honors english

Honors English

The Facets of Healthcare: America and the Affordable Care Act

Fall 2014 Honors Project

Contessa Cox

Madison College

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Introduction

Our health is the most precious commodity that we have as human beings. Without good

health, it’s nearly impossible for us to do the things that make up our lives: keep a job, travel

with friends and family, or gain an education to name a few. Health insurance or the lack thereof

has been a huge problem in America for many years, and I can attest to that from personal

experience. At one point I was homeless for a time along with my mom and my brother. It was

wintertime and I was unfortunate enough to come down with a bad case of pneumonia. Unlike

my brother and my mom, I didn’t have any health insurance at this time. I was taken to the ER

and was able to benefit from some special funding so that I didn’t have to pay for the care that

I’d received. It was a hard time for me personally, and I still remember the fear and helplessness

that I felt. I’m interested in working in health care so that I can possibly gain resources that will

allow me to help people who may be in a similar situation to the one that I was in.

For this honors project I chose to examine the Affordable Care Act or the ACA because I

wanted to see if this law has made a positive impact on the way Americans are being treated for

their medical concerns. I also wanted to see if it could be determined if the ACA is addressing

the growing issue of more and more people not having health insurance. This analysis will first

give an overview of the Affordable Care Act and break the law down title-by-title, highlighting a

few of the main points of each. The history of American hospitals, doctors, and health insurance

will also be briefly traced, to help explain the three main components that come together to form

the ACA. Finally, some common myths and misconceptions about the ACA will be studied, as

well as preliminary research into the success or failure of the Affordable Care Act, along with

the results of a survey I developed to get insight into what medical professionals and the general

public know about the ACA.

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The Affordable Care Act (ACA) is a law that was created to try and make healthcare

more dependable and flexible for Americans. The ACA was passed by Congress and signed into

law by President Barack H. Obama on March 23, 2010, which is why the law is also nicknamed

“Obamacare.” This name has taken on a more negative meaning over the years so I will not be

referring to the ACA by this name unless otherwise stated. The following information is all from

the official website for the U.S. Department of Health and Human Services

(http://www.hhs.gov/healthcare/rights/) which lists an entire breaking down of the ACA as well

as an overview of the purpose it’s meant to serve. There are some key aspects that make up the

Affordable Care Act and these aspects are coverage, care, and cost. Main features for coverage

under the ACA includes a guaranteed right to appeal any denial of payment, as well as the ability

for young adults under the age of 26 years old to be covered under their parents healthcare plan.

Under the act, healthcare insurers cannot deny or limit benefits to children age 19 years or

younger because of pre-existing illnesses.

In terms of costs, features include an end to lifetime limits on healthcare coverage for

most benefits as well as accountability for insurance companies to publically justify and explain

any raises in premium increases. Another cost aspect is that under the ACA the majority of the

premiums that patients pay must go toward the patients’ healthcare itself and not to be used on

administrative costs or services.

Some important features that were put together and included in the care that patients

receive under the ACA is a coverage of preventative health services with no copayment, as well

as allowing people to choose their own primary care physician from their plans’ network. The

ACA also puts an end to barriers for emergency services. This means that people can now seek

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emergency care anywhere, even if it’s outside their network of healthcare providers (About the

Law, n.d.).

The Affordable Care Act Explained

This is a basic overview of the entire Affordable Care Act as far as some of the important

specifics listed under each part. The ACA is broken down into 10 sections or titles, along with a

section for amendments or changes made to the law also included. Title One is called ‘Quality,

Affordable Care for All Americans’ and helps to explain the purpose of this act. Some important

sections listed under this title include immediate improvements in health care coverage,

immediate actions taken to preserve and expand coverage, and quality health insurance coverage

for all Americans. Access to insurance for people with pre-existing conditions was part of the

law that began immediately. Other important sections under Title One include a reissue of

insurance to early retirees, instant access to information for people to find affordable coverage

and plans, and taking steps to make sure Americans get the best value. The right to keep existing

coverage, as well as health benefit requirements and community health insurance options, are

also all listed under Title One of the ACA.

Title Two is called ‘The role of Public Programs’ and focuses on further extending

Medicaid as well as making the enrollment process easier and enriching community-based

healthcare. Some of the important components listed under Title Two of the ACA are improved

access to Medicaid as well as Medicaid coverage for even the lowest income population and also

coverage for children in foster care. Some other Title Two sections listed are requirements for

employers to offer help with paying insurance premiums if the insurance is sponsored by the

employer, rebates for prescription drugs, and giving back funding to sponsor abstinence

education.

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‘Improving the Quality and Efficiency of Health Care’ is the heading for Title Three of

the Affordable Care Act and the emphasis here is placed on Medicare and improving the health

and the lives of America’s elderly. This part of the ACA is designed to save Medicare recipients

thousands of dollars as well as trying to end overpayments to insurance companies and to

improve the quality of their healthcare. An improvement to the physician feedback program,

adjustments made to payments for conditions contracted in hospitals, and greater access to nurse-

midwife services that hold certification are all sections that are addressed under Title Three.

Payment adjustments for home health care and more funding being provided for outreach

programs and help for low-income programs are also listed here as well.

Title Four helps to encourage areas such as public health, wellness, and prevention of

illnesses and therefore drastically increases funding to these causes. Title Four of the ACA is

called ‘Prevention of Chronic Disease and improving Public Health,’ and some important

sections listed here contain plans to provide community transformation grants, oral healthcare

prevention activities, and clinical as well as community preventive services. Immunizations and

better care given to diabetics are also covered under Title Four of the Affordable Care Act.

Title Five goes into detail on how the act provides funding for more dentists, primary

care physicians, mental health providers, physician assistants, and nurses to be placed in the

areas across the U.S. where they’re needed the most. Help is also given to state and local

governments to aid in recruitment in the health workforce. Title Five of the ACA is called

‘Health Care Workforce,’ and some of the vital sections listed under this title include the creation

of a national health workforce commission, state healthcare workforce development grants, and

nurse education, practice, and retention grants. Increasing diversity through training health care

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professionals, increasing teaching capacity, and workforce diversity grants are also sections

included under Title Five of the Affordable Care Act.

‘Transparency and Program Integrity’ in the ACA discusses how more information will

be provided to patients in order to ensure that the patients make the best decisions possible.

Efforts to put an end to fraud are also discussed here in Title Six by enforcing new regulations as

well as bringing more transparency to facilities such as nursing homes so families can make the

best decisions for their loved ones. Changes such as a feature on the Medicare website for

comparing nursing homes, giving notifications of facility closings, and improving staff training

are issues referred to under this title in the ACA.

The Affordable Care Act strives to save money for the people who use it. The act also

gives money to communities and hospitals that serve low-income patients so that they can

receive discounts on medications. The act also allows for more generic versions of drugs to be

made so that patients have more affordable alternatives. This seventh title of the ACA is called

‘Improving Medical Therapies’ and central sections listed here are approved pathways for the

making of bio similar (generic) products and more affordable medicines for children and

underserved places.

The Community Living Assistance Services and Support Act, also known as the ‘CLASS

Act’, provides consumers with a voluntary, long-term insurance option and is Title Eight of the

ACA. Workers pay a premium so that they can receive a daily cash benefit if they ever develop a

disability and need long-term care. The amount of the cash benefit is based on need. This means

that amount of the cash benefit is based on how difficult it is for the injured person to do basic

things like getting dressed or eating food. Taxpayer money isn’t used in the funding of the

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CLASS Act and premiums are always enough to cover costs. This is guaranteed through

safeguards already built into the law.

One of the truly revolutionary results from the creation of the Affordable Care Act is that

it gave the largest amount of tax cuts to the middle class in American history. These credits will

help people in buying insurance and making their premium costs once they do. These tax cuts are

thought to reduce the national deficit by over 100 billion dollars over the next decade. This

portion of the ACA is called ‘Revenue Provisions’ and some key sections here are the inclusion

of employer-provided health insurance on the W-2 tax form, a tax placed on non-required

cosmetic procedures, and even a tax placed on indoor tanning services that is excised, which

means that it’s a tax in which the amount of the tax paid is based on how much that service (in

this case tanning) is consumed in the U.S. (Read the Law, n.d.).

The tenth and final title in the ACA is called ‘Reauthorization of the Indian Health Care

Improvement Act’ or the ICHIA. This act is reinforcing a law which provides health services to

Alaskan Natives as well as American Indians, in order to improve the health of an estimated 1.9

million American Indians and Alaskan Natives (Read the Law, n.d.).

A Short History of Hospitals

In order to explain how the Affordable Care Act itself came into being, it may be helpful

to first examine the history of hospitals, physicians, and private as well as employer-based health

insurance in the United States. We’ll begin with providing a brief history of hospitals in the U.S.

In the book Reinventing American Health Care (2014), author Ezekiel J. Emanuel, department

Chairman of Medical Ethics and Health Policy at the University of Pennsylvania, states that the

history of hospitals in America can be broken down into three historical phases.

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Phase one is thought to consist of the years prior to 1890. The irony is that during this

time period people stayed away from hospitals at all costs. This is because at that time, hospitals

were only for the poor and the hospitals of the day didn’t really treat conditions. Infections

spread like wildfire and surgeries often proved more lethal than helpful. Benjamin Rush, a

physician as well as one of the men to sign the Declaration of Independence, called the hospitals

of the late 18th century “the sinks of human life” (p.18). Hospitals at this time were mostly

funded by rich citizens and most of the doctors were unpaid volunteers because hospitals and

doctors back then were more focused on teaching new doctors and those doctors were more

interested in learning than actually healing patients.

Phase two in the history of American hospitals approximately falls in between the years

of 1890-1920. It’s thought to be during this time that hospitals began to gain respectability.

Many of the medical advancements that were also taking place at the same time helped to bring

about this drastic change. Men like Louis Pasteur and Robert Koch, located in France and

Germany respectively, were able to identify bacteria and develop the germ theory of disease.

This was also the same period of time when diagnostic tests such as x-rays were being created.

As more middle- and upper-class people began to use hospitals, the hospitals themselves relied

less and less on providing charity services and more and more on charging those who could

afford to pay for their services.

During the third phase that began in the year 1920 and continues until the present day, we

see many more advancements being made in hospitals, including the establishment of the first

Veteran’s Administration (VA) hospitals along with compensation and insurance for veterans.

It’s also during this time that we see the first primary health care act to be paid for by the federal

government. The Hill-Burton Act of 1946 helped provide money towards the building of more

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hospitals in the United States. A problem that developed out of this law, however, is that even

though the government provided some of the cost (about one-third), the communities had to

provide the remaining two-thirds of the cost for the hospital. This of course led to fewer hospitals

in the poorer areas of the country.

Emanuel also writes about another milestone in the history of hospitals with the creation

of Medicare in 1965. By the creation of Medicare, hospitals no longer had the need to give

discounted or free care to poor or elderly patients. Hospitals gained a profit through

compensation, which in turn caused hospitals to increase their costs to further increase their

compensation. Eventually safeguards were put in place to end this in the 1980’s. Even with all of

the medical breakthroughs and miracles happening, the 1990’s saw a disturbing rise in illness

and death due to both hospital-acquired disease and medical errors. According to the Center for

Disease Control (CDC), as many as 1.7 million patients catch some sort of sickness in hospitals

and out of those, as many as 100,000 die as a result. In a report published by the Institute of

Medicine in 1999, anywhere between 44,000-98,000 people died as a result of avoidable medical

mistakes made by hospitals. Many people today tend to avoid going to hospitals unless

absolutely necessary (as cited in Emanuel, 2014, p.22).

So far we have looked at one main source for explaining a history of hospitals. Another

interpretation of the developments of the U.S. health care system is given by Barbra Mann Wall.

Wall has a PhD as well as being a Registered Nurse and a Fellow of the American Academy of

Nursing (also known as FAAN). Her view on the history of hospitals in America starts in the mid

1700’s when hospitals were more for isolating sick people as well as giving custodial care for the

destitute and the poor. Pennsylvania Hospital is credited for being the first hospital to actually try

to treat illnesses, and Benjamin Franklin is credited with helping to establish this hospital. Both

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Wall and Emanuel agree that as hospitals gained respectability, hospitals became more

professionalized and moved away from home care (Wall, n.d., p.2).

By 1925 hospitals went from being cesspools for the sick and dying to focusing on

healing and recovery. By the time of the Great Depression, however, a shift was seen from the

use of private to public hospitals. Nurse Wall also credits the Hill-Burton Act of 1947 with

helping to create more hospitals in the United States as well as the creation of Medicaid and

Medicare to allow the poor and the aging gain health care coverage. The costs of hospital care

grew faster than the initial estimated costs for Medicare and Medicaid. When these programs

began in 1965, their costs were estimated to be $3.1 billion. In just five years costs were already

at $5.8 billion, mostly due to hospital expansions. From the 1950’s-1970’s, more of an emphasis

was placed on the education of medical professionals including both physicians and nurses

(Wall, n.d., pgs.4-5).

The 1980’s saw an expansion in the for-profit hospital networks, which at the same time

caused issues for the much smaller not-for-profit facilities. During the 1990’s, care began to

move from inpatient to outpatient hospices, nursing homes for the chronically sick, and

ambulatory services. The Balanced Budget Act of 1997 lowered the payments of Medicare to

hospitals by $115 billion over the next five years. The focus of this decade appeared to be the act

of containing costs for health care. At the start of the new millennium, many hospitals had to

close down while huge not-for-profit companies were able to use leasing agreements in order to

help public facilities facing foreclosure (Wall, n.d., p. 7).

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A Short History of Physicians

There is a long and fascinating history of physicians going back thousands upon

thousands of years to prehistoric times. According to an article called “The History of

Physicians/Doctors”, author Ryan Winter states that the very first healers were traced back by

radiocarbon dated paintings as existing as far back as 27,000 years ago in what is now France.

By the ninth century doctors had many of the tools that are being used until this very day at their

disposal. These include surgical spoons, forceps, plaster, and surgical needles. The field of

medicine had reached the point where it could more likely help people recover from sickness.

The 19th century saw physicians start to benefit from the blossoming field of science, and

chemistry in particular. This is also when medical subfields like genetics, immunology, which is

the study of the human immune system which helps keep us healthy, and psychiatry began to be

studied as well. 1920 marks the beginning of modern medicine as we know of it today.

Medications like Penicillin and other prescription drugs were healing illnesses before surgeries

were needed. Modern doctors have such cutting edge technology including high powered

magnetic imagers (like MRI machines), along with robots and lasers to help physicians in

surgeries (Winter, 2009).

Now we’ll examine even more on a history of physicians here in the United States.

According to Emanuel, in some ways the history of physicians in the United States is similar to

the history of hospitals in the fact that before the year 1900, physicians were reviled by the

general public and poorly educated. The field of medicine and health care would never be the

same when in the year 1904 the American Medical Association (or AMA) set up a group called

the Counsel on Medical Education (CME). The CME changed the educational requirements for

physicians and brought in a man named Abraham Flexner to conduct a survey of the 155 medical

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schools in the U.S. at that time. The situation he found was so dire that he insisted on changes to

take place, starting with the closing of many of the med schools and then modeling the ones

remaining after the med schools that were the most successful. Another suggestion made in the

Flexner Report was to hire full time faculty. Over the next 25 years, the Flexner Report would

cause a drastic decrease in the number of physicians, but just as drastic an increase in the quality

of remaining doctors. Due to this, doctors could naturally charge more of their patients

(Emanuel, 2014, p.24).

As hospitals gained respectability, so did doctors. A result of this shift was that the

training that doctors received was moved from doctors’ offices to hospitals. Two other changes

that resulted were a sharp increase in specialization and an overall lack in organization. Doctors

as a whole have had a history of wanting to be in control of the way they delivered patient care

and, because of that, they have resented having any sort of third-party involvement in their

business. Many doctors felt that having any sort of mediator between themselves and their

patients would change or lower their income or power. Emanuel feels that there were several

factors that allowed doctors to keep control. The first of these was the simple fact that because

fewer medical schools were turning out fewer certified doctors, those remaining had more to

bargain with. Another bargaining chip was that employers weren’t allowed to distribute any

medicine because they didn’t have the licensing. As the AMA got more powerful, they were able

to keep out doctors employed by companies which made it hard for those doctors to get work

and get insurance. Lastly, doctors were able to keep their patients’ loyalty because health care

was more affordable, and since it was relatively cheap to start a medical practice, doctors didn’t

have to worry about splitting their pay with anyone else (Emanuel, 2014, p.26).

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The elevation of physicians and of the entire medical field through the institution of the

Flexner Report is far from the only change that has occurred in the United States during the

history of physicians. As the health care industry became a ‘Big Business’, a bigger emphasis

began to be placed on doctors learning about studying and treating certain systems in the body,

instead of the human body as a whole. Due to this shift in mentality, we have far more specialists

practicing medicine in the United States than general doctors. In 2010, there were about 472

general doctors per 1 million people in the U.S along with 636 specialty doctors per 1 million

people. In comparison, a year prior to this report almost half of the doctors in Austria and France

were general doctors (Emanuel, 2014,p.25). Boards that certified doctors to practice a certain

kind of medicine started and grew during the 1930’s. Specialists were given higher ranking in the

military and eventually had to be authorized in order to be a specialist. Medical schools also

began to favor specialists doing research over general practitioners to be on their faculty. Of

course specialists were also paid more than generalists and could also care for more patients,

further raising their income. Now the medical industry is trying to encourage a more primary

care approach (Emanuel, 2014).

A Short History of Health Insurance

We have now come to studying a general history of health insurance, in particular

private, employer health care coverage here in the U.S. It’s traditionally thought that the start of

health care insurance began in the year 1929 in Dallas, Texas, when the Baylor University

Hospital gave teachers as many as 21 days of hospital care at $6 each. This was more like

prepaid coverage than health insurance. There were attempts to give Americans coverage for

their health care costs long before 1929. This included the first sickness fund put together in

1877 by the Granite Cutter Union. In 1910 Montgomery Ward gave its workers insurance, even

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though it was set up more like disability insurance. The 1930’s saw much advancement with the

Blue Cross/Blue Shield health insurance plans. Some of these changes include the start of

physicians being reimbursed for their services and the creation and implementation of the

National Labor Relations Act, which helped to first provide employer-based health insurance.

When companies saw the success of Blue Cross with their insurance, which began in 1939 as a

way to get patients back into hospitals during the Great Depression, they jumped on the

bandwagon as well. They realized that as long as they had enough people enrolled with their

plan, then the money they would make would outweigh the possible risks. Just as doctors were

wary of unions acting as mediators, they felt the same way about health insurance companies

(Emanuel, 2014).

When Medicare and Medicaid were first made into law and introduced during the 1960’s,

Blue Cross along with Blue Shield companies were among the first chosen to administer the

programs. Another important law in the history of health care was also first set in motion during

this decade. The Federal Employees Health Benefits Act made it so that employees of the U.S.

government, as well as their families had health insurance, and today 4.8 million of these people

have health care coverage. One very important addition to health care coverage was made into a

law during the 1970’s. The Healthcare Maintenance Organization (or HMO) Act of 1973 was set

up with the goal in mind to increase both the availability of health services to individuals along

with the competition in the health care industry (Lichtenstein, n.d.).

The 1990’s gave way to many changes to further increase health insurance coverage and

also privacy of patient information. The addition of Preferred Provider Organizations (also

known as PPOs) along with Point-Of-Service or POS products, gave insured Americans more

choice than ever before in regards to seeing the medical professionals that they

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desired(Lichtenstein, n.d.). In 1996 America saw the HIPPA law signed into action. HIPPA

stands for the Health Insurance Portability and Accountability Act. This law makes sure that all

medical service providers whether hospitals, insurance companies, and medical professionals

themselves, had to adhere to strict policies regarding the transportation and privacy of patient

information. Just a year later the Children’s Health Insurance Program or CHIP was

implemented. Blue Cross/Blue Shield would use money given to them by the U.S. Department of

Health and Human Services to help give health benefits to millions of young children uninsured

either because their families’ income is too low to provide them with insurance and yet too high

to qualify for Medicaid. The 2000’s saw of course the Affordable Care Act of 2010 signed into

law in an effort to provide health care coverage to millions of Americans (Lichtenstein, n.d.).

Tracing back the history of health insurance, there were some causes that made doctors

change their minds about insurance. First, since the Great Depression drastically decreased the

number of people going to the hospital, the incomes of the doctors who worked at these hospitals

decreased as well. Health insurance helped fix this problem by making it possible for people to

go back to the hospital. Second, doctors preferred private health insurance as opposed to the

government sponsored, national insurance that was being called for at the time.

As a way of maintaining at least some control, the AMA developed 10 codes of conduct

concerning health insurance including the right for a patient to choose his or her own doctor, that

no third-party come between doctor and patient, and that the medical community control the

medical practice. The health insurance plan that we know today as Blue Shield began in 1939

also, first in California and then in Michigan which covered house calls, office visits, and in-

hospital doctor visits (Emanuel, 2014).

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Twenty million Americans had health insurance by 1940, but World War 2 changed that

because with so many people gone, there was a huge labor shortage. Workers wanted higher pay,

and companies, wanted to give it to them because they needed the hands. However due to the

Stabilization Act of 1942, President Roosevelt had to keep wages at one level and couldn’t

change it. The good news was that health insurance was exempt from this act. As long as the cost

of the coverage didn’t exceed 5% of the person’s wage, then they could get health insurance.

This policy only added to the count and by 1950 almost two-thirds of Americans had health care

coverage (Emanuel, 2014).

At this point there needs to be a recap of what has been discussed in this paper thus far.

I’ve stated what the Affordable Care Act is and given a basic overview of what this law was

intended to provide in regards to helping Americans receive health care coverage. A literal walk

through the 10 titles of the law itself was then laid out including a few key sections listed under

each of these titles. We then looked at a brief history of the three main components that

essentially come together in the Affordable Care Act with regard to helping Americans with their

health care: hospitals, physicians, and private/employer based health insurance. Moving forward

from here, it’s now time to look at a short history to see how the ACA itself finally came into

being.

Timeline for the Implementation of the Affordable Care Act

The road toward the ACA becoming a law is one that was met with major opposition that

took the fight all the way to the Supreme Court, but President Obama and his supporters were

adamant that this is a law that should have been put into effect many years ago. What the ACA

was intended to do was give Americans health care coverage that would not have it otherwise, or

possibly never had it before. The following timeline, which is taken from the website of

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Affordable Health California, gives the time that it took for the ACA to come to fruition, as well

as a few things that will be implemented in the near future.

2008-2009

Fall 2008: “On health care reform, the American people are too often ruled by two extremes-

government run health care with higher taxes or letting the insurance companies operate without

rules…I believe both of these extremes is wrong.” This is a quote made by presidential candidate

Barack Obama during his campaign, in the election that he’d win a week later (as cited in

Affordable Health California, 2014).

March 2009: President Obama puts on a “health summit” in order to come up with possible

solutions to health care issues. He invites various drug companies, law makers, doctors, insurers,

and consumer advocates and also appoints Governor of Kansas Kathleen Sebelius to oversee the

federal Health and Human Services agency.

July 2009: A 1,000 page plan for a complete overhaul of the American health care system. Votes

on provisions and working out details also begin.

August 2009: A lawmaker says that Americans are feeling “shell-shocked” about the numerous

changes overall during the first months on the Obama administration.

November 7, 2009: In a 220-215 vote, the House of Representatives approves their version of a

health care reform, including one vote from Republican Joseph Cao.

December 24, 2009: The Senate goes on to approve its version of the health care overhaul on

Christmas Eve in a 60-39 vote as well as passing in both chamber of Congress.

2010-2011

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January 2010: A major upset happens when Republican Senator of Massachusetts Scott Brown

wins a special election and finishes the remainder of U.S. Senator Ted Kennedy’s term. Brown

uses this position to try and stop “Obamacare” (the ACA) and the House of Representatives,

which has a republican majority, tries to get the ACA repealed but is rejected by the Senate.

February 2010: When Anthem Blue Cross of California informed their member that they’d be

paying a 39% increase in premiums, Democrats were spurred into action and Congress along

with the White House launched an investigation. A bipartisan health care meeting is also set up

by the president.

March 2010: Speaker of the House Nancy Pelosi and President Obama continue to pressure

their fellow Democratic lawmakers to make sure the Affordable Care Act passes.

March 21, 2010: In a 219-212 vote, the Senates’ version of the ACA is passed with all

Republican members voting against it.

March 23, 2010: The big day! The Affordable Care Act is officially signed into law by

President Obama.

June 2010: The first major revision happens to the ACA.

September 2010: More specific parts of the Affordable Care Act become active including the

ability for dependent children to stay on their parents insurance until age 26, insurers banned

from applying copays to preventative care and vaccines, and restricting exclusions of kids 19

years old or younger due to pre-existing conditions.

January 2011: A judge in Florida rules that parts of the ACA are unconstitutional.

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September 2011: Health insurance companies are now required to make known to the public

any rates of increase by 10% or more.

November 14, 2011: The U.S. Supreme Court hears arguments from 26 states along with the

National Federation of Independent Business (NFIB) against the Affordable Care Act stating that

some elements of the law are unconstitutional.

2012-2013

June 28, 2012: The U.S. Supreme Court upholds the ACA as well as its revisions despite the

arguments made by the NFIB, along with 26 other states across America.

August 2012: There is a “contraceptive mandate” in the ACA, which is confirmed by the White

House with no cost sharing (copays). These services include domestic violence support services,

HIV screenings, and contraception counseling.

November 6, 2012: President Obama wins the presidential re-election.

January 2013: A limit is put on pretax contributions made to flex spending accounts at $2,500

per year.

June 27, 2013: California Governor Jerry Brown signs two wide spreading California health

reform bills that are designed to work directly with the Affordable Care Act.

July 2, 2013: The White House agrees to delay the requirement that large businesses must

provide their workers with affordable health care by one year.

October 1, 2013: Health insurance exchanges are set to begin which will go into effect on New

Year’s Day 2014.

2014 and beyond

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January 1, 2014: The majority of the Affordable Care Act goes into effect. This includes such

areas as prohibiting denial of coverage to adults with pre-existing conditions, providing tax

credits for small businesses that provide health care insurance, and requiring large employers to

provide coverage for employees who work at least 30 hours per week.

January 2018: All existing health insurance plans have to cover preventative care and checkups

with no copays.

January 2020: There will no longer be a coverage gap with Medicare Part D (Timeline

Affordable Care Act, 2014).

Myths about the Affordable Care Act

The Affordable Care Act gained the nickname “Obamacare” because of the president who

signed it into law. However, over the years the name “Obamacare” has taken on a much more

negative connotation due to alleged arguments from those opposed to the law. Whenever many

politicians discuss the Affordable Care Act, it appears that no one actually discusses the act

itself. It only seems to be ranting and raving about how successful or unsuccessful the law is and

on whom should all of the blame be placed. There are many misconceptions about the ACA and

these are just a few of the most common ones found on a website called Obamacare Facts:

dispelling the myths (2014).

1. Myth: The majority of Americans want to repeal “Obamacare.”

When people have been polled about the Affordable Care Act, it became clear that many

Americans simply don’t know what the ACA is. When many of the same people who had

earlier stated that they “don’t approve of Obamacare” were polled on actual provisions in

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the law, they showed an overwhelming amount of support in favor of the ACA

(Obamacare Facts, 2014).

2. Myth: Obamacare means higher taxes.

When the Affordable Care Act was signed into law, it set in motion the largest tax cuts

for the middle class in American history. Many Americans are expected to save on their

health care and medical costs, and many won’t pay any sort of difference in taxes. The

only tax that would directly impact an individual is the “individual mandate”, which

simply says that if someone doesn’t either gain insurance or an exemption by New Year’s

Day 2014, the person must pay a fee on their federal income tax return for every month

the person isn’t covered. The fee is $95 for adults per month, $47.50 for kids per month,

and the family maximum is $285 (Obamacare Facts, 2014).

3. Myth: Obamacare hurts Seniors and Medicare

The ACA conducts a complete makeover of Medicare and provides many new privileges

and benefits to senior citizens including the closing of the gap with Medicare Part D

prescription coverage that was mentioned here earlier in the timeline, as well as providing

better health services to seniors overall.

4. Myth: Obamacare is unconstitutional.

The simple fact is that the Affordable Care Act was signed into law and has been a law

since 2010 means that it’s most definitely not unconstitutional. That the U.S. Supreme

Court upheld the law also confirms this to be a fact.

5. Myth: Obamacare rations health care.

Health insurance companies have been in the business of rationing out coverage for the

duration; however, Obamacare doesn’t do this. The ACA provides funding for research,

21

puts in place provisions, and establishes committees in an effort to put an end to what

insurance companies have been doing for decades (Obamacare Myths, n.d.).

6. Myth: Obamacare creates health insurance.

The Affordable Care Act doesn’t necessarily provide Americans with health insurance;

rather it sets regulations on the health insurance industry and tries to improve the

availability, quality, and affordability of private health insurance. The ACA also attempts

to improve and expand public health insurance. It also tries to provide the tools such as

the Health Insurance Marketplace where people can buy regulated, subsidized health

insurance in a more competitive private market.

7. Myth: Most signing up already had insurance.

A Kaiser Survey that was conducted after the Open Enrollment period showed that about

6 out of 10 (60%) of the 8 million people who signed up for health insurance were

previously uninsured, and many of the others hadn’t had insurance in at least the past two

years (Obamacare Myths, n.d.).

8. Myth: The healthcare law will increase the deficit (the country’s debt).

As stated earlier in this essay, the Congressional Budget Office estimates that the ACA

will actually decrease the U.S. national debt by at least $100 billion dollars (and as high

as $109 billion). This is due to the fact that there are many tax cuts and other spending

cuts along with new taxes placed on healthcare industries such as health insurance

companies, medical device makers, pharmaceutical companies, and hospitals (Kliff,

2014).

9. Myth: The exchanges will transform the insurance industry.

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It’s believed that only a small number of Americans will actually use the official

marketplace (website) to sign up for their health insurance. Most will use the same

methods that have been used for decades: through their public employers or through

programs like Medicaid and Medicare.

10. Myth: If you like your health plan, you can keep it.

The Affordable Care Act has brought about many changes that will have affected the

lives of more than 165 million Americans with private health care plans. These changes

require a broader range of benefits to be covered, including mental health care and

maternity care. As far as individual insurance is concerned, the changes are even larger.

At least one-half (or possibly as much as 75%-80%) of the plans that exist now will be

discontinued during the 2014 year because they don’t meet the requirements set forth by

the ACA (Obamacare Myths, n.d., Five Myths about the Affordable Care Act, Kliff,

2013).

Effectiveness of the Affordable Care Act

Now that the Affordable Care Act has been a law for almost five years, many are

beginning to ponder how successful or unsuccessful it has been thus far. Policy analyst

Bob Semro wrote in an article that there are some signs of success with the ACA. In

terms of the main goal desired by the creation and signing of this law, which is giving

health insurance to more Americans, the ACA is succeeding. According to a Gallup

survey the number of uninsured Americans dropped from 18% in 2013 to 14.5% by

March of this year and the percentage is even lower for states that have expanded their

Medicaid and set up their own insurance marketplaces at 13.6%. These numbers are

expected to decrease as the next open enrollment dates come around (2014).

23

According to Rand Corporation, between September of 2013 and March or 2014,

about 9.3 million people gained health insurance and 3.9 million of the these people who

gained their insurance through the individual insurance market were previously

uninsured. Workers who gained their insurance through their employer rose by 8.2

million, mainly because employment itself has risen. Enrollment in Medicaid went up by

5.9 million people and most of these Americans were uninsured before enrolling in the

program. The Congressional Budget Office estimates that 19 million people will get their

insurance through the ACA by 2015, with as many as 25 million enrolled by 2016(as

cited in Semro, 2014).

All of these statistics suggest that the ACA is making a positive impact on health

care coverage enrollment but there seems to be one area that is still ineffective. Twenty-

four states in the U.S. have not yet expanded their Medicaid as the Affordable Care Act

now allows them to do so, and 21 of those states refuse do take this action. This will

leave 5.2 million Americans with no insurance until this change happens. Twenty percent

of these uninsured people are in the state of Texas alone and at least five public hospitals

throughout Virginia, Georgia, and North Carolina have had to reduce their staff as a

direct result of these states’ refusal to engage in expansion (Semro, 2014).

Another way that success of the Affordable Care Act will be measured is in the

improvement or lack thereof of the health of the Americans it serves. The point of the

ACA is to give more people health insurance so more people can see the health

professionals they need in order to either become or remain healthy and improve their

ways of life. In an article released by the U.S. Department of Health and Human

Services, they explain in detail the implementation of Community Transformation Grants

24

in an effort to improve communities by promoting a healthy lifestyle across the country.

These grants were set up to impact in five ways: tobacco-free living, social and emotional

wellness, safe and healthy physical environments, healthy eating along with active living,

and evidence-based quality preventative and clinical services, especially in preventing

and controlling high blood pressure and high cholesterol. Some examples of the kinds of

programs that could be implemented using these grants include increasing access to

healthy food alternatives and improving nutrition in schools. These grants can also be

used toward aiding in the prevention of chronic diseases such as HIV and other STDs,

mental health and disorders, arthritis, cancers, and diabetes (U.S. Department of Health,

$100 Million, 2011).

While positive statistics as well as positive efforts are beginning to become

visible, in the end, it will take years to come for more concrete proof of any overall

success or failure with the ACA in terms of the goals that are desired to be met. The main

reason for the Affordable Care Act being created was to make health care services more

easily available to more Americans. So far there is some preliminary evidence that

suggests the ACA is at least in many ways, accomplishing what it was set forth to do.

Mary Meehan, however, wrote an article for Forbes about a few unexpected ways that

the Affordable Care Act changes the lives of Americans. One of these changes is that the

ACA has allowed for people to have professional mobility. The economy is more global

than ever before, giving people the chance to literally work from any- and everywhere.

Many people started their own businesses when they lost their jobs during the Great

Recession. Now that Americans can gain reasonably priced health coverage, with the

25

economy improving as well, this could make freelancing and entrepreneurship a more

respectable (and possible) option than we’ve seen in the U.S.

The Affordable Care Act in reality changed very little in regard to how we’ll

manage health care at the end of our lives. Therefore, death is also a way that the ACA

brings about unexpected changes to people, and not exactly good changes. This is

probably because the American government chooses not to take on issues concerning

end-of-life care since it tends to be a politically charged, economically big, and

emotionally sensitive subject in our country. Some unplanned for changes will also

happen because each state will implement the required reforms to varying degrees. Some

states will only do the bare minimum, while others will go above and beyond. It’s

thought that as time passes this discrepancy among the states could create a haves and

have-nots type of situation regarding health insurance based on where people live.

We live in a world where technology changes the way that we live our lives at an

almost constant pace, and that fact is no more evident than here in America. Technology

is having a colossal impact on the healthcare industry, on the ACA, and how and where

it’s used. Having a larger pool of patients along with a larger focus on people’s long-term

overall health will shift the healthcare industry even further away from traditional

hospitals to more mobile venues. The technology that we have at our disposal would

certainly allow for this movement to take place, and as our technology advances even

more, we’ll only see this divide grow. A shortage of general physicians will only magnify

a current problem here in America. With literally millions of people entering the

healthcare system, the number of doctors isn’t increasing in order to meet the need. The

Association of American Medical Colleges or the AAMC says that if this situation

26

continues, there could be a shortage of as many as 45,000 primary care physicians by the

year 2020 (Meehan, 2014).

Controversy over the Affordable Care Act

There has been opposition placed against the ACA since the idea for the law was

put forth by President Obama. Many conservatives and/or Republicans have been the

biggest group against the ACA and now that they have the majority in both the House of

Representatives as well as the Senate, many are curious as to whether they’ll follow

through on their threats to repeal the law. Senior health writer Maggie Fox believes that

in spite of recent events, there isn’t much that Republicans can do in reality to terminate

the Affordable Care Act. One reason is because of the power of the veto. President

Obama will simply overrule any piece of anti-ACA legislation even if Republicans had

the 60 seats needed to override a veto.

Many Republicans do actually like many aspects of the ACA because it’s a way

for giving big business to health insurance companies, which then gives Conservatives

more money. Republicans have actually agreed that more Americans need health

insurance. The divide happened in determining how to make that happen. Another reason

the Republican Party won’t be able to get rid of the Affordable Care Act is because the

voters like the law. Many surveys have asked participants if they like Obamacare and

they’ve said no (probably because of the negative connotation that the nickname has

taken on). Yet when these same people were asked about specific aspects of the ACA,

they were all for the changes. People like the fact that with the ACA, health insurance

companies can’t pull their insurance from someone if they ever get very sick. They also

27

like the fact that young adults can stay on their parents’ plans and of course they like the

federal subsidies (Fox, 2014).

Republicans aren’t likely to strip away the Affordable Care Act for the simple fact

that it’s too late and too many people have gotten health insurance. About 10 million

people now have health insurance gained through exchanges and as many as 26 million

more will have coverage by the year 2022. By this same year, another 12 million will

qualify for programs like Medicaid (Fox, 2014). That’s a lot of people to take back health

insurance from. Instead of getting rid of the ACA, there are small changes or provisions

that Republicans could propose that many Democrats would actually get behind. These

include the creating and using of very cheap “copper” plans that provide very minimum

services, easing the requirements that employers now have to follow, and changing the

definition of part-time employees, along with allowing people to renew cheaper insurance

plans (Fox, 2014). For all of these reasons, it’s believed that not only will getting rid of

the Affordable Care Act be unlikely to happen, but even if it were to ever happen, it

wouldn’t improve the image that many have of the Republican Party as a whole.

Conclusion

It appears that the most accurate conclusion to be made based on this very preliminary

research that has been conducted is that in some major areas the ACA is showing signs of

having a positive influence on aspects of health insurance, such as increased enrollment, a

decrease in uninsured Americans, and in the distribution of grant money to communities in

order to help improve the health of the people they serve. The other part of this conclusion is

that there are many important aspects of the Affordable Care Act that need to be looked at

more closely because they are failing to address important issues. “Add dental coverage,”

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Mr. Antonio Re, the Associate Dean of the Health Education program at Madison College

states as a critical issue that the President needs to adjust in the ACA. “There are too many

Americans who still do not have dental insurance and dental health is critically important and

preventable.” Alan Wearing, the Chief Insurance Operations Officer with Group Health

Cooperative of South Central Wisconsin feels that improvements need to continually be

made to the website and the enrollment process. “The website is difficult to work through,

and the access to the website continues to cause issues.” There are health professionals who

seem optimistic about the positive impact that the law appears to be having in their

organizations, like Anne Statz, a Registered Nurse at Group Health Cooperative of South

Central Wisconsin. “Yes, it is a great start to our health care problems in America. I believe

health care is better than it was 4 or 8 years ago.”

The bottom line is that only time, along with possible adjustments, will give us

the true indications of the success or failure of the Affordable Care Act. Another fact that

became very clear throughout this research is that a huge emphasis needs to be placed on

educating the American public about the ACA. I believe that the educational foundation

was never properly set so that Americans had as full of an understanding as possible of

both the law itself and what issues in our health insurance system the law made with the

intention to address. So much publicity was placed on this law for all of the wrong

reasons, that I feel part of the challenge to this day is trying to break past the possible

misconceptions that people may have about the ACA. I hope that this is an aspect of the

Affordable Care Act that will continue to be fixed and improved because I am a big

believer in health insurance, as well as health care for all people, regardless of any

29

demographic groups. Our health is the most important aspect of our lives and it needs to

be given all of the attention it deserves.

Works Cited

Emanuel, E. J. (2014). Reinventing Health Care (First ed., pp. 18-23). New York, NY: PublicAffairs.

Emanuel, E. J. (2014). Reinventing American Health Care (First ed., pp. 23-27). New York, NY:

PublicAffairs.

Emanuel, E. J. (2014). Reinventing American Health Care (First ed., pp. 27-33). New York, NY:

PublicAffairs.

Fox, M. (2014, November 8). Here to Stay: Why the New Republican Congress Can't Gut Obamacare. In

NBC News. Retrieved from http://www.nbcnews.com/health/health-care/here-stay-why-new-

republican-congress-cant-gut-obamacare-n243711

Kliff, S. (2013, October 31). Five myths about the Affordable Care Act. In The Washington Post.

Retrieved from http://www.washingtonpost.com/opinions/five-myths-about-the-affordable-care-

act/2013/10/31/120a887c-36b4-11e3-ae46-e4248e75c8ea_story.html

Lichtenstein, M. (n.d.). Health Insurance From Invention to Innovation: A History of the Blue Cross and

Blue Shield Companies. In Blue Cross/Blue Shield Blog. Retrieved from

http://www.bcbs.com/blog/health-insurance.html

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Meehan, M. (2014, May 27). Five Unexpected Ways the Affordable Care Act Will Change Your Life. In

Forbes. Retrieved from http://www.forbes.com/sites/marymeehan/2014/05/27/five-unexpected-

ways-the-affordable-care-act-will-change-your-life/

Obamacare Myths: Myths about the Affordable Care Act. (n.d.). In Obamacare Facts: dispelling the

myths. Retrieved October 19, 2014, from http://obamacarefacts.com/obamacare-myths.php

Schabloski, A. K. (2008). Health Care Systems Around the World. Insure the Unisured Project, 2-7.

Retrieved October 24, 2014, from

http://www.itup.org/Reports/Fresh%20Thinking/Health_Care_Systems_Around_World.pdf

Semro, B. (2014, April 29). Numbers Tell the Story of ACA's Success, But They Also Show Millions are

Missing Out. In Huff Post Politics. Retrieved October 19, 2014, from

http://www.huffingtonpost.com/bob-semro/numbers-tell-the-story-of-

obamacare_b_5228695.html

Timeline: Affordable Care Act. (2014). In Affordable Health California. Retrieved October 19, 2014,

from http://affordablehealthca.com/timeline-obamacare/

U.S. Department of Health and Human Services. (n.d.). About the Law. In HHS.gov/HealthCare.

Retrieved September 9, 2014, from http://www.hhs.gov/healthcare/rights/

U.S. Department of Health and Human Services. (n.d.). Read the Law. In HHS.gov/HealthCare.

Retrieved September 9, 2014, from http://www.hhs.gov/healthcare/rights/law/index.html

U.S. Department of Health and Human Services. (2011, May 13). $100 Million in Affordable Care Act

Grants to Help Create Healthier U.S. Communities. In Business Wire (English). Retrieved October

21, 2014, from Ebsco Host.

Wall, B. M. (n.d.). History of Hospitals. Retrieved from http://www.nursing.upenn.edu/nhhc/Welcome

%20Page%20Content/History%20of%20Hospitals.pdf

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Winter, R. (2009, June 18). The History of Physicians/Doctors. In Soliant Health. Retrieved from

http://blog.soliant.com/careers-in-healthcare/the-history-of-physicians-doctors/

32

As a part of this project I really wanted to include the opinions of people who work in the

healthcare industry, and to get their feelings on the Affordable Care Act. I’m very fortunate to be

a graduate of the Healthcare Administrative Training Program (HATP). This is a program

partnered up by the Urban League of Greater Madison along with Madison College in which my

classmates and I took courses at Madison College and earned a certificate in basic medical

reception. My first step was to get in touch with Mr. Travis Graham, who is my job coach (a kind

of advisor) at the Urban League. Travis gave me the contact information of various individuals

who are involved with the HATP and also work at medical facilities here in Madison. One of my

teachers during my training, Amy Whitcomb, helped me develop my questions used in this first

appendix.

Appendix A: Words from Professionals

Name: Antonio Re

Occupation/Job Title: Associate Dean, Madison College School of Health Education

Experience with insurance and the Affordable Care Act: Educator/ Administrator

1. How much of a learning curve was involved in your learning of the Affordable Care Act?

What did you learn in terms of how it would affect your organization, your position and

duties, as well as your patients? There are different levels of learning for the ACA

depending on whether one is a direct health care provider or a staff member knowing and

understanding the law has implication on practice and administration. In terms of care the

cause and effect of the law is dependent on the insurance. Therefore, the biggest learning

curve knows the coverage and this is especially true for patients because if they are not

33

aware of the coverage they purchases (deductibles and other out-of-pocket expenses) the

patient could be surprised to receive a bill from the provider.

2. How has the Affordable Care Act changed the kind of patients or the amount of patients

that your organization sees as well as how they’re treated? More individual’s purchased

health insurance because of the law; patient volume has changed, most notably in areas of

preventative medicine where the real benefits of wellness reside.

3. In your professional opinion, is the Affordable Care Act built on sound ideology that will

stand the test of time? There were too many compromises in the law that was negotiated to

help it get it pushed through the Congress. My institution tells me that this law will need to

be reviewed on a bi-annual basis to make corrections and amendments so that changes

impact the citizens who are depended on the law.

4. What, if any, improvements do you feel could be made to the Affordable Care Act? Add

dental coverage, there are too many Americans who still do not have dental insurance and

dental health is critically important and preventable.

5. What do you feel will be the legacy left by the creation and implementation of the

Affordable Care Act not only in the United States, but around the world? Most countries

in the West provide universal healthcare to its clients and therefore most countries are

looking at the US and asking “what the big deal?” The US has the most expensive

healthcare in the world but the % of people who can access it are limited to those who are

insured. The real legacy of the Affordable Care Act will be its ability to increase access to

all of the citizens who need it.

6. Do you personally know anyone who has benefitted or not from the creation of the ACA

and all that it entails (you of course do not have to give any specific names-just the

34

general information about the person in regards to answering the question)? I do not know

anyone personally who has benefited from the law.

7. Additional Information: N/A

35

Name: Anne Statz

Occupation/Job Title: Registered Nurse, Group Health Cooperative of South Central Wisconsin

Experience with insurance and the Affordable Care Act: Medical Care Provider



duties, as well as your patients? I did not feel a learning curve. Health care is always

changing and so I am use to that. It actually made it seem easier, as more pt had coverage

and they could follow the treatment plan with less obstacles.


that your organization sees as well as how they’re treated? I know as an organization that

are numbers increased. Me personally as a RN, my working load seem to always be

increasing, again that is how nursing is.


stand the test of time? Yes, it is a great start to our health care problems in America. I

believe health care is better than it was 4 or 8 years ago. We still have a very long way to go.

4. What, if any, improvements do you feel could be made to the Affordable Care Act? All

patients have options for health care. That is amazing and fantastic.


Affordable Care Act not only in the United States, but around the world? Not sure, have

no thought about that.

36



general information about the person in regards to answering the question)? Yes,

thousands of patients.


37

Name: Allan Wearing

Occupation/Job Title: Chief Insurance Services Officer, Group Health Cooperative of South

Central Wisconsin

Experience with insurance and the Affordable Care Act: Insurance



duties, as well as your patients? It is interesting that the many components of the ACA

were standard insurance regulatory definitions and GHC-SCW was already meeting the

requirements. The amazing part of the ACA is the breadth of topics covered in the

legislation related to universal coverage, quality of care requirements, Medicaid expansion

guidelines, hospital and physician payment reforms, financing primary care physician

education and training, and a whole host of other items. My understanding is that there are

essentially eight components of the ACA and insurance is a rather small element of the

entire ACA bill. The biggest concern was probably related to the requirement to accept all

patients without any medical underwriting. Insurance companies are in the business to

evaluate risk, and then price the risk, to protect individuals from financial ruin in case of a

catastrophic diagnosis. In effect, the approach to introducing new patients had to be aligned

differently. Today, the only allowed rating factors are a person’s age and whether they are a

smoker. In the past, their age, gender, and health history weighed in a setting an individual

rate for each person. Today anyone at a particular age has the exact same rate, regardless

of their medical conditions. The goal now is to structure products to achieve a normal bell

curve of risk distribution to obtain a fair mix of healthy and not so healthy people. In

general, my role and my duties have really not changed as a result of ACA.

38


that your organization sees as well as how they’re treated? To be quite honest, GHC-SCW

did not do well in the addition of new patients as a result of the ACA. Our rates in the

exchange were based on some inaccurate assumptions, which created premium rates that

were not as competitive as we would have hoped in the Federally Facilitated Marketplace.

However, for the limited enrollment that did join GHC-SCW, there really has not been any

changes or differentiation for these patients compared to any of the other patients at GHC-

SCW.


stand the test of time? Actually, I do think the ideology behind the ACA is sound and will

be able to stand the test of time. Despite the various partisan political debates surrounding

the ACA, the fact is that the ACA is modeled after the Massachusetts Connector Program,

which was implemented by a Republican governor and has been in existence for many

years. The concept of universal coverage along with a mandate for all citizens to have

insurance should fundamentally improve the delivery of health care in this country, and

eventually have an impact on the overall cost of care in this country. Today, the uninsured

still do receive care, but it usually is at the most critical time in the development of their

illness, which results in emergency room visits which are uncompensated, and therefore, the

rest of the insured population subsidizes this uncompensated care with higher insurance

premiums. Those mechanisms over time will be minimized and thus insurance costs should

be able to reflect those changes in the future.

4. What, if any, improvements do you feel could be made to the Affordable Care Act? There

is still a great deal of confusion in the market regarding the administration of the ACA. The

website is difficult to work through, and the access to the website continues to cause issues.

Also, the many changes from the Federal Government adjusting the rules along the way

39

just adds to the confusion. For example, continuing the “you can keep what you have if you

like it” concept actually is very difficult to administer since now in both the individual and

small group markets there are two different sets of plans and procedures. It may have been

simpler to just administer the full mandate and require all individuals and small groups to

convert to ACA plans rather than holding onto the old plans along with the new ACA plans.

From a non-insurance point of view, the ACA also could have done more to change the

actual financing of health care in this country. For example, in Europe, one third of the

physicians are specialists, and two thirds are primary care physicians, and their incomes

are essentially the same. In this country, one third of the physicians are primary care, and

two thirds are specialists, and specialists earn anywhere from three to ten times more

income than primary care physicians depending on the specialty. Obviously, this investment

in specialists has not improved the health care outcomes in this country, and ACA should

have created financial incentives to reward more primary care physicians and discourage

more specialists, and their income disparities should be leveled out over time if anyone

really wants to reduce medical spending in this country. Essentially, the financial incentives

for specialists need to be more aligned with primary care, and then there would be a better

balance of physicians in this country.


Affordable Care Act not only in the United States, but around the world? First of all, the

ACA was necessary in this country. It probably is too early to define a legacy, because there

probably needs to be some fine tuning and modifying of the law to continue to improve it

and allow it to meet its ultimate goal of universal coverage. While the partisan politics

surrounding the implementation of this law have been the focus of the media, the fact is that

this has been the closest legislation to accomplishing universal health care access in the

history of this country. The rest of the world is wondering what took so long? Our country

40

is the last one in the industrialized world to attempt to achieve universal coverage, and we

are not quite there yet.



general information about the person in regards to answering the question)? As a matter

of fact, I do have a very close relative who has completely benefitted from the ACA. The

person works in a service industry which does not offer health insurance, and he is

uninsurable because he is a Type 1 Diabetic. Anyone without employer coverage with any

type of chronic condition was never eligible for insurance in the past. Since the

implementation of ACA, he has insurance coverage through the Common Ground

Healthcare Cooperative in Milwaukee. I am sure this is only one example of many where

the ACA has provided the necessary protection from catastrophic financial loss due to a

chronic medical condition.

7. Additional Information: I would like to add my own opinion for consideration as perhaps

some food for thought about the general approach of ACA. I obviously have been very

supportive of ACA, and I sincerely believe that access to medical care that is not financially

repressive is a right for every individual. I also indicated that the ACA was far broader

than simply providing uninsured citizens with health insurance. If I have any regrets, I

think the ACA should have remained focused on providing health insurance to those who

were not able to obtain it, rather than create a whole new set of administrative processes

and procedures which quite frankly are also expensive. The best analogy that I would have

is the former Health Insurance Risk Sharing Pool(HIRSP) in Wisconsin, and some other

states, but not all of them in this country. HIRSP was designed to provide coverage for any

individuals which were rejected for coverage in the prior insurance markets. Following a

rejection from a health insurance company, the person could apply to HIRSP without any

41

underwriting requirements. At least in Wisconsin, all we had to do was expand HIRSP to

address the remaining uninsured in Wisconsin, which was a relatively low percentage due

to the progressive nature of Wisconsin in health care delivery and financing, but it seemed

that the Federal Government was more interested in exerting their will onto all the States

and did not allow for any experimentation or different ideas to achieve the same results. I

think the States could have been incubators for all types of ideas to achieve the required

goals and targets of ACA, but the Federal Government insisted on their own method, which

as we all noticed, was burdened with many technical and communication problems right

from the start. It sort of is the age old adage that the Federal Government is not capable of

doing anything right, and within budget. The “our way or the highway” attitude actually

limits creativity and experimentation to help discover the best and most efficient

mechanisms to achieving universal access. The States should have been provided with the

opportunity to develop their own programs, and it may have also minimized the animosity

which has been created between the Federal Government and many of the states.

42

I also wanted to include the opinions of people who may not work in the healthcare

industry but may still have an invested interest in the ACA and how it impacts their lives.

This area of the appendix was harder to research for the reason that due to the HIPPA law

which protects patient privacy; my contacts were unable to provide any information about

how the ACA has changed patients’ lives. My teacher for this project, Mrs. Laurie Fitzgerald

was a huge help. Laurie had the idea to gather information from her students in order to learn

how young people and college students feel about the Affordable Care Act. I selected three

of the responses that I felt covered the three main categories that these student responses

seemed to fall into. Most students either had no understanding, a very basic understanding, or

a fairly good understanding of what the Affordable Care Act is. Then these students rejected,

were indecisive or unsure, or supported the ACA as a method to give more Americans health

insurance.

Appendix B: Words from Non-Professionals

Student Response #1

1. Do you feel that you know what the Affordable Care Act (Obamacare) is? Yes, to me

this is a complete scam on the American people. In my case I went from paying

$38.00/week and that got me a $25.00 copay and covered most of my medications.

Now I pay $58.00/week to have nothing covered until I hit my $3,000 deductible to

the year. Bullshit!!

2. Based on what you know of this law, are you in favor of the ACA? No. I am not in

favor. For one, any law that allows members of the government to be exempt from it

is horse crap. In my case I go to the doctor once, maybe twice a year. So I am now

paying $58.00/week to still have to pay my own medical bills.

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3. What do you think can be improved about the Affordable Care Act? Take it away and

develop something that is agreed upon and voted on by the American people, not

forced down our throats with the threat of penalties.



general information about the person in regards to answering the question)? N/A


Student Response #2

1. Do you feel that you know what the Affordable Care Act (Obamacare) is? Yes, I

know a little about it but not too much.

2. Based on what you know of this law, are you in favor of the ACA? Yes and no, there

are flaws to this ACA but I am at the same time in favor of the ACA.

3. What do you think can be improved about the Affordable Care Act? I mean there’s a

lot that can be fixed or modified. I don’t know where to start.

4. Do you personally know anyone who has benefitted or not from the creation of the

ACA and all that it entails (you of course do not have to give any specific names-just

the general information about the person in regards to answering the question)? I do

not know.

5. Additional Information: Obama is trying his hardest yet all these people are

putting him down. All presidents have had their mistakes, but as Obama being

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the first black/white president, everything he does is put out there. But I don’t

see much about the other presidents when they had any faults.

Student Response #3

6. Do you feel that you know what the Affordable Care Act (Obamacare) is? Mild

knowledge.

7. Based on what you know of this law, are you in favor of the ACA? I am in favor of it. I

believe in universal health care and see the Affordable Care Act as a step toward

this.

8. What do you think can be improved about the Affordable Care Act? Knowledge needs

to be expanded. There is a lot of misinformation.



general information about the person in regards to answering the question)? I do not.

10. Additional Information: Very interesting project! Hopefully you can help spread

knowledge to those of us who would like to know more.

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honors english

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