How Obamacare Will Impact Reproductive Health

Paul R. Brezina; Anish A. Shah; Evan R. Myers; Andy Huang; Alan H. DeCherney


Semin Reprod Med. 2013;31(3):189-197. 

In This Article

Patient Protection and Affordable Care ACT

On March 23, 2010, President Obama signed into law the 906-page PPACA.[9,23] This sweeping and complex piece of legislation will result in significant changes to many aspects of how health care is delivered in the United States. To understand how the PPACA will have an impact on the field of reproductive medicine, it is first necessary to understand the basic construction of the law.

Mandated Coverage

A central tenet of the PPACA is to mandate that the vast majority of individuals in the nation are enrolled in some type of health insurance program, be it private or public.[24] This portion of the law is considered to be critical to the overall viability of the bill. Mandating health coverage is necessary for two major reasons. First, such coverage helps private insurers comply with certain parts of the legislation, such as preventing higher insurance premiums for individuals with medical preexisting conditions. If healthy people are able to opt out of purchasing insurance, and premiums for preexisting conditions are capped, then eventually the costs of providing the care for those with preexisting conditions would exceed the revenue from premiums (and the returns on invested premiums), making private insurance unprofitable and, ultimately, unsustainable. Second, the current safety net provided through the Emergency Medical Treatment and Active Labor Act (EMTALA), which ensures that all individuals have access to emergency medical care, is not a viable economic model for providing primary care for patients with no insurance and is a driver of rising costs.[25]

PPACA Regulations

Under PPACA, a variety of regulations are created to ensure that the vast majority of Americans are able to obtain health insurance coverage. The following paragraphs are a brief outline of the core components of the PPACA.

Perhaps the most visible aspect of comprehensive insurance coverage is the individual mandate. The mandate states that all individuals must obtain health insurance or face a financial penalty, up to ~$2000 annually for noncompliance.[9,24] Economically disadvantaged individuals, up to 400% of the federal poverty level, will be provided with fiscal tools from the federal government to help purchase health insurance.[9] Insurance for this economically disadvantaged group will be made available through a new state-based American Health Benefit Exchange.[9] Although there will be some select demographic groups that exempted from this individual mandate, such as Native Americans, undocumented immigrants, and incarcerated individuals, the regulations are intended to be applied to the vast majority of the population.[9] A series of regulations, incentives, and disincentives will also be applied to private employers to strongly encourage increased availability of private employee-paid health insurance to a greater number of individuals.[9]

In addition, Medicaid will be expanded to all non-Medicare-eligible individuals <65 years, such as children and pregnant women, with incomes <133% of the federal poverty level.[9–24] Currently Medicaid and Medicare collectively purchase ~50% of all health services.[26] This has resulted in a significant and increasing fiscal strain for both Medicaid and Medicare.[26] Therefore, increased federal funding for the programs is included in the legislation. Because Medicaid is managed and largely funded at the state level, the federal government will, under PPACA, provide financial support to cover most of the costs associated with this expansion.[9] Many specifics of the Medicare program will also be modified in an effort to improve quality and cost effectiveness.[9] In addition, Medicaid reimbursement to primary care physicians will be increased to 100% of the Medicare payment rates, for 2013 and 2014.[9]

A variety of new or expanded taxes are also built into the PPACA that are designed to provide funding of these expanded programs.[9] These include increasing federal wage taxes, imposing an excise tax on insurers of more expensive employer-sponsored health plans, eliminating certain tax deductions, and assessing billions in fees from the pharmaceutical manufacturing and health insurance industries.[9] In an effort to further "bend the cost curve" downward, superimposed on these short-term increases in funding are significant long-term planned decreases in funding for Medicare and Medicaid.[24–28] Furthermore, long-term reductions in funding are aimed at physician compensation, although a relatively small proportion of overall health care costs are attributed to physician compensation, 9 to 21% of total health care expenditures.[24–30]

Health Insurance Exchanges

To facilitate access to health insurance, the PPACA will usher in health insurance exchanges (HESs).[9] HESs are a set of state coordinated and standardized health care plans where health insurance can be purchased.[9] Individuals who desire alternatives to private insurers can be offered state-based American Health Benefit Exchanges, and small companies of <100 employees can potentially obtain insurance through the Small Business Health Options Program.[9] These exchanges will not be available to larger companies that will still provide insurance through traditional private health insurance companies.[9 31] In addition, a Consumer Operated and Oriented Plan (CO-OP) program will be established to encourage the creation of nonprofit, member-run health insurance companies.[9] CO-OPs meeting certain criteria will be eligible to receive federal financial support. HESs will provide various tiers of coverage (Bronze, Silver, Gold, Platinum, and Catastrophic), each with different monthly premiums.[9] By federal law, all HESs must be fully certified and operational by January 1, 2014.[9–24]

Alterations to Private Insurance

Under the PPACA, the vast majority of Americans will still be covered through traditional medical insurance companies.[9] However, a variety of new consumer-friendly changes will be instituted to address how insurance coverage is provided. First, prohibitions of preexisting medical conditions and lifetime limits on dollar value of coverage will be prohibited.[9] Limits will be placed on waiting periods for start of health care coverage, and finally, dollar amount limits on deductibles will be placed.[9] The full enforcement of many of these provisions will be in place by 2014.[9] The PPACA also requires health plans to disclose how much of their budget is spent on clinical care, quality improvement, and so on.[9] In addition, if certain minimum proportions of funds are not invested in patient care, the PPACA will require insurance companies to provide rebates to consumers.[9]

Accountable Care Organizations

First coined as a term in 2006 by Elliot Fisher, an accountable care organization (ACO) is a network of physicians and hospitals that share responsibility for providing patient care.[32–36] In concept, ACOs are not dissimilar from the HMO.[34] In general terms, ACOs are entities that assess per capita fees for providing comprehensive medical care to a large pool of patients.[34,37] These payments are linked to quality improvements, providing an incentive for ACOs to maximize quality and efficiency.[24,27] A central purpose of the ACO is to shift physician payment from a "fee-for-service" to a salary-based employment model.[36,38] In addition, ACOs are externally monitored through sophisticated performance measurements to continuously optimize quality and cost savings.[33,36,39]

The ACO model has been embraced by the federal government.[38] Section 3022 of the PPACA establishes guidelines for the establishment of the Medicare Shared Savings Program (MSSP).[9,34] The MSSP began awarding Medicare and Medicaid service contracts in January 2012 to ACOs that represent a minimum of 5000 beneficiaries.[33] Although the ACO is clearly being adopted as the future model of choice for Medicare and Medicaid, there are no current mandates directing HESs or private insurers to use ACOs.[37]

However, some are critical of certain aspects of the ACO model. The American Hospital Association projects high financial costs associated with the implementation and maintenance of the ACO structure.[35] Some also worry that the ACOs may limit competition in the marketplace and actually introduce more inefficiencies into the system. To monitor for possible antitrust violations, the U.S. Department of Justice has established a voluntary antitrust review process for ACOs.[40]

The role that ACOs will ultimately play in the health care system at large is unclear at this early stage.[41] Some believe that private insurers will eventually follow the government's lead and embrace the ACO model.[26] Others disagree and do not think that ACOs will become the single dominant model throughout the country.[42] Even if adopted on a large scale, it is currently unclear about the impact ACOs will have on private physician groups, private surgery centers, and so on.[42]

Payment Modifications

The percentage of national GDP allocated toward health care, currently at ~17%, has been consistently increasing in America.[8,27,43] In response to this trend, a central tenet of the PPACA is to reduce health care costs. The current system of compensation for physicians and hospitals is based on quantity of care. However, a shift will be made by the PPACA to quality of care, to reduce inefficiencies resulting in increased cost. Thus the PPACA will require all physicians by 2015 to participate in a quality reporting initiative that will link physician compensation to quality rather than quantity of care delivered.[9] In addition, ACOs, as outlined earlier, will allocate funds based largely on quality and efficiency outcomes.[9,44]

Several oversight bodies will also be created under the PPACA. In 2015 an Independent Payment Advisory Board, composed of 15 presidential appointees with 6-year terms, will have the authority to reduce per capita Medicare spending.[9] Of note, this board will not have the authority to increase spending.[9] Additionally, Congress will only have limited ability to modify the recommendations of this board.[9] Also in 2015, the secretary of the Department of Health and Human Services (DHHS) will have a new authority to alter physician payment based on a value-based payment modifier.[9 44] The value-based payment modifier is a method in which the payments made to physicians will be increased or decreased based on the quality of care delivered relative to charges.[44]

Essential Health Benefit

The PPACA established the creation of a minimal set of benefits that all insurance programs, both inside and outside of HESs, must offer known as essential health benefits (EHBs).[45] These EHBs are not directly outlined in the PPACA.[45] Rather, the PPACA calls on the DHHS to formalize the EHB with input from multiple parties including the Institute of Medicine, the Department of Labor, members of Congress, physician groups, and private citizens.[45]

On December 16, 2011, the DHHS issued a bulletin outlining proposed policies that further outlined the medical services that would be provided under the PPACA.[45] [Table 1] and [Table 2] outline the scope of these EHBs.[45] In many ways, this document gave increased flexibility and freedom to the states in determining the scope of insurance coverage for a variety of medical conditions including the treatment of infertility.[45]

Emphasis on Primary Care

The PPACA will, by its very structure, place an increased emphasis on access to primary care physicians, generally defined as family medicine, general internal medicine, and pediatrics.[11] In the medical delivery system existing prior to PPACA, individuals without health insurance policies had limited access to outpatient primary care providers. EMTALA, since its enactment, has ensured that all individuals have access to emergency medical care.[25] Therefore, emergency departments in the United States, prior to PPACA, actually were involved in the delivery of much of the primary medical care for the uninsured.[11] This system has been criticized as being inefficient and associated with suboptimal delivery of medical care.[11] The passage of PPACA, however, will fundamentally change the paradigm of medical care delivery.

Under PPACA, essentially all individuals will have a payer source that will give access to receive nonemergent primary medical services.[9] In fact, it is estimated that the PPACA will make health insurance available to >32 million uninsured individuals by the year 2019.[46] In addition to this increased pool of insured individuals, a greater percentage of Americans will likely use medical professionals given the increasing elderly population.[11] The rapidly increasing number of nonphysician practitioners, such as physician assistants, will increasingly be used to help meet this increased demand in the long term.[11] From a supply-and-demand point of view, this should quickly increase the value of primary care providers, both physicians and midlevel providers.