Achieving a Deeper Understanding of the Implemented Provisions of the Affordable Care Act

Abstract

The Patient Protection and Affordable Care Act (ACA) was signed into law by President Barack Obama on March 23, 2010. Since that time, numerous regulations have been promulgated, legal battles continue to be fought and the major provisions of the law are being implemented. In the following article, we outline components of the ACA that are relevant to cancer health care, review current implementation of the new health care reform law, and identify challenges that may lie ahead in the post-ACA era. Specifically, among the things we explore are Medicaid expansion, health insurance exchanges, essential health benefits and preventive services, subsidies, access to clinical trials, the Medicare Part D donut hole, and physician quality payment reform.KEY POINTSThe ACA provides substantial premium and cost-sharing subsidies as well as out-of-pocket maximums for patients that limit their financial exposure. In addition, it prohibits annual and lifetime caps on the amount insurers will cover.The majority of the uninsured are covered by the expansion of the Medicaid program to patients with incomes less than 133% of poverty. This is an optional benefit and only 26 states including the District of Columbia are currently using this option. In those states that opt out of Medicaid expansion, patients with incomes less than 100% of poverty may not have subsidized insurance options.The ACA standardizes insurance packages offered in the Health Insurance Marketplace by mandating coverage of 10 essential health benefits and preventive services identified by the U.S. Preventive Services Task Force, but inadequately addresses coverage of appropriate follow-up and diagnostic testing, especially as related to genetic testing.Insurance coverage for routine patient costs associated with clinical trials will be provided to individuals with group health plans (including self-funded arrangements) and state-licensed health insurance, but coverage will not automatically be extended to individuals with Medicaid.The ACA includes many changes in how physicians and hospitals are paid under the Medicare program with a renewed focus on quality and cost of care with bonuses and penalties that will likely grow over time.