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6.ThePatientProtectionandAffordableCareAct.pptxThe Patient Protection and Affordable Care Act
What is the PPACA
No one knows: https:// youtu.be/N6m7pWEMPlA
Patient Protection and Affordable Care Act
Referred to as ACA or Obamacare
Signed into law in 2010 and upheld (essentially enacted) in 2012
Essentially put into law reform with these goals:
Expand coverage,
Hold insurance companies accountable,
Lower health care costs,
Guarantee more choice, and
Enhance the quality of care for all Americans.
What was the problem the ACA is trying to solve?
The government is paying too much in healthcare dollars
We’re already in debt, the government cannot afford this
There are too many uninsured citizens
When uninsured people seek care, the bill goes unpaid and the hospitals cannot afford the free care
Healthcare in general is too expensive
No matter who is paying for it (government, out of pocket, or private insurance), our system cannot sustain itself at this rate
The ACA wasn’t the first proposed healthcare reform: Brief History
1915: AALL Bill
Proposed: limited coverage to the working class and all others that earned less than $1200 a year, including dependents. The services of physicians, nurses, and hospitals were included, as was sick pay, maternity benefits, and a death benefit of fifty dollars to pay for funeral expenses. Costs were to be shared between workers, employers, and the state.
Ultimately failed, in part due to widespread fear of communism, and healthcare reform was not brought up again until the 1930s
History of Healthcare Reform
1935: President FDR passes Social Security Act
Healthcare reform was originally proposed with this Act, however, it was ultimately removed in fear that it would jeopardize the entire Act. Focus was placed on passing Social Security benefits as this was a higher priority with so many Americans out of work during the Depression
1939: FDR tries a second time with the Wagner Bill, National Health Act of 1939
Gave general support for a national health program to be funded by federal grants to states and administered by states
Ultimately failed with a resurgence of conservatives taking office around the same time and widespread opposition to national healthcare
History of Healthcare Reform
1945-1953: Truman Administration
Truman recommended to Congress a proposal for universal health insurance coverage, administered and paid for by a National Health Insurance Board
Widespread opposition to “socialized medicine” caused it’s failure
Passed “The Hospital Survey and Construction Act of 1946”
provided federal grants and loans to build, expand and modernize hospitals. The consequences of the resulting rapid and unregulated growth in healthcare facilities would require future legislation, during the Ford administration, to bring it under control
History of Healthcare Reform
1953 – 1961: Eisenhower Administration
In 1956 the "Military Medicare" program was enacted, providing payment for healthcare services for military dependents
1961 – 1963: Kennedy Administration
Kennedy supported a more modest form of universal health care, essentially laying the blocks of what would become Medicare (limiting coverage to those 65 years and older)
History of Healthcare Reform
1963 – 1969: Johnson Administration
the Social Security Amendments of 1965 provided healthcare coverage to those 65 years of age and older, and to the poor, blind and disabled. It covered healthcare services provided by hospitals, physicians, nursing facilities and home care providers. It would not be long before proposals for health coverage for those not covered under Medicare/Medicaid would surface.
History of Healthcare Reform
1969-1974: Nixon Administration
proposed the National Health Insurance Standard Act. The proposal called for government-prescribed minimal levels of insurance coverage, mandated to be provided through employers and financed by payment of premiums by employers and employees. This plan would maintain competition between private insurers and expand coverage. The NHISA would also provide government subsidies for premiums for certain employees. While the NHISA did not pass, Nixon was successful in gaining passage of the Health Maintenance Organization Act of 1973, which laid some of the ground work for managed care.
History of Healthcare Reform
1974-1977: Ford Administration
Runaway healthcare costs due to inflation and unchecked growth in the healthcare world, followed by an increase in government spending through Medicare/Medicaid programs. The National Health Planning and Resources Development Act of 1974 was an effort to reign in escalating healthcare costs. The goals of the HPRDA were to reduce and avoid unnecessary duplication of healthcare facilities and services; it sought to do so by essentially mandating certificate of need programs in the states. Eventually repealed.
History of Healthcare Reform
1977-1981: Carter Administration
Carter campaigned for president calling for national healthcare insurance with universal coverage, and as president he went to work to prepare a legislative proposal for the same. The details of President Carter's plan never received much of a congressional or public audience, as a deep recession and other economic issues took priority.
History of Healthcare Reform
1981-1989: Reagan Administration
Reagan started a movement to shift the cost of healthcare away from the government. Several new laws were enacted aimed primarily at reducing the growth in federal spending on health care, and improving efficiencies. This was to be accomplished by changing Medicare reimbursement methodologies — in most cases reducing reimbursement to hospitals and physicians — and stepping up anti-fraud measures.
History of Healthcare Reform
1989-1993: George H.W. Bush Administration
President Bush's agenda for healthcare legislation consisted of additional measures to reduce the growth of federal health care spending and reduce fraud and abuse in the Medicare and Medicaid programs. Notable among the Bush healthcare legislative reforms was a prohibition on physician "self-referrals" for clinical laboratory services
History of Healthcare Reform
1993-2001: Clinton Administration
proposed to provide affordable health insurance for all through a concept called “managed competition.” Under the Clinton proposal, health insurance coverage would be provided through private insurers competing for customers in a highly regulated market, overseen and coordinated by regional health alliances to be established in each state. All health plans would be required to provide a minimum level of benefits. Employers would be required to provide insurance coverage for their employees and pay 80 percent of the premium. The proposal ultimately failed due to widespread opposition.
History of Healthcare Reform
2001-2009: George W. Bush Administration
Healthcare was low priority, however, they did manage to pass one of the largest expansions to Medicare in the history of the program. The Medicare Drug Improvement and Modernization Act of 2003 made numerous changes to the Medicare program, the most important of which is the prescription drug coverage benefit, created as Medicare Part D.
History of Healthcare Reform
2009-2017: Obama Administration
Healthcare reform was one of Obama’s first priorities in office, proposing legislature at just 6 months in to his first term. The ACA went through widespread debate and controversy, but was ultimately signed into law in March 2010. In 2012 the ACA was taken to the supreme court to determine whether it was within the constitution, it was upheld that year.
Controversy
Among debate the question was raised whether Congress had a right to enact the law under the Constitution. The supreme court ruled:
The individual mandate is a permissible exercise of Congress' taxing power and thus constitutional.
The Medicaid expansion "cram down" provision (essentially requiring all states to expand Medicaid coverage to all otherwise eligible individuals with incomes up to 133 percent of the federal poverty level) is an impermissible exercise of Congressional power and thus unconstitutional.
In its irreducible essence, the PPAACA provides for:
A mandate for "large" employers to provide health insurance coverage for its employees;
A mandate for virtually all citizens to have health insurance coverage through an employer sponsored plan, a government plan or an individual plan;
Creation of federal and/or state healthcare exchanges to facilitate obtaining healthcare insurance;
Federal financial subsidies for health care insurance for individuals meeting low income standards;
A mandate that all health plans provide a certain minimal level of essential benefits; and
Prohibitions against denials of coverage based on pre-existing conditions and against lifetime benefit limits.
Details of the ACA
The ACA is in some respects a conglomeration of some of the pieces of past proposals for major healthcare reform. All of the following have been proposed in some form before the passing of the ACA:
The provision of health insurance coverage through private insurers instead of directly through the government,
Employer mandated health insurance,
The creation of state, regional or national clearinghouses for insurance,
Federal subsidies for low income individuals,
“Guaranteed eligibility”, you cannot be refused coverage due to a pre-existing condition
Details of the ACA: Expanded Coverage
By 2022, the Congressional Budget Office estimates the Affordable Care Act will have extended coverage to 33 million Americans who would otherwise be uninsured
Increased eligibility for Medicaid
Families making less than 133 percent of the poverty line ($29,000 for a family of four) will now be covered through Medicaid. Families between 133 percent and 400 percent of the poverty line will get tax credits on a sliding scale to help pay for private insurance
Increased coverage from employer mandate/incentive
Businesses that have 50 or more full time employees will be fined if they do not offer insurance
Small businesses that have fewer than 10 employees, average wages beneath $25,000, and that provide insurance for their workers will get a 50 percent tax credit on their contribution
Increased coverage by requiring the public to hold insurance
Require all US Citizens and Legal Residents to hold qualifying insurance or face fine of $695 per year or up to 2.5% of household income (whichever is greater)
Details of the ACA: Hold Insurance Companies Accountable
Insurance companies are not allowed to discriminated based on preexisting conditions
They cannot refuse coverage due to a known condition
Provide dependent coverage for children up to age 26 for all individual and group policies
Series of other small rules to essentially standardize insurance coverage from plan to plan with a goal of improving access to care for the consumer
Details of the ACA: Lower Healthcare Costs
Simplify health insurance administration by standardizing process
Series of cost containment changes to Medicare and Medicaid programs
Authorize the FDA to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed
Reduce waste, fraud, and abuse in public programs by:
allowing provider screening, enhanced oversight periods for new providers and suppliers, including a 90-day period of enhanced oversight for initial claims of DME suppliers, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs,
Require Medicare and Medicaid program providers and suppliers to establish compliance programs
Develop a database to capture and share data across federal and state programs, increase penalties for submitting false claims, strengthen standards for community mental health centers and increase funding for anti-fraud activities.
Details of the ACA: Guarantee More Choice
Create state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges, administered by a governmental agency or non-profit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage.
Establish an internet website to help residents identify health coverage options (effective July 1, 2010) and develop a standard format for presenting information on coverage options
Details of the ACA: Enhance Quality of Care
Support comparative effectiveness research by establishing a non-profit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments
Award five-year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigations in medical malpractice
Develop a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs
Future Directions
As stated previously, Presidential Administrations have a HUGE IMPACT on healthcare, and we just elected a president who is strongly against the ACA
Congress has chosen to move forward with repealing this act and everything that resulted from it
The future is uncertain, we’ll explore some of the repercussions we may see as a result of this decision
Repealing the ACA
The senate and the house have both chosen to start the repeal process as of Jan 13, but we have a ways to go
Logically, we should not be repealing this act without a replacement drafted FIRST, but it appears that we aren’t going to do that
Relevant committees will convene over the next few weeks to begin the process of drafting a repeal bill. The resolution has a provision that directs these committees to come up with a draft of the repeal bill by January 27
What’s Next?
Option 1: Replacement Superhighway
The fastest and least disruptive path for Republicans to follow would be to repeal the ACA and advance a replacement bill at the same time
This would provide both insurers and patients a clear picture of what's going to happen fairly quickly, which would prevent disruptions to the market
No details have been released of a potential replacement plan
The levels of government could prevent the replacement bill from being passed, leaving us with no replacement
Option 2: The Long and Winding Road
Partial repeal of the law under what is called budget reconciliation — delaying until a later date so that Republicans can craft a full replacement bill
In theory, this allows GOP lawmakers to advance the political goal of repeal while giving enough time to develop a comprehensive plan for replacement
Cons: Depending on the parts of the law that are repealed through the reconciliation process, you could see destabilization in the individual insurance market
An unstable market could mean an increase in cost for everyone in the face of uncertainty
Option 3: Leave As-Is
Simply pass a few bills that make minor but needed adjustments to the law without a full-on repeal
Changes would be most minimal for most consumers
Democrats would likely be agreeable because they have been calling for reform for a long time
Republicans likely wouldn’t take this route because they have been calling for complete repeal from the beginning and won’t back down
Option 4: Repeal without Replacement
After running against the bill for so long, the GOP could just repeal it and label it a disaster, making small changes along the way but not introducing a full-scale replacement
Seems the least likely option, ripple effect would be devastating
Political blowback
Millions lose coverage and unable to access insurance due to pre-existing conditions and cost
Worst Case Scenario
Closing Thoughts…
Behind Healthcare Reform: https:// youtu.be/0gcARSUEF0s
Durable healthcare -- redesigning a system to work for everyone: https:// youtu.be/mY2LIQbiGbo
