What Wonders Have They Wrought?

1. What Wonders Have They Wrought? The Patient Protection and Affordable Care Act

2. The Affordable Care and Patient Protection Act 2,409 pages 477,520 words Reconciliation Package 153 pages 34,000 words 13,000 Pages of Regulations

3. Prepared by the Joint Economic Committee Republicans

4. Health Care After Reform

5. 5 Key Components Individual Mandate Employer Mandate Insurance Regulation Subsidies & Medicaid Expansion Insurance Exchange

6. How Much Will It Cost?

8. Paying for PPACA • New Taxes $1 Trillion • Debt $1.48 Trillion

9. $1 Trillion in Taxes Under PPACA The Law Imposes 19 New Taxes Excise Tax on Charitable Hospitals “Black liquor” tax hike, a tax on a type of biofuel Tax on Innovator Drug Companies Blue Cross/Blue Shield Tax Hike Tax on Indoor Tanning Services Codification of the “economic substance doctrine” This provision allows the IRS to disallow completely-legal tax deductions and other legal tax-minimizing plans Medicine Cabinet Tax: HSAs, FSAs and HRAs taxed when buying over the counter medicine HSA Withdrawal Tax Hike Surtax on Investment Income Hike in Medicare Payroll Tax Tax on Medical Device Manufacturers High Medical Bills Tax Flexible Spending Account Cap – aka “Special Needs Kids Tax” Elimination of tax deduction for employer-provided retirement Rx drug coverage in coordination with Medicare Part D $500,000 Annual Executive Compensation Limit for Health Insurance Executives Individual Mandate Excise Tax Employer Mandate Tax Tax on Health Insurers Excise Tax on Comprehensive Health Insurance Plan Source: Americans for Tax Reform

10. My Insurance Premium? Premiums Will Double in Next 6-10 Years Change as Result of PPACA Big Business: No Change to 3% Savings Small Business: No change to 1% Savings Individual Policy: 10-13% Increase Young & Healthy: 17-95% Increase

11. Does PPACA Ration Care?No Direct Rationing

12. Independent Payment Advisory Board (IPAB) • Starting in 2017 • Not a “death panel” • Base Closing-Style Panel • If Medicare spending exceeds GDP + 1, IPAB must recommend cuts. • Congress can reject recommendations in total. If Congress does not act, recommendations are implemented • Cannot recommend cuts in benefits, increase out-of-pocket expenses or premiums, or restrict eligibility. Cannot cut hospital payments until 2020. What’s left?

14. Potential Problems • No Judicial Review • Physicians may stop accepting Medicare patients • 15 percent of hospitals and nursing homes that provide Medicare services could “become unprofitable” over a decade, according to CMS

15. Universal Coverage?

17. Some PPACA Benefits • “Donut Hole” closing • Improved coverage for screening and preventive care • Experiments in cost reduction: ACOs, Medical Homes, P4P • $ for community health centers

18. Issues for North Carolina • Should North Carolina Establish an Exchange? • Should North Carolina Expand Medicaid?

19. Status of Health Insurance Exchanges

20. Status of Medicaid Expansion Decisions

21. Medicaid Expansion in North Carolina

22. PPACA Timeline Enacted Pending