Padilla 1

Estevan Padilla
Gail Richard
Composition II
18 April 2016
Proposal
The primary goals of the Affordable Care Act (ACA) were to offer competitive individual
health plans, to hold insurance companies accountable and to benefit our national economy.
Individuals are supposed to be able to obtain an affordable, yet competitive plan through the
medical exchanges that have been set up, that allow an individual to compare several health
plans at once and then select the one that best fits their personal needs within their budget. The
law then has mandated that insurance companies and self-insured health plans provide certain
basic preventive services in hope that premiums collected, being used for these services, will in
the long run focus on keeping individuals healthy and possibly avoid major expenses that would
be incurred due to a catastrophic illness. The afore-mentioned are supposed to help reduce the
countrys deficit in the long run, by shifting more of the financial responsibility away from the
government and to the citizens of the United States. The question then remains as to whether or
not these goals have been attained with the implementation of the ACA.
Part of the law mandates that every individual is insurable, and for no one to be denied,
or have limited coverage due a medical condition that existed prior to the effective date of their
coverage. The issue of providing coverage for individuals with pre-existing medical conditions
was being addressed by 35 states prior to the passing of the ACA with State High Risk Pools.
With the passing of the ACA individuals that were insured within these plans have been merged

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with individuals from the healthy population to share the cost or risk pool. While this merger
greatly benefits the unhealthy portion of the population, it has had some negative affect on the
healthy population, making health insurance no longer affordable for those individuals. There
was a time when these healthy individuals were allowed to purchase plans with a high deductible
and/or limited benefits that were within their personal budgets, unfortunately these type of health
plans are no longer available.
While preventive care is another major benefit that is being mandated by the ACA, there
is no significant data available at this time to support the argument that these services have now,
or will in the future, drive down the cost of catastrophic illnesses, thereby saving money. The
ACA also mandates that no health plan may set coverage or benefit limitations, such as setting a
maximum an annual or lifetime limit for treatment of autism. Until more focus and attention is
being given to the actual services being provided and the cost of these services, we can expect
little success in attaining the goals of the ACA.
As previously discussed more that 60% of the insured population are insured through
employer sponsored self-insured health plans, and those plans are exempt from many cost
control requirements, such as the percentage of premiums collected that are applied towards the
actual administration of the health plan. These employer sponsored self-insured plans are also
able to make exceptions on a case by case basis to allow benefits for treatment that may be
excluded by the plan. Unfortunately, little consideration is given by these employers to the actual
employees that will have to bare this cost share, by an increase in health insurance premiums. A
health plan, regardless of being a fully insured plan, where a health insurance company assumes
the risk, or being self-insured, where the employees assume the risk, should all be legally bound
by their plan documents.

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While the hopeful end result of the ACA is to provide cost effective healthcare that all
individuals may have access to, the focus appears to be more on the insurance industry and does
not encompass the actual healthcare providers. Healthcare cost have continued to rise over the
years. We fail to realize that a relevant portion of the cost that we incur when receiving services
is for fees that a physician must assess to offset his or her administrative cost and for malpractice
insurance. We cant blame the physician fees for everything. We are a society that expects to
receive what we want. It is not uncommon for a person to go in for a physician exam, already
diagnosing themselves and advising the physician the drug they need prescribed that they have
seen on a television commercial.
No one likes managed care or socialized medicine. They both seem to be dirty words in
our society. These two terms immediately have a person thinking healthcare rationing or being
denied services due to their age or social standing within a community. These analogies are so far
from the truth. Unfortunately to control cost and quality of care we need a gate keeper, a primary
care physician or an organization, to assist in coordinating and arranging appropriate medical
care for each individual and the condition from which they suffer.
Socialized medicine doesnt even have to necessarily have a gate keeper. If you think
about it we already have this type of program within our country and its been in effect since
1965. Medicare, yes Medicare, is a form of socialized medicine. It fits the definition except for
the fact that we currently limit participation in the program to those individuals age 65 or over,
disabled or suffering from End Stage Renal Disease. The program has worked for than 50 years.
I would propose that we expand this program to encompass all Americans. The provider network
is already in place, along with physician and facility fee schedules. There are portions of the
Affordable Care Act that we could incorporate into Medicare, such as preventive services.

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The basic framework is there and already functional within the Center for Medicare and
Medicaid Services program. Take these two programs and incorporate our current population.
There have been many changes over the past several years, especially to the Medicare program,
that have incorporated prescription drug coverage in addition to some preventive services. While
there are reports and there is in fact Medicare fraud these occurrences are no less prevalent in
private pay plans for the portion of our population that are not insured under Medicare.
You have your basic Medicare which provides benefits for hospital services under Part A
and physician services under Part B that have deductibles and cost share with the patient referred
to as coinsurance. An individual receives Medicare Part A for free, provided they have worked
and paid into the program for the allotted time. If they havent then they have the option to
purchase Medicare Part A or they are able to purchase Part A at a reduced cost depending upon
how much has been paid into the program while they were working. Everyone pays a premium
for Medicare Part B. This basic plan has grown, expanding, changing over the past 20 years to
also offer what would be the equivalent of an HMO plan under Medicare Part C and this type of
plan normally cost less and shifts more of the financial responsibility to the patient by the
assessment of copayments for services rendered.
Use the Medicaid program to provide coverage for our population that is under the age of
21. In other words, expand Medicaid further. Medicaid offers many preventive services and in
some instances may mandate those services to help assure the wellbeing of our youth. There are
different levels of Medicaid based on the income level of the patients family or their own
personal income. Some individuals are able to receive care with no expense, while some
individuals will have a copayment or coinsurance assessed to the services they are being
provided, so they are sharing the cost.

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One of the earliest examples of a community based health care system, which is a step
forward to universal health care, first appears in 1929 when Dr. Michael Shadid, an American
immigrant, began the organizing of the building of the Community Hospital of Beckham
County (Watkins) in the state of Oklahoma. It is now 2016 and it has taken us almost 100 years
to recognize what was so clear to Dr. Shadid in the early 1900s that emphasis on fee-for-service
for the sick left out the opportunity to advise and assist people on maintaining their health.
(Watkins) He spoke of preventive medicine. The American Medical Association basically was
limiting the number of individuals that were being admitted to medical schools, thus limiting the
number of physicians available to treat the existing population which in turn raised the income
for these physicians.
The Beckham County Medical Association, Oklahoma Medical Association and the
American Medical Association (AMA) all attempted to block the organization and construction
of this community hospital, in attempts to protect themselves financially, but with the help and
financial funding from the Oklahoma Farmers Union the facility was opened and successful.
Individuals that lived within the county were able to receive preventive medical care, not just
services due to illness. What is ironic is that with the implementation of the ACA the artificial
control of the ratio of patients per physician is actually inhibiting one of the most positive things
to come out of the ACA, preventive care.
Dr. Shadid and the residents of Beckham County, Oklahoma showed us that a cooperative
or universal approach to health care delivery is workable. The first thing that we need to address
is the shortage of primary care, family and general practice physicians that were intentionally
limited by the American Medical Association. This shortfall of physicians needs to be rectified
and incentives should be given to new physicians to practice in not only rural communities but in

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those communities where poverty is prevalent. Take the existing demographic data, which should
include health services and costs, over the last few years from Medicare, Medicaid with the plans
offered through the medical exchanges, then mandate that self-insured and fully insured plans
outside of these three programs provide the same data. This comprehensive data could then be
used for actuarial review for our government to come up with a plan that is comprehensive of our
entire population that would provide fair and equitable healthcare to each individual.

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Works Cited
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AFFORDABLE CARE ACT AND MEDICAL LOSS RATIOS: NO IMPACT IN FIRST
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"The Patient Protection and Affordable Care Act (ACA): Pros and Cons." Paperity. Paperity
Open Science Aggregated, Feb. 2013. Web. 20 Feb. 2016.
Furman, Jason. Six Economic Benefits of the Affordable Care Act. Web log post. White
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Powers, Janis. "The Side Effects of Obama Care Are Just What the Doctor Ordered." The
Huffington Post. TheHuffingtonPost.com, 06 Sept. 2015. Web. 02 Mar. 2016.
"CMS.gov." CMS.gov. Centers for Medicare & Medicaid Services, n.d. Web. 17 Apr. 2016.
Medicare. "Medicare & You 2016." www.Medicare.gov. U.S. Government, n.d. Jan. 2016. Web.
17 Apr. 2016. <https://www.medicare.gov/Pubs/pdf/10050.pdf>.
Brochu, Mike. "Socialized Medicine." Socialized Medicine. Jmchar.people.wm.edu, n.d. Web. 19
Apr. 2016. <http://jmchar.people.wm.edu/Kin493/socmed.html>.
Young, Jeffrey, and Avik Roy, MD. "Top 10 Pros & Cons - Obamacare." ProConorg Headlines.
Procon.org, 21 July 2015. Web. 21 Feb. 2016.
Watkins, Thayer. "Michael Shadid and Cooperative Medical Care." Michael Shadid and
Cooperative Medical Care. San Jose State University, n.d. Web. 19 Apr. 2016.
<http://www.sjsu.edu/faculty/watkins/shadid.htm>.

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Norris, Louis. "Health Insurance and High-risk Pools." Health Insurance Resource Center.
HealthInsurance.org, 12 Aug. 2015. Web. 19 Apr. 2016.
<https://www.healthinsurance.org/obamacare/risk-pools/>.