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What's Missing in the Affordable Care Act (ACA)?

Three Important Aspects of Reform Were Not Addressed


Updated November 07, 2012

In 2012, two major events solidified the Affordable Care Act as the future of healthcare in the United States. Both the confirmation by the Supreme Court, and the re-election of President Barack Obama cemented the deal. As of January 2014, healthcare reform, AKA the Patient Protection and Affordable Care Act, or ObamaCare, will be the fully implemented law of the land.

While the ACA in its present state does address most of the problems Americans have encountered as they attempted to get the healthcare they need, there are a handful of problems that are not addressed by the law. But those aspects are important! Therefore, we may see them addressed over the next few years as the payment system for healthcare in the United States continues to evolve.

Here are some of the problems left unaddressed or not-well-addressed, and the interests of different parties, which may explain why they have not been included yet in reform:


Portabiity of health insurance has two facets:

1. The vast majority of health-insured Americans get their insurance through their employers. But that insurance is then tied to the employer, and not to the person who is insured. As a result, that person has no options for leaving that job and keeping that coverage unless he or she can find a new job that also offers the same healthcare coverage. The insurance is not portable with the person from job to job. Yes, if someone leaves a job (whether they are laid off, quit or change companies), they may have access to COBRA continuance. But the time span of COBRA is limited and the insurance continues to be based with the initial employer.

2. Private insurers are licensed to sell insurance only in certain states, and patients are allowed only to purchase health insurance that is valid and licensed in the state in which they live. In other words, if I live in California, and move to Oregon, I can't take my insurance with me. It's not portable to Oregon.

Portability would make perfect sense for patients, and insurers would probably even been supportive of it. But employers don't want their insurance to be portable to another employer. And states want to retain the rights to approve or disapprove certain insurers to sell policies in their states.

The Public Option

During the healthcare reform debates from 2008 to 2010, the "public option" was one of the lightening rods of reform.

As defined during that time, the public option meant the federal government would become an insurer, like a private insurer, offering a policy that would be similar to Medicare, but to those of any age who elected to purchase it. That would mean they would be competing for insurance customers alongside Kaiser, United Healthcare, Wellpoint, the Blues and all the other private insurance providers across the country.

Of course, the very low cost, basic insurance the government could offer would be a huge advantage to patients because it would offer good care at a low cost. But as you can imagine, insurers really hated the idea - so much so that they spent $1.4 million a day in lobbying efforts to make sure no public option was included in the reform bill that was passed.

Many providers objected to inclusion of a public option, too, because they felt as if it would lower their reimbursements. Their fear was that once they were expected to take a lower paycheck from a public option-insured patient, then other private insurers would begin lowering their reimbursements, too.

Learn more about the pros and cons of the public option.

Tort Reform

The word "tort" itself is a legal term for "negligence." When a patient's safety is violated, either through a medical error, or through lack of the right care at the right time, a patient may file a tort; a malpractice lawsuit.

The amount, in dollars, of malpractice lawsuits in the United States has grown exponentially, beyond the real "value" of the negligence imposed on a patient.

Not that malpractice lawsuits shouldn't be filed and won, and that providers or facilities shouldn't be held accountable; they most certainly should. But lawyers, seeing big dollar signs on the winning of a lawsuit, will file them frivolously for huge sums of money, promising patients or families big returns on the other end. What those patients and families find out is that they are the ones dragged through the legal mud, and it's only the lawyers who actually wind up making a lot of money. And, because these lawsuits have become so huge and expensive, insurers will often settle out of court, leaving a doctor with a black mark on his or her record which may, or may not be deserved, patients who are left wondering why their expectations were so badly violated, and lawyers with bigger bank accounts. p>Tort reform, then, would put constraints on malpractice lawsuits. It would limit the awards patients could receive, which, in turn, would limit the amount insurers would have to pay out for malpractice. It would also limit the amount of money lawyers could make from such lawsuits. You can see, then, who benefits and who does not. And of course, patients and families are simply caught in the middle.

Many of those who opposed the Accountable Care Act didn't do so because they didn't agree with the concept of reform; instead, they opposed it because it didn't include tort reform. Therefore, tort reform could well be the first issue addressed when it comes to amending the Act. Expect to hear discussions about tort reform beginning soon after the ACA in its current form is fully implemented in 2014.

Learn more about tort reform and the ACA.

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