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A Primer on the ACA (aka ObamaCare) I

Posted by John McDonough  November 13, 2011 03:30 PM

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In this blog, I will write often about the national health reform law known as the Affordable Care Act (ACA) or ObamaCare. I will refer to well-known and less-recognized parts of the law. In my talks around the nation, I find that while most people have strong opinions about the law, few believe they understand it. I also find that people appreciate seeing a framework to help them make sense of the ACA whether they like the law or not.

Over the next year and beyond, the ACA will figure mightily in our national political conversation.  The law's fate may be determined by the results of the 11/06/2012 federal elections. This election may become an unprecedented national referendum on the fate of the ACA.  I can't think of a parallel in US history. So to help promote better understanding of the law, here is a brief primer to help you understand the ACA as a whole. The framework is the same one I use in my new book, Inside National Health Reform. (Warning: this post is a bit longish. Much shorter posts ahead, I promise!)

Just like a book has chapters and a baseball game has innings, a federal law has "titles" that divide the statute into logical sections. The ACA has 10, and outlining these 10 provides a good path to understanding the essential architecture and logic of the law. So, without further ado, here is a list of the ten, followed by short descriptions of each:

  1. Quality, Affordable Coverage for All Americans (private health insurance)
  2. The Role of Public Programs (Medicaid)
  3. Improving the Quality and Efficiency of Health Care (Medicare and quality improvement)
  4. Prevention of Chronic Disease and Improving Public Health
  5. Health Care Workforce
  6. Transparency and Program Integrity (fraud and abuse and a lot more)
  7. Improving Access to Innovative Medical Therapies (biopharmaceutical similars)
  8. CLASS Act (disability support)
  9. Revenue Provisions
  10. Strengthening Quality, Affordable Health Care for All (amendments to titles I-IX)

A quick scan of titles reveals the law's breadth and depth. Few parts of the U.S. health care system are untouched by the ACA. The U.S. has the most complex health care system among all developed nations, and comprehensive reform of that system will be complex as well. Here are some key details on each title:

Title I: Quality, Affordable Health Care for All Americans. This is the title you have heard the most about. Many of its reforms have already taken effect such as allowing young adults up to age 26 to stay on their parents' insurance; helping early retirees and those with pre-existing conditions; requiring insurers to spend at least 80 or 85 cents of every premium dollar on medical costs; and lots more.

The biggest parts are yet to come. Title I, if fully implemented in 2014, will mark a revolution in private health insurance in America (whether you like it or hate it).  Four key provisions rule: first, insurance market reforms will forbid insurers from imposing pre-existing condition exclusions or rating prospective enrollees on their health status or history, also known as "guaranteed issue;" second, an individual responsibility requirement (or "mandate") is intended to prevent young and healthy persons from waiting until they get sick before signing up for coverage in order to keep everyone's premiums lower; third, premium and cost sharing subsidies for lower and moderate income Americans will make the purchase of insurance more affordable for those who can't get workplace coverage; and fourth, web-based insurance "exchanges" will provide an easy, Expedia-like way to buy health insurance. These changes will be dramatic in 49 states, though not in Massachusetts where all been in effect at least since 2007.

The Congressional Budget Office (CBO) estimates that about 16 million currently uninsured Americans will receive coverage as a result of Title I by the year 2019, half of the 32 million uninsured who will get covered. The other half will get covered via Title II.

Title II: The Role of Public Programs. This title deals mostly with Medicaid, which most Americans think is the health insurance program for the poor. In most states though, Medicaid covers only certain categories of poor people (children and their parents, disabled, seniors), leaving out poor, childless, working adults, a large part of America's uninsured. Beginning in 2014, the ACA will make Medicaid the health insurance program for nearly all Americans with household incomes less than 133% of the federal poverty line (just under $30,000 in annual income for a family of four).

Some governors (mostly Republicans) complain about Title II and the new costs it will impose on them.  But for newly eligible persons, the federal government will pay 100% of the costs in 2014, '15, and '16, phasing down to 90% by 2019 and beyond. Medicaid currently generally reimburses states between 50 and 85% for their other eligible populations, based on each state's per capita income. So why are the governors mad? Many are mad because they currently control their Medicaid programs by making it difficult for eligible persons to get on or to stay enrolled.  They worry that the individual mandate and the publicity to get people signed up will encourage many who are now Medicaid eligible, though unenrolled, to sign up. And for those folks, the federal government will pay states their traditional 50-85% share.

Just as Title I is a revolution in private health insurance, Title II is the biggest revolution ever in Medicaid since it was established in 1965.

Title III: Improving the Quality and Efficiency of Health Care. Title III is designed to trigger a revolution to make U.S. medical care better in quality and efficiency. It also changes Medicare to improve care for enrollees and to reduce Medicare's rate of spending growth by about $450 billion over ten years to finance nearly half the cost of the ACA.

The quality/efficiency improvements are many, and most are experiments. Key ones include: penalizing hospitals with high rates of hospital acquired infections and/or preventable readmissions; moving away from fee-for-service payments to hospitals and physicians by encouraging formation of "accountable care organizations," "medical homes," and other innovations; setting up a board to reduce Medicare costs if they grow above a certain level, called the Independent Payment Advisory Board (IPAB); creating the first ever national quality improvement strategy.

The Medicare changes allow enrollees to get preventive services without co-pays or deductibles, and close the so-called "Part D donut hole" which requires some enrollees with high prescription drug costs to pay the full cost for their drugs. Title III also reduces the rate of Medicare spending growth to hospitals, insurers, home health agencies, hospices and other providers. All groups, except insurers, agreed to these changes and supported the law's passage.

Title IV: Prevention of Chronic Disease and Improving Public Health. Title IV is perhaps the most ambitious law ever passed to make the U.S. health system more prevention focused. A National Prevention Strategy has already been created and published. A Prevention and Public Health Fund is investing $15 billion through 2014 in efforts across the nation to improve public health. Another section (4205) requires, beginning next year, chain restaurants to include the number of calories in each item on their menus and menu boards.

Title V: Health Care Workforce. This may be the most far-reaching law ever to increase and improve the nation's heath care workforce, particularly regarding primary care. It includes large funding increases for community heath centers (some of which has been reduced in recent federal budget negotiations) and the National Health Service Corps which pays medical students' debt in exchange for service in medically underserved areas; as a result of the ACA, the number of participating NHSC physicians has increased from 3,000 in 2008 to more than 10,000. The law sets up a National Health Care Workforce Commission to do comprehensive workforce planning, though the House of Representatives has been unwilling to appropriate funds to allow the commission to get to work.

Title VI: Transparency and Program Integrity. This Title is a grab bag. The Physician Payment Sunshine Act will require drug, device and medical supply companies to publicly report gifts and other payments to physicians, with reports to be available on a federal website. Transparency provisions will enable nursing home residents and their families to obtain important information about their homes. The Elder Justice Act provides the first ever national initiative to combat violence, neglect and financial exploitation of senior citizens. Fraud and abuse provisions include aggressive measures to prevent fraudulent providers from getting into Medicare and Medicaid programs. The Patient Centered Outcomes Research Institute (PCORI) provisions establish a new, public-private entity to commission and undertake research on the comparative clinical effectiveness of treatments and therapies.

Title VII: Improving Access to Innovative Medical Therapies. This title establishes, for the first time, a pathway for the U.S. Food and Drug Administration to approve the manufacture, marketing, and sale of biosimilar biological products. The future of the world drug industry is biopharmaceuticals and the costs are huge. The European Union, Australia, Japan and other industrialized nations have had a pathway for approval of biosimilars available for years. This title enables the U.S. to begin catching up.

Title VIII: Community Living Assistance Services and Supports -- the CLASS Act. In October, the Obama Administration announced it would not move forward to implement this controversial Title because it could not ensure that the program would be financially sustainable for 75 years from collected premiums. Had it been launched, CLASS would have been a federal public program option for working Americans to provide some financial protection in the case of permanent or temporary disability. Voluntary enrollees would pay monthly premiums (estimated between $125 and 250 per month, though never finalized) for at least five years; if disabled, enrollees would be eligible for daily cash payments of $50-75 per day to support the cost of living independently in the community, as an alternative to spending their resources down to poverty to qualify for Medicaid.

Title IX: Revenue Provisions. The sections in this title finance less than half the cost of the total law, about $439B over ten years. The biggest is $200B in new Medicare taxes on high-income earners (individuals making $200K+ and families making $250K+). Also included are new assessments and taxes on insurance, drug, and medical device companies as well as restrictions on the use of Health Savings and Health Reimbursement Accounts, plus a tax on high cost health insurance policies beginning in 2018, also a ten percent tax on the use of indoor tanning services, and more.

Title X: Strengthening Quality, Affordable Health Care for All Americans. This last title includes changes and amendments to titles I-IX, reflecting the unusual legislative process by which the ACA became law. Ordinarily, such changes would be blended into the original provisions; this was not possible because of the contentious process in the U.S. Senate by which the ACA passed. The most significant new provision is the reauthorization of the Indian Health Services Act.

Health Care and Education Reconciliation Act (HCERA). This is a separate law signed by President Obama on March 30, 2010, one week after he signed the original law. This law includes changes and amendments to Titles I-X. The original law signed by President Obama was titled the Patient Protection and Affordable Care Act (PPACA). The term, Affordable Care Act (ACA), is used to distinguish the original PPACA signed on 3/23/2010 from PPACA as modified by HCERA. Hence, the logic for the shorter acronym "ACA," as well as being more easily remembered. Many, even the President, prefer "ObamaCare."

In my next primer post, I will focus on the money flows in an out of the law.

Here are some helpful resources:

Fully merged text of the ACA. And section by section summary.

White House Health Reform site.

Health Reform GPS.

Commonwealth Fund health reform resource center.

Kaiser Family Foundation health reform source.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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