ACE

Author: Nina Robertson

  • Patient Protection and Affordable Care Act

    Patient Protection and Affordable Care Act

    This brief was originally published on October 5, 2021 by Nina Robertson. It was updated and republished on July 1, 2022 by Tra My Duong.

    The Patient Protection and Affordable Care Act, H.R. 3590, was passed on March 23rd, 2010 with three principal goals: lower the cost of healthcare, increase the quality of care, and increase access to care. The legislation aimed to make affordable health insurance available to more people living in the United States while also expanding Medicaid Programs to cover all adults with incomes below 139% of the Federal Poverty Level. In addition, it hoped to support innovative medical care delivery methods designed to lower the costs of healthcare more generally. Under the Obama Administration, the ACA was implemented to extend health insurance coverage to about 32 million uninsured Americans. A report released by the U.S. Department of Health and Human Services (HHS) indicated that between 2010 and 2016, the number of nonelderly uninsured adults decreased by 41% falling from 48.2 million to 28.2 million. 37 states and the District of Columbia have expanded Medicaid coverage under the ACA. 

    About the ACA

    The ACA had several main components:

    • A universal mandate required individuals to possess health insurance or pay a fine. In 2018, the mandate was repealed under the Trump Administration. However, some states have their own individual mandates with hopes of encouraging more coverage for the uninsured.
    • Dependents are covered until the age of 26 on their parents’ health insurance plans. Prior to the bill, insurance plans decided when young adults were removed after they turned 18.
    • The federal government encouraged the expansion of Medicaid to cover people with incomes below 133% of federal poverty guidelines. 
    • Minimum benefit standards for health plans were established and funding for states to expand Medicaid was provided, but expansion is left to the discretion of the states. 
    • Insurance is subsidized so the government pays individuals to buy private insurance while limiting premium costs to between 2% of income for those with incomes at 133% of federal poverty guidelines. 
    • New employer reporting mandates created the first model for paying health providers based on patient outcomes rather than volume of services. 
    • Insurers were barred from denying people coverage due to pre-existing conditions. 
    • Annual or lifetime limits of health insurance for individuals were eliminated. A health plan cannot limit the total amount it will spend to cover benefits during the time enrolled in the plan. 

    Strengths of the Legislation

    • Prevents insurers from making unreasonable rate increases on plans
    • People with pre-existing conditions cannot be denied coverage 
    • Preventative Services are covered such as: proactive healthcare, health screening, immunizations, and services for pregnant women or women who may become pregnant
    • Prescription Drugs are more affordable. In a Centers for Medicare and Medicaid Services press release from 2017, medicare beneficiaries have saved over $26.8 billion of prescription drugs under the ACA.

    Weaknesses of the Legislation

    • High costs if the system does not work well and insurance companies can now provide a wider range of benefits and coverage of pre-existing conditions which cause premiums to increase.
    • Weak enforcement mechanisms and weak competition between private and public health insurance. This leads to the reduction of the role of private non-profits.
    • There was a failure to establish a long-term care component to the ACA.
    • In order to pay for the ACA and new medical devices and pharmaceutical sales, there was an overall increase in taxes which was met with disagreement from conservatives. 

    Achievements and future development of the ACA:

    • A record of 14.5 Million Americans signed up for health insurance between November 1st 2021 and January 27th 2022.
    • According to ASPE, under the impact of the ACA, the size of the uninsured population decreased by about 20 million people from 2010 to 2020.
    • The ACA considerably increases rates of preventative services and provides free access to these services among more than 150 million Americans with private 
    • The ACA increased the access to healthcare, especially access to low-premium and zero-premium plans for lower-income adults. 
    • Along with the American Rescue Plan, ACA helped lower costs and expand healthcare access with an annual saving of about $2,400 on their annual premiums.
    • For future development, the Build Back Better Plan looks to strengthen the ACA and reduce premiums for 9 million Americans. The Build Back Better Plan seeks to expand affordable healthcare and patient protection.
  • Nursing and Residential Care in the United States One Pager

    Nursing and Residential Care in the United States One Pager

      

    Nursing and residential care consists of services that are utilized by people who require medical and/or custodial assistance and who will potentially move to a care facility that provides more support than caregivers can give. There are two types of care facilities: assisted living facilities and nursing homes. Assisted living facilities are for individuals who need some daily care, and can range in population from 25 to 120 residents. Individuals pay for higher levels of care depending on their needs and reside in single rooms or apartments, while sharing common rooms. In contrast, nursing homes are skilled nursing facilities that provide a greater range of health and personal care in comparison to assisted living facilities. They focus on medical care and rehabilitation services for individuals who can no longer care for themselves. Some residents live there permanently because they have ongoing physical or mental conditions that require more supervision.

    There are approximately 15,600 nursing homes in the United States. On average a patient receives around 4 hours of nursing care per day. The Centers for Medicare and Medicaid Services (CMS) created a quality rating for nursing homes to help families evaluate facility performance based on three areas:

    1. Health Inspections: based on the number, scope, and severity of deficiencies identified during the two most recent annual inspection surveys, as well as substantiated findings from complaint investigations
    2. Staffing: defined by the number of hours of care provided on average to each resident each day by nursing staff, subject to the needs to residents in the nursing homes
    3. Quality Measures (QMs): 15 different physical and clinical measures for nursing home residents to identify how well nursing homes are caring for their residents’ physical and clinical needs

    There are many ways to pay for nursing and residential home care depending on the services required. Care is divided into two sectors: custodial care and high-level inpatient medical care. Custodial care is for people who can no longer care for themselves entirely and need long-term residence and non-medical assistance with the activities of daily living such as bathing, eating, walking, and dressing. This care and the services required are often not covered by Medicare. High-Level inpatient medical care consists of skilled nursing or rehabilitation care and covered by Medicare Part A for a limited time. Skilled Nursing Facility Care is covered by Medicare but for only limited periods of inpatient care and can pay for short, costly rehabilitation. A benefit period begins on the day that an individual is admitted as an inpatient in a hospital or a skilled nursing facility and it ends when no care has been administered for sixty days in a row. Medicare Part A covers days 1-20 for $0 for each benefit period, day 21-100 covers $185.50 coinsurance per day of each benefit period, and for days 101 and beyond: all costs are covered by the individual. 

    There are four conditions for nursing home coverage to be covered by Medicare:

    1. Prior Hospital Stay – nursing home stay must begin within 30 days of an inpatient hospital stay of at least three days in length 
    2. Necessity for skilled nursing or rehabilitation – need for services every day
    3. Medicare-approved facility
    4. Improving condition – coverage only as long as the patient is improving, once stabilized, coverage is no longer available

    Medicare Part C/Medicare Advantage Plans include Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Medicaid has different eligibility requirements by states for various levels of income but residents are able to receive services from any level nursing home that is certified by Medicaid and accepts Medicaid payments. For eligible beneficiaries, Medicaid pays the full cost of room and board in a nursing facility plus any regular therapies and custodial care. There are no copayments and no time limit on Medicaid nursing home coverage. 

    Program of All-Inclusive Care for the Elderly (PACE) is a program for individuals eligible for Medicare and Medicaid benefits at the same time. This enables individuals to remain in their homes and communities, rather than receive care in a nursing or residential home. When individuals enroll in the program, it becomes the sole source of Medicaid and Medicare for PACE participants. Individuals can join PACE if they meet four criteria: 

    1. Age 55 or older
    2. Live in the service area of a PACE organization
    3. Eligible for nursing home care
    4. Be able to live safely in the community

    Health Savings Accounts (HSA) are options available for individuals who have or previously had high-deductible health plans. With an HSA, deductibles can be paid with pre-tax dollars. Individuals can add pre-tax dollars to the account and money in HSAs carries over each year to accumulate in total. However, once an individual is enrolled in Medicare, they can no longer add to a HSA. These accounts can be used to pay for qualified medical expenses such as long-term care services and premiums up to the maximum annual tax-free amount based on age.

    Through long-term care insurance, premium rates are much lower for people who are in good health when they purchase their policy. Some life insurance policies that cover long-term benefits are pricier than standard life insurance. 

  • Nina Robertson, University of Virginia

    Nina Robertson, University of Virginia

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    Nina is a current senior at the University of Virginia where she is pursuing a Global Public Health major and minor in Anthropology. Nina has been interested in Public Health since high school and immersed herself in many classes regarding comparative healthcare systems and the role public health policy plays in the wellbeing of individuals. She is excited to explore public health promotion with ACE through research and unravel how information regarding health and disease interventions directly impacts others. At UVA, she is a Program Director for Adopt-A-Grandparent and loves volunteering, spending time with others, and making new connections!