Policy Achievements of the Affordable Care Act
Health care absorbs an escalating proportion of government and private-sector spending, without commensurate benefits in health status and outcomes of care. Lack of coverage for health care is too often a crushing financial burden, as well as an avoidable cause of mortality, among the increasing number of the uninsured. Access to medical care helps to shape the economic and social status of individuals and communities, and financial barriers to health care perpetuate inequalities rooted in income, race, and ethnicity.
Although most Americans get health insurance coverage from their employers, until now there has been no requirement that employers provide it or that insurance companies accept anyone for coverage. Prior to adoption of the ACA, individuals who were not part of a large group found it difficult or impossible to find insurance. People with health conditions could be turned away for no other reason than the paradoxical one that they needed the service, and they also could be charged more if they succeeded in obtaining coverage.
The ACA establishes universal coverage for health care as a national goal and delineates the responsibility of individuals, employers, and the government to contribute to its cost (Table 1). It has already extended health care coverage for millions through provisions such as continuing coverage for dependents on a parent's health plan through age 26 years. Beginning in 2014, it will direct federal funds to states that choose to participate to significantly expand coverage for very-low-income residents through the state–federal Medicaid program. Other uninsured individuals and some employers will be required to purchase private health insurance through publicly administered health insurance exchanges. However, the law excludes undocumented immigrants from these new coverage options and offers reduced benefits for those legally present.
The law protects consumers from the most egregious insurance company abuses. Insurance plans that operate through the health insurance exchanges must accept all applicants and cannot set premiums according to health status. The ACA eliminates copays and deductibles for preventive services such as contraception, mammograms, colonoscopies, immunizations, prenatal and new baby care, and annual physicals for Medicare beneficiaries, and expands the number of primary care clinicians and the supply of services. However, it places some restrictions on coverage for abortions.
The law limits the percentage of revenues insurance companies can spend on administration, as opposed to medical benefits, and gives the Secretary of the Health and Human Services Department some leeway to reject excessive premium increases. States can strengthen premium rate regulation. The new Independent Payment Advisory Board proposes to apply the beginning of deliberative payment rates in the Medicare system. However, the continuing role of the private for-profit insurance industry and corporate imperatives such as consolidation among hospital chains are likely to frustrate efforts to control health care expenditures. The ACA provides significant leeway to states to experiment with alternative methods of financing and organizing health care, effective in 2017 (Table 2).