Predictions of the affordable care act's impact on neonatal practice
Venue: Journal of Perinatology

The 2010 Affordable Care Act (ACA) utilizes a multi faceted approach which aims to increase health care access and insurance, improve health care quality and ultimately reduce cost. The law increases access to care by providing federal funds to expand the Medicaid program to those who earn 133 to 138% of the Federal Poverty Level (FPL; Medicaid Expansion) from state based eligibility standards (which range from 50 to 200% of the FPL although states with Medicaid thresholds above this 138% FPL limit are not reduced) and prohibits insurance companies from excluding individuals with pre existing conditions. The ACA mandates that employers with at least 50 staff members provide health insurance and that Americans without employer based insurance either purchase health insurance or pay a penalty. The ACA also increased the age non dependent children may remain on parental health plans to 26 years of age and eliminates copayments from select primary care visits. Before this mandate, children who aged out of insurance coverage (most commonly at 18 years of age) were dependent on either state law or specific plan rules. Further, the law provides subsidies and tax incentives for those earning up to 400% of the FPL toward the purchase of health insurance. The ACA creates health exchanges online marketplaces for purchasing insurance where consumers can compare policies. The regulation of a minimum set of services which all health care insurance plans must cover creates a national quality standard. Improvements in health care quality are motivated by reduced federal payments for potentially preventable occurrences such as hospital acquired infections and readmission within 30 days for certain diagnoses. Quality care is incentivized by the creation of Accountable Care Organizations (ACOs) These large in/outpatient networks are eligible for financial bonuses if their actual number of hospitalizations is below established thresholds. A summary of ACA provisions relevant to neonatal practice is shown in Table 1. Provisions of the law were phased in over time. Now at the 6 year mark, all major tenets of the ACA are maturing, allowing for a preliminary assessment of its impact. The ACA will present neonatologists with unique opportunities related to payment, incentives, academic output and advocacy. Understanding the potential implications on neonatal practice will allow neonatologists to both protect vital interests and optimize newborn health. IMPACT OF INSURANCE PROVISIONS ON NEONATAL CARE AND MATERNAL HEALTH CARE ACCESS Although most US born neonates are eligible for insurance, maximizing pregnancy outcomes requires a life course perspective, spanning maternal preconception health, antenatal peripartum and postpartum, as well as inter conception health. Expansion of insurance coverage via mechanisms of the ACA particularly through Medicaid expansion could result in improved neonatal outcomes by creating constant access to health care for child bearing age women. Before the advent of the ACA, health coverage for high risk, low income women was contingent on pregnancy status. As no federal threshold existed for Medicaid eligibility, non pregnant women were subjected to the state specific Medicaid income requirements for this health insurance program, 28% of the FPL nationally. Pregnancy based insurance eligibility increased coverage of prenatal care, but left nearly 25% of healthy, non pregnant women without access to preconception or inter conception care. Current ACA requirements through Medicaid expansion are estimated to add coverage for 4.6 million women between 18 and 44 years of age. Another 7 million women of child bearing age are receiving assistance from the newly created federal sliding scale subsidies. These changes in coverage may improve neonatal outcomes by enhancing maternal health care continuity. Data suggest lapses in health care access across the mother's lifecourse may allow diabetes, hypertension and thyroid disease to worsen. Chronic disease exacerbation may then put the neonate at higher risk for adverse outcomes. Women, for example, with longer periods of well controlled diabetes (HgbA1C o6.5% before and during pregnancy have fewer neonates with congenital anomalies, death, shoulder dystocia and NICU admission compared with mothers with poorly controlled diabetes. Similar improved neonatal outcomes result from well controlled maternal chronic diseases including hypertension, obesity and hypothyroidism. Despite this regulatory intent, consistent access to prenatal care alone may not translate to improved neonatal outcomes. Independent of health insurance, higher parental incomes may influence child health through healthier behaviors such as avoidance of smoking and increased parental compliance with physician recommendations. Correlating prenatal care and birth outcome data is challenged by varying definitions of prenatal care and a focus on only a few select outcomes such as birth weight, survival and NICU admission. As randomized control trials are not feasible, it is difficult to establish direct causality between prenatal care and neonatal outcome. In addition, universal prenatal care for a diverse population may not be equally beneficial for the spectrum of pregnancies and degree of complications. Given that a large percentage of women (97% already have pre existing access to adequate or