ACA Overview

VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Overview (last updated 9.24.17)

Overview

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)

Basic Structure

Overview

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.

Selected Titles

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 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.

General Pressures on Health Spending

Cost Containment Provisions

Provisions Leading to Higher Total Spending and Price Pressures

Bill Summaries

• 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.

Other Materials

• Organizational Charts
  • Joint Economic Committee (2010)
• Citizens’ Council for Health Freedom (2012)

• Glossaries
  • 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.
  • DHHS has a site on PPACA implementation FAQs.
  • Read the Q & A from NAHU’s health reform webinars.
• 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).
• Timelines.
  • 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)
  • The Triple Aim: Care, Health, And Cost. Donald M. Berwick, Thomas W. Nolan and John Whittington. (Health Affairs, May 2008)
• History. 
  • 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.
  • Behind the Veil: The AARP America Doesn’t Know. “This report highlights AARP’s increasing reliance on the ‘for-profit’ sale of insurance, particularly health insurance, and the underlying implication for this storied ‘non-profit’ organization. In conducting the research, one of the central questions became: Why would AARP aggressively advocate for the Democrats’ health care law last year which contained nearly one half-trillion dollars in cuts that independent analysts said would negatively impact seniors’ access to affordable health care services? The report also details the Democrats’ health care law’s significant cuts to Medicare Advantage (MA) and how the interplay in the marketplace between MA and Medigap will increase Medigap sales. This will have a direct, significant, and positive impact on future profits at AARP. Also troubling is the report’s central finding: The Democrats’ health care law, which AARP strongly endorsed, could result in a windfall for AARP that exceeds over $1 billion during the next 10 years.”  (House Ways and Means Committee, 3.29.11)
  • Obama’s Deal. April 13, 2010 transcript of PBS Frontline program detailing dealmaking that occurred during creation of the Affordable Care Act.

The Basics

• 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)
• Independent Women’s Voice. ACA: the Good and the Bad.