5 controversies surrounding the Affordable Care Act

The continued implementation of the Affordable Care Act (ACA) in 2014 will be as controversial as in previous years.

Here are five main areas of concern:

1. The individual mandate.  By what right does the federal government “force” its citizens to buy a product they may not want? The Supreme Court upheld the mandate in 2012, but that does not end the matter. Partly — perhaps largely — because the ACA sets low penalties for noncompliance, some consumers will find that the cost of coverage exceeds that of paying the penalty. The adverse selection issue is a lively concern. If the older, sicker people who need coverage most enter the market but younger, healthier ones decline to do so, the insurance pool will be unbalanced and the costs of coverage will rise correspondingly. Which kinds of marketing appeals work best?

2. Medicaid. In 2012, the Supreme Court struck down the ACA’s requirement that the 50 states expand Medicaid coverage to include nearly all individuals with incomes at or below 138 percent of the federal poverty level. The financial terms the federal government offered were believed generous, but more than 20 states have refused.  Almost all the states in question argue against accepting the expansion on ideological grounds but have come under heavy pressure to reconsider. The expansion money is not only close to “free,” but can also stimulate positive economic activity. And, of course, rejecting the expansion leaves the traditional inequities intact. Optimists assume that in time most, if not all, the states will comply. Pessimists contend that declining popular support for the ACA will deter expansion in the resistant states.

3. Exchanges. The problematic rollout of the insurance exchanges may have seriously undermined the legitimacy of the reform. In part, the problem lies in federal underestimation of the scope, complexity, and unfamiliarity of the IT tasks. Beyond the technocratic dimensions, however, lie further problems. One is the reaction of several million insurance policy holders who found that their plans were cancelled and who protested that they had been repeatedly assured by President Obama that the ACA in no way prevented people who liked their health plans from keeping them. Lack of ease of entry into the exchanges aggravated the reaction. On top of these problems lies another: whether the income-related subsidies will prove to be large enough in some cases to permit the purchase of federally qualified plans.

4. Insurance regulations. In principle, the ACA proscribes most forms of preferred risk selection. How well these proscriptions work will depend on the capacity and commitment to enforcement of state insurance regulators. Meanwhile, the new rules entail cross-subsidies (“redistribution”) that is raising premiums for some of the already insured better risks. Although it is hard to disentangle the effects of the ACA from other premium-increasing forces in “normal” insurance markets, critics insist that the law now “owns” these increases. A related source of aggravation is the attempt by some insurers to manage costs by, in essence, using the ACA to achieve the selective contracting that proved to be unpopular in previous managed care efforts.

5. Cost. The ACA’s cost containment initiatives, crafted to be both substantively plausible and politically acceptable, arrive amid sharply declining growth in health spending. Consequently, enforcing the ACA’s cost-related provisions may not be easy. Medical device manufacturers seek repeal of a tax which, they contend, discourages innovation. Hospitals are upset about penalties for “excessive” readmissions. Conservatives continue to blast the Medicare payment review board as an exercise in rationing by unaccountable bureaucrats. The remit of the Patient-Centered Outcomes Research Institute is shot through with limitations on its work. The ability of accountable care organizations (ACOs) to deliver on their promise is in question. And whether Congresses between now and 2018 will hang tough on the ACA’s efforts to discourage “Cadillac” coverage is unclear.

Lawrence D. Brown is an adjunct professor of health evidence and policy, master’s program in health care delivery leadership, Icahn School of Medicine at Mount Sinai, New York City, NY.

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  • QQQ

    The mandate is to fund an increase in government spending, along with an increase in government powers over our Constitutional protections, period. Those protection which were obscenely violated by this Administration and John Roberts through his legislating from the bench by the way. When government controls your healthcare, they control you,
    and those like many, support them in this.

    As for the mandate bringing prices down…NO CHANCE. In order to pay for this monstrosity (according to the law itself) people must be forced to buy something they don’t want. Those who are forced to buy something will almost always choose the least expensive option. Most people who are made to buy something will find the cheapest “thing” that meets the
    requirement. In this case, if the “tax” is $695.00 and the product/service is $2,000.00, why would anyone ever pay $2000.00? They are essentially one and the same. If there is a “tax” option, and I say “option” because legally it’s not a criminal “penalty” according to the Supreme Court ruling, otherwise it would be unconstitutional and the law would have been thrown out (so says John Roberts) then all you have is option 1 and option 2. If I pay my tax then I am still covered by the law because I chose option 2 instead of option 1.

    Not to mention that states know this is unconstitutional in that the federal government is overreaching and usurping states rights by attempting to force them to create exchanges which it has no authority from the Constitution to do (i.e falls to the state’s authority), not to mention the federal government will be coming to the states to fund this nightmare and will penalize the states when it fails. If the states refuse to play along then the federal government would be required to create it’s own exchanges which will never be funded as there isn’t enough money in the world that foreign powers would be willing to bestow upon a government they know will never be able to pay it back.

    • NewMexicoRam

      Absolute government usurpation. Legislative, executive, judicial–all for something the majority of the people were not in support of.
      We need a new president, specifically someone who believes in better, less complicated free market alternatives.

      • Patient Kit

        If we elect President Clinton in 2016 and some of the ACA problems are fixed under her watch (what a fitting thing that would be!) — or we move closer to a single payer system — will it continue to be called Obamacare? Or will it morph into Hillarycare? :-D

        Personally, I have awesome memories of sitting in a small conference room with Hillary Clinton in the 1990′s discussing, among other things, healthcare reform. I would love to see her take the reins on healthcare reform in this country in 2016. I’m guessing you don’t agree with me, ;-) Hey!, you’re the one who started this by saying we need a new president.

        • DeceasedMD1

          What impressed you about her? it’s a discussion we need to hear differing opinions and clearly there was something you saw that you liked. you were the one that was there. How did you get the opportunity to see her in person?

          • Patient Kit

            Hi DeceasedMD. Sorry for the delay in responding to you. I’ve been off the grid in the sea (which is still free) this weekend and this mermaid leaves her technology behind when she’s in the water. :-D

            See my response to QQQ for how I came to have the opportunity to meet Hillary Clinton. In my years working in the nonprofit sector on social justice issues and advocating for those who were less fortunate than me, I had the dubious “opportunity” of meeting more than my fair share of politicians.

            I’m not going to put Hillary Clinton or any other politician on a pedestal. I have no rose-tinted glasses when it comes to politics. She’s not perfect and, like all politicians (and citizens), she has to work within our system. But I do like her. I liked her as my First Lady, as my Senator here in NY and as my Secretary of State.

            She’s very smart, very strong and very committed to the idea of universal healthcare in this country. I think she’s as knowledgeable about our healthcare system as anyone can be who doesn’t actually work in healthcare. Back in 1993, when I first heard her talk about healthcare reform, in a way, I think she was a little ahead of her time. The American people weren’t ready in 1993 to face the fact that our healthcare system was as dysfunctional as it was and getting worse. People wanted to hang on to the evil they knew in 1993. I also think she understands the value that a legitimate threat of going to a single payer system would have when dealing with the insurance companies.

            Whether the ACA is a work in progress or a bridge to something else, I really think Hillary Clinton can provide strong leadership as we transition our healthcare system. I believe she sincerely cares about universal healthcare in the US.

            Is she ambitious? Absolutely. But name one person who aims to be president of the US who isn’t ambitious! When it comes down to it, most doctors have ambitious personalities and care about their careers too. That’s not necessarily a bad thing, even in politicians. ;-)

            BTW, Hillary was actually much nicer in person than some might expect. Of course, she wanted something from us when she met witus’us. ;-)

          • DeceasedMD1

            Well that had to be an eye opening experience. No doubt she is a bright woman. I don’t have much faith in any of them at the moment since i think it takes reforming the system-including political which at the moment seems to be run by billionaires and powerful lobbyists. Well let’s just hope you get back to a job you love in the meantime.

          • Patient Kit

            Believe me, I hear you and understand what you’re saying. Nobody trusts politicians less than those of us who have tried to work with them. And yet…what does democracy mean without the involvement of us little people? Do we just give up and accept that 1% controls everything and we can’t do anything about it? We just have to do what they say?

            I guess I really do believe that “use it or lose it” applies to our voices and our votes and that we can make a difference. I don’t delude myself that I can eliminate poverty or make everything completely fair and just but I can vividly imagine how much worse things could get if nobody pushed back at all. Things could get much, much worse.

            And I remind myself that some very difficult change has been accomplished against formidable power — the civil rights movement, for example. What if everybody thought it was hopeless and nobody ever pushed back? pushed for change? pushed for what’s right? I guess I feel like a humane healthcare system for all Americans is worth fighting for. I can understand why people feel powerless and give up. But at the same time I can’t understand why more people don’t fight back harder. Maybe I’m just delusional enough to believe we can make our healthcare system better. Or maybe I’m just not ready to give up.

          • DeceasedMD1

            I am not sure what to think. There have been a few times where i have contacted my congress or state senator. Unfortunately, to my surprise they don’t even have time to give you lip service. Emails, letters more than not don’t get acknowledged. But agreed it is important to push back when possible.

        • QQQ

          Proof or it didn’t happen! 8*P

          • Patient Kit

            LOL, I have no way to prove it but I would have to be crazy to lie about meeting Hillary Clinton on this forum since it’s sure to make me a few new “enemies” here. ;-). Seriously though, until recently, I worked for 20 years for a NYC-based progressive liberal nonprofit organization where I focused on social justice issues. We were involved in both Bill Clinton’s presidential and Hillary Clinton’s senate campaigns. As a member of her volunteer campaign troops on the ground, she met with us to discuss issues, including healthcare reform, and to rally our support. More often, it was in a bigger venue but I was also lucky enough to meet with her in a small conference room set up. (I worked closely with the president of our organization.) I was just a lowly minion but it was an honor to meet with her.

  • QQQ

    “2. Medicaid. In 2012, the Supreme Court struck down the
    ACA’s requirement that the 50 states expand Medicaid coverage to include nearly all individuals with incomes at or below 138 percent of the federal poverty level. The financial terms the federal government offered were believed generous, but more than 20 states have refused. Almost all the states in question argue against accepting the expansion on ideological grounds but have come under heavy pressure to reconsider.The expansion money is not only close to “free,” but can also stimulate positive economic activity. And, of course, rejecting the expansion leaves the traditional inequities intact. Optimists assume that in time most, if not all, the states will comply. Pessimists contend that declining popular support for the ACA will deter expansion in the resistant states.”
    ————————————————————————————

    Many people have found that they can now get on Medicaid but are not aware of the “Medicaid Estate Asset Recovery Act” that came about in 1993. From the government web site: “State Medicaid programs must recover certain Medicaid benefits paid on behalf of a Medicaid enrollee. For individuals age 55 or older, states are required to seek recovery of payments from the individual’s estate for nursing facility services, home and community-based services, and related hospital and prescription drug services.” So your kids can kiss good-bye the inheritance they thought they would be getting.

  • Patient Kit

    One thing I do know for sure: I do not want to go back to the way things were pre-ACA. Our healthcare system pre-ACA was bad and only getting worse. I have plenty of issues with the ACA myself. But let it be a work in progress or a bridge to something new. But, please, let’s not start romanticizing the recent past in our healthcare system. The ACA only happened because there was so much wrong with the way things were.

    • Lisa

      Amen.

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