The Patient Protection and Affordable Care Act, also known as Obama Care, ACA, and Public Law 111–148, was passed by Congress, more specifically the House, and then signed into law by our former President Obama on March 23, 2010. With 906 pages the ACA has ten titles/sections; that is as complex as the Social Security Act as it has impacted almost all of America. “The three main goals of the ACA were to: Expand coverage to millions of previously uninsured individuals, move the U.S healthcare system from on that pays for the volume of services delivered to one that pays for value, and sustainably finance legislation.(Rawal.16)”
In 2014, Title I required the 32 million to 50 million uninsured Americans to buy insurance or pay a tax. This was part of the reason that the bill was questioned on its constitutionality. “Parents can add children up to twenty-six years of age, insurance companies cannot drop people for getting sick or deny for pre-existing conditions, Companies must spend at least 80 percent of premiums on medical services or give back to policyholders, and cover 100% of pregnancy and wellness programs.(Walker)” Title 1 requires insurance companies to have safeguards and additional benefits. The main goal of ObamaCare is to lower insurance premiums, if we have a ton of young healthy people with insurance not using the system premiums will be lower.
Title two of the ACA is titled the role of public programs because the Act gives more flexibility to States to try and create innovative strategies to improve care in their own State and in their own way. The States control the coordination of services for Medicare and Medicaid recipients. Title three is all about Improving the Quality and Efficiency of Health Care because the goal of this act was to close a coverage gap called “the donut hole”. The ACA means to phase this out completely by 2020. Healthcare providers like doctors, nurses, and hospitals will be given incentives to try and improve care and reduce unnecessary error that could harm patients. The Act also aims to enhance access to health care services in rural areas.
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Title IV. Prevention of Chronic Disease and Improving Public Health is the idea of evolving from a system that is mainly focused on treating people who are already sick rather than helping people stay well throughout their lives. By attacking diseases before they happen or show symptoms will save the people money by using achievable methods to advance the health status of Americans. Title V. Health Care Workforce aims to expand America’s health care workforce. The act funds scholarships and loan repayment programs to nurses, doctors, dentists, mental health providers, and primary care physicians. The act is currently focused on the prevailing nurse shortage. The act gives state and local governments flexibility and resources to achieve the common goal.
Title VI. Transparency and Program Integrity gives the patient the right to go elsewhere from the referred physician for imaging services to give the patient the best form of care. This act requires background checks for employees who provide direct care and encourages programs that aim to prevent and eliminate elderly abuse in care homes. The Act also intents to crack down on high-risk providers and suppliers who defraud the ACA programs. This title gives the states the power to take control of providers who have been penalized in one state from setting up in another state. Sanctions are imposed on people who purchase or sell Medicare receivers ID numbers or billing numbers, that include jail time.
Title VII. Improving Access to Innovative Medical Therapies ends anticompetitive behavior by pharmaceutical companies that keep adequate and modest generic drugs off the market. It gives discounts on drugs to hospitals that cater to low-income patients. Title VIII. Community Living Assistance Services and Supports Act also known as the CLASS act is a long term insurance choice for services in the event of a disability. People who are or become physically challenged will receive a $50 daily payment to put toward assisted living or assisted care after paying premiums for five years, and must be working for three of those years. No taxpayer funds are used to pay for benefits under this act, it is completely self-funded. The end game of this act is to prevent people from entering government paid nursing homes or assistance because people will continue to live in their homes.
Title IX. Revenue Provisions provides the largest middle class tax cuts for health care in American history thus making healthcare more affordable for families and small business owners. Families making less than 250,000 will have their taxes cut. Title X. Reauthorization of the Indian Health Care Improvement Act: this act authorizes The Indian Comprehensive Health Insurance Association (ICHIA). This provides health care services to American Indians and Alaskan Natives and will aim to modernize the current systems put in place for the 1.9 million American indians and Alaskan natives. The way that the ACA works is that it can be self sufficient is everyone is keyed in and buying this affordable insurance.
This biggest fear of this bill is that it will end with a “death spiral” which means that premiums will skyrocket and be unaffordable for anyone. It makes sense for people to start buying insurance ask they get sick since they can no longer be turned away for having pre-existing conditions. If only unhealthy people are buying and using insurance then the system cracks. While both political sides acknowledged and agreed, to an extent, on the problems plaguing the American healthcare system, their proposed solutions were understandably very different. “After the great recession fifty million Americans were uninsured and health care costs were 17% of the gross domestic product(GDP)(Rawal.16)” The bill was finally passed in 2010, after two years of much needed debate and a historic presidential election in 2008, but the bill’s history started many years before then.
The Affordable Care Act is a result of decades’ amount of bills, debates, forums, and discussions from both sides of Republican and Democratic parties. Obama stated that the ACA was a Republican idea that was based on RomneyCare. “Other health care experts have observed that the ACA closely resembles a Senate Republican plan that was unveiled in 1993 as an alternative to President Clinton’s proposed health care reforms.(NYT)” That bill advocated individual mandates, paid for it with medicare payment cuts, and reorganized small individual markets. That’s the irony having no Republican support for the ACA. In the Democratic preliminaries health care reform was a largely debated topic between Clinton, and the evental candidate Obama.
More than eight years after its passing its legal and policy foundation is called into question, and the law continues to be a lure for political criticism. One of the main reasons for this persisting divide is the lack of bipartisan support for the finalized version of the ACA. While a very small number of Republicans were key to developing the foundation of the ACA only two Republicans across both chambers voted for a health reform and zero Republicans voted for the final passage. On day one the new law faced repeal and thirty three times total to this day. Opposition and efforts to repeal the ACA have gained support from groups that are comprised of labor unions conservative advocacy groups, small business organizations and the Tea Party movement.
President Donald Trump has repeatedly promised to ‘repeal and replace’ it. “Trump claimed that, Obamacare has been repealed in this bill.(Mascaro)” It’s is much more complicated than this. This is where the law stands today, Republicans ended fines for people that don’t carry health insurance which is a large change, but did not dismantle the law in anyway. Many of the key gears of Obama’s law remain, like the medicaid expansion, protections that keep insurance companies from denying people with preexisting conditions, the requirement that insurers cover essential health benefits, and the mandate that employers provide coverage to workers or face fines. In addition, the tax bill doesn’t repeal fines for uninsured people until the start of 2019, meaning it’s still in force.
On March 6, 2017 Republicans introduced a bill in an attempt to repeal and replace called the American Health Care Act. There is much controversy in this, it even has Republicans calling it “ObamaCare 2.0” and “ObamaCareLite”. The House almost approved it’s repeal bill with a 217-213 vote. Twenty Republicans voted nay on the measure, many who are from swing-state distracts. The Republican agenda is to take credit for being the party that gave America health care. Trump is so against Obama and the Democrats and claims that everything they do is crooked and wrong, but it this were to succeed then the Democrats would be responsible for one of the biggest reforms since social security.
That’s why Republicans are laughing at the proposed new replacements for ObamaCare, because it’s the ACA only painted red. The difference between ObamaCare and the proposed TrumpCare(American Health Care Act) is that people don’t have to buy the insurance, but the trade off is that insurance companies get to charge older people five times as much as young people. Another huge change is that Medicaid was expanded to people who were over the poverty line, and this bill rolls back on that expansion and cuts spending to Medicaid. We also have to keep in mind that the bill has reached the Senate yet where it will probably be changed considerably. With the ACA; “The uninsured rate has fallen to an all-time low of around ten percent.Coverage would be higher still if nineteen states had not refused to expand Medicaid(Horsley).”
Both political parties have positioned themselves to where if this fails it’s the other parties fault. “Republicans Must Be Careful in That the Dems Own the Failed ObamaCare Disaster, with Its Poor Coverage and Massive Premium Increases……(Trump).” The reason the premiums increased in some areas a decrease in others is the amount of people that are buying insurance. The tax on people who refused to buy insurance was because now that insurance companies can’t turn people away for being sick or giving them high premiums it encouraged people to wait until they needed insurance to buy insurance. Now the Republicans took away the tax in 2019 so the feared “death spiral” is a possibility.
If the ACA fails because of this then the backlash will be on the Democrats. Mitt Romney figured it out in Clinton Administration, it only works if everyone is involved. Now how did the ACA get passed by the Democrats with almost no Republican support? The House was mostly Democratic at the end of 2008 because of the election by a margin of 257-199; Democrats had gained 21 seats from 2007. This is when the ACA political dynamics began during the senate elections. Going into the ‘08 elections, the senate consisted of forty-nine Republicans, forty-nine Democrats, and two independents, Joe Liberman, and Bernie Sanders. Both independents were more on the Democrats side, but even then the Democrats didn’t have the numbers to keep away any filibuster attempts by the Republicans. Democrats picked up eight seats. Then a republican, Arlen Specter, changed parties giving the Democrats that 60th vote.
After four months Ted Kennedy of Massachusetts died in August forfeiting that magic sixtieth vote. Democrat Paul Kirk was made an interim Senator to serve until the special election set for January 2010 giving the Democrats that sixtieth vote again. Now having the supermajority intacted again the Democrats didn’t want to waste time and moved quickly to pass the ACA on Christmas eve 2009 in a 60-39 vote, Republican Jim Bunning did not vote, the ACA was passed through Senate.The official record shows 506 amendments were offered. President Obama and House Speaker Nancy Pelosi were put in a bind because everyone thought the bill would be tweaked to fit in more with the House bill that have passed two months before it, but that could not longer work without the Senate supermajority vote.
Cannan put it: “Democrats unhappy with the legislation’s initial form were unwilling to block its path to consideration, but they threatened to filibuster if changes were not made. Reid had to have the support of each one to get to a vote. While Republicans had not dug in their heels to fight the motion to proceed, hoping to tarnish vulnerable Democrats by forcing them to vote in a way that could be characterized as a substantive vote for the health care bill, they would not be so accommodating with the next cloture motion, and they were united in their opposition(Cannan).”It ended with them taking up the identical bill that senate passed on Christmas eve. It passed on March 21, 2010 219-212 vote, but this time there were zero Republicans that voted for it and 34 Democrats voted against it.
President Obama signed it into law two days later. After being judged before the Supreme Court on grounds of being unconstitutional, the final Supreme court decision was to uphold the health care law on June 28, 2012. Twenty-six states, including several private parties and companies, challenged Obamacare in a number of federal level courts on the grounds of the bill being unconstitutional. In March of 2012 the Supreme Court heard arguments on ACA constitutionality. Then in June of 2012 the Supreme Court released its opinion on the challenges to the bills legality. Two main challenges to the ACA were (1) the mandatory expansion of Medicaid to cover all individuals living at or under 133% of federal poverty level and (2) the requirement that people obtain health insurance(Congress.gov)”. Justices Ginsburg, Breyer, Sotomayor, and Kagan, joined by the Chief Justice presided over the hearings to discuss the two key challenges against the ACA.
The Chief Justice then said,”“The individual mandate … does not regulate existing commercial activity. It instead compels individuals to become active in commerce by purchasing a product, on the ground that their failure to do so affects interstate commerce (Roberts).” Forcing people to buy something that they may not use and punishing them for refusing to purchase it is the concern of most of the discussions. The court held that states must have a choice of whether or not they will participate in a federal program such as medicaid. The court found that if they were to expand medicaid to this extent it would basically be a new program of public coverage because of the complexity.
The Court’s decision means that if the states choose not to expand their medicaid levels, they cannot lose their existing state funding. Congress’s spending power, however, does allow congress to offer new funding on expanding eligibility. Thus, making the medicaid expansion constitutional as long as the Secretary does not take away federal medicaid funds from states that do not comply with the decision to expand. The individual mandate cannot be supported by Congress’s commerce power on the grounds that it pull in people who aren’t in the healthcare market already. The Court ruling states that Congress does not have the power under the Commerce Clause to make people enter commerce, purchasing health care insurance, and engage in a particular activity. The Court found that this was beyond Congress’s power to do so. Lawsuits such as King v. Burwell, were significant in the final draft of the ACA.
Which resulted in a decision by the Supreme Court that limited Medicaid expansion but upheld the mandates and insurance subsidies. David King petitioned in the fourth circuit court of appeals that “the inter revenue service permissibly create a regulation that extended the tax credit the Affordable Care Act authorized to federal exchanges as well as those created by the states.(Oyez)” The conclusion was yes. Chief Justice John Roberts jr deliver the opinion of the court for the 6-3 majority. The court explained that Congress did not have the authority to claim that tax credits were available through state created and federally created exchanges to the IRS. “King v. Burwell was arguably the Affordable Care Act’s greatest existential threat since the Supreme Court upheld the individual mandate in 2012. The lawsuit, had it succeeded, would have ripped the subsidies out of 34 of the law’s state insurance exchanges — effectively destroying much of Obamacare in those states.(McIntyre)”
In the Case of Burwell vs Hobby, September 12, 2012, representatives of Hobby Lobby Stores, Inc., sued Kathleen Sebelius, the Secretary of the Department of Health and Human Services, and challenged the contraception requirement section of the ACA due the religious beliefs of the family. The family/founders explained that they built their company around Christian faith and told the courts of their desire to run the company according to biblical principles, one of which being that the use of contraception is immoral. Under the Patient Protection and ACA, employment group health care must provide certain types of preventive care, like contraceptive methods. There are exemptions available for religious employers and non-profits, but at the time there was not solution for Hobby Lobby Stores Inc.
The question to the court was “does the Religious Freedom Restoration Act of 1993 allow a for-profit company to deny its employees health coverage of contraception to which the employees would otherwise be entitled based on the religious objections of the company’s owners?(Oyez)” They argued that the requirement went against the First Amendment and the Religious Freedom Restoration Act of 1993. To these people contraception is considered abortion. They sought to prevent the enforcement of tax penalties, which the district court then denied after this they took it to the U.S Court of Appeals for a tenth circuit affirmed with a two-judge panel. The final decision was that corporations were “people” too and could be protected with rights under the Free Exercise Clause of the First Amendment in the bill of rights in the constitution of the United States of America. The Justice Alito delivered the court’s opinion for a 5-4 majority.
The Court also ruled that this only can be applied to contraception mandate in question rather than to the Affordable Care Act as a whole, which means that corporations cannot throw away the ACA due to beliefs only can trim a bit away. The Iron triangle of health care is quality, access, and cost. The idea of the triangle is that you could greatly improve maybe one or two, but at the expense of the third. People want reliable, measurable, and verified outcomes of healthcare. The ACA bill really tried to improve this, but it’s not as straightforward as it sounds. People on the outside look inwards like who can get the care when it is needed, not how long it takes to get an appointment or how long you may spend in the waiting room with a cold. The Health Reform largely tried to improve access to care for Americans by opening doors to insurance coverage for more of Americans.
We need to have the funding and manpower to tackle health disasters plaguing our country like phony pharmaceuticals, insurance scams, and potential epidemics without weakening the other points of the triangle. Another point in the iron triangle of health care is cost, systems need to make it cost affordable for patients and those who pay whether is government agencies, insurances providers, or employers. Many different forces are driving up costs that were noted before and the reform did not fully address this very important leg of the triangle. The ACA has worked very hard to provide a way to pay for the improved access to insurance that previously uninsured people would receive under the bill. The bill encouraged innovative ideas to finally fix problems that former health reform bills had and trimmed some fat out of some programs to make the ACA self sustainable.
Work Cited
- Huffington post 2009 “Internal Memo Confirms Big Giveaways in White House Deal with Big Pharma.” June 19, 2014 ‘King v. Burwell.’ Oyez, 24 Apr. 2018, www.oyez.org/cases/2014/14-114.
- McIntyre, Adrianna. “King v. Burwell Could Have Gutted Obamacare in 34 States.” Vox, 4 Sept. 2014, ‘Burwell v. Hobby Lobby Stores.’ Oyez, 24 Apr. 2018, www.oyez.org/cases/2013/13-354.
- Trump, Donald J. “Republicans Must Be Careful in That the Dems Own the Failed ObamaCare Disaster, with Its Poor Coverage and Massive Premium Increases……” Twitter, Twitter, 4 Jan. 2017, twitter.com/realDonaldTrump/status/816644321768312832?tfw_site=NPR.
- Ray, MD and Tim Norbeck, Walker. “A Look Back At How The President Was Able To Sign Obamacare Into Law Four Years Ago.” Forbes, Forbes Magazine, 29 Sept. 2015, www.forbes.com/sites/physiciansfoundation/2014/03/26/a-look-back-at-how-the-president-was-able-to-sign-obamacare-into-law-four-years-ago/.
- “Everything President Trump Has Tweeted (and What It Was about).” Los Angeles Times, Los Angeles Times, 20 Jan. 2018, www.latimes.com/politics/la-pol-updates-everything-president-trump-has-tweeted-and-what-it-was-about-2017-htmlstory.html.
- Horsley, Scott. “FACT CHECK: Once Again, Lawmakers Are Stretching The Facts On Obamacare.” NPR, NPR, 4 Jan. 2017, www.npr.org/2017/01/04/508242215/fact-check-once-again-lawmakers-are-stretching-the-facts-of-obamacare.
- Kleinke, J. D. “Opinion | Why Obamacare Is a Conservative’s Dream.” The New York Times, The New York Times, 29 Sept. 2012, www.nytimes.com/2012/09/30/opinion/sunday/why-obamacare-is-a-conservatives-dream.html.
- McIntyre, Adrianna. “King v. Burwell Could Have Gutted Obamacare in 34 States.” Vox, 4 Sept. 2014, www.vox.com/cards/obamacare-subsidies-lawsuit/what-is-the-case.
- McIntyre, Adrianna. “King v. Burwell Could Have Gutted Obamacare in 34 States.” Vox, 4 Sept. 2014, www.vox.com/cards/obamacare-subsidies-lawsuit/what-is-the-case.
- Rangel, and Charles. “H.R.3590 – 111th Congress (2009-2010): Patient Protection and Affordable Care Act.” Congress.gov, 23 Mar. 2010, www.congress.gov/bill/111th-congress/house-bill/3590?q=%7B%22search%22%3A%5B%22Patient%2BProtection%2Band%2BAffordable%2BCare%2BAct%22%5D%7
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- “What Is the Iron Triangle of Health Care?” The Penn Square Post, pennsquarepost.com/what-is-the-iron-triangle-of-health-care/.
