Affordable Care Act (ACA)

In 2012, the U.S. Supreme Court in NFIB v. Sebelius struck down a provision in the Patient Protection and Affordable Care Act (the “ACA”) which, for all intents and purposes, made the expansion of the Medicaid program voluntary for individual states.  As a consequence, the Medicaid expansion provided for in the ACA has been rolled out in piecemeal fashion, with various states opting to expand Medicaid in the years since the ACA’s passage, and other so-called “holdout” states choosing to preserve their respective pre-ACA structured Medicaid programs.  These holdout states tend to be more conservative and Republican-controlled, with governors and state legislatures opposed to the ACA’s Medicaid expansion for various political and economic reasons.  The COVID-19 pandemic, however, seems to have prompted some of these “holdout” states, even considerably conservative states, to reconsider their decision not to expand Medicaid.
Continue Reading Will COVID-19 Prompt “Holdout States” to Reconsider Medicaid Expansion?

The Supreme Court issued a long-awaited ruling on April 27, 2020, directed at a more than $12 billion challenge related to the temporary risk corridors program established by the Affordable Care Act (the “ACA”).  Challenges were brought under multiple consolidated cases, Maine Community Health Options v. United States, Moda Health Plan v. United States, Land of Lincoln Mutual Health v. United States, and Blue Cross Blue Shield of North Carolina v. United States (the “Consolidated Cases”).  In its decision, the Court reversed the decision of the United States Court of Appeals for the Federal Circuit and remanded the case for further proceedings.
Continue Reading Supreme Court Issues Long Awaited Ruling on Affordable Care Act Risk Corridors Program

The December 2017 Tax Reform Bill and the Repeal of the ACA’s Individual Mandate

The tax reform bill signed into law by President Trump on December 22, 2017, notably includes the repeal of the Affordable Care Act’s (ACA’s) individual mandate penalty. The individual mandate, which requires most Americans to maintain a basic level of health insurance coverage or pay a penalty to the federal government, had already endured multiple constitutional challenges and scrutiny by political pundits by the time it came into effect in 2014. The offering of affordable insurance coverage through the ACA’s healthcare exchanges was supported by the individual mandate, which was intended to ensure that enough healthy people would participate in insurance pools to balance out the sick, who cost more to insure.
Continue Reading Have the Reports of the Affordable Care Act’s Death Been Greatly Exaggerated?

Even as Senators continue to consider “Graham-Cassidy,” the latest Affordable Care Act (ACA) repeal legislation, insurance markets are already reacting to uncertainty and instability brought about by persistent GOP efforts to upend the post-ACA insurance landscape. Between the Trump Administration’s ongoing refusal to commit to long-term funding of the ACA’s cost-sharing reductions (CSRs) and legislative overtures to repeal key portions of the ACA, premiums have increased, insurers have exited state exchanges, and access to health care coverage has been compromised.
Continue Reading Effects of Insurance Marketplace Uncertainty

On July 16, 2013, the Centers for Medicare and Medicaid Services (CMS) announced the first year results from its Pioneer Accountable Care Organization (ACO) program. The program, launched by the CMS Innovation Center, is part of the Affordable Care Act’s efforts to promote lower cost, high quality, coordinated care for Medicare beneficiaries. In 2012, there were 669,000 beneficiaries assigned to the program.
Continue Reading Pioneer ACOs Exit the Program

The Obama Administration announced on Tuesday that it is delaying implementing a key component of the Affordable Care Act for a year following complaints from the private sector about reporting requirements. The so-called “employer mandate”, which penalizes employers with more than 50 employees if they fail to provide a minimum standard of affordable health insurance, was set to kick in in 2014, but now will take effect in 2015, the Treasury Department announced in a blog post late Tuesday. The delay not only allows the Administration time to ease concerns among business owners, but also takes a controversial component of the law off the table before the 2014 midterm elections. Enactment of the Affordable Care Act is expected to be a topic of debate in campaigns over the next few years, but Democrats running for the House and Senate in 2014 won’t have to answer questions about a newly applied employer mandate.
Continue Reading Obama Administration Delays ACA’s Employer-Coverage Mandate Until 2015

On June 3, 2013, the Departments of Health and Human Services (HHS), Labor (DOL), and the Treasury (collectively, the Departments) published joint final regulations in the Federal Register implementing the Affordable Care Act (ACA) requirements for wellness programs. More specifically, the final rule applies to group health plans that offer wellness programs with a financial reward component to employees for improving their health or impose financial penalties for not participating in wellness programs or for choosing to smoke. The final regulations will be effective August 2, 2013, and will apply to group health plans for plan years beginning on or after January 1, 2014.
Continue Reading Final Rule Implementing ACA Wellness Program Requirements Increases Financial Incentives to Participate and Allows Financial Penalties

The Affordable Care Act enables the establishment of Health Benefit Exchanges of several types, including (i) State-based, (ii) State-Federal partnerships and (iii) Federally Facilitated Exchanges.[1] The purpose of the Exchanges is to, among other things, “provide competitive marketplaces for individuals and small employers to directly compare available private health insurance on the basis of price, quality and other factors.[2]

In theory, the information provided by the exchanges will “give small businesses the same purchasing clout as larger businesses.”[3] Those goals are laudable and hard to quarrel with–anyone who has tried to buy individual health insurance knows that the available information on comparability of insurance plans is at best insufficient and at worst opaque.


Continue Reading Health Benefit Exchanges: False Claims Gold Mines?

Will bundled payments lead to restructuring of our primary care healthcare delivery system? Healthleaders has a great article discussing the vision for healthcare delivery system reengineering proposed by Thomas H. Lee, MD, the network president of Partners Healthcare and Michael E. Porter, PhD, Bishop William University Professor at the Harvard Business School. The two advocate for a revamping of our understanding of “primary care” doing away with the distinction between primary and specialty care in favor of an integrated care delivery model focused on patients. Lee and Porter propose grouping patients into categories and matching comprehensive physician services with patients. They promote embracing the bundled payment method of payment by insurers to provide incentive for these comprehensive services. The article specifically identifies several groups, including CareMore, as having already begun to transition into this coordinated care model.
Continue Reading Time to Revamp Primary Care?

By Eric Klein

The Supreme Court ruled today 5-4 that the Affordable Care Act is constitutional and upheld the individual mandate, requiring most Americans to maintain "minimum essential" health insurance coverage. The decision was written by Judge Roberts for the majority. The Court held that the argument relying on the Constitutional commerce clause would not support the Affordable Care Act, but then looked to the constitutional right of Congress to impose taxes. Noting that the enforcement and operational structure for the individual mandate compliance and penalties was administered through the Internal Revenue Service, the Court upheld the individual mandate as a valid exercise of the Taxing Clause of the U.S. Constitution.


Continue Reading Supreme Court Upholds Individual Mandate in the Affordable Care Act, but Medicaid Expansion is in Question

The Department of Justice and Federal Trade Commission recently issued their final “Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program” pursuant to the 2010 Patient Protection and Affordable Care Act. The final statement was issued in conjunction with the Department of Health and Human Services’ Centers for Medicare and Medicaid Services’ final regulations implementing the shared savings program as part of a coordinated interagency effort to facilitate health care provider participation in the shared savings program, so as to achieve the cost savings and improvement in quality of care Congress intended. Both the final statement and CMS’ final regulations aim to further encourage and incentivize formation of Accountable Care Organizations and participation in the shared savings program. As such, the final statement includes significant, material changes from the proposed statement of antitrust enforcement policy with respect to ACOs issued earlier this year. (See the April 15 article on the proposed statement.)
Continue Reading No Mandatory Antitrust Review for ACOs