Padilla 1

Estevan Padilla
Gail Richard
Composition II
18 April 2016
Proposal
The primary goals of the Affordable Care Act 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
countries deficit in the long run, by shifting more of the financial responsibility away from the
government and to the citizens of the United States.
Part of the law mandates that every individual is insurable, and for no one to be denied
and or have limited coverage due a medical condition that existed prior to the effective date of
their coverage. This issue 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 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

Padilla 2
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 provide 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.
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

Padilla 3
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
ACA that we could incorporate into Medicare, such as preventive services.
The basic frame work is there and already functional within the Center for Medicare and
Medicaid Services program. Take these two programs and incorporate our current population.

Padilla 4
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.
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

Padilla 5
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.

Padilla 6
Works Cited
Day, Benjamin, David D. Himmelstein, Michael Broder, and Steffie Woolhandler. "THE
AFFORDABLE CARE ACT AND MEDICAL LOSS RATIOS: NO IMPACT IN FIRST
THREE YEARS." Pros and Cons of Obamacare: Is It What the United States Needs?
(n.d.): 127-31. Healthcare-now.org. Healthcare-now.org. Web.
"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
House. The White House, 6 Feb 2014. Web. 2 Feb. 2016.
Powers, Janis. "The Side Effects of Obamacare 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>.