1. Justine Strand de Oliveira, DrPH, PA-C

2. Objective: Describe the major features of the Patient Protection and Affordable Care Act (PPACA) that will impact our students and the patients we care for now and in the future

4. Health expenditure per capita varies widely across OECD countries. The United States spends almost two-and-a-half times the OECD average 2007 1. Health expenditure is for the insured population rather than resident population. 2. Current health expenditure. Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

5. 5 % GDP OECD countries allocate about 9% of their GDP to health. This share varies from 16% in the United States to less than 6% in Mexico and Turkey 1. Public and private expenditures are current expenditures (excluding investments). 2. Current health expenditure.. 3. Health expenditure is for the insured population rather than resident population. Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

6. Higher health spending per capita is generally associated with higher life expectancy, although this link tends to be less pronounced in countries with higher spending. 2007 (or latest year available) Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

7. Health care costs Rising premiums Rising expenditures per capita 15% + uninsured Aging population with predicted increase in health care needs Health care expenditures as percentage of GDP

9. Philosophical differences, political framing Big government or saving America? Market justice or social intervention? Public opinion—visible shifts throughout 2009 and 2010 as the debate over the bill, then the law as enacted, intensified

10. Political climate 2009...

11. House bill HR 3590 introduced 9/17/09 Considered by Ways and Means Committee Passed by the House 10/8/09 Sent to the Senate (not a separate Senate bill)

12. The Senate votes...

13. Senate HR 3590 Passed by the Senate (as amended) on 12/24/09 Vote: 60-39 “Patient Protection and Affordable Care Act” (PPACA)

14. Final passage House agrees to the Senate amendment Passed HR 3590 on 3/21/10 Vote: 219-212 President Obama signed into law 3/23/10

15. Then, HR 4872 Health Care Education and Reconciliation Act of 2010 Passed 3/21/10 Modified certain provisions of PPACA President signed 3/30/10

18. Bismarckisms—still true! The law and sausage Politics is the art of the possible

19. Changes happening now What kicks in, 2014

20. Phase 1 (now) Limit health insurers administrative costs Preventive care no co-pay (new policies, Medicare) Medicare drug costs reduced Children covered to age 26 Small business assistance for providing health insurance Elimination of lifetime limits Can’t deny kids coverage due to pre-existing conditions High-risk pools for adults

21. Phase 2 (2014) Expansion of Medicaid to cover low-income families Tax credit to cover health insurance if not covered by employer, low income Health insurance exchanges if not covered by employer, government plans Insurers can’t reject patients for pre-existing conditions Mandates: individuals, large businesses 32 million uninsured covered 23 million undocumented aliens not covered

22. PA and PA education 15% carve out for PA education in Title VII, Section 747 (Primary Care Training Grants) Loan repayment for PA faculty from disadvantaged backgrounds PAs integrated into chronic care, medical homes Updated definition of a PA program (levels Title VII playing field) $30.1 million for Expansion of Physician Assistant Training (EPAT)

23. Costs and funding $938 billion over next decade per CBO Funding: cuts in payments to health care providers, Medicare Advantage plans Limiting fees paid to hospitals under Medicare CMS demonstration projects to improve quality and reduce costs Taxes on higher income Medicare beneficiaries Taxes on “high end” insurance plans Medical device and drug companies, tanning salons

24. CBO projects: Law as enacted will reduce federal deficit by $124 billion over next decade This is a very small percentage of the overall deficit...

25. What next?

26. Mid-term elections?

27. GOP Pledge