CHAPTER 1 - PATIENT PROTECTION AND AFFORDABLE CARE ACT
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Written by Julie Rovner, NPR
- Starting in October 2013, individuals and small businesses can start using new marketplaces, called health insurance exchanges, to sign up for coverage that takes effect on Jan. 1, 2014.1
- Starting Jan. 1, 2014, most Americans will be required to either have health insurance or else pay a tax penalty. At the same time, health insurers will no longer be allowed to deny coverage or charge higher premiums to people who have pre-existing health conditions.2
- States must decide in the coming months whether to expand their Medicaid programs to cover all individuals with incomes under 133 percent of the federal poverty level starting in 2014. The Supreme Court made the Medicaid expansion optional when it upheld the rest of the law as constitutional in 2012.3
- An estimated 14 million people will gain coverage in 2014, and 29 to 30 million will become insured who otherwise would not have been by the end of the decade, under the Patient Protection and Affordable Care Act (ACA), according to the Congressional Budget Office (CBO).4
- The CBO projects that the share of legal, nonelderly residents with insurance will rise from 82 percent in 2012 to 92 percent by 2022.5
- The insurance coverage provisions of the ACA will have cost the federal government an estimated $1.17 trillion from 2012 to 2022, according to the CBO. That’s $84 billion less than it estimated in 2011.6
- An estimated 71 million Americans in private health insurance plans received coverage of at least one free preventive health service due to the ACA in 2011 or 2012.7
- More than 6 million Medicare beneficiaries saved more than $6 billion in medication costs due to the ACA in 2011 or 2012.8
- The public understands less about the law in 2013 than it did at the time of enactment, according to a poll by the Kaiser Family Foundation. Among those most likely to benefit from the law, those without insurance and those with annual incomes under $40,000, the percentages saying they lacked sufficient knowledge of the law were 67 percent and 68 percent respectively.9
The Patient Protection and Affordable Care Act (ACA) celebrated its third anniversary March 23, 2013, but it remained as controversial as the day President Obama signed it, according to most polls. And the public remained confused about what the sweeping law does and does not do, even as the major provisions neared implementation.10
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 the bill passed by the House in November of 2009, and by the Senate that Christmas Eve.11 12
As a result, the health law is actually two separate bills. The Patient Protection and Affordable Care Act is technically 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.13 14
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.15
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.16
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.
WHAT THE ACA DOES
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.
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.17 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.18
And, the law requires that premium increases greater than 10 percent be automatically reviewed, making it easier for states to deny rate hikes.19
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 they are also intended to offload minor tasks to junior members of the team and free up physicians for activities that require their level of training.20
- 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.21
- Independent Payment Advisory Board, or IPAB, is one of the most controversial cost-related provisions of the ACA. It calls 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 is required to act on IPAB’s proposals or pass legislation that would save the same amount of money. If Congress fails to act, the secretary of health and human services is required to implement the cuts as recommended. However, the board has proved so controversial that as of August 2013, the Obama administration had not even tried to appoint anyone to it. For the moment the matter is moot — since passage of the ACA, Medicare spending has slowed to the point that no action appears imminent on IPAB’s part.22
Health Insurance Coverage Expansion
Most of the major expansions of insurance coverage are set to begin Jan. 1, 2014. But the law has already extended coverage to millions. An estimated three million young adults have maintained coverage on their parents’ plans, while insurers are already barred from denying coverage to children with pre-existing health conditions. And, an estimated 135,000 adults — though far fewer than was expected — have been getting coverage through “Pre-Existing Condition Insurance Plans” created by the law as a bridge to 2014. 23 24 25
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.26
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 to 10 million to 11 million. 27 28
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.29 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 — will be lower than the cost of purchasing insurance.30
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).31 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 use prevention; and public health workforce and training.32
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.33
ISSUES AND LIKELY POLICY DEBATES
- 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.
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.34
- Employer Impact. 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 more than 50 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 (See Employer-Based Health Coverage chapter.)35Some 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.36
- 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.37But 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 it can be attributed to the law, or that the trend will continue.38 39
- Contraception. Also, there are questions about 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.
For example, in order to ensure that people are able to compare insurance policies more easily, and that policies provide appropriate value for what they cost, the law called for a package of essential benefits. Within one of those categories, preventive care for women, the Department of Health and Human Services (acting on the recommendation of the Institute of Medicine) ordered that all forms of FDA-approved contraception be provided, without deductible or copay, to women of reproductive age.40 41
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, cried foul. They complained that being required to provide contraception, and particularly the morning-after pill, violated their religious freedom.42After 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 more than two dozen lawsuits continue around the country, and most people expect the issue to be eventually settled by the Supreme Court.43 44
Henry Aaron, senior fellow, economic studies, Brookings Institution, 202/797-6128, firstname.lastname@example.org
Drew Altman, president and CEO, Kaiser Family Foundation, 650/854-9400
Stuart Altman, professor of national health policy, Brandeis University 781/736-3804 email@example.com
Joseph Antos, Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute, 202/862-5800, firstname.lastname@example.org
Deborah H. Bae, senior program officer, Robert Wood Johnson Foundation,
Joe Baker, president, Medicare Rights Center, 212/869-3850, email@example.com
Georges Benjamin, executive director, American Public Health Association, 202/777-2742
Linda Blumberg, senior fellow, Health Policy Center, Urban Institute, 202/261-5709, LBlumber@ui.urban.org
Stuart Butler, director, Center for Policy Innovation, Heritage Foundation,
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, firstname.lastname@example.org
Gary Claxton, vice president and director, Health Care Marketplace Project, Kaiser
Family Foundation, 202/347-5270
David Colby, vice president of public policy, Robert Wood Johnson Foundation,
Sabrina Corlette, research professor and project director, Health Policy Institute,
Georgetown University, 202/687-3003, email@example.com
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, firstname.lastname@example.org
Jon Gabel, senior fellow, National Opinion Research Center, 301/634-9313,
Paul Ginsburg, president, Center for Studying Health System Change, 202/484-5261, email@example.com
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, firstname.lastname@example.org
Sinsi Hernández-Cancio, health equity director, Families USA, 202/628-3030,
G. William Hoagland, senior vice president, Bipartisan Policy Center, 202/204-2400, email@example.com
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, firstname.lastname@example.org
Timothy Jost, Robert L. Willett Family Professor of Law, Washington and Lee University School of Law, 540/421-1529, 540/564-2524, email@example.com
Genevieve M. Kenney, co-director and senior fellow, Health Policy Center, Urban
Institute, 202/261-5568, firstname.lastname@example.org
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, email@example.com
Enrique Martinez-Vidal, vice president for state policy and technical assistance,
Academy Health, 202/292-6729, Enrique.Martinez-Vidal@academyhealth.org
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
Edwin Park, vice president for health policy, Center on Budget and Policy Priorities, 510/524-8033, firstname.lastname@example.org
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, Rreischauer@urban.org
Sara Rosenbaum, Harold and Jane Hirsh Professor, George Washington University School of Public Health and Health Services, Department of Health Policy, 202/994-4230, email@example.com
John Rother, president and CEO, National Coalition on Health Care, 202/638-7151 x110, firstname.lastname@example.org
Diane Rowland, executive vice president, Kaiser Family Foundation, 202/347-5270,
James Tallon, president, United Hospital Fund, 212/494-0777, email@example.com
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, executive director, National Academy for State Health Policy, 202/903-0101
Gail Wilensky, senior fellow, Project HOPE, 301/656-7401, firstname.lastname@example.org
Cynthia Woodcock, executive director, The Hilltop Institute at UMBC, 410/455-6274, email@example.com
Steve Zuckerman, co-director and senior fellow, Health Policy Center, Urban Institute, 202/833-7200, SZuckerman@urban.org
Jonathan Blum, deputy administrator and director, Center for Medicare, Centers for Medicare and Medicaid Services, Department of Health and Human Services,
Michael Hash, director, Office of Health Reform, Department of Health and Human
Services, 202/205-1424, firstname.lastname@example.org
Joy Wilson, health policy director, National Conference of State Legislatures, 202/624-5400
Cindy Mann, deputy administrator and 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, email@example.com
Ida Hellander, director of policy and programs, Physicians for a National Health Program, 312/782-6006, Ida@pnhp.org
Karen Ignagni, president and CEO, America’s Health Insurance Plans, 202/778-3203, firstname.lastname@example.org
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, assistant to the president, AFL-CIO, 202/637-5237
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: www.allhealth.org
American Enterprise Institute: www.aei.org
Altarum Institute: www.altarum.org
Avalere Health: www.avalerehealth.net
Brookings Institution: www.brookings.edu
U.S. Department of Health and Human Services: www.Healthcare.gov
Center for Studying Health System Change: www.hschange.com
The Commonwealth Fund: www.commonwealthfund.org
Congressional Budget Office: www.cbo.gov
Heritage Foundation: www.heritage.org
Kaiser Family Foundation: www.kff.org
National Academy for State Health Policy: www.nashp.org
National Governors Association: www.nga.org
National Institute for Health Care Management: www.nihcm.org
Robert Wood Johnson Foundation: www.rwjf.org
Urban Institute: www.urban.org
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5 Ibid, pg 21.
6 Ibid, pg. 2.
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