1. How the idea became law
H.R.3590
Patient Protection and Affordable Care Act
Jared P. Wagner, MD
2. Feburary 2009
• In his first address to a full session of
congress, President Obama discusses
health care reform.
“health care reform cannot wait, it must not
wait, and it will not wait another year.” –
Obama February 24, 2009.
3. April 2009
• Senate Finance Committee Chairman Max Baucus,
D. Montana begins a series of roundtable
discussions.
• Initial debate centers around how to
finance the effort and how to best
expand coverage to the uninsured.
• Senator Arlen Spector leaves the Republican party
announcing that he will run for reelection in 2010 as
a Democrat.
• There are now 60 senate Democrats
4. Senate Mechanics
• Senate rules requires a supermajority of votes to end
debate legislation and advance to a final vote.
• Total of 60 votes out of 100 Senate members is needed.
• Controversial bills are unlikely to advance to a final vote unless 60
supporters can be found.
• Preventing a bill from coming to a vote for lack of 60 votes is referred
to as a filibuster.
• The one exception to this rule is a process called
reconciliation.
• Allows a bill automatically advance to a final vote. Only 50 votes are
needed.
• Strictly limited to mandatory spending programs or taxes.
• Must reduce the federal deficit over a 10 year period.
• Cannot include non budget related items
• Insurance regulations
5. March 2009
• American’s Health Insurance Plans (AHIP)
declares they are willing to cover preexisting
conditions if everyone is required to carry health
insurance.
• American’s Health Insurance Plans (AHIP) a
national association representing nearly 1300
member companies.
• AHIP support meant there would not be large scale
opposition from the insurance industry
6. June-July 2009
• Work on the Senate Finance committee shits to a small
group of six senators 3 Republicans and 3 Democrats.
Democrats Republicans
Max Baucus (MT) Olympia Snow (ME)
Kent Conrad (ND) Michael Enzi (WY)
Jeff Bingaman (NM) Charles Grassley (IA)
• These senators come to be called the gang of six.
• Obama and Congressional leaders the six to represent
the best chance for a bipartisan deal.
• Several controversial Democratic ideas are dropped.
Dropped Replaced With
Public Option Private but regulated exchanges
Income surtax on high earners Tax on high-end insurance plans
7. August 2009
• Congress adjourns for summer recess
– Senators and congressmen across the nation hold a
series of town hall meetings to explain the health
care legislation.
– These meeting are frequently disrupted by angry
protesters.
• Senator Ted Kennedy loses battle with cancer.
– Potential democratic votes (59)
8. Death Panel Scare
• Rumors that the health care law would establish
“death panels” to determine who deserved health care.
• In August, 2009 Sarah Palin wrote
• “The America I know and love is not one in which
my parents or my baby with Down Syndrome will
have to stand in front of Obama’s ‘death panel.”
• President Obama subsequently held a meeting where
he stressed that his plan would “not pull the plug on
grandma”.
• The source of the concerns the ability for a primary
care physician to obtain reimbursement for talking with
a patient about end of life care was quickly removed
from the legislation.
9. September 2009
• Senators Baucus bipartisan “Gang of Six” talks
collapse ending the possibility of broad
bipartisan consensus.
• Of the original three Republicans Only Olympia
Snow, R (MA) continues to support the bill.
• Senator Paul Kirk, D is sworn in as in interim
senator to fill Ted Kennedy’s seat until an
election is held in January 2010.
• Potential democratic votes (60)
10. October 2009
• The health care bill passes the Senate
Finance Committee on a vote of 14-9.
• Senate Majority Leader Harry Reid merges
the Finance Committee’s bill with the work
of another senate committee.
– The merged bill adds
a government run
public insurance option.
– Olympia Snow states
her opposition
to the
merged bill.
11. November 2009
• The House of Representatives passes its health
care reform bill by a vote of 220-115.
– House bill has a public option
– House bill pays for reform by increasing income tax
by 5.4% on wealthily Americans (income > $5,000)
• Reports emerge of Democratic opposition to the
bill in the senate.
– Mary Landreiu (LA) Opposed to public option
– Joe Lieberman (CT) Opposed to public option
– Ben Nelson (NE) Opposed to abortion funding
12. December 2009
• A number of compromises were done in the
senate to resolve opposition.
– Public option dropped from the senate bill.
– Deal is with senator Nelson allowing states to prohibit
abortion coverage for health insurance plans issues
on the new health care exchanges.
• As a result on December 24th the senate
overcomes a unified republican filibuster to pass
legislation 60-39.
– No Republicans vote for measure.
– One Republican hospitalized and unable to vote.
13. January 2010
• Efforts are made to combine the House and
Senate bills into a final common bill.
– Such a bill would have be passed by both the Senate
and the House again.
• January 15th House and Senate leaders say they
are close to a deal.
• Plans disrupted on January 19th when Scott
Brown, Republican wins the Massachusetts
special election.
– Potential senate democratic votes (59).
• House and Senate talks cease.
– Senate no longer has the needed votes.
14. Feburary 2010
• No major movement on health care legislation.
• Major news organizations announce that health
care reform may be dead.
– ABC News
• “Health care is effectively dead,” - ABC News’ senior political
correspondent Rick Klein
– Fox News
• “Prince Harry (Harry Reid) has to accept the fact that his
health care bill is dead.” – Sean Hannity
– Fox & Friends
– Weekly Standard
– Washington Post
– New York Post
15. March 2010
• Decision is made to attempt to pass the Senate bill
unchanged in the House of Representatives.
– Removes the need for another (60) vote in the Senate.
– Problem… Senate bill not popular in the more liberal House.
• To build sufficient support in the House the Senate
agreed to pass a series to tweaks to be passed through
reconciliation.
– Eliminating special deals given to some states (Nebraska).
– 3.8% tax on investment income for those > $250,000 annually.
– Funds from tax to close the medicare “donut hole” by 2020.
• March 21, 2010 Houses passes the senate’s version
219-212.
• March 25, 2010 Senate passes reconciliation “fixes” by a
vote of 56-43.
• March 31, 2010 Health care reform signed into law.
16. The First Year
• The health care bill included a number of
provision set to kick in over the first year.
• These were designed show the public an
immediate benefit from the legislation with the
hope of increasing public support.
17. Effective Immediately
• Young adults are now able to stay on their
parents’ insurance until their 26th birthday.
• Insurers not permitted to deny children coverage
based on preexisting conditions.
• Tax credit for small businesses (less then 25
employees) that offer health insurance.
– Credit for up to 35% of health care expenses.
18. Effective Within Three Months
Early 2010
• Individuals who can demonstrate inability to
obtain coverage due to pre-existing conditions
will be able to purchase it from special high-risk
insurance pools.
– Funded by government
– Temporary and active until 2014
– Replaced by insurance exchanges
• New plans will be required to implement an
appeals process for coverage determinations
and claims.
19. Effective Within Six Months
Mid-Late 2010
• New insurance policies must provide coverage
for preventive services without co-pays.
• Insurers can no longer cancel policies except in
cases of fraud.
• Insurers can no longer set lifetime coverage
caps on new policies.
• Medicare recipients who have fallen into the
coverage gap (“donut hole”) for Medicare
prescriptions will receive a $250 rebate.
20. Medicare and the Donut Hole
• Medicare patients pay for their prescription
needs until a deductible of around $300 is met.
– After the deductible is me Medicare covers 75% of
prescription costs until total cost reach approximatally
$2,800
• Once medication costs reach $2,800 the patient
pays 100% of drug cost until total costs
approach $6,200 when the costs are considered
to be catastrophic. (The Donut Hole)
• In 2010 seniors who fall into this payment range
will get a $250 rebate, the first in a series of
gradual closings of the gap phased in through
2020.
Good afternoon. The title of this talk is Opinions on Upper Extremity Reconstructive Surgery in Tetraplegia: Perceptions of Patients and Physicians
Thereare more than 100,000 Americans living with tetraplegia. With an annual incidence of greater then 5,000 new cases per year, Spinal cord injury is particularly devastating because the average age at injury is only 32 years old. Not surprising the primary goal for people with tetraplegia is to improve their functional independence
Procedures are available to improve upper extremity function for this patient population. This is a photo of a woman with a C6 injury who has undergone upper extremity reconstruction. Before her operation, she could only shrug her shoulders and extend her wrist. Here, she is demonstrating her new found ability to hold her arm in space which has finally allowed her to eat independently and brush her own teeth and hair.
Procedures are available to improve upper extremity function for this patient population. This is a photo of a woman with a C6 injury who has undergone upper extremity reconstruction. Before her operation, she could only shrug her shoulders and extend her wrist. Here, she is demonstrating her new found ability to hold her arm in space which has finally allowed her to eat independently and brush her own teeth and hair.
Procedures are available to improve upper extremity function for this patient population. This is a photo of a woman with a C6 injury who has undergone upper extremity reconstruction. Before her operation, she could only shrug her shoulders and extend her wrist. Here, she is demonstrating her new found ability to hold her arm in space which has finally allowed her to eat independently and brush her own teeth and hair.
Procedures are available to improve upper extremity function for this patient population. This is a photo of a woman with a C6 injury who has undergone upper extremity reconstruction. Before her operation, she could only shrug her shoulders and extend her wrist. Here, she is demonstrating her new found ability to hold her arm in space which has finally allowed her to eat independently and brush her own teeth and hair.
Tetraplegia (which has replaced the term quadriplegia) – is defined a paralysis or loss of function in all four limbs. It is subdivided by level of injury into the categories of high tetraplegia and low tetraplegia. And by the degree of injury using the American spinal injury association or Asia A-E scale. With Asia A representing a complete injury with no motor or sensory function below the level of injury, and Asia E representing complete motor and sensory preservation below the level of injury.
Tetraplegia (which has replaced the term quadriplegia) – is defined a paralysis or loss of function in all four limbs. It is subdivided by level of injury into the categories of high tetraplegia and low tetraplegia. And by the degree of injury using the American spinal injury association or Asia A-E scale. With Asia A representing a complete injury with no motor or sensory function below the level of injury, and Asia E representing complete motor and sensory preservation below the level of injury.
Tetraplegia (which has replaced the term quadriplegia) – is defined a paralysis or loss of function in all four limbs. It is subdivided by level of injury into the categories of high tetraplegia and low tetraplegia. And by the degree of injury using the American spinal injury association or Asia A-E scale. With Asia A representing a complete injury with no motor or sensory function below the level of injury, and Asia E representing complete motor and sensory preservation below the level of injury.
Thereare more than 100,000 Americans living with tetraplegia. With an annual incidence of greater then 5,000 new cases per year, Spinal cord injury is particularly devastating because the average age at injury is only 32 years old. Not surprising the primary goal for people with tetraplegia is to improve their functional independence
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)
13% of were fatal In 1997-2000 it accounted for 7 of 44 direct maternal deaths in Canada ranking it third behinde Tendon transfer procedures are most effective for individuals with injuries at the C5-C7 level as persons injured at this level have strong but redundant donor muscles that can be used to provide additional function Tendon transfer options for individuals injured above C5 are limited Due to the lack of voluntary muscles Experts estimate that approximatally 50% of people with tetraplegia would benefit from these operations (this represents at least 2500 procedures per year in the U.S)