VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Overview (last updated 4.18.17)
- 1 Overview
- 2 Statute and Regulations
- 3 Basic Structure
- 4 Bill Summaries
- 5 Other Materials
- 6 The Basics
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010; this was the bill passed by the Senate 60-39 on December 24, 2009, and the House 219-212 on March 21, 2010. The Health Care and Education Reconciliation Act (HCERA) was passed by the Senate 56-43 and House 220-207 on March 25, 2010 (because it used the budget reconciliation process, it did not have to attain 60 Senate votes to surmount a filibuster). HCERA reconciled some of the differences between the original House version (passed 220-215 on November 7, 2009) and Senate version. Together these two pieces of legislation are conventionally referred to as the Affordable Care Act (ACA) even though there is no single piece of legislation with that name.
Statute and Regulations
Full Text Statutes
ACA consisted of two separate laws: HR 3590 was the Senate version of health care reform, and HR 4872 was the reconciliation bill that made some fixes in the law to make it palatable to the House of Representatives. The reconciliation combined text is also available.
Regulations and Guidance
The U.S. Department of Health and Human Services lists all ACA regulations issued to date on various issues (e.g. coverage for children under 19). It also has maintains a Requests for Comments page on draft regulations and comment deadline dates. American Benefits Council maintains a comprehensive listing of official source documents related to PPACA regulations. The Congressional Research Service has issued a series of reports regarding ACA regulations:
- Regulations Pursuant to the Patient Protection and Affordable Care Act (P.L. 111-148). April 13, 2010.
- Initial Final Rules Implementing the Patient Protection and Affordable Care Act. December 10, 2010.
- Upcoming Rules Pursuant to the Patient Protection and Affordable Care Act. January 13, 2011.
Impact of Regulation
- The Regulatory Burden of the Affordable Care Act. “The Affordable Care Act (ACA) was signed into law nearly six years ago. Since that time, 106 regulations have been finalized to implement the ACA. These regulations will cost businesses and individuals more than $45 billion and will require approximately 165 million hours of paperwork in order to comply. In addition to these regulations, hundreds of guidance documents regarding the ACA have been published by various federal agencies during this time as well. However, more regulations—and additional costs—are still to come. Regulations for one of the most expensive and burdensome provisions of the ACA—the ‘Cadillac Tax‘—have yet to be written. Guidance documents were published last year, but a final rule may not be published for a few more years given that the implementation date of the tax was recently delayed until 2020. The cost of each ACA regulation published so far has averaged $426 million and required 1.6 million hours of paperwork.” (American Action Forum, 2.15.16)
- Paperwork Burden. Federal law requires agencies to estimate the paperwork burden created by rules and regulations. This publication reflects a survey of the new burdens created by the Affordable Care Act by the agencies’ own estimates. All in all, the annual burden of compliance is estimated to be 189,882,836 man-hours, while the one-time burden is projected to be 78,957,868 hours. (Ways and Means, Education, and the Workforce, Energy and Commerce Committees, May 2013)
The ACA has 10 titles, each of which has an overarching focus/purpose (Table 2).
- Title 1. Quality Affordable Coverage for All Americans. Purpose: reform and expansion of private health insurance.
- Title 2. The Role of Public Programs. Purpose: Medicaid expansion and reform (see ACA and Medicaid for details).
- Title 3. Improving the Quality and Efficiency of Health Care. Purpose: Medicare changes and delivery system reforms (see ACA and Medicare for details).
- Title 4: Prevention of Chronic Disease and Improving Public Health. Purpose: prevention, wellness and public health.
- Title 5: Health Care Workforce. Purpose: improving workforce quality and quantity.
- Title 6: Transparency and Program Integrity. Purpose: fraud and abuse control; clinical comparative effectiveness; transparency, physician payment sunshine act, and more.
- Title 7: Improving Access to Innovative Medical Therapies. Purpose: allowing follow-on biologic drugs in the U.S. pharmaceutical market.
- Title 8: Community Living Assistance Service and Supports (CLASS Act). Purpose: cash assistance for temporarily or permanently disabled Americans (now repealed).
- Title 9: Revenue Provisions. Purpose: financing about half of the cost of the full ACA (see ACA and Taxes for details).
- Title 10: Strengthening Quality Affordable Health Care for All. Purpose: amendments to Titles 1-9, including Indian Health Reauthorization Act.
Title 1. Title 1 is the most detailed, including:
- Immediate Improvements in Health Care Coverage. Examples include: a) elimination of annual or lifetime limits on coverage; b) required coverage of clinical preventive services without cost-sharing; and c) required coverage of young adults up to age 26 on parents’ policies.
- Health Insurance Market Reforms. Examples include: a) ten “essential” health benefits required in most health insurance policies; b) “minimum loss ratios” setting limits on insurer administrative expenses and profits; c) review of health insurance premium rate increases greater than 10%; d) limits on age and gender as allowable premium rating criteria.
- Creation of Health Exchanges. This includes provisions for establishment and operation of federal and state Exchanges, along with the provision of income-related tax subsidies to reduce the premiums and cost-sharing associated with health plans offered on the Exchanges.
- Risk Amelioration Provisions (3Rs). This includes risk adjustment, risk corridors and reinsurance
- Individual Mandate. This includes provisions specifying who is liable for mandate penalties and the amounts of such penalties (which steadily increase by year).
- Employer Mandate. This includes provisions specifying which employers are liable for mandate penalties and the amounts of such penalties (which vary depending on whether the employer offers no coverage or coverage deemed “unaffordable”).
Title 3. This title also has a number of provisions, the most familiar being:
- Subtitle A–Transforming the Health Care Delivery System. Examples include a) Accountable Care Organizations; b) bundled payment demonstrations; c) hospital penalties for high rates of Medicare patient readmissions and health care associated conditions; and d) the Center for Medicare and Medicaid Innovation.
- Subtitle B–Improving Medicare for Patients and Providers
- Subtitle C–Provisions Relating to Part C. Examples include a) reductions in payments to Medicare Advantage plans originally designed to achieve $68 billion in savings through 2016; and b) a provision to provide Medicare Advantage quality incentive payments.
- Subtitle D–Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans. An example is closing the Medicare Part D prescription drug “doughnut hole.”
- Subtitle E–Ensuring Medicare Sustainability. Examples include a) Medicare payment cuts originally designed to achieve $85 billion in savings through 2016; and b) Independent Payment Advisory Board.
Title 4. Some of the most familiar features of this title include:
- Prevention and Public Health Investment Fund (PPHIF). The Fund is intended to provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care quality.
- Calorie Labeling on Chain Restaurant Menus. These will become effective December 1, 2016.
Title 5: Health Care Workforce Provisions
- Innovations in the Health Care Workforce.
- Creates a National Health Workforce Commission to help define national priorities, goals and policies.
- Provides planning and implementation health care workforce development grants to states focused on education, training and retaining individuals for health careers/related industries.
- Establishes National/State and Regional Centers for Workforce Analysis. Provides grants for the development of information to describe and analyze the health care workforce. State and regional centers collect, analyze and report data. Enhanced grants to be provided for longitudinal evaluations.
- Increasing the Supply of the Health Care Workforce.
- Provides Loan Repayment and Scholarships for medical school, primary care practice, nursing, pediatric specialists, child and adolescent mental and behavioral health, public health workforce (in federal, state and local/tribal health) and allied health workers in public agencies. Mid-career workers will be eligible for scholarships to upgrade their education.
- Provides grant opportunities to Nurse Managed Health Clinics (NMHC) for comprehensive primary health care services or wellness services to underserved or vulnerable populations. The NMHC must be associated with a school, college, university or department of nursing, FQHC or independent non-profit health or social services agency.
- Eliminates caps on Commissioned Officers in Public Health Service Regular Corps; Revises Regular Corps and Reserve Corps and renames the Ready Reserve Corps— responds to public health emergencies both foreign and domestic.
- Enhancing Health Care Workforce Education and Training. Health Professional Training Program Grants will be awarded to enhance education and training for primary care; direct care workers; general, pediatric and public health dentistry; geriatrics; mental and behavioral health; nursing and advanced nursing; and community health workers. Grant opportunities to include support for residencies and internships; need-based financial assistance for traineeships/fellowships; preparation of faculty; medical home demonstrations; joint degree programs for inter-disciplinary and professional training; and pre- and postdoctoral training.
- Supporting the Existing Health Care Workforce. Revises funding allocations to assist schools in supporting programs of excellence in health professions education for underrepresented minority individuals and schools designated as centers of excellence.
- Continues support for Area Health Education Centers that provide community based training and education, interdisciplinary training and continuing education, and prepare individuals to more effectively provide health services to underserved areas and populations.
- Makes revisions to the Nursing Workforce Diversity Grants Program to increase nursing education opportunities for individuals from disadvantaged backgrounds, including stipends for diploma or associate degree nurses to enter a bridge or degree completion program and scholarships/stipends for accelerated nursing degree programs, pre-entry preparations, advanced education preparation and retention.
- Establishes a Primary Care Extension Program to provide support and assistance to educate primary care providers about preventive medicine, health promotion, chronic disease management, mental and behavioral health services, and evidence-based and evidence-informed therapies and techniques. Requires the Secretary to award grants to states for the establishment of Primary Care Extension Program State Hubs to coordinate state health care functions with quality improvement organizations and area health education centers.
- Strengthening Primary and Other Workforce Improvements.
- Expands access to primary care services and general surgery services by offering incentive payment programs of 10% in a health professional service area.
- Includes toward the determination of full-time equivalency for graduate medical education cost time spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is primarily engaged in furnishing patient care in nonpatient care activities.
- Reallocates unused residency positions to qualifying hospitals for primary care residents for purposes of payments to hospitals for graduate medical education costs.
- Revises provisions related to graduate medical education costs to count the time residents spend in nonprovider settings toward the full-time equivalency if the hospital incurs the costs of the stipends and fringe benefits of such residents during such time.
- Directs the Secretary, when a hospital with an approved medical residency program closes, to increase the resident limit for other hospitals based on proximity criteria.
- Requires the Secretary to: (1) award grants for demonstration projects that are designed to provide certain low-income individuals with the opportunity to obtain education and training for health care occupations that pay well and that are expected to experience labor shortages or be in high demand; and (2) award grants to states to conduct demonstration projects for purposes of developing core training competencies and certification programs for personal or home care aides.
- Authorizes the Secretary to award grants to teaching health centers for the purpose of establishing new accredited or expanded primary care residency programs. Allows up to 50% of time spent teaching by a member of the National Health Service Corps to be considered clinical practice for purposes of fulfilling the service obligation.
- Requires the Secretary to make payments for direct and indirect expenses to qualified teaching health centers for expansion or establishment of approved graduate medical residency training programs.
- Requires the Secretary to make payments to teaching health centers that operate graduate medical education program. Payments shall be provided for direct expenses and for indirect expenses to qualified teaching health centers that are listed as sponsoring institutions by the relevant accrediting body for expansion of existing or establishment of new approved graduate medical residency training programs.
- Requires the Secretary to establish a graduate nurse education demonstration under which a hospital may receive payment for the hospital’s reasonable cost for the provision of qualified clinical training to advance practice nurses.
- Improving Access to Health Care Services.
- Provides appropriations for federally qualified health centers to serve medically underserved populations.
- Requires the Secretary to establish through the negotiated rulemaking process a comprehensive methodology and criteria for designation of medically underserved populations and health professions shortage areas.
- Reauthorizes appropriations for the expansion and improvement of emergency medical services for children who need treatment for trauma or critical care.
- Authorizes the Secretary, acting through the Administrator of the Substance Abuse and Mental Health Services Administration, to award grants and cooperative agreements for demonstration projects for the provision of coordinated and integrated services to special populations through the co-location of primary and specialty care services in community-based mental and behavioral health settings.
Title 6. Some of the most familiar features of this title include:
- Physician Payments Sunshine Act. Creates the “Open Payments” website.
- Patient-Centered Outcomes Research Institute (PCORI). Created to conduct more comparative effectiveness research designed to better inform patients about treatment options.
- Medicare and Medicaid Fraud and Abuse Prevention Initiatives. Increases funding and activities related to detection and punishment for fraud and abuse.
- Kaiser Family Foundation. Summary of the Affordable Care Act (13 pp.)
- Blue Cross Blue Shield Association has a detailed bill summary.
- Wall Street Journal has a comparison of the bill as passed with versions originally enacted in House and Senate.
- National Association of Health Underwriters side-by-side comparison chart outlines what was contained in each bill. NAHU has a separate side-by-side comparison chart of all four pieces of legislation considered by the 111th Congress.
- American Public Health Association reviews major provisions of the health care reform and lists many resources.
- CoreSource. Commonly Used Terms
- Kaiser Family Foundation. Print Glossary of Key Health Reform Terms
- George Washington University. On-line Glossary
- Time. Understanding the Health Care Debate: Your Indispensable Guide
- CNN.com. Getting Past the Lingo of the Health Care Debate
- Health Care and You. Glossary
- American Action Forum. ACA Dictionary. This is a comprehensive resource of definitions and background on health care terms, acronyms, and all things Affordable Care Act. The dictionary has hundreds of health care and ACA specific terms with an easy-to-use search function for specific definitions.
- Frequently Asked Questions.
- Fact Checkers
- CNN Truth Squad: Health Care Fact Check.
- Annenberg Public Policy Center. FactCheck.org. Affordable Care Act.
- Tampa Bay Times. PolitiFact.com. Truth-0-meter Statements About Health Care. There is some evidence that PolitiFact.com is biased against Republicans both in general terms and in terms of health reform claims.
- Tampa Bay Times. PunditFact. This is a project of the Tampa Bay Times and the Poynter Institute, dedicated to checking the accuracy of claims by pundits, columnists, bloggers, political analysts, the hosts and guests of talk shows, and other members of the media.
- Washington Post. Fact Checker (Glenn Kessler).
- ACA Provisions. Several different groups have prepared timelines that codify when various ACA provisions take effect, including Kaiser Family Foundation, The Commonwealth Fund and Wall Street Journal. The most comprehensive (53 pages) was produced by Republicans on the House Energy and Commerce Committee. NAHU provides a detailed timeline on health care reforms and their effective dates, and a simplified timeline of implementation that outlines how the health care reform legislation will impact individuals and employers. American Action Forum provides a timeline of “key dates and facts critical to understanding the continuing evolution of the law.”
- Development of the ACA. Timeline of the Finance Committee’s Work to Reform America’s Health Care System. Lists activities from Feb. 13, 2007, through March 30, 2010.
- Payment and Delivery System Reforms.
- Commonwealth Fund. Summary of Select Affordable Care Act Payment and Delivery System Reform Provisions. (May 2015) Extensive list includes payment reform, changes in organization of health care delivery (with provisions related to “primary care transformation”), and changes to workforce policy.
- Transforming the Health Care Delivery System: Proposals to Improve Patient Care and Reduce Health Care Costs. Thought to be an analysis Congress heavily relied upon when drafting the ACA. “The dynamics in our health system affect the care that is delivered in both the public and private sectors. In many cases, changes to federal health programs like Medicare activate and pave the way for system-wide changes. The proposals contained in this document set forth ideas on ways to revise payment systems and policies in the Medicare program to promote higher-quality, and more cost-effective care and to reduce fraud, waste and abuse throughout the health system.” (Senate Finance Committee April 29, 2009)
- Foundation. Disclosed in the WikiLeaks Podesta email releases of October, 2016, this memo (dated 10.1.08), from Jeanne Landrew, describes the aims of the transition team for candidate Barack Obama’s health reform agenda.
- U.S. DHHS maintains the official site for health reform, HealthCare.gov, containing text and video explanatory materials.
- Kliff, Sarah. Everything You Need to Know About Obamacare (slideshow). Vox: 4.17.14
- NCSL. State Health Insurance Mandates and the PPACA Essential Benefits Provisions.
- Wall Street Journal. The Health Law Rollout.
- 2010 Patient Protection & Affordable Care Act (ACA – Obamacare)