Obama legislation that changed healthcare

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Another section requires that all health insurance policies must offer all clinically effective preventive services such as vaccines and cancer screenings that are recommended by the US Preventive Services Task Force, and with no cost sharing. On transforming medical care, the ACA has reset the US health system irreversibly on a course away from wasteful and inefficient fee-for-service payment toward value-based models that reward quality, effectiveness, patient centeredness, and population health management.

Yet another ACA landmark is the major expansion of federally qualified community health centers that now serve more than 24 million Americans at centers in communities, as well as the National Health Service Corps that provides medical student debt relief in exchange for service in underserved communities.

As of , Corps clinicians were providing primary care services, more that twice the number of doing so in The successful negotiation of the Paris Agreement on climate change, formally ratified in October , for the first time has set the global community on a low-carbon course.

The signing of the Family Smoking Prevention and Tobacco Control Act, giving the US Food and Drug Administration authority to regulate nicotine as a controlled substance, was only the most public evidence of progress.

Regarding nutrition and food policy, the Obama Administration has reformed essential federal nutrition programs that provide a critical safety net for millions of American children and families. Lead by the US Department of Agriculture, for the first time in decades, the most current dietary science is being applied to nutrition programs.

More than 50 million children now have healthier food environments at school. Because of new food standards, nearly four million schoolchildren have access to nutritious meals each day in summers, and eight million low-income women, infants, and young children receive improved WIC food packages. Unknown to the public has been massive upgrading and professionalization of emergency response systems in the United States and globally.

This new infrastructure helped to address health security threats from recent international crises such as the Haitian earthquake, the Japanese tsunami and nuclear power plan incident, and the Philippines typhoon.

Space constraints do not permit a thorough presentation of the public health achievements and progress by the Obama Administration. Every Presidency leaves a unique record and legacy of accomplishments and shortcomings, of wins and losses. Noteworthy during the Obama years has been the extraordinary number of initiatives, programs, experiments, and demonstrations that have moved the needle toward greater access, quality, equity, effectiveness, and efficiency in important matters relating to health care and public health.

Wherever Barack Obama lands in the historic hierarchy of significant and positive contributors to health, the extraordinary efforts made by him personally and by his talented, dedicated, and principled Administration have set a high bar and model for all who follow.

Am J Public Health. Published online January. John E. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Correspondence should be sent to John E. Accepted October 16, According to economist Peter A. Former OMB Director Peter Orszag stated: "Nearly thirty percent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas.

Gawande wrote that Obamacare contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates.

He described how the U. With a central oversight panel the U. He wrote:. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost.

Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care. Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation.

This would give clinicians an incentive to work together to smooth care and reduce complications. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds. The bill has ideas for changes in other parts of the system, too.

Some provisions attempt to improve efficiency through administrative reforms, by, for example, requiring insurance companies to create a single standardized form for insurance reimbursement, to alleviate the clerical burden on clinicians. There are tests of various kinds of community wellness programs. The legislation also continues a stimulus-package program that funds comparative-effectiveness research—testing existing treatments for a condition against one another—because fewer treatment failures should mean lower costs.

Increased use of preventive care e. Official budget scores of universal health care proposals state that most of its savings would be from providing preventative care to the uninsured. Preventing obesity and overweight conditions presents a significant opportunity to reduce costs. Nearly half of these costs were paid for by the government via Medicare or Medicaid.

State obesity rates ranged from Obesity rates were roughly equal among men and women. The study was performed by researchers at Cornell and Emory universities. However, in contrast to yearly costs, lifetime costs can be highest among healthy people, who live longer.

One study in the Netherlands indicated that: "Until the age of 56, yearly health costs were highest for obese people and lowest for healthy-living people. At older ages, the highest yearly costs were incurred by the smoking group. However, because of differences in life expectancy life expectancy at age 20 was 5 years less for the obese group, and 8 years less for the smoking group, compared to the healthy-living group , total lifetime health spending was greatest for the healthy-living people, lowest for the smokers, and intermediate for the obese people.

During April , nine physician groups identified 45 tests that were commonly used but that provided no proven benefits to patients or could actually be harmful. This was done at the urging of a Dr. Howard Brody, who published this recommendation in a article. The nine groups medical societies developed the lists after months of analyses and reviews of the medical literature by expert committees.

The New York Times editorial board wrote: "Eliminating needless care is not rationing. It is sound medicine and sound economics. One July proposal advocated that consumers of healthcare always have "skin in the game" such that their costs rise as more services are provided.

The CBO reported in May "Medicare spending is highly concentrated, with a small number of beneficiaries accounting for a large proportion of the Medicare program's annual expenditures. In , the costliest 5 percent of beneficiaries enrolled in Medicare's fee-for-service FFS sector accounted for 43 percent of total spending, while the costliest 25 percent These high-cost beneficiaries, compared with beneficiaries in the bottom 75 percent in terms of their spending, were slightly older, more likely to suffer from chronic conditions, such as coronary artery disease and diabetes, and more likely to die in a given year.

Peter Orszag wrote in May "The truth is that constraining future health care costs will require a variety of approaches, but in particular it will mean improving the information that providers have about their patients and best practices, and the incentives that providers are given to deliver better care, especially in expensive cases.

His January version of the plan includes the transition of Medicare to a voucher system, meaning individuals would receive a voucher which could be used to purchase health insurance in the private market. This would not affect those near retirement or currently enrolled in Medicare. Medicaid recipients could also be provided with tax credits or subsidies to purchase their own private insurance, reducing incentives for them to remain in the program.

Some conservatives advocate free market reforms such as breaking up state monopolies on insurance and licensing and allowing consumers to purchase health insurance licensed by other states. The GAO reported in using data the following statistics regarding insurance competition in state markets: "The median number of licensed carriers in the small group market per state was 28, with a range from 4 in Hawaii to 77 in Indiana.

The median market share of the largest carrier was about 33 percent, with a range from about 14 percent in Texas to about 89 percent in North Dakota. The five largest carriers, when combined, represented three-quarters or more of the market in 19 of the 34 states supplying information, and they represented more than 90 percent in 7 of these states.

Twenty-five of 37 states supplying information identified a Blue Cross and Blue Shield BCBS carrier as the largest carrier offering health insurance in the small group market, and in all but one of the remaining 12 states, a BCBS carrier was among the five largest.

The median market share of all the BCBS carriers in the 34 states supplying information was about 34 percent, with a range from about 3 percent in Vermont to about 89 percent in North Dakota; in 9 of these states BCBS carriers combined for half or more of the market.

The GAO reported in using data for the most part the following statistics: "The median number of licensed carriers in the small group market per state was The median market share of the largest carrier in the small group market was about 47 percent, with a range from about 21 percent in Arizona to about 96 percent in Alabama. In 31 of the 39 states supplying market share information, the top carrier had a market share of a third or more. The five largest carriers in the small group market, when combined, represented three quarters or more of the market in 34 of the 39 states supplying this information, and they represented 90 percent or more in 23 of these states.

Thirty-six of the 44 states supplying information on the top carrier identified a Blue Cross and Blue Shield BCBS carrier as the largest carrier, and in all but 1 of the remaining 8 states, a BCBS carrier was among the five largest carriers. The median market share of all the BCBS carriers in the 38 states supplying this information was about 51 percent, with a range of less than 5 percent in Vermont and Wisconsin and more than 90 percent in Alabama and North Dakota Economist Paul Krugman argued that allowing interstate competition would create a "race to the bottom," in which "[t]he states with the weakest regulations — for example, those that allow insurance companies to deny coverage to victims of domestic violence — would set the standards for the nation as a whole.

The result would be to afflict the afflicted, to make the lives of Americans with pre-existing conditions even harder. Critics have argued that the healthcare system has several incentives that drive costly behavior. Two of these include: [56]. Gawande quoted one surgeon who stated: "We took a wrong turn when doctors stopped being doctors and became businessmen. He contrasted this with lower-cost areas that used salaried doctors and other techniques to reward value, referring to this as a "battle for the soul of American medicine.

One option involves an integrated series of healthcare providers charging a premium or flat fee to patients to participate in the network, rather than a fee for each individual service. This modifies the doctor's incentive from ordering more services to solving the problem efficiently i.

The provider network would also purchase insurance for catastrophic extremely high cost cases. Critics have argued that medical malpractice costs insurance and lawsuits, for example are significant and should be addressed via tort reform. How much these costs are is a matter of debate. Some [ who?

A report by the Congressional Budget Office put medical malpractice costs at 2 percent of U. In August , physician and former Democratic National Committee Chairman Howard Dean explained why tort reform was omitted from the Congressional health care reform bills then under consideration: "When you go to pass a really enormous bill like that, the more stuff you put in it, the more enemies you make, right? And the reason tort reform is not on the bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on.

That is the plain and simple truth. Others have argued that even successful tort reform might not lead to lower aggregate liability. For example, the current contingent fee system skews litigation towards high-value cases while ignoring meritorious small cases; aligning litigation more closely with merit might thus increase the number of small awards, offsetting any reduction in large awards.

Bush Administration and members of Congress; CBO concluded that "the evidence available to date does not make a strong case that restricting malpractice liability would have a significant effect, either positive or negative, on economic efficiency. One option proposed includes specialized healthcare courts rather than the jury system. Such courts exist in other disciplines. In administrative health courts, an expert judge would decide cases based on best medical practice, writing an opinion that is subject to appeal to an appellate health court.

There would also be a requirement of full disclosure by hospitals, and all facts would be fed back into the health care system so providers learn from their mistakes. The U. Writing in Forbes, a physician argued that this is a "tiny band-aid at best," advocating full loan repayments and guaranteed positions upon graduation. This drives some doctors into higher paying specialties as opposed to primary care. As specialists, they prescribe more expensive treatments.

Making medical school free would help address the shortage in their view. Germany and France had approximately 3. The American Association of Colleges of Nurses cited studies estimating that a shortage of registered nurses would reach , by as America ages, with over , open positions during A study by Price Waterhouse advanced several strategies for addressing the nursing shortage, including developing more public-private partnerships, federal and state-level grants for nursing students and educators, creating healthy work environments, using technology as a training tool, and designing more flexible roles for advanced practice nurses given their increased use as primary care providers.

Newsweek wrote: "Lately, some policymakers have argued that instead of having a primary-care doctor, more people—especially young, healthy patients with simple medical needs—should see a nurse or physician assistant who administers routine care and kicks more complex problems up to a doctor when they arise. There's absolutely no reason to force all primary-care providers to have an M. The Congressional Budget Office has described how the tax treatment of insurance premiums may affect behavior: [81].

One factor perpetuating inefficiencies in health care is a lack of clarity regarding the cost of health insurance and who bears that cost, especially employment-based health insurance. Although both theory and evidence suggest that workers ultimately finance their employment-based insurance through lower take-home pay, the cost is not evident to many workers Employer-provided health insurance receives uncapped tax benefits.

According to the OECD, it "encourages the purchase of more generous insurance plans, notably plans with little cost sharing, thus exacerbating moral hazard". These two needs create cost-efficiency challenges for health care. Some have proposed an "excise tax" for high cost ' Cadillac ' insurance plans. The researchers found that only 3. Only 6. The employer's industry and regional variations in health care cost explain part of the variation, but most is unexplained.

The researchers conclude ". Premium tax subsidies to help individuals purchase their own health insurance have also been suggested as a way to increase coverage rates. Research confirms that consumers in the individual health insurance market are sensitive to price.

It appears that price sensitivity varies among population subgroups and is generally higher for younger individuals and lower income individuals.

However, research also suggests that subsidies alone are unlikely to solve the uninsured problem in the U. The Government Accountability Office lists Medicare as a "high-risk" government program due to its vulnerability to improper payments. This was 9. These costs appear on the Medicare statements provided to Medicare card holders. Attorney General Eric Holder said in an interview: "Clearly more auditing needs to be done and it needs to be done in real time.

Reforming or restructuring the private health insurance market is often suggested as a means for achieving health care reform in the U. Insurance market reform has the potential to increase the number of Americans with insurance, but is unlikely to significantly reduce the rate of growth in health care spending. Since most Americans with private coverage receive it through employer-sponsored plans, many have suggested employer "pay or play" requirements as a way to increase coverage levels i.

However, research suggests that current pay or play proposals are limited in their ability to increase coverage among the working poor. These proposals generally exclude small firms, do not distinguish between individuals who have access to other forms of coverage and those who do not, and increase the overall compensation costs to employers. In October the Wall Street Journal reported that while requirements to purchase health insurance were central to proposals in both the House and Senate, these coverage mandates were "under fire from both ends of the political spectrum, with some liberals saying the penalties are too harsh for those who refuse and conservatives denouncing the whole concept.

Arguing against requiring individuals to buy coverage, the Cato Institute has asserted that the Massachusetts law forcing everyone to buy insurance has increased costs: "Premiums are growing 21 to 46 percent faster than the national average, in part because Massachusetts' individual mandate has effectively outlawed affordable health plans. Massachusetts shows that such a mandate would oust millions from their low-cost health plans and force them to pay higher premiums.

Writing in the New York Times opinion blog "Room for Debate" the single-payer health care advocate Marcia Angell , former editor-in-chief of the New England Journal of Medicine , said that a coverage mandate would not be necessary within a single-payer system and that even within the context of current system she was "troubled by the notion of an individual mandate.

In April the Boston Globe reported that the number of people seeking emergency room care and the cost of emergency room visits increased after the mandates went into effect comparing to Addressing the issue when it was proposed in , CBO wrote: "A mandate requiring all individuals to purchase health insurance would be an unprecedented form of federal action. The government has never required people to buy any good or service as a condition of lawful residence in the United States. On June 28, , the U.

Supreme Court upheld the individual mandate provision as Constitutional. President Barack Obama argues that U. He argues that millions of Americans are denied coverage or face higher premiums as a result of pre-existing medical conditions. Peter Singer and David Leonhardt have each separately noted that health care rationing is not a choice, but an economic necessity.

All health care resources are finite and have to be allocated in some way or other. The issue is which way is the most sensible way to do it. Peterson has also argued that some form of rationing is inevitable and desirable considering the state of U.

He also recommended that a budget be established for government healthcare expenses, through establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. He has indicated that a combination of tax increases and spending cuts will be required. All of these issues would be addressed under the aegis of a fiscal reform commission. Rationing by price means accepting that there is no triage according to need. Thus in the private sector it is accepted that some people get expensive surgeries such as liver transplants or non life-threatening ones such as cosmetic surgery, when others fail to get cheaper and much more cost effective care such as prenatal care, which could save the lives of many fetuses and newborn children.

Some places, like Oregon for example, do explicitly ration Medicaid resources using medical priorities. Politicians on the right tend to be fearful of democratically elected governments becoming involved in rationing decision.

Former House Speaker Newt Gingrich R-GA argued that the reform plans supported by President Obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing. The Congressional Budget Office has concluded that increased use of health information technology has great potential to significantly reduce overall health care spending and realize large improvements in health care quality providing that the system is integrated.

The use of health IT in an unintegrated setting will not realize all the projected savings. One application of healthcare technology is the creation of registries or databases to relate treatments to outcomes.

Useful treatments could be identified and those less useful could be avoided to reduce costs. The payment system refers to the billing and payment for medical services, which is distinct from the delivery system through which the services are provided.

The over 1, U. For example, the Cleveland Clinic, considered a low-cost, best-practices hospital system, has 1, billing clerks to support 2, doctors. Proponents of health care reform argue that moving to a single-payer system would reallocate the money currently spent on the administrative overhead required to run the hundreds [] of insurance companies in the U. Advocates of "single-payer" argue that shifting the U.

Shifting to a single-payer system, by this view, would also eliminate oversight by managed care reviewers, restoring the traditional doctor-patient relationship. Initially, demanding patients insisted on scans; doctors feared malpractice suits if they refused; and doctors and hospitals wanted to maximize revenues. One study indicated that changing incentives may have reduced cost growth.

Increased out-of-pocket expenses have made patients and physicians more cost conscious. Further, a combination of prior notification, higher patient co-payments and restrained reimbursements may have contributed to slowing cost growth.

International comparisons of healthcare have found that the United States spends more per-capita than other similarly developed nations but falls below similar countries in various health metrics, suggesting inefficiency and waste. In addition, the United States has significant underinsurance and significant impending unfunded liabilities from its aging demographic and its social insurance programs Medicare and Medicaid Medicaid provides free long-term care to the elderly poor.

The fiscal and human impact of these issues have motivated reform proposals. According to World Bank statistics, the U. Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U. The underinsured were significantly more likely than those with adequate insurance to forgo health care, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs.

There are health losses from insufficient health insurance. A study found more than 44, excess deaths annually in the United States due to Americans lacking health insurance. Other studies, just as those examining the randomized distribution of Medicaid insurance to low-income people in Oregon in , found no change in death rate. The cost of insurance has been a primary motivation in the reform of the US healthcare system, and many different explanations have been proposed in the reasons for high insurance costs and how to remedy them.

One critique and motivation for healthcare reform has been the development of the medical—industrial complex. This relates to moral arguments for health care reform, framing healthcare as a social good, one that is fundamentally immoral to deny to people based on economic status.

Another concern is the rate of uninsured people in the US. In June , Gallup —Healthways Well—Being conducted a survey and found that the uninsured rate is going down. This is a decrease from the percentage at The survey also looked at the major demographic groups and found each is making progress towards getting health insurance. However, Hispanics, who have the highest uninsured rate of any racial or ethnic group, are lagging in their progress. Under the new health care reform, Latinos were expected to be major beneficiaries of the new health care law.

Gallup found that the biggest drop in the uninsured rate 2. He listed five causes for the waste: 1 overtreatment of patients, 2 the failure to coordinate care, 3 the administrative complexity of the health care system , 4 burdensome rules and 5 fraud. The International Federation of Health Plans provides a comparative annual survey of costs for drugs, devices and medical services across countries.

According to their report, the U. For example, the average cost of a hip replacement in the U. In other countries, governments intervene more forcefully in setting prices.

In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they're set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail. Congressional proponents argue that drugs manufactured overseas by U.

Drug manufacturers argue that certain foreign countries have price controls, which they recoup by charging higher prices in the U. Whitehouse spokesman Robert Gibbs said President Obama is supportive of importing drugs, provided safety concerns related to the drugs can be addressed. This is because drugs manufactured outside the country may be held to different standards.

From Wikipedia, the free encyclopedia. Proposed health care reforms. See also: Healthcare reform debate in the United States. Obama administration proposals Public opinion Reform advocacy groups Rationing Insurance coverage. Free market Health insurance exchange Nationalized insurance Publicly-funded Single-payer Canadian vs. American Two-tier Universal. Third-party payment models. All-payer rate setting Capitation Fee-for-service Global payment. This section may be too long to read and navigate comfortably.

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