Instructions: Response must be at least 350 words written in current APA format with at least two academic references cite. References must be within the last five years. Respond by extending, refuting/correcting or adding additional nuance.

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ACA and Health-Care Outcomes & Costs

           All human beings deserve health care coverage, whether they can afford it or not. In today’s U.S. healthcare system, to have good health care, it is not just about having health insurance coverage. It must be affordable and accessible. The Affordable Care Act (ACA), passed in 2010, represents the most extensive reform to the U.S. health care system since the introduction of Medicare and Medicaid in 1965 (Duggan, Goda & Jackson, 2019). The positive effect on improving health care outcomes is ACA’s main components, which is improving access to care by enabling more Americans to gain health insurance coverage and containment of healthcare costs (Mason, Dickson, McLemore, and Perez, 2016). By offering the expansion of Medicaid, changes in private (commercial) insurance coverage, the establishment of health exchanges, employer requirements for providing healthcare coverage, and the introduction of the individual mandate (LaFontaine, Vogenberg & Pizzi, 2019).

           ACA includes dozens of provisions to expand health insurance coverage, slow the growth rate in health care costs, and reform the market for private health insurance. After implemented many of these provisions in January of 2014, un-insurance rates among nonelderly adults fell substantially, from 20.1 percent in the fourth quarter of 2013 to 15.1 percent by the fourth quarter of 2014 and 12.6 percent by the fourth quarter of 2015 (Duggan, Goda & Jackson, 2019). Also, ACA seeks to contain Medicare costs and pay for coverage expansion by phasing out extra payments to insurers who offered Medicare Advantage Plans, managed the care of private plans that the older population can choose instead of traditional Fee-for-Service (FFS) Medicare. Medicare pays a lower annual increase and pays less for medical equipment. Furthermore, by reducing outstanding payment, taxing employers who offer high-cost private insurance plans, encouraging the development of Accountable Care Organizations (ACOs) for Medicare recipients, especially those with costly chronic conditions. Penalizing hospital by reducing their reimbursement if they have excessive 30-day readmissions and hospital-acquired infections, implementing aggressive  Medicare/Medicaid fraud and abuse prevention measures, establishing an Independent Payment Advisory Board (IPAB), implementing administrative simplification measures, and conducting comparative effectiveness research (Mason, Dickson, McLemore, and Perez, 2016).

           To tackle insurance coverage issues, it is essential for healthcare professionals and pharmacy and therapeutics (P&T) or related committees in all practice settings to realize that today’s ACA differs from the original 2010 act. As plan requirements, government funding, and patient affordability change, so too must the plans offered by third-party healthcare payers or purchasers (employers, municipalities, and unions). ACA established new coverage guidelines on plan eligibility and scope that private insurers must follow. The most well-known policy deriving from the changes prevents insurers from denying coverage to individuals based on pre-existing medical conditions. Another part of the rule made it illegal for insurers to charge a greater fee based on a person’s health status or gender. Moreover, coverage expanded for young adults, who can claim dependent status on their parents’ health insurance up to the age of 26, with no restrictions regarding their living situation, financial independence, or health insurance options offered by their employer. Insurers are prohibited from imposing lifetime limits on coverage, and this coverage could not be rescinded. Furthermore, to encourage wellness checks, the act established mandatory minimum coverage standards known as “essential health benefits” and instituted zero dollar co-payments for many preventive health services (LaFontaine, Vogenberg & Pizzi, 2019).

           ACA set out guidelines for employers with more than 50 full-time employees and instituted financial penalties for those who were unwilling to comply. A highly controversial aspect of ACA was the individual mandate. In 2010, the act laid the groundwork for supplementing insurance-risk pools with healthier patients by instituting an individual mandate for health insurance. Beginning in 2014 and extending through 2016, patients without insurance coverage were required to pay an annual tax penalty. Now: On December 20, 2017, the Tax Cuts and Jobs Act passed by Congress finalized the individual mandate’s permanent repeal, with the penalty phasing out in 2019. As conversations about the repeal were heating up in 2017, the Congressional Budget Office (CBO) estimated what repealing the mandate would cost: the report concluded that the number of people with health insurance would decrease by four million in 2019 and increase to 13 million by 2027. To provide patient-centered care in today’s healthcare environment, understanding the system within which patients and providers function is more critical than ever (LaFontaine, Vogenberg & Pizzi, 2019).

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