Introduction
The ObamaCare is a reform that focuses on the Patient Protection and Affordable Care Act (PPACA) and introduces shifts to the U.S. health system in terms of access to medical aid for all U.S. citizens, creation of new stimuli to alter clinical practice, and promoting better quality and coordination, and insurance of physicians with more information about their professional level (May, 2012).
Additionally, patients are also provided with sufficient data to make them value-conscious clients. However, the reform has undergone rigid criticism in terms of increased costs, leading to a decline in employment rates. Several pitfalls arise due to the inconsistency of the reform, which leads to unconstitutional actions and insufficient quality of care. Although the Court has accepted the majority of principles of the reform, its criticism gains momentum.
Concerning the above, PPACA has a number of advantages and disadvantages due to the changes and amendments made to the law. The purpose of the paper lies in examining, analyzing, and sorting out the major principles of the reform through understanding its history and external factors that influence its development. This is of particular concern to the inception period, social security amendments, healthcare policy, courts rulings, and controversy of the PPACA.
History of Managed Care
Definition
Kochers et al. (2010) defines PPACA as once-in-a-generation change to the U.S. health system [that] guarantees access to healthcare for all Americans, …gives physicians more information to make them better clinicians and patients more information to make them more value-conscious consumers, and changes the payment to reward value (n. p.)
Hence, healthcare professionals are morally responsible for promoting high-quality services for their patients. Additionally, the Act provides incentives for improving information exchange and fostering clinical practice (Kochers et al., 2010). The ACA permits physicians to eliminate the barriers, contributing to the delivery of exceptional services. Specifically, the reform significantly contributes to sorting out and classifying the information and removing the challenge of paperwork.
Inception Period
Historically, the public health system dealt with environmental hazards and community sanitation. However, there were other reasons for lethal outcomes, apart from poor sanitation and communicable disease. Such aspects as poor diets, smoking habits, lack of exercise, and social stresses, including alcohol and drug abuse have become the main issues on the agenda. The contemporary role of health care has spread efforts and research results addressing these problems. In this respect, the public health sector is liable for “understanding and mitigating the social, behavioral, and environmental factors that contribute to health status, sanitation, clear air and water, vaccination, isolation and quarantine, an inspection of food, and foodservice industry” (Cogan, 2011, p. 359).
In the nineteenth century, the system of health care and public health focuses on the failure to fulfill the gap. The physicians established common goals and joined the membership to take an active part in public health planning. Additionally, public health professionals seek to advance public health reforms. However, the membership of the health care system and public health did not last long. At the threshold of the 20th century, advances in physicians’ training and education, as well as hospital care and technology were evident and contributed to the quality of medical treatment.
The advent of the biomedical model, which relied on physiology, pathology, physiology, and biochemistry, managed to work out effective responses to disorders. As a result, the shifts from public health to individualized treatment were made because more patients were introduced into tertiary health care. The changes had a potent impact on environmental, social, economic, and behavioral patterns influencing health care. According to Cogan (2011), “as one history of the public health-health care split… the very nature of the biomedical paradigm was to uncouple disease from its social roots” (p. 357).
Reforms in healthcare have been the major concern for the U.S. government since the Democratic presidential elections in 2008. The attention was specifically given to the plans presented by Hilary Clinton and Barack Obama, taking the position of Illinois Senator during that period. Each candidate released a plan to solve the problem of 45 million uninsured Americans (Cogan, 2011). The major discrepancy between the positioned lied in the fact that Clinton’s project required all Americans to receive coverage whereas Obama insisted on providing a subsidy for Americans rather than on requiring coverage directly.
Growth
Managed care continues developing through the introduction of the Employee Retirement Income Security Act, which serves as a trigger to addressing consumer needs in terms of quality and access (Benjamin n. d.) Apart from social and commercial issues, the Affordable Act still needs to be modified to develop a stronger and healthier framework to face cost challenges. Additionally, the Health Insurance Association of America, the National Blue Cross Association, and other insurance organizations have been releasing their patient protection plans due to the rigid criticism on the behalf of the public (Benjamin n. d).
Rise and Fall
The shift from public health to an individual-centered approach has been dramatic and, therefore, the adoption of the Affordable Care Act has undergone challenges and opportunities for improving the state of health care in the United States (Cogan, 2011). Expanded access to health coverage is based on rises and pitfalls, but the Act also embraces significant provisions that relate to such aspects fostering the availability of prevention, along with wellness services. Even though these regulations have met mixed responses, little attention is paid to the preventive services mandate stipulated in the ACA (Cogan, 2011).
In short, the ACA focuses on altering the approaches to evidence-based services delivered for private insurance plans. By introducing these health plans, the Act replaces the American private and public health care financial system with tools for promoting the public sector.
The U.S. Government and Managed Care
The Social Security Amendments
Medicare
The introduction of the Medicare Advantage program allowed the recipients to develop a private plan for insuring healthcare. It has been reported that over 10 million Americans participated in private Medicare programs and almost every district in America owns a private insurance plan (The Administration of President, 2009). Additionally, to improve health care and education, President Bush was working on Medicare Prescription Drug Benefit, under which, “private drug plans compete against each other to provide coverage for beneficiaries” (The Administration of President, 2009, p. 20).
More importantly, the program has managed to promote the decline in prices, as well as develop 40 % percent lower rates than the original estimates. The administration took measures for protecting the rights of physicians and service providers to act following their conscience. At this point, President Bush also insisted on establishing family planning organizations to develop a strong social infrastructure. This Administration was a pioneer in making the federal funds available for medical research, particularly for embryonic stem cell research.
Medicaid
Cogan (2011) debates that Medicaid provisions differ within the context of PPACA and about government regulation and federal funding. In contrast to Medicare, which is supported solely by the federal government, Medicaid adheres to a federal public health insurance program for low-income individuals. The state government sustains the program to cover optional diagnostic services, as well as preventive services.
The federal government provides 1 % of additional payment in Medicaid funds to reimburse the costs of the preventive services, as well as recommended vaccines provided no cost-sharing is presented (Cogan, 2011). Hence, while requiring the preventive services to be provided at an additional cost to Medicaid, the Act ensures strong financial support and guarantees services free of costs. Concerning the proposed changes, the implications for the Act’s preventive mandate are extensive. Once the Act’s mandate is reinforced, almost all young U.S. residents could be ensued by identical evidence-based preventive services (Cogan, 2011).
The Health Maintenance Organization Act
The evolvement of the Health Maintenance organization Act is closely associated with the Employee Retirement Income Security Act of 1974, which establishes standards and provisions of pension plans. ERISA has developed based on court cases that introduce duties of disclosure. The disclosure of financial incentives should also be considered under the auspices of the Health Maintenance Act of 1974 (May, 2012). The incentives also concern the possibility for patients to rely on physicians’ advice to find out whether this recommendation is affected by the self-serving financial services that health insurance providers create.
The Politics of Healthcare in America
Big Business
According to ACA, big businesses are those that own more than 50 employees. Provided the company is unable to cover employees, it should be penalized. Therefore, the large corporations object to the regulation because they have to undertake considerable costs. They often seek to repeal the regulation or impose restrictions on certain provisions. Both functionally and conceptually, the U.S. health care system can be regarded as a combination of two major components, public health, and health care. Health care performs such functions as financing, organizing, and delivering patient-centered, curative medical care (Cogan, 2011).
For the majority of U.S. citizens, the concept of health care encompasses everything from insurance providers to hospitals, pharmacies, and physicians. It also embraces the policies in Medicaid, Medicare programs, as well as relies on physical and legal entities that invest in medical care.
The Bush Years
During the Bush presidency, preventing screening was added to the Medicare program to help diagnose and predict illnesses more efficiently. Apart from personal pension plans and health care systems, the Bush administration takes control of health care decision-making by developing tax-free Health Savings Accounts. Additionally, the provisions “infused transparency bout price and quality into the health care system and launched an initiative to make electronic health records available to most Americans within 10 years” (The Administration of President, 2009, p. 44). Apparently, these endeavors have become the precursors of the adoption of the Affordable Care Act, as well as of developing new policies in health care.
Medicare Part D
In 2006, the federal government introduced insurance coverage for recipients’ prescription drug expenditures by implementing a new program, which was also called Medical Part D. Under this provision, the government agreed with private coverage plans instead of establishing pharmaceutical prices. The utilization of this provision was optional, and users were permitted to select one insurer who provides coverage in a particular district.
From a theoretical perspective, it is unclear whether insurance coverage could rise or decline pharmaceutical prices. The reductions would anticipate the rise in prices for pharmaceutical products (Duggan and Morton, 2008). Therefore, the research studies have indicated that Part D significantly lowered the mean price, as well as increased the effects on the economic environment in the country.
Within the context of the enactment of ACA, it is purposeful to consider the problem of great expenditures because a prescription drug is considered to be one of the major sources of costs. In particular, nearly 60 % of all prescription drugs are supported by Medicare and Medicaid beneficiaries (Duggan and Morton, 2008). In this respect, the implementation of a government project to convert pharmaceutical production into a more efficient solution is necessary both to technological advancement and to governmental budgeting.
Duggan and Morton (2008) make surprising conclusions concerning the underpinnings of increased costs, stating, “moving consumers from cash-paying status to insured status lowers optimal prices for branded prescription drugs”. As a result, insurance affects inelastic demand and contributes to higher prices. Part D is regarded as the largest shift in the Medicare program’s policies because the program’s inception has become controversial. One of the major barriers to accepting the program consists in an increase in prices unless the government is engaged in a negotiation on behalf of the project’s participants to assure lower prices. Therefore, the program constitutes a tangible stance that influences the controversies of the Affordable Care Act.
“Change We Can Believe In”
44th President of the United States
Despite the evident controversies of the Affordable Care Act, the president pays attention to the genuine reasons for increased health care costs and recognizes that considerable shifts should be made. Additionally, Barack Obama believes that the situation can be changed for the better as soon as the nation faces adversity and reunite the efforts in overcoming the challenges. At this point, the president puts forward the provision that “bring down premiums for every family who currently has coverage; boosts quality; requires coverage of preventive care; reduces the price of prescription drugs; and stops insurance companies from denying coverage based on preexisting conditions” (Obama, 2008, p. 19).
Additionally, the head of the United States explains that the health care system should be treated through subsequent stages, but not as a unified system. As a result, although the initial costs spent on health care will be significant, they will be reimbursed in the future. As soon as large and small businesses realize the importance of these investments, the regulations will turn to a more consistent level of accomplishment.
The Patient Protection and Affordable Care Act
Law
The Patient Access to Affordable Care Act (PARCA) is closely associated with the Employee Retirement Income Security Act of 1974 that has been amended to allow consumers and employees to select their physicians, as well as provide them with direct access to health care professionals. In addition, patients will also be able to get medical aid without pre-authorization delivered by managed care schemes. The act reminds me of the 1994 Clinton health care reform that referred to guaranteed issues and community rating (Kocher et al., 2010). PARCA is supported by the House of Representatives and the Senate that strive to improve health maintenance organizations and eliminate restrictions on patients’ choices.
Controversy
As it has been previously mentioned, PARCA faces the challenges of costs controversy because managed care companies compete fairly. Additionally, the U.S. spends a great number of resources on health care. The expenditures were twice larger than the amounts of money spent by fifteen Western developed countries. If spending money influenced greater outcomes, the U.S. nation would be the healthiest economy on the planet.
Nevertheless, the case demonstrates the contrary (Cogan, 2011). Despite the incredible costs spent on health care, the country lags behind other countries in terms of the quality of health care services. According to the Commonwealth Fund report, the United States takes the sixth position after such developed countries as Canada, Australia, Germany, New Zealand, the United Kingdom, and the Netherlands.
The World Health Organization presents the nation’s health system with the 37th position in the world. Such estimates are heavily discussed and criticized. Statistics also confirm the low level of health care in the United States, as compared to other nations. For instance, the country has had the lowest living standards and life expectancy rates, as well as the highest mortality rate among children among the eight most developed countries. At this point, Cogan (2011) explains that American high expenditures and poor quality of health services are linked. A great ratio of the spending is attributed to unhealthy behaviors and lifestyles, leading to obesity and substance abuse.
Supreme Court Ruling
There is much controversy concerning the Supreme Court Ruling and the reactions of managed care companies to it. Specifically, most of the insurers have passed ahead of the Court to resist the denial of certain provisions of the Affordable Care Act to prove their readiness to adhere to the accepted law (Zigmond. 2012). However, most of the critics believe that the insurance company’s position is only their attempt to make the court overturn the provisions (Zigmond, 2012). At the same time, the company believed that active participation in adopting the regulations could enhance customers’ confidence in the genuineness of their intentions to proceed with the reform development.
Managed Care, Back to the Future
Pros
It has been discovered that over 45 million Americans do not have coverage, which leads to increased rates of mortality. Americans possessing insurance also have problems and obstacles to receiving medical aid (Kocher et al. 2010). In this respect, the Affordable Care Act eliminates most of these financial problems and removes the obstacles for Medicare beneficiaries in the future. At the same time, the reform removes lifetimes and annual restrictions, as well as outlaws the coverage practices, including rescissions, which often reject people’s care (Kocher et al., 2010). Finally, it lowers the health care cost. For instance, the Act introduces free entrance to prevent screening sessions. Overall, the Affordable Care Act facilitates the development of high-quality services, such as the right testing procedures.
Apart from positive shifts in healthcare, the Affordable Care Act introduces incentives for accurate information processing and storage, which contributes greatly to transparent reporting and constant information updates. To address to issue of the information gap, it is possible to combine ACA with the American Recovery and Reinvestment Act, according to which $ 25 billion will be provided to physicians to motivate them to change their methods in information recording and exchange (Kocher et al., 2010).
Cons
The main disadvantage of the ACA does not lie in the provisions adopted, but in the social, economic, and political contexts within which this legislation was considered. This is of particular concern to the reluctance of the population to observe healthy lifestyles, as well as change their outlooks on their habits. The incredible investment made to handle obesity, tobacco, and alcohol abuse among U.S. Americans. Therefore, the inconsistency of the Act with educational and training programs adopted in schools and practiced within families does not allow the government to solve the health problem and re-direct the financial funding to the health care insurance for the uninsured Americans.
Conclusions and Recommendations
In conclusion, the Patient Protection of the Affordable Care Act introduces shifts in visions on public and private healthcare networks. On the one hand, the reform contributes to the quality of health care services, as well as to the professionalism and competence of physicians. It also rescues millions of Americans from lack of health care coverage. Additionally, the reform introduces an individual-centered approach to treating patients in private industries.
On the other hand, the reform creates great problems for small and large businesses that will be penalized in case their employees do not receive insurance plans. Free access to medical aid was not always the case because the previous situation in health care was more concerned with public issues, ignoring the private sector. To remove the controversies, specific emphasis should be made on creating an adequate educational, social, political, and economic environment in which the system could work effectively.
References
Benjamin, G. C. (1998). The Future of Managed Care: The Debate Continues. Physicians Executive. 24(3), 67-69.
Cogan, J. A., (2011). The Affordable Act’s Preventive Services Mandate: Breaking down the Barriers to Nationalwide Access to Preventive Services. Journal of Law and Medical Ethics. 39(3), 355-365.
Duggan, M. & Morton, F. S. (2008). The Effect of Medicare Part D on Pharmaceutical Prices and Utilization. 13917, 1-48.
Kocher, R, Emanuel, E. J., and, DeParle, N.-A. (2010). Medicine and Public Issues Annals of Internal Medicine the Affordable Care Act and the Future of Clinical Medicine: The Opportunities and Challenges. Annual International Medicine. 153 (8), 536-539.
May, D. (2012). Referndum on Reform: America has begun Voting, with the Future of Healthcare Policy a Top-tier issue. Modern Healthcare, 42(2), 22.
Obama, Barack. (2008). Change We Can Believe: Barack Obama’s Plan to Renew America’s Promise. US: Broadway.
The Administration of President (2009). Highlights of Accomplishments and Results. Web.
Zigmond, J. (2012). Insurers Fail to Impress. Vows to Keep Parts of ACA not Enough, Critics Say, Modern Healthcare, 42(25),10.