The Affordable Care Act (ACA) or Obamacare is an example of a major political initiative aimed at improving the affordability and quality of healthcare in the U.S. The policy was issued on March 23, 2010, and declared universal access to Medicaid and expanded insurance coverage for previously uninsured individuals (Gaffney & McCormick, 2017). In 2016, in response to the issue of health disparities, the U.S. Department of Health and Human Services Office for Civil Rights introduced an amendment to the Act. The new rule guaranteed non-discriminative protection and coverage for LGBTQ populations (Baker, 2016). Before the introduction of the ACA, vulnerable patients from low-income populations, including LGBTQ individuals and minorities, did not have health insurance, so many of them developed serious complications due to the lack of affordable care. Such patients tend to have worse health outcomes and readmission rates compared to previously insured individuals, which creates challenges in the nursing practice and compromises safety and quality of care. Thus, the policy was an attempt to provide affordable care for patients with preexisting conditions and find a solution to the long-standing problem of healthcare inequality.
Financing is an essential aspect of a healthcare system and a clinical practice, so it is important to consider the sources of policy funding and its costs. Healthcare financing may come from taxes, government support, donations, or insurance premiums (RAND, 2020). The Act introduced cost-effective mechanisms of taxation and government spending cuts to achieve the financial efficiency of the policy via cost-containment and cost-control measures. The annual cost of the policy was about $1.1 trillion in 2019, which consisted of $644 billion of Medicare expenses and $427 billion spent on Medicaid (TPC, 2020). The annual cost of the ACA depends on current government financing of the healthcare sector and the number of insured individuals, so the total cost of the policy varies greatly from year to year.
Patient safety and quality of care is another vital aspect of any healthcare policy, including the ACA. According to the Triple Aim initiative, healthcare systems should be optimized to improve patient experience, decrease the costs of treatment, and enhance the health of patients (Institute for Healthcare Improvement, 2018). Despite the increase in the number of insured people, the Act introduced the penalties undermining the functioning of safety-net hospitals (SNHs) providing care for low-income patients. Overall, based on the overview of the ACA, the policy should be transformed to improve the outcomes, safety, and quality of care for vulnerable and medically underserved populations, including LGBTQ.
The ACA significantly improved the outcomes of medically underserved populations by promoting affordable insurance options, increasing the number of insured minorities, and facilitating their access to quality care. Gonzales and Henning-Smith (2016) argue that the Act increased the number of insured LGBTQ patients and provided minority populations with access to cost-effective healthcare. The policy also provided guidance for medical professionals and nurses as it established the standards of patient-focused care, competency, and adequate communication with colleagues (Mason et al., 2021). Furthermore, the ACA allowed nurses to participate in the decision-making process by evaluating the status of a hospital’s safety, timeliness, and quality of care, as well as patient satisfaction (Stimpfel et al., 2019). Therefore, the Act is a valuable healthcare reform with a considerable positive impact on patients and healthcare professionals via affordable insurance coverage options and professional guidance for doctors and nurses.
Despite the supporting aspects of the policy, the ACA received the negative feedback from its opponents that stems from its value-based approach to insurance coverage. The measure was selected for cost-control, but created the risks for SNHs specifically serving vulnerable populations, including LGBTQ, ethnical minorities, and low-income individuals cannot afford expensive treatment. Gaffney and McCormick (2017) discovered that the Hospital Value-Based Purchasing (HVBP) and the Hospital Readmission Reduction Programme (HRRP) introduced penalties for higher-than-expected readmission rates. The ACA-based initiatives ignored the fact that the majority of patients admitted to SNTs have complications due to inadequate medical care and poor living conditions, so they tend to have worse outcomes and readmission risks. Additionally, SNHs are often penalized for readmission rates regardless of their success in reducing 30-day mortality among the populations. Moreover, Figueroa et al. (2018) reported that SNHs encounter more barriers, such as homeless patients, poor transportation, and language difficulties when compared to the national standard. Thus, the ACA placed an unreasonable financial burden on safety-net providers instead of providing funding and strategies for their improvement of readmission rates, patient outcomes, and quality of care.
My position is that the ACA is one of the most remarkable healthcare reforms in the U.S., but it should be transformed as it negatively impacts SNHs and creates health disparities among diverse populations. The HVBP and the HRRP penalize hospitals with 3% of Medicaid payments for high rates of readmissions and there is evidence of disproportionate effects of penalties on SNHs (Figueroa et al., 2018). SNHs have limited resources and financing which create barriers to safety and quality of care and may result in frequent readmissions. Safety-net providers care for a large number of mental health patients and drug users, which Figueroa et al. (2018) describe as one of the most considerable barriers. Figueroa et al. (2018) included the report indicating the barriers in SNH versus non-SNHs, such 52.8% vs. 42% in transportation issues, 41% vs. 24% of homeless patients, and language barriers contributing to 25.6% vs. 13.2%. Moreover, the management of 68.3% of SNHs described the insufficiency of current funding as the main challenge undermining the outcomes and quality of care. Thus, the issues of SNHs require government support and funding to improve the quality of care.
Overall, the ACA is an important U.S. healthcare policy that needs to be revised in order to support SNHs providing essential care for vulnerable populations. The plan for action might be based on reviewing the conditions for readmission penalties, improving the funding of SNHs, and eliminating the existing barriers undermining the safety and quality of care. Firstly, the readmission penalties for SNHs should be minimized and their amount should be calculated considering the budget and overall performance of the hospital, including complications and mortality rates. Secondly, the federal funding for SNHs should be increased to support their efforts in providing care for underserved patients with poor health status and high rates of complications due to the history of inadequate care. Finally, the policy should be amended to remove the barriers to quality care in safety-net providers, which affect hospital readmission rates. The measures mentioned above might help to eliminate health inequities and lead to the improvement in financial stability of well-performing SNHs serving vulnerable individuals who cannot receive medical care in other hospitals without insurance.
References
Baker, K. (2016). LGBT protections in Affordable Care Act Section 1557. Health Affairs.
Figueroa, J. F., Joynt, K. E., Zhou, X., Orav, E. J., & Jha, A. K. (2018). Safety-net hospitals face more barriers yet use fewer strategies to reduce readmissions. Med Care, 55(3), 229–235.
Gaffney, A., & McCormick, D. (2017). The Affordable Care Act: Implications for health-care equity. The Lancet, 389(10077), 1442–1452.
Gonzales, G., & Henning-Smith, C. (2017). Coverage for lesbian, gay, and bisexual adults: Analysis of the behavioral risk factor surveillance system. LGBT Health, 4(1), 62–67. Web.
Institute for Healthcare Improvement. (2018). The IHI Triple Aim. IHI – Institute for Healthcare Improvement.
Mason, D. J., Dickinson, E. L., Perez, A., & McLemore, M. R. (Eds.). (2021). Policy & politics in nursing and health care (8th ed.). Elsevier.
RAND Corporation. (2020). Healthcare financing.
Stimpfel, A. W., Djukic, M., Brewer, C. S., & Kovner, C. T. (2019). Common predictors of nurse-reported quality of care and patient safety. Health Care Management Review, 44(1), 57–66.
TPC (2020). How much does the federal government spend on health care? Tax Policy Center.