The Affordable Care Act And Its Effect On American Healthcare (3)

Excellence Through Innovative Research
The Affordable Care Act And Its Effect On
American Healthcare
Apurva A Mande
Graduate Student
Systems Science and Industrial Engineering
State University of New York at Binghamton
April 10, 2015

2Binghamton University | March 2015
wise.binghamton.eduwise.binghamton.edu
Agenda
 Background of US Healthcare
 The Affordable Care Act
• Aims
• Aspects
 Impact of ACA on
• Nursing
• Medicare and Medicaid
• Employer based insurance
• Health insurance marketplace and private insurance
• Pharmacy
• Mental health services
• Dental and vision benefits
• Economy
 Conclusion
 Future work

US Healthcare Background
Healthcare industry comprises of 18% of Gross Domestic
Product (GDP) of the country and expected to rise up to
18.4% till 2016
Till 2022, healthcare expected to comprise of 19.9% of
GDP
Fiscal Year Expected healthcare growth rate
(%)
2013 4.1
2014 6.1
2015 6.2
[Blahous, 2013; CMS, 2013]

US Healthcare Background (Cont’d)
Fragmented in nature
Lack of universal access to quality and affordable health
services
High spending on healthcare
Percent of spending population Amount spent per person on
healthcare
30 12000
10 27000
1 90000
[Shi, 2014; Hoffman, 2014]

Implications Of Absence Of Coverage
Providers have a right to deny health services to the
uninsured (except ER)
Missed diagnosis and preventable hospitalization in case
of critical health conditions
Low chances of receiving follow-up treatments resulting
in further deterioration of health
Forgoing and postponing of essential care due to high
costs
High medical bills leading to financial insecurity, medical
debts and bankruptcy
[KFF, 2014]

Need For ACA
Significant number of uninsured individuals (41 million)
Healthcare spending very high
20% projected share of healthcare in GDP by 2020
Increased rate of loss of insurance under 2008-2010
recession
Emphasis on curative treatment instead of preventive
[APHA, 2012]

The Affordable Care Act

1. The Affordable Care Act (ACA)
Popularly known as the Affordable Care Act, the Patient
Protection and Affordable Care Act (PPACA) (Public Law
111-148) is a federal decree, signed by the President of
the United States on 23rd March 2010
Primarily consists of 2 pieces of legislation
• Patient Care and Affordable Care Act
• Health Care and Education Reconciliation Act
Serves with the aim to
• Provide health insurance to every American citizen
• Easy access to affordable and quality heath services
[Gruber, 2011]

2. Aims Of Affordable Care Act
Significant expansion of health insurance coverage
Mandatory health insurance to residents
Expanding eligibility criteria under insurance schemes
Ease of access [Ease Of Access]
• Coverage
• Services
• Timeliness
• Clinical staff
[Shi, 2014; DPHP, 2014; CMS, 2012]

2. Aims Of Affordable Care Act (Cont’d)
Equality in insurance coverage
• No discrimination on the basis of pre existing conditions
• Insurance coverage to all individuals regardless of
• Healthcare costs
• Severity of injuries
• Access to employer
• Limit on out of the pocket expenditure
Individual Family
Out-of-pocket
expenditure limit
per year
$6350 $12,700
[Matheson, et al., 2012; Hoffman, 2014]

Subsidies for people with low income
• Low costs for insurance premium
• Particularly for individuals uninsured by government or
employer
Mandating individual insurance
• Any individual must be insured either by
• Employer
• Public health insurance
• Individual market
• Fee payable in absence of insurance
Individual Family
Amount charged 2% of annual
income or
$325
$975
2. Aims Of Affordable Care Act (Cont’d)
[Matheson, et al., 2012; Healthcare.gov, 2015]

3. Aspects Of ACA
Allows young adults up to the age of 26 to be covered
under parents insurance
Prohibits insurance companies from
• Rejecting insurance to Americans with pre-existing
conditions
• Spending more than 20% on administrative costs
rather than patient care
• Differentiating for mental healthcare
• Charging women more than men
[Sommers, 2012; HHS, 2014]

Impacts Of Affordable Care
Act

1. Nursing
Estimated increase in primary care providers owing to
Minimum Essential Coverage (MEC) under ACA
ACA focused on providing routine check ups in outpatient
settings
$900 million granted to primary care workers for
improving access to health services for the less fortunate
all over the country
Allotment of $30 million to ‘Advanced Nursing Education
Expansion Program’ through ACA
1.2 million job openings for licensed and registered
nurses estimated by 2020
[American Nurses Association, 2014; Lathrop, et al., 2014]

1. Nursing (Cont’d)
10% bonus payment from fiscal year 2011 to 2016 to
• Nurse Practitioners
• Clinical Nurse Specialist
• Physician Assistant
$338 million distributed among the following categories in
nursing
• Advanced education
• Practice
• Quality
• Retention grants
[American Nurses Association, 2014]

1. Nursing (Cont’d)
Increase in health care jobs [Roles under nursing]
• 30% projected increase in the number of registered nurses
from year 2012-2022
• 432,000 registered nursing job availability over the next
decade
[HHS, 2013; Paranzino, et al., 2014]

Summary
Owing to ACA, focus on primary care has increased
Impact on nursing significant due this reason
Increment in incentives for expansion of nursing
programs (education, retention grants etc.)

2. Medicare
Federal law insuring people over the age of 65 and
permanently disabled individuals under 65
Prior to ACA, Medicare beneficiaries required to pay 20%
of the costs of services covered
Since implementation, entire cost of annual health
checkup funded under Medicare
No personal funds for preventive checkups
Programs regarding health awareness for beneficiaries to
prevent costs for expensive treatments
[Davis, et al., 2010; Krasner, 2012]

2. Medicare (Cont’d)
Estimated reduction of $390 billion from fiscal year 2010
to 2019 in Medicare spending
Beneficiaries entitled for independent care at home
• Physician and Nurse practitioner provide required primary
care at home
• Intention of reducing expenditure and increasing health
outcome
Guaranteed protection of Medicare
• Medicare life estimated to extend till 2029
Narrowing of the coverage gap
• Out-of-pocket funds estimated to be dropped to 25% by
year 2020
[Davis, et al., 2010; American Nurses Association, 2014; Medicare.gov, 2014; AARP, 2014]

2.1 Projected Savings In Medicare Under ACA
[Blahous, 2012]
In absence of ACA, Medicare Hospital Insurance Trust
Fund estimated to be depleted by 2016 resulting in
decreased Medicare spending
Expected solvency of the Medicare Hospital Insurance
Trust Fund till 2024 since implementation of ACA
 Projected savings under ACA
$(inbillions)

2.2 Decrease In Medicare Spending Under ACA
14% fall in the projected Medicare spending for FY 2020
Medicare spending projections
Amountinbillion$
[Rudowitz, 2014]

Summary
Over $1600 saved per person under Medicare since ACA
Increase in life of Medicare trust fund by 13 years
Increased drug coverage under Medicare
Eligible for insurance even with pre-existing conditions

3. Medicaid
Medicaid – Health care reform for citizens with limited
resources and income
Jointly ventured by federal and state government
The PPACA upgraded primarily the following aspects of
Medicaid
• Eligibility criteria
• Increase in federal funding
• Improved accessibility to health services
Applicable since January 1st 2014
12 million enrollees predicted by 2016
Estimated reduction of uninsured individuals by 26 million
by 2024
[NCSL, 2011; Artiga, et al., 2014]

3. Medicaid (Cont’d)
Improved eligibility
• Adults (below 65 years of age) with income increased from
100% to 138% below the Federal Poverty Line
Complete federal financing for 3 years for new enrollees
through 2014 to 2016 in states adopting Medicaid
expansion
• Decrease in funding by 10% till year 2020
25% budget increase in Children's Health Insurance
Program (CHIP)
Individual Family
Income $14,484 $29,726
[NCSL, 2011; Artiga, et al., 2014]

3. Medicaid (Cont’d)
Increase in Medicaid and CHIP enrollment
• Data till 3 quarters for FY 2014
[Haislmaier, 2015]

3.1 Medicaid Eligibility For Children Under ACA
(State Of New York)
Age
category
1 2 3 4 5 6 7 8 Additional
cost per
person
Children
under
1year &
Pregnant
Women
$2,169 $2,924 $3,678 $4,433 $5,187 $5,942 $6,696 $7,451 $755
1 to 18
years of
age
$1,498 $2,019 $2,540 $3,061 $3,582 $4,103 $4,624 $5,145 $522
[DOH, 2014]
Monthly income according to the size of the family

Summary
Medicaid expanded state wise
Increased eligibility for coverage from 100% to 138%
below FPL, since implementation of ACA
Individual eligible for insurance even with pre-existing
conditions
Increase in the number of enrollees

4. Employer Based Insurance
3 to 5 million fewer people estimated to obtain employer
based insurance
Increased schemes under individual health insurance
marketplace
• People can invest in their own start up
Young adults covered under parents insurance, hence
not mandatory to be employed for it
Increase in the number of young adults
CBOestimatesinmillion
[CBO, 2012; Furman, 2014; Blahous, 2014]

4. Employer Based Insurance (Cont’d)
Coverage for employers with less than 25 employees
• Small business health options program (SHOP)
• Available to businesses with 50 or fewer employees
• High quality health and dental coverage
• Small business health care tax credit
• Eligible for coverage if average annual income of employees
is $50,000 or less
• Number of full time equivalent employees 25 or less
• Health contingent wellness programs
• Rewarding employees for adopting healthier habits e.g.
reduction in use of tobacco
• Rewards in form of increase in coverage
[Healthcare.gov; SBA, 2015]

Summary
Around 3% decrease in employer based insurance since
ACA
Young adults till the age of 26 can be covered under
parents insurance
Individuals no longer dependent solely on employers for
insurance
Various coverage plans under SHOP for businesses
having
• Up to 25 employees
• Between 25 to 50 employees
• Between 50 to 100 employees
• More than 100 employees

5. Health Insurance Marketplace
A place for the uninsured to compare and purchase
health insurance
Facilitated federally and state wise
Cost assistance for families earning 400% below FPL
Insurance plans based on
• Age
• Income
• State
• Family size
[IRS, 2015; Healthcare.gov, 2013]

5.1 Individual Health Insurance
Self employed, freelancer, independent contractor can
get insurance through ‘Health Insurance Marketplace’
known as ‘Simple Cafeteria Plan’
According to the cost coverage offered, based on income
and property
Catastrophic only coverage also available which includes
free of cost primary care visits
Type of plan Costs covered (in %)
Bronze 60
Silver 70
Gold 80
Platinum 90
[Olafson, 2013]

5.1 Individual Health Insurance (Cont’d)
Coverage for the self-employed
• Individual mandate
• Additional Medicare tax
• 0.9% tax if income exceeds threshold of
• $200,000 if single
• $250,000 if married
• Net investment tax
• 3.8% tax on net investment income exceeding threshold
of
• $200,000 if single
• $250,000 if married and filing jointly
[SBA, 2015; IRS, 2014]

5.2 Selecting Insurance In Marketplace
Search for desired plan
[nystateofhealth.ny.gov, 2015]

5.2 Selecting Insurance In Marketplace (Cont’d)
Selecting and comparing plans
[nystateofhealth.ny.gov, 2015]

Summary
Individual can choose from a variety of plans suitable
Individual able to examine and compare each plan
thoroughly and then choose according to budget in mind
4 plans available, each with a specific range of insurance
coverage
Availability of coverage for the self-employed

6. Private Insurance
3 out of every 4 individuals covered by employer or
government program
ACA impacts individuals opting for private insurance in 6
major ways
• Liberty to choose from various policies
• Less out of the pocket funds
• Increased comprehensive benefits
• No discrimination with respect to income or pre-existing
conditions
• Increased enrollment
• Increased eligibility for subsidies

6.1 Impacts On Private Insurance
Liberty to choose from various policies
• Individual can choose any plan suitable
• Plans include essential health benefits (EBH)
• 80% of the premium allotted for medical expenses (82%
for the state of NY)
• 20% of premium allotted for administrative purposes (18%
for the state of NY)
[nyhpa.org, 2013]

6.1 Impacts On Private Insurance (Cont’d)
Significant costs covered in the insurance
• Limit on out of pocket funds
• Division of deductibles depending on type of plan
[nyhpa.org, 2013]

Increased comprehensive benefits
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance abuse
• Prescription drugs
• Laboratory services
• Pediatric dental services and vision care
• Disease management and wellness service
• Rehabilitation services
[nyhpa.org, 2013]

No discrimination
• Under ACA, insurance to be issued to any individual who
asks for it
• Known as ‘Guaranteed Issue’
• Individuals cannot be denied coverage based on the following
conditions
• Low income
• Pre-existing conditions
• Sex
• Individuals with poor health status cannot be charged with
higher premium
[nyhpa.org, 2013]

Increased enrollment
• Mandatory enrollment for insurance
• Estimated increase in the aging population (above 65)
• Increased average age of the insured due to baby
boomers
• Increment in total private market FY-2014
[Haislmaier, 2015]

[kff.org, 2013]
Increased eligibility for subsidies
• Premiums to decline by 84% for individuals with low
income
Annual
income
in $
% FPL Unsubsidize
d premium
in $
Potential
government
tax credit
subsidy in $
Premium
after
subsidy in $
Individual
17000 148 5400 4742 658
28000 234 5400 2565 2158
40000 348 5400 954 3800
Family of 4
35300 148 13500 12231 1269
58000 243 13500 8968 4532
83000 348 13500 5605 7895

Summary
Compulsory enrollment for insurance
Increase in the number of covered benefits
Decrement in premiums for low income individuals
No discrimination on the basis of income, pre-existing
conditions and sex of an individual while providing
insurance
Decline in premiums for individuals

7. Pharmacists
Pharmacy comprises of 10.1% of total healthcare
expenditure
Increase in expenditure of pharmaceutical industry by
33% in next 5 years
Projected increase in drug expenditure from $359 in 2012
to $483 in 2021
Year [CMS, 2012]

7. Pharmacists
Pharmacists play critical role in patient care
Growth in pharmaceutical sales since implementation of
ACA
ACA affected pharmacy in following primary areas
• Care delivery system
• 340B drug pricing program
[Forman, 2014]

7.1 Impacts On Pharmacists
Care delivery system
• Under ACA, pharmacists can participate in delivering care
to individuals with chronic conditions through
• Medical homes
• Medicaid patients funded through state
• Funded under U.S. Department of Health and Human
Services
• Home-based care
• Pharmacists included as integral part of the patient care team
along with physicians and nurses
• Medication therapy management (MTM)
• Grants provided to pharmacists to provide MTM services to
patients with chronic conditions
[ASHP, 2010]

7.1 Impacts On Pharmacists (Cont’d)
340 B drug pricing program
• Offering discounts to hospitals for reducing out patient drug
costs
• Accurately calculates the drug costs to avoid overpricing
• Extending participation to
• Children's hospital
• Cancer centers
• Rural referral centers
• Community hospitals
[Smith, et al., 2014]

Reduced drug expenditure
• Decreased costs for medicines, both branded and generic
• Increase in Medicare drug coverage
Year Amount deductible
for brand name
drugs (%)
Amount deductible
for prescription
drugs (%)
2015 45 65
2016 45 58
2017 40 51
2018 35 44
2019 30 37
2020 25 25
[CMS, 2015]

• Increase in Medicaid prescriptions
Year
PercentIncrease
[healthcare.gov, 2014]

• Decline in out of the pocket funds for drugs
• E.g. Contraceptives
Year
Prescriptionsdispensed
[healthcare.gov, 2014]

Summary
Growing pharmaceutical sales
Increase in pharmaceutical expenditure
Increase in the roles (involvement) of pharmacists right
from nursing homes to home based care
Decrease in out of the pocket cost for medicines specially
for Medicare
Extended participation of the 340 B drug pricing program

8. Mental Healthcare
Present scenario of mental healthcare in U.S.
Significant disorders
• Schizophrenia
• Bipolar disorder
• Depression
• Post-traumatic stress
45.6 million adults suffer from either mental health or
substance use conditions in the United States
24% of adults suffering from mental illness uninsured
Nearly 1/3rd insured under marketplace have no
coverage for substance use disorder
[Collins, 2015; DHHS, 2013]

8. Mental Healthcare (Cont’d)
ACA along with the Mental Health Parity and Addiction
Equity Act (MHPAEA) extends protection to nearly 62
million individuals
Ensures that, coverage for mental health and substance
use, should be comparable with coverage for medical
and surgical care
Three primary ways for expanding coverage
• Including Essential Health Benefit (EHB)
• Parity in individual and small market
• Access to quality healthcare
[DHHS, 2013]

Essential health benefits
• Starting 01/01/14, treatment for mental health and
substance use to be covered under EBH
• 3.9 million insured under individual marketplace will gain
access to stated services
• 1.2 million insured under small group market to gain
access to the same
Equality in individual marketplace and small group
market
[DHHS, 2013]

Improved access to health services
[DHHS, 2013]

Summary
Before ACA, individuals though insured, lacked coverage
for mental disorders and substance abuse
Improved access to mental health services
Mental health and recovery service for substance abuse
covered under essential health benefits included under
coverage
Equality of benefits offered in both market place and
small group market

9. Dental And Vision Benefits
Pediatric dental care included under the Essential Health
Benefits (EHB) since January 1,2014
 Adult dental care not covered in all health plans
Dental benefits classified primarily as follows
• Based on health plans
• Embedded dental plan (included in health plan)
• Stand alone dental plans
• Based on age groups
• Dental plans for adults (above 19 years of age)
• Pediatric dental plans
• Based on coverage
• High coverage, low deductibles
• Low coverage, high deductibles [healthcare.gov, 2014]

9.1 Dental Plans
Stand alone dental plan
• Not included in any medical policy
• Can be coupled with health insurance plan
• Maximum out of the pocket funds of $350
• $65 deductible
• Actuarial value of 70 to 85%
[deltadental, 2014]
Year
Amountin$

9.1 Dental Plans (Cont’d)
Embedded dental plan
• Medical and dental benefits combined in a health plan
• Deductible of around $2000
• Maximum out of the pocket limit of $6600
• Actuarial value of 50%
[deltadental, 2014]
Year
Amountin$

9.2 Pediatric Dental Benefits
Pediatric dental coverage more of a preventive nature
Oral assessments, cleanings, fluoride treatment etc.
included
Regular dental coverage through age 19
Owing to implementation of ACA, around 8.7 million
children to gain dental insurance by 2018
• 3.2 million via Medicaid
• 3.0 million via health exchanges
• 2.5 million via employer sponsored insurance
Increase in the number of children covered by 15% since
2010
Reduction in the number of uninsured by 55%
[American Dental Association, 2013]

9.3 Adult Dental Benefits
Since implementation of ACA, around 17.7 million adults
expected to gain dental benefits
Most benefits covered under Medicaid hence differ from
state to state
4.5 million adults to gain dental coverage through
Medicaid
800,000 adults to gain dental coverage through health
exchanges
Overall decrease in number of adults not having dental
coverage by 5%
Generation of 7.5 million adult dental visits

9.4 Overall Effect
Effect on economy
Increase in dental expenditures by $4 billion
4% of national expenditure
$2.4 billion growth in Medicaid dental expenditure

9.5 Vision Benefits
Vision benefits included in EHB
Mandatory to be included in any health plan unlike dental
Preventive service
Timely vision screening for early problem detection
Expansion in every state compulsory
Benefits provided by state include
• Vision screenings and primary examinations in the medical
facilities
• Extensive annual eye check up along with necessary
treatments
• Corrective remedies like contact lenses and spectacles in
case of refractive error
[AAPOS, 2013]

9.6 Vision Benefits For Pediatrics
Benefits for pediatrics according to age limits
[AAPOS, 2013]
Age limit Preventive tests
Newborn – 3 years Red reflex test
Corneal light reflection
Ocular motility
Pupil examination
Vision assessment
3 years – 5 years Vision screening
Visual acuity test
5 years and above Regular vision
screening

Summary
Dental and vision benefits included in essential health
benefits
Dental not mandatory to be included in the health
insurance plans as opposed to vision benefits
Stand alone dental plans more economic than embedded
dental plans
Excessive focus on preventive dental and vision benefits
for pediatrics
Increment in number of individuals getting coverage for
dental benefits
• 8.7 million children
• 17.7 million adults

10. Free Clinics
Health care organizations providing variety of medical
services to the economically challenged
• Dental
• Vision
• Pharmacy
Services limited to individuals who are
• Uninsured
• Underinsured
• Insured but lack access to necessary medical services
Employees are usually volunteers
Free clinics are usually charitable hospitals
[NAFC, 2015]

10. Free Clinics (Cont’d)
Even though number of insured is increasing, focus on
free clinics persistent due to increased importance of
primary care
However, small free clinics anticipated to go out of
business or estimated to turn towards advocacy
Free clinics willing to transform to adapt to the ACA
regulations
Willingness to start accepting Medicare and Medicaid
insurance patients
Need for the free clinics and charitable trusts to expand
their policies according to ACA
[Cohen, 2013]

10. Free Clinics (Cont’d)
Process flow of a free clinic in Michigan after
implementation of ACA
[FCOM, n.d.]

10.1 Impact Of King v. Burwell On Free Clinics
Free clinics and charitable organizations to be majorly
impacted if ruling in favor of King v. Burwell litigation
King V. Burwell claim in the opposition of expansion of
tax credits to federal marketplaces
As a result, significant portion of individuals to become
uninsured
Thus opportunity for the free clinics to flourish
With no insurance and increased premiums, preference
of individuals towards free clinics
[NPR.org, 2013 ; NAFC, 2015]

10.1 Impact Of King v. Burwell On Free
Clinics (Cont’d)
Free clinics are suggested to implement the following if
court favors the King v. Burwell claim
• Reconciling with former patients who are covered under
FFM
• Promote the clinic with the help of media and other social
means of communication
• Creating awareness and imparting knowledge regarding
effect of loss of subsidies
[NAFC, 2015]

Summary
Free clinics facing the need to change under ACA
Threat to small free clinics in view of decreasing number
of uninsured
Free clinics to expand services to Medicare and Medicaid
If results in favor of King v. Burwell, free clinics to have
booming business

11. EMS Billing
Billing for emergency medical services basically includes
costs for emergency transportation (ambulance)
[Plaintownship, 2013]

12. Uncompensated Care (UCC)
Uncompensated care
• Providing health services to the uninsured, publicly insured
and underinsured
• Patients treated free of charge
• Service costs incurred by the health care organization
• Comprises of ‘bad debt’ and ‘charity care’
Introduction of ACA led to
• Significant decrease in the number of uninsured
• Decrease of 10.3 million in the number of uninsured
• Increase in number of Medicaid patients
Projected decrease of $5.7 billion (16% decrease from
the spending baseline of UCC)
[DeLeire, et al., 2014]

13. Economy
Reduction in deficit
• Probable decrease in the deficit by $109 billion through
fiscal years 2013-2022
• Projected reduction in 0.5% of GDP over the decade 2023-
2032 totaling to a reduction of $1.6 trillion
• Change in deficit
[Furman, 2014]
$(inbillion)

13. Economy (Cont’d)
Reduction in job lock
[Finegold, 2013]

• Significant proportion of population employer-insured
• Fear of increase in premiums or cancellation of
insurance resulted in continuation of existing jobs
• Led to condition known as ‘job lock’, an obstacle to
labor mobility
• Employees eligible for insurance even with pre-existing
conditions through ACA
• Reduction in job locks resulting in entrepreneurship
ultimately contributing to economic growth of the
country
[Furman, 2014]

Improvement in the health of employees
• Implementation of ACA resulted in increased access to
primary health care
• Preventive health services accessible easily
• Resulting in increased productivity of employees
• Healthy employees able to contribute more, hence
incrementing the economy
Enhanced financial security
• Ban on insurance companies to sell policies with lifetime or
annual limits
• Reduction in out of the pocket catastrophic costs
Decrease in catastrophic costs
[Furman, 2014; Hoffman, 2014]

Summary
Increased access to primary care
Reduction in growth rate of healthcare expenditure by
0.5%
Reduction in job locks because of health insurance
marketplaces
No lifetime constraints on insurances

Challenges To Affordable
Care Act

1. King v. Burwell
Issue raised
• IRS (internal revenue service) willing to permissibly expand
tax credit subsidies to health insurances purchased under
federally funded health exchanges (‘Marketplace’)
Challenge (claim under King v. Burwell litigation)
• ACA allows expansion of tax subsidies to individuals
enrolled in health plans only funded through states i.e.
Qualified Health Plans and not through Federally
Facilitated Marketplace (FFM)
As a result, IRS facing opposition regarding the extension
of subsidies
Decision of IRS termed to be ‘unlawful’ by opposition
[Teitelbaum, 2015]

1.1 Background
ACA allows formation of health exchange under every
state
Every State at the liberty to whether or not adopt this
policy
As a result, two types of health exchanges created
• State funded (for states setting up their own exchanges)
known as Qualified Health Plans (QHP) – adopted by 17
states
• Federally funded (for states opting out of setting own
exchanges) know as Federally Felicitated Marketplace
(FFM) – adopted by 34 states
[Teitelbaum, 2015]

1.2 IRS Regulation And Opposition
As stated under ACA, individuals covered under QHP’s
that is State exchanges, eligible for financial assistance
(tax credits)
Regulation stating the expansion of tax credit benefits to
individuals covered under either exchanges (State or
Federal) issued by IRS
Under this regulation, around 90% individuals among the
5 million insured under FFM received the benefit of credit
This regulation of IRS contradictory to claim under ACA,
termed inappropriate
[Teitelbaum, 2015]

1.3 Effects
Appeals by
• Fourth Circuit Court of Appeals – subsidy applicable for
both
• D.C. Circuit Court of Appeals – subsidy limited to FFM
If ruling in favor of King v. Burwell claim,
• 8 to 10 million people will lose insurance
• Imbalance in the insurance markets due to removal of such
high percentage of population from insurance pool
• Federally funded states will have to make a decision
whether to implement marketplace or not
• States may implement 1332 waiver which gives privileges
to waive certain conditions under ACA
[NACC, 2015; Teitelbaum, 2015]

Summary
IRS to extend tax credit benefits to individuals covered
under federally funded exchanges
King v. Burwell law suit filed against this regulation
stating that expansion of subsidies applicable only for
state funded or Qualified Health Plans
If decision in favor of litigation filed, and subsidies for
FFM suspended, approximately 8-10 million individuals to
lose insurance
This may result in rise in premium costs all over the
country

2. Triple Aim
Benefits of the ACA combined together to create the
‘triple aim’
2 major aspects of the ACA
• Change in the delivery of care
• Expansion of insurance coverage
Improvements made till date
• Increased number of accountable care organizations (more
than 600)
• Increase in hospitals implementing bundled payments
contracts
• Increase in number of certified medical practices (more
than 5700)
[Berwick, et al., 2015]

2. Triple Aim (Cont’d)
Better care for
individuals
Better health for
population
Decrease in
health care costs

2. Triple Aim (Cont’d)
4 major steps required to be taken to successfully realize
the triple aim
• Incorporating technical adaptations like telemedicine for
improved access to care
• Innovations in delivery of care like community paramedics
and community health workers
• Building strong relationship between patient and health
care provider
• Alliance of healthcare providers and social leaders
(Leadership Alliance)

2.1 Care Design Principles For Triple Aim
In order for the triple aim to make progress following
design principles for care should be followed
• Investing in care systems showing potential for continuous
improvement
• Reducing waste and non-value added activities in
healthcare settings
• Increasing communication and co-operation between
workforce
• Complete utilization of resources
• Lowering the rate of healthcare expenditures to 15% of
GDP
• Equal power to patients, families and communities for co-
producing health and well being

Summary
Combination of benefits from ACA combined to form the
‘Triple Aim’
The triple aim intends to
• Reduce healthcare costs
• Improve quality of healthcare for individuals
• Improve healthcare for population
Measures taken to successfully implement triple aim
Designing of care principles for the same

3. Challenges To Insurers
Since implementation of ACA, insurers face certain
restrictions
Under ACA, the insurers are required to
• Propose plans covering all the essential health benefits
• Removal of prohibitions on annual and lifetime limits
• No discrimination on the basis of preexisting condition or
on basis of health status
• Guarantee the issuance of insurance
• Maintain the insurers’ medical loss ratio to 80% or above

3. Challenges To Insurers (Cont’d)
Owing to this situation, insurers unaware of the medical
conditions of applicants and thus uncertain about setting
premiums
In order to prevent insurers from facing this situation, 3
premium stabilization programs issued under ACA
• Reinsurance
• Risk Corridors
• Risk Adjustment

3.1 Reinsurance
Implemented though the ACA to help individuals with
unexpected high medical costs that is, ‘high risk’ patients
Effective for FY 2014 to 2016
Reinsurance payments include the following plans
• All ACA compliant plans
• Non-grandfathered plans (both outside and inside of the
health exchanges)
Program funded through fees charged on all available
insurance plans
Reinsurance fee limit totals amounts for, fixed limit for
reinsurance payment and U.S. treasury and varying limit
for administrative costs
[Boothe, et al., 2015]

3.1 Eligibility For Reinsurance
In order for the enrollee to be eligible for the reinsurance
payment plan, following financial limits are set
Reinsurance fee limit in $
Year Annual medical cost limit
reached by enrollee in $
2014 45000
2015 70000
2014 2015 2016
Reinsurance
payment
10 billion 6 billion 4 billion
U.S. Treasury 2 billion 2 billion 1 billion
Per person
cost
63 44 27
[Boothe, et al., 2015]

Summary
Reinsurance necessary for stabilizing the insurance
marketplace during 1st year of its operation
States at the liberty of expanding reinsurance even in the
absence of health exchanges
In absence of State participation, Department of Health
and Human Services (HHS) runs the reinsurance
program in that State
Prevents the high risk individuals from incurring high
medical costs

3.2 Risk Corridor
Intends to promote accurate premium values
Plan to be implemented on a trail basis from fiscal years
2014 through 2016
Encourages the insurers to eliminate uncertainty about
premium costs in health insurance exchanges
Administered by federal government
Expects the insurers participating through exchanges to
allocate 80% of premiums to developing health care and
improving its quality
This plan compares the allowable premium costs with a
particular target amount (target amount = premium cost –
administrative costs)
[healthaffairs.org, 2015; kff.org, 2014]

3.2 Risk Corridor (Cont’d)
Plan deemed to be eliminated by the federal government
in the case if insurers remain underpriced
This might be possible as a major amount of losses
suffered by insurers are not reimbursed by the program
In FY 2014, 80% insurers made payments to Medicare
whereas only 20% received money back
This resulted in contradiction of the aim of risk corridor of
equality among insurers regarding making and receiving
equal payments to and from the government, in order to
avoid net budgetary effect
[healthaffairs.org, 2015]

3.2 Risk Corridor Law Under ACA
Law states different responsibilities for insurers having
the range of, ratio of allowable costs to target costs,
within 3% points in both directions
Actual cost limit Responsibility of the insurer
Insurers with actual spending
below 92%
To refund 80% of the profit
earned to the federal government
between 92 and 97%
To pay department of health and
human services (HHS), an
amount half of their gains
between 97 and 103%
To keep the profits to themselves
and bear their own losses
between 103 and 108%
Half of the losses reimbursed
above 108%
80% of losses reimbursed by the
federal government
[healthaffairs.org, 2015]

3.2 Risk Corridor Example
Example of risk corridor for a target amount of $500
[kff.org, 2014]

Summary
Plan originally introduced to bring stability to premiums
for insurers introducing plans in marketplaces
Risk corridor plan to be run on a trial basis for years 2014
to 2016
Plan intends to have equal quantity of money going out
and coming in into the federal government via insurers
Primary intention to nullify net budgetary effect

3.3 Risk Adjustment
Under risk adjustment under ACA, payment received by
the insurer based on the predicted medical cost of the
enrollee
Medical costs estimated on the basis of risk factors
All the non-grandfathered plans whether individual or
small group market, whether included in the marketplace,
benefitted by the risk adjustment plan
Payments made to the insurers depend upon the
actuarial risk
Plans with higher than average actuarial risk to receive
payments from plans having lower than average actuarial
risk
[acadeathspiral.org, 2014; Pope, et. al., 2014]

3.3 Risk Adjustment (Cont’d)
In absence of risk adjustment, plans having high risk
enrollees, will have to charge higher average premiums
to the enrollees
States have an option to participate and if not, allow
federally exercised plan (by HHS) to run in the State
States not wanting to run the federally governed plan can
run their own risk adjustment plan, after getting a federal
approval
In the plan, insurers compared on the basis of financial
risk of their applicants
[acadeathspiral.org, 2014; kff.org, 2014]

3.3 Risk Adjustment Calculation
Each applicant (enrollee) assigned an individual risk
score based on gender, age and diagnosis
The diagnosis are assigned a numerical value and listed
under ‘Hierarchical Condition Category’, which determine
the price the plan is likely to cost for that particular
diagnoses
Risk score values vary depending upon the diagnoses of
a person
• An individual having multiple unrelated diagnoses, all the
corresponding HCC values are used while calculating risk
score
• An interaction factor is added to an individuals risk score,
suffering from multiple illnesses
[kff.org, 2014]

3.3 Risk Adjustment Calculation (Cont’d)
The risk score values are then averaged (weighted
average)
This weighted average value represents the predicted
expense of the plan
A scope for adjustment is kept for
• Actuarial value
• Geographic cost variation
• Rating variation
From these values, enrollees having higher and lower
risk values are calculated
[kff.org, 2014]

3.3 Risk Adjustment Calculation (Cont’d)
The risk adjustment costs calculated have the following
benefits for the enrollee and the plan
• Predicts the risk of healthcare cost (high or low) for an
enrollee
• Calculates the actuarial risk for every plan for all of its
enrollees
• Calculation determines the cost owed by each plan along
with the costs due to the same
[kff.org, 2014]

Summary
Risk adjustment plan aims to distribute funds from plans
covering low-risk enrollees to those covering high-risk
enrollees
[kff.org, 2014]

4. Maintenance Of Marketplaces
Marketplaces under ACA funded by two sources
• Federally funded marketplaces (federally facilitated
exchanges)
• State funded exchanges
Federally funded marketplaces are functional in the
States who have chosen not to establish their own health
exchanges

4.1 Issues Being Faced
Health exchanges even though provide a variety of
health plans to choose from, are facing certain
challenges themselves
Following are the challenges faced by health insurance
exchanges
• Availability of subsidies
• Assistance of consumer
• Funding of exchanges
• Threat of adverse selection
• Challenges due to States not expanding Medicaid
• Federal and State rules
[Health Policy Brief, 2014; NCSL 2015]

Readiness Of Grants (Subsidies)
Debate over availability of subsidies under Federally
Facilitated Exchanges for individuals with low income and
small businesses
Benefit of tax credits only to people insured through state
exchanges
However regulation stated by IRS suggests availability of
credits regardless of the type of exchange
Funding of exchanges
• State based exchanges to be financial sustainable till FY
2015
• In order for the FFE (federally facilitated exchanges) to
sustain, a user fee of 3.5 percent on the premium of all
plans sold only through exchanges is applicable
[Health Policy Brief, 2014; NCSL 2015]

Assistance to customers
Conflicts between customers regarding policies of
exchanges
Guidelines for help known as ‘navigators’ to assist low
income individuals and small businesses
The navigators expected to have thorough knowledge
regarding the policies about local markets
Navigators expected to have experience of working with
small firms and companies and also undergo training
However, number of navigators working depend on the
funds available for training in the federal budget
[Health Policy Brief, 2014]

Threat of Adverse Selection
States have option of regulating health plans, either
purchased through exchange or outside of exchanges,
equally
However FFE can regulate health plans only through
exchanges
This inequality may affect the stability of health
insurance market
If health plans outside FFE offer cheaper coverage which
is less comprehensive, there is a high possibility of
healthy people opting for that coverage, while sick people
will have to opt for broader coverage
This is adverse selection, leading to sick individuals
incurring more claims
[Health Policy Brief, 2014, NCSL, 2015]

Challenges For Non-Medicaid States
Under the ACA, States have option of not expanding
Medicaid
Along with Medicaid, many states (25) are reluctant for
setting up State exchanges
As a result, individuals in such States are ensured
through FFE
However the cost of private coverage is more than the
coverage under Medicaid
Also if decision is made in favor of King v. Burwell,
majority people insured under FFE will lose insurance
and in these States individuals would suffer because of
lack of Medicaid expansion

Federal And State Rules
Under ACA, both Federal and State exchanges and their
regulations exist.

Summary
Even though health exchanges, either Federal or State,
offer a variety of health plans to choose from, they face
numerous challenges
The major challenges are faced by Federally Facilitated
Exchanges mostly regarding their tax credits and
subsidies
Challenges faced by State exchanges are related to
Medicaid expansion

Operational Level Impacts
Of Affordable Care Act

1. Workforce
Destabilization among the workforce and of the system
due to increase number of the insured
Overload on the healthcare system
Catastrophic workforce shortages mainly in primary care
facilities
Healthcare workforce has following effects on its
operations due to ACA
• Improper distribution of workforce and unbalanced ratio
• Aging workforce
• Increased workload
• Increasing dissatisfaction among physicians
• Bottleneck in education pipeline
[Anderson, 2014]

1.1 Improper Distribution Of Workforce And
Ratio
Urban locations have increased access to health services
than rural areas
According to current distribution
• 10% of primary care physicians
• 18% of nurse practitioners available in rural areas
Rural areas have high potential of Medicaid patients
Projected need of 7987 primary care physicians for the
newly insured due to ACA
Shortage of 20000 to 45000 nurse practitioners and
physicians predicted
Disastrous outcomes of shortage resulting in increased
mortality and morbidity
[Anderson, 2014]

1.2 Aging Workforce
Currently 2.8 million registered nurses and 985,375
physicians estimated to be serving in healthcare industry
Of the estimated workforce, about 33% expected to retire
in the next 10 years
As a result, shortage of workforce is anticipated as
follows
Shortage due to more number of insured individuals
Type of workforce Expected shortage
Physicians 95,000 to 130,000
Registered Nurses 300,000 to 1.2 million

1.3 Increased Workload
Due to increased regulations owing to ACA, increase in
paperwork
As a result, time a physician or registered nurse spends
with patient is compromised
Estimated increase of 190 million hours of paperwork due
to mandatory regulations introduced under ACA
As a result, compromise in the quality of care provided
Difficult to maintain the quality of care provided due to
increasing insured population

Summary
Healthcare workforce (nurses, physicians etc.) impacted
severely by ACA
Increased workload for the existing workforce due to
tremendous increase in the number of insured individuals
Owing to the same, projected shortage of the workforce
for the coming decade
Ultimately, formation of a gloomy outlook of the
workforce towards the industry because of ACA resulting
in deteriorating quality of the care provided

2. Healthcare Delivery
Owing to the increased regulations, changes being
brought about in the healthcare delivery system
Merger of hospitals, healthcare businesses, independent
physicians in order to maintain position in marketplace
Merging results in
• Acquiring higher market share
• Increased negotiation power with insurers, government
agencies etc.
• Creation of a united healthcare system
Done in order to ensure solvency in light of policies of
ACA

2. Healthcare Delivery (Cont’d)
Following reasons are prompting healthcare institutions
to make changes to their delivery models
• Shortage in workforce
• Increased regulations
• Reduced interaction with patient (owing to increased
paperwork)
Providers taking up the approach of ‘cash-only’ practices
As a result elimination of third party insurers resulting in
less number of regulations
Hence physicians able to practice medicine as deemed fit
by them, keeping it patient centered
Such models claimed to be ‘direct’ models

Summary
Delivery in healthcare is affected to the health reforms
Hospitals, physicians practicing independently are
merging in order to survive in the healthcare marketplace
Healthcare institutions adopting ‘pay for performance’
and ‘cash only’ policies
Effort to keep third party insurers out of the delivery
scenario in order to provide quality health services

Conclusion
Reduction in the healthcare spending by 0.6% ($22
billion 800 million) in the year 2013
Historic decrease in the number of uninsured
Percentage
Year
[Furman, et al., 2014]

Conclusion (Cont’d)
Increase in public and private insurance FY-2014
[Haislmaier, 2015]

Future Work
Operational level impacts of ACA on hospital
operations
Effect of ACA
• Trauma and Emergency care
• Safety net providers
Timeline for ACA

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