Impact Of Affordable Care Act Research Articles

The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals.

Passage of the Affordable Care Act (ACA) in 2010 and subsequent Medicaid expansion has influenced access to HIV treatment and care in the USA. This review aims to evaluate whether the implementation of these policies has impacted progress toward UNAIDS 90-90-90 goals. Preliminary evidence has emerged suggesting that the ACA and Medicaid expansion has increased the likelihood of HIV testing and diagnosis, reduced the number of people unaware of HIV infection, and increased the number of people on antiretroviral therapy (ART) who are virally suppressed. While the ACA is associated with some progress toward 90-90-90 goals, more years of data after policy implementation are needed for robust analysis. Methods including difference-in-differences, instrumental variables, and propensity scores are recommended to minimize bias from unmeasured confounders and make causal inference about non-random Medicaid expansion among states.

Household Labor Search, Spousal Insurance, and Health Care Reform

Health insurance in the United States for the working age population has traditionally been provided in the form of employer-sponsored health insurance (ESHI). If employers offered ESHI to their employees, they also typically extended coverage to their spouse and dependents. Provisions in the Affordable Care Act (ACA) significantly alter the incentive for firms to offer insurance to the spouses of employees. We evaluate the long-run impact of ACA on firms’ insurance offerings and on household outcomes by developing and estimating an equilibrium job search model in which multiple household members are searching for jobs. The distribution of job offers is determined endogenously, with compensation packages consisting of a wage and menu of insurance offerings (premiums and coverage) that workers select from. Using our estimated model we find that households’ valuation of employer-sponsored spousal health insurance is significantly reduced under ACA, and with an “employee-only” health insurance contract emerging among low productivity firms. We relate these outcomes to the specific provisions in the ACA.

Household Labor Search, Spousal Insurance, and Health Care Reform

Health insurance in the United States for the working age population has traditionally been provided in the form of employer-sponsored health insurance (ESHI). If employers offered ESHI to their employees, they also typically extended coverage to their spouse and dependents. Provisions in the Affordable Care Act (ACA) significantly alter the incentive for firms to offer insurance to the spouses of employees. We evaluate the long-run impact of ACA on firms’ insurance offerings and on household outcomes by developing and estimating an equilibrium job search model in which multiple household members are searching for jobs. The distribution of job offers is determined endogenously, with compensation packages consisting of a wage and menu of insurance offerings (premiums and coverage) that workers select from. Using our estimated model we find that households’ valuation of employer-sponsored spousal health insurance is significantly reduced under ACA, and with an “employee-only” health insurance contract emerging among low productivity firms. We relate these outcomes to the specific provisions in the ACA. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Impact of Affordable Care Act Insurance Expansion on Pre-Hospital Access to Care: Changes in Adult Perforated Appendix Admission Rates after Medicaid Expansion and the Dependent Coverage Provision

The Affordable Care Act (ACA) changed the landscape of insurance coverage, allowing young adults to remain on their parents' insurance until age 26 (Dependent Coverage Provision [DCP]) and states to optionally expand Medicaid up to 133% of the federal poverty level. Although both improved insurance coverage, little is known about the ACA's impact on observed receipt of timely access to acute care. The objective of this study was to compare changes in insurance coverage and perforation rates among hospitalized adults with acute appendicitis "after vs before" Medicaid expansion and the DCP using an Agency for Healthcare Research and Quality (AHRQ)-certified metric designed to measure pre-hospital access to care. We performed a quasi-experimental, difference-in-difference (DID) analysis of 2008-2015 state-level inpatient claims. Adults, aged 19 to 64, in expansion states experienced an absolute 7.7 percentage point decline in uninsured (95% CI 7.5 to 7.9) after Medicaid expansion compared with nonexpansion states. This coincided with a 5.4 percentage point drop in admissions for perforated appendicitis (95% CI 5.0 to 5.8) that was most pronounced among young adults, aged 26 to 34, just age-ineligible for the DCP (DID: 11.5 percentage points). Medicaid expansion insurance changes were 4.1 times larger than those encountered under the DCP (DID: 1.9). They affected all population subgroups and significantly reduced access-related disparities in race/ethnicity and lower-income communities. Although both Medicaid expansion and the DCP were associated with significant insurance gains, those attributable to the DCP were more concentrated among more privileged patients. Despite this trend, both policies resulted in larger reductions in perforation rates for historically uninsured and underserved groups. Reductions in uninsured after Medicaid expansion and the DCP were associated with significant reductions in perforated appendix admission rates. Improvements in access to acute surgical care suggest that maintained/continued insurance expansion could lead to fewer delays, better patient outcomes, and reductions in disparities among the most at-risk populations.

A Reevaluation of the Effects of State and Federal Dependent Coverage Mandates on Health Insurance Coverage

State governments have been passing laws mandating insurers to allow young adults to stay on their parents' health insurance plans past the age of 19 since the 1970s. These laws were intended to increase coverage, but research has been inconclusive on whether they were successful. We reconsider the issue with an improved approach featuring three key elements: a new, accurate dataset on state mandates; recognition that effects could differ greatly by age due to take up rate differences; and avoidance of endogenous characteristics when identifying mandate eligible young adults. We find the impact of the state mandates was concentrated among the 19 to 22 age group, for which dependent coverage increased sharply by about 6 percentage points. Overall coverage increased by almost 3 percentage points, with the difference explained by crowd out of public insurance. Crowd out of coverage through young adults own jobs was negligible. For those above age 22, we find little evidence of changes in coverage. We incorporate these insights into analysis of the Affordable Care Act (ACA) dependent coverage mandate, showing its effects were focused among those whom were previously ineligible for state mandates, or were eligible but older than 22. We argue the ACA's impact was broader because it had fewer eligibility conditions that implied parental dependence; young adults could be on their parents' insurance but still be relatively independent.

Abstract IA28: Rural disparities in uptake of well visits and access to cancer screening in Medicare under the Affordable Care Act

Abstract Background: Under the Affordable Care Act (ACA), Medicare beneficiaries can receive annual wellness visits (AWV) to configure or update a personalized prevention plan. Previous data show the use of AWVs rose from about 7 percent overall (3.2 million visits) in 2011 to 20 percent (10.4 million visits) in 2016, but patterns of rural uptake of AWV have not been examined nor their potential to reduce rural disparities in cancer screening. Methods: We examined physician and outpatient claims for rural and urban beneficiaries enrolled in Medicare 5% FFS (“Fee for Service”) from 2011-2014 among beneficiaries with >1 year prior enrollment. Beneficiaries were classified into three groups based on previous care patterns: patients with annual health care visits but no AWV (controls); those without previous screening but who attended a subsequent AWV; and those with a previous screening episode with a subsequent AWV. Confounders considered included beneficiary race (white, black, other), gender, age category at reference, Charlson comorbidity score, reference date, National County Economic Distress from Appalachian Regional Commission, and NCHS rural urban status. Outcomes included receipt of colorectal (CRC) and breast (BC) cancer screenings, as well as a bundle of 7 recommended preventative services relating to cardiovascular disease, cancer, diabetes, and bone density. Results: Per beneficiary, AWVs were more likely to occur in metropolitan regions and regions with higher socioeconomic indices, along with individual characteristics such as white ethnicity, female gender, and older age groups. By 2014, the AWV utilization rates in metropolitan residents were 60% higher than rural residents. For both urban and rural US populations, screening access for those without an AWV was significantly lower than with an AWV. For CRC and BC screening, having an AWV was associated with a greater than two-fold increase screening compared to controls (p < .001). Only 20% of the control group had 1 of 7 possible preventive services examined compared to > 80% of the other patient groups. We examine evidence of the impact of ACA on access to screening in rural Appalachia to identify policy and implementation research solutions for the well-documented higher late-stage cancer burden in this region. Conclusions: Our findings strongly suggest that AWVs can be used to reduce disparities in preventive services, such as cancer screenings and vaccinations, especially in disadvantaged groups that tend to lack prior preventive services. However, rural beneficiaries have fewer opportunities to have an AWV. Policies to increase AWV penetration may involve increasing access through community health workers, practice-based supports, and increased financial incentives. Given the size of the screening effects found in this study together with the underutilization of AWV by rural populations, we believe policy seeking to expand the use of AWVs may help with early detection of cancer to improve survival. Citation Format: Roger T. Anderson, Fabian Camacho, Aaron Yao. Rural disparities in uptake of well visits and access to cancer screening in Medicare under the Affordable Care Act [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr IA28.

CN2 - Estimating the Impact of Affordable Care Act (ACA) on Likelihood of Receiving Mammography and PAP Smear Screenings

ACA removed cost sharing for preventive services including cancer screenings such as mammography and pap smear. In 2015, 65.3% of women >=40 years had a mammogram within previous two years, while 70.4% of women >=18 years had a pap test within three years. identify the impact of ACA on mammography and pap smear utilization rates by predicting the rates with and without ACA so that differential effects of ACA on screening rates by demographics, socioeconomics, and health status can be identified. Data source: The Medical Expenditure Panel Survey (MEPS) data for the years 2008 (pre- ACA) and 2015 (post- ACA). Mammography cohort included women aged >= 40 and pap smear cohort included women aged >= 21. There were 14,047 women in mammography cohort and 22,342 women in pap smear cohort. Measures: main outcomes are the receipt of mammography and pap smear; the covariates are income, insurance, age, race, education, marital status, region, and comorbidity. Statistical analysis: Multivariate logistic model was run to explain the likelihood of mammography and pap smear screenings pre-ACA. The estimated model was used to predict utilization of screenings in post-ACA years in absence of ACA. Differences between predicted probabilities and actual use reflect ACA-effects. Mammography coverage would have been 71% in 2015 without ACA but the actual coverage was 70%. Some population subgroups showed statistically significantly higher mammography use than predicted such as middle-income group, aged 51-64, separated, and low-educated. Pap smear coverage would have been 79% in 2015 without ACA but the actual coverage was 76%. We observed no impact of removing cost-sharing under the ACA on mammography and pap smears coverage rate. Financial barrier may not be the most important factor affecting utilization of screenings.

Trends in Insurance Status Among Patients Diagnosed With Cancer Before and After Implementation of the Affordable Care Act.

The Affordable Care Act (ACA) aimed to increase insurance coverage through key provisions such as expansion of Medicaid eligibility and enforcement of an individual mandate. The objective of this study is to examine the impact of the ACA on insurance rates among patients newly diagnosed with colon, lung, or breast cancer. Using the SEER database, patients younger than age 65 years diagnosed with colon, lung, or breast cancer between 2008 and 2014 were identified. Insurance rates were examined before versus after passage of the ACA (2011) and before (2011 to 2013) versus after (2014) Medicaid expansion in nine expansion states and five nonexpansion states. Difference-in-differences models were used to estimate the differential impact of ACA in expansion compared with nonexpansion states. A total of 414,085 patients with known insurance status were diagnosed with colon, lung, or breast cancer between 2008 and 2014. For all cancer types, there was a significant increase in patients enrolled in Medicaid after 2011 in expansion states. Between 2011 to 2013 and 2014, in patients living in states with Medicaid expansion, the uninsured rates decreased by ≥ 50% among patients with a new diagnosis of lung and colon cancer (6.5% in 2011 to 2013 to 3.1% in 2014 and 6.8% in 2011 to 2013 to 3.4% in 2014, respectively; P < .001); the uninsured rate decreased to a lesser degree for patients with breast cancer (2.7% in 2011 to 2013 to 1.6% in 2014; P < .001). This decrease in the rate of uninsured patients was absent in patients living in nonexpansion states. The ACA resulted in expanded insurance coverage for patients diagnosed with colon, lung, and breast cancer. However, the impact was only observed in states that increased their Medicaid eligibility.

Excess Deaths Among the Uninsured Before the Affordable Care Act (ACA), and Potential Post-ACA Reductions.

Despite implementation of the Affordable Care Act (ACA), as of 2015, about 25.8 million working-age Americans remained uninsured and vulnerable to premature death because of poor health care access. The ACA-mandated phasing out of disproportionate share hospital payments that supported charity care may aggravate care access for the residual uninsured. To estimate excess deaths among the uninsured and the potential ACA impact on the basis of a recent cohort's mortality experience. We hypothesized a higher uninsured mortality risk than the available pre-2000 estimate because of worsening of care disparities owing to technology-driven advances in life-saving care. We conducted a retrospective cohort study of the 1999 to 2002 National Health and Nutrition Examination Survey respondents observed through 2011. We estimated (a) weighted Cox proportional mortality hazard of uninsured working-age adults adjusted for demographics, comorbidity, and lifestyle behaviors, (b) weighted mortality rates among the uninsured and insured within age and comorbidity strata, and (c) excess deaths because of uninsurance using the Institute of Medicine methodology. Noninstitutionalized US population. Adults aged 20 to 64 years. Mortality. Of 7274 study-eligible respondents, 20.6% were uninsured and 478 died during follow-up, for an adjusted uninsured mortality hazard ratio of 1.57 (95% confidence interval, 1.12-2.21) versus privately insured, translating to 48 529 excess deaths among the population aged 25 to 64 years in 2011 (7.8% of total deaths in this age group). The estimated proportion of excess deaths was 52% higher than the pre-2000 cohort study. The mortality disparity increased with age and comorbidity. Findings support our hypotheses, and indicate that post-ACA, a residual 4.7% excess mortality among working-age adults will continue, about 30 428 excess deaths annually. Restoration of disproportionate share hospital supports and continued advocacy for universal health care coverage are needed to reduce avoidable deaths.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature.

IntroductionThis comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes.MethodsWe conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS.ResultsMany changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems.ConclusionEMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

The Affordable Care Act (2010) and its perceived impact on assisted fertility care access: Pilot data from a national sample of women’s health practitioners in USA

Objective: The Patient Protection &amp; Affordable Care Act (ACA), or “Obamacare”, represents the most substantial reform of the U.S. healthcare system since the 1965 creation of Medicare and Medicaid. This investigation sought to ascertain knowledge and opinion among physicians providing women’s healthcare services about how this national health program will impact access to fertility treatments.Methods: Between May-July 2014, doctor’s perceptions of ACA were registered by anonymous questionnaire submitted to program directors and house staff at 50 accredited obstetrics &amp; gynecology training centers in USA. Self-reported political preferences were also tabulated for each respondent.Results: Overall, 53.3% of participants (n = 114) claimed familiarity with ACA although this varied significantly by seniority (68.8% of faculty vs. 40% of trainees; p = .003). Among respondents 54.9% identified as liberal, 23% as moderate, and 19.5% as conservative. Most physicians in this sample (51.8%) anticipated a positive impact on assisted fertility care from ACA, 17.9% predicted an adverse effect, and just under one third (30.3%) either had no opinion or were unable to make a prediction.Conclusions: This study offers the first analysis of women’s healthcare physicians’ opinion about the impact of ACA on assisted fertility services. Our report finds low general familiarity of ACA among doctors. Moreover, marked divisions of opinion exist among physicians concerning the ACA in general, as well as what role the ACA should play in the provision of assisted fertility care specifically. If U.S. physicians are to provide leadership on women’s healthcare policy initiatives with a view to reach consensus (especially with respect to assisted fertility services), improved awareness of the ACA and its sequela will be crucial.

Impact of the Affordable Care Act on Health Care Access and Utilization Among Latinos.

In the United States, Latinos have poorer access to and utilization of health care than non-Latino whites. The Patient Protection and Affordable Care Act (ACA) may reduce these disparities. The ACA's impact among Latino subgroups is unknown. Using the 2011 to 2015 National Health Interview Survey, we examined access to and utilization of health care by Latino subgroups (18-64 years old). Subgroups were defined by Latino heritage group, citizenship status, and language use. Measures of access and utilization included insurance status, delaying medical care, forgoing medical care, visiting the emergency department, and visiting a physician. Logistic regression models were used to estimate the odds of the outcomes. Time period and subgroup interaction terms were used to test the effects of the ACA. Mexicans and Central Americans had lower odds of being insured than did non-Latino whites. After ACA implementation, most reductions in disparities occurred between Puerto Ricans and non-Latino whites. Limited impact of the ACA was observed by language and citizenship status. The ACA has reduced gaps in access to and utilization of health care for some Latino population subgroups. Remaining disparities necessitate policy solutions that move beyond the ACA, particularly for groups excluded from coverage options, such as noncitizens.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. Economic and value-based evaluation, level III.

A cross-jurisdictional evaluation of insurance coverage among HIV care patients following the Affordable Care Act

ABSTRACTThe impact of the Affordable Care Act (ACA) on HIV care patients, aged 18–64, was evaluated in three jurisdictions with Medicaid expansion (Chicago, New York State, and Washington) and three jurisdictions without Medicaid expansion (Georgia, Texas, and Virginia) using data from the Medical Monitoring Project. Multivariate regression models were used to evaluate insurance status that was reported pre- and post-ACA; self-reported impact of ACA on HIV care was explored with descriptive statistics. The likelihood of having insurance was significantly greater post-ACA compared to pre-ACA in Chicago (aRR = 1.33, 95%CI = 1.20, 1.47), Washington (aRR = 1.15, 95%CI = 1.08, 1.22), and Virginia (aRR = 1.14, 95%CI = 1.00, 1.29). In Washington and Chicago, the likelihood of being Medicaid-insured was greater post-ACA compared to pre-ACA implementation (Chicago: aRR = 1.25, 95%CI = 1.03,1.53; Washington: aRR = 1.66 95% CI = 1.30, 2.13). No other significant differences were observed. Only a subset of HIV care patients (range: 15–35%) reported a change in insurance that would have coincided with the implementation of ACA; and within this subset, a change in medical care costs was the most commonly noted issue. In conclusion, the influence of ACA on insurance coverage and other factors affecting HIV care likely varies by jurisdiction.

Impact of Affordable Care Act coverage expansion on women's reproductive preventive services in the United States

IntroductionThe Affordable Care Act (ACA) expansion mandated the private health plans to cover women's preventive services starting August 2012. With limited and contradictory evidence, this study intends to assess the impact of ACA on the utilization rates and the cost burden of women's reproductive preventive service. MethodsA pre-post analysis was conducted using a nationally representative sample of females (aged 15–44years, n=4397) participating in the 2011–2013 National Survey of Family Growth. The utilization rates and cost burdens were compared for six services using bivariate and multivariable logistic regression models. ResultsAfter the ACA expansion, there wasn't a significant increase in the utilization rates of birth control/prescription (33.7% vs. 30.7%), birth control counseling (17.7% vs. 16.9%), sterilization counseling (3.3% vs. 3.5%), STI counsel/test/treat (15% vs. 14.6%) and HIV screening (24.1% vs. 23.1%). Respondents paying through insurance increased after ACA, but out-of-pocket spending (cost-sharing) didn't decrease for respondents. Type of insurance was an important predictor of utilization rates with publicly insured having significantly higher Odds Ratio (OR) or likelihood of receiving birth control counseling (OR:1.71), sterilization counseling (OR:2.67), STI counsel/test/treat (OR:1.54) and HIV screening (OR:1.69) compared to privately insured. ConclusionsThe early-on impact of ACA expansion on utilization rates of women's reproductive preventive services didn't appear to be significant. Private health plans, however, might have expanded their coverage but burden of cost sharing still existed. Future research should evaluate the long term impact of ACA expansion on women's health and the economic gains.

Awareness, Perceptions, and Communication Needs About the Affordable Care Act Across the Life Span

Background: By March 2014, all U.S. citizens were required to have health insurance according to the Affordable Care Act (ACA). Purpose: Study objectives were to explore individuals' opinions, perceptions, and communication sources and needs about the ACA and to assess differences by age group. Methods:In November 2013, 10 1-hour focus groups (5 with adults aged 40+; 5 with adults < age 40) were conducted with 102 individuals in one southeastern county. Audio files were transcribed and organized using NVivo 10. Recurring themes were examined by age group. Results: Younger participants had less awareness of the ACA. Both older and younger groups mentioned benefits of receiving preventive care and being covered for preexisting conditions. Confusion and lack of perceived understanding were evident across age groups. Participants heard about the ACA mainly through media and few interpersonal sources. They preferred to obtain in-person ACA information through state officials or trusted experts. Discussion: Varying knowledge levels, perceptions, and communication sources about the ACA impact use of health insurance and access to care. Translation to Health Education Practice: Clear information should be communicated to each age group using their preferred communication channels to increase understanding of the ACA and its importance to prevent chronic diseases.

The Affordable Care Act and Diabetes Diagnosis and Care: Exploring the Potential Impacts

This article reviews available data on the implications of the Affordable Care Act (ACA) for the diagnosis and care of type 2 diabetes. We provide a general overview of the major issues for diabetes diagnosis and care, and describe the policies in the ACA that affect diabetes diagnosis and care. We also estimate that approximately 2.3 million of the 4.6 million people in the USA with undiagnosed diabetes aged 18-64 in 2009-2010 may have gained access to free preventive care under the ACA, which could increase diabetes detection. In addition, we note two factors that may limit the success of the ACA for improving access to diabetes care. First, many states with the highest diabetes prevalence have not expanded Medicaid eligibility, and second, primary care providers may not adequately meet the increase in Medicaid patients because federal funding to increase provider reimbursement for Medicaid visits recently expired. We close by discussing current gaps in the literature and future directions for research on the ACA's impact on diabetes diagnosis, care, and health outcomes.

Out of Sight, Out of Mind: The Implementation and Impact of the Affordable Care Act in U.S. Farmworker Communities.

Farmworkers are a unique population within rural communities and are often overlooked and undercounted. They face significant disparities in health and health care access compared with the general rural population. One goal of the Patient Protection and Affordable Care Act (ACA) is to increase access to health care and health insurance for the country's most vulnerable and underserved populations. Farmworkers' numerous barriers to health care and health insurance remain, despite the ACA's progress. Apart from anecdotal accounts, we lack the necessary data to assess the ACA's impact on farmworker communities. This commentary imparts information about farmworker enrollment in and barriers to accessing health insurance, collected through individual conversations, focus groups, interviews, and informal surveys. Based on identified challenges and limitations, we make policy recommendations to assess and improve the implementation and relevance of the ACA in farmworker communities.

Expected and Unexpected Consequences of the Affordable Care Act: The Impact on Patients and Surgeons–Pro and Con Arguments

The Patient Protection and Affordable Care Act (PPACA), called the Affordable Care Act (ACA) or “ObamaCare” for short, was enacted in 2010. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract (SSAT) hosted a debate with an expert panel to discuss the ACA and its impact on surgical care after the first year of patient enrollment. The purpose of this debate was to focus on the impact of ACA on the public and surgeons. At the core of the ACA are insurance industry reforms and expanded coverage, with a goal of improved clinical outcomes and reduced costs of care. We have observed supportive and opposing views on ACA. Nonetheless, we will witness major shifts in health care delivery as well as restructuring of our relationship with payers, institutions, and patients. With the rapidly changing health care landscape, surgeons will become key members of health systems and will likely need to lead transition from solo-practice to integrated care systems. The full effects of the ACA remain unrealized, but its implementation has begun to change the map of the American health care system and will surely impact the practice of surgery. Herein, we provide a synopsis of the “pro” and “con” arguments for the expected and unexpected consequences of the ACA on society and surgeons.

Affordable Care Act and Diabetes Mellitus.

The Affordable Care Act (ACA) has the potential for great impact on U.S. health care, especially for chronic disease patients requiring long-term care and management. The act was designed to improve insurance coverage, health care access, and quality of care for all Americans, which will assist patients with diabetes mellitus in acquiring routine monitoring and diabetes-related complication screening for better health management and outcomes. There is great potential for patients with diabetes to benefit from the new policy mandating health insurance coverage and plan improvement, Medicaid expansion, minimum coverage guarantees, and free preventative care. However, policy variability among states and ACA implementation present challenges to people with diabetes in understanding and optimizing ACA impact. This paper aims to select the most influential components of the ACA as relates to people with diabetes and discuss how the ACA may improve health care for this vulnerable population.