Discussion: The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery.

Abstract

www.PRSJournal.com 154e From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital. Received for publication June 29, 2020; accepted August 4, 2020. Copyright © 2020 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000007500 I this article, the authors examine the impact of the Patient Protection and Affordable Care Act in 2010 on breast reconstruction, craniofacial surgery, and gender-affirmation surgery.1 As the authors point out, the Affordable Care Act represents one of the most broad health care experiments borne out of a need to increase access, decrease cost, and improve quality. Conceptually, the Affordable Care Act sought to decrease costs and improve quality through Medicaid and Medicare payment reform and increase access and coverage to low-income Americans through Affordable Care Act insurance marketplaces and Medicaid expansion. Within payment reform, two attempts at reforming the traditional fee-for-system volume centric structure have been implemented by the Center for Medicare and Medicaid Innovation.2 The first rewards quality and penalizes poor outcome in hospital payments. The efficacy of these programs is still in question; they may disproportionately punish safety net hospitals serving socioeconomically disadvantaged patients.3–5 The second aspect of payment reform targets provider reimbursement. Accountable care organizations are groups of health care practitioners that are financially responsible for cost and quality for a defined patient population. Previous iterations of Bundled Payments for Care Improvement found equivalence in outcomes and modest reduction in spending, which may be offset by high administrative costs because of the complexities of adding new forms of coverage and payment without dismantling existing structures.6,7 Although plastic surgery has largely escaped the focus of these initiatives, with low participation in accountable care organizations and no Bundled Payments for Care Improvement plans, plastic surgeons need to study their contributions and grapple with optimal bundle payment design.8,9 The most successful aspect of the Affordable Care Act may have been its initiative to improve insurance coverage for Americans. Broad gains have been achieved in insurance coverage in the socioeconomically and racially disadvantaged, although rates of no insurance coverage remain high.10 The Affordable Care Act targeted two problems: barriers to coverage and comprehensive risk protection.11 In the former, the Affordable Care Act expanded eligibility for Medicaid to those below the 138 percent of the poverty level. For those between 100 and 400 percent of the poverty level who did not qualify for Medicaid or employer-based insurance, tax credits were offered to help offset the cost of plans within the insurance market. Employer-based insurance plans and plans purchased through the insurance marketplace were required to offer dependent child coverage until a child reaches the age of 26 years. To eliminate barriers to comprehensive risk protection, the Affordable Care Act prohibited insurers from underwriting policies based on sex and health, limited additional cost for the elderly and smokers, and eliminated exclusions for preexisting conditions. Perhaps the most compelling analysis in this study was the impact of the Affordable Care Act on care for the transgender population, a group facing wide limitations and injustices in access to care and coverage.12 Based on analysis of the National Inpatient Sample, National Surgical Quality Improvement Program, and Humana claims databases, the authors concluded that the Affordable Care Act had positive benefits on coverage for the transgender population. As correctly pointed out, future studies are needed. The examination falls Kenneth L. Fan, M.D. Gabriel Del Corral, M.D. David H. Song, M.D., M.B.A.