2. Patient Protection and Affordable Care Act
Public Law No: 111-148 Signed March 23,
2010
Health Care and Education Reconciliation Act
Cleared for President March 25, 2010
3. Bills reduce the number of uninsured (about
32 million) in 2019
Guarantees access
Certain employers could allow all of their
workers to choose among the plans available
in the exchanges
4. • Too Complex – an Unstable Collection of
Massive Government, Trillions in Spending,
Taxes, and Confusion
• over 2,700 pages of complex and confusing
provisions. Substantial new authorities are
handed to bureaucracies that will launch
more complexity and confusion. No one can
follow or predict the disruptions, distortions,
unintended consequences that flow from the
proposals.
5. • Financial Help is Not Generally Available to
Employees of Companies that Provide Qualified
Health Insurance
• Trillions of dollars of subsidies and entitlements
are generally not available to help workers who
get qualified insurance from their employers.
This means rising health care cost continue to
keep wages down.
• In response to the incentives of the bill, large
employers may reduce certain lower come, in-
house positions in favor of outsourcing or
contracting out.
6. • The Bill is Inconsistent with the President’s
Promise that Employees can Keep Health
Plans They Have Due to Government
Micromanagement
• The Federal government would take a more
substantial role in the design of health
insurance through dozens of new
requirements.
7. • The Bill is Inconsistent with the President’s
Promise that Employees can Keep Health
Plans They Have Due to Punitive Taxes
• Starting in 2018, the bill imposes a 40% tax
on certain high cost plans which employees
would ultimately pay for in either fewer
increases in salary changing plans.
• The tax will force many employers to change
their current plans in favor of cheaper plans –
plans that may carry fewer benefits and,
possibly, higher cost-sharing.
8. • The Bill will add to the Instability for Our
Economic Future
• Over an operating ten year window they are
$2. 5 trillion dollars (2014-2023) in new
spending. And that is based on estimates
that may or may not be reliable over time.
• The Congressional Budget Office, the
Medicare Actuaries, and many others do not
appear skeptical over the political
sustainability of hundreds of billions of
dollars of cuts to Medicare.
9. • Mandates, Penalties and Liabilities will Harm
Employers Who have Been Doing Their Part to
Provide Health Insurance
• The bill contains dozens of confusing,
conflicting, and burdensome provisions with new
bureaucrats and new penalties. These provisions
will create conflicting interpretation and pose
substantial new threats and liabilities for
employers. Employers may get out of the role of
providing health insurance.
• The employer mandates are punitive, create
needless bureaucracy, and may threaten jobs.
13. State Insurance Regulators Licensure, Accreditation
EXISTING REQUIREMENTS •Prompt pay
•Guaranteed renewal •Appeals and grievances
•Rating •Privacy/Confidentiality
•Preexisting conditions •Licensure/Accreditation
•Non‐discrimination •Antitrust
•Quality improvement and •Benefit plan
reporting material/information
•Benefit mandates •Consumer protection
•Solvency and financial •Fraud and abuse
requirements
•Market conduct
14. Department of Labor Internal Revenue Service
EXISTING PROGRAMS EXISTING AUTHORITIES
•ERISA •Enforcement for HIPAA,
Mental Health Parity,
•COBRA
Genetic nondiscrimination
•Health care portability •Tax provisions
•Privacy, Mental Health Parity,
Genetic Non Discrimination
•Benefit Requirements Health and Human Services
•Claims Processing EXISTING REQUIREMENTS/PROVISIONS
Requirements
•HIPAA Benefit Mandates
•Enforcement Authorities
•HIPAA Privacy/ARRA Privacy
•Mental Health Parity
•Genetic Information Nondiscrimination Act
•Medicaid/CHIP
•Medicare
15.
16. • Large Employers (Above 50)
• Auto Enroll (1511)
• Inform about coverage option (1512)
• Minimum essential coverage (1513)
• Eligible employer-sponsored plan
• Full time employees (and their dependents)
• Penalty if fails to provide opportunity and on
full time employee enrolls in a QHP involving
premium tax credit or cost-sharing
reduction. $2000 per employee cap.
17. Maintain Essential Coverage after 2013 for
individual and dependents
Penalty of $695 in 2016 with phase in
$2,250 for entire family
18. States to establish Exchanges by 2014
Certify Qualified Health Benefit Plans
Essential Health Benefit Requirements
Refundable tax credit for coverage under a
qualified health plan
Reduced cost-sharing for individuals
enrolling in qualified health plans
19. In 2010 through 2013, eligible employers can
receive a small business tax credit for up to 35
percent of their contribution toward the
employee’s health insurance premium. Tax-
exempt small businesses meeting the above
requirements are eligible for tax credits of up to
25 percent of their contribution. In 2014 and
beyond, eligible employers who purchase
coverage through the State Exchange can receive
a tax credit for two years of up to 50 percent of
their contribution. Tax-exempt small businesses
meeting the above requirements are eligible for
tax credits of up to 35 percent of their
contribution.
20. Excise Tax on High Cost Employer Plans in
2018 (9001)
Annual Fee on Health Insurance Providers
9010
Elimination of Deduction of Expenses
allocable to Medicare Part D Subsidy 9012
21. • No Lifetime or Annual Limit (PHSA 2711)
• Prohibiting rescissions (PHSA 2712)
• Coverage of preventive services (PHSA 2713)
• Extension of dependent coverage (PHSA
2714)
• Development and utilization of uniform
explanation of coverage documents and
standardized definitions (PHSA 2715)
• Prohibition of discrimination based on salary
(exception self-insured) (PHSA 2716)
22. • Ensuring quality of care (PHSA 2717)
• Accounting for Costs value (PHSA 2718)
• Appeals process (PHSA 2719)
• Administrative simplification (1104)
• Prohibition of preexisting condition (PHSA
2704)
• Guaranteed availability of coverage (2702)
• Non-discrimination in health care (2706)
• Comprehensive health insurance coverage
(2707)
23. • Guaranteed availability 2702
• Guaranteed renewability 2703
• Prohibiting discrimination based on health
status 2705
• Wellness program 2705
• Provider participation 2706
• Prohibition on excessive waiting periods
• Development of coverage documents and
standardized definitions (2715)
24. Between 6 million and 7 million people would
be covered by an employment-based plan
under the bill who would not be covered by
one under current law (largely because the
mandate for individuals to be insured would
increase workers’ demand for coverage
through their employers).
25. Between 8 million and 9 million other people
who would be covered by an employment-
based plan under current law would not have
an offer of such coverage under the proposal.
Firms that would choose not to offer
coverage as a result of the proposal would
tend to be smaller employers and employers
that predominantly employ lower wage
workers.
26. Under the legislation, workers with an offer of
employment-based coverage would generally
be ineligible for exchange subsidies, but that
“firewall” would be enforced imperfectly and
an explicit exception to it would be made for
workers whose offer was deemed
unaffordable.
27. Current Employer
Providing Insurance
Smaller Companies not Bigger Companies
Providing Insurance but Willing to Pay Penalty
Employees Receive But Employees Receive
Subsidy Subsidy
28. Small Business Tax Credit
Eliminating Pre-Existing Condition
Exclusions for Children
Prohibiting Rescissions
Eliminating Lifetime Limits
Regulating Use of Annual Limits
Covering Preventive Health Services
Extending Coverage for Young Adults
29. Standardizing the Definition of Qualified
Medical Expenses
Increased Additional Tax for Withdrawals
from Health Savings Accounts and Archer
Medical Savings Account Funds for Non-
Qualified Medical Expenses
Pharmaceutical Manufacturers Fee
30. Administrative Simplification
Limiting Health Flexible Savings Account
Contributions
Eliminating Deduction for Employer Part D
Subsidy
Increased Threshold for Claiming Itemized
Deduction for Medical Expenses
Additional Hospital Insurance Tax for High
Wage Workers
Medical Device Excise Tax
31. Reforming Health Insurance Regulations
Eliminating Annual Limits
Ensuring Coverage for Individuals
Participating in Clinical Trials
Establishing Health Insurance Exchanges for
Individual and Small Group Market
Providing Health Care Tax Credits
Individual Mandate
Employer Mandate
Health Insurance Provider Fee
33. Increasing the subsidies for premiums and
cost sharing that would be offered through
the new insurance exchanges;
Increasing the penalties for employers that do
not offer health insurance and modifying the
penalties for individuals who do not obtain
insurance;
Increasing the federal share of spending for
certain Medicaid beneficiaries;
34. Changing eligibility for Medicaid in a way that
effectively increases the income threshold
from 133 percent of the federal poverty level
to 138 percent for certain individuals;
Reducing overall payments to insurance plans
under the Medicare Advantage program;
Expanding Medicare’s drug benefit by
phasing out the “doughnut hole” in that
benefit;
35. Modifying the design and delaying the
implementation of the excise tax on
insurance plans with relatively high
premiums; and
Increasing the rate and expanding the scope
of a tax that would be charged to higher-
income households.
36. • Adding Problems and Instability for Our
Economic Future
• Relies on Cuts in Medicare that Are Not
Politically Sustainable Over Time
• Breaking the Promise to Allow Employees to
Keep Current Plans
• Failing to Address the Rising Cost of Health
Care
• Government Regulation of the Health Care
Quality of Hospitals and Doctors
37. Extensive Requirements to Provide
Information to the Government
Unfairly treating low and moderate income
workers
Pressure for outsourcing
