What are the most important elements of the Affordable Care Act in relation to community and public health? What is the role of the nurse in implementing this law?

The Patient Protection and Affordable Care Act1 (hereinafter referred to as the Affordable Care Act), amended by the Health and Education Reconciliation Act,2 became law on March 23, 2010. Full implementation occurs on January 1, 2014, when the individual and employer responsibility provisions take effect, state health insurance Exchanges begin to operate, the Medicaid expansions take effect, and the individual and small-employer group subsidies begin to flow. Along the way are a series of crucial intermediate steps.

A brief law column can hardly do justice to the Act and its sweep. Interested readers are encouraged to use the Obama Administration’s information portal,3 which provides multiple practical and policy tools related to implementation. Other special search-engine tools also can provide invaluable assistance in understanding the law’s many dimensions and the full range of issues that will arise as implementation moves forward.4


The Affordable Care Act is a watershed in U.S. public health policy. Through a series of extensions of, and revisions to, the multiple laws that together comprise the federal legal framework for the U.S. health-care system, the Act establishes the basic legal protections that until now have been absent: a near-universal guarantee of access to affordable health insurance coverage, from birth through retirement. When fully implemented, the Act will cut the number of uninsured Americans by more than half. The law will result in health insurance coverage for about 94% of the American population, reducing the uninsured by 31 million people, and increasing Medicaid enrollment by 15 million beneficiaries. Approximately 24 million people are expected to remain without coverage.5

Consisting of 10 separate legislative Titles, the Act has several major aims. The first—and central—aim is to achieve near-universal coverage and to do so through shared responsibility among government, individuals, and employers. A second aim is to improve the fairness, quality, and affordability of health insurance coverage. A third aim is to improve health-care value, quality, and efficiency while reducing wasteful spending and making the health-care system more accountable to a diverse patient population. A fourth aim is to strengthen primary health-care access while bringing about longer-term changes in the availability of primary and preventive health care. A fifth and final aim is to make strategic investments in the public’s health, through both an expansion of clinical preventive care and community investments.

Health insurance coverage reforms

Through a series of provisions that create premium and cost-sharing subsidies, establish new rules for the health insurance industry, and create a new market for health insurance purchasing, the Affordable Care Act makes health insurance coverage a legal expectation on the part of U.S. citizens and those who are legally present.68 The Act both strengthens existing forms of health insurance coverage while building a new, affordable health insurance market for individuals and families who do not have affordable employer coverage or another form of “minimum essential coverage” such as Medicare or Medicaid.9 In expanding existing coverage, the Act fundamentally restructures Medicaid to cover all citizens and legal U.S. residents with family incomes less than 133% of the federal poverty level (as measured through a new “modified adjusted gross income” test) and to streamline enrollment.10,11 (Medicaid’s five-year waiting period for legal residents will continue to apply to recently arrived people, who during this time will qualify for tax subsidies and enrollment through a health insurance Exchange.)

The quid pro quo for near-universal legally guaranteed coverage is the duty to secure it, as it is not possible to extend such a guarantee of insurance coverage without an attendant coverage obligation. This duty extends to all U.S. taxpayers, but individuals not legally present in the U.S. are excluded from both the coverage guarantee and the obligation to secure coverage. The law also provides exemptions for people for whom enrollment is contrary to religious belief or remains unaffordable or a hardship.9 But otherwise, the mandate extends to all people; indeed, it is this type of legal mandate that makes universal coverage feasible, because without it, large numbers of healthy individuals, whose presence is essential to the formation of a risk pool, would fail to enroll. Without the mandate, the private health insurance industry would not—and indeed, could not—eliminate discriminatory pricing and coverage practices, as such tactics are the means by which insurers protect themselves against adverse selection. Thus, without the mandate, universal coverage is virtually impossible, as is stabilization of the insurance foundation on which the entire health-care system rests.

In short, the Affordable Care Act represents an effort to reframe the financial relationship between Americans and the health-care system to stem the health insurance crisis that has enveloped individuals, families, communities, the health-care system, and the national economy as a whole.9 It is also this basic reinvention of Americans’ relationship to health insurance that lies at the epicenter of the legal battle over the law’s constitutionality. This is because the question of whether the law falls within Congress’ constitutional powers12 rests on whether the courts come to view the legislation as regulating our economic approach to the purchase of health care (because we all use care, the issue becomes how to pay for it), or instead (as the law’s opponents argue) as a law that forces individuals, as passive non-economic actors, to buy a product they do not want.13

In addition to establishing universal coverage and shared responsibility, the Affordable Care Act sets federal standards for health insurers offering products in both the individual and small-group markets, as well as employer-sponsored health benefit plans.6,14 These requirements considerably expand on federal standards first introduced as part of the Health Insurance Portability and Accountability Act of 1996.15 Some of the requirements (a prohibition against rescissions [i.e., cancellations], a ban on exclusion of children younger than 19 years of age with preexisting conditions, coverage of young adults up to 26 years of age under their parents’ plans, coverage of clinical preventive benefits, expanded appeals rights when claims are denied, a ban against lifetime limits, and restrictions on annual coverage limits) become effective prior to 2014.16 The broadest reforms—prohibitions against pricing and coverage discrimination against adults—become effective in 2014, when the mandate and subsidies go into effect.6

The Act’s expanded insurance standards are designed to set a federal minimum; it is the expectation under the Affordable Care Act that state insurance departments will implement and enforce these laws as part of their legal insurance oversight powers. As of August 5, 2010, the National Association of Insurance Commissioners reported that half the states indicate that their insurance departments hold implementation powers, either through explicit legislation or as a result of their general powers, while nearly all states have the capacity to enforce federal standards.17 At the same time, however, the federal government cannot force states to oversee and enforce federal laws without running afoul of the U.S. Constitution’s 10th Amendment protection against the commandeering of state law enforcement resources.18 Thus, under federal law, state implementation of federal insurance regulations remains voluntary, and the Public Health Service Act provides for direct federal regulation of state insurance markets if necessary.19

The Affordable Care Act sets an array of federal standards for insurers that sell products in both the individual and group health insurance markets, as well as (with certain limited exceptions not relevant to the topic of this article) for self-insured group health benefit plans sponsored by employers subject to the Employee Retirement Income Act.6,20 The purpose of these standards, as noted, is to ban discrimination against women, older people, and children and adults in less than perfect health. Thus, the Act bans lifetime and most annual dollar coverage limitations, the use of preexisting condition exclusions, and excessive waiting periods (i.e., longer than 90 days), and requires the use of “modified community rating” so that prices can vary only to a limited degree based on age, as well as by family size and tobacco use. The law also guarantees the right to internal and external impartial appeal procedures when coverage is denied, and requires insurers to cover routine medical care as part of clinical trials involving cancer and life-threatening illnesses.

Of particular note in a public health context is the extent to which the Act regulates the content and design of coverage itself. With the exception of “grandfathered” plans (plans in effect as of March 23, 2010, which are given a transition period that lasts until they make a significant change in coverage, premiums, or cost-sharing),21,22 insurers and employee health benefit plans will be required to cover (without cost-sharing) clinical preventive services with an “A” or “B” rating from the U.S. Preventive Services Task Force; immunizations recommended by the Advisory Committee on Immunization Practices; and other preventive services for children, adolescents, and women identified by the Health Resources and Services Administration. This requirement begins with the first plan year that occurs after September 23, 2010 (six months after the date of enactment).14 Parallel reforms are made under Medicare23 as well as in the case of Medicaid coverage for newly eligible adults,11 although for “traditionally eligible” adult Medicaid beneficiaries, preventive services remain an optional benefit.24

The Act also encourages employers to undertake workplace wellness activities that promote and incentivize actual health outcomes. Wellness activities need not be limited to the act of participating in wellness programs but can include incentives aimed at actually achieving improved health results.6

Beyond subsidizing coverage and regulating the insurance and group health plan markets, the Affordable Care Act creates state health insurance Exchanges for both individuals and businesses.25 Exchanges are meant to simplify and ease health insurance purchasing by creating a one-stop shopping market for insurance products that qualify for federal tax subsidies and that meet federal and state standards and, thus, are certified as “qualified health benefit plans.” Under the Act, Exchanges are empowered to select qualified health plans, provide information and enrollment assistance, coordinate enrollment with state Medicaid programs, calculate subsidy eligibility, oversee plans, and provide information to the federal government regarding subsidy eligibility and plan performance.26

Qualified health benefit plans, whether sold inside or outside Exchanges, will have to meet a series of federal requirements including coverage of “essential benefits,” defined under the Act to include both preventive services as well as a range of benefit classes that reflect a standard employer-sponsored plan. Qualified health plans also will be required to meet federal standards related to provider network sufficiency (including contracts with “essential community providers”) and health-care quality. In addition, qualified health benefit plans will be required to make performance information conforming to national quality measurement benchmarks available to patients and consumers.27 Qualified plans sold inside Exchanges will be required to follow certain funds segregation procedures if plan sponsors desire to offer coverage for abortions beyond those permitted under federal law (as of 2010, federally funded abortions are permitted in cases of rape, incest, and life endangerment); furthermore, states are empowered under the law to ban the sale of products covering any abortions.28

In advance of the 2014 effective date for the mandate, the subsidies, and the Exchanges, the Act permits states to expand Medicaid for low-income adults as a state option; states also, at their option, may extend coverage for family planning services to the low-income population.29 The Act also creates high-risk health insurance pools (known as preexisting condition health plans) that are meant to provide affordable coverage on an interim basis for several hundred thousand people whose preexisting health conditions make coverage unavailable, uninsurable, or both

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