it is proved that a higher social welfare would bring an increase in unemployment rate. Compared to the U.S. where the most of people must afford the whole or a part of healthcare costs, most of European countries provide their people with universal health care by tax revenues. Nonetheless, the unemployment rate of the U.S. in 2019 is 3.8% while this figure of the EU is 6.9%. Facing a higher cost of labor, employers would definitely cut off their employment scale. Moreover, they might also instead the full-time employment of the part-time employment. Both of the two choices would decrease the total employment scale.

Impacts from Policy A Based on Empirical Treatment

As showed in the following graph, control group have a higher average number of physician visits in each quarter before the implementation of policy A, compared to treatment group (Treatment group stays on parent’s health plan between the ages of 26~27 years while control group does not). But the situation has been reversed by policy A. The average number of physician visits of treatment group increases rapidly and deviates far from this figure of control group. This phenomenon might mean that the abuse of public medical resources due to moral hazard of the insured.

In contrast, the health status of treatment group also deviates upward far from that of control group. In other words, the policy A might really improve the health status of treatment group. But measuring the success of a policy should consider both its costs and results.

Difference-in-Differences Method

With a Difference-in-Differences method, this paper analyzes the impacts from policy A on the utilization of medical resources and health status. There are the general view of this method, including the graph and regression model for calculations. This method is often used for this kind of tasks and is relevant (Saeed et al., 2019).

As showed in the following table, the average number of physician visits of both treatment group and control group have increased. But this figure increased with a higher velocity for treatment group. Moreover, the deviation between these measurements of both groups has been raising. Thus, it is obvious that the implementation of policy A might increase medical demand of the insured. However, the reason of increasing medical demand is complicated.

It might result from over-usage of medical resources due to patients’ moral hazard even they were not in serious physical conditions. On the other hand, it might also refer to the potential demands’ meeting. Out of employer-sponsored health insurance, some young adults may not obtain necessary medical treatments before the implementation of policy A. However, their demands have been met because of policy A.

In contrast, the treatment group also shows a better self-reported health status under the same method. The average points of the treatment group are higher than that of control group by 8 points. Thus, it is proved that policy A actually improves the health status of young adults as showed in the following table.

In a summary, this policy is relatively successful, although it brings some problem due to patients’ moral hazard. Nonetheless, policy A makes more medical demand of young adults has been met and improve the overall health status of the whole treatment group. But it does not represent that policy A is perfect. Many facts (over-usage of medical resources, impacts on unemployment rate etc.) should be investigated and measured for amendment of policy A.

Claxton, G. (2018). Annual average premiums graph 1999–2018 [Diagramm]. Health Affairs. Web.

Erica. (2019). Difference-in-differences estimation [Illustration]. Aptech. Web.

Eurostat. (2021). EU unemployment rates [Diagram]. Euroindicators. Web.

Gerwyn, N. (2019). Mechanical description [Illustration]. Medium. Web.

Long, M., Rae, M., Claxton, G., & Damico, A. (2016). Trends in Employer-Sponsored insurance offer and coverage rates, 1999–2014 [Diagramm]. Kaiser Family Foundation. Web.

Saeed, S., Moodie, E. E., Strumpf, E. C., & Klein, M. B. (2019). Evaluating the impact of health policies: Using a difference-in-differences approach. International Journal of Public Health, 64 (4), 637-642.

Tolbert, J. (2015). Key coverage elements in the ACA . Kaiser Family Foundation. Web.

US Bureau of Labor Statistics. (2020). US unemployment rate . BBC. Web.

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