ACA Implementation: Welcome to the Marketplace

Written by: Jennifer Kolker, MPH, Co-Principal Investigator, Pennsylvania Public Health Training Center
Copy editor: Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center

On October 1, 2013, enrollment began for the Marketplaces under the Affordable Care Act (ACA) for coverage beginning on January 1, 2014. Signed into law in 2010, the ACA makes critical changes to health insurance in the United States. Some of the ACA changes (extending health insurance coverage of children until age 26 on parents’ insurance plans, for example) took effect in 2010. In January 2014, the most important changes go into effect.

A key component of the ACA is to increase the accessibility of health insurance for all Americans. To do this, the Health Insurance Marketplaces were established. The Marketplace in each state is made up of private health insurance plans that must cover a basic set of benefits, including preventative care (such as screenings and check-ups), other doctor visits, prescriptions, hospitalization, family planning and maternity care. It provides people with different plan options and costs. Approximately half of the states are operating their own Marketplace; the federal government is operating the Marketplace in the 26 states that opted not to create their own.

People who purchase insurance through the marketplace may be eligible for tax credits or a cost-sharing reduction, depending upon their income. Income also determines how much people have to pay for copays, co-insurance and deductibles. In some states people whose annual incomes are below 138% of the Federal Poverty Level ($15,856) may be eligible for premium-free coverage through Medicaid. People who can afford to purchase insurance may face a penalty fee if they decide not to buy it.

Pennsylvania has a Poor National Standing for Infant Mortality

Written by: Linda S. Duchak, EdM, MCHES, Associate Director, Pennsylvania Public Health Training Center
Copy editor: Kurt Holliday, Communications Specialist, Pennsylvania Public Health Training Center  

In the U.S., for every 1,000 babies born, about 6 die before age 1. In Pennsylvania, for every 1,000 babies born, about 7 die before they reach age 1 (2010). Only 11 states in the U.S. had higher rate of infant mortality than Pennsylvania.

Infant mortality is defined as the death of an infant before his or her first birthday. The infant mortality rate (IMR) measures this occurrence per 1,000 live births. In addition to being a key marker of maternal and child health, the IMR has been called the most sensitive indicator of overall societal health.

In the United States, substantial progress has been made over the last 50 years in reducing the IMR. Yet with an IMR of 6.05 in 2011, the U.S. still has a relatively poor global standing. In 2010, the United States ranked 32nd among the 34 nations of the Organization for Economic Cooperation and Development in infant mortality with an overall IMR three times that of the countries with the lowest IMRs. The main reason that the U.S. IMR remains higher than that of European nations is because the U.S. has a high percentage of preterm births (12%).

Infant mortality is divided into two age periods: neonatal (birth–27 days) and post-neonatal (28–364 days). Approximately two-thirds of all infant deaths occur in the neonatal period and are caused by complications arising from low birth weight, birth defects, maternal health, preterm birth, complications of labor and delivery, and lack of access to appropriate care at the time of delivery. These problems can be linked to a complex group of conditions, including systematic inequality and lack of access to care.

Racial and geographic disparities remain persistent. Non-Hispanic black infants continue to die at nearly twice the rate of non-Hispanic white infants. Additionally, preterm-related causes of death among black infants occur at a rate three times greater than that of white infants. Geographically, Pennsylvania is included with a majority of southern states in the top quartile for infant mortality.

Further reduction of preventable infant deaths remains a challenge. Prevention of infant deaths should begin in the preconception period; opportunities are available to improve the health of mothers and thus avoid preventable infant deaths. The rates of preterm birth, including rates of late preterm birth (births between 34 and 36 weeks of gestation) and elective preterm delivery, need to be reduced. Opportunities exist to reduce the mortality rate among infants born preterm by addressing key risk factors such as maternal smoking, drinking, drug use, and chronic maternal health problems such as high blood pressure and diabetes. Many very low birth weight infants in the United States are not born in hospitals that have level III neonatal intensive-care units, which have been shown to significantly reduce mortality, indicating a need to increase access to high quality care.

Source: Morbidity and Mortality Weekly Report, August 9, 2013 / 62(31);625-628.