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1 EQUALITY AND EQUITY OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA)

A PRACTICUM By Morgan La Femina

Submitted in partial fulfillment of the requirements for the degree of Master of Arts In Social Policy

Table of Contents

Abstract Introduction What is public policy? How we affect public policy Current healthcare reform policy overview The PPACA The healthcare reform debate Our public needs versus available resources The growing number of uninsured The increasing number of working uninsured Theory Ethical theories of resource allocation The limits of government Parties whom affect government policy Definitions of good public policy formulation The inefficiencies of the market Conservatism and Liberalism Conservative and Liberal views on current healthcare reform policy The bills studied Details of the PPACA bill Other current healthcare reform bills Recommendations regarding the bills studied Conclusion

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3 Abstract

Providing adequate healthcare for more individuals in our society is a need we as a community wish to address through the development of new public policy. This practicum involved working for an oncology patient advocacy nonprofit in Phoenix, Arizona. During this practicum, legislation such as the Patient Protection and Affordable Care Act along with related healthcare reform bills, which would affect the non-profits constituents, was analyzed. Research conducted during the practicum first consisted of reviewing proposed healthcare reform bills, and second, outlining ways for the non-profit to maximize the new legislation's benefits while minimizing its disadvantages. An understanding of how competing groups in our government debate policy was developed, in addition to a greater understanding of how we as a community solve the needs of our society; in this case providing healthcare coverage for more people.

Equality and Equity of the Patient Protection and Affordable Care Act (PPACA)

In the United States, public policies are made not just by presidents or Congress but by a complex political system that include them (Lindblom & Woodhouse, 1993). What we consider policy is most often just the surface manifestation of a bill or an executive order. Public policy encompasses not just the bill we see voted on when we watch TV or read the paper, but what is beneath the surface as well, the teams of people who work on the policy and all the bartering required for approval (Lindblom & Woodhouse, 1993). When our leaders develop a public policy, they cannot know all the effects the policy will have; however we can bring the best minds together with the most knowledge available to make a best effort at formulating solutions that provide for our societys needs (Lindblom & Woodhouse, 1993). This paper looks at the effect of policies affecting the health care industry. Developing policies that our government can utilize to provide for our needs requires a large number of experienced professionals. We need many professionals to work on solutions, which then provision our needs and wants, because no one person has all the information or the experience necessary to carry out the task. This is quite simply because humans have a limited capacity for understanding the world around us (Lindblom & Woodhouse, 1993). Unfortunately, ones own ability to formulate answers that are effective at reducing the problems we have as a society is so minimal that only a large group of empowered individuals working together can even attempt to positively affect issues such as expanding healthcare coverage nationally. Unless we consider what we can do as individuals, what we can do as a community and what we can

5 and cannot provide to our people, we cannot appreciate the great difficulty facing our political system (Lindblom & Woodhouse, 1993). Understanding what we can and cannot do as a society became quite apparent during a practicum. The Practicum involved working for the cancer advocacy nonprofit located in Phoenix, Arizona. Legislation was researched which would affect the non-profits key constituents, such as cancer specialists, small group practices, Medicare fee-for-service providers and on the medical services oncology patients receive. Most of my research involved analyzing the Patient Protection and Affordable Care Act, otherwise known by the abbreviation PPACA and other bills such as the Affordable Healthcare Act passed that will have an effect over how healthcare insurance is regulated. How the Medicare Budget is appropriated and how federal dollars for research is distributed also was studied. The PPACA act along with the Affordable Healthcare Act seeks to expand coverage to more of the public while slowing the growth of healthcare costs. These bills proposed various cuts in fee-for-service rates as well as the reformulation of what is billable to Medicare and how often. These new acts attempt to combine many doctors procedures that were once billed to Medicare as separate services. Another of the PPACAs focuses is to expand coverage for those people whose income is above the Medicaid coverage threshold, but is still too low for that person to afford to buy private insurance. The PPACA seeks to insure more people and prevent people from losing their coverage once they qualify for it. What I hoped to learn through the course of the Practicum was how our government tries to meet our needs through the creation of new policies. Of course, our society has only so many resources, through the creation of new policy, some groups will gain and some will lose (Lindblom & Woodhouse, 1993). As the practicum progressed, the truth about public policy was

6 learned first-hand learned first-hand, which Lindblom & Woodhouse refer, analysis rarely can find policies unequivocally good for all (Lindblom & Woodhouse (1993) p. 19). Also as Lindblom and Woodhouse (1993) write Utilitarian, that is, greatest good for the greatest number(p. 20) public policy decisions, are very difficult to achieve, even when there is enough information available to make them, because we always need more than we have been available to fill those needs. Complete healthcare insurance coverage for everyone in our society for as many healthcare services as we would like is one of those needs we as a society could benefit from but do not have enough resources to satisfy. In fact, even providing some people with adequate healthcare coverage for a limited amount of services is becoming difficult. In addition, the publics concern over healthcare costs and healthcare coverage has increased over time. As the costs of insuring oneself has risen and the number of Americans insured has dropped, the publics desire for government intervention has grown. The publics increasing concern over who gets to have healthcare coverage and how much it will cost them has pushed healthcare reform onto the public policy agenda. Over the past two elections, the public has expressed a very strong desire for the government to propose new rules, which would expand healthcare coverage, make it more affordable to the public and lower overall expenditures on Medicare and Medicaid. The publics concern is warranted because without policy intervention by 2015 the total number of uninsured could reach 56 million (Burton, Friedenzohn, & Martinez-Vidal, 2007). Employers, in addition to dropping coverage for employees all together, are making it difficult for them to obtain by tightening eligibility requirements (Burton, et al., 2007). In 2000, the average out of pocket costs that the employee had to pay for family health insurance coverage was 3,354 dollars; the 2008 figure for that same amount of coverage for families was

7 four times that amount (The Kaiser Commission on Medicaid and the Uninsured, 2009). The high cost of healthcare is, in essence, forcing employers and employees to drop their healthcare coverage. Those with private healthcare coverage insurance are losing their coverage the fastest (Haase, 2005). Many employers simply do not offer health insurance coverage to their employees at all. Twenty million US workers do not have employer-based, employer-sponsored or public sponsored health insurance at all (Haase, 2005). They are now called the working uninsured. Finally, thirty-one percent of middle class employees surveyed, would be unable to buy health insurance on their own if their employer decided to drop group coverage (Haase, 2005). The debate over healthcare insurance, healthcare services and the costs of both are a result of our societys limited resources. If medical care and the resources to provide it were abundant, the debate of cost and access would not have surfaced on our national policy agenda. We live in a world of limited resources. This limited supply of resources forces communities to make social choices deciding which persons in that community get which resources (Cochran & Malone, 2005). When scarcity forces the public to make choices with its resources, the public then begins deliberation, so a consensus on who gets what can be formed (Cochran & Malone, 2005). In modern democratic societies, that type of consensus building and resource allocation decision-making is called the public policy process. The public policy processes main task is to develop rules that we as a society can agree on so that some of our more pressing needs are met (Cochran & Malone, 2005). When societies work through the public policy process and agreements on where resources should go, social contracts are then made to enforce those agreements (Cochran & Malone, 2005). These new social contracts are then enforced through laws and governmental regulation.

8 The ethical theory of social contracts is an attempt to explain why societies function the way they do and how our personal interests can be shifted from self-centeredness to empathy (Cochran & Malone, 2005). However, our empathy toward others is tempered by what we want for ourselves and unfortunately; to provide more for others we usually must give up some of what we have to those who want more themselves. The desire to have more than others is played out in how we make policies and because we live in a democracy, our social and economic inequalities are copied right into the political arena (Lindblom & Woodhouse, 1993). In addition, to further complicate resource allocation, many important public tasks are given over to the private sector. This is done in part due to the limited ability of governments to provide for all its citizens needs and for the efficiency it brings to such a society. These private enterprises are composed of companies and the business people who manage them (Lindblom & Woodhouse, 1993). They too have a powerful interest in how we distribute our resources because they profit from their use by the government. Private enterprises would then prefer to yield as much influence as possible over the outcome of any policy that would dictate the distribution of such resources (Lindblom & Woodhouse, 1993). This use of the private sector to distribute healthcare has resulted in a patchwork of regulations, a patchwork of coverage and high costs. In order for the public to accept a redistribution of healthcare resources, the public must agree that the new policies that dictate such re-allocation is are fair and equitable to them, that the new policy is good and profitable for them to accept as law. In addition, good legislation must be grounded in reality in that it can be paid for by the public and not expanded national debt and not increase the national debt (Lindblom & Woodhouse, 1993). Good public policy should not be developed in isolation by those in Iron Triangles (Cochran & Malone, 2005). Iron

9 Triangles are tight knit reciprocal agreements between Congressional staff, special interests groups and the bureaucratic agencies they oversee (Cochran & Malone, 2005). This is because when policy is crafted by Iron Triangles there is a tendency for the finished policy to heavily favor the agencies those in the triangle oversee while neglecting the will of the people (Cochran & Malone, 2005). In addition, when designing a policy, the problem it will address should be accurately defined so that its causal relationships are known (Cochran & Malone, 2005). Once the issues causal relationships are known, then an analysis can be done to understand how a new policy will affect the need it is supposed to address (Cochran & Malone, 2005). In addition, rational analysis should be used as a plan for creating efficient, targeted public policies (Cochran & Malone, 2005). Rational analysis involves a comprehensive review of all of the options available to a policy maker, then reviewing each choice and selecting the alternative that will yield the best overall results (Cochran & Malone, 2005). Good public policy should help as many people as possible within the amount of time available to make the policy decision and with the resources that are available (Lindblom & Woodhouse, 1993). Good public policy should also include diverse viewpoints and should be developed by a coalition, which can take action without the policy becoming too inconsistent (Lindblom & Woodhouse, 1993). Finally, good public policy formulation should not only include the view of the politically active, but those who may not take part in the policy-making agenda, those marginalized and under privileged (Lindblom & Woodhouse, 1993). Thoughtful policy development by policy makers should always include a debate over how our societys resources should be distributed, within the context of the issue the new policy is to address. This debate should include a discussion on equity and equality; what is considered to make up a fair distribution of societys income (Cochran & Malone, 2005). Market economies

10 are an effective means of distributing resources to the public; however, markets generally fail to provide for all our needs because markets are not optimally efficient (Cochran & Malone, 2005).Inefficiencies in market economies result in a supply mix of goods that is different than what we as a society would want to have (Cochran & Malone, 2005). Therefore, as a society we usually support some governmental intervention in the free market, in order to alter the change the supply of goods, to achieve the free market provides an output, an output we are more likely to accept. This redistribution of goods and services reduce the inequalities between people created by the free-market and enhances the publics security or well-being. Moreover, this debate between who gets what and how much of it, occurs in every society each day (Cochran & Malone, 2005). The debate between who gets what reflects the bias of government, which is usually, but not always, a reflection of the publics view of what makes up a fair distribution of income. What a government believes constitutes an efficient, fair distribution of wealth and income can range from a planned economy to a complete laissez-faire environment and income must be decided whether the economy is laissez-faire or planned (Cochran & Malone, 2005). Good policy must promote equality if is to be generally accepted and not compromised (Cochran & Malone, 2005). The debate between the inefficiencies of our own market systems and what we believe is a fair distribution of wealth was played out during the development of the PPACA healthcare reform bill. Cochran and Malone suggest that a policy analyst would most recommend a policy be undertaken if its benefits outweigh its costs (2005). During the 2009-2010 healthcare reform debate, it seemed that earlier government intervention in the private healthcare sector was not enough to slow the healthcare coverage losses and the rapid increases in healthcare service costs. Previous government initiatives were able to expand health coverage for children, seniors and

11 those making some amount above the poverty line; however, these incremental changes over time became unacceptable to our society. A debate between what Cochran and Malone described as, right based lawful entitlement versus claims based on need, (pg. 12) surfaced over healthcare coverage with authoritative actors in the government. This debate over how healthcare resources should be distributed in our society was pushed onto our government public policy agenda. Healthcare reform was advanced onto our institutional agenda through the publics growing concern, intense lobbying and a new window of opportunity. That new window of opportunity for healthcare reform opened up after the 2008 political season. I think that previous incremental healthcare policy reform adjustments were not enough to suppress a larger healthcare debate for longer than a few years at a time. During the 2007 to 2009 recession, such large numbers of employees were losing their jobs and their healthcare coverage that healthcare reform was again pushed to the national level for debate. The debate seemed to be about the costs involved in expanding healthcare to those who have lost it or were not able to afford it and the costs involved in not expanding healthcare to them. The debate included who would be paying for this potential public insurance expansion and the amount of resources that should be transferred from one group to another to offer such services. The debate was between self-interest and social altruism and how much of each was rational in today's economic environment. The public and our governments concern over the rapid increase in healthcare costs as well as the decline in coverage helped push healthcare reform onto our governments public policy agenda. Once our government began to debate a reasonable policy solution to the problem, how to actually address the issue became the topic of debate first. How best to design a policy that would cut healthcare expenses and increase coverage came down to one's ideology;

12 the two most dominantly held in the United States conservatism and liberalism being the dividing line and source or contention (Cochran & Malone, 2005). During the 2009 healthcare reform debate, Congresss views on just how to change the way our private/public healthcare system functions, was a reflection of our nations dominant ideologies; conservative and liberal proposals, limited government versus social equality. Conservative ideology views that the role of government in public life should be kept at a minimum while Liberal ideology favors government intervention in society to mitigate the tendency of the free market to produce large income inequalities (Cochran & Malone, 2005). Conservatives also view the rights of the person as paramount to the role and authority of the government (Cochran & Malone, 2005). They place great value in a persons right to property and limited interference of the government in the free market (Cochran & Malone, 2005). Conservatives stress that a governmental redistribution of wealth from one group of people to another will cut the public incentive to work (Cochran & Malone, 2005). Likewise, conservatives reason that too much involvement in the free market by the government will lead to inefficiencies and lower productivity (Cochran & Malone, 2005). As mentioned, the liberal ideological view, however, favors government intervention in the public to mitigate the tendency, or the free-market to produce very large income inequalities resulting from lack of regulation (Cochran & Malone, 2005). Liberals stress the right to social equality of all citizens (Cochran & Malone, 2005). Liberals view the goal of any new public policy is to extend social and economic benefits not just to those who have, but to those who may not have as much (Cochran & Malone, 2005). Liberals seek to carry out redistributive policies through the transfer of wealth, or benefits from those who have extensive amounts of wealth to those who have much less wealth (Cochran & Malone, 2005). The most used public methods Liberals use to transfer wealth is through the issuance of taxes, the regulating of the

13 market, the regulating of the workplace and through the mandating of insurances such as health, disability, old age benefits and disability benefits (Cochran & Malone, 2005). However, the transfer of wealth from one person to another, or the regulating of markets, requires the government to limit personal liberty, which is at odds with those who are conservative (Cochran & Malone, 2005). Both those with conservative and liberal ideologies in our government debated the development of a public healthcare reform policy, which would be effective, providing the greatest good for the greatest number of people. In order for a final bill to be passed by our government, a majority of our legislation branches the House and the Senate must agree with it. Once our Legislative branch passes the bill our Executive branch must approve it, the President must sign the bill into law. What would make up good healthcare reform and create the greatest good for the greatest number of people was split between the two ideologies. Along the conservative line of ideology that was previously mentioned, conservatives wanted a bill that was targeted in scope and limited in function while liberals wanted significant reform with many new healthcare regulations. Conservatives, in my opinion, wanted a bill that would give consumers more choice in selecting their healthcare coverage, offer a way to subsidies their healthcare choices and offer tax cuts designed to allow employers to better afford to give healthcare benefits to their employees. Liberals, in my opinion, wanted to expand healthcare by expanding public healthcare insurance coverage and by the issuance of new regulations that targeted private healthcare insurance. These new regulations once passed and signed into law will modify how private insurances provide healthcare coverage to their customers. These new regulations also attempt to expand private coverage to those employees who do not have health

14 insurance by issuing penalties to employers who will not extend healthcare coverage to their employees. In order for any healthcare reform to pass and become law, those contrasting ideological viewpoints on what constituted good public healthcare policy needed to be reconciled in our government. However, the debate between the parties and their ideologies became so heated and uncompromising that in order for healthcare reform to be passed, that it had to be forced through by only one party. Through much bartering and debate the result of healthcare reform, a bill of over 900 pages was passed by pushing the policy through Congress by the party which at the time controlled the House, the Senate and the President, the Democratic Party. Unfortunately, because the bill passed with only one party the bill reflected a majority of that partys ideology. The fact that the resulting healthcare reform bill contained many liberal ideological regulations then became a target in the next election by those who are ideologically conservative because it was seen by them as too much governmental intervention into the private sector. The PPACA, the bill that passed into law, will affect each hospital and each state differently due to a variety of factors. These factors including how many of a states residents are already insured, their residents income, the unemployment levels in that state, their residents median age and their residents overall health, but on average charity care cases should go down (Edwards, 2010). The bill also requires the establishment of several pilot programs, which will attempt to bundle payments for post-acute care services (Edwards, 2010). Financing the expansion of public healthcare access will in part come from an increase in Medicare Part A payroll tax from 1.45% to 2.35% and by the adding of a 2.9% assessments on unearned income

15 on taxpayers with incomes above 200,000 for a single person, 250,000 dollars for a couple (Edwards, 2010). The PPACA act in theory is supposed to extend the solvency of Medicare part A until 2029 in contrast to 2017. This assessment is based in part on Medicare cuts in fee-for-services and cuts in medical products reimbursements to the amount of 500 billion as outlined in the act (Rangel, 2010). The PPACA attempts to expand healthcare coverage, expand access to healthcare services and to help keep those who have coverage from losing it. The PPACA rolls out these new provisions over a series of years from 2010 to 2014 (Troutman Sanders LLP, 2010). The PPACA also prevents health insurance companies from denying health coverage for children with pre-existing conditions under the age of nineteen (Troutman Sanders LLP, 2010). In addition, the PPACA eliminates the maximum lifetime benefit. Similarly, under the new act annual cost limits on insurance are not allowed after 2014 (Troutman Sanders LLP, 2010). As of this year, health insurance companies must give written notice if they wish to make significant changes to their plans 60 days before the change goes into effect (Troutman Sanders LLP, 2010). Furthermore, as of this year the PPACA mandates that healthcare insurance companies offer preventive care services and screenings as well as offer a standardized summary of benefits to its members (Troutman Sanders LLP, 2010). The PPACA mandates that by 2014 healthcare service waiting periods cannot be more than 90 days, and total deductibles for services may not exceed 2000 dollars or 4000 as adjusted (Troutman Sanders LLP, 2010). Finally, the PPACA also mandates that employers must offer free choice vouchers as of 2014, while those with 50 or more full time employees must provide mandatory healthcare coverage (Troutman Sanders LLP, 2010).

16 In addition to the PPACA, other healthcare reform laws were passed during my Practicum; these laws were H.R 3590 and H.R. 3962. H.R 3961 was the House docket numbers for the PPACA bill. According to the Henry J. Kaiser Family Foundation (2010), H.R. 3962 adjusts the Medicare physician fee schedule as well as H.R. 3590. These new laws cut Medicare payments to critical care hospitals for excessive hospital re-admissions (The Henry J Kaiser Family Foundation, 2010). H.R. 3962 also directs the Secretary of HHS to develop outline strategies to bundle payments for a variety of services (The Henry J Kaiser Family Foundation, 2009). Therefore, H.R. 3692 attempts to bundle formerly separate service payments for Medicare providers, while H.R 3590 attempts to separate healthcare service categories and decide their payment rates individually, in contrast to formulating one payment rate and applying it to all Medicare service providers (The Henry J Kaiser Family Foundation, 2010). H.R. 3590 covers physician fee changes mostly reductions in service payments, while H.R. 3962 freezes part B payment thresholds at 2010 levels through 2019 (The Henry J Kaiser Family Foundation, 2009; 2010). H.R. 3962 will also phase in changes for Medicare Advantage plans to 100% of fee-for-service costs from 2011 to 2013 with a 1.5% to 3.0% bonus payment to high-quality qualifying plans (The Henry J Kaiser Family Foundation, 2009). Currently, Medicare Advantage plans pay up to 113% of Medicare fee-for-service costs (The Henry J Kaiser Family Foundation, 2009). Added to the cuts proposed by the PPACA act is a separate 23% cut in doctor payments set to occur in November and another second cut of 6% in doctor payments shortly after (Rangel, 2010). The new laws as proposed in H.R 3590, once they take effect, will also reduce payments to hospitals that have excessive re-admissions that could be prevented such as with hospital acquired infections (Rangel, 2010). This bill reduces Medicare DSH payment's by 75%

17 and freezes market basket payments for 2010 for inpatient hospital treatment, home health treatments and skilled nursing facility services (Rangel, 2010). Today, in the United States public policies are made not by presidents or Congress alone, but also indirectly by the public, who through the electoral process appoint their leaders. This project was a practicum and as such certain tasks were assigned to me by the Chief Executive Officer of the cancer advocacy nonprofit. These assigned tasks focused on the interpretation of healthcare policy and the offering of recommendations on those policies to her by myself. Recommendations were suggested to the CEO that offered ways that these new policies either could be used to her constituent's advantage or could be worked around for those negatively impacted by those policies. During this practicum, our federal budgetary process, the National Coalition for Cancer Researchs opinion on the PPACA interim rules on grandfathered health insurance programs, statistics from the NHIS and CDC on the number and mix of those with health insurance, how the PPACA will be funded, and the CBOs cost estimates of healthcare reform were reviewed. In addition, during this practicum various components that make up Medicare insurance, Medicare parts A, B, C, D and Medigap coverage, how Medicare and Medicaid interact with HMO insurance coverage, as well as how contracted HMO Medicare functions, and the pending cuts in Medicare payments to service providers also was studied. Finally, based on the research into healthcare policy undertaken during this practicum, certain actions were recommended for the nonprofit to take which may benefit their constituents. Also recommended to the nonprofit was that lobbying of committee members in Congress who have oversight over clinical research budgets should be undertaken. The CEO was cautioned that the interim provisions on grandfathered health-plans did not contain specifics on pharmaceutical formularies. A detailed outline of who will benefit the greatest from these new

18 healthcare reform laws, those ages 18-35, male and with ethnically diverse backgrounds was submitted to the nonprofit. Also outlined for the CEO was how the new Medicare fee-for service cuts will affect their specialist constituency. Specifically, because of how the Centers of Medicare and Medicaid calculate payment rates, the negative impacts of the new healthcare reform laws will be reduced for those doctors who participate in HMO Medicare. Additionally, a provision in the new PPACA law that establishes the Patient-Centered Outcomes Research Institute was researched. This new institute will have the authority to recommend payment and policy changes to Medicare that will become law, unless specifically repealed by Congress. Finally, I recommended to the CEO to prepare her organization for a provision in the PPACA law, which mandates 1099s to be issued for any transaction totaling 800 dollars or more with any provider of goods or services. Previously, the law only required 1099s to be issued by an organization for services contracted out totaling 800 dollars or more; goods were excluded. The CEO was forewarned that the expansion of 1099 usage mandated by the PPACA would have a negative impact specifically on smaller non-profits due to the additional tax burden imposed by them. Currently, non-profits are seeking an exemption to the expanded use of 1099s the PPACA mandates.

19 Conclusion

From the research conducted during the practicum, it appears that good public policy should be thoughtfully crafted, with as many viewpoints incorporated as possible, targeted, using as little resources as possible, yet however, still able to maximize the benefit to its target. Unfortunately, the passing of the PPACA, the partisanship it took to get the bill passed and the extensive bartering it took to get it passed showed me just how dysfunctional our government is at this time. As mentioned previously, public policy encompasses not just the bill presented on TV or in newspaper reports, but what is beneath the surface as well. Elected officials and appointed professionals work on these policies; they are the people behind the closed doors, which afterward, when they leave the room announce the policy to the public. During this practicum, I learned about past and current healthcare law, healthcare policy and how new law will affect healthcare providers as well as their patients. I learned how bills are developed, the concepts of equity versus equality, consensus building, resource allocation and the ideologies that compete to mold new policy; those being conservatism and liberalism. Finally, what was learned was that we, as a society, must agree on policy in order to get it passed, or perhaps not agree very much at all, but those of one viewpoint must control enough of the government to get policy passed anyway. Unfortunately, it is this tendency not to agree on old policy and new policy that is most troubling to me. This tendency not to agree of course has always been an important part of our political discourse; political discourse is how compromise on policy is accomplished. However, the level of disparity exhibited in Congress in my option has negatively affected the people whose needs I was studying in this practicum.

20 The level of disparity exhibited in our government, in my opinion, has reached a level where in order to get a policy passed and signed into law so much bartering has to take place that the resulting bills grow to an unmanageably complex size. Each bill that was reviewed during this practicum was over 800 pages. These bills do not include the interpretations of the laws which will be written by the bureaucracy that has oversight in implementing and execution them. Such large bills and their subsequent interpretations, in my view, cause immense confusion with those people who feel they will be impacted by the new law. The complexity of the PPACA and the related bills that made up healthcare reform has resulted in scrambling attempts to comply by those people whose needs I was studying in this practicum, healthcare providers and their patients. It has caused providers to redesign their billing procedures without formal rules to apply, potentially violating Medicare billing procedures. It has caused insurance companies to petition HHS and CMS asking how they should go about implementing these new laws so as not to lose grandfathered health status on many of their plans. The PPACA act and its related laws have caused concern among those diagnosed with cancer because they do not know if they will be covered by some procedures that could be considered experimental. Additionally, those patients undergoing cancer treatment now may have to switch from what is considered standard treatments because of pending cuts to Medicare. These issues then place additional stresses on non-profits such as the nonprofit I worked with, because patients want to know how these new laws will affect their treatment and service providers want to know if they will be able to supply a given treatment to them. Such complex bills lead to lengthy regulatory interpretation and much ambiguity. The time spent on interpreting bills over 1000 pages means new points of contention and in my opinion uncertainty by those who will be affected by the law.

21 References

Burton, A., Friedenzohn, I., & Martinez-Vidal, E. (2007). State Strategies to Expand Health Insurance Coverage: Trends and Lessons for Policymakers (Vol. January, pp. 1-27). Commission on a. High Performance Health System. Retrieved from www.cmwf.org. Cochran, C. L., & Malone, E. L. (2005). Public Policy: Perspectives and Choices (3rd ed., p. 512). Colorado: Lynn Rienner. Edwards, R. (2010). Access. Hospitals and Health Networks, 16-19. Chicago. Haase, L. (2005). A New Deal for Health: How to Cover Everyone and Get Medical Costs under Control (pp. 1-71). New York: The Century Foundation, Inc. Lindblom, C., & Woodhouse, E. (1993). The Policy-Making Process. (J. Berrisford, Ed.) (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Rangel, C. (2010). Patient Protection and Affordable Care Act. Public Law (pp. 1-906). Washington, DC: House of Representatives. The Henry J Kaiser Family Foundation.(2009). Summary of Key Medicare Provisions in H.R. 3962, Affordable Health Care for America Act. State Legislatures (Vol. 36, pp. 1-11). Menlo Park. The Henry J Kaiser Family Foundation. (2010). Focus on Health Reform: Summary of Key Medicare Provisions in White House Proposal and House and Senate Health Reform Bills. State Legislatures (Vol. 36, pp. 1-3). Menlo Park. The Kaiser Commission on Medicaid and the Uninsured. (2009). The Uninsured, A Primer: Key Facts About Americans Without Health Insurance (pp. 1-36). Washington, DC: The Henry J. Kaiser Family Foundation. Retrieved from www.kff.org. Troutman Sanders LLP. (2010). Health Care Reform: Plan Design Requirements (pp. 1-8). New York.