ACA Policy Analysis Assignment (1)
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Health Science
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May 15, 2024
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1
Improving Health Insurance Access for Individuals with
Pre-existing Conditions in the Individual Market
Melissa Restrepo & Hemangi Vaishnav
Health Administration, Hofstra University
HADM 201: Healthcare Policy
Professor. Wool
March 12, 2024
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Prior to the enactment of the Affordable Care Act (ACA) in 2010, individuals with
pre-existing illnesses encountered substantial difficulties in acquiring health insurance coverage
in the individual market. Insurers possessed the power to refuse coverage or impose excessively
high rates based on an individual's health status, medical history, or pre-existing diseases.
Insurers frequently considered conditions like cancer, diabetes, or HIV/AIDS to be high-risk,
resulting in rejections of coverage or excessively expensive policies. This discriminatory
approach resulted in many individuals with pre-existing ailments being inadequately covered or
completely uninsured, leaving them vulnerable to financial hardship and restricting their ability
to obtain necessary medical treatment.
The enactment of the ACA led to significant changes in the health insurance landscape,
particularly for individuals with pre-existing conditions. An important aspect of the ACA was the
implementation of pre-existing condition protections, which prevented insurance companies
from refusing coverage or charging higher rates based on an individual's health status or medical
history. The purpose of these safeguards was to guarantee that all individuals, irrespective of
their health condition, could obtain reasonably priced health insurance in the individual market.
In addition, the ACA created health insurance marketplaces that allowed consumers to compare
and acquire health insurance policies, therefore increasing access to coverage for those who were
previously excluded from the insurance market.
As a component of the Affordable Care Act (ACA), the Pre-Existing Condition Insurance
Plan (PCIP) was created in March 2010 to offer health insurance coverage to anyone who had
previously been refused coverage because of pre-existing diseases. Before the ACA, individuals
with pre-existing medical conditions frequently had difficulty obtaining coverage at a reasonable
cost or faced outright denials from private insurance providers. The PCIP program offered
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temporary coverage to eligible individuals who were citizens or legal residents, those without
health coverage for at least 6 months, those with pre-existing conditions, or have been unable to
obtain coverage due to health conditions. The U.S. Department of Health and Human Services
oversees the program in conjunction with other federal departments. Depending on the state
where the person resides, the PCIP program's characteristics may change. In general, the PCIP
seeks to lower the cost of health insurance and increase accessibility for people with pre-existing
conditions while more extensive ACA measures, such as community rating and guaranteed
issues, come into effect.
The ACA enacted substantial reforms to address individuals with pre-existing diseases
being able to obtain health insurance. The ACA particularly addressed this issue through
prohibition of pre-existing condition exclusions, community rating rules, guaranteed issues, and
benefits coverage. The Affordable Care Act (ACA) implemented a prohibition on insurance
carriers rejecting coverage to individuals due to their pre-existing medical problems. Insurers are
now forbidden from denying coverage or raising rates based on an individual's medical history.
In addition, the ACA implemented limits on community rating, which prohibit insurers from
applying varying pricing to individuals who have identical pre-existing illnesses. This guarantees
that individuals residing in a specific geographical region are charged the same premium for a
given plan, regardless of their health condition. With respect to guaranteed issues under the
ACA, insurance companies are required to provide coverage to all applicants, regardless of their
health status or pre-existing diseases. This mandate prohibits insurance companies from refusing
coverage to those seeking insurance through the individual market. Moreover, under the ACA,
all insurance plans must include coverage for essential health benefits. Some of these benefits
encompass pharmaceuticals, inpatient treatment, prenatal and postnatal care, psychological
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support, and preventative medical services. Rating rules were also adapted to prohibit insurers
from making premiums based solely on age, which resulted in health benefits that came out of
this change such as prescription drugs, maternity care, and behavioral health. With all the
adaptations that came with the Affordable Care Act, there is still a lot of complexity consumers
have yet to navigate through. Some of these intricacies include reduction in uninsured rates,
enhanced availability of preventative care, financial stability for providers, focus on Value-Based
Care, provider capacity, and financial strain on insurers. The ACA has significantly decreased
the proportion of those without health insurance, extending coverage to nearly 20 million
Americans. This was accomplished through expansion of Medicaid, creating health insurance
marketplaces, and prohibiting insurers from refusing coverage. As a result, there has been a rise
in the availability of medical treatment for persons who were previously without insurance.
Thus, a larger number of individuals obtaining health insurance, connects to a significant rise in
the consumption of preventive care services, such as screenings, wellness visits, and vaccines.
The focus on preventative care has the capacity to enhance overall health outcomes by
prioritizing preventative care over reactive. The implementation of the ACA has led to a
decrease in the number of medical procedures that healthcare providers are not reimbursed for.
Hospitals, clinics, and other institutions, especially those catering to low-income populations,
have achieved more financial stability as a consequence. With the shift towards a more
value-based model, it is possible to decrease expenses and enhance the standard of treatment. As
the demand of services increases it begins to place a strain on physician capacity and availability.
These issues encompass deaths of specialists, primary care physicians, and other medical
personnel, which have grown more evident due to additional responsibilities placed on
physicians. Although the Affordable Care Act (ACA) implemented measures such as risk
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adjustment and reinsurance to stabilize the insurance market, several insurers had financial
challenges, especially during the initial phases. This was partially attributed to the concerns
surrounding the first surge of persons with more complex healthcare requirements and the
makeup of the risk pool.
The policies in place and the ones that continue to adapt within the Affordable Care Act
(ACA) are shaped by a blend of ideological, political, and economic considerations. The driving
force for the ACA was the belief that healthcare should be universally available and accessible to
all Americans, irrespective of their health condition. The incorporation of safeguards for persons
with pre-existing illnesses is by the principle that healthcare is an essential entitlement. The
policy approach to resolving healthcare disparities and preventing discrimination against persons
with pre-existing illnesses was guided by this ideological viewpoint. Secondly, the matter of
pre-existing conditions received substantial political focus, propelled by public sentiment and
advocacy campaigns that emphasized the difficulties experienced by individuals who were
refused coverage or burdened with excessive expenses because of their medical background. The
passing of the ACA necessitated bipartisan consensus, highlighting the influence of political
dynamics on the formation of healthcare policy. Lastly, economics was deemed essential to
provide those with pre-existing conditions access to cheap insurance coverage to foster financial
stability and mitigate total healthcare expenses. The ACA aims to stabilize insurance markets
and reduce healthcare spending overall by mandating coverage for pre-existing diseases and
adopting risk mitigation mechanisms such as the individual mandate and risk adjustment
programs.
As the US continues to incur expenses, Republicans are trying to focus on redistribution
of taxed funds while still ensuring individuals with pre-existing conditions are still covered.
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