(health care managers should be well versed on the ACA..read summary below)
The Patient Protection and Affordable Care Act (ACA) was enacted on March 23, 2010 to address theunsustainable increase in costs of the health care system in America. The ACAwas also designed to expand health insurance coverage to a large percentage of the 50 million citizens lacking health insurance today. The ACA is phased-in over several years with the most significant changes occurring in 2014. The legislation utilizes an expanded governmental structure to oversee health care in the country and relies heavily on the individual states to execute many of its provisions. The Patient Protection and Affordable Care Act originally consisted of ten primary segments (Titles) addressing a
wide variety of challenges facing health care today. One segment (Title VIII CLASS Act) has since been repealed.
Politics and Votes
The passage of the law was an extremely partisan process and used some rather questionable political strategies to attain final passage. At the time of passage, the House of Representatives, Senate, and the President were all Democrat.
The initial vote in the Senate followed party lines resulting in a 60-39 vote with all Democrats and 2 Independents voting for the law (1 Senator not voting). In the House the vote was 244-185 with 34 Democrats joining all 178 Republicans voting against the law.
Since its passage, the House of Representatives has voted over 30 times to repeal or roll-back the provisions of the law. In the latest attempt the House of Representatives voted 244-185 with 5 Democrats joining all House Republicans to support repealing the law.
The Congressional Budget Office (CBO) originally estimated the government cost of the ACA to be $940 billion over ten years with most of the costs incurred between 2014 and 2019. The CBO projected the ACA would reduce the federal deficit by $143 billion over this time period. The CBO updated the projections in March, 2012 and projects the net cost to the government to now be $1.7 trillion and a reduction of the deficit of approximately $200 billion between 2012-2022. An estimated $12.1 billion has been spent (as of April, 2012) primarily on grants and the activities related to create the Health Insurance Exchanges which will go into effect in 2014.
The Main Titles of the Patient Protection and Affordable Care Act
Title I: Quality Affordable Health Care For All Americans (Pages 12-156)
This is the section that is familiar to most. It includes many of the items implemented almost immediately including the elimination of lifetime limits on benefits, allowing children to remain on their parents health plan until age 26, establishment of high risk pools for those who cannot receive care, prevention coverage, eliminating insurance company unfair cancellation of coverage, and other items.
In addition, Title I establishes “minimum benefits” and benefit structures that can be sold or offered to employers and individuals and provides methods to help both employers and individuals pay for health insurance. There are many concerns here about both the structure and costs that could be involved. The Title establishes rating and pricing standards to assure health insurance companies are paying most of what they receive in premium for health care services and not retaining unreasonable amounts as profits.
This section shakes-up how many will be purchasing health insurance in the future by creating health insurance exchanges – or “insurance markets” in each state. Some are still trying to figure out how this might work but many states are moving forward and plan to be ready by 2014.
Finally, Title I includes the infamous Section 1501(the Requirement to Maintain Minimum Essential Coverage; page 124). This was requirement was determined constitutional by the Supreme Court and requires everyone to have health insurance or pay a “tax”; phased-in over several years. The ACA assumes a large part of the 50 million people with no health insurance (estimated at 30 million) are going to now be part of the system if this is all going to work. This includes those who haven’t been able to purchase health insurance in the past because of pre-existing conditions as well as those who are healthy and haven’t seen a need to be part of the insurance system in the past. It’s not just whether we have healthinsurance any more- it’s now about how we will pay for health care when we need it
“The legislation utilizes an expanded governmental structure to oversee health care in the country and relies heavily on the individual states to execute many of its provisions”
Title II: Role of Public Programs (pages 153-235)
Title II primarily addresses Medicaid (the state/federal program) and the Children’s Health Insurance Program (CHIP). While expanding the number of people who will be eligible for the programs (a justifiable concern of the states with the potential costs), Title II also allocates a lot of money to try out some new ideas to make the programs more cost effective. As a result of the Supreme Court decision, states will now have the option to expand Medicaid participation or not. The Title changes the way hospitals are paid and introduces the development of ways to measure quality, the ideas of using health care homes (medical homes), accountable care organizations, global payment arrangements, and integrated care as new ways to organize and pay for care more efficiently.
Title III: Improving the Quality and Efficiency of Health Care (pages 235-420)
This section is a big one and focuses on ways to improve the delivery and manage the increasing costs of Medicare. It is filled with research initiatives and new government functions responsible for improving the information available to make Medicare decisions. In addition to requiring the development of a “national” health care quality strategy for Medicare the Title creates the Center for Medicare and Medicaid Innovation to coordinate new initiatives for payment and care delivery and the Independent Payment Advisory Board (IPAB) to provide recommendations for managing Medicare costs.
This segment also introduces many new delivery and payment models (value-based purchasing, readmission reduction programs, patient-centered medical homes, shared savings programs, payment bundling, accountable care organizations, independence at home, and others) to try and test for improving the delivery of care and cost. The Title also begins to close the famous prescription-drug “donut hole” (the gap in coverage for prescription drugs) for seniors.
Title IV: Prevention of Chronic Disease and Improving Public Health (pages 420- 470)
Addressing the growing incidence of chronic disease in the population (cancer, heart, diabetes, obesity) is one of the major challenges facing health care in the future.
Title IV is intended to provide tools and resources to improve access to preventive services and encourage community involvement in their delivery. The Title creates another oversight group (the National Prevention, Health Promotion, and Public Health Council) to coordinate the efforts and monitor progress for the country as a whole. This Title also added preventive services to Medicare beneficiaries to better manage chronic diseases or prevent them from becoming a clinical diagnosis in the first place.
The Title encourages community education and outreach, provides community transformation grants, encourages school-based health centers, and provides for a number of other initiatives regarding oral healthcare, childhood obesity, and others.
Title V: Health Care Work Force (pages 470- 566)
Title V addresses the need to maintain an accessible health care work-force for care delivery. We are projecting a shortage of primary care doctors in the country and the responsibilities of those delivering care will likely change as a result. This Title establishes yet another oversight group (National Healthcare Workforce Commission) to coordinate and execute the efforts. It provides grants to states to develop their health care workforce and provides incentives to students (through loans and repayment arrangements) to study in some of the shortage areas.
The Title also provides grants for “nurse-managed health clinics”, rural health clinics, medical homes, and establishes a National Health Service Corp with the intention of increasing the supply of health care practitioners available to communities. The segment also provides other grants to enhance education and training for specific specialties (geriatric/mental and behavioral) and community education grants to assist in consumer and community education efforts.
Title VI: Transparency and Program Integrity (pages 566-686)
This section is intended to improve the data and information available in health care to make appropriate and effective health care decisions. It addresses the ownership of clinics and their potential to self-refer as part of a business strategy instead of an effective health care decision. It requires additional reporting from nursing homes, skilled nursing, and long-term care facilities and establishes quality requirements for those delivering care. The section is attempting to strengthen the performance and accountability of this market.
Title VI has a lot of reporting requirements for physicians to improve documentation and justify referrals to high cost facilities. The Title also includes the Elder Justice Act to address abuse, neglect, and exploitation of the growing population of seniors in long-term care settings.
This portion makes a brief mention of the opportunity for malpractice reform to manage both the legal costs and defensive medicine practiced as a result of the system today but doesn’t go much further.
“Addressing the growing incidence of chronic disease in the population (cancer, heart, diabetes, obesity) is one of the major challenges facing health care in the future.”
Subtitle D, page 609 creates the Patient-Centered Outcomes Research Institute and introduces comparative effectiveness research as a way to measure the effectiveness of the treatments and procedures patients receive on a national scale (these are the “Death Panels” we’ve heard about). In reality, the idea is to gather and disseminate clinical information to patients, providers, health plans, employers, and others to improve the clinical decision-making in health care. A very small portion of the services we receive in health care have used some evidence-based method to prove they work. One of the goals of Title VI is to provide the resource to start measuring results better than we do today.
Title VII: Improving Access to Innovative Medical Therapies (pages 686-710)
This section establishes a process where lower-cost, biologically equivalent products can enter the market in a reduced time than it takes today. The goal is to minimize the obstacles for allowing lower cost pharmaceuticals to enter the market while protecting brand name drugs for a period of time to allow companies to recoup the development investment required today. It also expands discounts for prescriptions for children and underserved communities that are available through an existing government program to other health care settings.
Title VIII: The CLASS Act (pages 710-729)
Title VIII establishes the Community Living Assistance Services and Support (CLASS) program; a voluntary, self-funded, long-term care and insurance program for individuals. The CLASS program has been repealed.
Title IX: Revenue Provisions (pages 729-765)
Title IX provides the details of how all of this is going to be paid and financed. When you look at it from the “30,000 foot level” paying for the ACA is simply a redistribution of the profits and money from where we are today (a major objection of the free-market purists). Most of the organizations paying additional fees have done very well in the health care market.
A large part of the ACA is funded by annual fees from pharmaceutical companies, medical device companies, and health insurance companies. These organizations have traditionally benefited very well from their participation in the health care system (in both profits and stock price) and are being asked to contribute some of it to make the system work better. Yes, stockholders and investors don’t like it, but gets back to striking the balance between what profits are reasonable in a free market while maintaining a health care system that is sustainable for society in the future.
Title IX also includes additional taxes and fees on individuals who may be able to afford them right now. Again, the basic question is the right way to balance the rights of the individuals, with what may be needed to prevent the health care system from collapsing as a whole.
Title X: Strengthening Quality, Affordable Health Care for all Americans (pages 765-906)
Title X is primarily additional language and clarifications about some of the previous points.
Nobody said reforming our health care system would be easy. We have been debating the best way to provide health care in this country for 100 years. Whether we want to accept it or not, we’re getting nearer to the “fiscal cliff” in health care and too many individuals are being harmed by the system we have today. We all agree that the status quo is not acceptable.
The Patient Protection and Affordable Care Act is an attempt to address many of the challenges facing the health care system. It uses a large and complex governmental structure to tackle the issues of cost, quality, and access on a national scale while relying on the individual states and private organizations to execute many of its provisions.
While the ACA is currently the approach we will follow- the politics and debate about it will continue. Can it be improved? Absolutely. But it will take an informed public to better understand the issues and legislators who will do what is right as opposed to simply following a political ideology to develop improved solutions. The real answer is somewhere in-between where we are today.
As stated in the recent Supreme Court decision concerning the constitutionality of some aspects of the law, “But the Court does not express any opinion on the wisdom of the ACA. Under the Constitution, that judgment is reserved to the people.”
The people need to be better informed to decide. I hope this summary provides a starting point.
“A large part of the ACA is primarily funded by annual fees from pharmaceutical companies, medical device companies, and health insurance companies.”
. . . . . . And Opposed