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Home > Covering Health Issues: A Sourcebook for Journalists Fall 2013 - Table of Contents > Chapter 1 - Patient Protection and Affordable Care Act

Chapter 1 - Patient Protection and Affordable Care Act

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Content Last Updated: 2/27/2015 3:10:09 PM
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Written by Julie Rovner, NPR. Updated February 2015 by Sabah Bhatnagar and Deanna Okrent, Alliance for Health Reform


  • A newly elected Republican Congress could impact the implementation of the Patient Protection and Affordable Care Act (ACA). For example, a bill that has already passed in the House seeks to define full time work as 40 hours a week instead of 30. Enactment of the bill could make it easier for employers to avoid paying a penalty for not providing health insurance coverage for their employees.1 
  • The Supreme Court is scheduled to hear oral arguments March 4, 2015 in the King v. Burwell case that questions the legality of subsidies offered through the federal health insurance marketplace, and is likely to hand down a decision in June.2 
  • Demographic data from the 2015 open enrollment period will impact premiums for 2016. As of January, a higher rate of young adults enrolled in marketplace plans for 2015 compared to 2014. But, demographic make-up may change due to an influx of sign-ups at the end of the open enrollment period.3  
  • CMS announced a special enrollment period extension, between March 15 and April 30 2015, for those facing a penalty when filing taxes for not having health insurance in 2014.4  


  • The percentage of uninsured individuals has dropped by 30 percent following the 2015 open enrollment period.5
  • Out of the 37 states using the marketplace, 7.1 million individuals have chosen plans or been automatically reenrolled as of January 2015. In states operating their own marketplaces, 2.4 million selected a plan during the same time period.6
  • The Congressional Budget Office (CBO) estimates that marketplace enrollment will reach 25 million by 2017.7 
  • The CBO projects that the share of legal, nonelderly residents with insurance will rise from 86 percent in 2014 to 92 percent by 2017.8 
  • The number of uninsured Americans fell from 37 million in 2010, about 20 percent of the population, to 29 million, or about 16 percent of the population, after the first open enrollment period ended in 2014.9
  • Enrollment numbers continue to rise, even in states opposed to the ACA. For example, 43 percent of those eligible for coverage in North Carolina are enrolled in a health plan as of January 2015.10


The Patient Protection and Affordable Care Act (ACA) officially rolled out its major coverage provisions on October 1, 2013, but it remained as controversial as the day President Obama signed it, according to polls. And the public remained confused about what the sweeping law does – and does not – do, even as the major provisions neared implementation.11

Some of the confusion likely came because lawmakers were forced to write the law in two separate parts. Due to the political situation arising from the loss of the Democrats’ 60-vote, filibuster-proof majority in the Senate in January of 2010, Congress could not finish work on the law in the normal manner: by convening a House-Senate conference committee to work out differences in the versions of bills passed by the House in November of 2009, and by the Senate that Christmas Eve.12 13

As a result, the health law is actually two separate laws. The Patient Protection and Affordable Care Act is actually the Senate-passed bill as passed without change by the House on March 21. The ACA’s March 23 signing by the president was followed a week later by that of the Health Care and Education Reconciliation Act, which included the changes to the bill negotiated by House and Senate Democrats. Both passed without Republican votes.14 15 

Within hours of the law’s signing, legal challenges were filed, including one that would ultimately be joined by more than half the states. It asserted that the law’s requirement for most people to either obtain health insurance or pay a penalty exceeded Congress’s constitutional authority.16


Although implementation was proceeding as scheduled, it was not until June 28, 2012, that the Supreme Court settled the threshold legal question. In a 5 to 4 ruling, with Chief Justice John Roberts writing the majority opinion, the court held that Congress could, in fact, impose the controversial so-called individual mandate, although not as an exercise of its power to regulate interstate commerce, as asserted in the law and by the Obama administration in court. Rather, wrote Justice Roberts, because the penalty for lacking insurance is paid to the Internal Revenue Service (IRS), it is a tax, and therefore the law is acceptable under Congress’ taxing power.17

But while the court upheld the individual insurance requirement, it did impose a significant — and unexpected — change to the law. The states had also argued that the law’s expansion of Medicaid — the joint federal-state health program for those with low incomes — was unfairly coercive. The states argued that the law essentially blackmailed them by making them either expand Medicaid to everyone with incomes up to 133 percent of the federal poverty level (amounting to $15,282 for an individual in 2013), or give up all their Medicaid funds. The court agreed, and the justices held that the Medicaid expansion is effectively a state option.

In November 2014, the Supreme Court announced its plans to hear King vs. Burwell, a case that questions the legality of subsidies offered through the federal health insurance marketplace. The plaintiff argues that wording in the ACA prohibits the issuance of tax credits and cost-sharing reductions offered by states that do not operate their own exchanges. The Supreme Court plans to hear oral arguments in the case on March 4, 2015.18 A verdict in favor of the plaintiffs could result in millions losing their subsidies and likely their health coverage.19 During 2014 enrollment, 87 percent of individuals enrolling through the federal marketplace were eligible for premium tax credits.20


The coverage provisions of the law have gained by far the most attention. But they are only one of three major pieces of a multi-part measure. There are many comprehensive summaries of the law (including several located at the links at the end of this chapter). What follows is a much more rudimentary summary that can serve as a beginner’s guide to the law:

Insurance Reforms

Most portions of the law that are already in effect attempt to establish new rights and benefits for patients from private insurance companies.

Several of the insurance-related provisions ensure that patients can see certain specialists without having to get permission from a primary care doctor and get preventive care services without having to pay deductibles or copayments. They also bar insurance companies from dropping coverage because a person gets sick.21 Also, parents now may keep adult children on their health insurance plans until age 26.

Another rule highly touted by the Obama administration requires insurance companies to spend 80 to 85 percent of each premium dollar (depending on the policy) on direct medical expenses, rather than on administrative costs or profit. If a plan exceeds the limit, called a medical loss ratio, it must refund the difference.22

And, the law requires that premium increases greater than 10 percent be automatically reviewed, making it easier for states to deny rate hikes.23

Controversy erupted late in 2013 when millions of individuals lost health insurance plans that did not comply with the ACA. The Obama administration responded to consumer complaints by giving health plans an additional two years to meet the law’s standards.24

Quality Improvement, Delivery System Changes and Cost Containment

One of the most frequent complaints about the ACA is that it does not do enough to contain the rising cost of health care. But it does include changes intended to test possible ways to make care more efficient, effective, and, hopefully, less expensive in the future. Here are just a few:

  • Patient-Centered Medical Homes are intended to encourage doctors to work in partnership with nurses and other health professionals to provide primary care services. The idea is to give patients a one-stop shopping experience where they can get multiple medical needs met. But it is also intended to offload minor tasks to junior members of the team and free up physicians for activities that require their level of training.25

  • Accountable Care Organizations, or ACOs, are groups of physicians, hospitals, and other health care providers that band together to manage the health of a population of patients, and take the financial risk for keeping those patients healthy across a wide variety of care settings. ACOs, which are similar to health maintenance organizations and other types of managed care plans, are designed to encourage care quality improvement.26
  • Independent Payment Advisory Board, or IPAB, one of the more controversial cost-related provisions of the ACA, called for a 15-member panel to make recommendations for keeping Medicare spending within certain limits compared to the growth of the economy as a whole. Starting in 2013, Congress was required to act on IPAB’s proposals or pass legislation that would save the same amount of money. If Congress failed to act, the secretary of health and human services was required to implement the cuts as recommended. However, as of January 2015, the Obama administration had not appointed anyone to the board. For the moment the matter is moot – since passage of the ACA, the growth of Medicare spending has slowed to the point that no action to launch IPAB appears imminent.27

Health Insurance Coverage Expansion

Most of the major expansions of insurance coverage are set to begin Jan. 1, 2014, and the law has already extended coverage to millions. An estimated three million young adults are covered on their parents’ plans, while insurers are barred from denying coverage to children with pre-existing health conditions. 

Much of the attention, when it comes to expanding coverage, has gone to the health insurance exchanges, which the Obama administration has renamed health insurance marketplaces. These are online portals where, at least at first, individuals and small businesses will go to shop for insurance, find out if they qualify for tax credits or subsidies to help them afford coverage and, if they have very low incomes, get referred for enrollment in Medicaid.28

Originally, Medicaid was expected to account for half of the law’s increase in coverage; about 17 million more people by the year 2022, according to the Congressional Budget Office (CBO). After the Supreme Court’s ruling, though, the Medicaid expansion estimate dropped. (See Medicaid chapter). 29 30

But while many people are expected to obtain insurance coverage under the ACA because they will be able to afford it for the first time, others will be able to get insurance because of the rule taking effect in 2014 that bars insurance companies from refusing to sell people insurance because they have a pre-existing health condition, or charging them more because of that.

It is that provision that prompted Congress — at the urging of the insurance industry — to also include the requirement for nearly every American to maintain insurance coverage, so the costs of people who are sicker can be more evenly spread across the broadest possible population.31 The insurance industry, however, has maintained that the penalties for failure to obtain that insurance — starting at the greater of $95 or one percent of taxable income in 2014 — is lower than the cost of purchasing insurance.32

Public Health and Prevention

The ACA also includes provisions geared toward improving population health. (See Public Health and Prevention chapter.) The law created the Prevention and Public Health Fund (PPHF).33 Money is used for activities ranging from prevention programs to workforce building initiatives. These activities include community and clinical prevention initiatives; research, surveillance and tracking; public health infrastructure; immunizations and screenings; tobacco prevention; and public health workforce and training.34 The ACA originally allocated $15 billion over its first 10 years for the PPHF. On February 22, 2012, President Obama signed legislation cutting the PPHF budget by $5 billion over 10 years to help pay for the continuation of payroll tax breaks and other initiatives.35 Due to these cuts and other budgetary decreases, federal funding for fiscal year 2014 was $1 billion instead of $1.5 billion, removing any money allocated toward ACA implementation.36 37

Long-Term Services and Supports

One thing the law will not include is a program to help people pay for long-term care services provided in the home. (See Long-Term Services and Supports chapter.) As part of the year-end bill to address the “fiscal cliff,” at the end of 2012, Congress repealed the Community Living Assistance Services and Supports (CLASS) Act. It had been the last legislative wish of the late Sen. Edward Kennedy, D-Mass. The Department of Health and Human Services had stopped implementation of the measure in the autumn of 2011, declaring it financially non-viable. But supporters of the measure had maintained hope that a way could be found for the measure to be mended rather than repealed.38


  • Affordability. The ACA was expressly designed to help spread the cost of insurance more broadly. That will help mostly older and/or sicker people pay lower premiums, thus making insurance more affordable. But to make that happen, others will pay more, mostly those who are younger and/or healthier.

    Insurance companies have referred to these higher premiums for the younger and healthier as “rate shock.” And they say that two things may happen. In the individual market, where people have a choice between purchasing coverage or paying a fine, many younger people will opt to simply pay the fine, since in most cases it will be far less than the cost of coverage, even after penalties are fully phased in. Though it may not be known how many people will pay fines for lacking coverage in 2014 until tax year 2014 Internal Revenue Service records are analyzed, it appears that rate shock will not materialize in 2015. A study analyzing premiums in cities in 15 states indicates a slight decline in premiums for benchmark insurance plans in 2015.39
  • King vs. Burwell. A verdict in favor of the plaintiffs could result in a few scenarios.  One possibility is that Congress will change the law’s wording to include subsidies offered through federally-facilitated marketplaces. Another option is for state legislatures to create their own exchanges in order to avoid the loss of subsidies, which advocates say are necessary for plan affordability and to avoid drop-off.

    Due to the complicated process involved in setting up a marketplace, the federal government could start defining “partnership exchanges” as state-based marketplaces. This challenge could also drive states to seek innovation waivers in order for them to design and implement an alternative plan that does not meet all ACA requirements, but still expands coverage.40
  • Employer Impact. Because young people will be more directly subsidizing older people (older people can only be charged three times more than younger people, compared to five or even seven times more under many states’ previous limits), their insurance could become unaffordable and they may be forced to drop it and pay the fine.41

Insurance companies and policymakers worry that businesses will stop offering coverage to workers, or cut back their hours, so they won’t be covered by the requirement that employers with 100 or more full-time workers provide a minimum level of insurance. That requirement was originally scheduled to take effect at the beginning of 2014, but the Obama administration delayed its start until 2015. The same requirement for employers with 50-99 employees has been delayed until 2016 (See Employment-Based Health Coverage chapter.)42

Some companies that have already made such cutbacks, however, have seen a public relations backlash. And, workers who no longer are eligible for workplace coverage will be able to obtain coverage in the new health care exchanges, likely with federal subsidies. That could, however, end up increasing the cost of the law to taxpayers.43

  • Cost Containment. Many critics have complained that the law doesn’t do enough to rein in health care spending, or that what it does do may not work.44

But there remains a huge debate about what would work. Republicans generally want to limit government involvement in health care and let markets work more freely. Democrats want to stay the course with the ACA and have been taking credit for the recent slowdown in health spending, even though it is far from clear that the slowdown it can be attributed to the law, or that the trend will continue.45 46

According to CMS, Medicare ACOs and Medicare Shared Savings Plans have improved quality and contained cost growth.47  Though, almost half of Pioneer ACOs have dropped out since 2011 due to financial losses and mixed results.48

A new CBO report issued late January 2015, reduced the cost estimate for providing health insurance coverage under the ACA. The new cost estimate of  $571 billion in the fiscal years 2015 through 2019 is 20 percent lower than the original estimate of  $710 billion for the same period,  according to the release.49

  • Contraception. The ACA includes a contraceptive mandate requiring that all forms of FDA-approved contraception be provided, without deductible or copay, to women of reproductive age as part of the essential benefits package.50 51However, some recent controversy has erupted over who gets to opt out. Some of the fights over details of the law have risen to levels nearly as high-profile as the fate of the law itself.

    The original proposal exempted churches and other houses of worship, but not religious hospitals, universities, and other entities that employ people of multiple religions. Religious entities, particularly the Catholic Church, objected. They complained that being required to provide contraception, and particularly the morning-after pill, violated their religious freedom.52

    After much negotiation and discussion, the Department of Health and Human Services (HHS) sought a compromise that attempted to guarantee access to contraception to women who work for religious entities, while protecting the religious rights of the employers. But  lawsuits continue around the country. In March 2014, the Supreme Court heard arguments in a case brought by a large arts and crafts company with thousands of employees. Hobby Lobby argued that the ACA requirement to cover contraception violates the Religious Freedom Restoration Act. The Supreme Court ultimately found for the plaintiff, Hobby Lobby.53 



Henry Aaron, senior fellow, economic studies, Brookings Institution, 202/797-6128,

Drew Altman, president and CEO, Kaiser Family Foundation, 650/854-9400

Stuart Altman, professor of national health policy, Brandeis University 781/736-3804

Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute, 202/862-5800,

Deborah H. Bae, senior program officer, Robert Wood Johnson Foundation,

Joe Baker, president, Medicare Rights Center, 212/869-3850,

Georges Benjamin, executive director, American Public Health Association, 202/777-2742

Linda Blumberg, senior fellow, Health Policy Center, Urban Institute, 202/261-5709,

Stuart Butler, The Brookings Institution,

Michael Cannon, director of health policy studies, Cato Institute, 202/789-5200,

Nancy Chockley, president and CEO, National Institute for Health Care Management, 202/296-4426,

Gary Claxton, vice president and director, Health Care Marketplace Project, Kaiser
Family Foundation, 202/347-5270

Sabrina Corlette, research professor and project director, Health Policy Institute,
Georgetown University, 202/687-3003,

Richard Curtis, president, Institute for Health Policy Solutions, 202/789-1491

Judy Feder, professor, Public Policy Institute, Georgetown University, 202/687-8397

Paul Fronstin, director, Health Research Program, Employee Benefit Research Institute, 202/775-6352,

Jon Gabel, senior fellow, National Opinion Research Center, 301/634-9313,

Paul Ginsburg, Norman Topping Chair in Medicine and Public Policy
Professor of the Practice of Health Policy and Management, USCPrice 202/494-9499,
Stuart Guterman, vice president, The Commonwealth Fund, 202/292-6735,

Dan Hawkins, senior vice president for public policy and research, National Association of Community Health Centers, 202/296-0131,

Sinsi Hernández-Cancio, health equity director, Families USA, 202/628-3030,

G. William Hoagland, senior vice president, Bipartisan Policy Center, 202/204-2400,

John Holahan, fellow, Health Policy Center, Urban Institute, 202/261-5666

Andrew Hyman, team director and senior program officer, Robert Wood Johnson
Foundation, 609/627-5764,

Timothy Jost, Robert L. Willett Family Professor of Law, Washington and Lee University School of Law, 540/421-1529, 540/564-2524,

Genevieve M. Kenney, co-director and senior fellow, Health Policy Center, Urban
Institute, 202/261-5568,

Robert Laszewski, president, Health Policy Strategy Associates, 703/727-9517,

Risa Lavizzo-Mourey, president and CEO, Robert Wood Johnson Foundation, 888/631-9989

John Lumpkin, senior vice president and director, Health Care Group, Robert Wood Johnson Foundation, 609/627-5724,

Enrique Martinez-Vidal, vice president for state policy and technical assistance,
Academy Health, 202/292-6729,

Dan Mendelson, founder and CEO, Avalere Health, 202/207-1310,

Tom Miller, resident fellow, American Enterprise Institute, 202/862-5886

Robert Moffitt, senior fellow, Heritage Foundation, 202/608-6210,

Len Nichols, director, Center for Health Policy Research and Ethics, George Mason
University, 703/993-1978

Edwin Park, vice president for health policy, Center on Budget and Policy Priorities, 510/524-8033,

Kip Piper, president, Health Results Group, 202/558-5658,

Ron Pollack, executive director, Families USA, 202/628-3030

Karen Pollitz, senior fellow, Kaiser Family Foundation, 202/654-1307

Robert Reischauer, distinguished institute fellow and president emeritus, Urban
Institute, 202/261-5400,

Sara Rosenbaum, Harold and Jane Hirsh Professor, George Washington University School of Public Health and Health Services, Department of Health Policy, 202/994-4230,

John Rother, president and CEO, National Coalition on Health Care, 202/638-7151 x110,

Diane Rowland, executive vice president, Kaiser Family Foundation, 202/347-5270,

James Tallon, president, United Hospital Fund, 212/494-0777,

Grace-Marie Turner, president, Galen Institute, 703/299-8900

Paul Van de Water, senior fellow, Center on Budget and Policy Priorities, 202/408-1080

Alan Weil, Health Affairs, 202/903-0101

Gail Wilensky, senior fellow, Project HOPE, 301/656-7401,

Cynthia Woodcock, executive director, The Hilltop Institute at UMBC, 410/455-6274,

Steve Zuckerman, co-director and senior fellow, Health Policy Center, Urban Institute, 202/833-7200,

Government/Government Related

Michael Hash, director, Office of Health Reform, Department of Health and Human
Services, 202/205-1424,

Joy Wilson, health policy director, National Conference of State Legislatures, 202/624-5400

Vicky Wachino, acting director, Center for Medicaid and CHIP Services, Centers for Medicare and Medicaid Services, Department of Health and Human Services, 401/786-3871

Mark Miller, executive director, Medicare Payment Advisory Commission, 202/220-3700

Matt Salo, executive director, National Association of Medicaid Directors,


Brenda Craine, director of media and editorial, American Medical Association, 202/789-7447

Elizabeth Fowler, vice president of global health policy, Johnson & Johnson,

Alissa Fox, senior vice president, office of policy and representation, Blue Cross and Blue Shield Association, 202/626-8618,

Ida Hellander, director of policy and programs, Physicians for a National Health Program, 312/782-6006,

Karen Ignagni, president and CEO, America’s Health Insurance Plans, 202/778-3203,

Charles Kahn, president and CEO, Federation of American Hospitals, 202/624-1500

Sister Carol Keehan, president and CEO, Catholic Health Association, 202/296-3993

Gerald Shea, project director,  Buying Value Project, National Quality Forum, 202/256-7577

Bruce Siegel, CEO, America’s Essential Hospitals, 202/585-0100

Janet Trautwein, CEO, National Association of Health Underwriters, 202/552-5060

Richard Umbdenstock, president and CEO, American Hospital Association, 202/626-4628


Alliance for Health Reform:

American Enterprise Institute:  

Altarum Institute:  

Avalere Health:  

Brookings Institution:

U.S. Department of Health and Human Services:

Center for Studying Health System Change:  

The Commonwealth Fund:  

Congressional Budget Office:  

Heritage Foundation:  

Kaiser Family Foundation:  

National Academy for State Health Policy:  

National Governors Association:

National Institute for Health Care Management:  

Robert Wood Johnson Foundation:  

Urban Institute:


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Sister Carol Keehan on Health Law Enrollment Challenges this Year

Graphics for This Chapter

Figure 1.1 Major Revenue Sources

Figure 1.2 Paying for Coverage Expansions

Figure 1.3 Health Coverage Under ACA

Figure 1.4 Timeline of Key Elements

Figure 1.5 The Requirement to Buy Coverage


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