March 23rd, 2010 was a historic day in Washington after a nearly century old struggle. After debate, false starts and incremental change, major healthcare reform legislation was passed by both the houses of congress and signed by President Barack Obama. The president and the congress and the senate succeeded in what several earlier presidents and their respective congresses had failed to achieve – a substantial move towards universal health insurance coverage and a critical transformation in the delivery and financing of health care (Cochran et al 262).
The health care reform 2010 battle was not won without struggle; it faced fierce ideological and political battles of epic scale and complexity. The victory only occurred by a slimmer than thin margin in an astonishingly bitter political climate. The new health care law strives to extend insurance to more than 32 million Americans. This will be achieved through the expansion of Medicaid and other federal subsidies that will help lower and middle income earners buy private insurance coverage. The provision seeks to create insurance exchanges for those Americans buying private coverage and restrict private insurers from excluding coverage based on pre-existing conditions. The law aims at reducing the costs of Medicare by engaging experts who will limit the federal government’s reimbursement to only effective treatments. It also creates incentives that encourage health care providers to ‘bundle’ services instead of charging them individually.
The implementation of the Health Reform bill 2010 will have a far reaching impact on US health care, both beneficial and disastrous to the common American citizen. In this term paper, I will attempt to reveal the positive side of health reform to American society. I will also touch on a few negatives of the law that affects contemporary American society.
The Background of the Health Care System
Traditionally, the American health care system was a combination of public and private institutions. At the top of the system were the health care professionals who operated on a fee-for-service basis (FFS). This practice was changed in fundamental about two decades ago and managed care system introduced. However, a part of this traditional practice is still operational. In the discounted FFS reimbursement, insurance companies negotiate reductions in the fees with hospitals, physicians and other medical care providers. The providers benefit from this arrangement as insurance companies direct subscribers to them. The system has flaws as it is fragmented and difficult to coordinate for those suffering from multiple medical conditions. It is also very expensive. Numerous changes in the health care system since 1980’s has provided little or no evidence of improved quality or cost reductions.
Following the protracted battle between the democrats and republicans over the Health Reform 2010, the health care industry is the only likely winner as evidence by the following.
Childbearing women and newborns
The PPACA has a number of provisions offering numerous benefits to childbearing women and newborns. This includes increased access to, and affordability of, maternal care. There are also other novel benefits and programs (MCHIPP 77).
Prior to the implementation of the health care reform provisions, Medicaid covered less than 50% of pregnant women’s hospital stays and a similar percentage for their newborns. Inaccessibility to insurance before being pregnant meant that many childbearing women had no ability to utilize health services to arrange for successful pregnancies. The process of establishing Medicaid eligibility after one was confirmed to be pregnant was lengthy thus barring timely access to prenatal health care.
The PPACA has three provisions that are going to transform this situation;
- Originally, it was the duty of states to offer coverage to uninsured pregnant women who had incomes of up to 133% of federal poverty level. But beginning January 2014, states will be required to provide minimal essential health services to all uninsured persons falling in this range. They (states) will have an option of also offering coverage to person above the income poverty range. With this reform, up to 8.2 million women below the age of 65 years will be covered.
- Uninsured women with low or moderate incomes will be able to access subsidies to purchase health insurance beginning 2014. Through state insurance ‘exchanges’ and discounts, up to 42% of uninsured women (additional 7 million below the age of 65) will be eligible for this benefit.
- Young adults’ access to health insurance is also headed for an increase. In the current situation, young people have been losing health insurance upon attaining the age of 19 years leaving them uninsured and at a risk of reduced well-being and increased medical debts. The provision stipulates an extension in health insurance policies in coverage for dependent children up to the age of 25 years (section 2751).
In section 1302 of the Patient Protection and Affordable Care Act (PPACA), ‘essential health benefits’ offers further protection for child bearing women and their babies. According to the provision, essential services must be covered in policies available. This will be through insurance exchanges and the individual and small group markets beginning 2014. In the current system, coverage of this nature has been excluded in majority of policies (Vivar 48).
Access to maternity care will be revolutionized through market reform come 2014. Market reform will proscribe exclusion of coverage for existing conditions and other exclusions on the basis of health status (section 2704). Group and individual health insurance policies will benefit from this arrangement. In the current health system, uninsured pregnant women are ineligible to purchase private health insurance, and, even if a pregnant woman could purchase insurance during pregnancy, the insurance does not entail maternity cover for the present pregnancy. Worse still, some insurance companies deem ineligible for maternity care coverage women who have had previous caesarean operations. Some also exclude from maternity care coverage women with pelvic floor problems among those who have had episiotomy. Come 2014, these practices will be illegal.
Help for the most vulnerable
Apart from seniors, young adults, and middle-income Americans, the other beneficiaries of the health care reform bill are uninsured ill workers. The implementation phase of the law will seek to cover these more than 40 million Americans. The provision will seek to benefit those Americans who, because of one reason or another, lack or lost their insurance (Jacobs & Skocpol 54). Although this provision will come in force in 2014, single mothers can buy private insurance at the present as the law bars insurance companies from denying low income earners from accessing coverage. These people can also benefit from substantial expansions of Medicaid, which is a long term federally subsidized and state administered program designed for those earning a low income.
The redesigning of Medicaid means that more Americans will become eligible. The new face of Medicaid will include coverage for 16 million more enrollees as it has expanded eligibility criteria that take care of childless adults (not limited to adults with children and pregnant women).
Benefits to the affluent- who pay much of the bill
Families making more than US$250,000 a year are in a mix. They have to share in general improvements in insurance. This can be translated to mean that majority of wealthier Americans will cater for their own health care and that of their neighbor’s. They are requested to part with a bit more to the system than their poorer counterparts. Like the rest of the Americans, the rich families will also benefit from the new restrictions on insurance companies that put caps on coverage and engross in egregious practices such as finding reasons to deny benefits to those who fall sick. In the past, such abuses have also been met by the rich and wealthy. In reality however, the rich have always been in a position to purchase premier coverage out of reach for majority of Americans and have, therefore, less likely to get pushed around by insurers.
Seniors and older Americans
The seniors and older Americans will benefit from the health care reform in several ways;
- Wellness and prevention services- There are many annual preventive checkups including cancer screening for those under Medicare. Nowadays, co-pays and deductibles are no longer required. Medicare patients can now access comprehensive health risk assessment and free individualized prevention plans that help them and their doctors shift their focus from sickness to well-ness.
- Prescription drug ‘donut hole’- Medicare senior patients will receive a partial rebate and their responsibility for their own drug will progressively lessen depending on their income levels. Seniors who qualify for Medicare programs and who are on private insurers’ coverage will additional services as the government pays the insurers for their services.
Health reforms and pharmacy benefits
There are profound changes in benefits and reporting requirement (sections 6005, 2501, 2502, 2503, 7002, PPSA, 6004). These changes mean that patients will be able to access several drugs previously not covered. Medicaid MCOS can now access section 340B pricing. This section has some of the lowest drugs prices in the pharmaceutical industry. This means that Medicaid can utilize these changes to manage its costs. However, this will require Medicaid to report certain items to the state governments. The states will in turn need to make capitation rates that will be reimbursed to the entity on the basis of cost experience related to rebates which will be subject to federal regulations (Parks 6).
As pharmaceuticals and medical device companies serving medical providers will be compelled to disclose payments made to medical providers, it will be possible for the government to scrutinize the physicians. This will enable the government unveil any conceivable conflicts of interest in their dealings. This information will be posted online thus enabling patients know physicians who receive payments from given manufacturers.
The law obliges manufacturers and distributors of prescription drugs to report to the government information relating to drug samples given to medical providers. This will act to discourage dispensing of samples as a marketing strategy and will enable the federal government to track and monitor this vice.
Demerits of the health care reform bill 2010
Although the health care reform 2010 has many benefits to the society, a few flaws do exist. This health care reform law has several problems that make it fail to meet the objectives of a good heath care reform. I have identified six main areas that I feel are necessary and that need correction before the law becomes fully pledged in 2014.
- Lack of real cost control. Because this law lacks essential cost control, it may fail to bring down premiums for majority of the Americans.
- Poor enforcement. Although there are pretty good regulations in it, the law lacks enforcing agency. Instead, enforcement was left on the same state insurance commissioners who lack everything required to hold private insurers honest.
- Individual mandate. Forcing Americans to buy products from poorly regulated private industry is a big disadvantage to the Americans.
- Abortion. The law does not give American women a right to choose. The law took away the abortion coverage.
- Competition. The law fails to address the problem of lack of competition in insurance market.
- Immigrants. This law leaves out undocumented immigrants even if they are willing to pay full cost of the insurance cover. This is not only cruel but also immoral.
The health care system was actually beneficial for the long protracted political and ideological battle that was witnessed for the better part of 2009-2010 between the democrats and the republicans. Among the benefits expected are in regard to the dependent children who now remain on their parent’s health insurance plans up to the age of 26 years. The senior citizens now pay less for their drugs. Previously uninsurable people with health problems were not left out in the reforms as they now qualify for medical coverage under the federal programs. Lifetime or annual caps on coverage have been removed and preventive care provided for free. The law has some flaws, for example, it leaves out undocumented immigrants, lacks competition, removed abortion coverage, lacks cost control and has poor enforcement. However, it is a good sign that we are moving towards the right direction.
Cochran, Clarke, Mayer, Lawrence, Carr, TR, Cayer, Joseph, and McKenzie Mark. American Public Policy: An Introduction. 10th ed. Boston, MA: Wadsworth Cengage Learning, 2011. Print.
Jacobs, Lawrence, and Skocpol Theda. Health Care Reform And American Politics: What Everyone Needs To Know. New York: Oxford University Press, 2010. Print.
MCHIPP. Publication no. 7952-03. Menlo Park, California: Kaiser Family Foundation, April 2010. (Publication 7952-03.)
Parks, Dave. Health Care Reform Simplified: Understanding The New Rules For Insuring Individuals, Families, And Employees. New York: Apress, 2011. Print.
Vivar, Molestina, Luis. Obama’s Health Care Reform 2010: From Change To Concession?: Health Care Reform As An Example For Structural Resistance Of The American Political System To Needed Change. Norderstedt: GRIN Verlag, 2011. Print.