Obamacare Act: A Summary of Its 10 Titles

10 Surprising Changes in the Affordable Care Act Itself

Doctor listening to baby's breathing with stethoscope
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The official name of the Obamacare bill is the Patient Protection and Affordable Care Act. It became law on March 23, 2010, when President Obama signed it. Many people have a basic idea of what the Affordable Care Act (ACA) does, but many components of the bill aren't well known.

The Act has 10 sections called titles. The Secretary of Health and Human Services implements all titles except for Titles VIII and IX. The Secretary of the Treasury Department implements those.

Title I. Quality, Affordable Health Care for All Americans

Starting in 2014, Title I required uninsured Americans to buy insurance or pay a tax. The requirement didn't apply to undocumented immigrants because they aren't eligible for ACA coverage. 

The government set up health insurance exchanges to allow everyone to compare health plans, and states received federal funding to set up the exchanges. Some states adopted the exchange run by the federal government. The exchanges also help people to find out if they qualify for Medicaid or tax credits. Title I mandates Congress to use the exchanges.

Businesses with 50 or more full-time employees must provide health insurance. If not, they pay an excise tax of $2,000 per employee except for the first 30 employees. Any company with fewer than 100 employees can use the exchanges. Companies with 25 employees or less that provide insurance can qualify for a tax credit of 50%.

Title I requires insurance companies to provide the following safeguards and additional benefits.

  • Parents can add children up to age 26 to their plans.
  • Insurance companies can't drop people if they get sick. They also can't put a ceiling on lifetime coverage.
  • They can't deny coverage to those with pre-existing conditions.
  • They must cover wellness and pregnancy exams.
  • Companies must spend at least 80% of premiums on medical services, or rebate the rest back to policyholders. They must submit justification for rate hikes to states for approval.

The tax penalty for not purchasing individual health insurance was repealed, going into effect in the 2019 tax year. Some states still have tax penalties, so confirm the consequences before dropping your health insurance.

Title II. The Role of Public Programs

Starting in 2014, the Act extended Medicaid coverage to anyone whose income is below 138% of the federal poverty level. It also allowed states to cover low-income adults without children. The federal government paid 100% until 2017. After that, the federal government reduced assistance and states that expanded Medicaid received more assistance than states that didn't.

Title III. Improving the Quality and Efficiency of Health Care

The Act closes the gap in prescription drug coverage, known as the doughnut hole, in Medicare Part D. In 2011, Medicare beneficiaries got a 50% discount on brand-name prescription drugs during the coverage gap. In 2020, the discount is 75%. The Act also provides wellness and preventive care visits for those on Medicare for free.

Title IV. Prevention of Chronic Disease and Improving Public Health

The Act established the National Prevention, Health Promotion, and Public Health Council to support preventive health care. The Surgeon General heads the council, which is composed of the heads of 12 federal agencies plus any others deemed appropriate by the Surgeon General.

The National Prevention Strategy coordinates federal health efforts around seven priority areas:

  1. Tobacco-free living.
  2. Preventing drug abuse and excessive alcohol use.
  3. Healthy eating.
  4. Active living.
  5. Injury and violence-free living.
  6. Reproductive and sexual health.
  7. Mental and emotional health.

Title V. Health Care Workforce

The Act funds scholarships and loans to increase the number of primary care physicians, nurses, physician assistants, mental health providers, and dentists. It also funded training in several areas, including geriatric medicine, cultural competency, and dentistry.

Title VI. Transparency and Program Integrity

The Act requires doctors to report any financial interest they have with imaging companies, etc., and provide a list of alternative service providers to patients. It requires medical device makers, drug companies, etc. to reveal financial arrangements they have with doctors. Enterprises that manage the prescription drug portion of Medicare or the state exchanges must report any financial concessions they receive from pharmaceutical companies.

Title VI provides training and requires background checks for nursing home staff to reduce elder abuse.

The Title also cracks down on fraud by identifying high-risk providers and preventing them from setting up in another state. It gives states the ability to test legal reforms to enhance patient safety, encourage efficient resolution of disputes, and improve access to liability insurance.

Title VII. Improving Access to Innovative Medical Therapies

The Act gives drug discounts to hospitals that serve low-income patients. It also requires competitive pricing for vaccines and hormone therapies.

Title VIII. Community Living Assistance Services and Supports Act

The CLASS Act allowed Americans who are or become disabled to receive a $50 daily payment to put toward assisted living. They were to pay premiums for five years and work for three of those years. The amount went toward home health care, adult daycare, and other services to allow them to stay in their homes. It also went toward assisted living facilities, nursing homes, and group homes. The program was self-funded and would have reduced the deficit by $70.2 billion over ten years. It would have allowed people to keep working and stay out of nursing homes and the hospital.

It entered into force on January 1, 2011, but by October 1 it was determined to be unworkable. It couldn't compete with private sector plans that offered better benefits. 

Title IX. Revenue Provisions

The Act levied an excise tax of 40% on insurance companies selling plans with annual premiums above $8,500 for single coverage and $23,000 for family coverage. It also increased taxes on HSA distributions not being used for medical expenses and limited FSA contributions.

Title X. Strengthening Quality, Affordable Care

This included authorizing appropriations for the Indian Health Care Improvement Act, improving Medicare services and payments, and funding for public health programs.

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Article Sources

  1. HealthCare.gov. "Patient Protection and Affordable Care Act." Accessed Sept. 20, 2020.

  2. National Immigration Law Center. "Immigrants and the Affordable Care Act (ACA)." Accessed Sept. 21, 2020.

  3. Marketplace. "Here Is Where the U.S. Congress Buys its Health Insurance." Accessed Sept. 21, 2020

  4. IRS. "Employer Shared Responsibility Provisions." Accessed Sept. 21, 2020.

  5. IRS. "Affordable Care Act Tax Provisions for Small Employers." Accessed Sept. 21, 2020.

  6. HealthCare.gov. "Rate Review and the 80/20 Rule." Accessed Sept. 21, 2020.

  7. HealthCare.gov. "No Health Insurance? See If You'll Owe a Fee." Accessed Sept. 21, 2020.

  8. Senate Democrats. "The Patient Protection and Affordable Care Act," Page 3. Accessed Sept. 21, 2020.

  9. Senate Democrats. "The Patient Protection and Affordable Care Act," Page 6. Accessed Sept. 21, 2020.

  10. Medicare.gov. "Costs in the Coverage Gap." Accessed Sept. 21, 2020.

  11. Department of Health and Human Services. "Title IV—Prevention of Chronic Disease and Improving Public Health," Pages 1114-1115. Accessed Sept. 21, 2020.

  12. National Prevention Council. "National Prevention Strategy," Page 1. Accessed Sept. 21, 2020.

  13. The Kaiser Family Foundation. "Health Care Reform and the Class Act," Pages 1-3. Accessed Sept. 21, 2020.

  14. PBS. "What the Death of the CLASS Act Means for Long-Term Disability Care." Accessed Sept. 21, 2020.