Mini Literature Review
Assessing the Impact of the Affordable Care Act on the Accessibility of Healthcare Delivery in the United States.
Over the years, the health sector of the United States has been much privatized as compared to other developed countries and as a result, the country spends more on healthcare. In 2007, it was recorded that more than half of the US population was covered by private insurance with the majority insured by their employers (Garrett, & Gangopadhyaya, 2016). Aside from the private insurance and workforce, government provides Medicare and Medicaid programs. The former is meant to provide health insurance for the disabled, and the elderly above 65 years whilst the latter initially covered single parents, children and pregnant women. Due to the requirements and caveats such as the premiums that raised 3 times that of the inflation associated with the private insurance (Garrett, & Gangopadhyaya, 2016), people who did not have public insurance and workforce coverage had a difficult time obtaining an individual insurance; thus, this problem of uninsured people has an effect on the individual, families, communities, and the nation at large. These and several other related issues influenced the initiation of the Affordable Care Act in 2010 under the Obama Administration.
Although the problem of insurance coverage and accessibility has persisted over the years, the Patient Protection and Affordable Care Act, mostly known as the Affordable Care Act (ACA) or “Obama Care” was introduced to expand access to health insurance coverage for those who were faced with the difficulty of being insured in the United States (Kominski, Nonzee, & Sorensen, 2017). Prior to the inception of the ACA, opponents of the ACA argued that it was not needed because uninsured people already had adequate access to health care in the sense that they had hospitals and clinics readily available to them (Garrett, & Gangopadhyaya, 2016; Glied & Borja, 2015). There were also allegations from the opposition that expansion of Medicaid access was acting ultra vires congressional power; hence, the opposition held that the expansion would only be allowed, if states could opt out of the expansion and still be entitled to their Medicaid funding (Hall, & Lord, 2014). In addition, majority of the opposition party had it that the government wants to control the delivery of health care and to decide what citizens will take as medicines which was later debunked and proven to be false (Hall, & Lord, 2014). The ACA did pass and has continued to face opposition.
The main purpose of this literature review is to assess the impact of the Affordable Care Act on accessibility of health care delivery in the United States. By examining the literature, we can determine its impact on access to health care laying more emphasis on the positive and negative impacts. This will help to know who gained health insurance coverage who was not insured and based on what reasons.
This review identifies how the ACA uses two primary approaches to increase access to health care as well as how it expands the access to Medicaid, the motive behind this expansion as well as how the ACA creates eligibility for those with incomes below 138% of the federal poverty level (Kominski, Nonzee, & Sorensen, 2017). Included in this review is a discussion of the relationship between healthcare and market enrollment as this will enhance the discussion of the cause of this and steps taken to reduce the rate of uninsured.
Discussions of the features of the ACA, quality of healthcare delivery under the ACA, and costs incurred as a result of the ACA will not be factored in this review because they have several dimensions; thus, the discussion will be limited to the assessment of the impact of the ACA on the accessibility of health care.
In conclusion, this review provides series of recommendations made in many articles, and discusses the channel of future research to promote the accessibility of the Affordable Care Act.
APPROACHES TO INCREASE ACCESS TO HEALTH CARE DELIVERY UNDER THE ACA.
The ACA was much focused on how to increase coverage for low and middle income individuals and families because majority of the uninsured is in this section of the population (Kominski, Nonzee, & Sorensen, 2017). The ACA is based on two main approaches to increase access to health care insurance (Kominski, Nonzee, & Sorensen, 2017). The first approach is that it expands access to Medicaid. With Medicaid, the health care needs of more than 74.5 million people is catered for nationally (Kominski, Nonzee, & Sorensen, 2017). More than 15 million people were enrolled in Medicaid due to the introduction of the ACA (Kominski, Nonzee, & Sorensen, 2017). Within a space of three years from the inception of the ACA, few states such as California, Colorado, Connecticut, Minnesota, new Jersey and the like extended their Medicaid eligibility for low income adults (Kominski, Nonzee, & Sorensen, 2017). As a result, states that expanded Medicaid under the ACA enhanced effectiveness of Medicaid and its contribution to improved coverage access. For instance, in Connecticut, Medicaid expansion increased significantly with about 4.9% points among the low income population. Washington DC also had an increase in its insurance coverage of 3.7%. Even though the expansion of Medicaid was not mandatory, several states took advantage of the ACA to expand Medicaid except a few and this negatively affected the effectiveness of Medicaid in these states (Garrett, & Gangopadhyaya, 2016; Adepoju, Preston, & Gonzales, 2015).
The second approach is creating eligibility for those with low incomes below 138% of the poverty level. The health sector of the United States experienced an era where people who were unemployed and those who had incomes below 138% the federal poverty level did not receive insurance coverage (Kominski, Nonzee, & Sorensen, 2017). For the first time in the history of the country, the Affordable Care Act has provided coverage for adults with income levels below 138% poverty level especially those without children (Kominski, Nonzee, & Sorensen, 2017). This has helped to increase the overall rate of insurance coverage and has also reduced the mortality rate among poor people who had no children. In addition, people with low incomes can now divert their low income to feed their families whilst insured under the ACA which offers free health care for all and sundry.
POSITIVE IMPACT ON ACCESS TO HEALTHCARE DELIVERY
In as much as these approaches under the ACA seek to close the coverage gap between the uninsured and those who have coverage, it also improved the standard of living of the American people, the Affordable Care Act has generated a positive relationship between the access to healthcare and marketplace enrollment. The first and second open enrollment periods after the inception of the Affordable Care Act identified a number of additional factors that likely influenced enrollment (Hall & Lord, 2014). Also, nearly 12.7 million individuals signed up for coverage in the Affordable Care Act’s (ACA) health insurance marketplaces during the third open enrollment period, and by the end of March there were 11.1 million beneficiaries with active coverage (Hall ; Lord, 2014). Many marketplaces also enhanced their web portals to help move through them hastily which will give the people better tools to decide on their coverage options (Hall ; Lord, 2014).
Coupled with the ACA’s impact on the market place enrollment, it increased insurance coverage within a three year period for about 20 million non-elderly people and as a result of this, the rate of uninsured reduced to a historically low percentage (Garrett, & Gangopadhyaya, 2016). The share of the uninsured nonelderly population was around 18.2% between 1998 and 2009, as early provisions of the ACA went into effect in 2010 through to 2015 and as the economy improved, the uninsured rate began to drop to about 11.2% (Garrett, & Gangopadhyaya, 2016).
Throughout its operation for three years, the ACA also increased health insurance coverage of males and females. Based on gender, the rate of the uninsured males and females before the ACA depicted about 20.2% and 16.3% respectively (Adepoju, Preston, & Gonzales, 2015). However, in the early 2010 a lot of people gained insurance coverage which reduced the rate of uninsured to about 12.7% (males) and 9.8%(females) (Garrett, & Gangopadhyaya, 2016). These data show a significant increase in the insurance coverage of the American people. Also, the insurance coverage for Lesbian, Gay, Bisexual and Transgender Queer (LGBTQ) as compared to the straight peers has had a significant increase in the course of the implementation of the Affordable Care. Even though data from the pre-ACA era is hard to find, the uninsured rates in the Behavioral Risk Factor Surveillance System (BFRSS) for 2012-2013 were 18.3% (Nguyen, Trivedi, & Shireman, 2018). However, the uninsured rate from 2014 to 2017 were 13.2 in the LGBTQ population and 12.8% in the straight peers (Nguyen, Trivedi, & Shireman, 2018). The ACA has therefore made a significant impact on the LGBTQ as well as their Straight peers but this was not so prior to the ACA.
Aside from the impact made based on gender, the ACA has also had positive impact on the accessibility of health care based on race of the people. The uninsured rate of non-Hispanic whites, non-Hispanic black, Hispanic in the year 2010 were, 13.0%, 21.2, 32.6%, and 17.4% respectively. These uninsured rates decreased to 7.9%, 13.2%, 20.8%, and 9.7% respectively in the next three years after the inception of the Affordable Care Act (Garrett, & Gangopadhyaya, 2016). The reduction in the uninsured rates of the various races proves that there has been a significant increase in the coverage of health care across the states in the United States.
In as much as the ACA has made significant impact on how different races have gained coverage after its inception, it has also allowed children to stay on their parents’ health insurance plans till they are above 26 years (Hall ; Lord, 2014). This has made majority of parents who did not have insurance for their children and themselves to be insured under the ACA. For instance, if a household of about nine people with the parents inclusive had income below the Federal poverty level and as a result had all children uninsured, these children can now be on the insurance coverage of their parents until they are above 26 years.
NEGATIVE IMPACTS TO ACCESS TO HEALTHCARE DELIVERY
Despite the large gains in coverage since the implementation of the ACA, more than 27 million people in the United States remain uninsured regardless of whether they live in Medicaid expansion states or non-expansion (Glied ; Borja, 2015). Those residing in Medicaid expansion states are faced with a series of challenges that result in a large percentage of the people being uninsured (Wilensky, 2012).
Impact on expansion Medicaid States.
In the Medicaid expansion states, most wealthy families are insured under the ACA because they already have private insurance. These wealthy families therefore, do not see the need to have additional insurance coverage since they are already insured and as a result, some are of the view that their private insurance covers more items and health needs than the benefits the ACA provides (Wilensky, 2012).
Coupled with the challenge these wealthy families face is how people do not insure themselves until they actually see the need for the health insurance. This is due to the mechanisms put in place such as the complex enrollment process which cause people to postpone their insurance and only be insured when they are of the view that it is their only option (Wilensky, 2012). Furthermore, the fine charged as a penalty on people who refuse to be insured is not high enough to deter them from being uninsured and consequently, they become insured as and when they see the need to be insured since the fine is very small, especially for young people with better incomes (Wilensky, 2012). These have caused majority of the non-elderly in these expansion Medicaid states to be uninsured.
Placing emphasis on the literature, although several states have expanded Medicaid under the ACA, people in these states are still unaware of the coverage expansions (Wilensky, 2012). With this, they do not receive the benefit the Affordable Care Act provides to the entire state and to the citizens of the country as a whole. In addition to this, the undocumented individuals are not eligible to Medicaid; hence, these individuals will not have the chance to be insured with a different private insurance firm (Wilensky, 2012). Challenges faced by the states that expanded Medicaid under the ACA can also be seen in the issue of how LGBTQ do not have personal doctors as compared to those who are not LGBTQ, whilst the LGBTQ are associated with the avoidance of necessary medical care and are therefore not insured due to this shortfall (Nguyen, Trivedi, ; Shireman, 2018).
Impact on those Non-expansion Medicaid States.
In as much as the Affordable Care Act faces negative impact in the states that expanded Medicaid, it is also faced with negative impacts which emanate from those in non-Medicaid expansion states. Medicaid expansion under the ACA sought to reduce the uninsured rate in all states in the US, but some states refused to expand their Medicaid. As a result, this has had a negative impact on the overall insurance coverage increase. Approximately 9% of the uninsured Americans after the Affordable Care Act was initiated was from the states that refused to expand their Medicaid access (Hall ; Lord, 2014). This percentage constitute about 3 million US citizens and falls under what is known as the “coverage gap” (Kominski, Nonzee, ; Sorensen, 2017). This group represents the poor, uninsured adults who reside in the nineteen (19) non-Medicaid expansion states (Kominski, Nonzee, ; Sorensen, 2017).
The Affordable Care Act has contributed to the health sector in terms of accessibility to healthcare delivery. In the near future, new reforms should focus more on how to provide more value to the people in terms of health insurance instead of volume of health care and also the implementation of the Affordable Care Act should be similar across all states (Kominski, Nonzee, ; Sorensen, 2017). For instance, how ACA is implemented and the benefits acquired in the state of California must be similar to the implementation and benefits acquired in the state of Ohio.
In addition to this, new phase of health reform should adopt the Culturally and Linguistically Appropriate Services (CLAS) model for improving access to health care delivery. The CLAS model is intended to advance health equity, improve quality, increase accessibility and help eliminate healthcare disparities by setting a standard for health organizations (Adepoju, Preston, ; Gonzales, 2015).
In conclusion, evidence from the above literature indicates that the Affordable Care Act since its inception has been of great benefit to the country and the citizens thereof. In as much as the impact is overwhelming, there people who are still uninsured due to several issues which have been discussed. Although steps have been taken to lessen these limitations, future assessments will need to continue to monitor the impact of the ACA across these domains to fully understand its impact on other sectors of the economy.
Kominski, G. F., Nonzee, N. J., ; Sorensen, A. (2017). The Affordable Care Act’s impacts on access to insurance and health care for low-income populations. Annual Review of Public Health, 38(1), 489-505. doi:10.1146/annurev-publhealth-031816-044555
Garrett, B., & Gangopadhyaya, A. (2016). Who gained health insurance coverage under the ACA, and where do they live? Retrieved from https://www.urban.org/sites/default/files/publication/86761/2001041-who-gained-health-insurance-coverage-under-the-aca-and-where-do-they-live.pdf
Adepoju, O. E., Preston, M. A., & Gonzales, G. (2015). Health care disparities in the Post–Affordable Care Act era. American Journal of Public Health, 105(S5). doi:10.2105/ajph.2015.302611
Glied, S. G., Ma, S. M., & Borja, A. A. (2015). How will the Affordable Care Act affect the use of health care services? Retrieved from https://www.commonwealthfund.org/publications/issue-briefs/2015/feb/how-will-affordable-care-act-affect-use-health-care-services
Hall, M. A., & Lord, R. (2014). Obamacare: What the Affordable Care Act means for patients and physicians. Retrieved from https://sph.umich.edu/sep/overview/pdf/Hall 2014.pdf
Wilensky, G. R. (2012). The shortfalls of “Obamacare.” New England Journal of Medicine, 367(16), 1479-1481. doi:10.1056/nejmp1210763
Nguyen, K. H., Trivedi, A. N., & Shireman, T. I. (2018). Lesbian, Gay, and Bisexual adults report continued problems affording care despite coverage gains. Health Affairs, 37(8), 1306-1312. doi:10.1377/hlthaff.2018.0281