Affordable Care Act

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Patient Protection and Affordable Care Act
Great Seal of the United States
Long titleAn act entitled The Patient Protection and Affordable Care Act.
Enacted bythe 111th United States Congress
EffectiveMarch 23, 2010
Legislative history
  • Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009
  • Committee consideration by Ways and Means
  • Passed the House on October 8, 2009 (416–0)
  • Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39) with amendment
  • House agreed to Senate amendment on March 21, 2010 (219–212)
  • Signed into law by President Barack Obama on March 23, 2010
Major amendments
Health Care and Education Affordability Reconciliation Act

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The Patient Protection and Affordable Care Act (H.R. 3590) was signed into law by President Barack Obama on March 23, 2010. Along with the Health Care and Education Affordability Reconciliation Act of 2010, the act is a product of the health care reform agenda of the Democratic-controlled Congress and the Obama administration.

The bill was originally drafted by the U.S. Senate as an alternative to the Affordable Health Care for America Act, which was passed by the U.S. House of Representatives two months earlier on November 7. However, after the Democrats lost their supermajority in the Senate on January 19, 2010, the House decided to pass the Senate version and amend it with a third bill. This will allow the Senate to pass the amendments via the simple-majority reconciliation process.

The Patient Protection and Affordable Care Act passed the Senate on December 24, 2009, by a vote of 60–39 and passed the House on March 21, 2010, by a vote of 219–212, with no Republicans in either house voting for the bill. At the time of the vote, there were 4 vacancies in the United States House of Representatives.

Background

Main articles: Health care reform in the United States and Health care reform debate in the United States

Formation

Main article: Health care reforms proposed during the Obama administration

The Patient Protection and Affordable Care Act reportedly includes 200 Republican amendments.[1]

Legislative history

On November 4, 2008, after winning the presidential election, President-elect Obama announced that healthcare reform would be one of his key agenda items. On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform. Debate over reform continued throughout the summer and Obama requested Congress pass legislation before the August recess, which Congress failed to do. During the summer recess, the Tea Party movement organized protests and many conservative groups targeted congressional town hall meetings to voice their opposition to proposed reform effort. In response, on September 9, Obama delivered a televised address to Congress to urge action. On November 7, the House of Representatives passed the Affordable Health Care for America Act (H.R. 3962) 220-215 and forwarded it to the Senate for passage.[2][3]

Senate

The Senate failed to take up debate on the House bill, instead utilizing H.R. 3590, a bill unrelated to healthcare already passed by the House, as the vehicle for their health care reform proposal, completely revising the content of the bill.[4] This method was chosen rather than initiating a new bill in the Senate because the United States Constitution requires all revenue-related bills to originate in the House.[5] The original title of H.R. 3590, before it was converted to a healthcare bill, was the Service Members Home Ownership Tax Act of 2009.[6] Although unrelated to healthcare reform, this was a revenue-related modification to the Internal Revenue Code. The bill, as amended, incorporates elements of earlier proposals that had been reported favorably by the Health and Finance committees.

Passage in the Senate was temporarily blocked by a filibuster threat by Nebraska Senator Ben Nelson who sided with Republican minority. Nelson's support for the bill was won after the bill was amended to offer a higher rate of Medicaid reimbursement for the State of Nebraska, the compromise was derisively referred to as the Cornhusker Kickback.[3] On December 23, the Senate voted 60–39 to end debate on the Patient Protection and Affordable Care Act, eliminating the possibility of a filibuster by opponents. The bill then passed by a party-line vote of 60–39 on December 24, 2009, with one senator not voting.[7][8] This was the first time the Senate had met on Christmas Eve since 1963 (for a debate relating to the Vietnam War), and the first roll call vote on the day since 1895.[9][10]

The bill was then forwarded to the House of Representatives for debate. In the interim, on January 19, 2010, Massachusetts Republican Senator Scott Brown was elected, giving the Republican minority enough votes to sustain a filibuster in the future.[3] On February 25, President Obama unveiled a health care reform plan of his own, drawing largely from the Senate bill. On February 25, he held a meeting with leaders of both parties again urging passage of a reform bill.[3]

Republican Senate Minority Leader Mitch McConnell has been quoted as saying the bill does not reflect the will of the people.[11]

House

The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.

Following Brown's Senate win, the fate of the health care reform was uncertain. Rahm Emanuel argued for a less ambitious bill. Nancy Pelosi pushed back, dismissing Rahm's scaled-down approach as "Kiddie Care".[12][13] Obama in the end sided with comprehensive reform and the news that Anthem Blue Cross in California intends to hike premium rates for its patients by as much as 39% gave him a new line of argument for reform.[12][13] The Bipartisan Health Care Summit that was held on February 25, proved to be a political success for Obama, shifting the narrative away from the Massachusetts loss back to healthcare policy.[13]

The most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and to instead pass the Senate's bill, and then pass amendments to it with a different bill allowing the Senate to pass the amendments via the reconciliation process.[14][15]

The House's reconciliation bill, the Health Care and Education Affordability Reconciliation Act of 2010, was introduced in March. The House Democratic majority leaders considered using the self-executing rule method to pass the legislation in a single vote along with the Senate bill, but this plan was eventually rejected. Instead, the House held a series of votes: the first on a special rule resolution that set the terms of debate, a second on the Senate bill, a third on a minority attempt to amend the reconciliation bill itself, and finally a vote on the reconciliation bill itself.[16] The debate was divisive, with Republicans accusing Democrats of "one-party rule".[17] The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[18] The following day, Republicans introduced legislation to repeal the bill.[19] President Barack Obama signed the bill into law on March 23, 2010.[20]

Provisions

H.R. 3590 is divided into ten titles.[21] The text of the bill cannot be meaningfully read from front to back as printed, because the tenth title is a list of amendments to the previous nine titles.[22] These amendments must be applied to the titles and sections to which they refer before the bill can be interpreted properly.

The bill contains provisions that go into effect six months after its passage, and provisions going into effect in 2014.[23][24]

Key provisions of the bill include measures to:[25][26]

Effective six months after passage

  • All insurers are fully prohibited from discriminating against or charging higher rates for children based on pre-existing conditions.[24]
  • Adults with pre-existing conditions will be eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.[24]
  • All existing health insurance plans must cover preventative care and checkups without co-payment.
  • Children and young adults will be permitted to remain on their parents' insurance plan until their 26th birthday.[27]
  • Insurers are prohibited from charging co-pays or deductibles for preventive care and medical screenings on all new insurance plans.[28]
  • Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50 percent of the gap will be eliminated in 2011.[29]
  • Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[24]
  • Insurers are prohibited from dropping policy holders when they get sick.[24]
  • Insurers are required to reveal details about administrative and executive expenditures.[24]
  • Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[24]
  • Indoor tanning services are subjected to a 10 percent service tax.[24]
  • Enhanced methods of fraud detection are implemented. [24]
  • Medicare is expanded to small, rural hospitals and facilities.[24]
  • Non-profit Blue Cross insurers are required to maintain a loss ratio (money spent on procedures over money incoming) of 85 percent or higher to take advantage of IRS tax benefits.[24]
  • Companies which provide early retiree benefits for individuals aged 55-64 are eligible to participate in a temporary program which reduces premium costs.[24]
  • A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.[24]
  • A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.[24]

Effective by 2014

  • All insurers are fully prohibited from discriminating against or charging higher rates for adult individuals based on pre-existing medical conditions.[24]
  • All insurers are fully prohibited from establishing annual spending caps.[24]
  • Expand Medicaid eligibility; individuals with income up to 133 percent of the poverty line qualify for coverage
  • Establish health insurance exchanges, and subsidization of insurance premiums for individuals with income up to 400 percent of the poverty line.[30]
  • Offer tax credits to small businesses who have fewer than 25 employees and provide health care benefits for them.
  • Impose a tax penalty on employers with over fifty employees who do not offer health insurance to their workers.
  • Impose an annual fine on individuals who do not obtain health insurance; exemptions to fine in cases of financial hardship or religious beliefs.
  • Creation of a new voluntary long-term care insurance program.
  • Creation of tax credits for individuals who purchase private insurance policies
  • Employed individuals who pay more than 9.5 percent of their income on health insurance premiums will be permitted to purchase insurance policies from a state-controlled health insurance option
  • Pay for new spending, in part, through spending and coverage cuts in Medicare Advantage, slowing the growth of Medicare provider payments, reducing Medicare and Medicaid drug reimbursement rate, cutting other Medicare and Medicaid spending.[26][31]
  • Revenue increases from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[32] Raising various taxes, and creating a new excise tax for high cost "Cadillac" insurance plans.[26]
  • Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.[33]

Effective by 2018

Deficit impact

According to the CBO, the legislation will reduce the deficit by $138 billion over the first decade and by $1.2 trillion in the second decade.[34][35] The CBO has revised their estimates several times, initially projecting a savings of $132 billion, then $118 billion, and later $143 billion.[36][37] The CBO estimates the cost of the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the benefits kick in.[37][38]

Legal opinions and analyses

The Congressional Budget Office (CBO) wrote:[34]

The legislation would establish a mandate for most legal residents of the United States to obtain health insurance; set up insurance exchanges through which certain individuals and families could receive federal subsidies to substantially reduce the cost of purchasing that coverage; significantly expand eligibility for Medicaid; substantially reduce the growth of Medicare’s payment rates for most services (relative to the growth rates projected under current law); impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs.

Bloomberg wrote:[39]

A 383-page amendment Reid offered [December 19] made some major and minor changes to the proposed legislation. Gone was a new government-run insurance program, or public option, designed to compete with private insurers. As an alternative, the U.S. Office of Personnel Management, which oversees benefits for all civilian federal workers and members of Congress, would contract with private insurers to offer multistate plans on the insurance exchange. Reid dropped plans for a tax on cosmetic surgery, dubbed the 'Bo-tax,' in favor of a 10 percent levy on indoor tanning salons. And he raised a Medicare payroll tax hike to 0.9 percent, from 0.5 percent earlier, on individuals earning more than $200,000 or families making more than $250,000. Reid also boosted penalties for companies that don't provide health insurance. Any company with more than 50 employees could face a penalty of $750 per worker, multiplied by the total number of full-time workers it employs, if just one obtains subsidized coverage through an exchange. That's up from a penalty of $400 in an earlier draft.

Senate Majority Leader Harry Reid said the bill would cover an additional 31 million uninsured Americans that do not have benefits, bringing full coverage to 94 percent of all Americans. Reid further stated that the bill will cost $848 billion over 10 years, while reducing deficits by $130 billion by adding new taxes and fees while reducing the growth of Medicare.[40]

Surgeon Atul Gawande wrote in The New Yorker that the bill contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.[41]

Legal challenges and state opposition

Organizations and lawmakers who opposed the passage of the bill threatened to take legal action against it upon its passage.[42] The target of the threatened lawsuits were several key provisions of the bill. Opponents claimed that fining individuals for failing to buy insurance is not within the scope of Congress' taxing powers. The mandate requiring individuals to purchase health insurance was another provision likely to be challenged. On March 18, before passage of the bill, Governor of Idaho Butch Otter was the first state governor to put a framework together to begin a legal challenge.[43] At least 36 other states were considering taking similar action at that time.[43]

Attorneys-General of eleven states announced on March 22 their intentions to sue the federal government, citing the bill as a violation of state sovereignty and saying Congress has no authority to require individuals to purchase health insurance.[44][45] All eleven of the Attorneys-General involved in the original proposal were members of the Republican Party.[46]

Less than an hour after the bill was signed into law on March 23, thirteen states (South Carolina, Nebraska, Texas, Michigan, Utah, Pennsylvania, Alabama, South Dakota, Idaho, Washington, Colorado, Louisiana, and Florida) formally filed a lawsuit challenging the bill. Other states were expected to join the multi-state lawsuit, while others are considering filing independent suits. The suit was filed in U.S. District court in Pensacola.[47] In a press release, the attorneys-general indicated their primary basis for the challenge was a violation of state sovereignty. Their release stated, "The Constitution nowhere authorizes the United States to mandate, either directly or under threat of penalty, that all citizens and legal residents have qualifying health care coverage", and that the law puts an unfair financial burden on state governments.[47] Legal experts commenting to the Los Angeles Times and Associated Press stated that specific argument was unlikely to succeed, citing federal law as trumping state law, but a legal professor at Georgetown University acknowledged the possibility that a court may find some legal ground to rule portions of the bill unconstitutional.[47][48] An alternate Constitutional argument that some states are looking at including in the suit(s), suggested by Nebraska Attorney General Jon Bruning, include possible violations of the Commerce Clause.[49]

Micheal Dorf, Professor of Law at Cornell University, wrote a lengthy analysis of present case law affecting the health care purchase mandate. He cited the 1922 Supreme Court case of Bailey v. Drexel Furniture Co as the current precedent for invalidating Federal fines imposed via the commerce clause. In the case the Supreme Court ruled that Congress could not impose fines through the commerce clause as a means to indirectly regulate activities. The case stated that commerce clause does not authorize Congress to "use taxation as a pretext for accomplishing a regulatory objective that it could not accomplish directly".[50] However, Congress does have the power through the revenue raising clauses of the constitution to make such an imposition. However in that instance the primary purpose of the tax must be to raise revenue, "a tax that serves a revenue-raising purpose is not invalid simply because it also serves a regulatory purpose."[50] He concluded that the revenue creation aspect trumped the questions raised by the commerce clause, and the ability to have the health care bill brought down by a legal case would require the court to find the fine's primary purpose is to influence behavior and effect regulations rather than provide revenue.[50]

Several state legislatures are attempting to counteract and prevent elements of the bill within their states. Twenty-nine states have introduced measures to amend their constitutions to nullify portions of the health care reform law, thirteen states have introduced statues to prohibit portions of the law; two states have already enacted statutory bans. Six legislatures had attempts to enact bans, but the measures were defeated.[51]

See also

References

  1. ^ Pappas, Cheryl (2010-03-23). "Reality Health Care Bill". The Huffington Post. Retrieved 2010-03-23. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  2. ^ Roll call vote 887, via Clerk.House.gov
  3. ^ a b c d "Timeline: Milestones in Obama's quest for healthcare reform". Reuters. Retrieved 2010-03-22.
  4. ^ S.Amdt. 2786 Leader's Amendment to H.R. 3590 in the nature of a substitute, November 21, 2009.
  5. ^ Ballasy, Nicholas, "Reid 'Likely' to Make Entire Health Bill an Amendment to Unrelated Tax Bill That House Passed in March", CNSNews.com, October 7, 2009
  6. ^ Service Members Home Ownership Tax Act of 2009
  7. ^ Senate Passes Health Care Bill - WBOY-TV - WBOY.com
  8. ^ Roll call vote 396, via Senate.gov
  9. ^ Young, Jeffrey (December 24, 2009). "Senate passes historic healthcare reform legislation in 60–39 vote". thehill.com. Retrieved 2010-01-13.
  10. ^ Kiely, Kathy (December 24, 2009). "Senate passes health care bill". USA Today. Retrieved 2010-01-13.
  11. ^ "Democrats hail landmark US healthcare bill", BBC, March 22nd, 2010 {{citation}}: Check date values in: |date= (help)
  12. ^ a b "Health Vote Caps a Journey Back From the Brink". New York Times. Retrieved 2010-03-23.
  13. ^ a b c "Pelosi steeled W.H. for health push". Politico. Retrieved 2010-03-23.
  14. ^ "Obama Urges Up-or-Down Vote on Health Care Bill". New York Times. March 3, 2010. Retrieved 2010-03-03.
  15. ^ Gay, Sheryl (March 17, 2010). "Health Vote Caps a Journey Back From the Brink". The New York Times. Retrieved 2010-03-21.
  16. ^ "COMMITTEE ON RULES – Senate Amendments to H.R. 3590 Patient Protection and Affordable Care Act H.R. 4872 Reconciliation Act of 2010". Rules.house.gov. Retrieved 2010-03-21.
  17. ^ "Pelosi Defends Health Care Fight Tactics". CBS News. March 22, 2010. Retrieved 2010-03-23.
  18. ^ Roll call vote 167, via Clerk.House.gov
  19. ^ "Pelosi Defends Health Care Fight Tactics". CBS News. March 22, 2010. Retrieved 2010-03-23.
  20. ^ Shailagh Murray, Lori Montgomery and Scott Wilson, (March 22 2010). "Obama to sign health-care bill into law Tuesday". Washington Post. {{cite news}}: Check date values in: |date= (help)CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
  21. ^ HR 3590 from Wikisource.
  22. ^ Title X
  23. ^ "Key Points Of The Health Care Reform Bil". The Kentucky Post. {{cite web}}: Unknown parameter |accedate= ignored (help)
  24. ^ a b c d e f g h i j k l m n o p Binckes, Jeremy (2010-03-22). "The Top 18 Immediate Effects Of The Health Care Bill". The Huffington Post. Retrieved 2010-03-22. {{cite news}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  25. ^ "Comparing the House and the Senate Health Care Proposals". New York Times. March 23, 2010..
  26. ^ a b c "Updated Health Care Charts". Committee for a Responsible Federal Budget. November 19, 2009..
  27. ^ H.R. 3590 Public Print, section 2714: A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age.
  28. ^ Bowman, Lee (2010-03-22). "Health reform bill will cause several near-term changes". Scripps Howard News Service. Retrieved 2010-03-23. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  29. ^ Rao, Smriti (2010-03-22). "Health-Care Reform Passed. So What Does It Mean?". 80beats. Discover. Retrieved 2010-03-23. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  30. ^ Galewitz, Phil (2010-03-22). "Health reform and you: A new guide". Kaiser Health News. MSNBC. Retrieved 2010-03-23. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  31. ^ "Health-Care Overhaul Proposals". Wall Street Journal. March 18, 2010..
  32. ^ Burkes, Paula (November 8, 2009). "Medical Expense Accounts Could be Limited to $2,500". The Oklahoman..
  33. ^ Spencer, Jean (2010-03-22). "Menu Measure: Health Bill Requires Calorie Disclosure". Washington Wire. Wall Street Journal. Retrieved 2010-03-23. {{cite news}}: Cite has empty unknown parameter: |coauthors= (help)
  34. ^ a b "Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act" (PDF). Congressional Budget Office. December 19, 2009. Retrieved March 22, 2010.
  35. ^ CNN (December 19, 2009). "Senate Democrats win over key holdouts to reach 60 votes on reform bill". Retrieved March 22, 2010. {{cite news}}: |author= has generic name (help).
  36. ^ "H.R. 3590, Patient Protection and Affordable Care Act" (PDF). Congressional Budget Office. March 11, 2010. Retrieved March 22, 2010..
  37. ^ a b "H.R. 4872, Reconciliation Act of 2010" (PDF). Congressional Budget Office. March 18, 2010. Retrieved March 22, 2010..
  38. ^ Dennis, Steven (March 18, 2010). "CBO: Health Care Overhaul Would Cost $940 Billion". Roll Call. Economist Group. Retrieved March 22, 2010.
  39. ^ Litvan, Laura; Kristen Jensen (December 20, 2009). "Senate's Health-Care Legislation Poised for Passage". Bloomberg L.P. Retrieved March 22, 2010.
  40. ^ Pear, Robert; David M. Herszenhorn (November 18, 2009). "Senate Says Health Plan Will Cover Another 31 Million". New York Times. Retrieved March 22, 2010.
  41. ^ Gawande, Atul (2009). "Testing, Testing". The New Yorker. Retrieved March 22, 2010. {{cite journal}}: Unknown parameter |month= ignored (help)
  42. ^ "Health Care Bill Could Face String of Legal Challenges". FOX News. December 22, 2009. Retrieved 2010-03-22.
  43. ^ a b Murphy, Brian (March 18, 2010). "Otter is the first governor to sign a law saying the state will defy a requirement to buy insurance". Idaho Statesman. Retrieved 2010-03-22.
  44. ^ Goodhue, David (March 22, 2010). "Attoneys General Sue To Stop Health Care Bill". AHN News. Retrieved 2010-03-22.
  45. ^ Richey, Warren (March 22, 2010). "Attorneys general in 11 states poised to challenge healthcare bill". Christian Science Monitor. Retrieved 2010-03-22.
  46. ^ Khan, Huma (March 23, 2010). "Obama to Sign Health Care Bill Today as GOP Challenges Constitutionality". ABC News. Retrieved 2010-03-23.
  47. ^ a b c FARRINGTON, BRENDAN (March 23, 2010). "13 attorneys general sue over health care overhaul". Associated Press. Retrieved 2010-03-23.
  48. ^ Hook , Janet (march 23, 2010). "Republicans mobilize healthcare opposition". Los Angeles Times. Retrieved 2010-03-23. {{cite web}}: Check date values in: |date= (help); Italic or bold markup not allowed in: |publisher= (help)
  49. ^ Funk, Josh. "AG Bruning says health reform violates Constitution". Lincoln Journal Star, Lincoln, 22 March 2010. Retrieved on 2010-03-23.
  50. ^ a b c Dorf, Michael (Novemeber 2, 2009). "The Constitutionality of Health Insurance Reform". findlaw.com. Retrieved 2010-03-23. {{cite web}}: Check date values in: |date= (help)
  51. ^ Cauchi, Richard. "State Legislation Opposing Certain Health Reforms, 2009-2010". National Conference of State Legislatures. Retrieved 2010-03-23.

External links

Wikinews has related news:
Wikimedia Commons has media related to Patient Protection and Affordable Care Act.
Wikisource has original text related to this article:
Copies of the proposed bill hosted online or readily downloadable
Latest Congressional Budget Office scoring (all previous scoring for now superseded Senate bills no longer applies)
Centers for Medicare and Medicaid Services Estimates of the impact of H.R. 3590
Additional commercially hosted information complimenting H.R. 3590
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