Running head: PATIENT PROTECTION AND AFFORDABLE CARE ACT DEBATE

Patient Protection and Affordable Care Act Debate

Team 2
Amanda Bryant, Jessica Ehinger, Tomasine Marx and Tayler Thelen
Siena Heights University

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

Introduction
The Patient Protection and Affordable Care Act (PPACA) was enacted into law on March
23, 2010 (Martin, 2015). The PPACA represents the most significant regulatory overhaul of the
countrys healthcare system since the passage of Medicare and Medicaid in 1965 (Martin, 2015,
p. 1). Before the enactment of PPACA, the number of uninsured Americans was estimated to be
between thirty-eight to forty-eight million (Martin, 2015). Additionally, the rate of growth in
healthcare spending was reaching unsustainable levels. As a proportion of national wealth
(percentage of gross domestic product (GDP)), expenditures on healthcare have increased from 6
percent in 1960 to 16 percent in 2006 and are estimated to grow to 20 percent in 2020 (Jaffe, et
al., 2006, p. 982). Three primary objectives of the PPACA are to reduce cost of healthcare
services to individuals and the government, improve quality, and increase overall access to
healthcare (Martin, 2015).
The PPACA aims to reduce healthcare costs and slow the growth curve by shifting the
system towards quality over quantity through increased competition, regulation, and incentives
to streamline the delivery of healthcare (Martin, 2015, p. 408). According to Martin (2015), in
order to promote increased access to healthcare, the PPACA stipulates that all Americans must
enroll in a health plan if not under an employer-sponsored plan, Medicare, or Medicaid otherwise
they are subject to a tax penalty. Furthermore, the PPACA requires insurers to provide standard
healthcare coverage without denying coverage due to pre-existing conditions. Will the PPACA
achieve its objectives? This paper will discuss and support the position that the Patient
Protection and Affordable Care Act (PPACA) will not achieve its objectives in improving the
cost, quality, and access of health services to the population of the United States.

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

Cost of Healthcare
The PPACA shaped many elements of our U.S. healthcare system that needed fixing such
as extending the age that young adults can be covered under their parents' health plan and ending
pre-existing condition exclusion, however, healthcare spending continues to increase and the
trajectory is an unsustainable level. Healthcare spending is expected to reach 20 percent of GDP
in the United States by 2020 (Jaffe, et al., 2006). The PPACA increased access to care for all
Americans and therefore, more utilization of services (demand) is occurring and will continue
driving up healthcare spending. Glied & Ma (2015) state:
Our analysis indicates that the ACA is expected to result in roughly 20.3 million
additional primary care visits nationally, with people newly insured through the
marketplaces accounting for more than a third of these visits, or about 3.8 percent above
base. Emergency room visits by the newly insured are predicted to increase by 1.1
million, with those gaining Medicaid coverage accounting for more than two-thirds of
these visits. (p.2)
One of the tenants of PPACA was to make healthcare more affordable for all Americans.
The PPACA allows individuals to purchase health insurance via the health exchanges or
marketplaces. PPACA may be successful for some Americans who qualify for large subsidies,
though there are many who cannot afford insurance coverage. Many of the estimated 11 million
Americans who have purchased plans on the ACA's exchanges face punishingly high
copayments and deductibles, which average more than $5,300 in Bronze plans (Gaffney,
Woolhandler, Angell & Himmelstein, 2016, p. 2). Consumers facing high copayments or
deductibles are more apt to go without care, borrow money, or not pay their liability. These
reactions will drive up the cost of healthcare indirectly. For example, if an individual postpones

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

needed healthcare services that could be preventative, then the potential exists for higher and
more catastrophic illness later on at a much higher cost to the system. Another way that
healthcare costs will continue to increase is due to adverse selection in the exchange risk pools.
For instance, young and healthy individuals are purchasing the lower premium health plans and
taking a risk, assuming they will not need additional if any healthcare services. Doing so, results
in adverse selection in the exchange risk pools because there is not enough premium dollars
flowing into the pool to help offset the cost of sicker people in the pool (Herman, 2016). The
adverse selection in the risk pools force insurers to raise premium rates to cover losses or drop
from the exchanges altogether (Herman, 2016). The higher insurance premiums raise the cost of
healthcare for all Americans. Additionally, the sicker and newly insured patients are seeking and
in need of healthcare services, thus driving up the cost of healthcare services as well. The
concern lies with sick and elderly individuals who have chronic illnesses and have high out of
pocket expenses. Most elderly individuals rely on Social Security to cover healthcare expenses.
According to Quinn & Cahill (2016), the Social Security and pension components have
declined modestly since the early 1990s, and the importance of income from assets has fallen
precipitously, from more than a quarter of all income in the early 1980s to only 10 percent today
(p. 2). Social Security was thought to cover any and all expenses of concern by the elderly. It
was soon learned that Social Security does not satisfy elderly living expenses. While Social
Security does not satisfy elderly living expenses, pre-existing conditions hinders individuals
from receiving health insurance coverage. The individuals who need health insurance the most
are retiring Americans. Retiring Americans are at a higher risk of being financially unstable.
This is due to the Affordable Care Act (ACA) allowing individuals who are unemployed acquire
health insurance. There is a lack of social security benefits. The ACA has a long way to go. There

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

also needs to be another source of income for older Americans, perhaps something mandatory
that forces savings. Another thing Quinn & Cahill (2016) refer to is older Americans working
longer; most are already doing so and others simply cannot.
With the implementation PPACA, insurers can no longer deny coverage based upon a
pre-existing health condition such as cancer. Although the elimination of pre-existing condition
allows for more coverage however, it comes with additional healthcare costs. According to
Obamacare (2016):
Insurance companies must cover sick people, and this increases the cost of everyones
insurance. In order to ensure individuals dont just buy coverage when they need it, most
people must obtain coverage or pay a per-month fee. Also, coverage can only be obtained
during annual open enrollment periods. One can owe the fee due to forgetting to pay a
premium, and then not be able to get coverage until next open enrollment. Some people,
like men in good health with no pre-existing conditions, who were not responsible for
anyone but themselves, and who remained healthy, were benefiting from being in a low
risk group. They possessed cheap limited coverage before the premium hikes took place
in 2014. (para. 9)
Healthcare costs continue to increase due to wasteful spending. A National Academy of
Sciences report estimated that 30 percent to 40 percent of health care spending in this country is
waste (Lynch, 2015, para.2). However, pharmaceutical companies make their plea. According to
Zuckerman & Wood (2016),
Pharmaceutical spokespeople claim that regardless of the costs, screening tests
and medications save money by reducing the need for hospitalization and other

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

expensive care. However, research indicates that is often not true. In fact, some
types of screening do more harm than good, and many highly priced drugs are not
safer or more effective compared with other, less expensive treatments. Even
those that have modest benefits may not be worth risking serious side effects or
sending one's family into debt. (p. 3)
Despite costs of more than $100,000 per year many of these drugs are still on the market, even
with published evidence of the lack of benefit (Zuckerman & Wood, 2016). To realize the full
potential for system wide improvement however, the private sector will need the right incentives
to discover and deploy novel approaches to improving the health care system in addition to
adopting approaches that prove successful in public programs (Furman & Fielder, 2016, p. 3).
Healthcare will experience many downfalls in the coming years, similar to the slowing down of
rate of employers changing over to private exchanges.
The PPACA did not fully address and solve the problem of excessive and increasing
healthcare cost. Health care in this country costs far too much. It is straining public finances at
every level of government. There is no quick and sure fire way to solve the issues of increasing
healthcare costs at hand in our nations healthcare system. It will take revision and effort to truly
root out the issues and make it accommodating to all individuals of our public, from our children
to the aging adults of the United States. The increased demand for healthcare services for newly
insured people, cost shifts to the consumer for premiums, deductibles and co-payments, as well
as wasteful spending, continue to increase healthcare spending. Therefore, PPACA does not
improve the healthcare cost trend despite other provisions in the plan to bend the cost curve.

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

Quality in Healthcare
PPACA raises controversy in relation to its strategy of increasing the quality of healthcare
patients receive within the United States. Many believe quality will improve as further
initiatives of the law roll out however, others feel PPACA has little to no effect on the quality of
care administered by our healthcare system. Naysayers cite many issues with the current
structure of the law that hinder quality improvement such as: inaccurate and irrelevant quality
metrics to determine reimbursement, pressure for lowering costs diminish quality care outcomes,
tighter controls over utilization of services, and increased transparency that can lead to
misinterpretations that cause unnecessary, harmful perceptions and outcomes for patients.
A primary objection to measuring quality under PPACA is that quality metrics are not
uniformly defined nor are they relevant to determining payment. For example, quality payments
are linked to the patient experience as measured by a survey known as Hospital Consumer
Assessment of Healthcare Providers and Systems (HCAHPS) scores. Patients who need surgery
and other procedures desire to have quality outcomes after surgery or the procedure, but
according to Tsai, Orav & Jha (2015), there is little relationship between patient experience
scores and patient outcomes after surgery and other procedures. For example, a patient may have
surgery and recover fully in less time than originally expected and is generally accepted as a high
quality outcome. However, if the patient does not give the provider high scores from a patient
experience perspective then this quality metric could result in lower payment. In terms of quality,
the patient received superb care but the provider did not receive credit for the care given because
of the subjective patient experience issue they had during their time of care with the provider.
With little correlation between patient experience scores and quality patient outcomes after
surgery, it supports the point of view that the patient experience ratings are a flawed quality

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

measurement. Tsai, et al. (2015) states that critics [of PPACA] argue that patients respond to
concierge' services and not the quality of actual clinical care provided (para. 2). There is a
relationship between patient outcomes and the intraoperative skills of the surgeon/physician, yet
patient experience surveys do include this kind of measure. Patient outcomes such as morbidity
and mortality rates after major procedures have a direct correlation with the abilities of the
surgeon/physician (Tsai, et al., 2015). Yet, PPACA has metrics that providers have to abide by
that are related to their adherence to process measures such as the Surgical Care Improvement
Project (SCIP). The issue with this type of measurement is that there is little relationship between
quality patient outcomes and compliance with process measures (Tsai, et al., 2015). PPACA is
shifting payment methods from volume to value and attributing dollars to be earned by providers
under the Centers for Medicare and Medicaid (CMS) Value Based Purchasing (VBP) program.
HCAHPS scores are a component of VBP and appear to be irrelevant to outcomes as discussed
above and therefore, do not adequately define or measure quality.
Under PPACA, healthcare providers must be diligent in cost reduction efforts to sustain
profitability and improve quality in order to compete in the market. We are moving from
volume to value and from fee-for-service to population-based payment (Futurescan, 2015, p.
20). As we move from volume to value, the payment structure is not adequately reimbursing
providers therefore, forcing cost reduction while concurrently working to improve quality. In
order to reduce costs, healthcare administrators apply reduction strategies to line items on
income statements such as personnel, space, equipment, and supplies to generate immediate
results for decreases in expenditures (Kaplan & Hass, 2014). The pressure to reduce costs may
inadvertently decrease expenses that clinicians and other healthcare professionals need to
properly care for patients. Tightening the budget in areas that take away tools and resources that

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

clinicians need to do their jobs effectively hinders the quality of care provided in our healthcare
system (Kaplan & Hass, 2014). Even if the proper tools and resources are available for
clinicians, there may not be adequate quantity of that tool or resource to meet the demand.
Additionally, there may not be the resources available to purchase current technologies and/or
equipment and this may hinder an organizations ability to maintain quality care.
In healthcare, staying on top of technological advances and new trends is vital in order to
stay competitive in the market. Cutting backroom personnel is a common strategy for expense
reduction and has minimal impact on patient care. The work done by clinicians is directly
reimbursable, whereas administrative and support staff are not (Kaplan & Hass, 2014). When
support staff and other non-clinical employees are let go, other areas are impacted downstream
by having to pick up the workload or by going without the work being done. For example, if a
hospital clerk at the front desk is let go leaving only one clerk to manage the responsibilities of
two clerks, patients and their families will not have the same experience as before when there
were two clerks. The help, timely service, or friendly greeting by the second clerk may have
been a memorable part of the patient experience that ultimately lead to a patient satisfaction
score of a nine or ten. In this case, PPACA hinders the quality of the patients experience when
healthcare organizations are under continuous cost reduction pressure.
Another component of PPACA that is expected to benefit the healthcare consumer is data
transparency for prices, quality, and outcomes. Price transparency may help consumers get an
estimate for their out of pocket costs for specific procedures and/or medications. However, this
data may be misleading and could steer patients to low cost and low quality providers.
Transparency on quality and outcome data can also be misleading. For example, as a way to
increase patient volume doctors and other professionals may treat patients in unconventional

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

10

ways in order to maximize performance ratings that are published externally (Isaac, 2016).
According to Thompson Media Group (2015), "good ratings depend more on manipulable
patient perceptions than on good medicineIn fact, the pressure to get good ratings can lead to
bad medicine (para.5). Physicians may spend more time focusing on aspects of the patients
experience that do not directly pertain to clinical care, which hinders the actual quality of care
administered. This stems from the idea that patients take into consideration factors such as wait
times, parking convenience, and other amenities into their evaluations more than the clinical
care. Since patient experience scores are becoming an important part of healthcare
reimbursement, clinicians are changing how they approach their jobs, which in turn can affect
quality of care in a negative fashion. For example, a doctor may unnecessarily prescribe a CT
scan for a patient with a headache in hopes that the patient feels that the physician went beyond
to ensure the best care possible. However, the patient was exposed to harmful radiation
unnecessarily by having the CT scan. Alterations in care such as this can cause serious problems
and ultimately reduce care quality. Organizations such as Healthgrades and The Leapfrog Group
are designed to create transparency within healthcare. The issue with this is that providers are
beginning to alter their priorities internally in order to receive good scores, not necessarily
improve the quality of care. This calls into question whether or not the intentions of PPACA to
improve quality are working. A negative implication to quality data transparency is that
providers shift focus on the end score and manage to achieve the good score sometimes at the
expense of good medicine. Additionally, the scoring criteria can change year to year. There are
organizations that score well in one category one year, but then the criteria changes and the next
year they receive a terrible grade, even though the quality of care and outcomes remain the same.
One little change in criteria from a rating group such as Healthgrades, The LeapFrog Group, etc.

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

11

and an organization can receive negative public perceptions even though quality of care is
comparable to other healthcare organizations.
Lastly, PPACA indirectly impedes quality of patient outcomes. Due to the growth in
managed care health insurance plans via the insurance exchanges, more patients experience
restrictions and tighter controls over the utilization of services. Polivka (2005) discussed
numerous studies that measured patient outcomes between Health Maintenance Organization
(HMO) plans to traditional Fee-for-Service (FFS) plans for Medicare beneficiaries. These
studies appear to be transferable to all patient populations. A study by Shaughnessy, Schlenker,
& Hittle (1994) found that the Medicare HMO enrollees received fewer home visits and had
longer intervals between visits than fee-for-service Medicare patients had (as cited in Polivka,
2005, p. 88). Furthermore, the study concluded that patient status outcomes (e.g., bathing
ability) and service utilization outcomes differed. The fee-for-service patients had better
outcomes than the outcomes of HMO patients (Polivka, 2005). Another study by Goldzweig et
al. (1997) compared rates of cataract extraction in [managed care plans] versus those in fee-forservice [plans]. The study concluded that FFS beneficiaries were more likely to undergo cataract
extraction as compared to those beneficiaries in managed care plans (as cited in Polivka, 2005).
Other studies discussed by Polivka (2005) further supported that HMO enrollees were not as
likely to receive as many chronic and long-term-care services (such as home health care and
rehabilitative services) as those in the fee-for-service sector (Polivka, 2005, p. 88). In addition,
HMO enrollees had fewer physician office visits and reported somewhat lower satisfaction with
the quality of care received (Polivka, 2005). Landon et al. (2012) analyzed utilization of services
of enrollees in Medicare Advantage HMO plans compared to enrollees in traditional Medicare
during 2003-2009 and concluded that utilization rates were generally 20-30 percent lower in

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

12

Medicare Advantage HMOs in all years. Based upon the comparison studies of Medicare HMO
vs. Medicare FFS, it appears that HMOs restrict and potentially reduce quality outcomes for
patients. Therefore, the PPACA hinders quality outcomes for patients because it encourages
increased participation in Medicare Advantage plans via insurance exchanges. However, a
contrary view to the point above is that the lower utilization of services in HMO plans is
indicative of more appropriate use of services than enrollees in traditional Medicare (Landon,
et al., 2012, p.1).
The PPACA supports the use of health information technology (HIT), especially
Electronic Medical Records (EMR) and this ties in with quality improvements. EMRs are
supposed to help increase quality of care for patients, however one of the major issues with EMR
implementation is their high cost. In order for EMR capabilities to be utilized, the systems have
to be purchased by a provider. Many small physician offices have a very hard time affording the
EMR systems and/or do not see enough return on investment (ROI) opportunity by investing in
the technology. The HITECH Act provides both incentives and penalties for meaningful use
initiatives. Hirsch (2015) states that EMRs are impeding payment reform and interoperability,
being a waste of resources and money, and stifling innovation. Yes, it accelerated the adoption of
EMRs, but even the Robert Woods Johnson Foundation says it fell short of its goals" (para. 3).
EMR and other HIT systems do not come without problems. Interoperability between different
healthcare organizations EMR systems can actually harm a patients quality of care because
necessary patient information for clinical utilization may be delayed or lacking all together. In
addition, the push for EMRs in healthcare settings is taking away from the clinician patient
relationship (Branche, 2016). Clinicians are becoming more focused on data entry than they are
with the patients experience. If a clinician is more focused on data entry than they are listening

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

13

to the patient, the doctor may interpret information incorrectly which could lead to improper
care.
Another support for PPACA implementation is the idea that increased competition and
transparency of services in the insurance market and provider settings will subsequently increase
quality of care. Increasing competition by having transparency tools applied to the newly opened
health insurance exchanges allows people to view costs for health plans and their associated
coverage, however, this does not mean quality will necessarily increase. Other than the new
Value Based Purchasing Program (VBP) incentivizing providers through quality outcomes and
patient satisfaction scores (many providers see little reason to invest in the initiative because
incentives are not high enough and penalties are not stiff enough), there is no way of accurately
measuring if transparency in the health insurance market improves care. Quality measures are
being addressed by VBP, not necessarily transparency in health insurance exchanges. In addition,
price transparency for hospital charges is proving to be inaccurate, which defeats the purpose of
transparency entirely. Versel (2015) goes on to support the claim that provider price transparency
is not always accurate by stating some quote prices for procedures but have 'incomplete
definitions of what constitutes a medical episode leaving out for example, outpatient
rehabilitation from the true cost of hip replacement surgery (para. 3). Competition in the
provider market is being driven by transparency as well through rating organizations such as The
LeapFrog Group, Healthgrades, US News and Word Report, and Consumer Reports. PPACA
does not necessarily support any of these organizations, however their prevalence in the market
has increased since the passing of PPACA in 2010. The issue with transparency for provider
ratings (showcased via scores on clinical outcome success and patient satisfaction) is that
different interest groups may be able to manipulate a rating organization. Budryk (2015) points

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

14

out that, most hospitals ranked as top performers by one system weren't ranked as top
performers by any of the other three. In fact, the study found that in several cases, hospitals that
were named as high performers under one system were considered low performers under
another (para. 3). Transparency is a method for increasing competition, however if those
administering the transparency are not completely honest and unbiased, trust cannot be
established between consumers and HCOs. To that point, the most important point of healthcare
transparency is to create trust in the system. Ultimately, healthcare transparency supported by
PPACA and similar initiatives do not have the foundations in place to be able to show that
healthcare transparency directly improves quality of care.
Access to Healthcare
The PPACA requires all individuals to enroll in a health insurance plan unless he/she is
covered under an employer sponsored health plan, Medicare or Medicaid. The PPACA provides
federal subsidies for individuals to assist with the affordability of health insurance coverage and
it allows flexibility for States to increase Medicaid eligibility. These measures were enacted to
cover all Americans and thus, increasing our access to healthcare services. However, there are
flaws in the PPACA that hinder access, including demand increase, changes in payment
methodologies, and changes to Medicaid.
The first flaw hindering access includes, expanded medical coverage achieved under
ACA once fully implemented will likely increase demand by about 16,000 to 17,000 physicians
(2.0 percent) over the increased demand resulting from changing demographics (Association of
American Medical Colleges, 2015, p. 2). The increased demand will put a strain on the primary
care available leaving many patients unsatisfied. There are other factors including the
participation and competition of providers that could restrict availability, drive providers out and

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

15

thus, hinder the access most patients would have in their geographic area. It is expected that
challenges incurred by the ACA will not only pose fiscal obstacles, but also put increased strain
on those who do stay (Ostermeier & Camp, 2016, p. 2). Societally speaking, a lack of direct
patient-care providers will result in increased wait times not only in emergency rooms, but also
for time-sensitive surgeries and access to health care (Ostermeier & Camp, 2016, p.1)
The second flaw hindering access is included under PPACA where there are changes in
payment methodologies, costly deductibles, and migration to Medicare Advantage (MA) plans
from traditional Medicare that effect access to healthcare services. Senger (2015) shared:
The law (PPACA) will reduce payments in the Medicare Advantage (MA) program, the
private insurance option under the Medicare, by $156 billion from 2013 to 2022. These
cuts are already causing MA plans to adjust their packages by restricting provider
networks. The end result of course is that seniors have fewer provider options and in
some cases are forced to find new doctors. (p. 2)
Although these changes will ultimately affect all individuals, the information provided reflects
the changes most directly affecting the senior citizens of our nation. Due to the increase in
Americans insured and seeking healthcare services, healthcare spending is expected to increase.
Therefore, to partially offset the ACAs new spending, the law contains spending cuts to
Medicare that amount to $716 billion from 2013 to 2022. Medicare Trustees have warned since
the laws passage that if these cuts are implemented as the law requires, they will significantly
impact seniors access to and quality of care (Senger, 2015, p.1-2). Another impact to access
results when employers shift from paying full health insurance premiums for selected health
plans to contributing a defined amount per employee. Employer sponsored plans may decrease
and shift employees to the exchange for healthcare insurance (Buttorff, Andersen, Riggs, &

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

16

Alexander, 2015). Due to the shift, employees may be forced to change providers or be limited
to narrow networks reducing their access. Also, benefit coverage under the exchange plans may
not be same quality of coverage as found in employer-sponsored coverage (Buttorff, et al.,
2015). Singer (2014) expressed These are startling results for a government-run health care
advertised as a quality substitute for private insurance. In reality, Obamacare has created a twotier health care system and its forcing millions of patients out of the top tier and into the
bottom (p.4). The shifts in the coverage and availability of care is what scares individuals the
most, the uncertainty in the care they may have once had to the care now available.
The third flaw hindering access contains, PPACA reduced payments and/or changed
payment methods to healthcare providers resulting in financial strain for these providers, thus
indirectly impeding access. Per the Obamacare informational website some Medicare payments
to doctors and hospitals have been limited; Medicare pays doctors more than any other type of
coverage, and these rates have led to very complex problems that are driving the costs of health
care up for everyone (Obamacare, 2016, para. 13). One of the major critiques of [PPACA] is
that it requires more of health care providers but, ultimately, pays them less (Ostermeier &
Camp, 2016, p. 3). Healthcare reform and lower payments are key reasons why primary care
physicians leave practice (Ostermeier & Camp, 2016). These effects have forced patients to seek
healthcare in other areas, propelling the amount of patient care to diminish, forcefully limiting
the actions and care propositions of our healthcare professionals.
The last flaw hindering access includes the PPACA failing to secure the most
fundamental access point for healthcare services to individualsthe Medicaid program. The
State Medicaid program is the primary vehicle to provide affordable healthcare coverage to
Americans. The PPACA intended States to expand Medicaid eligibility, especially when the

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

17

expansion is federally funded for the first years, however, not all States did. Therefore,
affordable access to care is hindered for individuals living in these States. The Kaiser Family
Foundation stated, ever since the Supreme Court ruled in June 2012 that states could effectively
choose whether or not to accept the Affordable Care Acts expansion of Medicaid eligibility, that
choice has been one of the most prominent and often one of the most contentious issues for
states (Buettgens, Holahan, and Recht, 2015, para. 1). The impact to the residents of these
states is that most remain uninsured. States such as Florida have 1,253,000 uninsured and Texas
has 1,186,000 uninsured. The states Medicaid expansion subsidy allowed for numerous states to
adopt and benefit but what happens when the years run out, Angeles (2012) stated:
Specifically, the federal government will, for the first three years (2014-2016), assume
100 percent of the costs of covering those made newly eligible by the health reform law.
Federal support will then phase down slightly over the following several years (95
percent in 2017, 94 percent in 2018, and 93 percent in 2019). By 2020 and for all
subsequent years, the federal government will pay 90 percent of the costs of covering
these individuals. (para. 15)
There is back and forth about the logistics of the 10 percent states will be required to pay once
the federal government backs down. The children of our nation require significant health
insurance and government funding, under the PPACA. Childrens Health Insurance Program
(CHIP) states while the health law continues CHIP through 2019, states will begin running out
of money shortly after Sept. 30, 2015 (Carey, 2014, para. 4). With the shortage approaching and
possibly already in effect is certain we need to be aware of the conditions our childrens health
insurance is in. Additionally, the States that expanded Medicaid will also experience the
elimination of the federal subsidy and will the States taxpayers pick up the tab at that point?

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

18

Major points defending the anti PPACA motive states The future of CHIP reauthorization will
have important implications for childrens coverage. Funding for CHIP reauthorization will be
challenging and more research will need to highlight barriers to coverage as well as differences
in coverage between CHIP and the Marketplace to understand the consequences tied to CHIP
reauthorization (Rudowitz, Artiga, and Arguello, 2014, para. 5). To remain a success as the
PPACA intended, requires reauthorization and cooperation from the federal government.
Although the PPACA has witnessed some success for children in the United States over 7
million children remain uninsured. Rates of uninsured children are higher in the south and the
west, and nearly half of all uninsured children reside in six states (Arizona, California, Florida,
Georgia, New York and Texas). An estimated 5.2 million are eligible for Medicaid or CHIP
coverage but not enrolled (Rudowitz, Artiga, and Arguello, 2014, para.3).
While the PPACAs primary benefit is to improve access to healthcare for Americans,
there are flaws that hinder access and/or change the benefits that some Americans have been
accustomed to.
Conclusion
Through our research and discussion, it appears that the PPACA elements of cost, quality,
and access are intertwined. The success or failure of one element may hinder the success or
failure of another element. For example, increasing access to healthcare for all Americans
increases demand for services and this ultimately increases healthcare spending (cost). Cost
reductions in healthcare spending often result in less services provided (ex. managed care plans)
that could negatively affect the quality outcome for the patient as well as access to services.
Healthcare costs have shifted to the consumer and this negatively affects access as some
consumers delay treatment due to high deductibles. With high copayments and high deductibles

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

19

comes underinsurance. Such underinsurance often compromises access to care and financial
wellbeing (Gaffney, Woolhandler, Angell & Himmelstein, 2016, p. 3). Furthermore, quality
reporting has highlighted disparities in measurement and the data transparency is often
misleading.
The PPACA has not succeeded in reducing healthcare costs. Increase in access has
increased healthcare spending for newly insured individuals. While supporters of PPACA claim
that healthcare spending increases have slowed, others say that the slower growth is attributable
to the tail end of the recession. Once the economy begins to recover, the rapid escalation of
health care costs is expected to resume, and at a faster rate than would have been the case in the
absence of PPACA (Tanner, 2013, p. 4). The National Health Expenditure Project estimated
that health spending will increase by 7.4%, or 2.1% faster than if PPACA had not passed (Tanner,
2013). Additionally, healthcare premiums will increase and healthcare costs will increase for the
younger and healthier individuals. The National Health Expenditures Survey estimates that
premiums will increase by 7.9% and is a higher rate than they would have in the absence of
reform (Tanner, 2013). As for access, the PPACA appears to have mixed success. PPACA
increased access for Americans previously uninsured. However, PPACA negatively impacted
access for individuals previously insured as most were required to shift from employersponsored plans to public exchange plans or move to affordable plans with narrow networks
thus, restricting access and/or choice. Finally, PPACA does not improve quality due to
inaccurate and irrelevant quality metrics to determine reimbursement, increased pressure for cost
reduction diminishes quality care outcomes, and tighter controls over utilization of services also
impedes quality outcomes. In summary and conclusion, we believe that PPACA will not achieve

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

20

its objectives in improving the cost, quality, and access of health services to the population of the
United States.

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

21

References
Angeles, J. (2012). How health care reforms Medicaid expansion will impact state budgets.
Center on budget and policy priorities, Retrieved from
http://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-statebudgets
Association of American Medical Colleges (2015). The complexities of physicians supply and
demand projections from 2013 to 2025. The association of American medical colleges,
Retrieved from
https://www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC_-ScientificAffairs-_-PDF-_-ihsreport
Branche, C. (2016). EHRs are ruining the physician-patient relationship.
medicaleconomics.modernmedicine.com. Retrieved from: http://
medicaleconomics.modernmedicine.com/medical-economics/news/ehrs-are-ruiningphysician-patient-relationship
Budryk, Z. (2015). Best and worst hospital rankings often conflict, confuse consumers.
fiercehealthcare.com. Retrieved from: http://www.fiercehealthcare.com/healthcare/bestand-worst-hospital-rankings-often-conflict-confuse-consumers
Buettgens, M., Holahan, J., Recht, H. (2015). Medicaid expansion, health coverage, and
spending: An update for the 21 states that have not expanded eligibility. The henry j.
kaiser family foundation, Retrieved from
http://kff.org/medicaid/issue-brief/medicaid-expansion-health-coverage-and-spending-anupdate-for-the-21-states-that-have-not-expanded-eligibility/

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

Buttorff, C., Andersen, M. S., Riggs, K. R., & Alexander, G. C. (2015). Comparing employersponsored and federal exchange plans: Wide variations in cost sharing for prescription
drugs. Health Affairs, 34(3), 467-476. doi:http://dx.doi.org/10.1377/hlthaff.2014.0615
Carey, M. A. (2014). FAQ: Childrens health insurance programs future is unclear under the
health law. Kaiser health news, Retrieved from
http://khn.org/news/faq-on-chip-funding-and-future/
Futurescan, (2015). Innovations in Primary Care. Futurescan 2015.
Furman, J., & Fiedler, M. (2016). The cadillac tax -- A crucial tool for delivery-system
reform. The New England Journal of Medicine, 374(11), 1008-1009. Retrieved from
http://search.proquest.com/docview/1774194832?accountid=28644
Gaffney, A., Woolhandler, S., Angell, M., & Himmelstein, D. U. (2016). Moving forward from
the affordable care act to a single-payer system. American Journal of Public
Health, 106(6), 987-988. doi:http://dx.doi.org/10.2105/AJPH.2015.303157
Glied, S., Ma, S. (2015). How will the affordable care act affect the use of health care services.
The commonwealth fund, Retrieved from
http://www.commonwealthfund.org/~/media/files/publications/issuebrief/2015/feb/1804_glied_how_will_aca_affect_use_hlt_care_svcs_ib_v2.pdf
Herman, B. (2016, May). What, me buy insurance? Modern Healthcare, 20-22.
Hirsch, M. (2015). Two unresolved EHR issues that will haunt the healthcare industry in 2016.
fiercehealthcare.com. Retrieved from: http://www.fiercehealthcare.com/ehr/twounresolved-ehr-issues-will-haunt-healthcare-industry-2016
Isaac, M. (2016). The drawbacks of rate-your-doctor medical transparency:

22

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

23

Encouraging physicians to try to get glowing reviews may skew treatment in unhealthy
ways. wsj.com. Retrieved from: http://www.wsj.com/articles/the-drawbacks-ofrate-your-

doctor-medical-transparency-1460501734

Jaffe, R., Nash, R. A., Ash, R., Schwartz, N., Corish, R., Born, T., et al. (2006). Healthcare
transparency: opportunity or mirage. Journal of Managment Development , 25 (10), 981995.
Kaplan, R., & Haas, D. (2014). How not to cut health care costs. hbr.org. Retrieved from:
https://hbr.org/2014/11/how-not-to-cut-health-care-costs
Landon, B. E., Zaslavsky, A. M., Saunders, R. C., Pawlson, L. G., Newhouse, J. P., & Ayanian, J.
Z. (2012). Analysis of medicare advantage HMOs compared with traditional medicare
shows lower use of many services during 2003-09. Health Affairs, 31(12), 2609-17.
Retrieved from http://search.proquest.com/docview/1242469289?accountid=28644
Lynch, S. (2015) Alain enthoven: How to fix the affordable care act. Stanford business,
Retrieved from https://www.gsb.stanford.edu/insights/alain-enthoven-how-fixaffordable-care-act
Martin, E. J. (2015). Healthcare policy Legislation and administration: Patient Protection and
affordable care act of 2010. Journal of Health and Human Services Administration,
37(4), 407-411. Retrieved from http://search.proquest.com/docview/1667636235?
accountid=28644
Obamacare (2016). Obamacare: Pros and cons of obama care. Obamacare facts, Retrieved from
http://obamacarefacts.com/obamacare-pros-and-cons/
Ostermeier, K., & Camp, K. M. (2016). An exploratory investigation of negative perceptions of

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

24

the affordable care act among patient-facing professionals and intentions to

leave. Journal of Applied Management and Entrepreneurship,21(2), 95-112.
doi:http://dx.doi.org/10.9774/GLEAF.3709.2016.ap.00007
Polivka, L. (2005). The ethics of medicare privatization. Ethics, Law and Aging Review, 11, 85203. Retrieved from http://search.proquest.com/docview/205298184?accountid=28644
Quinn, J. F., & Cahill, K. E. (2016). The new world of retirement income security in
america. American Psychologist, 71(4), 321-333. doi:http://dx.doi.org/10.1037/a0040276
Rudowitz, R., Artiga, S., Arguello, R. (2014). Childrens health coverage: Medicaid, CHIP and
the ACA. The henry j. kaiser family foundation, Retrieved from
http://kff.org/health-reform/issue-brief/childrens-health-coverage-medicaid-chip-and-theaca/
Senger, A. (2015). Eight groups harmed by the ACAs flawed policies. The heritage foundation,
Retrieved from
http://www.heritage.org/research/reports/2015/02/eight-groups-harmed-by-the-acasflawed-policies
Singer, J. A. (2014). Obamacares Medicaid expansion limits medical choices. Cato institute,
Retrieved from
http://www.cato.org/publications/commentary/obamacares-medicaid-expansion-limitsmedical-choices
Tanner, M. (2013). The patient protection and affordable care act: A dissenting opinion. Journal
of Family and Economic Issues, 34(1), 3-15. doi:http://dx.doi.org/10.1007/s10834-0139350-7
Thompson Media Group (2015). Patient satisfaction surveys seriously flawed, report says.

PATIENT PROTECTION AND AFFORADABLE CARE ACT DEBATE

25

asq.org. Retrieved from: http://asq.org/qualitynews/qnt/execute/displaySetup?

newsID=20897
Tsai, T., Orav, J., & Jha, A. (2015). Patient satisfaction and quality of surgical care in US
hospitals. europepmc.org. Retrieved from: http://europepmc.org/articles/PMC4248016/
Versel, N. (2015). Many healthcare consumer pricing tools still flawed. clinical-innovation.com.
Retrieved from: http://www.clinical-innovation.com/topics/health-it/many-healthcareconsumer-pricing-tools-still-flawed
Zuckerman, D., & Wood, S. F. (2016). When will presidential candidates ask, "what do women
want in health care?"/Wood responds. American Journal of Public Health, 106(5), 790793. doi:http://dx.doi.org/10.2105/AJPH.2016.303174