Affordable Care Act--Case Analysis

1. By: Brittney Butcavage, Paige Catizone, Karyssa Costagliola,
Bobbi Jo Glowacki, Alisha Mahoney, Judith Rodriguez

2.  During the 2008 presidential elections, an unknown Chicago
senator by the name of Barack Obama won over voters with the
promise of “change”. The first task on his list once in office was
to implement a socialized health care program ensuring health
coverage for all Americans, regardless of economic status.
Americans were assured time and time again that if they were
satisfied with their current doctor; the health care reform would
not force them to find a different primary care physician. Nancy
Pelosi’s famous statement on March 9, 2010, “we have to pass the
bill so that you can find out what is in it”, left many people
uneasy in terms of the future of American healthcare. After
much contentious debate between Republicans and Democrats,
President Obama signed the Patient Protection and Affordable
Care Act (PPACA) into law on March 23, 2010. This ill-thought-
out, yet well intentioned piece of legislation has turned into an
escalating commitment at the expense of the taxpayers.

3.  In the area of health care, Forbes ranks the U.S.A.
number eleven when compared to other developed
nations. Areas of consideration are: quality, access,
efficiency, and equity. This is a surprising revelation;
we are not as high on the ladder as we would like to
believe. Health care spending is out of control and the
services being offered are lacking. We hold the eighth
highest infant mortality rate and sadly the highest
nation having the probability of people dying between
the ages of 15 and 60 years of age.

4.  Two main goals of the PPACA were availability and cost control.
Obama’s hoped the implementation of this bill would cut spending
from $2.7 trillion to $1.1 trillion. A refocus on how we approach health
issues would help to control wasteful spending. The shift from
treatment to prevention was introduced. Treatments and services are
to benefit the community as a whole not just for individuals, much like
the traditional public health system. An overhaul such as this deeply
involves all stakeholders in order to function as a unit. The Affordable
Care Act is the new health care reform law in America and is often
referred as Obamacare. The Patient Protection and Affordable Care Act
are made up of the Affordable Health Care for America Act, the Patient
Protection Act, and the health care related sections of the Health Care
and Education Reconciliation Act and the Student Aid and Fiscal
Responsibility Act. Included in the act are amendments to other laws
such as the Food, Drug and Cosmetics Act and the Health and Public
Services Act. Since the ACA signed into law, additional rules and
regulations have expanded upon the law, and we have attempted to
update our summaries with those changes.

5.  This is a good accomplishment so far, with in rate of
uninsured Americans under 65 falling from 20 percent
to 15 percent. If people obtained insurance, 60 percent
of them were able to see a physician or get a
prescription filled. Of those who became insured
under private ACA plans, 59 percent were previously
uninsured, while 66 percent of those who became
insured under Medicaid had been previously
uninsured. However, the uninsured rate is still 18
percent for people between 19 and 34.

6.  No single payer, Obamacare keeps the same complex structure in place, while
adding another layer through the introduction of health care “exchanges” for
uninsured Americans. But the majority of Americans will continue to access
care through a variety of health insurance plans made available or subsidizes by
their employers. About 50 million elderly and disabled through the federal
Medicare program. Another 60 million have low income through the state
federal Medicaid arrangements.
 No universal coverage, Health care in Canada is based on a simple proposition;
very legal resident is covered through a financed provincial or terrorial plan.
Obamacare does change coverage plans, Americans now have more of
affordable insurance plans and more options.
 No equal access, there has been some problems in Canada lately over wait
times and access to timely care. Obamacare tries to address this in its
provisions for insurance reform, such as lifting pre-existing conditions and
limits on the different co-pays.

7.  No Cost containment, Obamacare is a step in America
health reform and seems to improve the system. It will
represent a major victory for Democrats. But like other
reforms of the past, it will entrench the private nature of
the system and will likely render nationally health
insurance or anything like the “Canadian style” healthcare
and might make it impossible to attain.
 No “national” health insurance, one of the main parts in
Canada is that although each province and territory
administers a health plan, everyone can expect to be
covered for a comprehensive range of services, no matter
where they live. The federal government is expected to chip
in to make it happen. The supreme court decision for the
federal governments obligation for the states will expand
their medical coverage.

9.  On September 30th, 2014 115,000 individuals were set to lose
their health care coverage under the ACA due to
insufficient documentation in regards to their
citizenship/immigration status. Another 350,000 face
losing health care subsidies they have been awarded due to
insufficient income information. These people may have to
pay back the subsidies received and may not be able to
afford the coverage they may now be eligible for. Many of
these individuals have either mailed the requested
documentation or tried submitting it by way of
HealthCare.gov, to no avail (Pear). A review of the website
and federal contractor must be conducted. It is essential
that the website and government contractor in place be
efficient for this program to work and handle these cases
efficiently.

10.  Many individuals who had signed up for medical
insurance through the ACA exchanges are having a
difficult time finding care, the list of participating
providers and hospitals is “narrow”. The idea is that
narrow network choices will supposedly help to keep
individual costs down. Some individuals with major
health issues have faced limited access and high out of
pocket cost for the care they have required (Williams).
The list of participating providers must be expanded
to ensure care for those suffering from pre-existing
conditions.

11.  The Obama administration has announced that more
health insurance options will be available to
consumers and these new options will be available in
the upcoming health care enrollment period starting
November 15, 2014. This will increase the number of
insurers by 25% and officials believe this will help to
control premiums for consumers (Pear). Despite the
high hopes of the administration, many networks are
already predicting premium rate hikes for consumers
in the 2015 period (Gonen).

12.  The effect of the ACA on jobs has been substantial.
The ACA mandate requires employers to provide
insurance for their employees. Many employers have
cut employee hours to less than 30 hours a week to
avoid the mandate. Small business owners are
discouraged from expanding their business, the
mandate applies to businesses with more than 50
employees (Legal Monitor Worldwide) restrictions on
small business should be reviewed.

13.  The Affordable Care Act requires employers to cover
the cost of birth control for female employees,
including abortion-inducing drugs. For family owned
business Hobby Lobby and religious organization
Little Sisters of the Poor-this requirement was seen as
a violation of religious freedom. On June 30, the
Supreme Court decided in favor of Hobby Lobby their
employees will have coverage for birth control, but not
abortion-inducing drugs such as the morning after
pill. The Little Sisters of the Poor are awaiting their
Supreme Court date (Fritze).

15.  The execution of the Affordable Care Act has helped
contribute to the need for more primary care doctors.
Medicare and Medicaid compensate specialists at a
higher rate than family practice physicians and many
persons going into the field of medicine specialize in a
specific field knowing this. Federal funds are being
used to bring in new primary care practitioners, but
one of these programs will be expiring in 2015.

16.  Educating new nurses and physicians takes years,
something the ACA did not take into account. With
the lack of graduates at this time families can expect
longer wait times as well as shortened appointments
and increased cost (Anderson). The “supply and
demand” of the ACA will be hard to maintain,
patients will have a harder time accessing providers
and in turn have new frustrations with the delivery of
care (Anderson). In order to remedy this shortage,
additional ACA funding must go toward incentive
programs to attract more primary care physicians and
the biased compensation scale of Medicare and
Medicaid must be overhauled (Krasselt).

17.  Incentives are being placed in order to up the number of
healthcare graduates and prospective students. According
to an article by Amy Anderson, on www.heritage.org, “The
ACA reauthorized loan repayment and forgiveness,
scholarships, increases in Medicare-funded Graduate
Medical Education (GME) residency slots, funding for
workforce planning, and increased funding for the Public
Health Service.” However, medical students are exhibiting
less interest in primary care, mostly due to a “$3.5 million
income gap over a lifetime of work and the increasing debt
of student loans” (Anderson). Amy goes on to tell us that
currently medical education institutions enrollment has
increased, but it is predicted that due to the long process of
education the demand will surpass the supply by
approximately 2025 (Anderson).

18.  The ongoing lack of residency slots is also a determining
factor when it comes to educating these graduates. The
American Association of Medical Colleges is supporting
legislation to increase the number of Medicare-funded
residency slots, none the less this shortfall could persist at
least through 2017(Anderson). Nursing is also
experiencing a similar dilemma: “More than 79,000
qualified applicants were turned away from nursing
programs in 2012. Complicating matters, the average salary
for positions in nursing education is significantly lower
that what these experts can earn outside academia, making
it difficult to recruit and retain key academic personnel”
(Anderson).

19.  In order to maintain a higher graduate ratio, we need
to offer higher incentive and reimbursement to try and
alleviate the financial burdens of pursuing an
education in health care; also the number of residency
slots available need to be raised in order to keep up
with the staggering numbers of those now insured.
This may just convince individuals that a future in
medicine is attainable and may persuade them to
consider all that is has to offer.

20.  In today’s society and economy the Affordable Care Act is having
its affects not only on consumers, but with all of the healthcare
systems that provide care to patients. For many years in the
healthcare industry hospitals relied on reimbursements from
insurance and other sources based on the volume of patients
they see. The long term care facilities have always suffered when
it came to Medicare reimbursements which they will hopefully
see a change when it comes to the implementation of the ACA
with the creation of long term care services and supports. This
way of payments is going to change drastically over the course of
time and the transition to the rules set forth in the Affordable
Care Act. This Act wants providers to focus more on the quality
of work they are doing rather than trying to treat as many people
as possible to get their payout.

21.  The hospital systems have to make major adjustments to
how they give treatment and care to the patients they see.
With the main focus of care in hospitals now being more of
quality not quantity so the hospital are forced to take a
different approach of care. The ACA does not have many
guidelines to the quality control of service and how they
accomplish it which, “It allows hospitals to create entities
called accountable care organizations, third-party groups
that oversee the quality of care at hospitals”
(http://www.usatoday.com/story/news/nation/2013/10/20/
hospitals-face-whole-new-world-under-health-
law/3078353/).

22.  The implementation of the ACA is giving every hospital an
initiative to improve their quality to receive the maximum
reimbursement from Medicare especially. They determine the
quality of hospitals based off patient surveys that are given post
care and the outcomes of procedures performed for the patient.
The lower the scores on surveys and other areas the hospital is
subject to a penalty and also hospitals that have an increase in
hospital acquired infections are subject to penalties.
Unfortunately, some negative aspects of the ACA are hospitals
are resorting to cutting back employees to prepare for the money
loss with this new system. Local hospitals like Blue Mountain
Health Systems have dismissed multiple employees from both
the Lehighton and Palmerton Campus. Another aspect is most
independent hospitals are forced to merge with larger networks
to stay afloat with the drastic changes in reimbursement.

23.  http://video.foxnews.com/v/2813185414001/why-top-
hospitals-are-opting-out-of-obamacare/#sp=show-
clips
 http://video.foxbusiness.com/v/3483675999001/hospit
als-now-offering-obamacare-alternatives/
 http://video.foxbusiness.com/v/3483675999001/hospit
als-now-offering-obamacare-alternatives/

24.  The effects on long term care facilities are having a more
positive effect in regards to the ACA. Currently most
elderly patients that are in need of a long term care facility
or at home care and do not have a supplemental insurance
are unable to afford to pay for their stay and care at these
facilities or in home care givers. Their inability to pay is
leading to the elderly using up their savings and or their
family’s savings just trying to maintain their stays which for
most people it isn’t realistic. The growing population is
increasing in the elderly community because of the
changes in healthcare leading to longer life spans. With
people living longer these facilities are almost necessary to
have and most elderly people utilize them which increase
the need to have coverage.

25.  The ACA is going to make this possible for those people in need
of the long term care and even make it possible to receive their
care at home. The changes to healthcare involving the ACA and
long term care state that with the change it will, “build the long-
term care workforce creating a new long-term care insurance
program giving states incentives to expand home- and
community-based services in Medicaid, creating programs to
improve resources that help caregivers, and creating programs
that protect seniors and people with disabilities creating
programs that improve nursing home care”
(http://familiesusa.org/product/affordable-care-act-provisions-
will-help-caregivers). The changes will put families at ease
knowing that there is care available for their parents or
grandparents and they won’t have to worry about the cost or high
medical bills they would have to pay.

26.  With the upcoming changes to the way health care is
delivered, the way hospitals and long term care settings are
reimbursed it is crucial they take everything into account.
If these care facilities focus on the best quality care they
can give verses the amount of patients they treat it will
lower the risk of layoffs and closures of facilities. If these
facilities would monitor unnecessary spending like
departmental costs it could lower the impact that the ACA
has on reimbursements with insurance. When dealing
with Medicare patients, hospitals are facing penalties and
or no money for services rendered because they are not
focusing on the quality care. If a hospital can control
readmissions it would significantly increase the
reimbursements that they receive.

27.  Medicare patients after the third day of admission the insurance
does not pay so the hospital is resorting to absorbing the loss
which increases their debt. Another problem that they face is
the penalties they receive for hospital acquired infections which
if they would make sure every preventative measure is taken and
possibly giving private rooms to more patients it would lower
these occurrences. Over all, hospitals and long term facilities
would stand a better chance of reimbursement in every aspect of
care if they continue to keep an advisory group in place to send
out surveys to patients and to oversee the quality performance
done at each facility. If they hold strong with these new
standards and ways to fix the quality of care the drastic changes
the ACA is going to have on these facilities won’t be as
significant.


28.  Alternative therapies may flourish when the Affordable
Care Act is in full swing, thanks to a clause written within
the new law. Section 2706, “Non-Discrimination in Health
Care”, states: “A group health plan and a health insurance
issuer offering group or individual health insurance
coverage shall not discriminate with respect to
participation under the plan or coverage against any health
care provider who is acting within the scope of that
provider’s license or certification under applicable state
law” (Cahill). In layman’s terms this simply means that if a
Complementary and Alternative Medicine (CAM)
practitioner is licensed within that state, insurance
companies must compensate them the same as they would
a traditional physician (Cahill).

29.  It seems only expected that alternative therapies now be
considered by health insurers; for years millions of
American have paid out-of-pocket for CAM treatments on
a yearly basis. In the article, “What is the Future of
Complementary and Alternative Medicine under the
Affordable Care Act”, a 2011 survey implemented by
Consumer Reports, “every year 38 million Americans
receive more than 300 million CAM treatments” (Cahill).
The argument stands that CAM offers limited research to
prove its efficiency, however the ACA rules can now allow
for research and experimental treatments to be
implemented based on a “probable cause” standard used in
evaluating CAM modalities (Turner).

30.  The ACA has intentions on focusing on preventative
medicine and wellness-based treatment; however it
has not fully taken into account the contributions that
can be made by integrating Complementary and
Alternative Medicine, and conventional medicines
(Abbott). I propose that in order for this to work,
practitioners alike have to maintain an open mind.
The benefits of CAM can speak for themselves if you
research the statistics, just imagine if we integrated
both conventional and alternative therapies; a world of
opportunity waits!

31.  For many people alike, the ACA is a touch and go subject. It has
many different groups of people either for it against it. Not only
because it is considered to be “forced” upon American citizens,
but on the opposite spectrum, have some seen it as a blessing.
There is now a link that describes what a citizen will pay for
every year they are insured. For example, in 2014 $95 will be
taken out of your refund and in 2015 $325 will be taken out. This
alone has many people outraged due to many not being able to
afford such rising high costs for healthcare. However, when
doing an in depth research on these establishments, there wasn’t
much research to back certain claims that were made by these
institutions. What will next be examined is how it affects
different organizations, government run institutions that
currently have the ACA in effect and the research they use to
speak to patients to “put their minds at ease.”

32.  The first hospital researched was VA (also known as Veteran
Affairs), from reading all of the research on the ACA and VA it
was rather frightening. If a veteran has VA benefits, then they are
considered to be “OK” and that no enrollment is required,
however, the down side to not having the VA benefits can also
put a dent into someone’s pocket. In order to get the VA benefits,
the veteran MUST enroll into ACA or a large portion of their
taxes gets taken from them during the year. According to the
website www.va.gov , it has little to no explanation of the
enrollment for the ACA. It just mentions that if one does not
enroll into veteran benefits, they must use the Healthcare
marketplace to enroll. Additionally, upon further reading, it is
now changed that a family member cannot be put onto veterans
benefits if they have inquired to healthcare marketplace. This
can be frustrating for family members who are not aware that
they cannot be placed just for researching the ACA. As for
putting a dent into the pockets as mentioned earlier, family
member will have to pay steeper co pays if they are not enrolled
under the VA.

33.  Another institution researched was the catholic hospitals. With
all the current trends in healthcare (including these hospitals
allowing contraception), many have opted to allow such changes
into their hospitals as early as June of 2013. There are still many
controversies within the CHA whether patients can receive all
cares that are covered under the ACA. There has been a mandate
done earlier in the year that if a hospital or institution that is
deemed “private” does not want to give patients full care, they
can refuse that right if they consider it immoral and make the
insurance company find a different provider to give the patient
contraception. Sister Carol Keehan who is front runner for
Catholic hospitals to use all avenues for ACA states that
regardless of religious beliefs, everyone should be able to get the
care they deserve and that’s what healthcare is all about.

34.  After looking into both these organizations, RAND was then
researched to see public opinion since ACA was put into effect.
The questions that RAND had used were to see if people really
were changing their minds about the ACA. The data runs from
Sept 2013 up until Sept 2014, within one year, there was a 45%
increase of people who are not in favor of the ACA. When
reading the FAQ’s page, RAND had asked people why they went
from favoring to unfavoring, their response was that they were
deceived into thinking that it was health care that everyone
(extremely low income participants) could afford. However,
RAND itself is rather biased with their research, even though
they ask the questions as to why they report the “unfavorings” of
the ACA, they are still consider government and only reporting
the “good qualities” of the ACA. It seems as though someone
who is not well versed in reading into research, they can easily be
fooled.

35.  Upon Researching what The Children’s Hospital of
Philadelphia (CHOP) was doing for families to provide care
for the children that use such insurance. According to the
website, they accept the ACA, but what gets parents is that
some tests (which are considered possibly vital to the
child’s health), may not be covered and a third party must
be contacted to provide all or partial payment to receive a
test or treatment. This can burden a lot of parents with a
sick child, especially one who needs round the clock care.
For children, who are terminally ill, they should cover all
costs, this one major reason as to why people oppose the
ACA and what it “provides.”

36.  Plans to decreases number of Americans without health
insurance
 Benefits low income families
 Healthcare coverage for people with per-existing conditions
 Prescription drugs will be available at a lower cost
 Prohibits payout caps
 Doctors and hospitals are rewarded for quality of care instead of
quantity of care
 Has a requirement implemented that the FBI is to establish a
nationwide background check on direct patient access
employees
 Each state can run its own health insurance exchange or they can
default to have the federal government manage it

37.  It is being funded by the tax payers
 Penalty tax is starting at $95 or 1% of your income, and then going up in
consecutive years
 People are forced to purchase coverage or face penalty tax
 Coverage for people with pre-existing conditions are facing higher premiums
 Uncertainty and arguments in regards to what is actually considered essential
care and how much coverage will be allotted (i.e. rehabilitation)
 Exemptions for people below federal established poverty line
 People with certain religious beliefs are exempt
 Shortage of healthcare providers
 Small businesses are forced to have at least 50 full-time employees and provide
insurance or face a fine
 Biased research
 Open lawsuits from healthcare providers and religious groups
 Pharmaceutical companies face higher taxes, fees and rate increases for their
medications to be marketed

38.  Reduce overall cost of healthcare
 Individuals and small businesses are able to buy affordable
insurance
 Prescription drugs available at lower costs
 Tax credits
 Extended coverage for dependents to age 26
 Increase in patient volume
 Medicaid coverage now available for more Americans
 States can receive funds from federal government to cover
low income families on medicaid
 Accountable care organizations

39.  Funding from taxpayers
 Pharmaceutical companies releasing employees to cover costs of
inflated taxes and fees
 Creation of Independent Payment Advisory Board (IPAB)
 Lack of physicians to provide coverage for influx of patients
 Funding from the government (i.e. residencies)
 Technological advancements not considered in current
regulations
 Lawsuits from individual states as well as healthcare providers
 Lawsuits in regards to unconstitutional legislation
 Religious groups
 Accountable Care Organizations (ACOs)

40.  - in 2012 there was 47 million Americans that had no
healthcare coverage, the ACA plans to drastically
decrease that or even eliminate that amount
 - Medicaid eligibility expanded to all Americans under
65 with incomes up to 133% of the federal poverty level
 - Prior to implementing people with a pre-existing
condition such as asthma, could not get health
insurance now they can
 - Medicare recipients who reach the drug coverage gap
now are offered their prescriptions at a 50% discount
until the prescription gap closes in 2020

41.  - Under new consumer protections provisions of 2014,
insurance companies are prohibited to impose dollar limits
on the amount of coverage an individual may receive
 -Provisions in 2012, Improving and lowering costs are
linking payments to quality outcomes based on patient's
perception of care
 - Previously it was only required to have a state background
check ran in order to have direct access to patients, now it
is being implemented that a federal background check be
ran on the employee seeking employment as to prevent
possible abuse or criminal situations
 - States may run their own exchanges to provide health
benefits, they must however meet federal guidelines for
minimum coverage known as “essential health benefits

42.  - The taxpayers can choose to simply not file their taxes, or simply pay the
“fine”. This would reduce the amount brought in to cover overall plan by not
having the full amount for premiums.
 - The one percent is for income at or below the filing threshold for your income
tax as filing single on your 2011 taxes ($9500)
 - The requirement known as the “individual mandate” requires most
Americans to have insurance or face the penalty. The exemption is if cost of
insurance would exceed 8% of your income, or people below federal poverty
limits
 - 2010 New Consumer Protections provisions state that insurance companies
cannot deny coverage to children under 19 for preexisting conditions. New
Consumer protections of 2014, prohibits companies from refusing to renew or
sell coverage regardless of their preexisting conditions, gender or health status
 - At the end of 2012 regulations were still needing to develop standards in
regards to nonquantitative treatment limitations (NQTLs) which would decide
how much or little treatment was necessary to determine success in a rehab
program in regards to drug and alcohol treatment.

43.  - Although a strength, people who are barely over the poverty line may
choose to reduce work hours in order to receive coverage or prevent
themselves from facing fines for not having coverage
 - Religious exemptions have always sparked controversy, this issue can
cause people to “practice” religions to be exempt. It can also cause
people to fight for equality straight across the board
 - The US has a population of 316 million people, in that population
there is only approximately 2 million healthcare providers, when
comparing the numbers that potentially leaves 158 patients per
healthcare worker. In that number there is only about 700,000
practicing physicians in the US
 - By forcing small businesses to have a certain amount of employees,
this will push out the Mom and Pop shops in the areas. This will bring
in more corporations such as Walmart and will raise the cost of
products. Eventually leading to lower economies.

44.  - Too many times when trying to research anything on the ACA,
you will find the information is put in place by the government
or agencies that are sponsored by the government. Other
agencies will put their opinions out there such as Catholic
organizations. This makes it hard to have honest facts.
 - Groups such as doctors and religious groups have been filing
lawsuits in regards to constitutional violations. The Arch Diocese
in Washington filed a lawsuit against the ACA in 2012 with
regards to they felt it violated their beliefs with medications and
procedures that were to be covered under the legislation.
 - The more penalties pharmaceutical companies face, could push
them to lay off workers. This will add to the already existing
unemployment problem. It also can result in higher cost to
medications which will be not be visible to consumers as
companies will hide the fees in red tape

45.  Healthcare costs Americans over 2.7 trillion and is over 17%
of our gross domestic product. By reducing overall costs,
we can increase a profit margin
 - Being able to afford coverage promotes a healthier society.
It increases time spent at work instead of wasted and loss
from days off.
 - Individuals will now be able to afford to purchase their
medications, again this will increase in the over all well
being of the population
 - Small businesses through the first phase in 2010 were
eligible for tax credits up to 35% of their contribution to
their employees insurance. Nonprofit companies were able
to claim up to 25% credit

46.  By allowing dependents staying at home and going to college to remain
on their parents health insurance policies, it relieves them of a burden
to work full time to maintain insurance. This could increase repayment
of student loans. It also gives parents peace of mind that their children
have the chance to remain cared for.
 - By having a rise in the amount of patients needing to be seen, it will
create job openings for those educated in the medical field. It can serve
as a job gateway. This could lower unemployment rates in the field
 - By increasing the federal poverty level to a higher rate and increasing
the income limits for Medicaid, this allows families to have the needed
coverage to maintain health to continue to be productive in society
 - In 2010 provisions under Increasing Access to Affordable Care, it
provides the federal government the ability to match state funding to
cover low income families and individuals
 - ACOs must provide care for a minimum of 5000 Medicare recipients.
They also must meet established quality measures of care to include
safety, coordination, appropriateness and timeliness

47.  - As we discussed earlier in our weakness section of the SWOT, if funding is
coming from the tax payers, they hold the aces so to speak. They can either
decrease work hours and become reliable on the Medicaid program, they can
not file taxes and evade the penalty or they can simply pay the fine and not
contribute to the cost of a health plan.
 - If pharmaceutical companies have to cut employees, this will add to the
unemployment issues we have here in the country. By doing so, it will now add
to the burden of uninsured or add to the list of low income families on
Medicaid program. This will add to the cost and need of federal funding
 - Independent Payment Advisory boards are meant to recommend policies to
Congress to curb Medicare wasteful spending. In 2015 they must report to the
President as well as Congress, their recommendations to slow expenditures.
This can be swayed in what ever way the majority of the board decides it should
report. It can take away from a well needed part and give to a lesser part.
 - Having a lack of physicians, upsets their patients. It could cause a longer
increase of wait time for patients at their appointments. This has a risk to
impact their attendance and scheduling of appointments. Patients already wait
huge amounts of time to see their doctors.

48.  - Depending on where the government decides to place budget costs, funding
to residencies can be affected for example, cuts in schools budgets due to lack
of federal funding will lower the quality of education prospecting physicians
receive, therefore their quality of care is substandard
 - Individual states for example Florida in Florida et al. v. Department of Health
and Human Services et al.; National Federation of Independent Business et al. v.
Kathleen Sebelius, Secretary of Health and Human Services, et al.; and
Department of Health and Human Services et al. v. Florida et al, the state of
Florida filed suit to determine whether or not Congress exceeded their
enumerated powers as provided by the Constitution and if they “unduly coerced”
states into increasing their contributions to Medicaid program.
 - Matt Sissel is suing Congress stating that the penalty tax is unconstitutional,
he claims the bill originated in the Senate and is in direct violation of the
Constitution because a provision in the Constitution called the Origination
Clause: Article I, Section 7, Clause 1. It reads as follows:

49.  “All Bills for raising Revenue shall originate in the House of Representatives;
but the Senate may propose or concur with Amendments as on other Bills.” In
this lawsuit, he claims that although the bill originated in the House, when it
arrived at the Senate the whole body of the bill was removed and replaced with
the PPACA, and then decided on and returned to the House. By doing so, it
means the bill did in fact originate in the Senate as the bill passed was not the
original bill passed by the House.
 - Religious groups are a huge threat, they feel that the ACA violates an act put
in place in 1993 that “Government shall not substantially burden a person’s
exercise of religion even if the burden results from a rule of general
applicability.” This is known as the Religious Freedom Restoration Act. They can
tie the act up in courts for years forcing the mandates to be placed on hold
until the Supreme Court rules.
 - Accountable Care Organizations can throw a wrench into the ACA if they do
not appease the doctors working for the facilities, the doctors can simply go
work elsewhere. ACOs set the standards for payments, and if service is
substandard they can withhold payment but as I stated, doctors can simply
remove their services and cause the hospital to lose patients.