The ACA Turns 10: A Diagnosis

The ACA Turns 10: A Diagnosis

As the nation battles COVID-19, the health policy world is quietly observing a milestone: the 10th anniversary of the Affordable Care Act (ACA).

As he was signing the bill into law on March 23, 2010, then-President Obama said, “The bill I’m signing will set in motion reforms that generations of Americans have fought for and marched for and hungered to see.” He listed some of the bill’s provisions, including a ban on insurer discrimination against enrollees with preexisting conditions, a mandate to cover children up to age 26 on their parents’ policies, and a requirement that all health insurance policies cover 10 categories of “essential health benefits.”

The law also strongly encouraged states to expand their Medicaid programs to include able-bodied adults making up to 138% of the federal poverty level — failure to do so would result in a state losing its federal Medicaid match — and created health insurance marketplaces in which individuals and small businesses could shop for health insurance plans. (The Medicaid expansion provision was later changed as a result of a Supreme Court case and is now completely optional for states.)

One Thing’s for Sure…

Analysts looking back at the law all agree on one thing: it did increase the insurance rolls — “primarily through Medicaid,” said Bob Moffit, PhD, senior fellow in health policy studies at the Heritage Foundation, a right-leaning think tank here. “Roughly 90% of new coverage came out of Medicaid. And there’s no question it increased access to healthcare, particular mental health benefits and services for low-income people,” as well as reducing uncompensated care costs.

Currently, the percentage of uninsured Americans stands at 9.1%, down from 16% when the law was signed into effect, Rosemarie Day, CEO of Day Health Strategies in Somerville, Massachusetts, and the author of Marching Toward Coverage: How Women Can Lead the Fight for Universal Health Care, noted in a blog post on Monday. However, although the ACA made these gains possible, there are still many uninsured and underinsured patients who likely would be afraid to seek care if they thought they had COVID-19, because they might not be able to pay for it, Day said in a phone interview.

“We don’t have a culture of universal healthcare; we have a culture of ‘Gotcha,'” she said. “You show up in the ER? Here’s a bill. People are afraid of that if they don’t have the resources … Also right now, immigrants are going to be very afraid because they’re told they’re going to be deported if they use anything that’s publicly funded,” such as Medicaid.

On the other hand, the ACA has done a lot to help people get care earlier for other types of illnesses, including preventive care, which is one of the ACA’s essential health benefit categories. “Many preventive services are free, so people are availing themselves and therefore getting tested earlier than they would, meaning that if perchance you have cancer, you’re getting screened earlier in the game,” Day said. “That whole flow prevents unnecessary deaths and it’s all about that access to healthcare.”

…But Problems Remain

But the law still has a lot of problems, said Joe Antos, PhD, scholar in healthcare and retirement policy at the American Enterprise Institute, a right-leaning think tank here. “The most obvious one is the Democrats’ overreach on Medicaid,” he said in a phone interview. “They wanted to make it look like states would have a choice about whether they expanded Medicaid or not. But the penalty … goes beyond a simple penalty. They didn’t have to do that.”

Instead, the Obama administration “could have found some way to phase in mandatory eligibility up to where they ended up,” said Antos. “In retrospect, that was a really terrible mistake. What we have now is 13 states — mostly Southern states — who did not expand their Medicaid eligibility under the ACA and they’re in even greater trouble now than they were before. So that’s a truly lost opportunity with regard to this virus pandemic, because that would have been resolved by now.”

Moffit sees a different flaw with the ACA. “The problem the ACA had is that the ACA did not control costs,” he said in a phone interview. “If you look back to 2010, and asked Americans what was the number one problem in the healthcare system, it was how to control healthcare costs. When President Obama was campaigning for the ACA, he made the argument that we’d see a $2,500 reduction in typical family health care costs” each year. But “that was total nonsense; it never happened,” Moffit said, adding that instead premiums jumped from an average of $244 per month in 2013 to $550 per month.

Differing Solutions

Moffit has his own solution to the ACA’s problems. “We ought to target the funds a lot better than in the past,” he said. “I like the idea of taking all the money we’re spending on the ACA — about $1.6 trillion — and turning it into block grants for states, on two conditions: that states offset the cost of health insurance for people who are low-income; and that states offset the cost of coverage for people with preexisting medical conditions.”

He praised the ACA’s provision banning discrimination against patients with preexisting conditions, adding that in order to improve the law, the federal government could “allow states to address this in different ways, whether through reinsurance pools, risk transfer pools, or direct subsidies … there are a lot of different ways of doing that.” Moffit’s home state of Maryland, where he is a former member of the state’s Health Care Commission, is using a 1332 waiver to establish a reinsurance program for higher-cost patients. The program “has been dramatically successful. There has been a 10% reduction in individual market premiums, so it’s working out quite well,” he said.

Day prefers a different approach: universal coverage using a hybrid public/private system. One way to improve coverage would be to increase enrollment among people who are eligible for government health insurance — such as for the Children’s Health Insurance Program — but haven’t yet been enrolled. “We ought to have some form of auto-enrollment for kids,” she said. The federal government also should put more “guardrails” on the plans in the ACA’s health insurance exchanges, “regulating the plans to include essential health benefits and do the things the private market wouldn’t do on its own. That’s how other countries do it,” such as Germany, she said.

By Joyce Frieden, News Editor, MedPage Today

Stanford Study Finds no Link Between Immigrant Health Coverage and In-Migration Rates

Stanford Study Finds no Link Between Immigrant Health Coverage and In-Migration Rates

Extending insurance coverage to immigrant children and pregnant women did not appear to influence whether they crossed state borders (known as in-migration) to acquire care, according to survey data.

Among 36,438 lawful permanent residents with children, the average in-migration rate 1 year before public health insurance was expanded to cover immigrants was 3.9% and 1 year after the implementation, the rate remained essentially unchanged at 3.7%, reported Vasil Yasenov, PhD, MA, of the Immigration Policy Lab at Stanford University in California, and colleagues.

Similarly, among 87,418 women of reproductive age, the in-migration rate 1 year before expansion was 2.7% and 1 year after it was 4.6%, the team wrote in JAMA Pediatrics.

“No Discernable Association” Between In-Migration and Insurance Expansion

“If an expansion of health insurance coverage was associated with in-migration to another state, the probability of in-migration would have increased in the treatment group compared with the control group,” the researchers wrote. “There was no discernable association between the in-migration from any state among the treatment group relative to the control group and public health insurance expansion.”

The authors compared the group of immigrants with children with a control group of lawful permanent residents without children. The proportion that migrated among immigrants without children was slightly higher before and after expansion (4.0% and 5.9%, respectively), but not significantly different from immigrants with children, Yasenov and his team reported.

Meanwhile, among a control group of post-reproductive women, the rate of in-migration was 3.5% and 3.9% in the years before and after expansion, respectively, which was also not significantly different than the group of women of reproductive age, the researchers added.

“We hope policy makers concerned with spiraling costs and people flooding in from other states will have the evidence they need to make a decision when thinking about extending public healthcare benefits for legal immigrants in the U.S.,” Yasenov told MedPage Today.

Findings Indicate Immigrants are Fleeing Violence and Corruption, Not Chasing Health Coverage

As of 2016, immigrants with children were covered by public insurance in 31 states and pregnant immigrants were covered in 32 states. Many Democratic candidates for the 2020 election support extending healthcare to undocumented immigrants, a policy that has been suggested will increase the flow of immigration within the U.S.

These null findings make sense in the context in which most U.S. immigration takes place, wrote Jonathan Miller, JD, of the Office of the Massachusetts Attorney General in Boston, and Elora Mukherjee, JD, of the Immigrants’ Rights Clinic of Columbia Law School in New York City, in an accompanying editorial.

Namely, many people coming to the U.S. are fleeing from violence or political corruption in their home countries, and “do not seek refuge in the [U.S.] because of potential access to healthcare,” Miller and Mukherjee said.

“Making it easier for immigrant communities to connect to and seek care from physicians will not radically shift migration patterns. Instead, allowing access to the basic human right of health care shows a common commitment to human decency for all who are in the [U.S.],” the editorialists stated.

Immigrants Sampled Were Below 200% of Fed Poverty Thresholds

For this study, data were collected from individuals residing in the U.S. from 1 to 6 years — but who were not born in the U.S. and were not citizens — from the American Community Survey. Notably, the sample was restricted to individuals who were below 200% of the federal poverty thresholds to identify people who would qualify for public insurance if it were extended, the authors noted. Immigrants on student visas, veterans, or those married to U.S.-born citizens were excluded because they qualify for other healthcare benefits, the team added.

The data were controlled for personal characteristics like age, race/ethnicity, and marital status, as well as things that varied by state and time such as cash assistance and economic conditions.

In total, 208,060 immigrants — mean age of 33 years, 47% of whom were female — were included. About two-thirds were Hispanic (63%), and the in-migration rate among the entire sample was 3%.

“Near-Zero” Likelihood

Overall, the likelihood that lawful permanent residents would migrate to a state where public health insurance has been expanded to cover immigrants was practically zero before and after expansion was implemented (percentage change from -1.21 to 1.78), the authors reported.

The likelihood was also close to zero among lawful permanent-resident women of reproductive age when compared with a control group of lawful permanent-resident post-reproductive women (percentage change from -1.20 to 1.38).

In a model specifically looking at whether public health insurance expansion would bring in migrants from a neighboring state, no association was found between policy implementation and the rates of in-migration of immigrants with children (–0.03 percentage points, 95% CI –0.5 to 0.44) or pregnant women (–0.02 percentage points, 95% CI –0.48 to 0.09), the researchers reported.

The primary limitation of the study, they said, was the inability to account for time-varying factors that could undermine the analysis, and it was also not possible to isolate states among the border and determine whether there was an association between in-migration and health policy specifically in these states. Lastly, the investigators said, the association was not analyzed among county-level or city-level programs.

The study was funded by the Stanford Child Health Research Institute.

The authors and editorialists reported having no conflicts of interest.

Primary Source

JAMA Pediatrics

Source Reference: Yasenov V, et al “Public health insurance expansion for immigrant children and interstate migration of low-income immigrants” JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.4241.

  • Secondary Source

JAMA Pediatrics

Source Reference: Miller J, Mukherjee E “Health care for all must include everyone” JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.4247.

by Elizabeth Hlavinka, Staff Writer, MedPage Today

This story was originally published by MedPage Today.

University of Virginia School of Nursing Offers Course on US Health Care and ACA Repeal Efforts

University of Virginia School of Nursing Offers Course on US Health Care and ACA Repeal Efforts

The University of Virginia (UVA) School of Nursing is offering a course on US healthcare, an appropriate and important topic at a time when many legislators are trying to repeal the Obama-era Affordable Care Act (ACA). The graduate course is titled, “Intro to the US Health Care System.”

The course will be taught by UVA nursing professor Rick Mayes, a Talbott Visiting Professor at the School of Nursing this fall and a former White House health policy adviser. UVA first developed a course on US healthcare in fall 2014 as a primer for nursing and medical students, but the course has evolved to acknowledge today’s rapidly changing healthcare landscape, making a fixed syllabus impossible so that the course can follow and discuss up-to-date news.

Mayes’ personal reservoir of knowledge will be combined with content from news sites and professional journals, providing diverse content to drive discussion. Due to high interest, Mayes was forced to cap the class at 60 students. The course is open to all graduate-level students and will include students from a wide array of programs including nursing, medical, business, education, public policy, and more. Mayes tells

“It’s such a prominent topic, maybe the most-discussed topic of our time. There are so many students who are touched by health care, who see its effects, and because of that, the class has gotten more popular – and more personal.”

Students in the class will be examining European and American health care systems with a focus on growing their understanding of how primary care prevents catastrophic health events and high medical costs down the line. The class will also hear from health care stakeholders including device manufacturers, occupational and physical therapists, and mental health professionals. Mayes cites the growing interest in his course as part of larger trend of student interest in health policy work as a career and non-clinical way to be part of health care change and progress.

To learn more about UVA’s new course on US Health Care and ACA Repeal, visit here.

Nursing Community Condemns Graham-Cassidy Healthcare Bill

Nursing Community Condemns Graham-Cassidy Healthcare Bill

In the latest effort to repeal and replace the Affordable Care Act, Republican lawmakers have introduced the Graham-Cassidy Healthcare Bill which many anticipate will deny healthcare to millions of low and middle-income Americans. The bill has received widespread criticism from the healthcare community including nursing organizations, insurance groups, state hospital associations, and more.

The Capitol Beat, published by the American Nurses Association (ANA), states that the legislation sponsored by Sens. Bill Cassidy and Lindsey Graham would make drastic and dangerous cuts to the American healthcare system by repealing Medicaid expansion starting in 2020, eliminating the critical Prevention and Public Health Fund, and creating high-risk pools for individuals with pre-existing conditions, among other misguided policies.

The legislation would also eliminate the definition of essential health benefits, allowing individual states and insurance companies to opt out of covering maternity care, mental health, substance abuse treatment, and hospitalization, while also allowing insurers to deny coverage to people with pre-existing conditions, according to

Proposed just 10 days before the September 30 deadline for Republicans to pass ACA repeal, nurses believe the Graham-Cassidy Amendment is worse than previous versions of ACA repeal. National Nurses United (NNU) Co-President Deborah Burger tells, “Graham-Cassidy is especially punitive to the sick and ill, and others with pre-existing health conditions who stand to lose any of the protections established by the ACA under the state waiver provisions to the proposal.”

To learn more about the Graham-Cassidy Bill and nurse opposition to the pending ACA repeal, visit here.