Analysis of the Patient Protection and Affordable Care Act

Case Analysis 1
Analysis of the Patient Protection and Affordable Care Act
Brittney Butcavage
Paige Catizone
Karyssaann Costagliola
Bobbi Jo Glowacki
Alisha Mahoney
Judith Rodriguez
Professor Eltgad Roces
Alvernia University
Healthcare Science 410
October 15, 2014
Case Analysis 2
During the 2008 presidential elections, an unknown Chicago senator by the name of Barack
Obama won over voters with the promise of “change”. The first task on his list once in office was to
implement a socialized health care program ensuring health coverage for all Americans, regardless of
economic status. Americans were assured time and time again that if they were satisfied with their
current doctor; the health care reform would not force them to find a different primary care physician.
Nancy Pelosi’s famous statement on March 9, 2010, “we have to pass the bill so that you can find out
what is in it”, left many people uneasy in terms of the future of American healthcare. After much
contentious debate between Republicans and Democrats, President Obama signed the Patient
Protection and Affordable Care Act (PPACA) into law on March 23, 2010. This ill-thought-out, yet
well intentioned piece of legislation has turned into an escalating commitment at the expense of the
taxpayers.
In the area of health care, Forbes ranks the U.S.A. number eleven when compared to other
developed nations. Areas of consideration are: quality, access, efficiency, and equity. This is a
surprising revelation; we are not as high on the ladder as we would like to believe. Health care
spending is out of control and the services being offered are lacking. We hold the eighth highest infant
mortality rate and sadly the highest nation having the probability of people dying between the ages of
15 and 60 years of age.
Two main goals of the PPACA were availability and cost control. Obama’s hoped the
implementation of this bill would cut spending from $2.7 trillion to $1.1 trillion. A refocus on how we
approach health issues would help to control wasteful spending. The shift from treatment to prevention
was introduced. Treatments and services are to benefit the community as a whole not just for
individuals, much like the traditional public health system. An overhaul such as this deeply involves all
stakeholders in order to function as a unit. The Affordable Care Act is the new health care reform law
in America and is often referred as Obamacare. The Patient Protection and Affordable Care Act are
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made up of the Affordable Health Care for America Act, the Patient Protection Act, and the health care
related sections of the Health Care and Education Reconciliation Act and the Student Aid and Fiscal
Responsibility Act. Included in the act are amendments to other laws such as the Food, Drug and
Cosmetics Act and the Health and Public Services Act. Since the ACA signed into law, additional rules
and regulations have expanded upon the law, and we have attempted to update our summaries with
those changes.
In terms of insuring the previously uninsured, the ACA has been successful with the rate of
uninsured Americans under 65 falling from 20 percent to 15 percent. If people obtained insurance, 60
percent of them would be able to see a physician or get a prescription filled. Out of those now insured
under private ACA plans, 59 percent were previously uninsured, while 66 percent of those who became
insured under Medicaid had been previously uninsured. However, the uninsured rate is still 18 percent
for people between 19 and 34.
The ACA is being compared to Canadian Healthcare system; one thing Americans and
Canadians can agree on is that we don’t want each other’s health care systems. In truth, most
Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S.
system. The differences between the both are:
1. No single payer, Canada-Competitive practices such as advertising are kept to a minimum,
maximizing the percentage of revenues that go directly towards care. In general, costs are
paid through funding from income taxes, the only province to impose a fixed monthly
premium which is waived or reduced for those on low incomes. There are no deductibles on
basic health care and co-pays are extremely low or non-existent. US-Medicare is the United
States is a single-payer healthcare system, but is restricted to only senior citizens over the
age of 65, people under 65 who have specific disabilities, and anyone with end stage renal
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disease government is increasingly involved in US healthcare spending, paying about 45%
of the $2.2 trillion the nation spent on individuals' medical care in 2004.
2. No universal coverage, Health care in Canada-All insured persons must be covered for
insured health services. This definition of insured individuals excludes those who may be
covered by other federal or provincial legislation, such as serving members of the Canadian
Forces or Royal Canadian Mounted Police, inmates of federal penitentiaries, and people
covered by provincial workers' compensation. US-The United States does not have a
universal health care system, however the Patient Protection and Affordable Care Act
(PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks
to have expanded insurance coverage to legal residents by 2014.
3. No equal access, Canada-Common complaints relate to access, usually to elective surgery
(especially hip and knee replacement and cataract surgery) and diagnostic imaging. These
have been the primary targets of health care reinvestment, and it appears that considerable
progress has been made for certain services, although the implications for procedures not on
the target list are unclear. US-Access to health insurance is very limited for immigrants
living in the U.S. both undocumented immigrants and permanent residents.
4. No Cost containment, Canada-Canada's relative success in containing costs is the result of
public financing of the health insurance system. Our single payer, publicly financed health
care system, allows for cost containment and universal access based on need for services
rather than ability to pay. US-U.S. health spending reached an estimated 2.7 trillion dollars
in 2010 and the health share of the gross domestic product is projected to increase from 17.6
Case Analysis 5
percent in 2009 to 19.8 percent by 2020. This creates the challenge of how health care
spending while continuing to enjoy the improvements in quality and quantity of life that
result from innovation in medical care.
5. No “national” health insurance, one of the main parts in Canada is that although each
province and territory administers a health plan, everyone can expect to be covered for a
comprehensive range of services, no matter where they live. The federal government is
expected to chip in to make it happen. The Supreme Court decision for the federal
government’s obligation for the states will expand their medical coverage. US-Medical
costs would be offset in part by replacing insurance premiums with taxes. Hundreds of
billions of dollars of immediate savings would be realized from the elimination of insurance
company overhead and hospital billing costs, but offsetting immediate expenses would
include training and paying for the much larger number of general practitioners and other
physicians necessary to provide coverage to several million formerly uninsured.
On September 30, 2014 115,000 individuals were set to lose their health care coverage under
the ACA due to insufficient documentation in regards to their citizenship/immigration status. Another
350,000 face losing health care subsidies they have been awarded due to insufficient income
information. These people may have to pay back the subsidies received and may not be able to afford
the coverage they may now be eligible for. Many of these individuals have either mailed the requested
documentation or tried submitting it by way of HealthCare.gov, to no avail (Pear). A review of the
website and federal contractor must be conducted, it is essential that the website and government
contractor in place be efficient for this program to work and handle these cases efficiently.
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Many individuals who had signed up for medical insurance through the ACA exchanges are
having a difficult time finding care, the list of participating providers and hospitals is “narrow”. The
idea is that narrow network choices will supposedly help to keep individual costs down. Some
individuals with major health issues have faced limited access and high out of pocket cost for the care
they have required (Williams). The list of participating providers must be expanded to ensure care for
those suffering from pre-existing conditions. The Obama administration has announced that more
health insurance options will be available to consumers and these new options will be available in the
upcoming health care enrollment period starting November 15, 2014. This will increase the number of
insurers by 25% and officials believe this will help to control premiums for consumers (Pear). Despite
the high hopes of the administration, many networks are already predicting premium rate hikes for
consumers in the 2015 period (Gonen).
The effect of the ACA on jobs has been substantial. The ACA mandate requires employers to
provide insurance for their employees. Many employers have cut employee hours to less than 30 hours
a week to avoid the mandate. Small business owners are discouraged from expanding their business;
the mandate applies to businesses with more than 50 employees (Legal Monitor Worldwide).
Restrictions on small business should be reviewed. Small business growth should be encouraged to
help grow our economy, not be hampered by government restrictions and mandates.
The Affordable Care Act requires employers to cover the cost of birth control for female
employees, including abortion-inducing drugs. For family owned business Hobby Lobby and religious
organization Little Sisters of the Poor-this requirement was seen as a violation of religious freedom.
On June 30, 2014 the Supreme Court decided in favor of Hobby Lobby. Their employees will be
provided coverage for birth control, but not abortion-inducing drugs such as the morning after pill. The
Little Sisters of the Poor are awaiting their Supreme Court date (Fritze).
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The execution of the Affordable Care Act has helped contribute to the need for more primary
care doctors. Medicare and Medicaid compensate specialists at a higher rate than family practice
physicians and many persons going into the field of medicine specialize in a specific field knowing
this. Federal funds are being used to bring in new primary care practitioners, but one of these programs
will be expiring in 2015. . Educating new nurses and physicians takes years, something the ACA did
not take into account. With the lack of graduates at this time families can expect longer wait times as
well as shortened appointments and increased cost (Anderson). The “supply and demand” of the ACA
will be hard to maintain, patients will have a harder time accessing providers and in turn have new
frustrations with the delivery of care (Anderson). In order to remedy this shortage, additional ACA
funding must go toward incentive programs to attract more primary care physicians and the biased
compensation scale of Medicare and Medicaid must be overhauled (Krasselt)
Incentives are being placed in order to up the number of healthcare graduates and prospective
students. According to an article by Amy Anderson, on www.heritage.org, “The ACA reauthorized
loan repayment and forgiveness, scholarships, increases in Medicare-funded Graduate Medical
Education (GME) residency slots, funding for workforce planning, and increased funding for the Public
Health Service.” However, medical students are exhibiting less interest in primary care, mostly due to
a “$3.5 million income gap over a lifetime of work and the increasing debt of student loans”
(Anderson). Amy goes on to tell us that currently medical education institutions enrollment has
increased, but it is predicted that due to the long process of education the demand will surpass the
supply by approximately 2025 (Anderson).
The ongoing lack of residency slots is also a determining factor when it comes to educating
these graduates. The American Association of Medical Colleges is supporting legislation to increase
the number of Medicare-funded residency slots, none the less this shortfall could persist at least
through 2017(Anderson). Nursing is also experiencing a similar dilemma: “More than 79,000 qualified
Case Analysis 8
applicants were turned away from nursing programs in 2012. Complicating matters, the average salary
for positions in nursing education is significantly lower that what these experts can earn outside
academia, making it difficult to recruit and retain key academic personnel” (Anderson).
In order to maintain a higher graduate ratio, we need to offer higher incentive and
reimbursement to try and alleviate the financial burdens of pursuing an education in health care; also
the number of residency slots available need to be raised in order to keep up with the staggering
numbers of those now insured. This may just convince individuals that a future in medicine is
attainable and may persuade them to consider all that is has to offer.
The Affordable Care Act is having its affects not only on consumers, but on all of the healthcare
systems that provide care to patients. For many years in the healthcare industry hospitals relied on
reimbursements from insurance and other sources based on the volume of patients they see. The long
term care facilities have always suffered when it came to Medicare reimbursements which they will
hopefully see a change when it comes to the implementation of the ACA with the creation of long term
care services and supports. This system of payment is going to change drastically over the course of
time in order to comply with rules set forth in the Affordable Care Act. This Act wants providers to
focus more on the quality of work they are doing rather than trying to treat as many people as possible
to get their payout.
The hospital systems have to make major adjustments to how they give treatment and care to
the patients they see. With the main focus of care in hospitals now being more of quality not quantity
so the hospital are forced to take a different approach of care. The ACA does not have many guidelines
to the quality control of service and how they accomplish it which, “It allows hospitals to create entities
called accountable care organizations, third-party groups that oversee the quality of care at hospitals”
(http://www.usatoday.com/story/news/nation/2013/10/20/hospitals-face-whole-new-world-under-
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health-law/3078353/). The implementation of the ACA is giving every hospital an initiative to
improve their quality to receive the maximum reimbursement from Medicare especially. They
determine the quality of hospitals based off patient surveys that are given post care and the outcomes of
procedures performed for the patient. The lower the scores on surveys and other areas the hospital is
subject to a penalty and also hospitals that have an increase in hospital acquired infections are subject
to penalties. Unfortunately, some negative aspects of the ACA are hospitals are resorting to cutting
back employees to prepare for the money loss with this new system. Local hospitals like Blue
Mountain Health Systems have dismissed multiple employees from both the Lehighton and Palmerton
Campus. Another aspect is most independent hospitals are forced to merge with larger networks to
stay afloat with the drastic changes in reimbursement.
The effects on long term care facilities are having a more positive effect in regards to the ACA.
Currently most elderly patients that are in need of a long term care facility or at home care and do not
have a supplemental insurance are unable to afford to pay for their stay and care at these facilities or in
home care givers. Their inability to pay is leading to the elderly using up their savings and or their
family’s savings just trying to maintain their stays which for most people it isn’t realistic. The growing
population is increasing in the elderly community because of the changes in healthcare leading to
longer life spans. With people living longer these facilities are almost necessary to have and most
elderly people utilize them which increase the need to have coverage. The ACA is going to make this
possible for those people in need of the long term care and even make it possible to receive their care at
home. The changes to healthcare involving the ACA and long term care state that with the change it
will, “build the long-term care workforce creating a new long-term care insurance program giving
states incentives to expand home- and community-based services in Medicaid, creating programs to
improve resources that help caregivers, and creating programs that protect seniors and people with
disabilities creating programs that improve nursing home care”
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(http://familiesusa.org/product/affordable-care-act-provisions-will-help-caregivers). The changes will
put families at ease knowing that there is care available for their parents or grandparents and they won’t
have to worry about the cost or high medical bills they would have to pay.
With the upcoming changes to the way health care is delivered, the way hospitals and long term
care settings are reimbursed it is crucial they take everything into account. If these care facilities focus
on the best quality care they can give verses the amount of patients they treat it will lower the risk of
layoffs and closures of facilities. If these facilities would monitor unnecessary spending like
departmental costs it could lower the impact that the ACA has on reimbursements with insurance.
When dealing with Medicare patients, hospitals are facing penalties and or no money for services
rendered because they are not focusing on the quality care. If a hospital can control readmissions it
would significantly increase the reimbursements that they receive. Medicare patients after the third day
of admission the insurance does not pay so the hospital is resorting to absorbing the loss which
increases their debt. Another problem that they face is the penalties they receive for hospital acquired
infections which if they would make sure every preventative measure is taken and possibly giving
private rooms to more patients it would lower these occurrences. Over all, hospitals and long term
facilities would stand a better chance of reimbursement in every aspect of care if they continue to keep
an advisory group in place to send out surveys to patients and to oversee the quality performance done
at each facility. If they hold strong with these new standards and ways to fix the quality of care the
drastic changes the ACA is going to have on these facilities won’t be as significant.
Alternative therapies may flourish when the Affordable Care Act is in full swing, thanks to a
clause written within the new law. Section 2706, “Non-Discrimination in Health Care”, states: “A
group health plan and a health insurance issuer offering group or individual health insurance coverage
shall not discriminate with respect to participation under the plan or coverage against any health care
provider who is acting within the scope of that provider’s license or certification under applicable state
Case Analysis 11
law” (Cahill). In layman’s terms this simply means that if a Complementary and Alternative Medicine
(CAM) practitioner is licensed within that state, insurance companies must compensate them the same
as they would a traditional physician (Cahill).
It seems only expected that alternative therapies now be considered by health insurers; for years
millions of American’s have paid out-of-pocket for CAM treatments on a yearly basis. The article,
“What is the Future of Complementary and Alternative Medicine under the Affordable Care Act”, a
2011 survey implemented by Consumer Reports notes that, “every year 38 million Americans receive
more than 300 million CAM treatments” (Cahill). The argument stands that CAM offers limited
research to prove its efficiency, however the ACA rules can now allow for research and experimental
treatments to be implemented based on a “probable cause” standard used in evaluating CAM modalities
(Turner). The ACA has intentions of focusing on preventative medicine and wellness-based treatment;
however it has not fully taken into account the contributions that can be made by integrating
Complementary and Alternative Medicine, together with conventional medicines (Abbott). In order for
this to work, practitioners alike have to maintain an open mind. The benefits of CAM can speak for
themselves if you research the statistics, just imagine if we integrated both conventional and alternative
therapies; a world of opportunity waits!
For many people alike, the ACA is a touch and go subject. It has many different groups of
people either for it against it. Not only because it is considered to be “forced” upon American citizens,
but on the opposite spectrum, have some seen it as a blessing. There is now a link that describes what a
citizen will pay for every year they are insured. For example, in 2014 $95 will be taken out of your
refund and in 2015 $325 will be taken out. This alone has many people outraged due to many not being
able to afford such rising high costs for healthcare. However, when doing an in depth research on these
establishments, there wasn’t much research to back certain claims that were made by these institutions.
What will next be examined is how it affects different organizations, government run institutions that
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currently have the ACA in effect and the research they use to speak to patients to “put their minds at
ease.”
A long time government run healthcare organization has been the Veterans Administration.
Hospital researched was VA (also known as Veteran Affairs), from reading all of the research on the
ACA and VA it was rather frightening. If a veteran has VA benefits, then they are considered to be
“covered” and that no enrollment is required, however, the down side to not having the VA benefits
can also put a dent into someone’s pocket. In order to get the VA benefits, the veteran MUST enroll
into ACA or a large portion of their taxes gets taken from them during the year. According to the
website www.va.gov , it has little to no explanation of the enrollment for the ACA. It just mentions that
if one does not enroll into veteran benefits, they must use the Healthcare marketplace to enroll.
Additionally, upon further reading, it is now changed that a family member cannot be put onto veterans
benefits if they have inquired to healthcare marketplace. This can be frustrating for family members
who are not aware that they cannot be placed just for researching the ACA. As for putting a dent into
the pockets as mentioned earlier, family member will have to pay steeper co pays if they are not
enrolled under the VA.
Catholic hospitals are also largely affected. With all the current trends in healthcare (including
these hospitals allowing contraception), many have opted to allow such changes into their hospitals as
early as June of 2013. There are still many controversies within the CHA whether patients can receive
all cares that are covered under the ACA. There has been a mandate done earlier in the year that if a
hospital or institution that is deemed “private” does not want to give patients full care, they can refuse
that right if they consider it immoral and make the insurance company find a different provider to give
the patient contraception. Sister Carol Keehan who is front runner for Catholic hospitals to use all
avenues for ACA states that regardless of religious beliefs, everyone should be able to get the care they
deserve and that’s what healthcare is all about.
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After looking into both these organizations, RAND was then researched to see public opinion
since ACA was put into effect. The questions that RAND had used were to see if people really were
changing their minds about the ACA. The data runs from Sept 2013 up until Sept 2014, within one
year, there was a 45% increase of people who are not in favor of the ACA. When reading the FAQ’s
page, RAND had asked people why they went from favoring to unfavoring, their response was that
they were deceived into thinking that it was health care that everyone (extremely low income
participants) could afford. However, RAND itself is rather biased with their research, even though they
ask the questions as to why they report the “unfavorings” of the ACA, they are still consider
government and only reporting the “good qualities” of the ACA. It seems as though someone who is
not well versed in reading into research, they can easily be fooled.
Lastly, I had read into what The Children’s’ Hospital of Philadelphia (CHOP) was doing for
families to provide care for the children that use such insurance. According to the website, they accept
the ACA, but what gets parents is that some tests (which are considered possibly vital to the childs
health), may not be covered and a third party must be contacted to provide all or partial payment to
receive a test or treatment. This can burden a lot of parents with a sick child, especially one who needs
round the clock care. For children, who are terminally ill, they should cover all costs, this one major
reason as to why people oppose the ACA and what it “provides.”
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SWOT Analysis for Affordable Care Act
Strengths
 Plans to decreases number of Americans without health insurance
 Benefits low income families
 Healthcare coverage for people with per-existing conditions
 Prescription drugs will be available at a lower cost
 Prohibits payout caps
 Doctors and hospitals are rewarded for quality of care instead of quantity of care
 Has a requirement implemented that the FBI is to establish a nationwide background check on
direct patient access employees
 Each state can run its own health insurance exchange or they can default to have the federal
government manage it
Weaknesses
 It is being funded by the tax payers
 Penalty tax is starting at $95 or 1% of your income, and then going up in consecutive years
 People are forced to purchase coverage or face penalty tax
 Coverage for people with pre-existing conditions are facing higher premiums
 Uncertainty and arguments in regards to what is actually considered essential care and how
much coverage will be allotted (i.e. rehabilitation)
 Exemptions for people below federal established poverty line
 People with certain religious beliefs are exempt
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 Shortage of healthcare providers
 Small businesses are forced to have at least 50 full-time employees and provide insurance or
face a fine
 Biased research
 Open lawsuits from healthcare providers and religious groups
 Pharmaceutical companies face higher taxes, fees and rate increases for their medications to be
marketed
Opportunities
 Reduce overall cost of healthcare
 Individuals and small businesses are able to buy affordable insurance
 Prescription drugs available at lower costs
 Tax credits
 Extended coverage for dependents to age 26
 Increase in patient volume
 Medicaid coverage now available for more Americans
 States can receive funds from federal government to cover low income families on medicaid
 Accountable care organizations
Threats
 Funding from taxpayers
 Pharmaceutical companies releasing employees to cover costs of inflated taxes and fees
 Creation of Independent Payment Advisory Board (IPAB)
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 Lack of physicians to provide coverage for influx of patients
 Funding from the government (i.e. residencies)
 Technological advancements not considered in current regulations
 Lawsuits from individual states as well as healthcare providers
 Lawsuits in regards to unconstitutional legislation
 Religious groups
 Accountable Care Organizations (ACOs)
SWOT Explanation
Strengths
- in 2012 there was 47 million Americans that had no healthcare coverage, the ACA plans to drastically
decrease that or even eliminate that amount
- Medicaid eligibility expanded to all Americans under 65 with incomes up to 133% of the federal
poverty level
- Prior to implementing people with a pre-existing condition such as asthma, could not get health
insurance now they can
- Medicare recipients who reach the drug coverage gap now are offered their prescriptions at a 50%
discount until the prescription gap closes in 2020
- Under new consumer protections provisions of 2014, insurance companies are prohibited to impose
dollar limits on the amount of coverage an individual may receive
-Provisions in 2012, Improving and lowering costs are linking payments to quality outcomes based on
patient's perception of care
- Previously it was only required to have a state background check ran in order to have direct access to
patients, now it is being implemented that a federal background check be ran on the employee seeking
employment as to prevent possible abuse or criminal situations
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- States may run their own exchanges to provide health benefits, they must however meet federal
guidelines for minimum coverage known as “essential health benefits”.
Weaknesses
- The taxpayers can choose to simply not file their taxes, or simply pay the “fine”. This would reduce
the amount brought in to cover overall plan by not having the full amount for premiums.
- The one percent is for income at or below the filing threshold for your income tax as filing single on
your 2011 taxes ($9500)
- The requirement known as the “individual mandate” requires most Americans to have insurance or
face the penalty. The exemption is if cost of insurance would exceed 8% of your income, or people
below federal poverty limits
- 2010 New Consumer Protections provisions state that insurance companies cannot deny coverage to
children under 19 for preexisting conditions. New Consumer protections of 2014, prohibits companies
from refusing to renew or sell coverage regardless of their preexisting conditions, gender or health
status
- At the end of 2012 regulations were still needing to develop standards in regards to nonquantitative
treatment limitations (NQTLs) which would decide how much or little treatment was necessary to
determine success in a rehab program in regards to drug and alcohol treatment.
- Although a strength, people who are barely over the poverty line may choose to reduce work hours in
order to receive coverage or prevent themselves from facing fines for not having coverage
- Religious exemptions have always sparked controversy, this issue can cause people to “practice”
religions to be exempt. It can also cause people to fight for equality straight across the board
- The US has a population of 316 million people, in that population there is only approximately 2
million healthcare providers, when comparing the numbers that potentially leaves 158 patients per
healthcare worker. In that number there is only about 700,000 practicing physicians in the US
- By forcing small businesses to have a certain amount of employees, this will push out the Mom and
Pop shops in the areas. This will bring in more corporations such as Walmart and will raise the cost of
products. Eventually leading to lower economies.
- Too many times when trying to research anything on the ACA, you will find the information is put in
place by the government or agencies that are sponsored by the government. Other agencies will put
their opinions out there such as Catholic organizations. This makes it hard to have honest facts.
- Groups such as doctors and religious groups have been filing lawsuits in regards to constitutional
violations. The Arch Diocese in Washington filed a lawsuit against the ACA in 2012 with regards to
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they felt it violated their beliefs with medications and procedures that were to be covered under the
legislation.
- The more penalties pharmaceutical companies face, could push them to lay off workers. This will add
to the already existing unemployment problem. It also can result in higher cost to medications which
will be not be visible to consumers as companies will hide the fees in red tape
Opportunities
- Healthcare costs Americans over 2.7 trillion and is over 17% of our gross domestic product. By
reducing overall costs, we can increase a profit margin
- Being able to afford coverage promotes a healthier society. It increases time spent at work instead of
wasted and loss from days off.
- Individuals will now be able to afford to purchase their medications, again this will increase in the
over all well being of the population
- Small businesses through the first phase in 2010 were eligible for tax credits up to 35% of their
contribution to their employees insurance. Nonprofit companies were able to claim up to 25% credit
- By allowing dependents staying at home and going to college to remain on their parents health
insurance policies, it relieves them of a burden to work full time to maintain insurance. This could
increase repayment of student loans. It also gives parents peace of mind that their children have the
chance to remain cared for.
- By having a rise in the amount of patients needing to be seen, it will create job openings for those
educated in the medical field. It can serve as a job gateway. This could lower unemployment rates in
the field
- By increasing the federal poverty level to a higher rate and increasing the income limits for Medicaid,
this allows families to have the needed coverage to maintain health to continue to be productive in
society
- In 2010 provisions under Increasing Access to Affordable Care, it provides the federal government
the ability to match state funding to cover low income families and individuals
- ACOs must provide care for a minimum of 5000 Medicare recipients. They also must meet
established quality measures of care to include safety, coordination, appropriateness and timeliness.
Threats
- As we discussed earlier in our weakness section of the SWOT, if funding is coming from the tax
payers, they hold the aces so to speak. They can either decrease work hours and become reliable on the
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Medicaid program, they can not file taxes and evade the penalty or they can simply pay the fine and not
contribute to the cost of a health plan.
- If pharmaceutical companies have to cut employees, this will add to the unemployment issues we
have here in the country. By doing so, it will now add to the burden of uninsured or add to the list of
low income families on Medicaid program. This will add to the cost and need of federal funding
- Independent Payment Advisory boards are meant to recommend policies to Congress to curb
Medicare wasteful spending. In 2015 they must report to the President as well as Congress, their
recommendations to slow expenditures. This can be swayed in what ever way the majority of the board
decides it should report. It can take away from a well needed part and give to a lesser part.
- Having a lack of physicians, upsets their patients. It could cause a longer increase of wait time for
patients at their appointments. This has a risk to impact their attendance and scheduling of
appointments. Patients already wait huge amounts of time to see their doctors.
- Depending on where the government decides to place budget costs, funding to residencies can be
affected for example, cuts in schools budgets due to lack of federal funding will lower the quality of
education prospecting physicians receive, therefore their quality of care is substandard
- Individual states for example Florida in Florida et al. v. Department of Health and Human Services et
al.; National Federation of Independent Business et al. v. Kathleen Sebelius, Secretary of Health and
Human Services, et al.; and Department of Health and Human Services et al. v. Florida et al, the state
of Florida filed suit to determine whether or not Congress exceeded their enumerated powers as
provided by the Constitution and if they “unduly coerced” states into increasing their contributions to
Medicaid program.
- Matt Sissel is suing Congress stating that the penalty tax is unconstitutional, he claims the bill
originated in the Senate and is in direct violation of the Constitution because a provision in the
Constitution called the Origination Clause: Article I, Section 7, Clause 1. It reads as follows:
“All Bills for raising Revenue shall originate in the House of Representatives; but the Senate may
propose or concur with Amendments as on other Bills.” In this lawsuit, he claims that although the bill
originated in the House, when it arrived at the Senate the whole body of the bill was removed and
replaced with the PPACA, and then decided on and returned to the House. By doing so, it means the
bill did in fact originate in the Senate as the bill passed was not the original bill passed by the House.
- Religious groups are a huge threat, they feel that the ACA violates an act put in place in 1993 that
“Government shall not substantially burden a person’s exercise of religion even if the burden results
from a rule of general applicability.” This is known as the Religious Freedom Restoration Act. They
can tie the act up in courts for years forcing the mandates to be placed on hold until the Supreme Court
rules.
- Accountable Care Organizations can throw a wrench into the ACA if they do not appease the doctors
working for the facilities, the doctors can simply go work elsewhere. ACOs set the standards for
Case Analysis 20
payments, and if service is substandard they can withhold payment but as I stated, doctors can simply
remove their services and cause the hospital to lose patients.
Case Analysis 21

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Analysis of the Patient Protection and Affordable Care Act

  • 1. Case Analysis 1 Analysis of the Patient Protection and Affordable Care Act Brittney Butcavage Paige Catizone Karyssaann Costagliola Bobbi Jo Glowacki Alisha Mahoney Judith Rodriguez Professor Eltgad Roces Alvernia University Healthcare Science 410 October 15, 2014
  • 2. Case Analysis 2 During the 2008 presidential elections, an unknown Chicago senator by the name of Barack Obama won over voters with the promise of “change”. The first task on his list once in office was to implement a socialized health care program ensuring health coverage for all Americans, regardless of economic status. Americans were assured time and time again that if they were satisfied with their current doctor; the health care reform would not force them to find a different primary care physician. Nancy Pelosi’s famous statement on March 9, 2010, “we have to pass the bill so that you can find out what is in it”, left many people uneasy in terms of the future of American healthcare. After much contentious debate between Republicans and Democrats, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law on March 23, 2010. This ill-thought-out, yet well intentioned piece of legislation has turned into an escalating commitment at the expense of the taxpayers. In the area of health care, Forbes ranks the U.S.A. number eleven when compared to other developed nations. Areas of consideration are: quality, access, efficiency, and equity. This is a surprising revelation; we are not as high on the ladder as we would like to believe. Health care spending is out of control and the services being offered are lacking. We hold the eighth highest infant mortality rate and sadly the highest nation having the probability of people dying between the ages of 15 and 60 years of age. Two main goals of the PPACA were availability and cost control. Obama’s hoped the implementation of this bill would cut spending from $2.7 trillion to $1.1 trillion. A refocus on how we approach health issues would help to control wasteful spending. The shift from treatment to prevention was introduced. Treatments and services are to benefit the community as a whole not just for individuals, much like the traditional public health system. An overhaul such as this deeply involves all stakeholders in order to function as a unit. The Affordable Care Act is the new health care reform law in America and is often referred as Obamacare. The Patient Protection and Affordable Care Act are
  • 3. Case Analysis 3 made up of the Affordable Health Care for America Act, the Patient Protection Act, and the health care related sections of the Health Care and Education Reconciliation Act and the Student Aid and Fiscal Responsibility Act. Included in the act are amendments to other laws such as the Food, Drug and Cosmetics Act and the Health and Public Services Act. Since the ACA signed into law, additional rules and regulations have expanded upon the law, and we have attempted to update our summaries with those changes. In terms of insuring the previously uninsured, the ACA has been successful with the rate of uninsured Americans under 65 falling from 20 percent to 15 percent. If people obtained insurance, 60 percent of them would be able to see a physician or get a prescription filled. Out of those now insured under private ACA plans, 59 percent were previously uninsured, while 66 percent of those who became insured under Medicaid had been previously uninsured. However, the uninsured rate is still 18 percent for people between 19 and 34. The ACA is being compared to Canadian Healthcare system; one thing Americans and Canadians can agree on is that we don’t want each other’s health care systems. In truth, most Americans don’t know how Canada’s system works and Canadians don’t know much about the U.S. system. The differences between the both are: 1. No single payer, Canada-Competitive practices such as advertising are kept to a minimum, maximizing the percentage of revenues that go directly towards care. In general, costs are paid through funding from income taxes, the only province to impose a fixed monthly premium which is waived or reduced for those on low incomes. There are no deductibles on basic health care and co-pays are extremely low or non-existent. US-Medicare is the United States is a single-payer healthcare system, but is restricted to only senior citizens over the age of 65, people under 65 who have specific disabilities, and anyone with end stage renal
  • 4. Case Analysis 4 disease government is increasingly involved in US healthcare spending, paying about 45% of the $2.2 trillion the nation spent on individuals' medical care in 2004. 2. No universal coverage, Health care in Canada-All insured persons must be covered for insured health services. This definition of insured individuals excludes those who may be covered by other federal or provincial legislation, such as serving members of the Canadian Forces or Royal Canadian Mounted Police, inmates of federal penitentiaries, and people covered by provincial workers' compensation. US-The United States does not have a universal health care system, however the Patient Protection and Affordable Care Act (PPACA) as amended by the Health Care and Education Reconciliation Act of 2010, seeks to have expanded insurance coverage to legal residents by 2014. 3. No equal access, Canada-Common complaints relate to access, usually to elective surgery (especially hip and knee replacement and cataract surgery) and diagnostic imaging. These have been the primary targets of health care reinvestment, and it appears that considerable progress has been made for certain services, although the implications for procedures not on the target list are unclear. US-Access to health insurance is very limited for immigrants living in the U.S. both undocumented immigrants and permanent residents. 4. No Cost containment, Canada-Canada's relative success in containing costs is the result of public financing of the health insurance system. Our single payer, publicly financed health care system, allows for cost containment and universal access based on need for services rather than ability to pay. US-U.S. health spending reached an estimated 2.7 trillion dollars in 2010 and the health share of the gross domestic product is projected to increase from 17.6
  • 5. Case Analysis 5 percent in 2009 to 19.8 percent by 2020. This creates the challenge of how health care spending while continuing to enjoy the improvements in quality and quantity of life that result from innovation in medical care. 5. No “national” health insurance, one of the main parts in Canada is that although each province and territory administers a health plan, everyone can expect to be covered for a comprehensive range of services, no matter where they live. The federal government is expected to chip in to make it happen. The Supreme Court decision for the federal government’s obligation for the states will expand their medical coverage. US-Medical costs would be offset in part by replacing insurance premiums with taxes. Hundreds of billions of dollars of immediate savings would be realized from the elimination of insurance company overhead and hospital billing costs, but offsetting immediate expenses would include training and paying for the much larger number of general practitioners and other physicians necessary to provide coverage to several million formerly uninsured. On September 30, 2014 115,000 individuals were set to lose their health care coverage under the ACA due to insufficient documentation in regards to their citizenship/immigration status. Another 350,000 face losing health care subsidies they have been awarded due to insufficient income information. These people may have to pay back the subsidies received and may not be able to afford the coverage they may now be eligible for. Many of these individuals have either mailed the requested documentation or tried submitting it by way of HealthCare.gov, to no avail (Pear). A review of the website and federal contractor must be conducted, it is essential that the website and government contractor in place be efficient for this program to work and handle these cases efficiently.
  • 6. Case Analysis 6 Many individuals who had signed up for medical insurance through the ACA exchanges are having a difficult time finding care, the list of participating providers and hospitals is “narrow”. The idea is that narrow network choices will supposedly help to keep individual costs down. Some individuals with major health issues have faced limited access and high out of pocket cost for the care they have required (Williams). The list of participating providers must be expanded to ensure care for those suffering from pre-existing conditions. The Obama administration has announced that more health insurance options will be available to consumers and these new options will be available in the upcoming health care enrollment period starting November 15, 2014. This will increase the number of insurers by 25% and officials believe this will help to control premiums for consumers (Pear). Despite the high hopes of the administration, many networks are already predicting premium rate hikes for consumers in the 2015 period (Gonen). The effect of the ACA on jobs has been substantial. The ACA mandate requires employers to provide insurance for their employees. Many employers have cut employee hours to less than 30 hours a week to avoid the mandate. Small business owners are discouraged from expanding their business; the mandate applies to businesses with more than 50 employees (Legal Monitor Worldwide). Restrictions on small business should be reviewed. Small business growth should be encouraged to help grow our economy, not be hampered by government restrictions and mandates. The Affordable Care Act requires employers to cover the cost of birth control for female employees, including abortion-inducing drugs. For family owned business Hobby Lobby and religious organization Little Sisters of the Poor-this requirement was seen as a violation of religious freedom. On June 30, 2014 the Supreme Court decided in favor of Hobby Lobby. Their employees will be provided coverage for birth control, but not abortion-inducing drugs such as the morning after pill. The Little Sisters of the Poor are awaiting their Supreme Court date (Fritze).
  • 7. Case Analysis 7 The execution of the Affordable Care Act has helped contribute to the need for more primary care doctors. Medicare and Medicaid compensate specialists at a higher rate than family practice physicians and many persons going into the field of medicine specialize in a specific field knowing this. Federal funds are being used to bring in new primary care practitioners, but one of these programs will be expiring in 2015. . Educating new nurses and physicians takes years, something the ACA did not take into account. With the lack of graduates at this time families can expect longer wait times as well as shortened appointments and increased cost (Anderson). The “supply and demand” of the ACA will be hard to maintain, patients will have a harder time accessing providers and in turn have new frustrations with the delivery of care (Anderson). In order to remedy this shortage, additional ACA funding must go toward incentive programs to attract more primary care physicians and the biased compensation scale of Medicare and Medicaid must be overhauled (Krasselt) Incentives are being placed in order to up the number of healthcare graduates and prospective students. According to an article by Amy Anderson, on www.heritage.org, “The ACA reauthorized loan repayment and forgiveness, scholarships, increases in Medicare-funded Graduate Medical Education (GME) residency slots, funding for workforce planning, and increased funding for the Public Health Service.” However, medical students are exhibiting less interest in primary care, mostly due to a “$3.5 million income gap over a lifetime of work and the increasing debt of student loans” (Anderson). Amy goes on to tell us that currently medical education institutions enrollment has increased, but it is predicted that due to the long process of education the demand will surpass the supply by approximately 2025 (Anderson). The ongoing lack of residency slots is also a determining factor when it comes to educating these graduates. The American Association of Medical Colleges is supporting legislation to increase the number of Medicare-funded residency slots, none the less this shortfall could persist at least through 2017(Anderson). Nursing is also experiencing a similar dilemma: “More than 79,000 qualified
  • 8. Case Analysis 8 applicants were turned away from nursing programs in 2012. Complicating matters, the average salary for positions in nursing education is significantly lower that what these experts can earn outside academia, making it difficult to recruit and retain key academic personnel” (Anderson). In order to maintain a higher graduate ratio, we need to offer higher incentive and reimbursement to try and alleviate the financial burdens of pursuing an education in health care; also the number of residency slots available need to be raised in order to keep up with the staggering numbers of those now insured. This may just convince individuals that a future in medicine is attainable and may persuade them to consider all that is has to offer. The Affordable Care Act is having its affects not only on consumers, but on all of the healthcare systems that provide care to patients. For many years in the healthcare industry hospitals relied on reimbursements from insurance and other sources based on the volume of patients they see. The long term care facilities have always suffered when it came to Medicare reimbursements which they will hopefully see a change when it comes to the implementation of the ACA with the creation of long term care services and supports. This system of payment is going to change drastically over the course of time in order to comply with rules set forth in the Affordable Care Act. This Act wants providers to focus more on the quality of work they are doing rather than trying to treat as many people as possible to get their payout. The hospital systems have to make major adjustments to how they give treatment and care to the patients they see. With the main focus of care in hospitals now being more of quality not quantity so the hospital are forced to take a different approach of care. The ACA does not have many guidelines to the quality control of service and how they accomplish it which, “It allows hospitals to create entities called accountable care organizations, third-party groups that oversee the quality of care at hospitals” (http://www.usatoday.com/story/news/nation/2013/10/20/hospitals-face-whole-new-world-under-
  • 9. Case Analysis 9 health-law/3078353/). The implementation of the ACA is giving every hospital an initiative to improve their quality to receive the maximum reimbursement from Medicare especially. They determine the quality of hospitals based off patient surveys that are given post care and the outcomes of procedures performed for the patient. The lower the scores on surveys and other areas the hospital is subject to a penalty and also hospitals that have an increase in hospital acquired infections are subject to penalties. Unfortunately, some negative aspects of the ACA are hospitals are resorting to cutting back employees to prepare for the money loss with this new system. Local hospitals like Blue Mountain Health Systems have dismissed multiple employees from both the Lehighton and Palmerton Campus. Another aspect is most independent hospitals are forced to merge with larger networks to stay afloat with the drastic changes in reimbursement. The effects on long term care facilities are having a more positive effect in regards to the ACA. Currently most elderly patients that are in need of a long term care facility or at home care and do not have a supplemental insurance are unable to afford to pay for their stay and care at these facilities or in home care givers. Their inability to pay is leading to the elderly using up their savings and or their family’s savings just trying to maintain their stays which for most people it isn’t realistic. The growing population is increasing in the elderly community because of the changes in healthcare leading to longer life spans. With people living longer these facilities are almost necessary to have and most elderly people utilize them which increase the need to have coverage. The ACA is going to make this possible for those people in need of the long term care and even make it possible to receive their care at home. The changes to healthcare involving the ACA and long term care state that with the change it will, “build the long-term care workforce creating a new long-term care insurance program giving states incentives to expand home- and community-based services in Medicaid, creating programs to improve resources that help caregivers, and creating programs that protect seniors and people with disabilities creating programs that improve nursing home care”
  • 10. Case Analysis 10 (http://familiesusa.org/product/affordable-care-act-provisions-will-help-caregivers). The changes will put families at ease knowing that there is care available for their parents or grandparents and they won’t have to worry about the cost or high medical bills they would have to pay. With the upcoming changes to the way health care is delivered, the way hospitals and long term care settings are reimbursed it is crucial they take everything into account. If these care facilities focus on the best quality care they can give verses the amount of patients they treat it will lower the risk of layoffs and closures of facilities. If these facilities would monitor unnecessary spending like departmental costs it could lower the impact that the ACA has on reimbursements with insurance. When dealing with Medicare patients, hospitals are facing penalties and or no money for services rendered because they are not focusing on the quality care. If a hospital can control readmissions it would significantly increase the reimbursements that they receive. Medicare patients after the third day of admission the insurance does not pay so the hospital is resorting to absorbing the loss which increases their debt. Another problem that they face is the penalties they receive for hospital acquired infections which if they would make sure every preventative measure is taken and possibly giving private rooms to more patients it would lower these occurrences. Over all, hospitals and long term facilities would stand a better chance of reimbursement in every aspect of care if they continue to keep an advisory group in place to send out surveys to patients and to oversee the quality performance done at each facility. If they hold strong with these new standards and ways to fix the quality of care the drastic changes the ACA is going to have on these facilities won’t be as significant. Alternative therapies may flourish when the Affordable Care Act is in full swing, thanks to a clause written within the new law. Section 2706, “Non-Discrimination in Health Care”, states: “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable state
  • 11. Case Analysis 11 law” (Cahill). In layman’s terms this simply means that if a Complementary and Alternative Medicine (CAM) practitioner is licensed within that state, insurance companies must compensate them the same as they would a traditional physician (Cahill). It seems only expected that alternative therapies now be considered by health insurers; for years millions of American’s have paid out-of-pocket for CAM treatments on a yearly basis. The article, “What is the Future of Complementary and Alternative Medicine under the Affordable Care Act”, a 2011 survey implemented by Consumer Reports notes that, “every year 38 million Americans receive more than 300 million CAM treatments” (Cahill). The argument stands that CAM offers limited research to prove its efficiency, however the ACA rules can now allow for research and experimental treatments to be implemented based on a “probable cause” standard used in evaluating CAM modalities (Turner). The ACA has intentions of focusing on preventative medicine and wellness-based treatment; however it has not fully taken into account the contributions that can be made by integrating Complementary and Alternative Medicine, together with conventional medicines (Abbott). In order for this to work, practitioners alike have to maintain an open mind. The benefits of CAM can speak for themselves if you research the statistics, just imagine if we integrated both conventional and alternative therapies; a world of opportunity waits! For many people alike, the ACA is a touch and go subject. It has many different groups of people either for it against it. Not only because it is considered to be “forced” upon American citizens, but on the opposite spectrum, have some seen it as a blessing. There is now a link that describes what a citizen will pay for every year they are insured. For example, in 2014 $95 will be taken out of your refund and in 2015 $325 will be taken out. This alone has many people outraged due to many not being able to afford such rising high costs for healthcare. However, when doing an in depth research on these establishments, there wasn’t much research to back certain claims that were made by these institutions. What will next be examined is how it affects different organizations, government run institutions that
  • 12. Case Analysis 12 currently have the ACA in effect and the research they use to speak to patients to “put their minds at ease.” A long time government run healthcare organization has been the Veterans Administration. Hospital researched was VA (also known as Veteran Affairs), from reading all of the research on the ACA and VA it was rather frightening. If a veteran has VA benefits, then they are considered to be “covered” and that no enrollment is required, however, the down side to not having the VA benefits can also put a dent into someone’s pocket. In order to get the VA benefits, the veteran MUST enroll into ACA or a large portion of their taxes gets taken from them during the year. According to the website www.va.gov , it has little to no explanation of the enrollment for the ACA. It just mentions that if one does not enroll into veteran benefits, they must use the Healthcare marketplace to enroll. Additionally, upon further reading, it is now changed that a family member cannot be put onto veterans benefits if they have inquired to healthcare marketplace. This can be frustrating for family members who are not aware that they cannot be placed just for researching the ACA. As for putting a dent into the pockets as mentioned earlier, family member will have to pay steeper co pays if they are not enrolled under the VA. Catholic hospitals are also largely affected. With all the current trends in healthcare (including these hospitals allowing contraception), many have opted to allow such changes into their hospitals as early as June of 2013. There are still many controversies within the CHA whether patients can receive all cares that are covered under the ACA. There has been a mandate done earlier in the year that if a hospital or institution that is deemed “private” does not want to give patients full care, they can refuse that right if they consider it immoral and make the insurance company find a different provider to give the patient contraception. Sister Carol Keehan who is front runner for Catholic hospitals to use all avenues for ACA states that regardless of religious beliefs, everyone should be able to get the care they deserve and that’s what healthcare is all about.
  • 13. Case Analysis 13 After looking into both these organizations, RAND was then researched to see public opinion since ACA was put into effect. The questions that RAND had used were to see if people really were changing their minds about the ACA. The data runs from Sept 2013 up until Sept 2014, within one year, there was a 45% increase of people who are not in favor of the ACA. When reading the FAQ’s page, RAND had asked people why they went from favoring to unfavoring, their response was that they were deceived into thinking that it was health care that everyone (extremely low income participants) could afford. However, RAND itself is rather biased with their research, even though they ask the questions as to why they report the “unfavorings” of the ACA, they are still consider government and only reporting the “good qualities” of the ACA. It seems as though someone who is not well versed in reading into research, they can easily be fooled. Lastly, I had read into what The Children’s’ Hospital of Philadelphia (CHOP) was doing for families to provide care for the children that use such insurance. According to the website, they accept the ACA, but what gets parents is that some tests (which are considered possibly vital to the childs health), may not be covered and a third party must be contacted to provide all or partial payment to receive a test or treatment. This can burden a lot of parents with a sick child, especially one who needs round the clock care. For children, who are terminally ill, they should cover all costs, this one major reason as to why people oppose the ACA and what it “provides.”
  • 14. Case Analysis 14 SWOT Analysis for Affordable Care Act Strengths  Plans to decreases number of Americans without health insurance  Benefits low income families  Healthcare coverage for people with per-existing conditions  Prescription drugs will be available at a lower cost  Prohibits payout caps  Doctors and hospitals are rewarded for quality of care instead of quantity of care  Has a requirement implemented that the FBI is to establish a nationwide background check on direct patient access employees  Each state can run its own health insurance exchange or they can default to have the federal government manage it Weaknesses  It is being funded by the tax payers  Penalty tax is starting at $95 or 1% of your income, and then going up in consecutive years  People are forced to purchase coverage or face penalty tax  Coverage for people with pre-existing conditions are facing higher premiums  Uncertainty and arguments in regards to what is actually considered essential care and how much coverage will be allotted (i.e. rehabilitation)  Exemptions for people below federal established poverty line  People with certain religious beliefs are exempt
  • 15. Case Analysis 15  Shortage of healthcare providers  Small businesses are forced to have at least 50 full-time employees and provide insurance or face a fine  Biased research  Open lawsuits from healthcare providers and religious groups  Pharmaceutical companies face higher taxes, fees and rate increases for their medications to be marketed Opportunities  Reduce overall cost of healthcare  Individuals and small businesses are able to buy affordable insurance  Prescription drugs available at lower costs  Tax credits  Extended coverage for dependents to age 26  Increase in patient volume  Medicaid coverage now available for more Americans  States can receive funds from federal government to cover low income families on medicaid  Accountable care organizations Threats  Funding from taxpayers  Pharmaceutical companies releasing employees to cover costs of inflated taxes and fees  Creation of Independent Payment Advisory Board (IPAB)
  • 16. Case Analysis 16  Lack of physicians to provide coverage for influx of patients  Funding from the government (i.e. residencies)  Technological advancements not considered in current regulations  Lawsuits from individual states as well as healthcare providers  Lawsuits in regards to unconstitutional legislation  Religious groups  Accountable Care Organizations (ACOs) SWOT Explanation Strengths - in 2012 there was 47 million Americans that had no healthcare coverage, the ACA plans to drastically decrease that or even eliminate that amount - Medicaid eligibility expanded to all Americans under 65 with incomes up to 133% of the federal poverty level - Prior to implementing people with a pre-existing condition such as asthma, could not get health insurance now they can - Medicare recipients who reach the drug coverage gap now are offered their prescriptions at a 50% discount until the prescription gap closes in 2020 - Under new consumer protections provisions of 2014, insurance companies are prohibited to impose dollar limits on the amount of coverage an individual may receive -Provisions in 2012, Improving and lowering costs are linking payments to quality outcomes based on patient's perception of care - Previously it was only required to have a state background check ran in order to have direct access to patients, now it is being implemented that a federal background check be ran on the employee seeking employment as to prevent possible abuse or criminal situations
  • 17. Case Analysis 17 - States may run their own exchanges to provide health benefits, they must however meet federal guidelines for minimum coverage known as “essential health benefits”. Weaknesses - The taxpayers can choose to simply not file their taxes, or simply pay the “fine”. This would reduce the amount brought in to cover overall plan by not having the full amount for premiums. - The one percent is for income at or below the filing threshold for your income tax as filing single on your 2011 taxes ($9500) - The requirement known as the “individual mandate” requires most Americans to have insurance or face the penalty. The exemption is if cost of insurance would exceed 8% of your income, or people below federal poverty limits - 2010 New Consumer Protections provisions state that insurance companies cannot deny coverage to children under 19 for preexisting conditions. New Consumer protections of 2014, prohibits companies from refusing to renew or sell coverage regardless of their preexisting conditions, gender or health status - At the end of 2012 regulations were still needing to develop standards in regards to nonquantitative treatment limitations (NQTLs) which would decide how much or little treatment was necessary to determine success in a rehab program in regards to drug and alcohol treatment. - Although a strength, people who are barely over the poverty line may choose to reduce work hours in order to receive coverage or prevent themselves from facing fines for not having coverage - Religious exemptions have always sparked controversy, this issue can cause people to “practice” religions to be exempt. It can also cause people to fight for equality straight across the board - The US has a population of 316 million people, in that population there is only approximately 2 million healthcare providers, when comparing the numbers that potentially leaves 158 patients per healthcare worker. In that number there is only about 700,000 practicing physicians in the US - By forcing small businesses to have a certain amount of employees, this will push out the Mom and Pop shops in the areas. This will bring in more corporations such as Walmart and will raise the cost of products. Eventually leading to lower economies. - Too many times when trying to research anything on the ACA, you will find the information is put in place by the government or agencies that are sponsored by the government. Other agencies will put their opinions out there such as Catholic organizations. This makes it hard to have honest facts. - Groups such as doctors and religious groups have been filing lawsuits in regards to constitutional violations. The Arch Diocese in Washington filed a lawsuit against the ACA in 2012 with regards to
  • 18. Case Analysis 18 they felt it violated their beliefs with medications and procedures that were to be covered under the legislation. - The more penalties pharmaceutical companies face, could push them to lay off workers. This will add to the already existing unemployment problem. It also can result in higher cost to medications which will be not be visible to consumers as companies will hide the fees in red tape Opportunities - Healthcare costs Americans over 2.7 trillion and is over 17% of our gross domestic product. By reducing overall costs, we can increase a profit margin - Being able to afford coverage promotes a healthier society. It increases time spent at work instead of wasted and loss from days off. - Individuals will now be able to afford to purchase their medications, again this will increase in the over all well being of the population - Small businesses through the first phase in 2010 were eligible for tax credits up to 35% of their contribution to their employees insurance. Nonprofit companies were able to claim up to 25% credit - By allowing dependents staying at home and going to college to remain on their parents health insurance policies, it relieves them of a burden to work full time to maintain insurance. This could increase repayment of student loans. It also gives parents peace of mind that their children have the chance to remain cared for. - By having a rise in the amount of patients needing to be seen, it will create job openings for those educated in the medical field. It can serve as a job gateway. This could lower unemployment rates in the field - By increasing the federal poverty level to a higher rate and increasing the income limits for Medicaid, this allows families to have the needed coverage to maintain health to continue to be productive in society - In 2010 provisions under Increasing Access to Affordable Care, it provides the federal government the ability to match state funding to cover low income families and individuals - ACOs must provide care for a minimum of 5000 Medicare recipients. They also must meet established quality measures of care to include safety, coordination, appropriateness and timeliness. Threats - As we discussed earlier in our weakness section of the SWOT, if funding is coming from the tax payers, they hold the aces so to speak. They can either decrease work hours and become reliable on the
  • 19. Case Analysis 19 Medicaid program, they can not file taxes and evade the penalty or they can simply pay the fine and not contribute to the cost of a health plan. - If pharmaceutical companies have to cut employees, this will add to the unemployment issues we have here in the country. By doing so, it will now add to the burden of uninsured or add to the list of low income families on Medicaid program. This will add to the cost and need of federal funding - Independent Payment Advisory boards are meant to recommend policies to Congress to curb Medicare wasteful spending. In 2015 they must report to the President as well as Congress, their recommendations to slow expenditures. This can be swayed in what ever way the majority of the board decides it should report. It can take away from a well needed part and give to a lesser part. - Having a lack of physicians, upsets their patients. It could cause a longer increase of wait time for patients at their appointments. This has a risk to impact their attendance and scheduling of appointments. Patients already wait huge amounts of time to see their doctors. - Depending on where the government decides to place budget costs, funding to residencies can be affected for example, cuts in schools budgets due to lack of federal funding will lower the quality of education prospecting physicians receive, therefore their quality of care is substandard - Individual states for example Florida in Florida et al. v. Department of Health and Human Services et al.; National Federation of Independent Business et al. v. Kathleen Sebelius, Secretary of Health and Human Services, et al.; and Department of Health and Human Services et al. v. Florida et al, the state of Florida filed suit to determine whether or not Congress exceeded their enumerated powers as provided by the Constitution and if they “unduly coerced” states into increasing their contributions to Medicaid program. - Matt Sissel is suing Congress stating that the penalty tax is unconstitutional, he claims the bill originated in the Senate and is in direct violation of the Constitution because a provision in the Constitution called the Origination Clause: Article I, Section 7, Clause 1. It reads as follows: “All Bills for raising Revenue shall originate in the House of Representatives; but the Senate may propose or concur with Amendments as on other Bills.” In this lawsuit, he claims that although the bill originated in the House, when it arrived at the Senate the whole body of the bill was removed and replaced with the PPACA, and then decided on and returned to the House. By doing so, it means the bill did in fact originate in the Senate as the bill passed was not the original bill passed by the House. - Religious groups are a huge threat, they feel that the ACA violates an act put in place in 1993 that “Government shall not substantially burden a person’s exercise of religion even if the burden results from a rule of general applicability.” This is known as the Religious Freedom Restoration Act. They can tie the act up in courts for years forcing the mandates to be placed on hold until the Supreme Court rules. - Accountable Care Organizations can throw a wrench into the ACA if they do not appease the doctors working for the facilities, the doctors can simply go work elsewhere. ACOs set the standards for
  • 20. Case Analysis 20 payments, and if service is substandard they can withhold payment but as I stated, doctors can simply remove their services and cause the hospital to lose patients.