SNMA Region VIII Political Advocacy Presentation for Leadership Retreat 2013-2014, Drexel University

1. Patient Protection and Affordable
Care Act (Obamacare)
Luther D. Quarles IV, OMS-IV
PCOM
Political Advocacy Liaison, SNMA Region
VIII

2. Disclosures
• None

4. Quick Timeline
• March 2010
– US Congress passed HR
3590, the Patient
Protection and
Affordable Care Act
(PPACA), and HR 4872,
the Health Care and
Education Reconciliation
Act of 2010
– President Barack Obama
signed them into law
• Thursday June 28, 2012
the US Supreme Court
upheld the
constitutionality of the
PPACA in a 5-4 ruling

5. Provisions of PPACA
• Aims to increase the quality and affordability
of healthcare:
– Lower the rate of uninsured, to include 32 million
previously uninsured Americans
– Requires insurances to cover everyone regardless
of sex or pre-existing conditions (Exclusion:
Tobacco Use)
– Individual Mandate
– Medicaid
– Health Insurance Exchanges

6. Individual Mandate
• Requires all individuals not covered by an
employer sponsored plan, Medicaid, Medicare, or
other public programs to secure an approved
private-insurance policy or pay a penalty, unless
the applicable individual is a member of a
recognized religious sect

7. Guaranteed Mandate
• Insurers are prohibited from establishing annual spending
caps of dollar amounts on essential health benefits
• Requires insurance companies to cover all applicants within
new minimum standards and offer same rates regardless of
pre-existing conditions or sex
• Expanded covering of children on their parents insurance until
age 26
• No Cost for preventative health care services, i.e.
Immunizations, screening exams, etc

8. Medicaid Expansion
• Medicaid eligibility is expanded to include all
individuals and families with incomes up to
133% of the Poverty Line
• Children's Health Insurance Program (CHIP)
enrollment process has been simplified.
• States have the right to refuse the Medicaid
Expansion

9. Health Insurance Exchanges
• set of government-regulated and standardized
health care plans, from which individuals may
purchase insurance which is eligible for federal
subsidies
• commence operation in each state, offering a
marketplace where individuals and small
businesses can compare policies and
premiums, and buy insurance

10. Cost
• Congressional Budget Office:
– produce a net reduction in federal deficits of $143
billion over the 2010–2019 (site CBO)
– That figure comprises $124 billion in net
reductions deriving from the health care and
revenue provisions and $19 billion in net
reductions deriving from the education provisions.
Approximately $114 billion of the total reduction
would be on budget

11. Top 10 Debates on PPACA

12. Can I keep my current coverage?
Pro
• "No matter how we reform health care,
we will keep this promise: If you like
your doctor, you will be able to keep
your doctor. Period. If you like your
health care plan, you will be able to
keep your health care plan. Period. No
one will take it away. No matter what.
My view is that health care reform
should be guided by a simple principle:
fix what’s broken and build on what
works.”
• Barack H. Obama, JD 44th President of
the United States Address to the
annual meeting of the American
Medical Association, June 15, 2009
Con
• "According to experts, more than 87
million American could lose access to
their current health care plan under the
new law. Workers at a majority of the
nation’s employers – including as many
as four out of every five small
businesses – would lose their current
coverage, thus providing further
evidence that ObamaCare is doing
exactly the opposite of what Democrats
promised it would do."
• John Boehner Minority Leader of the
United States House of Representatives
(R-OH) "Obamacare, Three Months of
Broken Promises,"
www.gopleader.gov, June 23, 2010

13. Will the quality of care from Medicare and
Medicaid improve?
Pro
• "Patient care under Medicare will
improve as pilot programs to improve
efficiencies are implemented. Doctors
and hospitals are encouraged to
coordinate care through payment
incentives. For the first time, Medicare
will reward quality, not quantity; thus,
bonus payments will be given to those
doctors and hospitals that provide good
quality care."
• Alliance for Retired Americans (ARA)
"Medicare Benefits and Changes,"
www.retiredamericans.org, Apr. 2010
Con
• ”…Our care will suffer. If the Democrats'
plans become law, fewer than 700,000
physicians would be available to treat a
patient population growing in size,
aging in years, shunning medical
education and receiving 'free' health
care or insurance coverage from the
government in increasing numbers.
• The result will be longer wait times to
see a doctor and a decline in the high
quality of care Americans are
accustomed to as overworked
physicians try to keep up."
• Investor's Business Daily "The Doctor
Shortage," www.investors.com, Mar. 4,
2010

14. Are the health care reform laws
socialist?
Pro
• "Opponents of health insurance reform
continue to spread myths, including peddling
the bogus notion that the health reform bill
is 'socialism' and a 'government takeover of
health care.' The fact is the reform
legislation builds on our existing private
health insurance system...
• [H]ealth insurance reform legislation expands
private health insurance in America, and is
based on increasing choice and
competition... among a variety of private
insurance plans."
• Nancy Pelosi Speaker of the US House of
Representatives (D-CA) www.speaker.gov
• March 19, 2010
Con
• "Obama is a socialist. If you take over
banks, if you take over car companies, if
you take over financial institutions, the
way that he has - now the health care
system. If you're going to use every
crooked deal that you can come up with
to get a bill like that passed - most
recently the health care bill - that is by
definition, if you look up the dictionary
definition of socialism, this is it.”
• Sean Hannity Host of Fox News
Channel’s Hannity show Interview with
CNSnews.com, Mar. 25, 2010

15. Is Obamacare constitutional?
Pro
• "The Constitution gives Congress the power to tax and spend
money for the general welfare. This tax [PPACA] promotes
the general welfare because it makes health care more
widely available and affordable. Under existing law,
therefore, the tax is clearly constitutional...
• Many important and popular government programs are
based [on] Congress's ability to give incentives through
taxation and redistribute tax revenues for public purposes. To
strike down the individual mandate the Supreme Court would
have to undermine many years of precedents justifying these
programs that stretch back to the New Deal (and in the case
of the rules for direct taxes, to the very founding of the
country).
• Opponents of the individual mandate insist that they are only
defending individual freedom, but they are actually taking a
far more radical position. They are really claiming that it is
unconstitutional to make Americans pay taxes."
• Jack M. Balkin, JD, PhD Knight Professor of Constitutional
Law and the First Amendment at Yale Law School "Is the
Health Care Law Unconstitutional?," New York Times, Mar.
28, 2010
Con
• Can Congress really require that every person purchase
health insurance from a private company or face a penalty?
The answer lies in the commerce clause of the Constitution,
which grants Congress the power 'to regulate commerce...
among the several states.'
• ...[T]he individual mandate extends the commerce clause's
power beyond economic activity, to economic inactivity. That
is unprecedented. While Congress has used its taxing power
to fund Social Security and Medicare, never before has it used
its commerce power to mandate that an individual person
engage in an economic transaction with a private company.
Regulating the auto industry or paying 'cash for clunkers' is
one thing; making everyone buy a Chevy is quite another.
Even during World War II, the federal government did not
mandate that individual citizens purchase war bonds."
• Randy E. Barnett, JD Carmack Waterhouse Professor of
Legal Theory at the Georgetown University Law Center "Is
Health-Care Reform Constitutional?," Washington Post, Mar.
21, 2010

16. Healthcare Insurance Premiums
Pro
• We estimate that, on net, the combination of
provisions in the new law will... lower
premiums by nearly $2,000 per family...
• Without reform, premiums are expected to
increase from $13,305 in 2010 to $21,458 in
2019. Relative to this increase, premiums
under reform increase only three-quarters as
much. By 2019, family premiums are nearly
$2,000 lower. Adding reductions in out-of-
pocket costs and lower taxes for Medicare
and Medicaid will result in estimated savings
for the typical family of over $2,500 that
year."
• Center for American Progress (CAP) "The
Impact of Health Reform on Health System
Spending,"
www.americanprogress.org, May 2010
Con
• "Throughout the year-long debate over health care reform,
President Obama promised that the legislation would reduce
the spiraling cost of health care... But a couple of new
government reports confirm what many of us who opposed a
federal takeover of the health care system feared all along -
higher costs...
• CMS [Centers for Medicare and Medicaid Services] says that
the health care law will impose billions of dollars in annual
fees on manufacturers and importers of brand-name
prescription drugs and on health insurance plans, and new
taxes on medical device sales. CMS said it anticipates that
these new fees and taxes will be passed down to consumers
in the form of higher drug and device prices and higher
insurance premiums, raising health care costs from $2.1
billion in 2011 to $18.2 billion in 2018.
• Throughout the health care debate, Americans were told the
Democrats' health care reform measure would make
premiums more affordable; instead, as the President's own
actuary at CMS confirms, Americans will face higher
premiums..."
• Lisa Murkowski, JD US Senator (R-AK), New Health Care
Law Will Increase Costs, Reduce Benefits,"
murkowski.senate.gov, May 18, 2010

17. Will people no longer be at risk of
medical bankruptcy?
Pro
• "The Senate plan limits how much even the
wealthiest family buying insurance in the Exchange
can be expected to pay, out-of-pocket, in a given
year to a total of $11,900 for a family, and $5,950
for an individual. Again, lower-income households
are expected to pay less…
• These caps should virtually eliminate medical
bankruptcy. The total amount that a family can
possibly owe is low enough that providers will be
willing to give them time to pay it off, and in many
cases, to negotiate discounts.
• When providers know that there is no way that you
can ever pay a $50,000 bill, you wind up in
bankruptcy court. When the amounts are smaller,
and doable over time, negotiations are possible."
• Maggie Mahar, PhD Fellow at the Century
Foundation Response to Paul Starr's article "What Is
in the Health Care Bill,"
www.talkingpointsmemo.com, Dec. 17, 2009
Con
• "Most people with medical bankruptcies already
have insurance, and out-of-pocket expenses will
continue to be a burden on the middle class.
• In 2009, 1.5 million Americans declared bankruptcy
• Of those, 62% were medically related
• Three-quarters of those had health insurance
• The Obama bill leaves 24 million without insurance
• The maximum yearly out-of-pocket limit for a family
will be $11,900 on top of premiums
• A family with serious medical problems that last for
a few years could easily be financially crushed by
medical cost
• Real health care reform is needed. But this bill falls
short of that on many levels."
• Jane Hamsher, MFA Founder and Publisher of
Firedoglake "Fact Sheet: The Truth About the
Health Care Bill," www.huffingtonpost.com, Mar.
19, 2010

18. Will the health care reform laws
decrease the federal deficit?
Pro
• "CBO [Congressional Budget Office] and JCT
[Joint Committee on Taxation] estimate that
enacting both pieces of legislation—H.R.
3590 and the reconciliation proposal—would
produce a net reduction in federal deficits of
$143 billion over the 2010–2019 period as
result of changes in direct spending and
revenues. That figure comprises $124 billion
in net reductions deriving from the health
care and revenue provisions and $19 billion
in net reductions deriving from the education
provisions."
• Congressional Budget Office (CBO) Report
(untitled) on the estimated budgetary effects
of the March 2010 health care reform laws,
www.cbo.gov, Mar. 20, 2010
Con
• "In reality, if you strip out all the
gimmicks and budgetary games
and rework the calculus, a wholly
different picture emerges: The
health care reform legislation
would raise, not lower, federal
deficits, by $562 billion..."
• Douglas Holtz-Eakin, PhD
President of the American Action
Forum and former Director of the
Congressional Budget Office "The
Real Arithmetic of Health Care
Reform," New York Times, Mar.
20, 2010

19. Will Obamacare lower taxes?
Pro
• "The health reform legislation signed
into law by President Obama includes
the largest health care tax cut in history
for middle class families, helping to
make insurance much more affordable
for millions of families...
• The Small Business Health Care Tax
Credit can cover up to 35 percent of the
premiums a small business pays to
cover its workers. In 2014, the rate will
increase to 50 percent..."
• Dan Pfeiffer White House
Communications Director "Health
Reform and the Recovery Act:
Unprecedented Tax Cuts for the Middle
Class," www.whitehouse.gov, Apr.
13, 2010
Con
• "The Senate bill would: impose job-killing mandates and
penalties on businesses, [and] increase taxes and burdens on
small businesses... H.R. 4872 is no 'fix' for the Senate-passed
bill. It includes a long term hidden tax by deferring the
'Cadillac tax' on certain high cost health plans until 2018. The
number of Americans that will ultimately suffer from this
hidden tax will mushroom each year because the tax is
indexed to inflation...
• This bill would also impose a new 3.8 percent 'Medicare tax'
on non-wage income that would target high income earners,
income from interest, dividends, capital gains, and some
profits from investments in partnerships and S-corporations.
If this tax and other tax increases included in the President's
FY 2011 budget become law, certain taxpayers could expect a
marginal tax rate on capital gains and qualified dividends of
23.8 percent, and a marginal tax rate on nonqualified
dividends of 43.4 percent."
• US Chamber of Commerce "H.R. 3590, the 'Patient
Protection and Affordable Care Act,' and the Related Budget
Reconciliation Legislation, H.R. 4872, the 'Student Aid and
Fiscal Responsibility Act of 2009,'"
www.library.uschamber.com, Mar. 19, 2010

20. Physician Shortage
Pro
• "The recently enacted PPACA (H.R. 3590) includes
numerous policies to train more primary care
physicians and increase the supply of primary care
physicians. These policies include: mandatory and
increased discretionary funding for the National
Health Service Corp (NHSC), reauthorization of
Section 747 of Title VII, Training in Family Medicine,
General Internal Medicine, General Pediatrics, and
Physician Assistantship; creation of a Primary Care
Training Extension Program and increased faculty
scholarship loans, redistribution of 65% of the
current unused Graduate Medical Education slots to
primary care and general surgery and allowing
residents to count their time spent in ambulatory
settings to count towards their residency
requirements, such as physician offices and
community health centers; and the establishment
of Teaching Health Centers, creating primary care
residency programs in non-hospital settings."
• American College of Physicians (ACP) "Ensuring an
Adequate Supply of Primary Care Internists and
Other Specialties Facing Shortages,"
www.acponline.org, Apr. 7, 2010
Con
• "Questions have been raised as to whether there
will be a sufficient supply of physicians and other
health professionals to serve the nation, especially
in light of concerns that the nation was facing
potentially significant shortages even before health
care reform...
• [W]e project an overall shortage of 91,500 and
130,600 active patient care physicians in 2020 and
2025 respectively, and a primary care shortage of
45,400 and 65,800 physicians in 2020 and 2025...
• These revised estimates are consistent with earlier
estimates: they indicate the health care system is
likely to be facing severe pressure as demand rises
more rapidly than the supply."
• Association of American Medical Colleges (AAMC)
"The Impact of Health Care Reform on the Future
Supply and Demand for Physicians Updated
Projections Through 2025," www.aamc.org, June
2010

21. Medical Malpractice Lawsuits
Pro
"As part of a 'grand bargain' to create a bipartisan health care bill, some
have said tort reform should be included. Look at what the actual data
says: 98,000 people dead every year from preventable medical errors, at a
cost of $29 billion. Countless more are seriously injured with astronomical
costs. The Congressional Budget Office and Government Accountability
Office have looked at tort reform multiple times, and said it will save
practically no money. They also found no evidence of so-called 'defensive
medicine,' finding that doctors run more tests because of the fee-for-
service structure, or because of the benefits extra tests have on patient
care. Additionally, a 2006 study from Harvard found that 97% of cases
were meritorious, totally debunking the idea that frivolous lawsuits plague
our courts. And while 46 states have enacted some kind of tort reform,
health care costs have continued to skyrocket, while injured patients or
their families often can't seek justice…Forty-six states have tort reform,
and American families still shoulder exorbitant health care costs. All the
facts and data say it doesn't work. There's still 98,000 people dead every
year from medical errors. But when political gamesmanship and backroom
deals take over, the facts fly out the window. This health care bill has a
long way to go. But let's be perfectly clear: patients' rights aren't
negotiable. Tort law changes won't fix health care, but only make it more
difficult for injured patients to seek justice. Instead of bargaining away
patients' rights, Congress should [put] their safety first."
Anthony Tarricone, JD Former President of the American Association of
Justice "Tort Reform: A Bad Bargain That Won't Fix Health Care,"
www.huffingtonpost.com, Sep. 22, 2009
Con
• "You would think that any effort to reform our health care
system would include tort reform, especially if the stated
purpose for Obama’s plan to nationalize our health care
industry is the current high costs...
• Many states, including my own state of Alaska, have enacted
caps on lawsuit awards against health care providers. Texas
enacted caps and found that one county’s medical
malpractice claims dropped 41 percent, and another study
found a '55 percent decline' after reform measures were
passed.
• Texas Gov. Rick Perry noted that, after his state enacted tort
reform measures, the number of doctors applying to practice
medicine in Texas 'skyrocketed by 57 percent' and that the
tort reforms 'brought critical specialties to underserved
areas.' These are real reforms that actually improve access to
health care.
• ...[R]esearch shows that around $200 billion per year could be
saved with legal reform. That’s real savings.
• If you want to save health care, let’s listen to our doctors.
There should be no health care reform without legal reform.
There can be no true health care reform without legal
reform."
• Sarah Palin Former Governor of Alaska "No Health Care
Reform Without Legal Reform,"
www.realclearpolitics.com, Aug. 21, 2009

22. References
• Patient Protection and Affordable Care Act HR
3590
http://www.gpo.gov/fdsys/pkg/BILLS-
111hr3590enr/pdf/BILLS-111hr3590enr.pdf
• Procon.org
http://healthcarereform.procon.org/obamacare.
pdf
• Congressional Budget
Office.http://www.cbo.gov/sites/default/files/cb
ofiles/ftpdocs/113xx/doc11379/amendreconprop
.pdf