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What is the Affordable Care Act?

Main reforms in 2 “Categories”

1. [ Expansion of health insurance ]

Access to healthcare
Costs
Quality

2. [ Reforms in healthcare delivery ]

Healthcare System efficiency
Changes in organization of healthcare delivery
Changes in workforce policy
Changes in government contribution

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Health Insurance Costs Basics

Premium - The constant fee you pay to keep your insurance plan active (usually pay per month, and you must pay it regardless of whether or not you use your insurance at all that year)

E.g. Paying $200 a month to keep your insurance going

Deductible - The threshold amount of money you had to have paid for your own healthcare, before which your insurance actually starts covering you

E.g. $1000 deductable = pay $1000 worth of your medical bills before your insurance kicks in
Note: resets every year, so in this example if you only paid $200 that year( Yay you’re healthy!!) then the insurance doesn’t need to pay anything

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Health Insurance Costs Basics (Cont.)

Coinsurance - The percentage amount of your medical bills which you share with your insurance once you have passed your deductible

E.g. “80-20” plan - if you incur a medical bill of $5000, your insurance will pay for $4000, and you would pay $1000

Copay- flat fee that you pay per medical visit

E.g. The ~15 dollars you pay when you go into Kaiser

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Medicaid/Medicare Basics

Both programs provide healthcare for people, but under different circumstances
Note: These are separate programs, so it’s possible to have both
Medicaid = a joint federal and state program that helps low income people with medical costs
Medicare = federal healthcare program for individuals 65 or older, or with disabilities(4 parts)

A - Covers most medically needed hospital services; free if you have paid social security for more than 10 years; otherwise, it will cost a fee
B- Covers medical services (e.g doctor visits and X-rays) for a monthly premium
C-Allows private health insurance companies to provide Medicare benefits (so you don’t necessarily have to get it from the government, and have more options)
D- Provides outpatient prescription drug coverage; different plans depending on which insurance you select

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[ Expansion ] - Accessibility

Estimated between 7.4 - 16 million people that have gained coverage since the passing of the ACA
Groups that have historically been most at risk for lacking insurance have made the greatest coverage gains

Young adults, hispanics, blacks, and members of the low income community

As of February 2015, over 11.7 million patients have gotten health insurance plans from the marketplace provided by the ACA

87% of these marketplace customers are eligible for government-subsidized plans

Expansion of the range of citizens eligible for Medicaid

Now covers Americans up to 138% above the national poverty line
10.8 million additional people have been able to enroll in Medicaid since ACA started

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[ Delivery ] - Changes in Government Payment

Use of negative and positive reinforcement onto healthcare providers
Negative reinforcement examples

Penalties for hospitals for high rates hospital readmissions of Medicare beneficiaries

AKA focus more on getting patients healthy enough from their first visit!

Reduced funding for hospitals for ranking in the lowest 25% in terms of Medicare patient safety

AKA highlights the importance of better care and precautions for patients so they don’t have to experience hospital-acquired conditions (e.g. contract avoidable infections/face adverse drug effects/fall)

Positive reinforcement example

Bonus funding distribution to hospitals which improve in terms of cost, efficiency, and quality

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[ Delivery] - Changes in Organization

Monetary incentives for healthcare professionals to form Accountable Care Organizations (ACO’s)

Benefits patients because their healthcare professionals will be an integrated team with better communication, instead of separate “you-do-your-part, I-do-mine” fragments

So far, there are 405 participating ACO’s, serving 7.2 million Medicare beneficiaries (14% of the total Medicare population)

Quality measures have generally improved; patients report better care experiences

Savings so far have been estimated to be $700 million

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[ Delivery] - Workforce Policy

Essentially incentivizing primary care as a career, thus leading to more providers for Medicaid populations
Raised pay of Medicaid primary care physicians for 2 years

Resulted in availability of appointments for Medicaid patients rose 8%
However, now, only 15 states are continuing this incentive, while others have retracted this or remained unsure (results may not have been as high as expected)

Invested $1.5 billion into the National Health Service Corps

Offers scholarships and loan forgiveness for decades to young primary care clinicians who volunteer to practice in underserved areas

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Center for Medicare and Medicaid Innovation (CMMI)

Funded at $1 billion per year for 10 years, CMMI has the authority to undertake a wide variety of experiments for the purpose of improving quality and reducing cost within the Medicare and Medicaid programs.
authority to implement new ideas in Medicare and Medicaid without prior congressional approval if programs increases quality without costs

saves time!!!!

One notable program, Partnership for Patients, provides technical assistance to 3700 hospitals to reduce hospital acquired conditions and Medicare readmissions.

payment reforms that provide incentives for improvements in patient safety

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Overall Summary

the ACA has brought about considerable improvements in access to affordable health insurance in the United States
the implementation of the ACA has coincided with another important development — a slowdown in the rate of increase in national health care spending
The reductions in hospital-acquired conditions and Medicare readmissions since the enactment of the ACA are unprecedented and encouraging, but here again, the causes of these favorable trends are uncertain. It may be some time before we can assess the quality effects of this major new legislation.

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