Wayne State University Law School, USA.
J Law Med Ethics. 2011 Fall;39(3):340-54. doi: 10.1111/j.1748-720X.2011.00604.x.
The Patient Protection and Affordable Care Act (ACA) sets in motion a wide range of programs that substantially affected the health system in the United States and signify a moderate but important regulatory shift in the role of the federal government in public health. This article briefly addresses two interesting policy paradoxes about the ACA. First, while the legislation primarily addresses health care financing and insurance and establishes only a few initiatives directly targeting public health, the ACA nevertheless has the potential to produce extensive public health benefits across the United States population by improving access to health care and services and reducing cost. Essentially, the ACA does not take the explicit form of a public health law but instead strives to advance public health indirectly through its effects. Second, while the ACA does not establish a right to health - or even a right to health insurance - in the United States, it does set in motion a number of significant structural and normative changes to United States law that comport with the attainment of the right to health. Most significantly, key provisions of the bill are designed to improve availability, accessibility, acceptability, and quality of conditions necessary for health, and to prompt the government to respect, protect, and fulfill these conditions. These developments mean that, to a degree, the United States essentially has undertaken the same types of legal and policy steps that a country would be required to take to uphold the right to health without actually recognizing the right to health in any formal or legally binding way. Despite these dual paradoxes and the upside potential for public health improvements resulting from the ACA, the public health impact of the law remains uncertain and will be decided by numerous subsequent regulatory and implementation decisions. The ACA authorizes multiple federal agencies to engage in rulemaking, a process that will largely dictate the systemic and health impacts that will become its legacy. This reality opens up ample opportunity to bolster public health aspects and interpretations of the law, and to simultaneously augment the corresponding components of the right to health.
《患者保护与平价医疗法案》（ACA）启动了一系列广泛的计划，这些计划对美国的医疗体系产生了重大影响，并标志着联邦政府在公共卫生领域的作用发生了适度但重要的监管转变。本文简要探讨了 ACA 的两个有趣的政策悖论。首先，尽管该立法主要涉及医疗保健融资和保险，并仅建立了几项直接针对公共卫生的举措，但 ACA 通过改善医疗保健和服务的可及性并降低成本，有可能为美国人口带来广泛的公共卫生效益。本质上，ACA 并没有采取明确的公共卫生法形式，而是通过其影响间接推动公共卫生。其次，尽管 ACA 没有在美国确立健康权——甚至没有确立健康保险权——但它确实启动了美国法律的一系列重大结构性和规范性变革，以符合实现健康权的目标。最重要的是，该法案的关键条款旨在改善健康所需条件的可得性、可及性、可接受性和质量，并促使政府尊重、保护和履行这些条件。这些发展意味着，在一定程度上，美国实质上已经采取了与一个国家在不正式或具有法律约束力的方式承认健康权的情况下维护健康权所需的相同类型的法律和政策步骤。尽管存在这两个悖论以及 ACA 为改善公共卫生带来的潜在好处，但该法律对公共卫生的影响仍不确定，将取决于随后的众多监管和实施决策。ACA 授权多个联邦机构参与制定规则，这一过程将在很大程度上决定其成为遗产的系统和健康影响。这一现实为加强法律的公共卫生方面和解释提供了充足的机会，并同时增强了健康权的相应组成部分。
