Essay: Patient Protection and Affordable Care Act

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PPACA

The Patient Protection and Affordable Care Act (PPACA) is a federal U.S. statute dealing with health care. This act was passed by the Congress and signed into law by President Barack Obama on March 23, 2010. The law constitutes the principal health care reform legislative action of the 111th United States Congress ("Msnbc.msn.com"). Public Law 111-148 was the first installment of this body of legislation and signed into law by President Barack Obama on 3/23/2010

("Public law 111 -- 148," 2010) This was amended by Public Law 111-152 when it was signed by the President on 3/30/2010 ("Public law 111 -- 152," 2010).

This complicated new body of legislation leaves many questions unanswered in terms of its impact upon physicians and specialists. However, there is one commonality between the various portions of the law. Due to the new insurance provisions and financial compliance procedures, Health Information Technology (HIT) issues take center stage, requiring an overhaul of the technological infrastructure in an effort to bring about economy by achieving the paperless office.

Therefore, whether it be the business decisions of a family practice physician in private practice or of a specialist healthcare provider, everyone will be affected. However, the providers of long-term care (such as nursing home administrators) and hospital administrator will likely be affected the most due to the HIT issues, Medicaid and Medicare compliance issues and reduced reimbursement formulas are problems with family physicians and general internists as well.

PPACA Overview

First, we will examine the act itself in detail. Only then can we consider a break down of its affect by the division of the health care system it will effect.

It was intended that PPACA will reform the health care system by performing a fundamental transformation of the health insurance in the United States by sharing responsibility for paying for healthcare costs. PPACA is set to reform many aspects of the private health care and public health insurance programs. This includes the increasing insurance coverage of preexisting conditions as well as in expanding access to insurance for over 30 million people. The bill will also mandate an increase in the total national medical expenditure on healthcare. It is the intention of the bill's designers to achieve these reforms while at the same time not increasing health insurance premiums. In essence, this will mean that all Americans have to be a part of the system and have coverage. Individuals and family tax credits will ensure that the insurance is affordable for all. All of the above is necessary three elements are the essential links to achieve healthcare reform ("Patient Protection and Affordable Care Act Detailed Summary," 1) .

From the beginning, PPACA has had a cloud of constitutional controversy. Since then, the majority of the states as well as numerous private organizations as well as individuals have filed separate actions in U.S. federal court to challenge the constitutionality of the Act PPACA. As recently as September 2011, the federal appellate courts are just about divided about constitutional issues raised in the federal litigation at the district court level. Here, three federal judges upheld the PPACA's constitutionality of and three of them declared the act to be partially unconstitutional. There have been several other challenges that have been dismissed on technical grounds. The Supreme Court possible may review the matter by the end of 2011 ("Catholic.org").

The PPACA contains many provisions that will take effect only over several years beginning in 2010. There are many policies that were issued before the law was and that are grandfathered from other federal regulations. The total new tax revenue from the Act is expected to amount to $409.2 billion over the first 10 years. The federal government expects to realize $78 billion before the end of fiscal year 2014 ("Patient Protection and Affordable Care Act Detailed Summary" 1).

Much has been made of the economic impact of the Act, so it would do well to consider quickly the size of the health care market to help gauge the scale of the effects. The industry has been estimated to encompass some one-seventh of the U.S. economy. As one of the largest industries in 2008, healthcare provided 14.3 million jobs for wage and salary workers. The health care field is one of 10 of the 20 fastest growing occupations are healthcare related. The healthcare field will generate 3.2 million new wage and salary jobs between fiscal years 2008 and 2018. This is more than any other industry and is largely in response to the rapid growth in the elderly population. Whether one is for or against the PPACA, the economic impact upon a huge U.S. economic market is certain to be huge as well ("Bls.gov").

PPACA Stages

The Act is set to come into effect in stages. It is divided into 10 titles and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions that will become effective in 2014. Some of the key provisions of the Act. The amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this time line ("Patient Protection and Affordable Care Act Detailed Summary," 1).

PPACA Provisions

This will include health insurance market reforms. Some immediate reforms are to be implemented within six months which will include the treatment of temporary a high-risk pool with subsidized premiums for certain people with preexisting conditions . This is intended to end health insurance rescission abuse. The Act will ban the coverage exclusions of preexisting health conditions for all children. It will also require the public disclosure of overhead/benefit spending by health insurance companies. PPACA will provide coverage of certain preventive health services without the cost-sharing.

Lifetime limits on benefits and restrictions on the annual limits on benefits will be eliminated.

Insurers will be required to offer dependent coverage to allow all children to be covered on their parents' insurance policy up to the age 26 years old. There will be the uniform explanation of coverage documents for all enrollees. Coverage exclusions of preexisting conditions or rating or coverage restrictions based on health status for adults. This will provide standards for medical loss ratios that will ensure the premiums pay for necessary benefits (ibid).

PPACA will require that there be guaranteed issue and guaranteed renewability of insurance coverage. The Act allows individual states to form compacts to facilitate the interstate sale of insurance. The aim of this is to increase the transparency by mandating health insurers to provide a complete summary terms of coverage to all applicants and enrollees. It allows enrollee to select their primary care provider (or pediatrician children). There will be no prior authorization or increased cost-sharing for ER visits. There will be direct access to obstetrical and gynecological care (ibid).

PPACA creates by 2014 what will be know as state-based and state-administered health insurance exchanges. In other words, these will be marketplaces for the individual and small group markets. States may be granted waivers to opt out of this requirement if they provide can coverage at least as comprehensive as that required under PPACA. Under the Act, only qualified health benefit plans that meet very specific criteria will be sold in the exchanges. Insurers may opt to sell policies outside of the exchanges. Large employers will be phased into these exchanges in fiscal year 2017. Plans are not required to contract with just any willing provider that requires the health plans to implement a process for the appeal of coverage determinations and claims ("Patient Protection and Affordable Care Act Detailed Summary" 2).

PPACA allows qualified health plans to provide their coverage through a qualified direct primary care medical nursing home that meets federal requirements established by the secretary of the U.S. Department of Health and Human Services. The Act requires health plans to publicly disclose their information on claims payment policies. This is to include enrollments, denials, rating practices, out-of-network cost-sharing and enrollee rights as well (ibid 4).

PPACA requires that health care plans implement activities that will reduce health disparities to include the use of language services, community outreach as well as cultural competency trainings. This includes CO-OP and multi-state health plans and creates the Consumer Operated and Oriented Plan (CO-OP) program to foster the creation of non-profit, member-run health insurance companies in all 50 states. PPACA specifies that a CO-OP may not be an existing organization. All of its activities are required to consist of the issuing of qualified health benefit plans in each of the 50 states they are licensed in state in. The governance of the organization will be subject to a majority vote of the COOP members. COOP profits must be used to lower organizational premiums, improve benefits or improve quality of care that is delivered to its members. PPACA provides the initial grants to enable that CO-OP organizations meet state solvency requirements. It precludes insurer or insurance industry involvement in COOPS. The organizations cannot operate until a state has implemented the small group insurance and individual market… [END OF PREVIEW]

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