Accountable Care Organizations: Updates to know
Accountable Care Organizations: Updates to know

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The Affordable Care Act in progress

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Doctor holding in hand Affordable Care Act

Enrollment of patients under the Affordable Care Act (ACA) grows, but some parts of the program have been postponed. When the period of open enrollment closed earlier this year, more than 8 million people had signed up for private health care insurance under the act.

ACA increasing coverage for the uninsured

The ACA also increased coverage for uninsured Americans by expanding the Medicaid program, making eligible anyone with income less than 138 percent of the federal poverty level. (In 2014 in the 48 contiguous states, 138 percent of the poverty level is $16,105 for one person and $32,913 for a family of four.) The Rand Corporation estimates that Medicaid enrollment increased by 5.9 million since enrollment expanded under the ACA.

The number of persons covered by expanded Medicaid would have been larger had it not been for the U.S. Supreme Court decision, which although upheld most of the ACA, gave states the right to opt out of Medicaid expansion (National Federation of Independent Business et al v. Sebelius, 2012). Approximately 24 states have opted out.

The cost of not expanding Medicaid

Researchers at Harvard University Medical School and City University of New York, writing in the Health Affairs Blog, estimated that between 7,115 and 17,104 will die each year because of the lack of Medicaid expansion in opt-out states. The deaths occur because many patients without insurance will forego screenings and treatments, including medications.

The decision by some states to not expand their Medicaid programs was made even though the federal government will pay 100 percent of the costs of expansion in the first three years of the program and 90 percent of the costs thereafter.

The ACA has reduced the number of people without insurance, but 32 million are estimated to still be without insurance. According to Gallup, those most likely to be without insurance are Hispanic (37 percent) or Black (18 percent). Eleven percent of Whites are uninsured.

The Obama administration has acted to prohibit discrimination against same-sex married couples under the ACA. Insurance companies issuing policies through insurance exchanges will be obliged to offer coverage to same-sex married couples, even if the marriage is not recognized by the state in which the couple lives.

Postponing parts of the program

As a result of lobbying by various groups and administrative difficulties within the government in setting up the expanded health care program, the start dates for some parts of the ACA have been delayed, generally by about one year.

ICD-10: The tenth revision of the International Classification of Diseases (ICD-10) will not be implemented until October 1, 2015. Originally, it was to be implemented in 2013; then it was postponed to 2014; and, in April of this year, President Obama signed the Protecting Access to Medicare Act of 2014, which moved the date to 2015. ICD-9 uses 13,000 codes; ICD-10 will use 68,000 codes, providing more precision in tracking treatments and use of products.

Many small physician groups and hospitals opposed the earlier implementation of ICD-10 because of the administrative burdens. Many larger hospitals, physicians groups and insurance companies favored more prompt implementation.

“Doc Fix” for Medicare rates: Congress punted again on passing a law to permanently fix the Sustainable Growth Rate (SGR) formula, which determines physician payment rates under Medicare. Without legislation to fix the SGR, the formula would have mandated a 24 percent cut in physician pay. Democrats and Republicans had agreed in principle that the current formula needed to be replaced by a system based more on quality guidelines than on fee-for-service.

They also agreed that the payment system did not have to be a zero-sum game and that all physicians who meet quality guidelines could be eligible for increased payments. Congress could not agree, however, on how to pay for the new payment system, the cost for which is estimated to be between $128 and $180 billion over 10 years.

So Congress, as part of the Protecting Access to Medicare Act, voted for the 17th time to suspend application of the formula and its reduction in payment rates.

Two-Midnights Rule: A third feature of the Protecting Access to Medicare Act was to extend the moratorium on the Centers for Medicare and Medicaid Services’ enforcement of the Two-Midnights Rule.

Under the rule, a patient’s admission to the hospital is usually considered “reasonable and necessary” if the patient stays in the hospital for two midnights. If the patient is admitted to a hospital for less than that, Recovery Audit Contractors may impose penalties. Under the act, the audit contractors will not be able to audit for enforcement of the rule until April 1, 2015.

Employer mandate for medium-sized companies: The obligation of companies with 50 to 99 full-time employees to provide health insurance to their employees has been postponed from Jan. 1, 2015 to Jan. 1, 2016.

The mandate—referred to in the law as “employer shared responsibility”—was delayed by rules issued by the Treasury Department. In order for a company with 50 to 99 employees to postpone their obligation to provide insurance, the employers will need to certify that they have not laid off any employees in order to be under the 100-employee limit. Employers with 100 or more employees still will have to meet the Jan. 1, 2015 deadline.

Though the Affordable Care Act is accomplishing its primary purpose—providing health insurance to more individuals—several administrative aspects of the program have been difficult to implement, and the time for full implementation has been


Jeff Atkinson

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