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