The Patient Protection and Affordable Care Act:
Key Provisions for Public Health
Policy and Practice
Sara Rosenbaum
Jane Hyatt Thorpe
Katherine Hayes
Paula Lantz
October, 2011
Introduction
• The Patient Protection and Affordable Care Act (Affordable Care Act) and
the Health Care and Education Reconciliation Act (HCERA)
 Enacted March 23, 2010
 Major evolution in longstanding federal laws in order to achieve coverage for
nearly all Americans (92% of population including persons not lawfully present
in the U.S., 94% of all persons lawfully present)
 Pluralistic approach (employer-sponsored coverage, Medicaid, individual
coverage through state insurance Exchanges)
 Reforms aimed at improving the public’s health and health care quality and
efficiency
• Comprehensive information about the legislation and federal
implementation, as well as library of relevant reports and articles at Health
Reform GPS (www.healthreformgps.org), a joint project of the Robert
Wood Johnson Foundation and the Hirsh Health Law and Policy Program
of the GW SPHHS department of health policy.
Getting There by 2014
• Transforming the insurance market: Bars insurers selling
individual and group policies from barring access or charging
premiums based on health status
• Shared responsibility: Requires large (>50 fulltime workers)
employers who do not insure their employees or who offer
unaffordable coverage (>9% of employee modified adjusted
gross income) to contribute to the cost of coverage; requires
individuals to either buy affordable coverage or pay a penalty
• Exchanges: Establishes state insurance Exchanges to provide
access to affordable coverage through “qualified health plans”
for “qualified” individuals and “qualified” small employer
groups. Premium subsidies for individuals with incomes
between 133% and 400% FPL (cost-sharing assistance also
provided).
• Medicaid: Expand Medicaid for the poorest Americans
(<133% FPL)
Estimated Health Insurance Coverage in 2019
Total Nonelderly Population = 282 million
SOURCE: Kaiser Family Foundation analysis of Congressional Budget Office estimates, March 20, 2010
PRIVATE INSURANCE REFORMS (Pre-2014)
DEPENDENT COVERAGE*
To age 26
PREVENTIVE BENEFITS
EFFECTIVE:
1st Plan Year after 09/10
Preventive benefits with no cost-sharing: A or B (USPSTF).
ACIP- recommended immunizations,
Preventive care for children & additional care/screenings for women recommended by
HRSA.
PRE-EXISTING CONDTIONS
No pre-existing condition exclusions for children <19
TAX CREDITS,HIGH RISK POOLS,
REINSURANCE FOR OLDER
WORKERS
Small employer tax credit (<25 employees moderate average annual wage; pre-existing
condition plan: individuals with pre-existing conditions and uninsured for 6 months or
longer; reinsurance for retiree plans
PATIENT PROTECTIONS AND
APPEALS
Emergency coverage; direct access to pediatrician and ob-gyn; internal and external
appeals
RECISSIONS*
Barred except in cases of intentional fraud
LIFETIME CAPS*
ANNUAL LIMITS
WAITING PERIODS*
RESCISSIONS
Lifetime caps barred
Annual limits regulated
Waiting periods regulated
Rescissions barred
PREMIUMS
Rate reviews for unreasonable rate increases, beginning 2010
MEDICAL LOSS RATIO
RATE REVIEWS
Medical loss ratio reporting, rebates in 2011 for group plans not meeting 85% MLR &
individual plans not meeting 80% MLR
Annual
CONSUMER WEBSITE
Consumer website and information improvement
PRIVATE INSURANCE REFORMS (2014)
State Insurance
Exchanges (state or
federally operated)
Individuals and small groups (100 or fewer FT employees, state option to set at 50 or
fewer until 2016) purchase “qualified health plans.” Premium subsidies and cost-sharing
assistance
Insurance market
reforms
1.
2.
3.
4.
5.
1.
2.
No pre-existing condition exclusion
Discrimination on health status barred (wellness program exception)
Excessive waiting periods barred
Lifetime and annual limits barred
Coverage for routine costs related to approved clinical trials
Annual limits on out-of-pocket spending
Essential benefit coverage requirements in the individual and small
group markets
Exceptions for “Grandfathered” Health Plans
State Insurance Exchanges
• Broad state discretion
 Whether to establish by January 2014
 Structure and governance
 Whether to keep non-Exchange markets
 Degree of Medicaid integration
 Qualified health plan (QHP) standards across “insurance
affordability programs” (Medicaid, CHIP, state basic health
programs, premium credits)
 Whether to continue state benefit mandates for Exchange
plans
 Role of Navigators
Medicaid
• Children and all non-elderly adults who are ineligible for
Medicare, with modified adjusted family incomes (MAGI)
below 133% FPL; enhanced FMAP for newly eligible adults
(100% dropping to 90% by 2020)
• Retains traditional Medicaid eligibility standards (which may
be higher) for persons with disabilities
• Streamlined eligibility determination and redetermination
process with online applications and enrollment through
Exchanges
• “Benchmark” coverage for newly eligible persons paralleling
“essential health benefits” and including preventive coverage
• Reforming care for “dual eligibles”
• Increased Medicaid payments for primary health care
• Pre-2014 expanded eligibility for family planning and
“family planning-related” services
Quality and Efficiency
• Center for Medicare and Medicaid Innovation (CMI) to “test innovative payment
and service delivery models to reduce program expenditures under [Medicare and
Medicaid] while preserving or enhancing the quality of care. . ..”
• National Quality Strategy to set priorities to improve the delivery of health care
services, outcomes, and population health, and to create processes for
development of quality measures.
• Encouraging high-quality care at lower cost:
 Expand quality measurement and reporting programs for hospitals, physicians
 New quality measurement and reporting programs for long-term care hospitals, inpatient rehab
hospitals, hospice, and non-PPS exempt cancer hospitals
 Value-based purchasing programs for hospitals and physicians; CMS to develop VBP plans for
ambulatory surgery centers, skilled nursing facilities, and home health
 Additional payment incentives (bundled payments, non-payment for hospital-acquired
conditions, reduced payments high readmission rates)
 Bonus payments for high performing Medicare Advantage plans
 Medicare medical homes/Medicaid health homes
 Medicare Shared Savings Program – Accountable Care Organizations
• Patient-Centered Outcomes Research Institute for comparative effectiveness
research
Wellness and Prevention
• Recommended preventive care fully covered with no co-pays and
deductibles
• Annual wellness exam in Medicare
• Employer wellness programs incentivized
• Sustained funding for prevention and public health – Public
Health Trust Fund and Community Transformation Grants
• Calorie information on restaurant menus
Copyright - AHA
Confidential & Proprietary
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Creating Access and Expanding Hospitals’
“Community Benefit” Obligations
• Health center expansion and National Health Service
Corps
• Expanded “community benefit” obligations for
nonprofit hospitals through community health needs
assessment, implementation strategies, and public
health consultation
Key Issues for Public Health Policy and Practice
•
•
•
•
Reforming state insurance laws
Implementing Medicaid expansions
Setting up insurance Exchanges
Enrolling the uninsured and reducing “churning”
across Medicaid and Exchanges
• System transformation in Medicaid for individuals at
greatest health risk
• Community benefits and integration with community
transformation
• Transition to a value-based system of care