Health and Fitness

Affordable Care Act: what you need to know

Bundled payments

Medicare switched from fee-for-service to bundled payments.

A single payment should be paid to a hospital and a group of doctors for a defined episode of care (such as a hip replacement) rather than separate payments to individual providers.

Responsible care organizations

The Medicare Shared Savings Program (MSSP) was established by section 3022 of the Affordable Care Act. It is the program through which a responsible assistance organization interacts with the federal government and through which responsible assistance organizations can be created. It is a fee-for-service model. The law allowed for the creation of responsible care organizations (ACOs), which are groups of doctors, hospitals, and other providers that are committed to providing coordinated care for Medicare patients. ACOs were allowed to continue using fee-for-service billing. They receive government bonus payments to minimize costs while meeting quality standards that emphasize the prevention and mitigation of chronic diseases. The lack of cost or quality benchmarks subject them to penalties. Unlike health maintenance organizations, ACO patients are not required to obtain all ACO care. Also, unlike HMOs, ACOs must meet quality of care goals.

Medicare Drug Benefit (Part D)

Medicare Part D participants received a 50% discount on branded drugs purchased after they had exhausted their initial coverage and before reaching their catastrophic coverage threshold.

By 2020, the “donut hole” would be completely filled.

state exemptions

Starting in 2017, states can apply for a “state innovation waiver”, which allows them to conduct experiments that meet certain criteria.

To obtain an exemption, a state must pass legislation establishing an alternative healthcare system that provides insurance at least as comprehensive and affordable as the ACA, covers at least as many residents, and does not increase the federal deficit.

These states may evade some of the core requirements of the ACA, including individual and employer mandates and the offer of an insurance grant.

The state would receive compensation equal to the full amount of any federal grants and tax credits that its residents and employers would be eligible for under the ACA if they cannot be paid under the state plan.

Other insurance provisions

The Community Living Assistance Services and Supports Act (or CLASS Act) established a voluntary, public long-term care insurance option for employees. The program was abolished as being impractical without ever having gone into effect. member-run non-profit insurers could begin providing health care coverage, based on a 5-year federal loan.

In 2017, only four of the original 23 cooperatives were still in operation.

Nutrition labeling requirements

Nutrition labeling requirements officially went into effect in 2010, but implementation was delayed and actually took effect on May 7, 2018.

legislative history

The ACA followed a long series of unsuccessful attempts by one party to pass major insurance reforms.

Innovations were limited to health savings accounts (2003), medical savings accounts (1996) or flexible spending accounts, which increased insurance options but did not materially expand coverage.

Health was an important factor in multiple elections, but until 2009, neither party had the votes to overcome the other’s opposition.

individual mandate

The concept of individual mandate dates back to at least 1989, when The Heritage Foundation, a conservative think-tank, proposed an individual mandate as an alternative to single-payer healthcare. It was championed for a while by conservative economists and Republican senators as a market-based approach to healthcare reform based on individual responsibility and the prevention of hitchhiking problems. Specifically, because the Emergency Medical Treatment and Active Work Act of 1986 (EMTALA) requires any Medicare participating hospital (almost all to do so) to provide emergency care to anyone who needs it, the government often indirectly bears the cost. those who were unable to pay. . President Bill Clinton proposed a major health care reform bill in 1993 that ultimately failed. Clinton negotiated a compromise with the 105th Congress to enact the State Children’s Health Insurance Program (SCHIP) in 1997. Clinton’s failed plan included a mandate for employers to provide health insurance to all employees through a regulated market of health maintenance organizations. Republican senators have proposed an alternative that would require individuals, but not employers, to buy insurance. The Republican Health Equity and Access Reform Today (HEART) Act of 1993 contained a requirement for “universal coverage” with a penalty for non-compliance – an individual mandate – as well as subsidies to be used in ‘buying groups’ based on in the state. Supporters included prominent Republican senators such as John Chafee, Orrin Hatch, Chuck Grassley, Bob Bennett, and Kit Bond. The Republican Consumer Choice Health Safety Act of 1994 initially contained an individual mandate with a penalty clause; however, author Don Nickles later removed the mandate, stating that “the government should not force people to buy health insurance”. At the time of these proposals, Republicans did not raise constitutional issues; Mark Pauly, who helped develop a proposal that included an individual term for George HW Bush, commented, “I don’t remember it being raised. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax.” In 2006, an insurance expansion bill has been enacted at the state level in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Governor Mitt Romney vetoed the term, but after Democrats overrode his veto, he signed it into law. Romney’s implementation of the ‘Health Connector’ exchange and individual mandate in Massachusetts was initially praised by Republicans. During Romney’s 2008 presidential campaign, Senator Jim DeMint praised Romney’s ability to “take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured.” Romney said of the individual mandate, “I’m proud of what we’ve done. If Massachusetts can implement it, then that will be the model for the nation.” In 2007, Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which featured an individual mandate and state-based regulated insurance markets called “State Health Aid Agencies.” The bill attracted bipartisan support, but died on the committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate. By 2008, many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bears similarities to the 2007 bill that drew ideas from Massachusetts reforms. which featured an individual mandate and state-based regulated insurance markets called “State Health Aid Agencies.” The bill attracted bipartisan support but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate. By 2008, many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bears similarities to the 2007 bill that drew ideas from Massachusetts reforms. which featured an individual mandate and state-based regulated insurance markets called “State Health Aid Agencies.” The bill attracted bipartisan support but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate. By 2008, many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bears similarities to the 2007 bill that drew ideas from Massachusetts reforms. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate. By 2008, many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bears similarities to the 2007 bill that drew ideas from Massachusetts reforms. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate. By 2008, many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bears similarities to the 2007 bill that drew ideas from Massachusetts reforms.

academic foundation

A driving force behind Obama’s healthcare reform was Peter Orszag, Director of the Office of Management and Budget. Obama called Orszag his “health czar” because of his knowledge of health care reform. Orszag had previously been director of the Congressional Budget Office, and under his leadership, the agency focused on using cost analysis to create an affordable and effective approach to health care reform. Orszag said healthcare reform became the top item on Obama’s agenda because he wanted it to be his legacy. According to an article by Ryan Lizza in The New Yorker, the core of “Obama’s budget is Orszag’s belief [in] … a government empowered with research into the most effective medical treatments.” Obama bet”

Health Debate, 2008–10

Health care reform was a hot topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans put forward by the two leading candidates, Hillary Clinton and the eventual candidate, Barack Obama. Each candidate proposed a plan to cover the estimated 45 million Americans who are estimated to be without health insurance at some point during the year. Clinton’s proposal would require all Americans to obtain coverage (actually, an individual term), while Obama’s proposal provided a subsidy without a term. Obama and his opponent, Senator John McCain, proposed health insurance reforms, although their plans were different. McCain proposed tax credits for health insurance purchased on the individual market, which was estimated to reduce the number of uninsured people by about 2 million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protection, and Medicaid and SCHIP expansions, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost. Obama announced to a joint session of Congress in February 2009 his intention to work with Congress to build a plan for health care reform. In July, a series of bills were approved by committees of the Chamber of Deputies. On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a proposal. This group—in particular, Democrats Max Baucus, Jeff Bingaman, and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe, met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the basis of a Senate bill. Congressional Democrats and Health Policy experts such as MIT economics professor Jonathan Gruber and David Cutler argued that guaranteed issuance would require both community ranking and an individual mandate to ensure adverse selection and/or “free ride” would not result in an insurance “death spiral”. They chose this approach after concluding that Senate obstruction proof support was not present for more progressive plans such as the single payment. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate Majority Leaders Howard Baker, Bob Dole, Tom Daschle, and George J. Mitchell—the drafters of the bill hoped to garner the necessary votes. However, after incorporating an individual mandate into the proposal, Republicans threatened to obstruct any bill that contained it. Senate Minority Leader Mitch McConnell, who led the Republican response, concluded that Republicans should not support the bill. Republican senators, including those who supported previous proposals with a similar term, began to describe the term as “unconstitutional”. Journalist Ezra Klein wrote in The New Yorker, ” The nascent Tea Party movement organized protests and many conservative groups and individuals attended meetings to oppose the proposed reforms. Threats were made against members of Congress during the debate. In September 2009, Obama delivered another speech to a joint session of Congress supporting the negotiations. On November 7, the House of Representatives passed the Affordable Health Care for America Act by 220-215 votes and forwarded it to the Senate for approval. The nascent Tea Party movement organized protests and many conservative groups and individuals attended meetings to oppose the proposed reforms. Threats were made against members of Congress during the debate. In September 2009, Obama delivered another speech to a joint session of Congress supporting the negotiations. On November 7th,

Senate

The Senate began working on its own proposals while the House was still working. The United States Constitution requires that all revenue-related bills originate in the House. To formally comply with this requirement, the Senate reformulated HR 3,590, a bill that deals with changes in the housing tax for civil servants. It had been approved by the House as a revenue-related modification of the Internal Revenue Code. The bill became the Senate’s vehicle for its health care reform proposal, scrapping the bill’s original content. The bill eventually incorporated elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Senate Republican minority vowing to obstruct, it would take 60 votes to pass the Senate. At the start of the 111th Congress, Democrats had 58 votes. The Minnesota Senate election was eventually won by Democrat Al Franken, with 59. Arlen Specter switched to the Democratic party in April 2009, giving them 60 seats, enough to end the obstruction. Negotiations were held trying to satisfy moderate Democrats and bring Republican senators on board; special attention was given to Republicans Bennett, Enzi, Grassley and Snowe. After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Senate Majority Leader Harry Reid focused on satisfying centrists. The strongholds were Connecticut’s Joe Lieberman, an independent who had caucused with Democrats, and Nebraska’s conservative Democrat Ben Nelson. Lieberman’s demand that the bill not include a public option has been met, although supporters have won several concessions, including allowing state-based public options such as Vermont’s failed Green Mountain Care. The White House and Reid addressed Nelson’s concerns during a 13-hour negotiation with two concessions: a compromise on abortion, modifying the bill’s language “to give states the right to prohibit coverage of abortion within their own insurance grants”, which would require consumers to pay out-of-pocket for the procedure if the State so decides; and an amendment to offer a higher Medicaid reimbursement rate for Nebraska. The second half of the compromise was ironically called the “Cornhusker Kickback” and was later removed. On December 23, the Senate voted 60 to 39 to end debate on the bill: a vote to end obstruction. The bill passed, also by 60 to 39, on December 24, 2009, with all Democrats and two Independents voting in favor, and all Republicans against (except for Jim Bunning, who did not). The bill was endorsed by the American Medical Association and AARP. On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Edward Kennedy, having campaigned to give the Republican minority the 41st vote needed to support Republican obstructionists. Furthermore, the symbolic importance of losing Kennedy’s traditionally Democratic seat in Massachusetts left many Democratic congressmen worried about the political cost of the bill. Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Edward Kennedy, having campaigned to give the Republican minority the 41st vote needed to support Republican obstructionists. In addition, the symbolic importance of losing Kennedy’s traditionally Democratic seat in Massachusetts has many Democratic congressmen worried about the political cost of the bill. Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Edward Kennedy, having campaigned to give the Republican minority the 41st vote needed to support Republican obstructionists. In addition, the symbolic importance of losing Kennedy’s traditionally Democratic seat in Massachusetts has many Democratic congressmen worried about the political cost of the project.

home

With Democrats no longer getting the 60 votes to break a Senate obstruction, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill, but House Speaker Nancy Pelosi argued backed off, rejecting more moderate reforms like “Kiddie Care”. Obama remained insistent on comprehensive reform. The news that Anthem in California intended to increase premium rates for its patients by as much as 39% gave him new evidence of the need for reform. On February 22, he presented a proposal “inclined to the Senate” to consolidate the bills. He held a meeting with the leaders of both parties on 25 February. Democrats decided that the House would pass the Senate bill, to avoid another Senate vote. House Democrats had hoped to be able to negotiate changes at a House-Senate conference before passing a final bill. Because any bill that emerged from the conference that differed from the Senate bill would have to pass the Senate over another Republican obstructionist, a majority of House Democrats agreed to pass the Senate bill on the condition that it be amended by a bill. subsequent. They drafted the Health and Education Reconciliation Act, which could be passed through the reconciliation process. But reconciliation is limited to budget changes, which is why the procedure was not used to pass the ACA in the first place; the bill had inherently non-budgetary regulations. While the already-passed Senate bill could not have passed through reconciliation, most of the House Democrats’ demands were budgetary: “these changes — higher levels of subsidies, different types of taxes to pay for them, vetoing the deal Nebraska Medicaid – mostly involve taxes and spending. In other words, these are exactly the types of policies that are suitable for reconciliation.” The remaining obstacle was a key group of pro-life Democrats led by Bart Stupak, who were initially reluctant to support the bill. The group considered the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill did not include language that satisfied their concerns, but they could not address abortion in the reconciliation project, as it would be non-budgetary. Instead, Obama issued Executive Order 13535, reaffirming the principles of the Hyde Amendment. This won the support of Stupak and members of his group and secured the bill’s approval. The House passed the Senate bill with a vote of 219-212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. He passed the second bill, 220-211, on the same day (with the Senate passing this bill via reconciliation by 56-43 a few days later). The day after the ACA passed, March 22, Republicans introduced legislation to repeal it. Obama signed the ACA into law on March 23, 2010. Republicans have introduced legislation to repeal it. Obama signed the ACA into law on March 23, 2010. Republicans have introduced legislation to repeal it. Obama signed the ACA into law on March 23, 2010.

post enactment

Since passing, Republicans have voted to repeal the Affordable Care Act in whole or in part more than sixty times. The Tax Cuts and Jobs Act of 2017 eliminated the fine for violating the individual mandate, effective in 2019. .) In 2019, Congress repealed the so-called “Cadillac” tax on health insurance benefits, a special tax on medical devices, and the health insurance tax.

Impact

Roof

The law caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance dropped from 16.0% in 2010 to 8.9% from January to June 2016. The uninsured rate dropped in all congressional districts in the US from 2013 to 2015. The Congressional Budget Office reported in March 2016 that approximately 12 million people were covered by grants (10 million of whom received grants) and 11 million were added to Medicaid. Another million were covered by the ACA’s “Basic Health Program”, totaling 24 million. The CBO estimated that the ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different calculation to the numbers above, totaling ACA’s coverage of 26 million, minus 4 million for reductions in “employment-based coverage” and “non-group and other coverage”. The US Department of Health and Human Services (HHS) estimated that 20.0 million adults (ages 18 to 64) obtained health coverage via ACA in February 2016; similarly, the Urban Institute found in 2016 that 19.2 million non-elderly Americans obtained health insurance coverage from 2010 to 2015. In 2016, the CBO estimated the uninsured at approximately 27 million people, or about 10 % of population or 7-8% excluding unauthorized immigrants. States that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not had a 14.1% uninsured rate among adults ages 18 to 64. In December 2016, 32 states (including Washington DC) had adopted the Medicaid extension. A 2017 study found that the ACA reduced socioeconomic disparities in access to healthcare. years after the enactment of the ACA. Ten years after its enactment, studies showed that ACA also had a positive effect on health and caused a reduction in mortality.

fees

Affordable Care Act excise taxes raised $16.3 billion in fiscal 2015. $11.3 billion came from an excise tax applied directly to health insurers based on their market share. Annual consumption taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. The individual mandate tax was $695 per individual or $2,085 per family minimum, amounting to 2.5% of household income (whichever was greater). The tax was reduced to 0 at the end of 2018. In fiscal 2018, individual and employer mandates yielded $4 billion each. Excise taxes on insurers and drug manufacturers added $18 billion. Income tax surcharges produced 437 billion. The ACA has reduced measured after-tax income inequality due to income tax surcharges and subsidies. The CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for the 10 million individuals who receive them, about $42 billion. The tax subsidy for the employer market was approximately $1,700 per person in 2016, or $266 billion in total.

insurance exchanges

As of August 2016, 15 states operated their own health insurance market.

Other states used the federal grant or operated in partnership or supported by the federal government.

As of 2019, 12 states and Washington DC operated their own exchanges.

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