ObamaCare Specifics

What is ObamaCare?

ObamaCare Impact
Here Are Some Details on ObamaCare


Why – Almost 60  million Americans do not have health care insurance. When they get sick or have an accident they can have huge out of pocket costs or if they can’t afford to pay, the system must absorb the costs. Many people are locked into their jobs for fear of losing their health insurance coverage.

How – Summarized from Kaiser Family Foundation  (Summary of Health Reform Law) Full 14 page PDF here (R 4/15/2011)

Individual Mandate

Require US Citizens and legal residents to have qualifying health insurance. Those who chose not to comply will be pay a phased in penalty. Those below an income threshold will receive coverage assistance. By requiring coverage the risk pool is broadened, which impacts individual rates.


Employer Mandate

Requires employers with 50 or more full time employees with certain exceptions  to offer health insurance or pay a penalty. The first 30 employees are excluded from the penalty. In some cases tax credits are available to employers to comply with the law.


Expands Public Programs

Expands Medicaid to eligible individuals who meet a income qualification. States will receive 100% funding for this expansion from 2014 through 2016. This amount is reduced in later years.

Also expands Children’s Health Insurance Programs (CHIP) at the state level with federal support to help offset costs.


Cost Subsidies to Individuals

Premium credits and cost sharing  for families under an income threshold capped at 400% of the family poverty level (FPL).


Premium Subsidies to Employers

Provides phased in tax credits for small business with under 25 employees and annual wages of less than $50K who purchase health insurance for employees


Creates State Based Health Insurance Exchanges

Available for small businesses or individuals with under 100 employees. Must have at least two exchanges  per state (at least one of which is to be non-profit) to encourage competition.  Allows for state cooperation to form regional exchanges.

The state exchanges to operate four individual  level pans plus catastrophic coverage. Allow cost to be assigned and limited based on age and tobacco use. Also sets minimum coverage requirements and clear disclosure of plan coverage.


Changes to Private  Insurance

Creates a temporary national high risk pool to provide coverage to  individuals with pre-existing conditions subject to certain requirements. Participants could  receive subsidized premiums.

Limits insurance outlays on non service areas, those who exceed the limits are requires to rebate the difference to policy holders. Also requires justification on premium hikes.

Requires dependant coverage for children up to age 26 on individual and group policies.

Removes lifetime limits on dollar coverage or rescinding coverage except for fraud.

Grandfathers existing plans regarding new benefit coverage under certain conditions.

Limits  deductibles in the small group markets and limits the maximum waiting period for coverage to 90 days.

Creates an Internet based web site to assist in selecting  coverage options and creates standards for coverage.

Creates and funds the Health Insurance Reform Implementation Fund within the Department of Health and Human Services


State Role

Creates an American Health Benefit Exchange and A Small Business Options Program (SHOP) to provide oversight regarding regulations, protections etc.

Enrol new Medicaid beneficiaries into Medicaid program no later than January 2014 and coordinates enrollment into other related programs.

Creates consumer assistance for the small business and individual markets.

Permits states to create Basic Health Plans for uninsured individuals in lower income categories.


Cost Containment

Simplifies health insurance administration by standardizing operating rules.

Rewards quality performance in Medicare Advantage Plans

Freezes the threshold for income related Medicare Part B payments from 2011 through 2019 and reduces the premium subsidy for higher income participants.

Creates  a 15 member Independent Advisory Board to suggest cost savings if cost  exceed annual growth goals. The board is specifically prohibits from recommending proposals which would rations care, increase revenue or change benefits, eligibility  or Medicare beneficiary costs and other specifics.

Eliminate the Medicare Improvement Fund

Creates an Innovation Center to explore improvements in Medicare and Medicaid Services.

Reduce Medicare payments t0 hospitals who do not meet preventable readmission standards.

Increase Medicaid drug rebates for brand name drugs to 23.

Authorize the FDA to approve generic verizon of biologic drugs and grand biologic manufacturers 12 years of exclusive use before generics can be developed.

Reduce Waste, Fraud and Abuse by providing more provider screening, enhanced oversight and the creation of a database to capture and share information across state and federal programs.


Improving Quality/Health Systen Performance

Establish a non-profit Patient-Centered Outcomes Research Institute to compare effectiveness of clinical treatments

Award 5 year grants to states to explore alternatives to current tort litigation

Establish a national Medicare pilot program to explore bundled payments alternatives

Establish a Medicare value -based purchasing program.

Better coordinate dual eligibility via the Federal Coordinated Health Care Office

Expand Medicaid chronic condition coverage to cover home health care

Increase Medicaid payments in fee for service and managed care for primary care services

Develop a national quality improvement strategy

Require disclosure of financial relationships between health entities including doctors, hospitals and drug manufacturers



Establish the National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness and pubic health activities.

Establish a Prevention and Public Health Fund to coordinate federal prevention, wellness and public health activities.

Authorize Medicare coverage of personal prevention services

Provide grants for small employers to establish employee wellness programs and reward employee who participate

Require national restaurants  and food sold from vending machines to disclose nutritional  contents of each item


Long Tern Care

Establish a national , voluntary insurance program for purchasing community limited  assistance services

Provide states with new options for offering hope and community based services through  Medicaid state plans

Increase Medicaid coverage for individuals with disabilities who require institutional care

Expand disclosure of ownership, accountability and expenditures for specific Medicare and Medicaid providers


Other Investments

Increase Medicare benefits and reduce coinsurance rates

Reduce out-of-pocket Medicare amounts for catastrophic coverage

Add incentives for primary care physicians practices in Medicare shortage areas

Bonus payments fr Medicare hospitals demonstrating efficiencies

Create Workforce Advisory Committee  to create a workforce strategy

Increase number of Graduate Medical Education training positions

Promote workforce supply of health care professionals

Promote the retention of nurses in the workforce

Improve access to health care by expanding community health centers


CBO estimates that the cost of coverage in the new law to be $938 Billion over ten years and the law will reduce the deficit by $214 Billion over the same period

How ObamaCare is Funded