Changes to healthcare in 2012

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Distribution of health plan enrollment of covered workers, by plan type, — A portion of the change in plan type enrollment for is likely attributable more The ACA included payment-reform provisions to incentivize the adoption of more effective care-delivery models Abrams et al.

The new models involve some combination of shared risk among providers to enhance collaboration and coordination of care so as to reduce avoidable hospitalizations, ED visits, and other forms of expensive or unnecessary care. To protect against stinting, quality metrics are often used to evaluate provider performance. Beyond payment models, the ACA encouraged perhaps unintentionally the narrowing of provider networks and reshaped the delivery of long-term services and supports, all of which have implications for the ways in which people who have disabilities receive care and for the documentation of that care in the medical record.

We discuss each in turn. The payment, contractually determined in advance, is intended to encourage better coordination among the various providers involved in a given patient's care. Some 7, post-acute care providers, hospitals, and physician organizations have signed up to participate in bundled-payment demonstrations Abrams et al. Early evidence suggests that bundled payments can reduce medical costs and improve patient satisfaction CMS, The ACA also incentivized the development of alternative delivery models, such as accountable care organizations.

Those involve collaboration among physicians, hospitals, and other health-care entities in a shared-risk arrangement. The alternative delivery models were intended to encourage provider organizations to address patient health needs better, to reduce the amount of hospital and ED care, and to meet quality goals.

Their effectiveness and their effects on clinical practice, however, are still matters of considerable debate Schulman and Richman, ; Song and Fisher, The primary goal of the PCMH is to keep people ambulatory in the community, in addition to aligning provider financial incentives with the best interests of patients.

The PCMH is not a physical home but rather a care delivery system in which each patient's care is coordinated through his or her primary care physician PCP.

The PCP manages and coordinates care with the goals of having each patient receive the necessary care when and where he or she needs it, and in a manner that the patient can understand and that is consistent with and respectful of the patient's preferences, needs, and values Blumenthal et al. In patient-centered models, there is greater potential for providers to identify people who have comorbidities and to coordinate their care. Visits for both ambulatory care sensitive and non-ambulatory care sensitive conditions were reduced; this suggests that steps taken by practices to attain PCMH recognition might decrease some of the demand for outpatient ED care van Hasselt et al.

NCQA also noted that PCMH recognition is associated with fewer inpatient hospitalizations and lower utilization of both specialist and emergency services Harbrecht and Latts, ; Raskas et al. Money was offered to physician practices to meet compliance with health information technology or so-called meaningful use criteria or face penalties in Medicare reimbursement.

EMRs offer the promise of aggregating records from many providers into a single, legible medical record as long as all providers seen by a patient participate in the same EMR system; interoperability among systems is imperfect. The HITECH Act offers the promise of a more complete medical record that details the full history of care provided to a patient who applies for disability benefits.

The change in provider network size is another indicator of how the ACA has transformed the care that people get. So-called narrow networks existed before the implementation of the ACA, but they have grown more common as a result of it.

Many consumer protection measures, such as the prohibition of medical underwriting, have made it difficult for many insurers to rely on traditional strategies to keep costs low. Other elements of the law, such as the availability of the online marketplace where consumers can compare premiums, have made it possible for insurers to compete with each other.

Plans that have narrow networks might benefit consumers by lowering premiums. Negotiations between insurers and providers on network participation might encourage more efficient delivery of care. And the ability to contract selectively might allow insurers to attract a small group of providers that meet raised standards of quality and potentially would result in care of higher value Health Affairs, But narrow networks also pose risks to consumers.

For example, if a network gets too narrow, it will jeopardize the ability of consumers to obtain needed care in a timely manner. That can also happen if the network contains an unsatisfactory mix or insufficient number of providers.

Network limitations can have the additional effect of turning away sicker patients who have more health needs and thus changing the risk pool. One study notes that consumer advocates argue that narrow networks adversely affect access to care, especially for patients who have chronic illnesses. They claim that insurers structure the networks strategically to discourage the higher-cost patients from enrolling. Patients who have high needs will then have to go outside the network and possibly outside the EMR system and as a result tend to incur high expenses and receive surprise medical bills EBRI, Their medical documentation is also more likely to be missing elements.

The ACA included several provisions aimed at improving deficiencies in the nation's long-term care system to ensure that people can receive LTSS in their home or the community KFF, a. In addition, in states that accepted the Medicaid expansion, funds were made available to pay for home- and community-based attendant services in connection with matching by the federal government KFF, a.

Nonetheless, Wiener has argued that despite the growing need for HCBS, not enough progress had been made in improving the financing of long-term care. A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use KFF, c found that health insurance coverage has expanded overall, access to and use of care have increased, self-reported health status has improved, and flow of federal health-care resources into expansion states has risen.

One study by Barakat et al. It did not, however, detect a substantial change in top diagnoses or in the overall rate of ED visits and hospitalizations. The authors argued that there appeared to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization. In contrast, Sommers et al. Wherry and Miller observed an increase in office visits to physicians but also an increase in overnight hospital stays after the Medicaid expansion.

Chen et al. There is consensus among studies on the effects of the ACA on utilization of preventive services. Sommers et al. Similarly, Wherry and Miller found that Medicaid expansion under the ACA led to higher rates of preventive services, which resulted in more diagnoses of diabetes and high cholesterol.

Several studies have specifically identified ACA-related improvements in health-care utilization by people who had chronic conditions. They found improvements in multiple measures: affordability of care, regular care for the chronic conditions, medication adherence, and self-reported health. A related study by Sommers et al. They echoed the findings in the report by suggesting that regular care for chronic conditions increased substantially after Medicaid expansion. The findings of those two studies were consistent with the findings of an earlier study by Sommers et al.

Although evidence suggests that on average people who had chronic conditions experienced an increase in access to regular care for those conditions, coverage effects vary among diseases Baicker et al. Because of the many design features that are common to the ACA, the Massachusetts health-care reform of , and the Oregon Medicaid lottery of , the experiences of Massachusetts and Oregon are informative about potential effects, and in particular long-term effects, of the ACA on utilization.

A study by Cole et al. It found no effect of Medicaid coverage on diagnoses or on the use of medication for blood pressure and high cholesterol, but Cole et al. The Oregon Medicaid study Baicker et al. The evidence on cancer care is also mixed. One study of the Massachusetts health-care reform did not find any changes in breast-cancer stage at diagnosis Keating et al. A third study of the Massachusetts reform echoed the improvement in cancer care by revealing that coverage expansion was associated with an increase in rates of treatment for colon cancer in low-income patients and a reduction in the number of patients waiting until the emergency stage for treatment Loehrer et al.

In addition to health-care service utilization, the use of prescription drugs serves as an important measure of the ACA's effect, especially given their prominent role in the management of chronic conditions. Mulcahy et al. They attributed the increase in treatment rates for chronic conditions and the reduction in out-of-pocket spending to the decrease in financial barriers to care under the ACA.

The ACA has many provisions that are important for people who have disabilities. For example, denial of coverage because of pre-existing conditions is no longer allowed. Removal of a lifetime cap on benefits will enable people with disabilities to continue to receive care. Perhaps most important, the expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify for SSDI or SSI.

And the ACA authorizes federally conducted or supported studies to collect standard demographic characteristics that include disability status Krahn et al. In this section, we summarize the early literature on those effects. The ACA's dependent coverage provision appears to have benefited young adults who have disabilities.

Porterfield and Huang analyzed the periods before and after implementation of the dependent coverage provision in the ACA and compared adults who had disabilities and were 19—25 years old with adults who had disabilities and were 26—34 years old.

People in both age groups experienced coverage gains after the ACA dependent coverage provision took effect in , but for people in the older group who were unaffected by the dependent coverage provision, the coverage gains were entirely attributable to changes in public insurance.

In contrast, the coverage gains for people in the younger group who were affected by the dependent coverage provision were driven by changes in private insurance. By , low-income and moderate-income nonelderly adults—including both those who had and those who did not have chronic illnesses—also experienced coverage gains.

The Kaiser Family Foundation KFF, c notes that in some states and the District of Columbia, those gains resulted from the Medicaid expansion to adults who had incomes up to percent of the federal poverty level. In other states and the District of Columbia, the coverage gains for people who had disabilities resulted from subsidies for qualified health plans offered on the health insurance marketplaces combined with private insurance reforms, such as the prohibition of discrimination based on health status.

The ACA appears to have brought about improvements in treatment for mental disorders and substance abuse. Saloner and LeCook examined the effect of the ACA on young adults who had mental health or substance-use disorders by using data from the — National Survey of Drug Use and Health.

The authors found that after implementation of the ACA, mental health treatment of people who were 18—25 years old and had possible mental health disorders increased by 5. Uninsured visits by people who used mental health treatment decreased by Consistent with those findings, Ali et al.

If those possibilities are fully realized, that would represent a 40 percent increase in behavioral services utilization, primarily for mental health services. Golberstein et al. A recent study Hall et al.

The authors noted that people who have disabilities often experience psychologic distress and comorbid health conditions and have low income and employment. New coverage options under Medicaid expansion that allow people to work more and accumulate assets could benefit people who have disabilities because they would no longer need to apply for SSI or live in poverty to qualify for Medicaid.

Results from the Hall et al. Those changes were not statistically significant, because of the small sample in the pre-ACA period. However, after the ACA, those who had disabilities and lived in expansion states were more likely to be employed The authors concluded that Medicaid expansion is an important policy for reducing disparities in access to care for people who have disabilities and for supporting their employment and financial independence.

Despite the many positive benefits of the ACA, there remain barriers to access to care among people who have disabilities. Among them is the complexity of the Medicaid application process Gettens and Adams, Cost-related difficulties present another barrier. Despite the ACA's subsidies for qualified health plans, which have reduced premium costs to some degree, deductibles and other out-of-pocket costs remain high and pose financial challenges to many people who have disabilities Gettens and Adams, Health care in the United States is financed by a combination of public and private insurance, employers, and out-of-pocket payments by individuals.

In , 37 percent of the US population received health care through a public insurance program at some point during the year. The US health-care delivery system consists of an array of clinicians, hospitals and other health-care facilities, insurance plans, and purchasers of health-care services, all of which operate in various configurations of groups, networks, and independent practices.

The healthcare delivery system historically has been organized around the concept of fee-for-service medicine. Because provider revenues increase as more services are provided—and insured and some uninsured patients do not bear the full cost of the services—the fee-for-service model creates incentives to increase utilization of health-care services and leads in many cases to overutilization of physician and hospital visits.

It brought about structural changes in the health-care system, which included sweeping efforts to improve access to health insurance through expansion of the Medicaid program and through subsidized and lower-cost health insurance plans made available through new health insurance marketplaces exchanges , elimination of pre-existing condition restrictions on coverage, elimination of lifetime caps on health-care spending, and efforts to slow growth in health-care costs through innovative payment reforms.

The plan had two major components: expansion of the Medicaid program and new structures to support the individual and small-group health insurance markets. As a result, only 32 states and the District of Columbia elected to expand Medicaid. For the individual and small-group markets, the ACA established health insurance exchanges in states to allow individuals and small groups to buy standard insurance policies with income-based subsidies from percent to percent of the federal poverty level.

The ACA eliminated medical underwriting and imposed a legal mandate to purchase health insurance, with a penalty for those who did not comply. The ACA's individual mandate was designed to compel healthier people to purchase insurance and thereby balance the risk pool and lower premiums for everyone.

The ACA included payment-reform provisions to incentivize the adoption of more effective care delivery models. The new models involve some combination of shared risk among providers to enhance collaboration and coordination of care in an effort to reduce avoidable hospitalizations, ED visits, and other forms of expensive or unnecessary care.

Beyond payment models, the ACA encouraged perhaps unintentionally the narrowing of provider networks and reshaped the delivery of LTSS, all of which have implications for how people who have disabilities receive care and the documentation of that care in the medical record. The expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify also for SSDI or SSI.

A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use finds that health insurance coverage overall has expanded, access and use of care have increased, self-reported health status has improved, and the flow of federal health-care resources into expansion states has risen.

Coverage categories are not mutually exclusive; some people switch coverage during a year or have multiple forms of coverage. Federal law requires that state Medicaid programs make DSH payments to qualifying hospitals that serve a large number of Medicaid and uninsured people. The CLASS Act would have created a voluntary and public long-term care insurance option for employees, but in October the Obama administration announced it was unworkable and would be dropped. Turn recording back on. Help Accessibility Careers.

Search term. Narrowing Provider Networks The change in provider network size is another indicator of how the ACA has transformed the care that people get. The Affordable Care Act's payment and delivery system reforms: A progress report at five years.

New York: The Commonwealth Fund; The implications of the Affordable Care Act for behavioral health services utilization. American College of Emergency Physicians. The Oregon experiment—effects of Medicaid on clinical outcomes. New England Journal of Medicine. Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments. The Affordable Care Act at 5 years. What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics.

The Quarterly Journal of Economics. Veterans' disability compensation: Trends and policy options. Medicaid managed care enrollment and program characteristics, At federally funded health centers, Medicaid expansion was associated with improved quality of care. Health Affairs Millwood.

Issue brief no. Gettens J, Adams A. While I have always been interested in improving the law—and signed 19 bills that do just that—my administration has spent considerable time in the last several years opposing more than 60 attempts to repeal parts or all of the ACA, time that could have been better spent working to improve our health care system and economy.

In some instances, the repeal efforts have been bipartisan, including the effort to roll back the excise tax on high-cost employer-provided plans. Although this provision can be improved, such as through the reforms I proposed in my budget, the tax creates strong incentives for the least-efficient private-sector health plans to engage in delivery system reform efforts, with major benefits for the economy and the budget.

It should be preserved. While historians will draw their own conclusions about the broader implications of the ACA, I have my own. These lessons learned are not just for posterity: I have put them into practice in both health care policy and other areas of public policy throughout my presidency. The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported.

For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in but opposed them in the ACA.

They supported the individual mandate in Massachusetts in but opposed it in the ACA. Moreover, through inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation, Republicans undermined ACA implementation efforts. We could have covered more groundmore quickly with cooperation rather than obstruction. It is not obvious that this strategy has paid political dividends for Republicans, but it has clearly come at a cost for the country, most notably for the estimated 4 million Americans left uninsured because they live in GOP-led states that have yet to expand Medicaid.

The second lesson is that special interests pose a continued obstacle to change. We worked successfully with some health care organizations and groups, such as major hospital associations, to redirect excessive Medicare payments to federal subsidies for the uninsured.

Yet others, like the pharmaceutical industry, oppose any change to drug pricing, no matter how justifiable and modest, because they believe it threatens their profits.

But we also need to reinforce the sense of mission in health care that brought us an affordable polio vaccine and widely available penicillin. The third lesson is the importance of pragmatism in both legislation and implementation. Simpler approaches to addressing our health care problems exist at both ends of the political spectrum: the single-payer model vs government vouchers for all.

Yet the nation typically reaches its greatest heights when we find common ground between the public and private good and adjust along the way. That was my approach with the ACA. We engaged with Congress to identify the combination of proven health reform ideas that could pass and have continued to adapt them since. This includes abandoning parts that do not work, like the voluntary long-term care program included in the law.

It also means shutting down and restarting a process when it fails. When HealthCare. Both the process and the website were successful, and we created a playbook we are applying to technology projects across the government. I often think of a letter I received from Brent Brown of Wisconsin. We can help them. I will repeat what I said 4 years ago when the Supreme Court upheld the ACA: I am as confident as ever that looking back 20 years from now, the nation will be better off because of having the courage to pass this law and persevere.

As this progress with health care reform in the United States demonstrates, faith in responsibility, belief in opportunity, and ability to unite around common values are what makes this nation great.

All of the individuals who assisted with the preparation of the manuscript are employed by the Executive Office of the President. Published online Jul Barack Obama , JD. Author information Copyright and License information Disclaimer. Copyright American Medical Association.

All rights reserved. Impetus for Health Reform In my first days in office, I confronted an array of immediate challenges associated with the Great Recession. Open in a separate window. Figure 1. Percentage of Individuals in the United States Without Health Insurance, — Data are derived from the National Health Interview Survey and, for years prior to , supplementary information from other survey sources and administrative records.

Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Building on Progress to Date I am proud of the policy changes in the ACA and the progress that has been made toward a more affordable, high-quality, and accessible health care system. Published December 3, Accessed June 14, Health spending in OECD countries: obtaining value per dollar. Health Aff Millwood ; 27 6 — The implications of regional variations in Medicare spending: part 1: the content, quality, and accessibility of care.

Ann Intern Med. The implications of regional variations in Medicare spending: part 2: health outcomes and satisfaction with care. The quality of health care delivered to adults in the United States. N Engl J Med. Commonwealth Fund Why not the best? Published July 1, National Center for Health Statistics. Early release of selected estimates based on data from the National Health Interview Survey. Published May 24, Health insurance coverage trends, — estimates from the National Health Interview Survey.

Cohen RA. Trends in health care coverage and insurance for — Published November 15, Council of Economic Advisers Methodological appendix: methods used to construct a consistent historical time series of health insurance coverage. Published December 18, Mortality and access to care among adults after state Medicaid expansions. Changes in mortality after Massachusetts health care reform: a quasi-experimental study.

Covering the uninsured in current costs, sources of payment, and incremental costs. Health Aff Millwood ; 27 5 :w—w Is employer-based health insurance a barrier to entrepreneurship?

J Health Econ. Dillender M. Do more health insurance options lead to higher wages? Lee J. Published March 15, Accessed June 20, Updated June 9, Oberlander J. Long time coming: why health reform finally passed. Health Aff Millwood ; 29 6 — Published April Estimating the counterfactual: how many uninsured adults would there be today without the ACA?

Health insurance coverage and the Affordable Care Act, — Published March 3, Witters D. Arkansas, Kentucky set pace in reducing uninsured rate. Published February 4, Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. Access to care and affordability have improved following Affordable Care Act implementation; problems remain. Health Aff Millwood ; 35 1 — Is health insurance good for your financial health? Federal Reserve Bank of New York.

Published June 6, Published December Pinkovskiy M. The Affordable Care Act and the labor market: a first look. Published October Office of the Assistant Secretary for Planning and Evaluation.

Published December 16, The Affordable Care Act: promoting better health for women. Published June 14, Accessed June 18, Employer health benefits: annual survey. The Henry J. Kaiser Family Foundation. Published September 22, Published February 8, White C. Contrary to cost-shift theory, lower Medicare hospital payment rates for inpatient care lead to lower private payment rates.

Health Aff Millwood ; 32 5 — Clemens J, Gottlieb JD. Accessed June 29, Muhlestein D. Growth and dispersion of accountable care organizations in Health Affairs Blog. Bureau of Economic Analysis Table 1. Price indexes for gross domestic product. Congressional Budget Office The budget and economic outlook: fiscal years to Published January 7, Congressional Budget Office Updated budget projections: to Published March 24, Congressional Budget Office.

Furman J. Next steps for health care reform. White House.

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Health benefit costs expected to rise 5. Quality and Safety. Clinicians need the right messaging to pay attention to cybersecurity. Billing and Collections. Payers: Data is key for Transparency in Coverage requirements.

Claims Processing. Leveraging AI to benefit the healthcare ecosystem for providers, payers and members. RN turnover in healthcare on the rise. Hint Connect expands direct primary care network. Medical Devices. Medical devices are inherently vulnerable to security breaches. Physicians would rather leave than work for Envision, doctor says. Court rules transgender care and transition infringes on religious freedom.

Policy and Legislation. AHIP pushes education on Medicaid redeterminations. Community Benefit. Sentara Healthcare moves into the community. Accountable Care.

Acute Care. Patient acuity is driving up hospital costs, AHA says. Ambulatory Care. Hospitals face direct competition from the 'retailization' of healthcare. CMS aims to improve health equity data. Business Intelligence. Optum, Northern Light form strategic partnership. Practices keeping close watch on risk adjustment coding. Meaningful Use. CMS overhauls meaningful use as 'Promoting Interoperability'. Medicare Advantage tops traditional Medicare on diabetes. Patient Engagement.

Perceived cost a barrier to health insurance coverage. HHS will begin negotiating 10 Part D drug prices this year. Population Health. RSV still challenging for nation's physicians. Risk Management. Hospitals need a battle plan for end of Medicaid's continuous coverage. Payers must change dynamic with providers to survive in the post-Affordable Care Act world. Retail newcomers could amp up pressure for digital health adoption in Events Newsletters Sponsored About.

Top Stories. Provider Consolidation Some industry analysts have predicted the number of independent organizations could decrease by two-thirds over the next 10 years. Cost Reduction by Focusing on Quality Healthcare suppliers and vendors need to focus more on bottom-line growth in , which requires a focus on quality patient care as a means to reduce costs. The financial incentives that support the implementation of this process can then be put in place.

Quality of care at an acceptable cost can only be obtained if waste is identified and eliminated, resources are applied to necessary and appropriate care, variations in the quality of care are eliminated, and economic policies consistent with a country's culture and expectations of value for money are adopted.

Accomplishing these objectives will be difficult and costly. However, the effort must be made, if for no other reason than that the existing system in the United States, whereby health insurance is not provided for everyone, is unacceptable. Abstract The goals of a health system should be to provide all necessary care to everybody, improve the mean level of quality of care, reduce variations in this care, and eliminate waste.