The Best WritersHealth Care Reform, Medicaid and MedicareWhy Needed, Barriers, and the Affordable Care Act of 2010Why Reform Needed?U.S. Spends 17.6% of Gross Domestic Product (GDP), more than any other developed nation, to get poorer outcomes (infant mortality, life expectancy) than countries that spend lessThousands have limited access to careThousands have no insurance to finance careBarriers to reformNo clear goals, philosophy, or consensus on what or howLess support in U.S. for single payer like other nationsNo constitutional mandateFederal/state constitutional roles limit actionsPolitics and interest groupsPath dependencyPrevious EffortsTruman in 50’s after WWIINixon liked HMO idea as profit makingLBJ did Medicaid and Medicare 1965Clinton, never got started stopped by pharmacies, insurers, and other interest groups (90’s)Previous Efforts (Con’d)Reagan fought against any government involvement in healthcare viewing it to be “socialized medicine”Some administrations viewed healthcare as a market commodity to be left to each individual and not needing government involvementWhy did President Obama succeed with ACA?Democrats had control of House of Representatives, Senate, and White HouseManaged the threat of interest groupsPragmatism of the PresidentProposed national ACA was like one that had bi-partisan support successfully implemented in Massachusetts in 1996 signed by Mitt Romney as Governor, who became 2012 Republican Presidential & against the ACAFeatures of ACA of 2010Have insurance or pay tax or fine. Federal government can tax, but not mandate insurance. Repealed in Republican tax law Jan 2019.State exchanges allow affordable insuranceEmployers mandated to offer insurancePrivate market insurance provisionsPre-existing conditions & Lifetime limits bannedDependent care to age 26 addedACAInsurers must spend 80%/90% income from premiums on care or must give rebate to insuredTaxes on tanning beds, some equipmentInsurance plans must cover minimum prevention measures and assessments at no cost to consumerHospital reimbursement rates reduced if patient return rates are highACAQuality and Prevention incentivesPractitioners reimbursed to give end of life consultations (not death panels as critics claimed)Sharing of best practices among practitioners (not rationing as critics claimed)See videos at Kaiser Family Foundation website ( overall and on health exchanges)Political, Legal, or Health Issue?Republican controlled House of Representatives voted to repeal ACA 60+ times, stopped by Senate DemocratsSome Republican controlled states still refuse to expand Medicaid in their states even when100% financed by federal government (TN is one).Many Republican controlled states still allow federal government to run health exchanges in their state, not running their own.Future of ACARepublican critics of ACA worried public would learn to like ACA if it actually experienced its benefits. Republicans under Trump controlling government were unable to repeal in 2017 seems to support that.ACA proponents seem determined to keep it intact, willing to improve, not delete itDeemed constitutional by Supreme Court, but challenges continue.Legal Challenges to ACAHobby Lobby, et alSued to get exemption from financially supporting contraception as a for-profit employerNot for profit 501 (C) (3) corporations already exempt from contraception provision before Hobby Lobby filedDoes federal government have a compelling interest to mandate corporation to provide insurance over corporate religious objections?Challenges to ACAHobby Lobby, et al determined by Supreme Court to be exempt as for profit employer from participating in providing or financing employees insurance that includes contraceptives.Legal Challenges to ACADoes the ACA only mentioning state run exchanges can subsidize insurance mean that federally run health insurance exchanges cannot offer subsidies?Court concluded an entire reading of the language and intent of the ACA is to promote insurance coverage, so subsidies were intended to be offered in both state and federal health insurance exchanges.Trump Administration Erosion of ACA90% reduction ACA enrollment notice moneyRemoved financial incentives to insurance companies to accept higher risk insured in exchangesRemoved subsistence to individuals not eligible for Medicaid, in exchanges earning $10-40 KLegal Challenges to ACAIn 2019 Republicans eliminated tax on those not having insurance, making the rather than a constitutional federal tax.In 2020 Republican states (led by Texas) sued arguing the total ACA is now unconstitutional if mandate without a tax is unconstitutional.Case is being argued at lower level courts, but likely to come before Supreme Court 2021ACA futureWas functioning prior to Trump Administration, despite political rhetoricCritics unable to repeal, so effort now is openly try to undermine ACADespite rhetoric to replace, no evidence from critics of a replacementJust using administrative rule changes and removing a tax, health system in U.S. goes back to pre-2010 pre ACA statusNext administration can promote ACA or not.Future of ACAUsing administrative rules to limit enrollment and eliminate subsidies to providers and enrollees, the Trump administration has openly engaged in trying to sabotage the ACA.Some states have supported that effort.Others seeing benefits of ACA have resisted efforts to undermine the law, continuing to use and support the law still in place.Updated 7/10/20