Dr Solomon Alemu Feyissa
American Health Care System prior to the Affordable Care Act ( ACA) is primarily financed by a combination of private medical insurances ( mainly employer sponsored like blue cross blue shield, united, etc with employee contribution), government medical insurance like Medicare ( federal sponsored and for people >65), Medicaid ( state sponsored and for low income and poor), military sponsored ( veteran affairs health care system and military health care) and charity care through charitable organizations.
The pre ACA health care financing and coverages leave out about 20 % of the population who don’t fall in to one of the above categories . These include people who don’t meet criteria for Medicaid ( medical assistance) due to their income , self employed individuals and their families who are left on their own to provide their own insurance, people who don’t get employee sponsored insurance as the program is optional to the employers.
Pre ACA people with no insurance were forced to pay out of pocket or go to the emergency room to get routine/primary and non emergent health care. People with no insurance always had the option to go to emergency room for emergency and inpatient care and are always treated equally as per the ALMATA declaration ( hospitals can’t refuse emergency care including admissions regardless of patient’s ability to pay or not).
Thus ACA tried to address the coverage issue and aimed to make heath insurance reform in order to increase the coverage up to 95 to 100% of the population.
Core Aspects of the ACA: Primarily based on the Massachusetts health care reform ( Romney Care)
1. Medicaid ( medical assistance ) expansion by changing the income criteria so that many more million would be eligible.
2. Mandating employer sponsored insurance for employers with work force of 50 or more.
3. Allowing children to stay on their parents plan/insurance until age of 26.
4. Creating health exchanges as online one stop insurance comparison and shopping site/tool to encourage competition among insurance providers and help individuals get a better choice and deal. Think of it as priceline or expedia for travel and hotel bookings.
5. Provide subsidies for those who can’t afford insurance so that they will be able to buy one.
6. Individual mandate ( every one should buy insurance or pay penalty) to decrease risk pool by mandating young and healthy people to buy insurance in order to off set the cost for health care of older and sicker people.
7. Individuals will not be discriminated based on age, gender and pre-existing medical condition by insurance companies.
1. Supreme court decided that Medicaid expansion should be optional for individual states thus limiting implementation of the law.
2. Malfunction in initial roll out of federal sponsored health insurance exchanges.
1. The law mainly addressed health care financing /medical insurance reform.
2. Didn’t address major issues with regard to cost of care including cost and monopoly of medications and pharmaceuticals who charge many more times for similar drug/pharmaceutical/device/product in the US as compared to Europe and Canada due to lack of competition and monopoly and strict FDA policy ( only US manufactured drugs can be sold in the US)
3. Didn’t address the issue of defensive medicine which sky rocketed the cost of care and unnecessary care ( this could have been addressed by tort /malpractice reform and limiting law suits and liability compensation).
4. Law was passed only with support of democratic law makers which is making it difficult to implement specially with republican law makers who are trying to de fund it ( including recent government shut down) and republican governors who are refusing to cooperate in implementation of the law, for example most republican run states are not implementing the optional Medicaid expansion.
Dr Solomon A Feyissa is a practicing Internist / Hospitalist in the DC Metro/Baltimore area.