Health-Care Utilization as a Proxy in Disability Determination (2018) / Chapter Skim
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3 Changing Patterns of Health Insurance and Health-Care Delivery
3 Changing Patterns of Health Insurance and Health-Care Delivery
Pages 39-56
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From page 39... ...
The ACA was the largest federal health policy initiative since the creation of Medicare and Medicaid. It brought about structural changes in the health-care system, which included efforts to improve access to health-care insurance (through expansion of the Medicaid program and through subsidized and lower-cost health insurance plans made available through new health insurance marketplaces, or exchanges)
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. In addition, the federal government provides funding to federally qualified health centers whose mission is to provide direct medical services to the uninsured.
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Although the employer share of health insurance premiums is considered an expense for employers like other forms of compensation, employer contributions are tax-free to employees, and employees can pay for their share of health insurance premiums on a pretax basis through payroll deductions. Before the ACA, dependent children could remain on their parents' insurance policies through the age of 18 years or until completion of a college education, but they could have a gap in insurance coverage if they did not start jobs before the coverage lapsed.
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and other plan types. Average general annual health plan deductibles for PPOs (preferred provider organization)
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The risk of adverse selection motivates many structural features of private health insurance that are designed to ensure that health plans have large risk pools with sufficient healthy, low-cost participants. In the individual market, insurance companies would protect themselves financially by using medical underwriting (charging higher premiums for those who have chronic conditions)
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. THE HEALTH-CARE DELIVERY SYSTEM BEFORE THE PATIENT PROTECTION AND AFFORDABLE CARE ACT The health-care delivery system in the United States consists of an array of clinicians, hospitals and other health-care facilities, insurance plans, and purchasers of health-care services, all operating in various configurations of groups, networks, and independent practices (IOM, 2003)
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. Although the fee-for-service model remains the most common payment form in the private health insurance market, private insurers have integrated aspects of the managed-care model into broader efforts to address the incentive problems created by the fee-for-service payment structure, such as utilization management and performance metrics for providers.
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SOURCE: KFF, 2017d. HOW THE PATIENT PROTECTION AND AFFORDABLE CARE ACT CHANGED THE HEALTH-CARE DELIVERY SYSTEM The ACA included payment-reform provisions to incentivize the adoption of more effective care-delivery models (Abrams et al., 2015)
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Those involve collaboration among physicians, hospitals, and other health-care entities in a shared-risk arrangement. The alternative delivery models were intended to encourage provider organizations to address patient health needs better, to reduce the amount of hospital and ED care, and to meet quality goals.
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was a US federal law, enacted as Title VIII of the Patient Protection and Affordable Care Act. The CLASS Act would have created a voluntary and public long-term care insurance option for employees, but in October 2011 the Obama administration announced it was unworkable and would be dropped.
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They echoed the findings in the 2017 report by suggesting that regular care for chronic conditions increased substantially after Medicaid expansion. The findings of those two studies were consistent with the findings of an earlier study by Sommers et al.
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Removal of a lifetime cap on benefits will enable people with disabilities to continue to receive care. Perhaps most important, the expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify for SSDI or SSI.
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notes that in some states and the District of Columbia, those gains resulted from the Medicaid expansion to adults who had incomes up to 138 percent of the federal poverty level. In other states and the District of Columbia, the coverage gains for people who had disabilities resulted from subsidies for qualified health plans offered on the health insurance marketplaces combined with private insurance reforms, such as the prohibition of discrimination based on health status.
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For the individual and small-group markets, the ACA established health insurance exchanges in states to allow individuals and small groups to buy standard insurance policies with income-based subsidies from 138 percent to 400 percent of the federal poverty level. The ACA eliminated medical underwriting and imposed a legal mandate to purchase health insurance, with a penalty for those who did not comply.
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A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use finds that health insurance coverage overall has expanded, access and use of care have increased, self-reported health status has improved, and the flow of federal health-care resources into expansion states has risen. It is less clear whether the ACA has altered utilization of EDs and hospitals.
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2015b. The coverage provisions in the Affordable Care Act: An update.
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2016. Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: A quasi-experimental study.
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Health Affairs (Millwood)
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