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By Tom Cushing

Obromneycare, Part One: What is it, exactly?

Uploaded: Mar 22, 2012

The Affordable Care Act is (choose only one):

a. Socialized medicine

b. The moral equivalent of strapping grandma to an ice floe

c. The moral imperative of a civilized nation

d. Compromise legislation mandating universal coverage by private health insurers

e. Okay, none of the above is a complete description

The answer, of course, is "e", although "d" isn't a bad start. Over the next two weeks, we'll take a look at this hallmark legislation of the last four years. It is President Obama's version of universal health care legislation – about which there has been so much controversy, and so little actual description. This week's blog will cover its major provisions – if I miss any, I am certain to receive assistance from the readership. Next week's edition will cover costs and the legal arguments over its Constitutionality, mostly under the Commerce Clause. The Supreme Court has set aside an unusual six hours for oral argument on the subject.

The so-called Patient Protection and Affordable Care Act (hereinafter the ACA, or the Act) has ten major titles, and seeks to do many things. It will be phased-in over several years, with a few parts already in effect, but most others to-come. First and foremost, it will mandate that everyone secure coverage, eventually adding some 32 million presently uninsured Americans to the rolls of private insurers. Those who have coverage, mostly through employers, need see no change in their direct circumstances. Some 16 million uncovered Americans who are also ineligible for Medicaid assistance will need to buy-in, via web-based "exchanges" or otherwise. These are primarily healthy younger persons who don't choose coverage now because they believe they are immortal – err, no, they generally perceive it as a bad deal they will likely not need until age and stress take their inevitable tolls.

In return for delivering those millions of customers to the insurance market, the Act requires certain decencies of health insurers, to wit: that pre-existing conditions not disqualify applicants, that young adults (boomer-ang-ers?) may remain on their parents' policies up to age 26, and that 80-85% of premiums must go to provide benefits.

Controversy deepens, for some, in Title II, where the other 16 million uncovered Americans are treated. Medicaid coverage currently does not extend to many among the poor and working poor, including childless adults. They will be brought within the Medicaid umbrella in 2014, under a criterion of household incomes less than 133% of the so-called federal poverty line (about $30,000/year). Although Medicaid is state-administered, the feds will reimburse 100% of new costs, at least through 2019. It is anticipated, though, that others who are now eligible, but have been excluded by dint of state program shenanigans or their own inattention, will also now obtain such coverage.

Titles III and IV deal with systemic improvements and strategic direction, focusing on improving Medicare's efficiency and developing a national disease prevention strategy. These were relatively uncontroversial elements of the Act, albeit they fueled the hysterical "death panels" claims. In an environment in which our diets have changed more in the last 50 years than in the previous 10,000 years (to quote Michael Pollan), my expanding girth and I eagerly await their report.

Titles V through VII cover miscellaneous topics like improving primary care availability in under-served areas, support for research into clinical effectiveness of treatments and therapies, and facilitating FDA focus on bio-similar products. The latter is a catch-up provision, as most other industrialized countries already have such programs in their regulatory regimes. Title VIII, the CLASS Act, has been scrapped as not fiscally sustainable.

Title IX, then, tells us how this will be paid-for, at least in-part. It includes surcharges on Medicare taxes for high-earners ($200K individuals, $250K families), assessments on insurance, drug and device manufacturers, and restrictions on Health Savings Accounts. It projects revenue of about $40 billion/year ($439B over ten years). Title X is a basket category of miscellaneous amendments to the earlier Titles.

So there you have it – there's a lot to chew-on, philosophically. It is certainly communitarian in that it throws us all-in together, and progressive in terms of its fiscal impact. It is also both more and less than many people believe. Next week: cost estimates (which, contrary to some reports, have actually declined, of late), and a few words to frame the legal arguments over its Constitutionality (which has much to do, oddly, with home-grown wheat). Stay tuned!