Health Care Reform
Patient Protection and Affordable Care Act of 2010
Public Law No: 111-152
On March 21st, the House of Representatives voted 219-212 to approve the "Patient Protection and Affordable Care Act (PPACA)." The Senate passed identical legislation on December 24, 2009. President Obama then signed a budget reconciliation bill that made a series of changes to PPACA. Passage of this reconciliation bill was necessary to secure the support of a majority of House Democrats for PPACA.
PPACA and the reconciliation bill will institute sweeping reforms impacting Medicare, Medicaid and the private health insurance market. According to the Congressional Budget Office the legislation will cost $940 billion over 10 years and provide coverage to 32 million currently uninsured Americans. Starting in 2014, the legislation requires guaranteed issue and renewability of coverage and allows rating variation based only on age, rating area, family composition, and tobacco use.
There will be no government-run "public option" as a result of the legislation. Instead, each state will be required by 2014 to establish an "American Health Benefit Exchange" and a "Small Business Health Options Program." These will be marketplaces where insurance companies can offer plans to individuals and small businesses. Subsidies will be made available to low-income individuals to assist with the purchase of coverage via the exchanges. Tax credits will be offered to small business to assist in providing coverage to employees. Penalties will be enforced on individuals who fail to purchase coverage and on small businesses that fail to offer coverage.
A summary and implementation timeline follow.
Provisions of the bill of specific interest to the medical library community:
- Increases funding for Community Health Centers by $11 million over the next 5 years.
- Requires the Commissioner of the insurance exchange within, 2 years, to report on methods to encourage increased qualified health benefit plan use of electronic health records. The report will include the effect of offering higher reimbursement rates for meaningful use, and promoting the use of low cost electronic health record software packages.
- Requires the Health Information Technology Policy Committee to provide recommendations to the Office of the National Coordinator for Health Information Technology standards, implementation specifications, and certification criteria for the electronic exchange and use of certified electronic health records.
- Establishes an Assistant Secretary for Health Information within the Department of Health and Human Services to ensure the collection, reporting and publishing of information on key health indicators regarding the nation's health and performance of the nation's health care system.
- Requires the Assistant Secretary for Health Information to develop standards on the collection of accurate data on health and health care by race ethnicity, primary language, sex, sexual orientation, gender identity, disability socioeconomic status, rural, urban or other geographic setting and any other population or subpopulation as it relates to the nation's health.
- Requires the Assistant Secretary for Health Information to provide support for federal departments and agencies whose programs have a significant impact on health and facilitate the sharing of information between federal departments that have a significant impact on health.
- Requires the Assistant Secretary for Health Information to provide public accessibility (consistent with privacy safeguards) to health related data sets such as de-identified Medicare data sets or publicly available data on key health indicators by making the information available online.
- Requires the Assistant Secretary for Health Information to identify key health indicators and publish statistics on the health of the public at least once every three years.
- Funds the Assistant Secretary for Health Information office to provide public health information from the Public Health Investment Fund at $300 million per year over FY10-FY14 and provides $330 million for FY15- FY19.
- Requires the HHS Secretary along with the Office of the National Coordinator of Health Information Technology to establish a national medical device registry to assist in gathering information about patient outcomes and post market safety of medical devices.
- Requires public access to comparative effectiveness information that describes the potential for differences in the effectiveness of health care items and services used within various subpopulations.
- Requires the Secretary to report on quality of and availability of patient-centered and population based programs administered through the Centers for Medicare and Medicaid services (CMS), using heath information technologies provided by the electronic exchanges. The findings of this report must be free of charge and made available to the public.
- Creates a multi-stakeholder pre-rulemaking for selection of quality health measures and review. Groups like MLA and AAHSL will be eligible to take part in this rulemaking process.
- Permits doctors to use a telehealth encounter with patients in place of a face to face meeting with patients before they can in engage in home health services under Medicaid.
- Expands and enhances telehealth by establishing a "Telehealth Advisory Committee" of nine members appointed by the HHS Secretary to make recommendations regarding telehealth services. The makeup of the committee will include five practicing physicians, two non-practicing health care practitioners, and two will be administrators of telehealth programs. The committee will make recommendations on the application and standards for telehealth programs.
90 Days After Enactment the bill:
- Establishes high-risk pools for people with pre-existing conditions who have been uninsured for at least six months.
Six Months After Enactment:
- Prohibits insurers from rescinding policies once a beneficiary become sick.
- Prohibits insurers from denying coverage to children (up to age 19) who have a pre-existing condition.
- Prohibits insurers from imposing lifetime benefit caps.
- Requires insurers to allow young adults to stay on their parents' policy until age 26.
In 2011 the bill:
- Requires individual and small group market insurance plans to spend 80% of premium dollars on medical services. Large group plans would have to spend a minimum of 85%. If carriers fail below these percentages they will have to rebate the difference to policyholders.
- Begins the process of closing the Medicare Prescription Drug Program "Donut Hole." Beneficiaries will receive a 50% discount on brand name drugs in the coverage gap.
- Establishes a national, voluntary insurance program for purchasing community living assistance services (CLASS program). Following a five-year vesting period, the program will provide individuals with functional limitations a cash benefit of not less than an average of $50 per day to purchase non-medical services and supports necessary to maintain community residence. The program is financed through voluntary payroll deductions: all working adults will be automatically enrolled in the program, unless they choose to opt-out.
In 2014 the bill:
- Requires states to establish health insurance exchanges for individuals and small businesses.
- Establishes subsidies for low income families to purchase coverage through the exchanges. Households making up to four times the federal poverty level, $88,200 for a family of four, will be eligible. Premiums for a family of four making $44,000 would be capped at approximately 6 percent of income.
- Requires employers with 50 or more employees to provide coverage or face penalties.
- Requires most individuals to obtain coverage or face penalties.
- Eliminates pre-existing coverage exclusions for adults.
- Prohibits annual benefit caps.
- Provides guaranteed issue and renewability of coverage for small group and individual plans.
- Allows premium rating variation based only on age, rating area, family composition, and tobacco use.
- Prohibits waiting periods of greater than 90 days for coverage to begin.
In 2018 the bill:
- Establishes an excise tax on high-cost employer-sponsored health coverage. The threshold taxable amounts are $10,200 for single coverage and $27,500 for family coverage. Stand-alone dental and vision plans are excluded from the total value of the benefit package subject to the new tax.
The new law also:
- Requires insurance coverage of routine patient care costs associated with clinical trials.
- Requires the NIH to establish a Cures Acceleration Network that will accelerate cures by conducting clinical research, enhancing communication between federal agencies and will establish a Cures Acceleration Network Review Board.
- Reduces or eliminates beneficiary cost sharing for preventive screenings and services in both private and public plans.
- Requires enhanced disclosure of the financial relationships pharmaceutical manufacturers and distributors have with healthcare providers and non-profit organizations. Funding for Continuing Medical Education is an area of focus.
- Expands federal support for Comparative Effectiveness Research by creating a "Patient-Centered Outcomes Research Institute." Findings derived from CER research cannot be used as guidelines for treatment, coverage or reimbursement.
- Establishes a Center for Medicare and Medicaid Innovation to test innovative coverage models based on Institute of Medicine recommendations.
- Establishes an Independent Medicare Payment Advisory Board. This 15 member panel of physicians and healthcare financing experts will be chosen by the President and confirmed by the Senate. The Advisory Board will propose changes to Medicare aimed at bringing the entitlement program in line with reduction targets. Congress cannot modify or filibuster the Advisory Board's proposals. A supermajority vote of the House and Senate will be required to reject the panel's recommendations. If rejected, Congress then will be required to find alternative ways to save the same amount of money.
- Establishes new federal initiatives to reduce waste, fraud, and abuse in Medicare and Medicaid including, expanded provider screening, greater oversight of providers and suppliers, enrollment moratoria in areas identified as being at elevated risk of fraud, and increased penalties for submitting false claims.
- Reduces reimbursement for Medicare Advantage plans by $200 billion over 10 years.