Patient Protection and Affordable Care Act

[Square]

This is stolen from a different website (reddit), but I found it to be a decent attempt to explain the Patient Protection and Affordable Care Act (Obamacare). I'm assuming most of us haven't read the actual law so hopefully this helps clarify some the timeline of what is actually "supposed" to happen.

 

 

 

Okay, explained like you're a five year-old (well, okay, maybe a bit older), without too much oversimplification, and (hopefully) without sounding too biased:

What people call "Obamacare" is actually the Patient Protection and Affordable Care Act. However, people were calling it "Obamacare" before everyone even hammered out what it would be. It's a term mostly used by people who don't like the PPACA, and it's become popularized in part because PPACA is a really long and awkward name, even when you turn it into an acronym like that.

Anyway, the PPACA made a bunch of new rules regarding health care, with the purpose of making health care more affordable for everyone. Opponents of the PPACA, on the other hand, feel that the rules it makes take away too many freedoms and force people (both individuals and businesses) to do things they shouldn't have to.

So what does it do? Well, here is everything, in the order of when it goes into effect (because some of it happens later than other parts of it):

Already in effect:

• It allows the Food and Drug Administration to approve more generic drugs (making for more competition in the market to drive down prices)
  

 

• It increases the rebates on drugs people get through Medicare (so drugs cost less)
  

 

• It establishes a non-profit group, that the government doesn't directly control, PCORI, to study different kinds of treatments to see what works better and is the best use of money. ( Citation: Page 665, sec. 1181 )
  

 

• It makes chain restaurants like McDonalds display how many calories are in all of their foods, so people can have an easier time making choices to eat healthy. ( Citation: Page 499, sec. 4205 )
  

 

• It makes a "high-risk pool" for people with pre-existing conditions. Basically, this is a way to slowly ease into getting rid of "pre-existing conditions" altogether. For now, people who already have health issues that would be considered "pre-existing conditions" can still get insurance, but at different rates than people without them.
  

 

• It renews some old policies, and calls for the appointment of various positions.
  

 

• It creates a new 10% tax on indoor tanning booths. ( Citation: Page 923, sec. 5000B )
  

 

• It says that health insurance companies can no longer tell customers that they won't get any more coverage because they have hit a "lifetime limit". Basically, if someone has paid for health insurance, that company can't tell that person that he's used that insurance too much throughout his life so they won't cover him any more. They can't do this for lifetime spending, and they're limited in how much they can do this for yearly spending. ( Citation: Page 14, sec. 2711 )
  

 

• Kids can continue to be covered by their parents' health insurance until they're 26.
  

 

• No more "pre-existing conditions" for kids under the age of 19.
  

 

• Insurers have less ability to change the amount customers have to pay for their plans.
  

 

• People in a "Medicare Gap" get a rebate to make up for the extra money they would otherwise have to spend.
  

 

• Insurers can't just drop customers once they get sick. ( Citation: Page 14, sec. 2712 )
  

 

• Insurers have to tell customers what they're spending money on. (Instead of just "administrative fee", they have to be more specific).
  

 

• Insurers need to have an appeals process for when they turn down a claim, so customers have some manner of recourse other than a lawsuit when they're turned down.
  

 

• New ways to stop fraud are created.
  

 

• Medicare extends to smaller hospitals.
  

 

• Medicare patients with chronic illnesses must be monitored more thoroughly.
  

 

• Reduces the costs for some companies that handle benefits for the elderly.
  

 

• A new website is made to give people insurance and health information. (I think this is it: http://www.healthcare.gov/ ).
  

 

• A credit program is made that will make it easier for business to invest in new ways to treat illness.
  

 

• A limit is placed on just how much of a percentage of the money an insurer makes can be profit, to make sure they're not price-gouging customers.
  

 

• A limit is placed on what type of insurance accounts can be used to pay for over-the-counter drugs without a prescription. Basically, your insurer isn't paying for the Aspirin you bought for that hangover.
  

 

• Employers need to list the benefits they provided to employees on their tax forms.
  

 

8/1/2012

• Any health plans sold after this date must provide preventative care (mammograms, colonoscopies, etc.) without requiring any sort of co-pay or charge.
  

 

1/1/2013

• If you make over $200,000 a year, your taxes go up a tiny bit (0.9%). Edit: To address those who take issue with the word "tiny", a change of 0.9% is relatively tiny. Any look at how taxes have fluctuated over the years will reveal that a change of less than one percent is miniscule, especially when we're talking about people in the top 5% of earners.
  

 

1/1/2014

This is when a lot of the really big changes happen.

• No more "pre-existing conditions". At all. People will be charged the same regardless of their medical history.
  

 

• If you can afford insurance but do not get it, you will be charged a fee. This is the "mandate" that people are talking about. Basically, it's a trade-off for the "pre-existing conditions" bit, saying that since insurers now have to cover you regardless of what you have, you can't just wait to buy insurance until you get sick. Otherwise no one would buy insurance until they needed it. You can opt not to get insurance, but you'll have to pay the fee instead, unless of course you're not buying insurance because you just can't afford it.
  

 

• Insurers now can't do annual spending caps. Their customers can get as much health care in a given year as they need. ( Citation: Page 14, sec. 2711 )
  

 

• Make it so more poor people can get Medicaid by making the low-income cut-off higher.
  

 

• Small businesses get some tax credits for two years.
  

 

• Businesses with over 50 employees must offer health insurance to full-time employees, or pay a penalty.
  

 

• Limits how high of an annual deductible insurers can charge customers.
  

 

• Cut some Medicare spending
  

 

• Place a $2500 limit on tax-free spending on FSAs (accounts for medical spending). Basically, people using these accounts now have to pay taxes on any money over $2500 they put into them.
  

 

• Establish health insurance exchanges and rebates for the lower and middle-class, basically making it so they have an easier time getting affordable medical coverage.
  

 

• Congress and Congressional staff will only be offered the same insurance offered to people in the insurance exchanges, rather than Federal Insurance. Basically, we won't be footing their health care bills any more than any other American citizen.
  

 

• A new tax on pharmaceutical companies.
  

 

• A new tax on the purchase of medical devices.
  

 

• A new tax on insurance companies based on their market share. Basically, the more of the market they control, the more they'll get taxed.
  

 

• The amount you can deduct from your taxes for medical expenses increases.
  

 

1/1/2015

• Doctors' pay will be determined by the quality of their care, not how many people they treat. Edit: a_real_MD addresses questions regarding this one in far more detail and with far more expertise than I can offer in this post. If you're looking for a more in-depth explanation of this one (as many of you are), I highly recommend you give his post a read.
  

 

1/1/2017

• If any state can come up with their own plan, one which gives citizens the same level of care at the same price as the PPACA, they can ask the Secretary of Health and Human Resources for permission to do their plan instead of the PPACA. So if they can get the same results without, say, the mandate, they can be allowed to do so. Vermont, for example, has expressed a desire to just go straight to single-payer (in simple terms, everyone is covered, and medical expenses are paid by taxpayers).
  

 

2018

• All health care plans must now cover preventative care (not just the new ones).
  

 

• A new tax on "Cadillac" health care plans (more expensive plans for rich people who want fancier coverage).
  

 

2020

• The elimination of the "Medicare gap"
  

 

.

Aaaaand that's it right there.

The biggest thing opponents of the bill have against it is the mandate. They claim that it forces people to buy insurance, and forcing people to buy something is unconstitutional. Personally, I take the opposite view, as it's not telling people to buy a specific thing, just to have a specific type of thing, just like a part of the money we pay in taxes pays for the police and firemen who protect us, this would have us paying to ensure doctors can treat us for illness and injury.

Plus, as previously mentioned, it's necessary if you're doing away with "pre-existing conditions" because otherwise no one would get insurance until they needed to use it, which defeats the purpose of insurance.

Whew! Hope that answers the question!

Edits: Fixing typos.

Edit 2: Wow... people have a lot of questions. I'm afraid I can't get to them now (got to go to work), but I'll try to later.

Edit 3: Okay, I'm at work, so I can't go really in-depth for some of the more complex questions just now, but I'll try and address the simpler ones. Also, a few I'm seeing repeatedly:

• For those looking for a source... well, here is the text of the bill, all 974 pages of it (as it sits currently after being amended multiple times). I can't point out page numbers just now, but they're there if you want them.
  

 

• The website that was to be established, I think, is http://www.healthcare.gov/.
  

 

• A lot of people are concerned about the 1/1/2015 bit that says that doctors' pay will be tied to quality, not quantity. Because so many people want to know more about this, I've sought out what I believe to be the pertinent sections (From Page 307, section 3007). It looks like this part alters a part of another bill, the Social Security Act, passed a long while ago. That bill already regulates how doctors' pay is determined. The PPACA just changes the criteria. Judging by how professionals are writing about it, it looks like this is just referring to Medicaid and Medicare. Basically, this is changing how much the government pays to doctors and medical groups, in situations where they are already responsible for pay.
  

 

Edit 4: Numerous people are pointing out I said "Medicare" when I meant "Medicaid". Whoops. Fixed (I think).

Edit 5: Apparently I messed up the acronym (initialism?). Fixed.

Edit 6: Fixed a few more places where I mixed up terms (it was late, I was tired). Also, for everyone asking if they can post this elsewhere, feel free to.

Edit 7: Okay, I need to get to work. Thanks to everyone for the kind comments, and I hope I've addressed the questions most of you have (that I can actually answer). I just want to be sure to say, I'm just a guy. I'm no expert, and everything I posted here I attribute mostly to Wikipedia or the actual bill itself, with an occasional Google search to clarify stuff. I am absolutely not a difinitive source or expert. I was just trying to simplify things as best I can without dumbing them down. I'm glad that many of you found this helpful.

Edit 8: Wow, this has spread all over the internet... and I'm kinda' embarrassed because what spread included all of my 2AM typos and mistakes. Well, it's too late to undo my mistakes now that the floodgates have opened. I only hope that people aren't too harsh on me for the stuff I've tried to go back and correct.

Edit 9: Added a few citations (easy-to-find stuff). But I gotta' run, so the rest will have to wait.

 

[borge007]

This is stolen from a different website (reddit), but I found it to be a decent attempt to explain the Patient Protection and Affordable Care Act (Obamacare). I'm assuming most of us haven't read the actual law so hopefully this helps clarify some the timeline of what is actually "supposed" to happen.

 

Thanks.

[rocknrobn26]

Good stuff. Thanks.

[bpwallace49]

That is a great post!

[bushwacked]

Hey Square...can you provide the link this so I can share?

[WashingtonD]

http://www.reddit.com/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx

[Square]

Hey Square...can you provide the link this so I can share?

 

It's the first response in this thread. http://www.reddit.co...nd_what_did_it/

 

 

This response from a doctor on the subject is a link from above, but I think it's also worth a read.

 

 

Doctors' pay will be determined by the quality of their care, not how many people they treat.

 

Doctor here. I'm seeing a lot of questions about how exactly this will be implemented and what it will mean for physicians and patients. I will do my best to explain what's already happening, and what will happen in the future. The basic idea is that there will be an established list of "ideal care" criteria that must be met, and reimbursement will be adjusted accordingly. This is already happening, but in a different form.

What we have now

There are several groups that come by to certify and accredit hospitals based on a set of national guidelines. The major group for Hospital accreditation is the much-feared Joint Commission (http://www.jointcomm...tion/npsgs.aspx) who comes by every so often and performs an intensive review of the hospital and it's policies and outcomes which are then compared to their National Patient Safety Goals. Public quality reports are generated based on their results and accreditation is granted. Here is the public report for UCSF, for example: http://www.qualitych...095#comparative. They identify deficiencies and mandate swift policy changes to ensure adherence to guidelines.

Even more feared and applicable is CMS, The Centers for Medicare and Medicaid Services (http://www.cms.gov/). CMS also comes by and performs an intensive review of the hospital's outcomes and adherence to nationally established safety guidelines. For example, as part of the SCIP (Surgical Care Improvement Project), they will look at how often patients received their dose of pre-operative antibiotics within 1 hour prior to incision. CMS knows what the national average adherence rate among hospitals is and thus, can quickly identify centers that are not compliant. Non-compliant centers are generally notified of their deficiencies formally and then must quickly remediate or risk losing Medicare/Medicaid reimbursements, the loss of which would essentially kill any hospital.

The reason I mention these groups is because they are already beginning to extrapolate on their national data collection programs, as I will detail below.

What's to come

The nationalized accreditation and quality monitoring groups such as CMS and The Joint Commission already know how well hospitals are doing regarding established patient safety measures. What's next is the providers. Already, mandatory reporting regarding provider outcomes is beginning. For example, Dr. Johnson, who is a Surgeon, will have to report his average operative time for a cholecystectomy and his post-operative wound infection rate. If he falls below a certain percentile nationally, his reimbursement will be negatively affected. If he is in say, the top 10% nationally, he will receive a small bonus (this is the tentative plan as I've heard it from the higher-ups at my hospital).

How this will work for primary care is a little murkier. The general consensus seems to be that they will try to reimburse based on a similar set of nationally defined "quality measures" like they are using for hospital accreditation, Medicare center status, etc. For example, is Dr. Smith keeping his patient's HbA1C below 7.0%? (An indication of good long-term diabetes control). Is he keeping his patient's LDL less than 100? So on and so forth.

This all seems like a great idea on the surface, but without putting my own opinions into this, I offer the following scenarios for your consideration:

1. Dr. Smith and Dr. Johnson are both primary care physicians. They both have 10 identical patients with diabetes, for whom each physician prescribes the exact same, evidence-based, standardized diabetes protocol. 4 of Dr. Smith's patients are non-compliant with their insulin regimens, despite optimal counseling and the best efforts of Dr. Smith, thus their HbA1C values will be above the cutoff that qualifies them for a "good outcome." In the end, medication compliance is a patient choice which cannot be controlled by the physician and although Dr. Smith did everything right from a medical standpoint, those patients will be red-flagged and reimbursement decreased.

    

2. Dr. Unlucky is a cardiologist, and Bill is a patient of his with Congestive Heart Failure. Bill is receiving the evidence-based optimal medical management for his CHF (Carvedilol, ACE inhibitor, etc). Bill has been counseled extensively on the importance of a low sodium diet and careful fluid intake because of his CHF. Bill is a Cleveland Browns fan and they make it to the Superbowl for the first time since god only knows. Bill has a Superbowl party with his buddies and eats a ton of potato chips and drinks a few beers and ends up in the hospital with a CHF exacerbation. Dr. Unlucky is now dinged for a hospitalization for CHF exacerbation for a patient under his care, which will be reported and affect his pay.

 

It's situations like this that are worrying physicians. I urge you to remember these are just example scenarios, to give you, the reader, pause to consider what could be a greater problem.

What criteria will comprise these quality of care outcomes remains to be seen, so no one knows yet exactly how it will look, but believe me when I say that it's not the mandate that's the game-changer, it's what I've discussed above. This will fundamentally alter the face of the medical field, whether it's for better or for worse remains to be seen. Hopefully this was helpful.

 

 

Edited June 28, 2012 by Square

[bushwacked]

Gracias guys.

[wiegie]

This all seems like a great idea on the surface, but without putting my own opinions into this, I offer the following scenarios for your consideration:

1. Dr. Smith and Dr. Johnson are both primary care physicians. They both have 10 identical patients with diabetes, for whom each physician prescribes the exact same, evidence-based, standardized diabetes protocol. 4 of Dr. Smith's patients are non-compliant with their insulin regimens, despite optimal counseling and the best efforts of Dr. Smith, thus their HbA1C values will be above the cutoff that qualifies them for a "good outcome." In the end, medication compliance is a patient choice which cannot be controlled by the physician and although Dr. Smith did everything right from a medical standpoint, those patients will be red-flagged and reimbursement decreased.

2. Dr. Unlucky is a cardiologist, and Bill is a patient of his with Congestive Heart Failure. Bill is receiving the evidence-based optimal medical management for his CHF (Carvedilol, ACE inhibitor, etc). Bill has been counseled extensively on the importance of a low sodium diet and careful fluid intake because of his CHF. Bill is a Cleveland Browns fan and they make it to the Superbowl for the first time since god only knows. Bill has a Superbowl party with his buddies and eats a ton of potato chips and drinks a few beers and ends up in the hospital with a CHF exacerbation. Dr. Unlucky is now dinged for a hospitalization for CHF exacerbation for a patient under his care, which will be reported and affect his pay.

 

 

My first thought was: yes, that sucks. My second thought was: I guess the doctors will now know how it feels to be a teacher whose performance gets evaluated based on student performance.

Edited June 30, 2012 by wiegie

[Big John]

 

My first thought was: yes, that sucks. My second thought was: I guess the doctors will now know how it feels to be a teacher whose performance gets evaluated based on student performance.

 

 

My first thought was that the Browns were never in a Super Bowl.

[MikesVikes]

I was reading from the Wikepedia page earlier. It has all you want to know but was afraid to ask.

[Chargerz]

 

My first thought was: yes, that sucks. My second thought was: I guess the doctors will now know how it feels to be a teacher whose performance gets evaluated based on student performance.

 

 

 

 

My first thought was that the Browns were never in a Super Bowl.

 

 

My first thought was I'm glad I'm retiring next year.