Affordable Care Act
After reading several empirical studies and systematic reviews, here are some of the major concerns that people raised around the time the ACA passage (or in early implementation) and as tested by later research. One issue was that insurers wouldn’t be able to reject people with preexisting conditions. Another related concern is whether risk adjustment/ risk transfer would work well or be gamed, or whether some groups are under- compensated under the risk models so insurers might have incentives to avoid enrolling them. There was worry that insurers would avoid entering or would exit the marketplace if the risks were too high or returns too uncertain. If insurers exit, consumers will have few options and premiums might rise due to less competition. Also, it is concerned that off- market plans might have looser regulations, and that consumers might migrate to them, undermining the exchange risk pool. There were concerns that cost burdens for consumers, especially those with chronic illnesses or lower incomes even people with insurance, will have high deductibles, copays and cost- sharing might still make access difficult. People worried that coverage wouldn’t fully equate to access, especially for chronic conditions. The ACA would cause states to incur substantial costs, especially for Medicaid expansion, perhaps more than
they anticipated. Concerns about long – term fiscal sustainability for both states and federal government. Due to the differing political climates, implementation (especially Medicaid expansion) might vary a lot. Some states might refuse to expand Medicaid or add restrictions. The effects on disparities and whether ACA would reduce health outcome gaps. Some were concerned that even with expanded coverage disparities (racial, ethical, geographic, income) might persist. For example, that some improvements might accrue more to those better positioned to take advantage (knowledge, resources, access), leaving others behind. A number of these concerns were borne out in some form; others have been mitigated or disproven. Thus, this concern is real: having insurance does not always eliminate financial barriers or fully equalize access. Although many states did expand Medicaid coverage there are states that did not expand and still face coverage gaps. My thoughts on the ACA passage are that the ACA was ambitious, especially in trying to address both coverage (so many uninsured) and insurance market failures (adverse selection, lack of regulation of insurers). Many of the concerns were valid, and indeed some of the predicted problems- legal resistance, insurer withdrawals, cost burdens for some- did happen. Several of the concerns predicted or raised early were directly connected to outcomes where ACA provisions got scaled back, repealed, or modified, especially in relation to state control vs. federal mandates. Some fears turned out to be less severe than feared. For example, the adverse selection problem was mitigated more than many expected, perhaps because there were multiple mechanisms (like subsides, mandate (until its penalty was zeroed), risk adjustment, etc.) that worked (to different extents) to help pull healthy individuals into coverage, thus balancing risk pools. I believe the ACA was meant to help low-income individuals and families have access and more healthcare options within their community. The ACA was implemented for lower income families, elderly and those who are under the age 25 to have access to care, mental, and other resources as needed. The ACA was designed and implemented to assist struggling families overcome the burden of receiving proper healthcare. Before the ACA was created families struggled with finding affordable healthcare within their community and the surrounding area.
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What were the major concerns raised about the ACA during passage and early implementation?,
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How did issues with insurers and risk adjustment affect market stability?,
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What were the concerns about consumer costs and access to care?,
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How did state-level implementation especially Medicaid expansion influence outcomes?,
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Did the ACA reduce disparities in health coverage and outcomes?