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Pain Physician Mar 2017The Affordable Care Act (ACA), of 2010, or Obamacare, was the most monumental change in US health care policy since the passage of Medicaid and Medicare in 1965. Since... (Review)
Review
The Affordable Care Act (ACA), of 2010, or Obamacare, was the most monumental change in US health care policy since the passage of Medicaid and Medicare in 1965. Since its enactment, numerous claims have been made on both sides of the aisle regarding the ACA's success or failure; these views often colored by political persuasion. The ACA had 3 primary goals: increasing the number of the insured, improving the quality of care, and reducing the costs of health care. One point often lost in the discussion is the distinction between affordability and access. Health insurance is a financial mechanism for paying for health care, while access refers to the process of actually obtaining that health care. The ACA has widened the gap between providing patients the mechanism of paying for healthcare and actually receiving it. The ACA is applauded for increasing the number of insured, quite appropriately as that has occurred for over 20 million people. Less frequently mentioned are the 6 million who have lost their insurance. Further, in terms of how health insurance is been provided, the majority the expansion was based on Medicaid expansion, with an increase of 13 million. Consequently, the ACA hasn't worked well for the working and middle class who receive much less support, particularly those who earn more than 400% of the federal poverty level, who constitute 40% of the population and don't receive any help. As a result, exchange enrollment has been a disappointment and the percentage of workers obtaining their health benefits from their employer has decreased steadily. Access to health care has been uneven, with those on Medicaid hampered by narrow networks, while those on the exchanges or getting employer benefits have faced high out-of-pocket costs.The second category relates to cost containment. President Obama claimed that the ACA provided significant cost containment, in that costs would have been even much higher if the ACA was not enacted. Further, he attributed cost reductions generally to the ACA, not taking into account factors such as the recession, increased out-of-pocket costs, increasing drug prices, and reduced coverage by insurers.The final goal was improvement in quality. The effort to improve quality has led to the creation of dozens of new agencies, boards, commissions, and other government entities. In turn, practice management and regulatory compliance costs have increased. Structurally, solo and independent practices, which lack the capability to manage these new regulatory demands, have declined. Hospital employment, with its associated increased costs, has been soaring. Despite a focus on preventive services in the management of chronic disease, only 3% of health care expenditures have been spent on preventive services while the costs of managing chronic disease continue to escalate.The ACA is the most consequential and comprehensive health care reform enacted since Medicare. The ACA has gained a net increase in the number of individuals with insurance, primarily through Medicaid expansion. The reduction in costs is an arguable achievement, while quality of care has seemingly not improved. Finally, access seems to have diminished.This review attempts to bring clarity to the discussion by reviewing the ACA's impact on affordability, cost containment and quality of care. We will discuss these aspects of the ACA from the perspective of proponents, opponents, and a pragmatic point of view.Key words: Affordable Care Act (ACA), Obamacare, Medicare, Medicaid, Medicare Modernization Act (MMA), cost of health care, quality of health care, Merit-Based Incentive Payments System (MIPS).
Topics: Health Expenditures; Humans; Insurance Coverage; Insurance, Health; Medicaid; Medicare; Patient Protection and Affordable Care Act; United States
PubMed: 28339427
DOI: No ID Found -
JAMA Health Forum Mar 2023
Topics: Insurance, Health; Health Benefit Plans, Employee; Income
PubMed: 36897580
DOI: 10.1001/jamahealthforum.2022.5486 -
Revista Brasileira de Enfermagem 2020to analyze lawsuits brought by beneficiaries of health insurance operators.
OBJECTIVES
to analyze lawsuits brought by beneficiaries of health insurance operators.
METHODS
this was a cross-sectional descriptive study carried out in a large-capacity private health insurance operator using data collected by the company from 2012 to 2015.
RESULTS
ninety-six lawsuits were brought by 86 beneficiaries regarding medical procedures (38.5%), treatments (26.1%), examinations (14.6%), medications (9.4%), home care (6.2%), and other types of hospitalization (5.2%). The procedures with the highest number of lawsuits were percutaneous rhizotomy; chemotherapy; treatment-related positron-emission tomography scans; and for medications relative to antineoplastic and Hepatitis C treatment.
CONCLUSIONS
the lawsuits were filed because of the operators' refusal to comply with items not established in contracts or not regulated and authorized by the Brazilian National Regulatory Agency for Private Health Insurance and Plans, refusals considered unfounded.
Topics: Brazil; Cross-Sectional Studies; Humans; Insurance Coverage; Insurance, Health; Jurisprudence; Liability, Legal; Private Sector
PubMed: 32294709
DOI: 10.1590/0034-7167-2018-0748 -
Annals of Family Medicine 2015Once a year, Stuart, a long-haul truck driver, visited a physician to get a signature on the forms that allowed him to continue driving his 18-wheeler. Over 8 years, he...
Once a year, Stuart, a long-haul truck driver, visited a physician to get a signature on the forms that allowed him to continue driving his 18-wheeler. Over 8 years, he had never seen the same physician twice, in large part because of a lack of health insurance. Upon seeing him for the first time, I assured him that we could make financial arrangements, and he subsequently became my continuity patient. Two years later, we both looked forward to his impending 65th birthday, allowing Medicare to ease his fiscal health care burdens. His unexpected death made me ponder how a lack of access to affordable health care profoundly affects patients and their clinicians.
Topics: Delivery of Health Care; Humans; Insurance, Health; Medically Uninsured; Medicare; Patient Protection and Affordable Care Act; United States
PubMed: 26195685
DOI: 10.1370/afm.1806 -
JAMA Health Forum May 2021
Topics: Insurance, Health; Value-Based Health Insurance
PubMed: 36218677
DOI: 10.1001/jamahealthforum.2021.1440 -
PloS One 2021We introduce a new experimental approach to measuring the effects of health insurance policy alternatives on behavior and health outcomes over the life course. In a...
We introduce a new experimental approach to measuring the effects of health insurance policy alternatives on behavior and health outcomes over the life course. In a virtual environment with multi-period lives, subjects earn virtual income and allocate spending, to maximize utility, which is converted into cash payment. We compare behavior across age, income and insurance plans-one priced according to an individual's expected cost and the other uniformly priced through employer-implemented cost sharing. We find that 1) subjects in the employer-implemented plan purchased insurance at higher rates; 2) the employer-based plan reduced differences due to income and age; 3) subjects in the actuarial plan engaged in more health-promoting behaviors, but still below optimal levels, and did save at the level required, so did realize the full benefits of the plan. Subjects had more difficulty optimizing choices in the Actuarial treatment, because it required more long term planning and evaluating benefits that compounded over time. Contrary, to model predictions, the actuarial priced insurance plan did not increase utility relative to the employer-based plan.
Topics: Cost Sharing; Health Benefit Plans, Employee; Health Policy; Humans; Insurance, Health; Models, Statistical; United States
PubMed: 33822805
DOI: 10.1371/journal.pone.0248784 -
Tropical Medicine & International... Oct 2021This study explores population-level variation in different types of health insurance coverage in India. We aimed to estimate the extent to which contextual factors at...
OBJECTIVES
This study explores population-level variation in different types of health insurance coverage in India. We aimed to estimate the extent to which contextual factors at community, district, and state levels may contribute to place-based inequalities in coverage after accounting for household-level socioeconomic factors.
METHODS
We used data from the 2015-2016 National Family Health Survey in India, which provides the most recent and comprehensive information available on reports of different types of household health insurance coverage. We used multilevel regression models to estimate the relative contribution of different population levels to variation in coverage by national, state, and private health insurance schemes.
RESULTS
Among 601,509 households in India, 29% reported having coverage in 2015-2016. Variation in each type of coverage existed between population levels before and after adjusting for differences in the distribution of household socioeconomic and demographic factors. For example, the state level accounted for 36% of variation in national scheme coverage and 41% of variation in state scheme coverage after adjusting for household characteristics. In contrast, the community level was the largest contextual source of variation in private insurance coverage (accounting for 24%). Each type of coverage was associated with higher socioeconomic status and urban location.
CONCLUSIONS
Contextual factors at community, district, and state levels contribute to variation in household health insurance coverage even after accounting for socioeconomic and demographic factors. Opportunities exist to reduce disparities in coverage by focusing on drivers of place-based differences at multiple population levels. Future research should assess whether new insurance schemes exacerbate or reduce place-based disparities in coverage.
Topics: Adult; Aged; Cross-Sectional Studies; Family Characteristics; Female; Humans; India; Insurance, Health; Male; Middle Aged; Models, Economic; Risk Factors; Socioeconomic Factors
PubMed: 34181806
DOI: 10.1111/tmi.13645 -
Inquiry : a Journal of Medical Care... 2019This commentary outlines the health insurance disparities of Compact of Free Association (COFA) migrants living in the United States. Compact of Free Association...
This commentary outlines the health insurance disparities of Compact of Free Association (COFA) migrants living in the United States. Compact of Free Association migrants are citizens of the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau who can live, work, and study in the United States without a visa. Compact of Free Association migrants make up a significant proportion of the rapidly growing Pacific Islander population in the United States. This article describes the historical and current relationships between the United States and the Compact nations and examines national policy barriers constraining health insurance access for COFA migrants. In addition, the commentary describes the state-level health policies of Arkansas, Hawai'i, and Oregon, which are the states where the majority of COFA migrants reside. Finally, policy recommendations are provided to improve health equity for COFA migrants.
Topics: Health Equity; Health Services Accessibility; Health Status Disparities; Humans; Insurance, Health; Micronesia; Transients and Migrants; United States
PubMed: 31823677
DOI: 10.1177/0046958019894784 -
Medical Care Research and Review : MCRR Apr 2022In concentrated labor markets, where workers have fewer employers to choose from, employers may exploit their monopsony power by contributing less to workers' health...
In concentrated labor markets, where workers have fewer employers to choose from, employers may exploit their monopsony power by contributing less to workers' health benefits. This study examined if labor market concentration was associated with higher worker contributions to health plan premiums. We combined publicly available data from the Census to calculate labor market concentration and the Medical Expenditure Panel Survey Insurance/Employer Component to determine premium contributions from 2010 to 2016 for metropolitan areas. After controlling for year fixed-effects and market characteristics, we found that higher labor market concentration was associated with higher worker contributions to health plan premiums, lower take-home income, and no change in employer contributions to premiums, consistent with the hypothesis that greater labor market concentration is associated with less generous health benefits. When evaluating the effects of mergers and acquisitions on labor markets, regulatory agencies should critically assess worker contributions to health insurance premiums.
Topics: Health Benefit Plans, Employee; Humans; Income; Insurance Coverage; Insurance, Health; United States
PubMed: 33957807
DOI: 10.1177/10775587211012992 -
JAMA Dermatology May 2020Hair removal can be an essential component of the gender affirmation process for gender-minority (GM) patients whose outward appearance does not align with their gender...
IMPORTANCE
Hair removal can be an essential component of the gender affirmation process for gender-minority (GM) patients whose outward appearance does not align with their gender identity.
OBJECTIVE
To examine the health insurance policies in the Affordable Care Act (ACA) marketplace and Medicaid policies for coverage of permanent hair removal for transgender and GM patients and to correlate the policies in each state with statewide protections of coverage for gender-affirming care.
DESIGN AND SETTING
Private health insurance policies available on the ACA marketplace and statewide Medicaid policies were examined in a cross-sectional study from September 1 to October 31, 2019, and January 17 to 30, 2020. Policies were assessed for coverage of permanent hair removal. Language concerning hair removal was found in each policy's medical or clinical coverage guidelines and separated into general categories.
MAIN OUTCOMES AND MEASURES
Logistic regression analyses were performed to compare Medicaid policies and ACA policies in states with and without transgender protections.
RESULTS
A total of 174 policies were analyzed, including 123 private insurance policies and 51 statewide Medicaid policies. Of these policies, 8 (4.6%) permitted the coverage of permanent hair removal without explicit restrictions. The remaining 166 policies (95.4%) broadly excluded or did not mention gender-affirming care; prohibited coverage of hair removal or did not mention it; or only permitted coverage of hair removal preoperatively for genital surgery. The ACA marketplace policies in states without transgender care protections were less likely to cover hair removal without restrictions than ACA policies in states with protections (2 of 85 policies [2.4%] in states without transgender care protections vs 5 of 38 policies [13.2%] in states with transgender care protections), and Medicaid policies were less likely to cover preoperative or nonsurgical hair removal compared with ACA policies (6 of 51 Medicaid policies [11.8%] vs 47 of 123 ACA policies [38.2%]).
CONCLUSIONS AND RELEVANCE
Despite adoption of statewide restrictions on GM health care exclusions by several states, most Medicaid and ACA policies examined in this study did not cover permanent hair removal for transgender patients. Many GM patients seeking hair removal may be required to pay out-of-pocket costs, which could be a barrier for gender-affirming care.
Topics: Cross-Sectional Studies; Female; Gender Identity; Hair Removal; Humans; Insurance Coverage; Insurance, Health; Male; Medicaid; Patient Protection and Affordable Care Act; Sexual and Gender Minorities; Transgender Persons; United States
PubMed: 32211825
DOI: 10.1001/jamadermatol.2020.0480