Nuts and Bolts of a New Healthcare System

BY Siavash Zamirpour


Many senators have made clear their intention to repeal and replace the Patient Protection and Affordable Care Act (ACA), passed under President Obama in 2010.  However, it has been less clear what this new healthcare legislation would look like. This article considers some of the provisions of the current ACA that make the biggest impact for Americans’ health care, especially for populations historically underserved by the health care system. New healthcare legislation would ideally include some form of the following provisions: patient protections, extension of childhood coverage, and a center for health costs innovations.

Although rising healthcare costs are a serious concern, covering otherwise uninsured people should be a priority for any new universal healthcare bill. The current ACA resulted in at least 10 million people newly insured after its first enrollment cycle, with recent sources citing around 20 million newly insured over the bill’s lifetime. There’s debate surrounding exactly how many people the ACA has insured, largely the consequence of ambiguity on what exactly we mean by. Regardless of the exact number, we know now that a realistic benchmark is on the order of tens of millions of people.

Some feel that legislation should play a lesser role in ensuring opportunities to purchase health insurance or in establishing insurance standards that include, for example, that having a preexisting condition shouldn’t make it next to impossible to obtain affordable health insurance. We know from past experience that this sort of hands-off approach undermines health care access unjustly for large groups of working people, with minorities bearing the brunt of the impact.

We know, for example, that among working adults, Hispanic workers are least likely to have their insurance sponsored by an employer, for the prominent industries employing large percentages of Hispanic workers tend to offer fewer health care benefits. Indeed, the majority of those uninsured prior to the ACA worked full time. In the absence of basic standards of coverage, and especially in light of rising health care costs- employers cut health care benefits on their own accord, especially in industries that predominantly employ minority workers

Other reasons people might find themselves without affordable access to health insurance by no fault of their own is by having a preexisting condition or by simply being a child -- often, sadly, both. At the same time that the Epi-Pen, an emergency treatment for severe allergic reactions, saw an over 800 percent price increase from 2007 to 2016, the prevalence of food and skin allergies among children also increased, roughly 2% for food allergies and 5% for skin allergies from 1997 to 2011. The same study found that black children were at disproportionate risk of developing skin allergies.

When it comes to asthma, a child health epidemic, the picture is even starker. Asthma rates increased from 7.3% in 2001 to 8.4% in 2010, the highest they had ever been before. Children are more likely to suffer from asthma than adults, and among children, those who are multi-racial, black, or American Indian are at disproportionate risk for developing the condition, with asthma-related ER visits and hospitalizations highest among black patients. In the absence of regulation, the same people who are more likely to suffer from costly chronic health issues are less likely to find affordable health insurance, even while working full time, or before they can even work.

For many children, becoming a legal adult only worsens their problems. No one expects young adults to have it all figured out, yet before the ACA, that meant that the 18-24 age group--full of students and those transitioning into full time positions--had the highest uninsured rate in the entire non-elderly population at 28.1 percent. That’s why it’s so important to have a provision that keeps young adults on their parents’ coverage until they’ve established a stable source of income, not to mention a provision that prevents insurance companies from charging exorbitant rates from those with preexisting conditions.

And lacking health insurance isn’t just an issue of individual human rights; it actually affects the whole health care system. A testament to this is the fact that the uninsured routinely pay more than insurance companies are billed for the exact same procedures. Private insurance companies, including their public counterparts Medicare, Medicaid, and SCHIP, have the power to set price standards that they will not exceed for certain procedures. Individual patients don’t. Typically, when health care providers and consumers agree upon certain price standards, it becomes the responsibility of health care providers and health manufacturers to work on the efficiency of their delivery systems and products to meet the price. Health care costs have historically skyrocketed in the absence of such motivation.

Yet achieving high insured rates isn’t enough to drive down health care costs. As recently as last August, health care costs saw their highest monthly increase since 1981- even after roughly 20 million people became insured as a result of the ACA.  Some of the most revolutionary recent public health thinking has centered around the question of how to remove financial incentives for health care providers to overcharge and to motivate them to improve their efficiency and cut costs. A little-known provision of the ACA aims to do just that, and it has nothing to do with insured rates. The Centers for Medicare and Medicaid Services Innovation Center. The Innovation Center applies much-needed rigor to identifying money-sapping practices and inefficiencies in the health care system and testing potential fixes. If the Innovation Center is forgotten by a new ACA, it is not clear that any degree of success in expanding health care coverage will check the troubling, unsustainable grown in health care costs.

As with any health care system, ours operates best when as many consumers as possible are insured. Beyond addressing civil rights lapses, universal health care coverage is the first step in stopping unsustainable growth in health care spending. The next step is to test the system, to find and eliminate financial incentives that lead to wasteful delivery practices and seemingly innocuous inefficiencies that have very real financial consequences. Any legislature tasked with implementing a new universal health care bill is responsible for protecting all patients and lowering health care costs in the long term.

Siavash Zamirpour is a freshman at Harvard College. He plans on concentrating in chemistry and physics and is interested in health care policy.


To learn more about the current status of the ACA, healthcare legislation, and to take action: 

Official ACA Website

Official ACA Blog

National Association of Healthcare Advocacy Consultants

House G.O.P. Leaders Outline Plan to Replace Obama Health Care Act, New York Times, February 16, 2017

"Republican Health Proposal Would Redirect Money From Poor to Rich," New York Times, February 16, 2017

"Conservatives Just Made Obamacare Repeal More Difficult," Business Insider, February 14, 2017

Kaiser Family Foundation

The Commonwealth Fund

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