What did the affordable care act change in our healthcare system

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Before sharing sensitive information, make sure you're on a federal government site. The site is secure. NCBI Bookshelf. This list is the rapporteurs' summary of the main points made by individual speakers and participants, and does not reflect any consensus among workshop participants. Key features of the Affordable Care Act ACA are access to health care through expanded coverage, improved quality and efficiency and lower health care costs, and consumer protections.

Incremental reforms have been made to the ACA since it was passed in For example, expanded coverage will not be universal coverage, because some states are electing to not expand their Medicaid programs, and the change in care management will not happen overnight, as all of the speakers point out in this chapter. Comprehensive changes that take effect in were summarized by Jack Ebeler, principal, Health Policy Alternatives see Box Understanding the reforms and details of the law can help to clarify how preparedness programs should adapt to the changing health care delivery landscape.

The mechanism for organizing the individual and small group insurance markets and administering subsidies. The health insurance marketplace includes state-based exchanges and more Additionally, although in effect prior to , one ruling that is notable for preparedness efforts previously mentioned by Lurie is the New Requirements for Charitable c 3 Hospitals. It imposes new requirements on c 3 organizations that operate one or more hospital facilities hospital organizations.

One of the requirements is to conduct a community health needs assessment CHNA and adopt an implementation strategy for addressing the prioritized health needs at least once every 3 years.

The ACA also added section , which imposes an excise tax for failure to meet the CHNA requirements, and added reporting requirements under section b related to sections r and Lisa Tofil, partner at Holland and Knight, explained that expansion of health care coverage under the ACA is achieved by expansion of Medicaid eligibility up to percent of the federal poverty level 6 :.

In , in response to a constitutional challenge to the ACA, the Supreme Court upheld the individual mandate, but the Medicaid expansion became optional for states. As a result, there may be significant gaps in coverage in states that decide to not expand their Medicaid programs, Tofil said. People between and percent of the federal poverty level in any state can get the sliding-scale subsidy when selecting coverage in the federal health exchange, Ebeler explained. But those below percent of the poverty level and above current Medicaid coverage limits will have no source of subsidy in the states that are not expanding their programs.

As of fall , about half of the states are not moving forward with Medicaid expansion Kaiser Family Foundation, , which could leave as many as 6 million uninsured, nonelderly adults without access to coverage. Ebeler said it is important to consider implementation of the ACA over the longer term, pointing out that when Medicaid went into effect in , only 26 states participated in the first year, but 4 years later in , nearly all states were participating. He cautioned that even with the ACA, there will still not be universal coverage.

Current projections show that overall, including those with lowest income living in non-Medicaid expansion states, undocumented residents, and those unwilling to purchase their own insurance, 30 million Americans will still lack coverage by Nardin et al. As summarized by Ebeler, there are two key fundamental changes in financing and delivery underlying system reform. First, is the shift in measurement and payment, moving from discrete fee-for-service transactions payment for each task or service that is done at each moment to payment for clinically and economically relevant episodes for patients and providers, referred to as bundled payments.

Accountability for care may be spread across provider types and over a period of time, which incentivizes those providers to work together and integrate services and provides some degree of risk transfer. Second, there is a change in care-management capacity to favor providers over insurers in driving health care decisions.

Groups of providers e. Ebeler referred to work of the Commonwealth Fund, which suggests that it is easier to implement combinations of payment, accountability, and risk if delivery is more collaborative and integrated Davis and Schoenbaum, Tofil highlighted other key changes to payments for providers under the ACA.

Partially through Section , they focus on value-based payments to incentivize quality and safety as well as to lower use and increase efficiency. There are Medicare and Medicaid penalties for health care—acquired conditions not limited to hospital acquired , penalties for excessive preventable Medicare readmissions, as well as a focus on value-based purchasing i. ACOs, which will primarily still be fee-for-service, will focus on prevention and wellness to minimize hospitalizations, readmissions, and unnecessary care use.

There are also market-driven innovations in payment through various methods. Increased transparency has led to downward price pressure, tougher negotiations by employers with insurers, and a greater need to demonstrate value. One area of payment reform that was of particular concern to some participants who spoke was cuts to the disproportionate share hospital DSH payments for both Medicare and Medicaid.

This means that states that do not expand Medicaid will provide about the same level of uncompensated care to uninsured individuals but will now receive less federal funding for that care discussed further in Chapter 3. It also creates a voluntary long-term-care insurance program, the Community Living Assistance Services and Support Act.

The Affordable Care Act will fundamentally alter the policy landscape in which public health is practiced. The legislation will take years to implement, and its full meaning can only be conceptualized at this point. But January will arrive in the blink of an eye. How do public health practitioners and policy makers seize the opportunities presented by this seminal change in policy while also working with others to rise to its challenges?

Certain aspects of the law—including the availability of prevention or health center funding—present important funding opportunities. These opportunities are vital to communities throughout the country, and public health agency responsiveness and assistance to local community coalitions will be key.

At the same time, these aspects of the Act perhaps represent relatively familiar public health practice turf, from a conceptual and practical perspective. The more intriguing questions arise from the more nuanced opportunities that arise from the new coverage and regulatory environment in which public health policy-making and practice will take place.

For example, how will public health's role in prevention be affected by expanded coverage of clinical preventive services in public and private insurance? Should public health become more involved in the direct provision of certain types of clinical preventive care to assure that access is realized?

How will Medicaid agencies and state Exchanges find the supply of health professionals needed to expand existing sources of care? How might public health agencies work with health professions training and residency programs in their states to begin to plan for the vast increase in demand for care? How might public health agencies work directly with employers, insurers, and health-care providers on ways to translate coverage reforms into actual improvements in health-care services?

The law requires nonprofit hospitals to engage in major community health planning; hospitals also will be expected to demonstrate how their investment of resources into the communities they serve reflects the priorities contained in their plans. How can public health agencies engage in hospitals around planning?

How can agencies and communities assure optimal use of the resources that will be invested in these community planning activities and the resulting impact of plans on hospitals' community benefit expenditures? In a similar vein, how might public health agencies relate to employers in the development of wellness programs?

Programs can now contain health outcomes incentives; how can public health agencies work with employers, employees, and their families to help them actually achieve the outcomes that are incentivized, such as immunization status, weight reduction, or better management of chronic health conditions?

State Medicaid agencies, along with state health insurance Exchanges as they come on line , will spend the next several years wrestling with the enormous challenges involved in enrolling tens of millions of people. Many will never have had insurance, many will be hard to reach, many will not have English as their primary language, and some will have limited mental capacity.

What role can public health outreach play? Health insurance Exchanges will be expected to implement broad federal standards related to access and quality for qualified health plans. Medicare and Medicaid demonstrations aimed at improving health and health care for individuals with complex and chronic conditions will be implemented.

And throughout the system, large amounts of data on enrollment, health-care utilization, and performance will become available over time. What are the opportunities that flow from these changes? How might public health be involved in 1 outreach and enrollment, 2 the creation of more integrated systems of care for people with chronic conditions who depend on health-care teams drawn from both health-care and public health professionals, and 3 working with Exchanges to assure that the health plans that do business in Exchanges are positioned to offer quality products whose performance can be measured?

Finally, the law will leave nearly 25 million people without health insurance. What role can public health continue to play for these populations? How can effective systems of care be created to protect these individuals and the communities in which they live from the consequences of inadequate health-care access?

In sum, the Affordable Care Act is transformational, and enormous implementation challenges lie ahead. But the opportunities for major advances in public health policy and practice are simply unparalleled.

The Act represents a singular opportunity not only to transform coverage and care, but also to rethink the basic mission of public health in a nation with universal coverage. Public Health Rep. Sara Rosenbaum , JD. Find articles by Sara Rosenbaum. Author information Copyright and License information Disclaimer.

NW, Ste. Health insurance coverage reforms Through a series of provisions that create premium and cost-sharing subsidies, establish new rules for the health insurance industry, and create a new market for health insurance purchasing, the Affordable Care Act makes health insurance coverage a legal expectation on the part of U.

Improving health-care quality, efficiency, and accountability Beyond insurance, the Affordable Care Act begins the job of realigning the health-care system for long-term changes in health-care quality, the organization and design of health-care practice, and health information transparency.

Making primary health care more accessible to medically underserved populations An estimated 60 million individuals are considered medically underserved as a result of a combination of elevated health risks and a shortage of primary health-care professionals.

Improving the public's health and training health professionals In addition to insuring most Americans, making an effort to rationalize health care, investing in primary health care in medically underserved communities, and broadening coverage for effective clinical preventive health services, the Affordable Care Act makes direct public health investments.

Long-term care To provide for those who need long-term care, the Act creates new Medicaid options to promote community-based care and protect spouses of those with serious illness from becoming impoverished.

See, e. Health reform GPS. Congressional Budget Office. Letter from Douglas W. Table 3. Rosenbaum S, Gruber J. Buying health care, the individual mandate, and the Constitution. N Engl J Med. Understanding the Affordable Care Act: timeline: what's changing and when. Department of Health and Human Services, August 5, United States v Lopez, U. See generally, 75 Fed.

Access denied: a look at America's medically disenfranchised. National Association of Community Health Centers. Expanding health centers under health care reform.

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