The Affordable Care Act (ACA) intended to provide medical coverage to as many people as possible. In its fundamental purpose, the Act looked at reducing the number of uninsured Americans. Since its signing in 2010, ACA has made a huge impact in enabling Americans to access to medical care. The success of the Act is perhaps visible through the reduction in the number of uninsured (Sanger-Katz, 2014). Despite the advances made in providing access to medical care, there are still challenges to the Act. In looking at the successes and challenges to the three pillars of the Act (Access, Quality, and Cost) it is important to consider some fundamental factors that include an individual mandate, the employer mandate, insurance marketplaces, Medicaid expansion, and pharmaceutical costs.
As of the pillars of ACA, providing access is one of the most important factors that the Act wanted to address. Perhaps one of the most successful elements of the Act, its passage and provisions taking effect show a decline in the number of uninsured. According to statistics presented by Obama (2016), the number of uninsured dropped by 43 percent in 2015. Ideally, the number dropped from 16.0 percent of uninsured in 2010 to 9.1 percent in 2015 (Obama, 2016). Most of the decline took place in 2014 following the law’s main coverage taking effect. In terms of numbers, the level of uninsured citizens dropped from 49 million to 29 million between 2010 and 205 (Obama, 2016). One of the challenges of the ACA in the run-up to its implementation was the individual mandate clause that imposed a fine for adults who did not have insurance coverage. Even as the Supreme Court upheld the constitutionality of the fine, RAND’s research indicated that eliminating the individual mandate provision would have meant missed insurance coverage for 12 million people (Eibner & Hussey, 2016).
Providing access to medical attention has gone hand in hand with Medicaid expansion. Although the Supreme Court ruled against requiring states to expand Medicaid, with the passage of the law, half of the states expanded Medicaid (Price & Eibner, 2013). With the Act ensuring that the federal government will pay fully for newly insured individuals, many states have expanded eligibility. According to Pear (2014), the states have included people whose incomes are up to 138 percent of the poverty level. Through this expansion, 8.7 million people have found their way into the Medicaid rolls (Pear, 2014). Of the 8.7 million new entries into the Medicaid roll, 7.5 million are from states with expanded Medicaid eligibility (Pear, 2014). Moreover, states that have expanded Medicaid have also experienced a reduction in the number of uninsured, some of which have fallen by up to 40 percent (Pear, 2014; Price & Eibner, 2013).
ACA has also made progress in improving the quality of care in hospitals. One of the areas of assessment of the quality of care is the rate of hospital-acquired conditions. According to Obama (2016) since the passage of ACA, there has been a 17 percent decrease in the rates of hospital-acquired infections. The number has declined from 145 in every 1000 discharges in 2010 to 121 in every 1000 discharges (Obama, 2016). With a decline in hospital-acquired infections, so is there a decline in mortality from these infections. Obama (2016) informs that the reduction in incidences of hospital-acquired infections has enabled the prevention of more than 87,000 mortalities in four years. Among the measures of quality of care is readmission to the hospital within 30 days after discharge. Since the ACA took effect, the number of readmissions has decreased from a mean of 19.1 percent in 2010 to 17.8 percent in 2015. In numbers, there were 565,000 fewer readmissions between 2010 and 2015 (Obama, 2016).
Apart from opening access to more uninsured individuals, ACA’s goal was also to reduce the cost of healthcare for the majority who could not afford healthcare insurance. In essence, it was to make healthcare affordable to all. Making healthcare insurance affordable meant taking of individuals, and employers, expanding Medicaid and opening insurance marketplaces for the masses. The individual mandate requires that all adults enroll for insurance or pay a fine. The individual mandate has especially had an impact on the enrollment of individuals. Goodenough, Abelson, and Hartocollis’s (2014) estimates indicate that 7.3 million people have coverage through ACA’s online private marketplaces. The coverage includes those with costly medical conditions, who would otherwise have been blocked by insurers. Moreover, with the law in place, subsidies that help pay the premiums have reduced the cost for individuals by up to 76 percent (Goodnough, Abelson & Hartocollis, 2014).
There were fears that the employer mandate would see employers opt out of covering their employees due to the high cost of providing the cover. The employer mandate requires that the firm should offer coverage for employees with at least 30 hours of work per week, failure of which there would be a $2000 penalty for every employee (Eibner & Hussey, 2016). Enrollment figures have on the other hand shown increased enrollment by employers. Of the 14.5 million newly insured, 8.2 million had coverage through employers (Eibner & Hussey, 2016). The law, therefore, helped employees find coverage through their employers, without a necessarily huge impact on the employers’ profitability.
Online insurance marketplaces and pharmaceutical companies have seen an increase in the number of people insured and using their drugs respectively. The insurance marketplace has also seen increased competition from players coming in to provide cover for individual insurance as well as Small Business Insurance Marketplaces (SHOP), which help cover firms with 50 or fewer employees (Eibner & Hussey, 2016). Moreover, insurers and pharmaceutical companies have seen their shares rise, with the S. & P. 500 health care index at 120% beating S. & P. 500 stock index at 90% (Abelson, 2014).
Although ACA has opened access to healthcare to the masses, it locks out some people. Among these are higher-income families and individuals who earn more than 400 percent of the federal poverty line (Eibner & Hussey, 2016). Such families and individuals (representing 16 of the ineligible uninsured people) do not qualify for Medicaid or marketplace tax credits (Eibner & Hussey, 2016). Undocumented immigrants are also among those disfavored by the Act, given the prohibitions set. Estimates indicate that undocumented immigrants make up about 23 percent of the uninsured who are not qualified for the tax credits. Yet another challenge is to include low-income earners in states that do not expand Medicaid. While these individuals have incomes below 100 percent of the federal poverty level, the states’ laws render them ineligible. This is a huge coverage gap given that 28 percent (5.3 million) of the 19 million people uninsured fall within this category (Eibner & Hussey, 2016).
ACA has opened access to healthcare for millions of previously uninsured. The expansion, it has improved health outcomes, including reducing hospital-acquired infections, mortality rates, and readmission into hospitals. Despite these, there are still gaps in access to healthcare for undocumented immigrants, high-income earners, and low-income earners in states without Medicaid expansions. Ensuring no one is left behind was part of the goal of the Act. It is important therefore to find ways of including this population, as they make the bulk of the uninsured.
References
Ableson, R. (2014).Has the Health Care Industry been helped or hurt by the Law? The New York Times.
Eibner, C. & Hussey, P. (2016). Affordable Care Act in Depth. RAND Corp.
Goodnough, A., Abelson, R., & Hartocollis, A. (2014). Has Insurance under the Law been Affordable? The New York Times.
Obama, B. (2016). United States Health Care Reforms: Progress to Date and Next Steps. JAMA, 316(5), 525-532
Price,C., A., & Eibner, C. (2013). ForStates That Opt Out OfMedicaid Expansion: 3.6Million Fewer InsuredAnd $8.4 Billion LessIn Federal Payments. Health Affairs, 32(6), 1030–1036
Sanger-Katz, M. (2014). Has the Percentage of Uninsured People been Reduced. The New York Times.