ACA Summary

Summary of the Affordable Care Act
The following is extracted from the US Senate democratic summary with some comments from this blog’s author.  The most controversial elements of the Act are the requirements for all who can afford insurance to purchase insurance and to subsidize the insurance for low income Americans.

Title I. Quality, Affordable Health Care for All Americans

  • Eliminate lifetime and unreasonable annual limits on benefits
  • Prohibit rescissions of health insurance policies
  • Provide assistance for those who are uninsured because of a pre-existing condition
  • Require coverage of preventive services and immunizations
  • Extend dependant coverage up to age 26
  • Develop uniform coverage documents so consumers can make apples-to-apples comparisons
  • when shopping for health insurance
  • Cap insurance company non-medical, administrative expenditures
  • Ensure consumers have access to an effective appeals process and provide consumer a place to
  • turn for assistance navigating the appeals process and accessing their coverage
  • Create a temporary re-insurance program to support coverage for early retirees
  • Establish an internet portal to assist Americans in identifying coverage options
  • Facilitate administrative simplification to lower health system costs


Title II. The Role of Public Programs

The Patient Protection and Affordable Care Act expands eligibility for Medicaid to lower income persons and assumes federal responsibility for much of the cost of this expansion. It provides enhanced federal support for the Children‟s Health Insurance Program, simplifies Medicaid and CHIP enrollment, improves Medicaid services, provides new options for long-term services and supports, improves coordination for dual-eligibles, and improves Medicaid quality for patients and providers.


Title III. Improving the Quality and Efficiency of Health Care

  • Linking Payment to Quality Outcomes in Medicare (value based purchasing for high cost programs like cardiac surgery)
  • Strengthening the Quality Infrastructure (interagency working group)
  • Encouraging Development of New Patient Care Models (i.e. accountable care organizations)
  • Ensuring Beneficiary Access to Physician Care and Other Services (i.e. rural, military and dialysis patients)
  • Rural Protections
  • Improving Payment Accuracy (reduce payments for home health services and adjust hospital and physician payments to reflect higher numbers of insured persons)
  • Medicare Advantage (Part C) (adjust payments)
  • Medicare Prescription Drug Plan Improvements (Part D) (50% discount on generic drugs, increased coverage limit by $500)
  • Ensuring Medicare Sustainability (a board will advise on [reduced] payments to hospitals and other providers)
  • Health Care Quality Improvements (encourages primary care generally and better coordination of care)


Title IV: Prevention of Chronic Disease and Improving Public Health

  • Modernizing Disease Prevention and Public Health Systems
  • Increasing Access to Clinical Preventive Services
    • For the operation and development of School-Based Health Clinics.
    • For an oral healthcare prevention education campaign.
    • To provide Medicare coverage – with no co-payments or deductibles – for an annual wellness visit and development of a personalized prevention plan.
    • To waive coinsurance requirements and deductibles for most preventive services, so that Medicare will cover 100 percent of the costs.
    • To authorize the HHS Secretary to modify coverage of any Medicare-covered preventive service to be consistent with U.S. Preventive Services Task Force recommendations.
    • To provide States with an enhanced match if the State Medicaid program covers: (1) any clinical preventive service recommended with a grade of A or B by the U.S. Preventive Services Task Force and (2) adult immunizations recommended by the Advisory Committee on Immunization Practices without cost sharing.
    • To require Medicaid coverage for counseling and pharmacotherapy to pregnant women for cessation of tobacco use.
    • To award grants to states to provide incentives for Medicaid beneficiaries to participate in programs providing incentives for healthy lifestyles.
  • Creating Healthier Communities (Grants to community programs)
  • Support for Prevention and Public Health Innovation (funding for research on best practices)

Title V — Health Care Workforce

  • Increasing the Supply of the Health Care Workers (better financial aid for potential primary care providers)
  • Enhancing Health Care Workforce Education and Training (new support for training programs)
  • Supporting the Existing Health Care Workforce (scholarships)
  • Supporting the Existing Health Care Workforce (redistribute primary care training to areas of need)
  • Improving Access to Health Care Services (increased funding to some programs)

Title VI—Transparency and Program Integrity
To ensure the integrity of federally financed and sponsored health programs, this Title creates new requirements to provide information to the public on the health system and promotes a newly invigorated set of requirements to combat fraud and abuse in public and private programs.

Title VII – Improving Access to Innovative Medical Therapies

  • Biologics Price Competition and Innovation (has little to do with competition but restricts some aspects of equivalent drugs)
  • More Affordable Medicines for Children and Underserved Communities (requires drug companies to give discounts to some children’s’ hospitals and cancer centers)

Title VIII – Community Living Assistance Services and Supports

Establishment of national voluntary insurance program for purchasing community living assistance services and support (CLASS program).


TITLE IX – REVENUE PROVISIONS

  • Excise Tax on High Cost Employer-Sponsored Health Coverage
  • Increasing Transparency in Employer W-2 Reporting of Value of Health Benefits:
  • Distributions for Medicine Qualified Only if for Prescribed Drug or Insulin
  • Increase in Additional Tax on Distributions from HSAs and Archer MSAs Not Used for Qualified Medical Expenses
  • Limiting Health FSA Contributions ($2500)
  • Corporate Information Reporting: This provision requires businesses that pay any amount greater than $600 during the year to corporate providers of property and services to file an information report with each provider and with the IRS.
  • Additional fees on Pharmaceutical Manufacturers, Medical Device Manufacturers and Health Insurance Providers (clawback of profits from Medicare and other programs)
  • Eliminating the Deduction for Employer Part D Subsidy
  • Modification of the Threshold for Claiming the Itemized Deduction for Medical Expenses: This provision increases the adjusted gross income threshold for claiming the itemized deduction for medical expenses from 7.5 percent to 10 percent.
  • Tax on Elective Cosmetic Surgery.
  • Executive Compensation Limitations. This provision limits the deductibility of executive compensation for insurance providers…
  • Additional Hospital Insurance Tax for High Wage Workers.
  • Special Deduction for Blue Cross Blue Shield (BCBS): Requires that non-profit BCBS organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for unearned premium reserves.
  • Simple Cafeteria Plans for Small Businesses.

Additional information from Kaiser Family Foundation.

  1. #1 by mdtaber on August 19, 2012 - 10:26 AM

    This is a great summary. To earn credibility from your readers, share with them http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf which is where they can see the law in its original form. I know all about this law as I helped write federal health care law for the physicians (Dr. John Barrasso MD and Dr. Tom Coburn MD) of the U.S. Senate HELP Committee back in 2008 when health care reform was being conceived. I now personally help physicians lobby the physicians in Congress.

    Blue Cross Blue Shield has violated the MLR and the IRS is in the process of revoking all of their special tax benefits they receive as a “non-profit”. If they actually cared about people and not about getting millions in compensation for their executives, they would not be in trouble with HHS and the IRS like they are now. If they were not this way, we would not have health care reform. It is as simple as that. UnitedHealthcare, Humana, BCBS, Aetna, and Cigna are the real reason why my former physician bosses in Congress wrote health care reform.

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