For decades, the USA has been working on a program to mitigate the lack of healthcare among the poor, including the availability of universal healthcare. In the interim, some stop-gap measures to expand availability of healthcare services such as the Patient Protection and Affordable Care Act PPACA have come into effect. PPACA mainly targets individual policies and the expansion of Medicare and Medicaid (US Congress, 2010). The PPACA reduces the cost of healthcare insurance for poorer Americans and expands coverage through government programs. However, the Act only provides a limited solution to a substantive problem thus standing in the way of a comprehensive solution. The PPACA had a positive impact on overall healthcare in the USA, but it also acts as a limitation to a substantive solution to the lack of universal primary health in America.
Reasons for PPACA
The primary reason for the PPACA was to mitigate healthcare-based inequalities in the USA. As with most capitalist nations, the USA has a substantive level of economic inequalities. The USA leads in almost all affluence lists such as numbers of billionaires, most powerful corporations in the world, and most powerful economy in the world. However, the nation also has some grim statistics including those relating to poverty. (French et al., 2016) For example, some of the inner-city communities have experienced a generational cycle of poverty. Many such families cannot afford basic amenities including primary healthcare services. The most common form of healthcare programs is the health insurance system. Most Americans can afford premium insurance covers that pay for most of their healthcare needs. Further, there are those Americans who can afford relatively cheaper insurance, which involves programs such as cost-sharing. Poorer Americans lack any medical insurance, which is perilous. Many employers offer healthcare programs for employees. The government also has programs such as Medicare and Medicaid. All the programs above left approximately fifty million Americans without any form of insurance cover (French et al., 2016). The purpose of PPACA was to expand the insurance coverage to some of the tens of millions who do not have any insurance cover.
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Summary PPACA Features
The PPACA expanded and improved health insurance coverage through a collection of key provisions. First, rules out the use of pre-existing conditions are a cause for declining insurance coverage or increasing the costs of insurance. Through this provision, individuals with pre-existing conditions who apply for health insurance from private companies should get covers at the same cost as normal applicants (US Congress, 2010). Secondly, the Act provides that, at a minimum, every medical cover must provide essential medical services. Under general definition, such services include ambulatory services, in-patient services, emergency services, childcare-based services, and mental-health related services. This provision rules out a scenario where the customer has to take out an extra cover for some services, such as mental health issues. The third important feature relates to proviso of reproductive health services, more so to women. The act also outlawed the practice where insurance companies reserved the right to drop customers if they get sick. PPACA puts an upper limit on maximum out of pocket (MOOP) amounts, which are the amounts a customer has to pay for medical services in spite of having a medical cover (US Congress, 2010). Further, under the provisions of the PPACA, co-payment programs such as MOOP cannot apply to preventative health services, such as vaccination. The act also provided that 80% of insurance revenue should go towards patient care. Finally, PPACA provided that Americans who can afford healthcare insurance should procure medical insurance or pay a penalty. The provision aimed to increase the number of Americans who buy insurance cover in order to benefit from the concept of economies of scale.
Whether the PPACA has Improved the U.S. Healthcare System
The PPACA did not result in an optimum healthcare system in the US, but it has provided substantive improvements. The US healthcare system is still struggling. Some members of the underclass still lack primary healthcare services. However, due to the PPACA, the situation is better both from a pecuniary perspective and from a healthcare perspective.
Overall Cost Perspective
Among the positive effects of PPACA was to improve the overall cost of healthcare in the nation. First, PPACA increased the number of customers for private insurance companies and under both Medicare and Medicaid. Under the concept of economies of scales, the increase in customers directly resulted in a reduction of overall costs (French et al., 2016). Secondly, the 80% rule ensured that insurance companies either spend more on healthcare services or reduce their premiums. The increase in expenditure on healthcare services ensured that patients get more value for the money they pay in premiums. For example, spending more on drugs means that drug marketers have an expanded market; hence, they can still make a profit at lower prices. Finally, and perhaps most importantly, the expansion of cover ensured that more Americans seek medical services soon after they get sick as opposed to seeking medical services as a last result. Timely intervention normally reduces the cost of treatment. Similarly, more patients were able to adhere to prescriptions and afford necessary medical procedures (French et al., 2016). This ability ensured that clinicians could treat conditions before they exacerbate, a fact that limits overall costs. The limitation of costs occasioned by timely treatment benefited patients through cost-sharing programs, insurance companies who paid less for treatment, and the government, which pays for emergency and critical care.
Defensive Medicine Perspective
One of the ramifications of the PPACA is its effect on the frequency and extent of the practice of defensive medicine. Defensive medicine involves clinicians undertaking diagnostic and other clinical procedures purely as a means to avoid lawsuits. Normally, the practice of defensive medicine not only augments the overall cost of healthcare but also jeopardizes positive patient outcomes (Durand et al., 2015). PPACA did not create the problem of defensive medicine in America. Further, the Act has not substantively increased the said problem. However, to some extent, PPACA has resulted in only a limited increase in defensive medicine. For a start, defensive medicine is expensive and mainly happens to patients with good covers. PPACA mainly covers poorer patients whose covers mostly include a cost-sharing clause (French et al., 2016). Such patients may not be keen on unnecessary tests and procedures. However, PPACA does increase the number of insured Americans by over ten million. The act thus increased the propensity for seeking medical services even when such services are not necessary. Such behavior may increase defensive medicine but only mildly.
Managed Care and its Various Models
Managed care is a process that combines the management of healthcare payments and the management of healthcare services paid for. Normally, managed healthcare happens when the entity that pays for healthcare, such as a medical cover provider, also seeks to control where the customers seek the medical services and the kind of clinical care provided (Tumialán, 2019). There are three main types of managed care models. The first is the Health Maintenance Organizations (HMO). Under HMO, the organization that provides funds for healthcare costs also provides healthcare services. For example, an HMO can be an insurance company that also runs a chain of hospitals and clinics (Tumialán, 2019). The organization will only pay for services provided in its branches. The second is the Preferred Provider Organizations (PPO). Under PPO, the organization providing medical cover has a partnership with several healthcare providers. The company will only for services sought from the partners. Finally, there is the Point of Service (POS) managed service system that provides both PPO and HMO alternatives for the customer to choose.
Role that Managed Care Plays in the U.S. Healthcare System
Managed care plays a variety of roles, most of which positively contribute to the US healthcare system. Most government-based medical covers adhere to a form of managed care, including Medicare, Medicaid, and the Veterans Health Administration. These organizations handle a large number of Americans under different programs (Tumialán, 2019). Managed care ensures ease of communication and coordination between the service provider and the payee thus increasing efficiency. The increased efficiency effect spread across managed care system even in the private sector. Secondly, managed care facilitates quality improvement as it enables the organizations paying for clinical services to have an element of oversight over the organizations providing. Finally, managed care facilitates specialization, more so for some niche of customers such as military veterans whose healthcare needs have congruencies (Tumialán, 2019). From a different perspective, managed care can facilitate corruption and embezzlement when the payees and service providers collude.
Conclusion
It is evident from the analysis and discussion above that the PPACA generally plays a positive role within the US healthcare system. Granted, the PPACA did not result in an optimum healthcare system, and there is still need for a better approach. However, some millions of Americans, the PPACA has made a monumental difference. Unfortunately, although the USA has one of the best healthcare systems in the world, the services come at a steep cost among other things, due to their high quality. The basic philosophy behind the US economy is extreme capitalism. The philosophy has driven the healthcare industry to develop high-quality products within the healthcare system, with the USA being the most powerful economy in the world; a majority of Americans can afford these products. However, the minority who cannot afford the services is in tens of millions. Some of the Americans in the lower echelons of the social strata cannot even afford primary healthcare services. The PPACA makes a difference to these Americans. Conversely, the concept of managed care adds augments the benefits provided by the PPACA, more so within government programs.
References
Durand, M. A., Moulton, B., Cockle, E., Mann, M., & Elwyn, G. (2015). Can shared decision-making reduce medical malpractice litigation? A systematic review. BMC health services research , 15 (1), 167.
French, M. T., Homer, J., Gumus, G., & Hickling, L. (2016). Key provisions of the Patient Protection and Affordable Care Act (ACA): a systematic review and presentation of early research findings. Health services research , 51 (5), 1735-1771.
Tumialán, L. M. (2019). Healthcare Systems in the United States. In Quality Spine Care (pp. 155-169). Springer, Cham.
US Congress. (2010). Patient Protection and Affordable Care Act; Health Care and Education Reconciliation Act of 2010: text of P.L. 111-148, as signed by the President on March 23, 2010; text of P.L. 111-152, as signed by the President on March 30, 2010: Jct technical explanation of P.L. 111-148 and P.L. 111-152 . Chicago, IL: CCH.
