The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice

TL;DR: The Affordable Care Act (ACA) has supported individuals across the U.S. with accessing healthcare. It helped protect patients from previously predatory practices that insurance companies implemented, and ultimately encouraged hospitals and physicians to treat patients more thoroughly.

Key terms

• Affordable Care Act (ACA): A U.S. law passed in 2010 to make health insurance cheaper and easier to get

• Health insurance: A plan that helps pay for doctor visits, medical care, and prescription drugs. It aims to protect patients from high medical costs.

• Medicaid: Government insurance for people with low income

• Premium: The amount you pay every month for insurance 

• Subsidy: Money from the government to help you pay for insurance

Overview 

In 2010, the Affordable Care Act (ACA), also known as Obamacare, became a law. This act changed a lot about how healthcare worked in the United States. The main goal of this act was to make sure all Americans have access to affordable, high-quality health insurance. Before this act was passed, many people couldn’t afford health insurance because they were sick, or because their employer did not provide affordable coverage. 

After this law was passed: 

• Insurance became easier to get 

• All U.S. taxpayers shared the responsibility to make sure everyone is covered by insurance (the U.S. balanced the risk and cost across the entire population)

• Medicaid (a program for low-income people) got expanded 

• New state websites (called Exchanges) became available to help people buy insurance more easily. 

This program predicted that by the time everything was set in place: 

• About 94% of Americans will be covered 

• 31 million more people will have insurance 

• 15 million more people will be using Medicaid 

• Only about 24 million people will have no insurance, which is a big improvement. 

Health Insurance Coverage Reforms 

The Affordable Care Act stated that:

• Everyone who can afford health insurance must get it 

• The original law included a federal penalty for those who could afford coverage but chose not to buy it, but this penalty was later eliminated starting in 2019

This change occurred because if only sick people bought insurance, then insurance would become too expensive. However, if everyone had to buy insurance, then the cost is shared and everyone gets the benefits!

This law also helped many people financially, as now: 

• Low-income people get Medicaid to help pay for their health insurance

• Middle-income people get discounts to help buy insurance 

Medicaid was also changed by ACA. The ACA allowed states to expand Medicaid to cover nearly all non-elderly adults with incomes up to 138% of the federal poverty line (133% plus a 5% disregard), even those without dependent children (a 2012 Supreme Court ruling made this expansion optional for states). However, people who recently moved to the US still need to wait 5 years before they can use Medicaid. 

New Standards for Insurers

 Before the ACA, many insurance companies could: 

• Deny people with preexisting conditions insurance 

• Set lifetime limits on how much care they would cover

• Drop people’s plans if they became really sick

But, after ACA, insurance companies: 

• Can’t cancel your plan because you got sick 

• Must cover people with preexisting conditions too

• Can’t place limits on how much they will spend on your healthcare in your lifetime (no lifetime limits)

• Have to give the option to get kids stay on their parent’s insurance until age 26 

• Must cover important preventive care for free

• Must allow appeals if they deny a claim 

However, prices can still vary based on: 

• Age

• Family Size

• Tobacco Use 

• Location 

The ACA generally expects states to enforce these new rules. However, if a state chooses not to, or doesn't do it adequately, the federal government will step in and enforce the rules directly. They do this by having a federal agency watch over the insurance companies instead of the states doing it. Under the ACA, the states are expected to make sure these new rules are followed: like stopping companies from denying coverage or charging unfair prices.

ACA also created Insurance Marketplaces called Exchanges. Exchanges are run by the states, and this is where people can compare insurance plans, apply for financial aid, sign up for Medicaid, and get advice and support on exchanges. Insurance plans sold on exchanges are all qualified plans who meet the strict rules set by the government. 

All qualified insurance plans must cover essential benefits like

• Doctor visits 

• Hospital care 

• Mental health 

• Maternity care

• Prescription drugs 

Moreover, all qualified plans must also be affordable, high quality, and share performance reports so people know how good the plans are. Plans can’t use federal money unless an abortion is needed in cases of rape, incest, or life-threatening pregnancies. However, states also have the option to ban all abortion coverage in their exchanges. 

Improving Health Care Quality, Efficiency, and Accountability

The ACA wanted to improve how doctors and hospitals work together, so instead of just paying both the hospital and doctor for each test or visit, they are encouraged to focus on:

• Keeping patients healthy

• Avoiding unnecessary waste

• Treating patients with team-based care. 

Programs like Medicare and Medicaid can now also test new ideas like “medical homes” (where one doctor team manages all your care), use bundled payments where hospitals can receive payment to cover everything related to a treatment, and create accountable care organizations where groups of doctors and hospitals share rewards if a patient stays healthy. 

Many areas around the U.S. also do not have enough doctors (especially small towns and poor neighborhoods). This puts 60 million people at risk. However, the ACA has a solution for this. It will invest $11 billion into community health centers (which gives anyone care, even if they cannot afford it), and $1.5 billion into the National Health Service Corps, which gives doctors who work in unserved areas scholarships and loan help. 

The Affordable Care Act made big changes for the U.S. healthcare system by getting more people insurance, protecting patients from unfair treatment by insurance companies, and improving the quality of care. It also gave states and the federal government important jobs to make sure these new rules are followed. The ACA is a major step forwards to make healthcare more fair and accessible for everyone. 

doi: 10.1177/003335491112600118