Elsevier

The Lancet

Volume 384, Issue 9937, 5–11 July 2014, Pages 75-82
The Lancet

Series
The Patient Protection and Affordable Care Act: opportunities for prevention and public health

https://doi.org/10.1016/S0140-6736(14)60259-2Get rights and content

Summary

The Patient Protection and Affordable Care Act, which was enacted by the US Congress in 2010, marks the greatest change in US health policy since the 1960s. The law is intended to address fundamental problems within the US health system, including the high and rising cost of care, inadequate access to health insurance and health services for many Americans, and low health-care efficiency and quality. By 2019, the law will bring health coverage—and the health benefits of insurance—to an estimated 25 million more Americans. It has already restrained discriminatory insurance practices, made coverage more affordable, and realised new provisions to curb costs (including tests of new health-care delivery models). The new law establishes the first National Prevention Strategy, adds substantial new funding for prevention and public health programmes, and promotes the use of recommended clinical preventive services and other measures, and thus represents a major opportunity for prevention and public health. The law also provides impetus for greater collaboration between the US health-care and public health systems, which have traditionally operated separately with little interaction. Taken together, the various effects of the Patient Protection and Affordable Care Act can advance the health of the US population.

Introduction

On March 23, 2010, US President Barack Obama signed the Patient Protection and Affordable Care Act of 2010 (frequently referred to as the Affordable Care Act).1 The legislation marked the greatest change in health policy in the USA since the 1960s. As Obama said when he signed the bill, the law is intended to enshrine “the core principle that everybody should have some basic security when it comes to their health care”.2 To achieve this aim, the law addresses fundamental problems within the US health system, including the high and rising cost of care, insufficient access to health insurance and health services for many people, low health-care efficiency and quality, and an inadequate emphasis on disease prevention.

The story of the Affordable Care Act is just beginning and its effects will unfold over many years. At the time of publication, more than 4 years after the law was adopted, its main provisions have already become firmly established in US health policy. Even so, the Affordable Care Act remains the subject of controversy and political debate, fuelled partly by difficulties in the implementation of insurance expansion.3, 4, 5 In the midst of these challenges, however, the law's salutary effects on prevention and public health are steadily taking hold. Few articles so far have described the potential effects of the Affordable Care Act on prevention and public health. In this Series paper, we briefly outline the main components of the law and then describe the parts of the law that will affect prevention and public health on a practical level, including a review of how the law is promoting collaboration between the health-care and public health systems in the USA.

Section snippets

Overview of the Affordable Care Act

A constant issue in the US health system has been that a sizeable proportion of the population has not had health insurance. The enactment in 1965 of Medicare and Medicaid, the USA's largest public health insurance programmes (panel 1), began to address this problem on a national scale. Before Medicare, only about 50% of the USA's senior citizens had hospital insurance, but now it covers nearly all people aged 65 years or older for hospital and other services.8 Similarly, before Medicaid, only

Prevention and public health

Observers have described the US health-care system as a “sick care system”—an allusion to its emphasis on treatment rather than prevention. The low proportion of state and federal government health spending that is devoted to public health activities—only 2·7% in 2012—shows how low a priority it is.53 The Affordable Care Act aims to better emphasise prevention and public health in the US health system through establishment of national prevention priorities, catalysis of prevention initiatives,

Public health–health-care collaboration

Some of the Affordable Care Act's effects will result from increasing the impetus for collaboration between the US public health and health-care systems, which for nearly a century have operated with little interaction.68 The health-care system mostly provides individual care. The public health system focuses on the detection of, and response to, disease threats through epidemiology, disease surveillance, community-wide preventive interventions, and clinical services that are necessary for

References (74)

  • T McAfee et al.

    Effect of the first federally funded US antismoking national media campaign

    Lancet

    (2013)
  • The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education...
  • SG Stolberg et al.

    Obama signs health care overhaul bill, with a flourish

  • L Hamel et al.

    Kaiser health tracking poll: April 2014

  • DM Berwick

    The toxic politics of health care

    JAMA

    (2013)
  • TS Jost

    Beyond repeal—a Republican proposal for health care reform

    N Engl J Med

    (2014)
  • P Fronstin

    Sources of health insurance and characteristics of the uninsured: analysis of the March 2012 current population survey. Employee Benefit Research Institute Issue Brief 2012, No. 376

  • CMS fast facts

  • N De Lew

    Medicare: 35 years of service

    Health Care Financ Rev

    (2000)
  • The uninsured: a primer—key facts about health insurance on the eve of coverage expansions

  • AK Driscoll et al.

    Health and access to care among employed and unemployed adults: United States, 2009–2010

  • J Hadley et al.

    Covering the uninsured in 2008: current costs, sources of payment, and incremental costs

    Health Aff (Millwood)

    (2008)
  • K Baicker et al.

    The Oregon experiment—effects of Medicaid on clinical outcomes

    N Engl J Med

    (2013)
  • Care without coverage: too little, too late

    (2002)
  • H Levy et al.

    The impact of health insurance on health

    Annu Rev Public Health

    (2008)
  • CBO's April 2014 estimate of the effects of the Affordable Care Act on health insurance coverage

  • Report shows Affordable Care Act has expanded insurance coverage among young adults of all races and ethnicities

  • Health insurance market reform: rate restrictions

  • How do I qualify for an exemption from the fee for not having health coverage?

  • Essential health benefits standards: ensuring quality, affordable coverage

  • 77 Fed. Reg. 30,377, 30,400 (May 23, 2012) (to be codified at 26 C.F.R. Part 1 and 26 C.F.R. Part 602)

  • Annual updated of the HHS poverty guidelines

  • Issue brief: state-by-state estimates of the number of people eligible for premium tax credits under the Affordable care Act

  • Transcript of news conference on the Affordable Care Act

  • L Levitt et al.

    The numbers behind “young invincibles” and the Affordable Care Act

  • Health insurance marketplace: March enrollment report

  • Profiles of Affordable Care Act coverage expansion enrollment for Medicaid/CHIP and the Health Insurance Marketplace, May 1, 2014

  • Questions and answers on options available for consumers with cancelled policies, January 3, 2014

  • National Federation of Independent Business, et al. v. Kathleen Sebelius, et al. 11-393, 11-398, 11-400 (US Supreme...
  • GM Kenney et al.

    Opting in to the Medicaid expansion under the ACA: who are the uninsured adults who could gain health insurance coverage? Timely Analysis of Immediate Health Policy Issues, August 2012

  • R Nardin et al.

    The uninsured after implementation of the Affordable Care Act: a demographic and geographic analysis

  • M Andrews

    Despite health law's protections, many consumers may be “underinsured”

  • EJ Topol

    Topol asks Sebelius 5 ACA questions

  • M Abrams et al.

    Realizing health reform's potential: how the Affordable Care Act will strengthen primary care and benefit patients, providers, and payers. The Commonwealth Fund (report), January 2011

  • Long-term growth of medical expenditures—public and private

  • AB Martin et al.

    Rate of health spending in 2012: rate of health spending growth remained low for the fourth consecutive year

    Health Aff (Millwood)

    (2014)
  • Cited by (95)

    • The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York

      2021, American Journal of Emergency Medicine
      Citation Excerpt :

      Beyond health insurance coverage, the ACA sought to address the deficiencies in quality and efficiency of healthcare provision by enhancing patient-centered care and increasing the use of preventive services [13,14]. The ACA also aimed at restraining the growth of healthcare costs through policies that strengthened the link between cost and quality of care and targeted the utilization of high-cost services such as emergency department (ED) visits [14-19]. Advocates of the ACA argued that by expanding insurance coverage, ED use would decrease after ACA implimentation [20,21].

    View all citing articles on Scopus

    A S Rein was with the US Centers for Disease Control and Prevention at the time of this work but is no longer affiliated with it

    View full text