On September 24, 2013, Senator Ted Cruz (R-TX) launched what developed into a 21-hour speech on the floor of the U.S. Senate in an attempt to filibuster consideration of a temporary spending bill that included a provision that would block funding for the Affordable Care Act (ACA). With control of the Senate in the hands of the Democratic Party, the senator from Texas took to the floor to delay a vote that would strip this language from a House-passed measure defunding President Obama’s health care law. Although Cruz’s effort to prevent the Senate vote was unsuccessful, Congress ultimately failed to reach an agreement on even a short-term spending bill before the close of the fiscal year. As a result, on October 1, the federal government was forced to shut down nonessential services for the first time in 17 years.

In an interesting twist, October 1 also saw the launch of open enrollment for health insurance marketplaces or exchanges – where Americans will go to buy a health care plan if they don’t receive health insurance coverage through Medicaid, Medicare, or their employer. The introduction of this key provision of the ACA went ahead as planned, despite the federal shutdown caused by the congressional battle over funding for the ACA itself. By the end of the day, 2.8 million people had reportedly visited the federal marketplace online, and an additional 81,000 had dialed in to the help center.¹ Unsurprisingly, the launch was not perfectly smooth – visitors to the site encountered error messages that froze their applications. Politics inevitably played a prominent role in how these IT infrastructure issues were interpreted. Democrats claimed the high volume of Web traffic and ensuing glitches represented an endorsement of the new law among Americans who are currently uninsured and eagerly seeking coverage. Republicans argued that the early problems underscored the fact that the service was rolled out prematurely, reminding the public that Republicans had offered to pass a spending bill that would avert a shutdown in exchange for a 1-year delay in ACA implementation.

Senator Cruz’s marathon effort to roll back the health care reform process, together with the subsequent government shutdown, symbolizes the animosity that remains more than 3 years after the ACA was signed into law. Since its passage into law, the controversial health care reform package has survived a Supreme Court challenge, a presidential election billed as a referendum on the law itself, and more than 40 votes in the House of Representatives to repeal it.

Amid the vocal (and sometimes hyperbolic) criticism of the law, the process of implementing the ACA has been under way since 2010. The more controversial provisions, including the individual mandate, have dominated the headlines, but the 906-page law includes a wide range of measures aimed at increasing the quality and affordability of health insurance, lowering the uninsured rate, and reducing the costs of health care for individuals and the government. The following is a summary of what the law has achieved to date and what we can expect in the coming years. This is presented as a factual overview and is not intended as a commentary on the law itself.

ACA Implementation Timeline

2010

Comparative Effectiveness Research – Establishes a nonprofit Patient-Centered Outcomes Research Institute to conduct research that compares the clinical effectiveness of medical treatments

Prevention and Public Health Fund – Provides $5 billion for fiscal years 2010–2014 and $2 billion for each subsequent fiscal year to support prevention and public health programs. Programs include efforts to improve the supply of primary care providers; prevent tobacco use, obesity, heart disease, stroke, and cancer; and increase immunizations.

Medicare Beneficiary Drug Rebate – Provides a $250 rebate to Medicare beneficiaries who reached the Part D coverage gap in 2010. Further subsidies and discounts that ultimately closed the coverage gap (donut hole) began in 2011.

Small Business Tax Credits – Provides tax credits to small employers with no more than 25 employees and average annual wages of less than $50,000 that provide health insurance for employees

Generic Biologic Drugs – Authorizes the U.S. Food and Drug Administration to approve generic versions of biologic drugs and to grant biologics manufacturers 12 years of exclusive use before generics can be developed

Preexisting Condition Insurance Plan – Establishes a temporary program to provide health coverage to individuals with preexisting medical conditions who have been uninsured for at least 6 months. The plan will be operated by the states or the federal government.

Adult Dependent Coverage to Age 26 – Extends dependent coverage for adult children up to age 26 for all individual and group policies

Consumer Protections in Insurance – Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage, from rescinding coverage except in cases of fraud, and from denying children coverage on the basis of preexisting medical conditions or from including preexisting condition exclusions for children

Coverage of Preventive Benefits – Requires new health plans to provide, at a minimum, coverage without cost sharing for preventive services, including immunizations; preventive care for infants, children, and adolescents; and additional preventive care and screenings for women

2011

Minimum Medical Loss Ratio for Insurers – Requires health plans to report the proportion of premium dollars spent on clinical services, quality, and other costs and to provide rebates to consumers if the share of the premium spent on clinical services and quality is less than 85% for plans in the large-group market and 80% for plans in the individual and small-group markets

Medicare Payments for Primary Care – Provides a 10% Medicare bonus payment for primary care services; also, provides a 10% Medicare bonus payment to general surgeons practicing in health professional shortage areas

Medicare Prevention Benefits – Eliminates cost sharing for Medicare-covered preventive services that are recommended (rated A or B) by the U.S. Preventive Services Task Force and waives the Medicare deductible for colorectal cancer screening tests; authorizes Medicare coverage for a personalized prevention plan, including a comprehensive health risk assessment

Center for Medicare and Medicaid Innovation – Creates the Center for Medicare and Medicaid Innovation to test new payment and delivery system models that reduce costs while maintaining or improving quality

Chronic Disease Prevention in Medicaid – Provides 3-year grants to states to develop programs that provide Medicaid enrollees with incentives to participate in comprehensive health lifestyle programs and meet certain health behavior targets

National Quality Strategy – Requires the secretary of the federal Department of Health and Human Services (HHS) to develop and update annually a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health

Medicaid Payments for Hospital-Acquired Infections – Prohibits federal payments to states for Medicaid services related to certain hospital-acquired infections

Medicare Independent Payment Advisory Board – Authorizes an Independent Advisory Board, composed of 15 members nominated by the president and Congress, subject to Senate confirmation, to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds targeted growth rates

2012

Medicare Accountable Care Organizations – Allows providers that are organized as accountable care organizations (ACOs) and that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program

Uniform Coverage Summaries – Requires private individual and group health plans to provide a uniform summary of benefits and coverage to all applicants and enrollees. The intent is to help consumers compare health insurance coverage options before they enroll and understand their coverage once they enroll.

Medicare Independence at Home Demonstration – Creates the Independence at Home Demonstration program to provide high-need Medicare beneficiaries with primary care services in their home

Fraud and Abuse Prevention – Establishes procedures for the screening, oversight, and reporting of providers and suppliers that participate in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP); requires additional entities to register under Medicare

Annual Fees on Pharmaceutical Industry – Imposes new annual fees on the pharmaceutical manufacturing sector

Medicaid Payment Demonstration Projects – Creates new demonstration projects in Medicaid that will allow up to eight states to make bundled payments for episodes of care that include hospitalizations and that will allow pediatric medical providers organized as ACOs to share in the cost savings

Medicare Value-Based Purchasing – Establishes a hospital value-based purchasing program in Medicare to pay hospitals according to performance on quality measures and requires plans to be developed to implement value-based purchasing programs for skilled nursing facilities, home health agencies, and ambulatory surgical centers

Reduced Medicare Payments for Hospital Readmissions – Reduces Medicare payments that would otherwise be made to hospitals to account for excess (preventable) hospital readmissions

2013

State Notification Regarding Exchanges – States indicate to the secretary of the HHS whether they will operate an American Health Benefit Exchange. Seventeen states and D.C. have notified the HHS that they plan to run a state-based exchange, and another seven states have indicated that they will run a partnership exchange.

Medicare Bundled Payment Pilot Program – Establishes a national Medicare pilot program to develop and evaluate the feasibility of making bundled payments for acute, inpatient hospital services; physician services; outpatient hospital services; and post–acute care services for an episode of care

Medicaid Coverage of Preventive Services – Provides a 1 percentage point increase in federal matching payments for preventive services in Medicaid to states that offer Medicaid coverage with no patient cost sharing in the receipt of services recommended by the U.S. Preventive Services Task Force and recommended immunizations

Medicaid Payments for Primary Care – Increases Medicaid payments to 100% of the Medicare payment rate for 2013 and 2014 for primary care services provided by primary care physicians (financed with 100% federal funding)

Medicare Tax Increase – Increases the Medicare Part A (hospital insurance) tax rate on wages by 0.9% (from 1.45% to 2.35%) on earnings over $200,000 for individual taxpayers and $250,000 for married couples filing jointly and imposes a 3.8% assessment on unearned income for higher-income taxpayers

Medicare Device Tax – Imposes an excise tax of 2.3% on the sale of any taxable medical device

Extension of CHIP – Extends authorization and funding for CHIP through 2015 (current authorization is only through 2013)

2014

Expanded Medicaid Coverage – Expands Medicaid to all individuals not eligible for Medicare younger than 65 years (children, pregnant women, parents, and adults without dependent children) with incomes up to 138% of the federal poverty level (FPL) and provides enhanced federal matching payments for those newly eligible

Individual Requirement to Have Insurance (Individual Mandate) – Requires U.S. citizens and legal residents to have qualifying health coverage (there is a phased-in tax penalty for those without coverage, with certain exemptions)

Health Insurance Exchanges – Creates state-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) exchanges, administered by a governmental agency or nonprofit organization, through which individuals and small businesses with up to 100 employees can purchase qualified coverage. Exchanges will have a single form to apply for health programs, including coverage through the exchanges and the Medicaid and CHIP programs. Federally facilitated exchanges will be run by the HHS in states that have not established an exchange or have elected to run a partnership exchange.

Health Insurance Premium and Cost-Sharing Subsidies – Provides refundable and advanceable tax credits and cost-sharing subsidies to eligible individuals. Premium subsidies are available to families with incomes between 133% and 400% of the FPL to purchase insurance through the exchanges, and cost-sharing subsidies are available to those with incomes up to 250% of the poverty level.

Guaranteed Availability of Insurance – Requires guaranteed issue and renewability of health insurance, regardless of health status, and allows rating variation based only on age (limited to a 3:1 ratio), geographic area, family composition, and tobacco use (limited to a 1.5:1 ratio) in the individual and small-group market and the exchanges

No Annual Limits on Coverage – Prohibits annual limits on the dollar value of coverage

Essential Health Benefits – Creates an essential health benefits package that provides a comprehensive set of services, limiting annual cost sharing to health savings accounts ($5950/individual and $11,900/family in 2010). Creates four categories of plans to be offered through the exchanges, which, in the individual and small-group markets, vary according to the proportion of plan benefits each category covers

Basic Health Program – Permits states the option to create a basic health program for uninsured individuals with incomes between 133% and 200% of the FPL who would otherwise be eligible to receive premium subsidies in the exchange

Wellness Programs in Insurance – Permits employers to offer employees rewards of up to 30%, potentially increasing to 50%, on the cost of coverage for participating in a wellness program and meeting certain health-related standards; establishes 10-state pilot programs to permit participating states to apply similar rewards for those participating in wellness programs in the individual market

Fees on Health Insurance Sector – Imposes new fees on the health insurance sector

2015

Employer Requirements (delayed from 2014) – Assesses a fee of $2000 per full-time employee, excluding the first 30 employees, on employers with more than 50 employees that do not offer coverage and that have at least one full-time employee who receives a premium tax credit. Employers with more than 50 employees that offer coverage but that have at least one full-time employee receiving a premium tax credit will pay the lesser of $3000 for each employee receiving a premium credit or $2000 for each full-time employee, excluding the first 30 employees.

Further Information

For additional information on the ACA:

Healthcare.gov (a federal government Web site managed by the Centers for Medicare & Medicaid Services): https://www.healthcare.gov/timeline-of-the-health-care-law/

The Commonwealth Fund (a private foundation working toward a high-performance health system): http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx

Deloitte Center for Health Solutions (the health services research arm of Deloitte LLP): http://www.deloitte.com/view/en_US/us/Insights/centers/center-for-health-solutions/index.htm

Kaiser Family Foundation (a nonprofit, private operating foundation focusing on the major health care issues facing the United States): http://kff.org/health-reform/

Medicare Initiative Advocacy

Elected officials need to hear about the need to establish a comprehensive medication management (CMM) benefit under Medicare Part B  from clinical pharmacists delivering direct patient care services in their states and districts.

Contacting your elected officials is simple. We have prepared a letter to Congress describing our Medicare initiative that you can review and edit. You can send this letter in just a few easy clicks, but for maximum impact, we encourage you to personalize the letter by sharing some additional information about your clinical practice and the patients you care for.

Simply click here to visit our Legislative Action Center, and follow the instructions to send your message to your representative and senators.

Two important resources related to our Medicare initiative are now available online. Take the time to familiarize yourself with these documents to guide your communications with Congress related to the initiative and help ensure we deliver a consistent message around how CMM helps “get the medications right” and why Congress should enact legislation to achieve this.

Click here to access the Medicare Initiative Congressional Issue Brief.

Click here to access the Medicare Initiative Data Document

For more information on our advocacy effort in general, visit our Medicare Coverage Initiative Web page for up-to-date resources and details about how you can get more involved, or contact ACCP’s Associate Director, Government Affairs at [email protected] or (202) 621-1820.

Thank you for participating in this important advocacy effort!

Your Contribution to ACCP-PAC Can Help Advance Our Medicare Coverage Initiative

ACCP-PAC is the only political action committee dedicated to electing members of Congress who are committed to advancing our Medicare initiative. Contributions from ACCP-PAC to members of Congress will raise our profile on Capitol Hill, improve our standing among key lawmakers, and provide unique opportunities to discuss our initiative with potential congressional champions. Our PAC will also help ensure that elected officials who support our initiative remain in office to advance the goals of the proposal in the future.

Only ACCP members are eligible to contribute to the PAC and allow us to make these vital political contributions. With more than 14,000 ACCP members ACCP is in a position to become one of the most prominent pharmacy PACs in Washington. To do this, we need the widespread support of our membership.

If each ACCP member contributed just $25, ACCP-PAC would raise $350,000. All ACCP members should consider making a donation of at least $25 to ACCP-PAC. CLICK HERE to support your PAC today!

Contact Us! For more information on any of ACCP’s advocacy efforts, please contact:

John K. McGlew
Associate Director, Government Affairs
American College of Clinical Pharmacy
1455 Pennsylvania Avenue NW
Suite 400
Washington, DC 20004-1017
(202) 621-1820
[email protected]

¹Washington Post article: Obamacare Site Goes Live, with Some Glitches. Available here. Accessed October 2, 2013.