The Affordable Care Act is a watershed in U. Through a series of extensions of, and revisions to, the multiple laws that together comprise the federal legal framework for the U.
When fully implemented, the Act will cut the number of uninsured Americans by more than half. Approximately 24 million people are expected to remain without coverage. Consisting of 10 separate legislative Titles, the Act has several major aims.
The first—and central—aim is to achieve near-universal coverage and to do so through shared responsibility among government, individuals, and employers. A second aim is to improve the fairness, quality, and affordability of health insurance coverage. A third aim is to improve health-care value, quality, and efficiency while reducing wasteful spending and making the health-care system more accountable to a diverse patient population. A fourth aim is to strengthen primary health-care access while bringing about longer-term changes in the availability of primary and preventive health care.
A fifth and final aim is to make strategic investments in the public's health, through both an expansion of clinical preventive care and community investments. Through a series of provisions that create premium and cost-sharing subsidies, establish new rules for the health insurance industry, and create a new market for health insurance purchasing, the Affordable Care Act makes health insurance coverage a legal expectation on the part of U.
The quid pro quo for near-universal legally guaranteed coverage is the duty to secure it, as it is not possible to extend such a guarantee of insurance coverage without an attendant coverage obligation. This duty extends to all U. The law also provides exemptions for people for whom enrollment is contrary to religious belief or remains unaffordable or a hardship.
Without the mandate, the private health insurance industry would not—and indeed, could not—eliminate discriminatory pricing and coverage practices, as such tactics are the means by which insurers protect themselves against adverse selection.
Thus, without the mandate, universal coverage is virtually impossible, as is stabilization of the insurance foundation on which the entire health-care system rests. In short, the Affordable Care Act represents an effort to reframe the financial relationship between Americans and the health-care system to stem the health insurance crisis that has enveloped individuals, families, communities, the health-care system, and the national economy as a whole.
This is because the question of whether the law falls within Congress' constitutional powers 12 rests on whether the courts come to view the legislation as regulating our economic approach to the purchase of health care because we all use care, the issue becomes how to pay for it , or instead as the law's opponents argue as a law that forces individuals, as passive non-economic actors, to buy a product they do not want.
In addition to establishing universal coverage and shared responsibility, the Affordable Care Act sets federal standards for health insurers offering products in both the individual and small-group markets, as well as employer-sponsored health benefit plans. The Act's expanded insurance standards are designed to set a federal minimum; it is the expectation under the Affordable Care Act that state insurance departments will implement and enforce these laws as part of their legal insurance oversight powers.
As of August 5, , the National Association of Insurance Commissioners reported that half the states indicate that their insurance departments hold implementation powers, either through explicit legislation or as a result of their general powers, while nearly all states have the capacity to enforce federal standards. Constitution's 10th Amendment protection against the commandeering of state law enforcement resources.
The Affordable Care Act sets an array of federal standards for insurers that sell products in both the individual and group health insurance markets, as well as with certain limited exceptions not relevant to the topic of this article for self-insured group health benefit plans sponsored by employers subject to the Employee Retirement Income Act. Thus, the Act bans lifetime and most annual dollar coverage limitations, the use of preexisting condition exclusions, and excessive waiting periods i.
The law also guarantees the right to internal and external impartial appeal procedures when coverage is denied, and requires insurers to cover routine medical care as part of clinical trials involving cancer and life-threatening illnesses. Of particular note in a public health context is the extent to which the Act regulates the content and design of coverage itself. Preventive Services Task Force; immunizations recommended by the Advisory Committee on Immunization Practices; and other preventive services for children, adolescents, and women identified by the Health Resources and Services Administration.
This requirement begins with the first plan year that occurs after September 23, six months after the date of enactment. The Act also encourages employers to undertake workplace wellness activities that promote and incentivize actual health outcomes.
Wellness activities need not be limited to the act of participating in wellness programs but can include incentives aimed at actually achieving improved health results. Beyond subsidizing coverage and regulating the insurance and group health plan markets, the Affordable Care Act creates state health insurance Exchanges for both individuals and businesses. In addition, qualified health benefit plans will be required to make performance information conforming to national quality measurement benchmarks available to patients and consumers.
In advance of the effective date for the mandate, the subsidies, and the Exchanges, the Act permits states to expand Medicaid for low-income adults as a state option; states also, at their option, may extend coverage for family planning services to the low-income population.
Beyond insurance, the Affordable Care Act begins the job of realigning the health-care system for long-term changes in health-care quality, the organization and design of health-care practice, and health information transparency. It does so by introducing broad changes into Medicare and Medicaid that empower both the Secretary of the U.
HHS and the states are expected to test payment and delivery system reforms that also attract private payer involvement to maximize the potential for cross-payer reforms that can, in turn, exert additional pressure on health-care providers and institutions.
The Act also invests in the development of a multi-payer National Quality Strategy, whose purpose is to generate multi-payer quality and efficiency measures to promote value purchasing, greater safety, and far more extensive health information across public and private insurers.
In addition, the Act establishes the Institute for Comparative Clinical Effectiveness Research to promote the type of research essential to identifying the most appropriate and efficient means of delivering health care for diverse patient populations.
The changes include requiring hospitals to undertake ongoing community health needs assessments; furnish emergency care in a nondiscriminatory fashion a requirement already applicable under the Emergency Treatment and Active Labor Act; which is unaltered by the Affordable Care Act ; alter their billing and collection practices; and maintain widely publicized written financial assistance policies that provide information about eligibility, how the assistance is calculated, and how to apply for assistance.
Affordable Care Act Implementation Timetable 1. The only exception is if the parent s has an existing job-based plan and the young adult can get job-based coverage. Many plans have made a business decision to provide this coverage earlier, so if a parent has coverage with one of these plans, the young adult was insured before September Also, starting as early as September , new health plans must cover certain preventive services without cost sharing.
Exchanges are new transparent and competitive insurance marketplaces where individuals and small businesses will be able to buy affordable and qualified health benefit plans. Exchanges will offer a choice of health plans that meet certain benefits and cost standards. The Federal government provides a portion of the funding for Medicaid and sets guidelines for the program. States also have choices in how they design their program, so Medicaid will continue to vary state by state.
Each citizen is required to have basic health insurance coverage or pay a fee to help offset the costs of caring for uninsured Americans. Reciprocally, each health insurance plan will have to offer the minimum yet comprehensive health benefits package. To reduce the bur- intervals from the onset of symptoms and signs of cancer to its den on employers, they have until the end of to amend diagnosis11Y14 but also have been shown to have even longer their cafeteria plan documents to incorporate this change.
The dem- cancer problem have just been published. They are now eligible via insurance industry. This alone should allow earlier detection of Evolving Medical Discipline recurrence or progression of their malignancy and potentially Also, now that adolescent and young adult oncology is prolong survival.
At a minimum, it should improve the quality of becoming a recognized discipline,9 young adults will have more life of these persons not only in allaying the anxiety and fear of opportunity to take advantage of the increasing expertise, re- being uninsurable but also in directly providing supportive care. Because young cancer survivor par- ynx. Each of these measures has the potential to Participation in Clinical Trials reduce the cancer incidence in young adults, and several are in- Accrual to the national treatment trials has been strikingly variably likely to reduce the cancer burden in the age group, such age-dependent in the 0- to year-old groups, with the lowest as the Papanicolaou test and HPV vaccine.
The calorie and nu- rate in patients 0 to 44 years and a nadir in the 0- to year-old trition information is relevant because the risk of many cancers age group Fig. United States cancer patients entered on national of disease that requires less therapy will improve the quality of treatment trials by 5-year age intervals, Y Data from survival both during and after treatment.
Quantity of Survival After Treatment The survival gaps could be narrowed with better health deaths attributed to cancer in the United States Fig. Moreover, coverage includes clinical trials conducted outside the state in which the patient resides. The ACA requires self-insured plans to submit an annual report beginning one year after enactment and a study to compare characteristics of fully insured and self-insured group health plan markets within one year.
Given that lack of health insurance is a major reason that clinical trial participation is so low in young adults, the ACA should allow more entries onto trials in this age group. Also, the improved coverage should stimulate the development of more clinical trials for the age group because reimbursement of phy- sicians and other care providers will be improved.
Acquisition of Biologic Specimens and Translational Research The young adult age group also has the fewest specimens in malignant and corresponding normal tissues in biorepositories tumor banks across the country. Average annual percent reduction in deaths from specimens and the facilitated translational research may be cancer and other neoplasms in the United States, to , by available with ACA-mediated improvement in tissue acquisi- sex and age at death.
Data from the National Center for Health tion and clinical trials. There should be treated by experts with the most optimum methods of staging be little surprise in the number of companies that agreed to and treatment. This is particularly important for older adolescents raise the age limit before this provision of the ACA took effect.
Finally, the im- come reliance on parental and authoritarian resources. Also, rine cervix, ovary by excessive body weight and weight gain.
Third, disease prevention and early detection are not in- What Young Adults and Parents Need to Access herent interests of the young adult population.
Their perceived Insurance and Optimize Their Cancer Prevention, invincibility and lack of awareness of cancer and other chronic Early Diagnosis, Treatment, and Outcome diseases as a real risk and problem for their generation will Frequently Asked Questions not, automatically or naturally, endear them to the ACA. Another caveat regarding cancer prevention in young adults is the many years it takes for most interven- Watch for Open Enrollment tions to have an impact.
With the special open enrollment period. Watch for it or ask about it. To get the coverage, young adults loopholes in the legislation that will prevent full implementa- and their parents need not do anything but sign up and pay for tion of the intended effects. This has already become apparent this option.
The companies are restaurants will, by , be required to have caloric and other claiming administrative costs to be necessary expenses, includ- nutritional information, young adults will be able to help them- ing fraud prevention and detection, utilization management, pro- selves prevent and reduce obesity and otherwise reduce their risk vider credentialing and network development, and the startup of cancer occurrence and recurrence. Also, the cost of covering clinical trial costs adolescents and young adults with cancer described previously, for enrolled subjects and developing cures for cancer will chal- it is unlikely that they will be as successful as intended.
More than amendments and appeal. Given that young adults in their life a dozen states had already enacted similar legislation and sev- phase of seeking stability, the political pendulum will not en- eral had an age limit older than 26, as high as Because these franchise them to full ACA support and utilization.
The Affordable Care Act requires plans and issuers that offer dependent coverage to make the coverage available until the adult child reaches the age of Many parents and their children who worried about losing health insurance after they graduated from college no longer have to worry.
What plans are required to extend dependent coverage up to age 26? The Affordable Care Act requires plans and issuers that offer dependent coverage to make the coverage available until a child reaches the age of Both married and unmarried children qualify for this coverage. This rule applies to all plans in the individual market and to new employer plans.
It also applies to existing employer plans unless the adult child has another offer of employer-based coverage such as through his or her job.
Watch for open enrollment. Insurers and employers are required to provide notice for this special open enrollment period. Expect an offer of continued enrollment for plans that begin on or after September 23, Insurers and employers that sponsor health plans will inform young adults of continued eligibility for coverage until the age of Young adults and their parents need not do anything but sign up and pay for this option.
Check with your insurance company to see if they will provide that coverage to you now. If not, watch for the special open enrollment period and sign up then. The law says that the extension of dependent coverage for children is effective for plan years beginning on or after 6 months after the enactment of the lawVthat means plan years beginning on or after September 23, Learn More.
The law is persistently contentious as a matter of public opinion, but represents a historic achievement in United States healthcare reform. While it was incremental in many respects—health insurance plans for the vast majority of Americans were relatively unchanged—the ACA left an indelible mark on the healthcare system through its expansion of insurance coverage and efforts to improve the healthcare delivery system.
In the past decade, the country has witnessed a substantial decline in the number of uninsured individuals, while other elements of the law have sought to make inroads into affecting the cost and quality of care [ 1 ]. Yet looking forward, the ACA continues to face challenges that make its abiding impact and legacy uncertain.
The ACA expanded insurance coverage in two principal ways. First, it created health insurance marketplaces at the state level on the premise of competition and choice; individuals could compare similar coverage options and choose among competing plans.
The ACA reshaped private insurance in other important ways. It established new minimum federal consumer protections; of note, insurers were prohibited from discriminating on the basis of health status—they could not turn people away or charge higher premiums due to pre-existing medical conditions.
Annual and lifetime limits on covered health benefits were abolished. Expansions in health insurance were aided by complementary policies that encouraged people to enroll in coverage. Federal tax credits that reduced the financial burden of monthly premiums—and, in some cases, reduced cost-sharing—made plans on the marketplaces more appealing to low-income consumers.
When it launched in , this type of regulated individual market was new terrain for most insurers. They were responsible for projecting the likely healthcare costs of people who would elect to take up coverage, with limited experience to guide these estimates. The first two were temporary; they expired after three years but gave insurers an opportunity to find their footing and price their products accurately.
Risk adjustment is a permanent program, intended to mitigate against insurers selecting healthier enrollees and avoiding sicker populations. The law has endured numerous legislative challenges following its passage.
The House of Representatives advanced over 50 bills to repeal the ACA in whole or in part, with the Senate voting on a subset of them [ 4 ]. These started out as largely symbolic—a presidential veto was virtually guaranteed while President Obama was in office—but began to pose an existential threat to the ACA under a unified Republican government that held power during the first two years of the Trump administration.
The narrow to vote defeat of the last prominent repeal effort in the summer of illustrated the tenuous grounds upon which the law sat in the previous Congress. However, its survival was also a testament to its legislative durability; the political challenge of withdrawing health benefits shared across different constituencies has thus far been insurmountable, despite lukewarm public opinion on the law. Proponents of the ACA have identified some regulatory actions by the Trump administration as unilateral efforts to undermine the law.
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