a Comparison of Global Healthcare Expectations

UC Davis Roosevelt Institute Healthcare Center

U.S. versus the World Health Organization:

Akshaya Ramanujam, Jenna Christophersen, Leanna Friedrich, Levon Baburyan, and Nicole Sears

Editors

acknowledgements

Special Thanks to Dr. Krishnan Nambiar & The Davis Honors Challenge

Coauthors: Gabrielle Almanza, Katherine Anderson, Levon Baburyan, Catherine Broderick, Jenna Christophersen, Trevor Fleshman, Leanna Friedrich, Emily Guidos, Kevin Labarbera, Meighan Middleton, Akshaya Ramanujam, Aaron Riggs, Zeeve Rose, Nicole Sears, and Tyler Wilson.

Table of Contents

Section I: The Patient Protection and Affordable Care Act..............................2

1. Key Terms...........................................................................................................................................................................................................................................2 2. History of U. S. Healthcare Reform: From Theodore Roosevelt to Barack Obama..............................................................................................2 3. Framing the U. S. Healthcare Overhaul in a Global Context........................................................................................................................................3

Section II: The Patient Protection and Affordable Care Act.............................4

4. The Patient Protection and Affordable Care Act: An Overview.................................................................................................................................4 5. The Act and The Constitution ..................................................................................................................................................................................................5

Section III: Effects of The Patient Protection and Affordable Care Act......6
6. The Economics of Healthcare Reform: From Concepts to Policy Implementation..............................................................................................6 7. A Social Perspective on Healthcare Reform: Age and Gender......................................................................................................................................8

Section IV: The Patient Protection and Affordable Care Act in Review.........11
8. The U.S. versus the World Health Organization: A Comparison of Global Expectations.................................................................................11

Abstract
In a country as large and diverse as the United States, the topic of healthcare reform is both relevant and imperative. Since the beginning of the 20th century, many United States officials have striven to establish numerous healthcare reform policies, which have been repeatedly defeated. However, in March 2010, U.S. President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA) into law, which ignited a fire of political argument and vehement disagreement among various politicians, medical professionals, and the American public. By looking at the Patient Protection and Affordable Care Act itself, as well as the political and economic consequences resulting from its implementation, this paper seeks to compare the United States healthcare system to the 5 components of a well functioning healthcare system set forth by the World Health Organization of what a healthcare system should ideally be.

Section I: U. S. Healthcare at a Glance

The World rights ofOrganizations constitution declares, The enjoymentreligion, highest attainable standard of health is one of the Health of the fundamental every human being without the distinction of race, political belief, economic or social condition.
Founded as a specialized agency of the United Nations in 1948, the World Health Organization (WHO) remains an authoritative advocate for the improvement of global public health and health systems. In May 2010, the organization published 5 Components of a Well-Functioning Health System, stating its firm expectations about the efficiency of an ideal health system. These components encourage a health system that (1) improves the health status of individuals, families, and communities, (2) defends the population against what threatens its health, (3) protects people against the financial consequences of ill-health, (4) provides equitable access to people-centered care, and (5) makes it possible for people to participate in decisions affecting their health and health system (Key Components of a Well-Functioning Health System).

The United States, a prominent member of the WHO, continues to focus on healthcare reform through many political and social debates. While approximately 85% of the US population is covered by some form of insurance, 15% of the US population currently lacks health insurance coverage (Johnson). To combat this extremely high number of uninsured people, The Patient Protection and Affordable Care Act (PPACA), signed into effect by President Obama in March 2010, aims to provide health insurance benefits to an additional 32 million Americans who currently are not covered by insurance companies (Kaiser Commission on Medicaid and the Uninsured). In addition, the Act heavily affects those individuals currently receiving government assistance in terms of Medicare and Medicaid. The passing of the Act instigated arguments between various politicians, medical professionals, and the American public about the necessity of healthcare reform in the United States. While the Act provides both positive and negative contributions to the current U.S. healthcare system, whether the PPACA brings the United States closer to fulfilling the WHOs idea components of a well-functioning system remains debatable. This paper first presents various elements of the Act and its social, political, and economical consequences, comparing the reformed American healthcare system and the WHOs ideals. The PPACA shows promising improvement toward meeting some of these expectations, but does not adequately fulfill other areas, indicating additional changes must occur before the United States meets the ideals of the World Health Organization.

Key terms

Healthcare is a broad term that refers to the treatment and prevention of illness in a country, and is administered by professionals who must meet certain government standards in order to practice medicine. Healthcare facilities are locations where healthcare is administered. Health insurance is monetary compensation to healthcare providers for health services. Public health coverage is insurance provided by the government, including Medicare and Medicaid. Medicare is a government social insurance program that provides health insurance coverage for persons age 65 and older. Medicaid offers healthcare for eligible individuals and families with limited income. Private health insurance includes all forms of health insurance that is not provided by the government. Healthcare reform is governmental policy created with the specific purpose of improving health conditions in a certain country.

2. History of U. S. Healthcare Reform: From Theodore Roosevelt to Barack Obama

The function, and roles of healthcare today arise from a long history of economic, foreign, and domestic policy. Over the years, healthcare has developed into a controversial political debate with each side addressing different figures, statements, and solutions. Since the time of Theodore Roosevelt, there have been efforts to spread knowledge pertaining to health (PBS- Healthcare Crisis: Healthcare Timeline). After President Theodore Roosevelt, the next President to pursue healthcare was Franklin D. Roosevelt. As a part of Roosevelts New Deal polices, the U.S. government passed the Economic Security Act, more commonly referred to as the Social Security Act of 1935 (PBS- Healthcare Crisis: Healthcare Timeline ). The Roosevelt Administration set the foundation for a broader healthcare and social security program. When the U.S. entered World War II in 1941, so did the economy. The U.S. began to finance the war by printing money while imposing wage and price controls, which caused a shortage in goods, services and labor as the government, rationed the factors of production for the war. In response to the price controls, in 1943 the National War Labor Board implemented a policy to draw in labor by allowing employers to offer health insurance instead of higher wages (PBS- Healthcare Crisis: Healthcare Timeline ). Competing firms had no real choice in the matter; in order to stay in business, they too had to offer medical benefits to their employees. Due to the war, further healthcare reform was limited for over a decade. When the war ended, employee healthcare provision continued and was set into place as a social and legal requirement for all businesses. After World War II, a major political concern became whether to expand Social Security with a new payroll tax. (Public Policy). Congress passed the Medicare and Medicaid Acts of 1965 as an alternative to amending Social Security (PBS- Healthcare Crisis: Health2

care Timeline ). Medicare and Medicaid were created as government welfare programs aimed at insuring the elderly and the poor as a part of Lyndon Johnsons Great Society. The program for Medicare was originally divided into two: Part A, hospital insurance and Part B, medical insurance, or physician expense. Reform in the 1970s amended the Medicare and Medicaid act and expanded it to the four parts it currently has (PBS- Healthcare Crisis: Healthcare Timeline). Part A is financed though payroll and income taxes. Parts B and D are funded through personal beneficiary premiums, where those enrolled pay monthly fees, which are adjusted to inflation, costs, and benefits. Part C enables Health Maintenance Organization to process Medicare, and Part D also allows the funding of prescription drugs for the elderly. As a result of Medicare and Medicaid, healthcare costs rose dramatically. In response to these rising healthcare costs Congress passed the Health Maintenance Organization (HMO) Act of 1973 under the Nixon Administration (PBS- Healthcare Crisis: Healthcare Timeline). Reforms during the Carter Administration expanded Medicare and Medicaid to aid the chronically ill and disabled (PBS- Healthcare Crisis: Healthcare Timeline). The Emergency Medical Treatment and Active Labor Act passed, mandating hospitals to stabilize all individuals who seek treatment, even those unable to pay for the treatment received (Overview EMTALA). More expansion of Medicare covered prescription drugs. When President Clinton took office, he appointed Hillary Clinton to be in charge of the potential healthcare reform. Eventually, the Clintons proposed a healthcare model that would allow private industries to work with government to regulate healthcare costs (PBS- Healthcare Crisis: Healthcare Timeline). The Health Insurance Portability and Accountability Act was passed, creating more privatization of medical records and limiting the ability of insurers to charge more money for those with preexisting illnesses (Overview HIPAA - General Information). Despite the many reformations to healthcare over the years, millions of individual Americans were still uninsured when Obama began his presidency. The Obama Administration prioritized healthcare reform and healthcare issues of rising costs, coverage, government medical welfare and sustainability. The passage of the Patient Protection and Affordability Care Act of 2010 marked the beginning of a new chapter in government intervention and oversight in U.S. healthcare management and reform.

3. Framing the U. S. Healthcare Overhaul in a Global Context

While the history of U.S. Healthcare provides relevant background, it is also important to compare the U.S. health system with those of other developed countries. U.S. healthcare expenditure is the most consistent among developed nations. This means that while costs in other countries continue to increase significantly with time, U.S. costs remain stable. Yet, the U.S. spends approximately 16% of its GDP on healthcare and health related expenses, while the current average global expenditure is only 9% (OECD Multilingual Summary). Although the U.S. spends nearly double the amount on healthcare as most developed countries, major health indicators in the U.S., including birthrate, death rate, life expectancy, and likelihood of chronic disease, are dramatically inferior (WHO | Global Health Observatory Database). It is important to note that statistical facts do not take into account the quality of care, rapidity with which the care is delivered, or affordability of the care relative to the individual citizen. Yet these facts still raise the question of why other systems around the world seem statistically much more successful. In this case, statistical success refers to the longevity of the national population and the efficiency of healthcare spending. Although the U.S. has a relatively high life expectancy of 78 years, its GDP per capita spent on healthcare tops the charts at $7,285 per person, the U.S. falls short of other developed countries, including countries that are part of the Organization of Economic Cooperation and Development (OECD Multilingual Summary). For comparison, refer to figure 1 below: Figure 1 Country: Health Expenditure Per Capita*: Germany $3737 United Kingdom $3129 (factored out of taxes) Taiwan --Japan $2729 Switzerland $4627 Canada $4079

Life Expectancy+: 80 80 79 83 82 81

*OECD Health Data (in US $ PPP/ 2008 value); +WHO health observatory statistics (2008 values); Note: UK citizens do not pay premiums for healthcare, they are deducted from their taxesissue directly addressed later.

It is also important to understand that each countrys wealth is distributed differently among the populace. Therefore, a country with a greater impoverished population may significantly lessen per capita health expenditure, while a country with a wealthy population may inflate the per capita health expenditure (Reid). In addition, certain countries implement policies of gate-keeping, which restrict citizens access to secondary and tertiary care specialists without first visiting a primary care doctor. For those countries without gate-keeping policies, expenditures may be much higher because citizens seek expensive treatment from specialists (OECD Multilingual Summary).

For organizational purposes, countries are categorized into those that deliver health services through a market-based system, and those that utilize a public command and control system. A market-based system is driven primarily by the private sector, with minor government regulation to assist with payments for the services and goods provided by the private sector. Germany, Switzerland and Japan are all countries with market-based systems. Alternately, a public command and control system of delivering healthcare is one dominated by the government, which pays for and provides a majority of healthcare. Great Britain is one of the countries with this type of system. Although the U.S. operates as a market-based system, the government offers much less financial assistance for individuals than other market-based systems do. Before the PPACA passed, the U.S. was the only country that did not legally require its citizens to have health insurance. The passing of the Act places the U.S. more in line with other countries in this way, but raises questions of constitutionality and practicality, as discussed in Part 5 of this paper.

Section II: The Patient Protection and Affordable Care Act

4. The Patient Protection and Affordable Care Act: An Overview

In the 2008 election, President Barack Obama ran his campaign platform on both affordable healthcare and a public option for such healthcare. During the first two years of Obamas presidency, multiple attempts were made to uphold this healthcare reform promise, though none of those bills passed. On March 17, 2010, South Carolina Democrat John Spratt introduced the PPACA to the House of Representatives. The Act passed the House on March 21, 2010 with a vote of 220 to 211, continued to the Senate, and passed on March 25, 2010, with 56 votes for it and 43 against (U.S. Cong. H.R.3590Patient Protection and Affordable Care Act). Though the public option was never approved or included in the bill, the PPACA mandates that U.S. citizens and legal residents have to own health insurance, either through an employer or through newly created health insurance exchanges. Those uninsured by the year 2014 will be forced to pay fines (Grier). As of now 83.3% of citizens have health insuranceeither though their employers, spouses, parents, individual purchase or government provision (Galewitz and Villegas). However, that means that 16.7% of U. S. citizens do not have healthcare coverage. In order to help these citizens obtain healthcare coverage, the federal government offers some programs (Medicare and Medicaid). These programs do not offer universal coverage, but instead provide insurance to a select few who meet the eligibility requirements. However, since not all members of the public can afford to purchase health insurance, the Act offers subsidies for certain lower and middle income individuals and families (Grier). The Act also states that insurance companies can no longer deny coverage to those with pre-existing conditions, a practice that insurance companies have been frequently employing. Below is an overview of the most important details of the most current Act in effect (Information provided by Jackson and Nolen): Cost: $940 billion over ten years. Deficit: Would potentially reduce the deficit by $143 billion in the first ten years and then $1.2 trillion in the second ten years. Coverage: Expands coverage to 32 million Americans who are not insured. Health Insurance Exchanges: The uninsured and self-employed would be able to purchase insurance through state-based exchanges with subsidies available to individuals and families with income between the 133 % and 400 % of the poverty level. Paying for the Plan: 3.8 percent tax on investment income for families making more than $250,000 a year. Excise tax- Beginning in 2018, insurance companies will pay a 40 percent excise tax on so called Cadillac high-end insurance plans worth over $27,500 for families. Medicare/Medicaid: Closes the Medicare prescription drug donut hole by 2020 and beginning in 2011 seniors in the gap will receive a 50 percent discount on brand name drugs. Expands Medicaid to include 133 percent of the poverty level, the Federal Government will be paying 100 percent of costs for covering newly eligible individuals through 2016, and illegal immigrants will not be given Medicaid. Insurance Reforms: Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions and insurance companies must allow children to stay on their parents insurance plan until the age of 26. Individual Mandate: In 2014 everyone must purchase health insurance or face a $695 annual fine. Most of the Acts controls on insurance companies began to take effect in September of 2010. Almost all of the amendments the Act enacted on current insurance policies seem to benefit the patient. For instance, companies are prohibited from dropping patients from their plans when an individual becomes ill, and new insurance plans will not be allowed to charge a co-payment (Congressional Budget Office). As of January 1, 2011, insurance companies are now required to spend 85% of large-group and 80% of small-group/ individual plan premiums on healthcare or improving healthcare quality. If they fail to meet this requirement, they will have to return the difference to the customer (Congressional Budget Office). Some of the Acts stipulations effective at its signing include a reform on the Food and Drug Administrations ability to pass biologics drugs, a higher Medicare drug rebate (increased to 23.1%), and the establishment of a non-profit Patient-Centered Outcomes 4

Research Institute to evaluate existing treatments and their effectiveness. The Institutes board consists of doctors, patients, and healthcare providers. Although this institutes research cannot be the sole evidence Medicare uses to construct a patients plan, it can be a contributing factor (States Diverge on How to Deal with Healthcare Ruling). The Act also offers a provision to protect consumers by preventing insurance agencies from canceling coverage simply due to mistakes on an application. While they are still allowed to rescind coverage if intentionally false information was put on the application, they must provide a 30-day notice to allow for any appeals. This provision applies to all healthcare plans, regardless of if coverage is through an employer or purchased individually (Provisions of the Affordable Care Act, By Year). Apart from these federal programs, there are programs developed by each state government for its residents that are specific to each region. For example, the California Department of Public Health is the government department that works toward optimizing the health and well-being of Californian residents through all sorts of programs, including programs for AIDS assistance, HIV care, Alzheimers and obesity prevention, and the highly controversial stem cell research (Programs).

5. The Act and The Constitution

Since The Patient Protection and Affordable Care Act passed in March 2010, there has been much discussion about whether the section that mandates all citizens over the age of 18 to purchase or obtain health coverage or pay a penalty is constitutional. Currently there are various lawsuits working their way up to the U.S. Supreme Court in relation to the Constitutionality of this individual mandate. As of May 8, 2011, there have been 31 lawsuits filed against the act in regards to its Constitutionality: 9 are in federal courts and 9 are in Court of Appeals; the other cases have been dismissed (Sack). It is important to note that until the Supreme Court rules on the matter, enforcing the Act will be legal. Yet the suggestion that the individual mandate should simply be removed from the Act persists. Though apparently a viable option, this modification would make the entire new healthcare system irrelevant. As Yales Jack M. Balkin explains, Without an individual mandate people will wait until they become sick to buy health insurance, raising insurance premiums for others and undermining the ability to spread risk that is necessary for private insurance markets. Requiring people to make a choice between buying health insurance or paying a tax gives people incentives to act responsibly and not attempt to game the system (Editors). If the Supreme Court concludes that this portion of the Act is unconstitutional, or if Congress successfully overturns the individual mandate, then the new healthcare system laid out by the Act may fail. In order to discuss the issue of Constitutionality we will have to define and examine various terms and sections of the Constitution. First, we must look at the Commerce Clause. This clause states that the Congress shall have the power to regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes (Transcript of the Constitution of the U.S.). It is very hard to come up with a universally agreed upon definition of the term commerce, but for this paper, commerce will refer to the trade and/or exchange of goods and services (Bork and Troy). Next, we must define the term to regulate. Chief Justice Marshall described the power to regulate as the power to prescribe the rule by which Commerce is to be governed (Bork and Troy). Lastly, it is important to clarify that the phrase Commerce among the several States, is referring to the idea of interstate trading and/or exchange of goods and services. Before looking at the Commerce Clause in relation to the individual mandate, we must also consider the very first clause in Article 8, the Welfare Clause. The Welfare Clause states, The Congress shall have power to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general Welfare of the U.S. (Transcript of the Constitution of the U.S. Official ). Furthermore, an understanding of the Necessary and Proper Clause is needed to examine the individual mandate. This clause states that the Congress has the power to make all Laws which shall be necessary and proper for carrying into execution the foregoing powers, and all other powers vested by this Constitution in the Government of the U.S., or in any Department or Officer thereof (Transcript of the Constitution of the U.S. - Official). When considered with respect to the Commerce Clause, this clause states that the Congress can pass a law, which is necessary and proper for carrying out the regulation of trade or exchange of goods or services. Drawing from the fact that the individual mandate is necessary for the Act to work, it is easy to argue that the individual mandate is constitutional under the Necessary and Proper Clause. This means that if the Supreme Court were to rule that the individual mandate is unconstitutional, then they would have to give a reason why it is not proper. After defining the Commerce Clause and briefly explaining the Welfare Clause and the Necessary and Proper Clause, we can finally examine the wording of individual mandate itself. The individual mandate states: Requires individuals to maintain minimum essential coverage beginning in 2014Failure to maintain coverage will result in a penalty of the greater of $95 in 2014, $495 in 2015 and $750 in 2016, or up to two percent of income by 2016, up to a cap of the national average bronze plan premium. Families will pay half the amount for children up to a cap of $2,250 for the entire family. After 2016, dollar amounts will increase by the annual cost of living adjustment. Exceptions to the individual responsibility requirement to maintain minimum essential coverage are made for religious objectors, individuals not lawfully present, and incarcerated individuals. Exemptions from the penalty will be made for those who cannot afford coverage, taxpayers with income under 100 percent of poverty, members of Indian tribes, those who have received a hardship waiver and those who were not covered for a period of less than three 5

months during the year (United States. Cong. H.R.3590 -- Patient Protection and Affordable Care Act). The individual mandate can be viewed either as a tax or as a government mandate for private citizens to buy a private service. The liberal interpretation of the individual mandate is to define the mandate as a tax. Once the mandate is seen as a tax, it is easy to defend it as Constitutional by relating it to the Welfare Clause. As Balkin explains, the Constitution gives Congress the power to tax and spend money for the general welfare. This tax promotes the general welfare because it makes healthcare more widely available and affordable. Under existing law, therefore, the Tax is clearly constitutional (Editors). In contrast, the conservative interpretation of the individual mandate is that it is not a tax, but an excessive fine. Since the 8th Amendment states, excessive bail shall not be required, nor excessive fines imposed, nor cruel and unusual punishments inflicted (Editors), conservatives argue that the individual mandate is an excessive fine and therefore unconstitutional. Because both positions come from Constitutionally valid standpoints, disagreement as to whether the mandate for every individual to own health insurance is Constitutional or not runs deep. No clear-cut or decisive answer is readily apparent, as varying definitions of tax or fine complicate the issue. Nevertheless, until and unless the case reaches the Supreme Court, the mandate and its implications on American healthcare reform will remain in tact.

Section III: Effects of The Patient Protection and Affordable Care Act
6. The Economics of Healthcare Reform: From Concepts to Policy Implementation
The report from the Congressional Budget Office forecasts that the new legislation will decrease the federal budget deficit over the next ten years (Congressional Budget Office). Likewise, the White House claims the Act will reduce the deficit by $143 billion in the first ten years (Jackson and Nolen). An analysis from the House Budget Committee Republicans, however, predicts that the Healthcare Reform will actually increase the national deficit by $701 billion over the next ten years, totaling a $2.7 trillion spending by the time it is fully implemented (Obamacare: A Budget Busting, Job Killing Healthcare Law). With multiple, disagreeing cost estimates, it becomes very apparent that the future of this legislation is still very uncertain. The national debt now stands at over $14 trillion, while GDP in 2009 was $14.1 trillion (GDP (current US$) | Data | Table, U.S. Debt Passes $14 Trillion - CBS News). The management of a few hundred billion dollars over the next ten years seems a trivial amount compared to the debt, deficit, and the trillions of unfunded liabilities.

Economic Results of Healthcare Policy: The U.S. healthcare system is divided between three major financiers who pay for medical and health services: the government, insurance companies, and private financiers, including businesses and individuals. The government has the highest expenditure of the three sources, and Medicare and Medicaid, have nearly doubled their spending. In addition to increasing the state and federal deficits, government spending on social welfare programs may have taken away from spending on health services and research in both the public and private sectors. Economic Effects on Government Services: The Act includes new regulations that will affect the financial climate within both the Medicare and Medicaid programs. Beginning in 2011, many provisions will begin to increase aid given to Medicare beneficiaries. Although the Medicare program receives a large portion of the Department of Health and Human Services (HHS) budget, some seniors have had to endure high costs for prescription drugs not covered within the coverage gap or donut-hole present in Part D of the Medicare plan (United States). To combat this, one primary benefit added in 2011 includes a 50% rebate on all Medicare Part D costs that fall within the coverage gap, resulting in thousands of dollars of additional coverage for some Medicare subscribers. Under a provision of the PPACA, the coverage gap will shrink more each year until the year 2020, when it will be eliminated (California Health Advocates: Medicare Policy, Advocacy and Education). Another major Medicare benefit provided under the Affordable Care Act is the extension of the Medicare Trust fund by four or five 6

years (United States). But all Medicare subscribers face the serious possibility of the programs eventual bankruptcy; some estimates have projected the exhaustion of one Medicare trust fund as soon 2017 (United States). Fraudulent claims against Medicare cost taxpayers $60 billion annually (Tompkins). Additionally, a 2003 addition that allows for limited private care options, known as Medicare Advantage, has increased Medicare bills for all beneficiaries by about 14% (Tompkins, United States). In order to pay for these benefits, provisions in the Act call for increased funding of fraud detection, projected to save American taxpayers more than $1 billion over ten years. The Act also calls for cuts in the Medicare Advantage program, which will help curb the escalating cost of monthly premiums. Provisions in the Act aim to recapture about $100 million of the annual 60 billion budgetary loss (Provisions of the Affordable Care Act, By Year). The Act also significantly affects the Medicaid program, which is projected to take on an additional 16 million patients half of the projected number of citizens who will receive coverage due to health insurance reform (Rosenbaum). Under the new Medicaid regulations, almost all adults under 65 will be eligible if they fall under and up to 133% of the poverty line based on annual income, defined as $14,404 for an individual and $29,326 for a family of four (Kaiser Commission on Medicaid and the Uninsured ). Individuals who fall between 133% and 400% of the poverty line will be given need-based tax credit toward a healthcare plan made available through the health insurance exchange starting in 2014 (Provisions of the Affordable Care Act, By Year). A mandated increase in payment to primary care medical providers who accept Medicaid insurance is intended to assure continued program support from primary care physicians. This payment increase will be fully funded by the federal government, which will provide 100% of all funding for additional Medicaid patient coverage from 2014-2016, with percentages decreasing until additional federal funding of Medicaid is phased out in 2020 (Kaiser Commission on Medicaid and the Uninsured ). Given the drastic increase in federal funding of Medicaid programs, it is important to note that none of the fundamental restructuring of the program is aimed specifically at reducing cost. Economic Results on Individuals and Businesses: Many business and individuals are engaged in one of three types of Managed Care Organizations (MCO): Health Maintenance Organizations (HMO), Preferred Provider Organization (PPO), or Point-of-Service Plans (POS) (Managed Health Care Plans). HMOs were adopted by the government in the 1970s to reduce to the price of medical costs and services, which had risen due to Medicare and Medicaid (Wilson). Through MCOs, businesses can provide their employees with a network of high-quality, low-cost medical providers. Co-payments and deductibles are used to regulate the price for both MCOs and insurance companies. A co-payment is a method of cost sharing, in which the co-payer pays a fixed amount for the services and medicine he or she receives. The co-payee pays the remaining amount. In businesses, the co-payer is the employee, and the co-payee is the employer. For insurance companies the co-payer is the insured, and the co-payee is the insurance company. Deductible and premiums are inversely related; the higher the deductible the lower the premium and vise versa. A deductible is a set amount a patient pays. In other words, if a payee or insured cannot pay the initial amount out-of-pocket for the received services, then the insurance company or the MCO is not obligated to pay (Managed Health Care Plans). HMOs are the most common of the three (Wilson). Members of an HMO are required to see doctors who fall into a particular network. HMOs do not pay for doctors or services provided outside the network. HMOs usually have low co-payments and require members to first see a primary doctor. Much like HMOs, PPOs provide members with a network of medical providers. Members can see doctors outside the network, but at a higher cost. The primary difference between PPOs and HMOs is that PPOs do not require members to initially visit a primary care provider. Members also have low co-payments, and deductibles (Managed Health Care Plans). A POS is a HMO/PPO hybrid, sharing characteristics of both HMOs and PPOs. POS are usually more lenient than HMOs when determining which medical provider the members should see. The primary goal of MCOs is to keep cost low by creating a contractual network with medical providers (Managed Health Care Plans). The PPACA attempts to reform insurance polices regarding individuals and businesses. Provisions in the Act require all insurance companies to provide coverage regardless of patients pre-existing conditions (Health Insurance Exchange Establishment Grants Fact Sheet). The PPACA also provides for the creation of a health insurance exchange by 2014 (Health Insurance Exchange Establishment Grants Fact Sheet). This exchange is intended to provide consumers with the ability to make educated comparisons between a variety of private health insurance packages, all of which are required to meet certain essential levels of coverage, outlined in the Act (Health Insurance Exchange Establishment Grants Fact Sheet). The exchange is open to individuals who do not qualify for Medicare and Medicaid. Mandated health insurance for all U.S. citizens coupled with the health insurance exchange is intended to increase competition between private insurers, driving down prices. Although the Affordable Care Act is intended to increase insurance coverage nationwide, there is little information about how the federal government intends to provide such a vast array of benefits to the population. If the Act provisions fail to better balance the federal healthcare budget, the only two options that remain are higher taxes or an increased national debt. If Act based healthcare reform succeeds, Americans enrolled in government funded insurance or new health insurance exchanges may benefit. In order to create conditions in which an increased number of individuals can receive quality healthcare and medical services with affordable costs, the U.S. government has created a social welfare system and required employers to provide aid to their employees. When Medicare and Medicaid were enacted, prices rose dramatically. In the recent century healthcare costs have risen dramatically. In just 7

the last twenty years, healthcare expenditure has tripled, exceeding 2.3 trillion dollars in 2008 (U.S. Healthcare Costs: Background Brief - KaiserEDU.org, Health Policy Education from the Henry J. Kaiser Family Foundation). U.S. expenditure on healthcare services is 16.2 percent of GDP, or total output and income, estimated by the World Bank to have been $14.1 trillion in 2009 (U.S. Healthcare Costs: Background Brief - KaiserEDU.org, Health Policy Education from the Henry J. Kaiser Family Foundation, GDP (current US$) | Data | Table).

7. A Social Perspective on Healthcare Reform: Age and Gender

The Patient Protection and Affordable Care Act devotes several new laws and programs to the protection of children and youth. One such program reauthorizes and fully funds the Childrens Health Insurance Program (Klain). The Childrens Health Insurance Program (CHIP), jointly operated by a partnership between the federal government, state governments, and Medicaid, provides less expensive health insurance for children in families whose income exceeds Medicaid maximum eligibility requirements, but who cannot afford health insurance through private companies. In 2009, CHIP provided healthcare insurance for roughly 8 million children (Healthcare.gov). As for Medicaid, the federal government matches state expenditures for CHIP up to a specified amount (Kaiser Commission on Key Facts: Childrens Heath Insurance Program Reauthorization Act of 2009). The new law includes a 23% increase in the CHIP match rate from 2014-2019 (Klain). This paves the way for continued coverage of routine check-ups, immunizations, dental and vision care, inpatient and outpatient hospital care, and laboratory and X-ray services (Healthcare.gov). Aside from the renewal of CHIP, the Act guards against the discrimination of children with preexisting conditions by prohibiting insurance companies from denying coverage to children based on health status (Healthcare.gov). The Act calls for increased educational health programs for children, such as school-based health clinics, Community Health Centers, and personal responsibility education programs. The U.S. Department of Health and Human Services will receive grant money to support school-based health clinics with the purpose of providing preventative and primary physical and mental health services to children and teens. Schools in areas serving a large population of Medicaid-eligible children will gain preferences for the allotment of grant money (Klain). While Community Health Centers, operating under the Public Health Services Act, do not specifically target children, these centers should provide care to low-income people in general, indirectly benefiting children. States and groups within states may apply for funding for personal responsibility education programs for children and teens, which may address healthy life skills among other approved subjects if so desired (Klain). Provisions within the PPACA demonstrate the governments consideration to the fact that some states need more help than others. The expansion of Medicaid takes into consideration citizens in states recovering from natural disasters, such as Louisiana in the wake of Hurricane Katrina (Jarlenski). Home visiting programs, intended to prevent child abuse or injury, will enter areas of high risk of parent or child health (Klain). Children in foster care or awaiting adoption may also receive special attention under the Act, which requires welfare agencies to consider several health issues for youths transitioning out of foster care (Klain). These individuals will need information regarding health insurance options, and the importance of authorizing a proxy to make treatment decisions in cases when the child cannot (Healthcare.gov). States will provide Medicaid coverage to people who were in foster care up to their twenty-sixth birthday. The individual must have been in foster care at least at their 18th birthday, and will receive all applicable Medicaid benefits. The Act also guarantees a benchmark benefit package that provides essential health benefits to newly eligible Americans, such as those leaving the foster care system (Summary). The Act extends and increases the adoption credit that reimburses the tax liability of individuals who adopt children eighteen or younger. This tax credit can cover expenses related to adoption, such as court fees and travel costs, as long as the child is under the age of eighteen, or subject to a mental or physical condition impeding independence. Unlike in previous years, the tax credit will be refundable (Klain). Additional programs and provisions target the special needs of women, with the goal of supporting pregnant and parenting teens and women. CHIP, for example, offers coverage to some pregnant women for pre-birth laboratory tests, labor and delivery costs, and up to sixty days of post-natal care costs (Healthcare.gov). The Act directs a pregnancy assistance fund toward state-run services designed to provide pregnant and parenting teens services such as childcare, parenting education, and maternity clothing. This assistance also extends to the material needs of the child, in proving necessities such as food and clothing. The new legislation offers grants to organizations that research postpartum depression and provides services for women and families suffering the effects of such depression (Klain). Such efforts work toward ensuring safe, healthy conditions for children. In addition to children, the Act increases the ability of young adults to obtain healthcare coverage. A recent study found that young adults aged 21 to 24 years are the most likely to be uninsured (Price). This number at least partially reflects individuals who have recently graduated from college, and thus lost the health insurance required and provided by most colleges. The extension of parents private health insurance for children up to age twenty-six provides the most significant potential for reducing this high percentage of uninsured young adults (Klain). Certain job-provided or private health insurances for young adults will provide preventative services like cancer screenings, vaccines, pregnancy tests, and consultations for weight, pregnancy, or smoking habits for free (Heathcare. gov). For current college students, Michelles Law mandates the protection of a students health insurance while he or she takes a medical leave of absence. The law does not cover students who take a leave of absence for any other reason, but protects the health insurance of seriously ill or injured students during a leave of absence or a decrease to part-time status (United States. Cong. H.R.3590 -- Patient Protection and Affordable Care Act). 8

On the other end of the spectrum, the number of senior and elderly citizens continues to climb as the Baby Boomers age. By 2050, the number of individuals age sixty-five is expected to be double the number of the same age group in 2000, and the number of individuals above eighty-five will increase five-fold (Clemmitt 2006). Therefore, health reform also targets improved coverage for senior citizens, many of whom fall into a coverage gap within Part D of their Medicare health insurance, nicknamed the doughnut hole (Coughlin). The doughnut hole creates the problem that Medicare Part Dcovers medications up to $2,830 a year (in 2010), and then stops until the beneficiarys out-of-pocket spending reaches $4,550 in the year, when the coverage begins again (Coughlin). This leaves many senior citizens struggling to pay out of pocket for medications for much of the year, and although many Medicare patients have supplemental coverage, about one in eight senior citizens lack any such supplemental coverage. The law sets in motion the elimination of this coverage gap, beginning with a $250 rebate to Medicare patients who fall into the gap during 2010, followed by a fifty-percent discount on prescription drugs within the doughnut hole in 2011 (Coughlin). The law intends to close the gap entirely by 2020, leaving patients to pay for twenty-five percent of drugs until Medicare drops copayments to five percent (Coughlin). The out-of-pocket requirements for receiving this catastrophic coverage will decrease between 2014 and 2019 (Coughlin). Since Part D covers drug costs for over half of senior citizens under Medicare health insurance, these changes should aid many elderly beneficiaries (Cubanskil and Newman). The Act also establishes a reinsurance program for retirees. This program is targeted at early retirees over the age of 55, but who are not yet eligible for Medicare. The government has allocated $5 billion in order to reimburse employers and other sponsors of early retiree healthcare plans for up to 80% of healthcare claims between $15,000- $90,000. This is a temporary program that will remain in effect until the Health Insurance Exchange is ready to be implemented (The Affordable Care Act: Strengthening Medicare, Combating Misinformation and Protecting Americas Senior). A new, voluntary, government-run Long Term Care program called the Community Living Assistance Services and Supports (CLASS) Act will offer basic help for both the elderly and disabled. CLASS is a program designed to expand long-term care services for functionally disabled Americans. It works toward establishing a new financing strategy for community living assistance services in order to facilitate financial and personal independence in community living. CLASS will help pay for non-medical services, as well as the costs of assisted living, personal care or nursing home care. This program makes individuals who have paid a premium for five years eligible to receive benefits of more than fifty dollars a day, dependent on the level of disability. Since employers will offer this service, an individual must be actively employed and not enrolled in Medicare to qualify (Cubanskil and Newman). The funds may purchase non-medical long-term care services and supports necessary to maintain community residence (Coughlin). Such services may include assisted living, nursing home care, or even care provided by a family member. However, despite general agreement that the program is necessary, many believe the current model to be poorly designed. A commission appointed by President Obama reviewing the Act has recommended that CLASS be either revamped or repealed (Education & Outreach). For the sake of those in nursing home care, legislation will require reports accounting for pertinent information regarding care quality, including but not limited to quality and quantity of staff and hours of care. The law will also require public disclosure of individuals affiliated with control of nursing homes, as well as increased security requirements for nursing home staff. An Elder Justice Act included in the legislation establishes an Elder Justice Coordinating Council. In two years, this council will recommend certain actions for coordinating federal, state, local and private entities helpful for preventing elder abuse, which can include neglect and exploitation. Further, funds for state-specific research on methods of adult protective services will be administered for the first time (Coughlin). The law instigates an Independent Medicare Advisory Board for recommending cost-saving measures for Medicare. These recommendations may not ration care, increase revenues or change benefits, eligibility, or Medicare beneficiary cost sharing, although reduced payments to Medicare Advantage may result in the loss of program membership incentives such as free eyeglasses and gym memberships (Coughlin). Impacts on Healthcare Providers and Patients: Expanding coverage for Medicaid may reduce administrative costs as guaranteed eligibility for Medicaid can reduce frequent movement or churning of people in and out of the program as their eligibility changes (Clemmitt 2010). The problem is that Medicaid pays only about half as much as private insurance and Medicare pays roughly 81%. Due to cuts in Medicare payments, speculation is that doctors will see a decrease in payments, and some may not even want to see Medicare patients anymore (Moffit). Up to 15% of hospitals and other care facilities that rely on Medicare reimbursements could become unprofitable and drop Medicare patients altogether. However, due to increases in insurance coverage, the decreased payment should be offset by increased volume of paying patients (Clemmitt 2010). How and what doctors are paid for is addressed in the Act as well, with special focus on locating and eliminating inefficiencies. Right now, doctors are paid for services performed, and the dynamic of care is to see as many patients in a day as possible. However, the Act aims to change this dynamic and includes payment plans that require doctors and hospitals to take responsibility for the care they provide. Specifically, the Act cuts payments hospital readmissions that may suggest [the patients] earlier care was ineffective or harmful (Clemmitt 2010). By limiting Medicare payments if a patient is readmitted into a hospital, hospitals will be obligated to provide effective, quality care for patients, increasing savings and making Medicare more economically sustainable (Clemmitt 2010). In order to increase savings and ensure efficient spending, the PPACA establishes the Center for Medicare and Medicaid Innovation 9

within the Centers for Medicare and Medicaid Services. The center is to test innovative payment and delivery system models that show important promise for maintaining or improving the quality of care in Medicare...while slowing the rate of growth in program (Heather Drake, et al.). Theoretically, having such a center will ensure payments from public programs will be spent wisely, increasing healthcare coverage and the quality of patient care. The new Act also has many implications for medicine and patient care. Patient numbers will surge, but the number of caregivers will remain the same. The influx of 32 million previously uninsured patients may cause backups throughout all levels of care, stretching physicians and resources. Currently, 11 percent of uninsured people are in fair or poor health, compared to only 5 percent of privately insured people who report poor health (Clemmitt 2010). Uninsured patients go an average of two years without visiting a doctor, and 78% of uninsured patients do not go to their suggested yearly health screenings (DuPre). On the primary care level, this means more patients in worse shape will flood clinics, decreasing doctors time per individual as they try to see as many patients as possible per day. To augment the ranks of overworked and fatigued doctors, nurse practitioners will be used for what were normally physicians duties (Clemmitt 2010). The physician shortage will not end at the primary care level. Emergency Medical Treatment and Labor Act (EMTALA) to treat and stabilize all patients presenting at the Emergency Department (ED) require hospitals. For hospitals, especially safety net hospitals focused on serving the underrepresented segments of the population, the obligations of EMTALA and their associated challenges are even more pronounced (United States of America). One website predicts As a result of reform, emergency room visits will increase from 5 to 10 percent over the next decade, increasing the need for improved patient throughput, despite the common misconception that ED visits will decrease with the reforms as poor patients stop using them as clutch care (Patient Throughput). A main program is the Patient Centered Medical Home (PCMH) (Burke). The PPACA accelerates pilot testing and implementation of new models like the patient-centered medical home, which will reimburse primary care physicians in qualified practices for instituting best practices to improve outcomes for patients with chronic illnesses (Doherty). Joint Principles of the Patient-Centered Medical Home, provides insight into the various elements of the medical home. The most important is the pairing of each patient with a single PCP (Primary Care Provider). Other elements include a physician-directed medical practice that involves teams comprised of all office staff with important roles to play; a whole person emphasis on care coordination and high quality; enhanced patient access to care through virtual communication enhancements; improved tracking and accountability for care deliver; and appropriate payment to recognize the added value of medical home type care (Hoff). How well PPACA does this is yet to be seen, but the PCMH is a step in the right direction. One of the reasons healthcare costs are so high in the U.S. is because people do not seek primary and preventative care. Emergency rooms see a lot of cases that are either non-emergencies or that could have been prevented (Pitts et al.). According to the American College of Physicians, Americans receive recommended levels of preventative care only about 55% of the time, despite the prevalence of obesity, diabetes and cardiovascular disease (DuPre). This attitude of ambivalence toward preventative care is counterintuitive and drives up healthcare costs because it usually costs less to provide ongoing care than to wait until peoples health deteriorates (DuPre). Studies show that decreased gaps in insurance coverage lead to greater overall health (Clemmitt 2010). With the medical home in place, not only will more people have access to care with their insurance, but they also receive higher quality care from a doctor who knows their medical history and them personally. The PCMH is one of the most important provisions in the Healthcare Bill; however, its implementation will not be possible until U.S. medical schools start producing primary care providers. Currently, there is a shortage of primary care providers, and the PCMH will not work unless we have more primary care doctors. In this respect, the Act seeks to increase the number of medical school graduates that go into the primary care field by providing loan forgiveness provisions for primary care providers who work in underserved areas (Burke). Also, the PPACA aims to ameliorate the primary care shortage through increased funding for National Health Services Corps and Title VII health professions programs and creates a new program to provide grants and graduate medical education dollars to primary care residency programs at teaching health centers. The law requires residency programs to redistribute at least 65% of unfilled slots in nonprimary care programs to primary care residency or general surgery residency programs (Doherty). Medical schools are also integral in closing the PCP gap, because right now they seem to subliminally teach students that primary care is low-income, high-stress care and that they are smart enough to bypass primary care for a specialty (Voelker). Medical schools do not currently teach the Patient Centered Medical Home model, however, theoretically, a change in the ideology of doctors should be possible within four years, the length of time needed to complete medical school. Until and unless these changes to medical school policies occur, America will face critical physician shortages as the number of patients sharply rises. The Associate of American Medical Colleges states that the U.S. will face a shortage of physiciansfrom 134,000 to 159,000 physicians by 2035, and healthcare reform will add to overall demand for physicians and increase this projected shortfall by 25 percent (Hammer). DuPre corroborates this statistic, expecting Careers in medicine and surgery to grow faster than the national average, at a growth rate of 14%, and shortages in general care physicians, family practice, OB/GYNS, and internal medicine especially in the more rural areas of the country (DuPre). Many worry that access to care will be limited, and that a decrease in the overall quality of care compared to what patients with insurance are used to will occur. While any care is an improvement for uninsured people, the insured may notice a longer wait time for a shorter visit the next time they go to their doctor. The new limits 10

in access to care could result in unintended consequences such as rationing of care and prioritizing of patients based on their condition, one of the reasons the healthcare reforms were instigated (Hammer). Hospitals will also be required to take even more stringent steps toward off hospital-acquired infections, or infections occurring outside of the hospital, and nurses will be required to counsel patients about staying healthy before they are discharged from the hospital (Clemmitt 2010). In addition to the penalties, hospitals will be rewarded bonuses for accurate data reporting and riskadjusted good outcomes (Casscells). The Act also emphasizes preventative care and patient safety. Insurance companies will not be allowed to deny coverage for routine check ups and doctors visits. Starting on January 1, 2013, some states will get tax cuts if they offer preventative care programs for their constituent citizens. In July of 2010, the National Prevention, Health Promotion and Public Health Council began action. This council, established by President Obama, was designed to strategize the improvement of illness prevention to reduce the number of serious primary care visits in order to decrease the cost of primary care and decongest hospitals, waiting rooms, emergency rooms and primary care offices (Congressional Budget Office). The problem is that even though states are required to use a households modified gross income when determining eligibility for Medicaid, they may continue to disregard or deduct income for applicants who are elderly, blind or disabled (Weil). By allowing states to restrict Medicaid eligibility to these groups, the Act does not guarantee healthcare coverage to all eligible American citizens. The states share the responsibility of creating policies, and implementation practices will largely determine whether the new federal law translates into meaningful, affordable coverage and access to services for the American people (Weil). While there are methods, such as prohibiting asset tests, to increase the likelihood that states will comply with the healthcare legislation, there is still no guarantee that all states will be able to provide to all needy citizens, and even if individuals are eligible for Medicaid, they may still end up under-insured. In addition, Medicaid and Medicare are called to offer an annual exam and wellness plan free of charge, to eliminate co-payments and deductibles for preventive services, and to set incentives for healthy lifestyles (Casscells). Funding was appropriated beginning in 2011 and continuing for the following four years to set aside grant money available to states to develop, implement, and evaluate alternatives to current tort litigations (Kaiser Commission on Key Facts: Childrens Heath Insurance Program Reauthorization Act of 2009 ). This means that medical malpractice will be tightly monitored and that patients will have more access to liability insurance, potentially leading to greater patient safety and reduced medical error. Under the new legislation, drug cost and coverage will change. Beginning in 2011, the law prohibits using flexible spending accounts provided by some employers to pay for non-prescription drugs (Clemmitt 2010). The Act promises more access to drugs for patients with chronic conditions. For example, the AIDS Drug Assistance Program (ADAP) is a program available in all 50 states that aids in paying for some HIV/AIDS medications that insurance does not cover. This, along with the new Medicare expansion of coverage to include patients with preexisting conditions, in this case HIV/AIDS, will help these patients bridge the doughnut hole gap (Young). Another popular provision of the Act is the decrease of the number of years from eighteen to twelve that drug and biologics companies can maintain exclusive rights before generics can be developed (Kaiser Commission on Key Facts: Childrens Heath Insurance Program Reauthorization Act of 2009 ). This results in lower costs of life saving drugs and decreased brand monopoly of certain life-saving formulas. Although choice increases in the prescription drug market as a result of the Health Reform Bill, the Act actually negates competition between hospitals and other primary care facilities such as clinics and nursing homes (Brook). This is because patient choice in hospitals and primary care providers decreases as a result of the added number of people to the Medicaid System. Where patients receive care may be dictated by government and what package they have even more so than it is now (Brook). Since hospitals will not have to compete for patients, they will lose the incentive to house some state of the art technologies that previously influenced patients to choose their facility over a competitors. Robert Brook further postulates that the stricter enforcement of Medicaid and Medicare and the mandate on having health insurance may lead to a society in which the wealthy receive care from the better hospitals and physicians, and they know it (Brook). Ironically, this is a major criticism of the current American healthcare system as it stands today.

Section IV: The Patient Protection and Affordable Care Act in Review
8. The U.S. versus the World Health Organization: A Comparison of Global Expectations
Key Component 1: Improving the health status of individuals, families, and communities: An often noted provision of the Act is the expansion of dependent coverage for children up to the age of 26 under the guardians health plan (Summary of New Health Reform Law - Kaiser Family Foundation). In a struggling economy, this means many young adults no longer have to worry about finding immediate health insurance through employment, and their parents or guardians can feel secure in the fact that their young adult will be covered. Through this extended coverage plan, young adults may be able to afford to keep up with preventative check-ups, deal with emergency situations, and access needed prescription medicine.

11

Another contribution that the Act makes toward overall health improvement in individuals, families, and communities is the establishment of grants for small-business employers who implement wellness programs in the workplace (Summary of New Health Reform Law - Kaiser Family Foundation). Encouraged by their employers, employees across the country may choose healthier decisions by attending these programs. This may lead to an improvement in the employees quality of life. The inclusion of these two points in the Act works toward improving the health status of individuals, families, and communities. Key Component 2: Defending the population against what threatens its health: While the Act does not directly mention defense against health threats, there is a strong emphasis on prevention. The Act calls for the establishment of the National Prevention, Health Promotion and Public Health Council to facilitate preventative health programs and determine a strategy for overall American health improvement (Summary of New Health Reform Law - Kaiser Family Foundation). Additionally on a more local level, grants will be available for community programs that deliver proven-preventative services directed at diminishing chronic disease rates and the disparity of health services in rural and frontier areas (Summary of New Health Reform Law - Kaiser Family Foundation). While the Act does not directly address the concerns about what threatens the populations health, it does make strides toward preventative action and education about the importance of chronic disease prevention. Key Component 3: Protecting people against the financial consequences of ill health: On one hand, the Act prohibits insurance companies from placing monetary lifetime limits on the coverage of the patients (Summary of New Health Reform Law - Kaiser Family Foundation). With this in place, a person suffering from a disease no longer has to worry about coverage running out and having to pay out of pocket for expensive procedures. This eases a significant financial burden on those who are ill, and it provides them and their families with the comfort of knowing their coverage is secure, regardless of their healthcare needs. However, in 2014 the Act will also require most people to buy healthcare plans. If a person does not purchase a plan, he or she will be penalized and fined (Summary of New Health Reform Law - Kaiser Family Foundation). While the Act protects people against lifetime limits, it also may cause unnecessary financial hardship through enforcing the plan requirement. Additionally, the financial cost of implementing this Act is immense, which also may result in financial burdens. While there are some promising contributions that may ease financial burden, there may be gaps that cause monetary difficulties for individuals. Key Component 4: Providing equitable access to people-centered care: Although the Act has extended access to medical coverage through its insurance requirement, it is still arguable whether or not the new system advocates people-centered care (Key Components of a Well-Functioning Health System). The Act does mention strategies to improve effectiveness through the establishment of the non-profit Patient-Centered Outcomes Research Institute, which would research and compare the efficiency of certain medical treatments (Summary of New Health Reform Law - Kaiser Family Foundation). However, beyond that establishment, the Act does not mention anything else related to people-centered care and some have even argued that the Act removed the personalization from healthcare and significantly limits options. In this category, it is difficult to determine if the Act meets the requirements of this component. Key Component 5: Making it possible for people to participate in decisions affecting their health and health system Since the U.S. is a democratic republic political system, in theory American citizens have the ability to vote in elections and vote for candidates who will best serve their needs. However, regarding this Act, the U.S. Senate, House of Representatives, and President Barack Obama determined the results of most of the major decisions Although these officials were elected by the public, the average American person did not have direct input when the bill was crafted, nor does he or she have the sole ability to participate in decision-making about the components of this Act. With the mandatory health insurance policy that the Act mandates, it appears that Americans have very few choices when it comes to their health and the health system.

9. Conclusion

At its heart, the PPACA seeks to extend the coverage of current health insurance plans and provide health insurance to more people who were previously uninsured. It aims to make it easier for virtually everyone to maintain continuous access to health insurance and care, focusing on the very old and very young ends of the population (Clemmitt 2006). The economic, political and social consequences of the Act, however, may not prove as positive in implementation as they do in theory, and may not adequately meet the WHO requirements. The plausibility of paying for the changes concerns many. The Act plans to cover the costs of activating new programs while maintaining old ones by eliminating waste and maximizing efficiency. In an economy riddled with debt, the funds generated by this plan may not prove sufficient to support such ventures. The Act seeks to cover 34 million uninsured Americans through the institution of exchanges and mandates that all U.S. citizens over the age of 18 must own health insurance. While the goal of providing health insurance for all Americans certainly has merit in protecting people against financial hardship due to illness, the mandatory quality of health insurance has caused some Americans to question whether the Act impinges on their right to have a say in decisions regarding their personal well-being. The constitutionality of mandated healthcare, is currently being debated in several lawsuits making their way up to the U.S. Supreme Court, and could drastically alter its implementation. The PPACA creates programs and policies designed to improve preventative care, making an effort at meeting the second WHO standard of healthcare. Yet the effects on patient to doctor ratios may actually damage overall healthcare quality. As a stable number of doctors attempt to treat an exponentially increased number of patients, it seems difficult to imagine the quality of care could remain the same. Clearly, while the Act takes steps to mend some of the gaping holes in the current U.S. healthcare system, it simultaneously creates new holes, raising 12

serious questions and doubts as to whether the new Act has more or less value than former practices. Ultimately, only time will tell to what degree this major movement toward reform rectifies or aggravates the fundamental problems of healthcare in America.

13

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