ECO561 Week 5 Assignment RubricIndividual Assignment Effec.docx

ECO/561 Week 5 Assignment Rubric
Individual Assignment: Effectiveness of the Counter-Cyclical
PoliciesPurpose of Assignment
This assignment addresses how both monetary and fiscal
policies have been used during the so-called Great Recession,
which began in December 2007 and ended in June 2009, to the
present to moderate the business cycle. Resources Required
Tutorial help on Excel® and Word functions can be found on
the Microsoft® Office website. There are also additional
tutorials via the web offering support for Office
products.Grading Guide
Content
Met
Partially Met
Not Met
Comments:
Selected an industry that suffered heavy losses during the Great
Recession and produced an Excel® Workbook including the
following data from December 2007 to the present:
· One dataset related to the U.S. housing industry such as
housing starts, the FHFA housing price index, or another dataset
of your choice related to the housing market.
· One dataset related to personal or household income or to
personal or household saving.
· One dataset related to the labor market such as the
unemployment rate, initial claims for unemployment insurance,
or another dataset of your choice related to the U.S. labor force.
· One dataset related to production and business activity within

the market or industry you choose to analyze.
15 points
Using data results analyzed the economic and sociological
forces that drove the market equilibrium to unsustainable
heights, commonly referred to as "bubbles," and the shocks that
brought the markets back down.
10 points
Discussed specific changes in supply and demand within the
markets and/or industries you chose to analyze.
10 points
Determined whether specialization of industry had any
influence on the impact of the recession. 10 points
Examined prior government policies and legislation that might
have exacerbated the impact of the shocks. Also, discuss
government actions/regulations that might be undertaken, and/or
have been undertaken, to moderate the effects of extreme
economic fluctuations. 15 points

Evaluated the actions of the federal government (fiscal policy)
and the Federal Reserve (monetary policy) to restore the
economy and foster economic growth. Based your evaluation on
information available at Internet sources such as, but not
limited to, the Fed's The Economy Crisis and Response website
as well as other appropriate sources found on the Internet and in
the University Library. You did address the effectiveness of
those counter-cyclical policies. 20 points
The analysis is a minimum of 1,050 words in length. 5 points
Total Available
Total Earned
85
#/85
Writing Guidelines
Met
Partially Met
Not Met
Comments:
The paper—including tables and graphs, headings, title page,
and reference page—is consistent with APA formatting

guidelines and meets course-level requirements. 10 points
Intellectual property is recognized with in-text citations and a
reference page. 10 points
Paragraph and sentence transitions are present, logical, and
maintain the flow throughout the paper. 5 points
Sentences are complete, clear, and concise.
5 points
Rules of grammar and usage are followed including spelling and
punctuation. 5 points
Total Available
Total Earned

35
#/35
Assignment Total
#
120
#/120
Additional comments:
SYSTEMS-LEVEL QUALITY IMPROVEMENT
Opportunities and Accountable Care Organizations
Julie Babyar1
Received: 12 September 2016 /Accepted: 21 September 2016
# Springer Science+Business Media New York 2016
As new health systems realize new policy and structure in the
United States, opportunities for redesign are abundant.
Accountable Care Organization models are part of this rede-
sign. Recent research has provided insight into coordinated
healthcare prior to the Affordable Care Act, and ongoing re-
search strives to capture opportunities for cost containment
and quality improvement. Studies also work to identify pro-
grams and policies that are ineffective at quality improvement
and patient care delivery as well as detect ones that do not
result in cost effective care. While ongoing service delivery
research is necessary to continually identify best practice for
care delivery models and financial incentives, there are many
opportunities to refresh outdated professional norms. The cur-

rent climate surrounding Accountable Care Organizations
provides a clean slate and fresh potential in medical education
and health systems research.
Under the Affordable Care Act, new regulations allow hos-
pitals, healthcare providers and doctors to better coordinate
care for Medicare patients through Accountable Care
Organizations (ACOs). Under a specific program adminis-
tered by Medicare, ACOs are rewarded when they meet
Bquality’ performance standards and lower healthcare cost
growth. In voluntary ACO participation, measures are report-
ed through clinical quality reports and patient experience sur-
veys. ACOs must manage 5000 Medicare beneficiaries for at
least 3 years. Claims data are used to calculate measures in
order to reduce administration burden. ACOs pay for the
survey and reporting through CMS certified vendors. ACOs
are scored on a point system for each measure and then deter-
mine sharing rate [1]. As of December 2015, there were 782
ACOs covering 23 million persons [2].
Original pilot programs assisted in initial insight, and these
included the Medicare Pioneer Program. The Pioneer Program
consisted of 20 ACOs and 333 Shared Savings initiatives, in
which $411 million savings was generated but $2.6 million of
a trust fund was lost. Still, quality and cost measures were
overall viewed as favorably improved for ACOs as compared
to other healthcare organizations [3]. While specifics in defi-
nition of ACOs continue to evolve, and design of ACOs are
individually tailored, measures are standardized and specifi-
cally calculated on a point system [3]. The Department of
Health and Human Services’ goal by 2018 is to have 50 %
of Medicare payments to be tied to quality or value through
new payment models [1].
The assessment of ACOs for shared savings qualifications

includes 33 required quality measures that fall under four do-
mains: patient and caregiver experience, preventative health
measurements, care coordination and patient safety and iden-
tifying at-risk populations. This structure is similar to previous
managed care incentives designed decades ago. The differ-
ence in new structures under new shared savings models is
that responsibility for these measures is not under the payer,
rather it is the responsibility of the provider. While some
ACOs consist of provider groups without external manage-
ment, newer strategies incorporate ACOs as part of hospital
investments [4]. Because the design of ACO models will in-
creasingly incorporate multiple players, under the ultimate
responsibility of the provider, it is imperative that medical
education and training shift accordingly.
Decades of managed care and reimbursement models have
encouraged financial and administrative provider knowledge.
Increasingly, care coordination, quality metrics and health
This article is part of the Topical Collection on Systems-Level
Quality
Improvement
* Julie Babyar
[email protected]
1 Hermosa Beach, CA, USA
J Med Syst (2016) 40:248
DOI 10.1007/s10916-016-0625-z
systems research are core components of medicine. As such,
medical education redesign initiatives should incorporate
these concepts in development of ideal team players in
medicine.

Current research on ACOs is published by many profes-
sionals originating from many schools of health and policy. In
a literature search and review through PubMed, 27 observa-
tional or experimental studies were returned on the subject of
Accountable Care Organizations and outcomes. The majority
of these studies listed a medical doctor as a contributing au-
thor. Recognition that clinical analytics and metrics are in-
creasingly tied to payments has led to new physician leader-
ship in healthcare organizations. Quality and patient safety
have grown as distinctive in educational offerings. While
unique positions assist in organization focus on quality, new
responsibilities on providers, including public reporting, set
the tone that places all clinicians at the forefront of this culture
change. Organizational support to clinicians and medical stu-
dents will assist in foundational build.
Evidence based practice and clinical analytic interpreta-
tions will strengthen as a result of this transformation.
Current literature is consistent in approach, aware of limita-
tions and acknowledges future need for ongoing research.
Literature is inconsistent on findings regarding ACOs and
utilization as well as inconsistent on specifics of quality mea-
sure improvement. Cost savings has also been reported in
multiple reports and studies on Accountable Care
Organizations.
Research and implications
Accountable Care Organizations hold promise in addressing
current healthcare challenges. One such challenge is behav-
ioral health, an area of healthcare consisting of unmet needs in
which improvement opportunities are clear. Behavioral health
can be measured with feasibility. Current measures on
readmissions involve emergency department assistance in be-
havioral health data analytics. A recent study reported that

Pioneer ACO contracts demonstrated lower spending on men-
tal health admissions, while other ACOs have not realized
success in mental health spending changes, diagnoses or
readmissions. Many ACOs have not yet focused on mental
illness altogether [5]. An integrated academic medical center
in California instituted behavioral health care as part of ACO
care and realized a three-fold increase in behavioral patient
population served as well as 13 % reduction in ED use [6].
Opportunities in sustainable reimbursement favor systematic
and replicated design. Behavioral health care coordination
involving these changes is not just a concern for behavioral
health providers; rather, it is part of integrated care all
providers should have familiarity on. This comes not just
with current basic understanding in medical education but
with quality, metrics and clinical analytic comfort
cemented through culture change in all medical training.
Vulnerable and disadvantaged populations are another
challenge in current healthcare. Early analyses indicate
ACOs are concentrated away from disadvantaged popula-
tions, potentially widening health inequities [7]. A potential
solution and strategy to mitigate these effects, as well as real-
ize health equity, may also involve ACO structures for vulner-
able and disadvantaged populations. One large safety net
Accountable Care Organization applied to Medicaid patients
in Minnesota realized financial savings through a model that
reduced emergency department utilization, increased preven-
tative visit utilization and redistribute funds. Patient satisfac-
tion scores are high with this Medicaid ACO model, a model
that has also increased patient outcomes in optimal care [8].
Replication of this system alongside incorporation of required
medical student participation, education in clinical analytics
and process improvement would encourage the systems cul-
ture change necessary for future model sustainability.

ACOs have also demonstrated success with pediatric pop-
ulations. One study found that the duration of ACO use was
associated with utilization differences in pediatric Medicaid
populations. Continuous attribution to the ACO, for more than
2 years, was associated with a decrease in inpatient days but
increase in office visits [9]. An Ohio program demonstrated
that costs were lower and grew slower in association to a
pediatric ACO, with mixed quality measure outcomes.
Specifically, quality measures improved in 5 categories,
declined in 3 and remained consistent in others over the
years [10]. This same program demonstrated that provid-
er incentives produce mixed results among ACO versus
non ACO performance [11].
Given that ACO agenda is derived from Medicare admin-
istration with Medicaid involvement, pediatric perspective is
imperative. As most physicians in the country accept
Medicare and Medicaid, medical education reform with new
and changing Accountable Care Organization models is
logical.
Clinical outcome research on Accountable Care
Organizations is growing. By studying nondiscretionary ca-
rotid and coronary imaging and procedure codes, researchers
found no difference in utilization of discretionary or nondis-
cretionary cardiovascular care among Accountable Care
Organization patients and matched controls [12].
Opportunities in payment reform can address imaging utiliza-
tion and hospital readmissions through physician leadership,
which can positively affect oncology care [13]. End Stage
Renal Disease patients have coordinated care and structured
payment initiatives already in place, and some authors argue
that ACO options may not benefit ESRD population care in
the same manner as the general Medicare population [14].
Still, opportunities for better care coordination, including in
addressing comorbidities [14], offer the flexibility of ACO

248 Page 2 of 3 J Med Syst (2016) 40:248
design and subsequent research on clinical outcomes and
different, smaller and scattered risk pools. The develop-
ment of measures for clinical care must involve medical
direction and leadership, as demonstrated in recent model
development of risk-standardized acute admission rates
(RSAARs) for patients with diabetes and heart failure
[15]. Efforts to analyze and create future ACO recommen-
dations based on cost effective care and financial projec-
tions will ultimately be compared to, and shaped by, clin-
ical outcomes. Clinical outcome research can be resource
intensive, but investments in high impact research through
clinical analytics can provide great return. To shape this
research and analytical structure, medical provider educa-
tion, training and support is crucial.
Conclusion
In conclusion, the opportunities for optimal population health
with Accountable Care Organizations are abundant.
Flexibility in design, accompanied by research and data ana-
lytics, has potential to optimize cost effectiveness, utilization,
patient satisfaction and quality. Unlike previous financial
modeling in managed care, providers are at the helm of lead-
ership in accountable care. Never has there been a better time
for education, training and positive culture change in provider
instruction on behalf of metrics and analytics research. The
highest impact research shaped through genuine and system-
atic involvement of all providers will transform care coordi-
nation and accountable care.
Compliance with ethical standards

Conflict of interest Author declares that she has no conflict of
interest.
Human and animal rights This article does not contain any
studies
with human participants or animals performed by any of the
authors.
References
1. Centers for Medicare and Medicaid Services., Improving
quality of
care for medicare patients: accountable care organizations.
https://www.cms.gov/medicare/medicare-fee-for-service-
payment/sharedsavingsprogram/downloads/aco_quality_
factsheet_icn907407.pdf. Published 2016. Accessed August 21,
2016, 2016.
2. Muhlestein, D., Gardner, P., Caughey, W., De Lisle, K.,
Projected
growth. Leavitt Partners. 2015.
3. Gold, J., Accountable Care Organizations Explained. Kaiser
Health
News. http://khn.org/news/aco-accountable-care-organization-
faq/.
Published 2015. Accessed August 19, 2016. 2015.
4. Koury, C., Iannaccone, L., Strunk, A., et al., The accountable
care
organization summit: a white paper on findings, outcomes, and
challenges. Hosp Top. 92(2):44–57, 2014. doi:10.1080
/00185868.2014.906839.

5. Busch, A.B., Huskamp, H.A., and Mcwilliams, J.M., Early
efforts
by Medicare accountable care organizations have limited effect
on
mental illness care and management. Health Aff. 35(7):1247–
1256,
2016. doi:10.1377/hlthaff.2015.1669.
6. Clarke, R.M.A., Jeffrey, J., Grossman, M., Strouse, T., and
Skootsky, S.A., Delivering on accountable care: lessons from a
behavioral health program to improve access and outcomes.
Health Aff . 35(8):1487–1493, 2016. doi:10.1377
/hlthaff.2015.1263.
7. Yasaitis, L.C., Pajerowski, W., Polsky, D., et al., Physicians’
partic-
ipation in ACOs is lower in places with vulnerable populations
than
in more affluent communities. Health Aff. 35(8):1382–1390,
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doi:10.1377/hlthaff.2015.1635.
8. Sandberg, S.F., Erikson, C., Owen, R., et al., Hennepin
health: a
safety-net accountable care organization for the expanded
Medicaid
population. Health Aff. 33(11):1975–1984, 2014. doi:10.1377
/hlthaff.2014.0648.
9. Christensen, E.W., and Payne, N.R., Effect of attribution
length on
the use and cost of health Care for a Pediatric Medicaid
Accountable Care Organization. JAMA Pediatr, 2016.
doi:10.1001/jamapediatrics.2015.3446.
10. Kelleher, K.J., Cooper, J., Deans, K., et al., Cost saving and

quality
of Care in a Pediatric Accountable Care Organization.
Pediatrics.
135(3), 2015. doi:10.1542/peds.2014-2725.
11. Gleeson, S., Kelleher, K., and Gardner, W., Evaluating a
pay-for-
performance program for Medicaid children in an accountable
care
organization. JAMA Pediatr. 170(3):259–266, 2016.
doi:10.1001
/jamapediatrics.2015.3809.
12. Colla, C.H., Goodney, P.P., Lewis, V.A., Nallamothu, B.K.,
Gottlieb, D.J., and Meara, E., Implementation of a pilot
accountable
care organization payment model and the use of discretionary
and
nondiscretionary cardiovascular care. Circulation. 130:1954–
1961,
2014. doi:10.1161/CIRCULATIONAHA.114.011470.
13. Apte, S., and Patel, K., Payment reform: unprecedented and
evolv-
ing impact on gynecologic oncology. Front Oncol. 6:84, 2016.
doi:10.3389/fonc.2016.00084.
14. Pauly, M.V., Accountable care organizations and kidney
disease
care. Am J Kidney Dis. 60(4):524–529, 2012. doi:10.1053/j.
ajkd.2012.05.019.
15. Spatz, E., Lipska, K., Dai, Y., et al., Risk-standardized
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J Med Syst (2016) 40:248 Page 3 of 3 248
Journal of Medical Systems is a copyright of Springer, 2016.
All Rights Reserved.
T h r e e W o r d s a n d t h e F u t u r e
o f t h e A f f o r d a b l e C a r e A c t
N ic h o la s B a g le y
University of Michigan
Editor’s Note: JHPPL has started an ACA Scholar-Practitioner
Network
(ASPN). The ASPN assembles people o f different backgrounds
(practi-
tioners, stakeholders, and researchers) involved in state-level
health
reform implementation across the United States. The newly
developed
ASPN website documents ACA implementation research
projects to assist
policy makers, researchers, and journalists in identifying and
integrating
scholarly work on state-level implementation o f the ACA. I f
you would like
your work included on the ASPN website, please contact web
coordina-
tor Phillip Singer at [email protected] You can visit the site at

//ssascholars. uchicago. edu/jhppl/.
JHPPL seeks to bring this important and timely work to the fore
in
Report on Health Reform Implementation, a recurring special
section.
Thanks to funding from the Robert Wood Johnson Foundation,
all essays
in the section are published open access.
— Colleen M. Grogan
A bstract As an essential part of its effort to achieve near
universal coverage, the
Affordable Care Act (ACA) extends sizable tax credits to most
people who buy
insurance on the newly established health care exchanges. Yet
several lawsuits have
been filed challenging the availability of those tax credits in the
thirty-four states that
refused to set up their own exchanges. The lawsuits are
premised on a strained inter-
pretation of the ACA that, if accepted, would make a hash of
other provisions of the
statute and undermine its effort to extend coverage to the
uninsured. The courts should
reject this latest effort to dismantle a critical feature of the
ACA.
Journal o f Health Politics, Policy and Law, Vol. 40, No. 3,
June 2015
DOI 10.1215/03616878-286788 i © 2015 by Duke University
Press
590 Journal o f Health Politics, Policy and Law

K e y w o r d s Affordable Care Act, exchanges, tax credits,
statutory interpretation,
Halbig, King
Put yourself in the shoes of my kids’ piano teacher. She’s got a
part-time job
accompanying music students at the University of Michigan and
stitches
together the rest of her modest income from teaching and
performing at
church services, weddings, funerals, and the like. She doesn’t
get health
coverage through the university— she only works part-time—
nor is she so
poor that she can go on Medicaid.
Instead, she has to find coverage on the private market. Before
the
Affordable Care Act (ACA), however, private coverage was out
of reach
for her. Even without a preexisting condition, she couldn’t
afford to pay
thousands of dollars for an individual health plan. She was
barely scraping
by as it was.
To help people like my kids’ piano teacher, the ACA extends
tax credits
to anyone earning between one and four times the poverty level
who buys a
qualified health plan (26 U.S.C. § 36B(c)(l)(A)), so long as the
individual is
ineligible for Medicaid and doesn't have access to employer-
sponsored
coverage. The tax credits are substantial, averaging about

$2,890 per
person (Levitt, Claxton, and Damico 2014). And they are an
essential part
of the ACA’s effort to achieve what the statute calls “near-
universal cov-
erage” (42 U.S.C. § 18091(2)(D)).
As Jonathan H. Adler and Michael F. Cannon read the ACA,
however,
my kids’ piano teacher can’t get tax credits at all. Nor should
roughly 9.5
million other people scattered throughout the country (Levitt
and Claxton
2014). In their view— a view endorsed by a panel of the D.C.
Circuit
(Halbig v. Burwell, 758 F.3d 390 (D.C. Cir. 2014))— the ACA
instead
armed hostile state governments to thwart the ACA’s effort to
cover the
uninsured. Their contention has assumed new urgency now that
the Supreme
Court has agreed to resolve the statutory dispute in King v.
Burwell.
Yet Adler and Cannon fail to offer persuasive reasons to adopt
their
peculiar interpretation of the ACA. To the contrary, the
government’s
alternative reading makes much better sense of the statute as a
whole and
avoids assigning a meaning to the ACA that is blatantly at odds
with what
the statute aims to accomplish.
The Supposed Glitch

To better organize the individual and small-group insurance
markets,
section 1311 of the ACA instructs the states to establish health
care
B a g le y ■ R e p o r t o n H e a lt h R e f o r m I m p l e m
e n t a t i o n 5 9 1
exchanges. From the consumer’s perspective, the exchanges are
just web-
sites that allow for the easy comparison of health plans sold in a
particular
area. The hope is that the exchanges will enable price and
quality com-
petition in an unruly insurance market.
Congress anticipated that the states would welcome the
opportunity to
establish their own exchanges (Pear 2 0 12). Better to retain
state control
over health insurers than cede that authority to the federal
government.
Nonetheless, Congress recognized that not every state might
wish to
establish an exchange. In states that declined to do so, section
1321 of
the ACA tells the secretary of the US Department of Health and
Human
Services (HHS) to “establish and operate” the state’s exchange.
As it happened, the choice of whether to establish an exchange
got
caught up in the political furor over Obamacare. For the thirty-
four states

that refused to establish exchanges, the federal government had
to shoulder
the unexpected burden of setting up the exchanges.
In Adler and Cannon’s (2011) telling, that’s where the ACA’s
supposed
“glitch” comes in. The provision of the ACA governing the
calculation of
tax credits links the amount of the credit to the price of a health
plan
purchased on “an Exchange established by the State under
1311” (26
U.S.C. § 36B(b)(2)(A)). But what about people living in states
whose
exchanges were established by the federal government? Literal
adherence
to the statutory formula would suggest that subsidies aren’t
available on
those exchanges. My kids’ piano teacher would be out of luck.
The Obama administration isn’t buying this interpretation of the
stat-
ute. In 2012 the Internal Revenue Service (IRS) issued a rule
extending
tax credits to eligible individuals, whether or not their state
established
an exchange. That rule has now been challenged in four separate
lawsuits.
As Adler and Cannon see it, the rule ought to be struck down
because
it’s inconsistent with the ACA. If they’re right, tax credits that
millions
of people now depend on to buy health insurance would
evaporate.
To make their case, however, it’s not enough for Adler and

Cannon
to show that it’s possible to read the ACA as withdrawing tax
credits from
refusal states. If the statute is ambiguous on that point, it’s
black-letter
law that the courts must defer to the IRS’s authoritative
interpretation
(Chevron U.S.A. v. Natural Res. Def. Council, 467 U.S. 837
(1984)). Adler
and Cannon instead have to demonstrate that the statute
unambiguously
withdraws tax credits from people in refusal states— and that
the IRS’s
contrary interpretation is downright unreasonable. They haven’t
come close
to making such a demonstration.
The Statutory Text
When the federal government sets up an exchange on a state’s
behalf, it
does not create some sort of federal exchange. Rather, it creates
a state
exchange. The text of the ACA is crisp on this point. Recall that
section
1311 instructs states to establish their own exchanges. Under
section 1321,
when a state fails to set up the “required Exchange” — which is
to say, a
state exchange under section 1311— the secretary of HHS must
“establish
and operate such Exchange within the State” (my emphasis).

In other words, the backup exchange isn’t established under
section
1321. It is established under section 1311, just as the provision
authoriz-
ing tax credits requires. The secretary merely stands in the
shoes of state
officials in setting up their states’ exchanges. Any exchange
that the sec-
retary establishes is the legal and functional equivalent of a
state exchange.
Adler and Cannon seem to acknowledge the force of this
argument, as
did the D.C. Circuit panel that invalidated the IRS rule. They
nonetheless
resist the implication that tax credits are available in states with
federally
established exchanges. Their argument hinges on the claim that
Congress
linked tax credits to exchanges “established by the State under
1311” (my
emphasis). Yes, they seem to say, a federally established
exchange may be
established “under 1311.” But they maintain that Congress used
those
three words— “by the State” — to signal that tax credits would
be unavail-
able on federally established exchanges.
Reading the statute as a whole, however, it quickly becomes
apparent
that Congress never meant those three words to bear the
immense weight
that Adler and Cannon would assign to them. In several places
in the ACA,

Congress used similar “Exchange established by the State”
language to
refer generally to exchanges— including federally established
exchanges.
If that’s so elsewhere in the statute, then why not in the
provision governing
the calculation of tax credits?
Most obviously, the ACA limits who can buy insurance on an
exchange
to those who “resid[e] in the State that established the
Exchange” (42
U.S.C. § 18032(f)(1)(A)).If Adler and Cannon were correct that
Congress
scrupulously distinguished between state-established exchanges
and
exchanges in general, then no one in a state with a federally
established
exchange could go on that exchange to buy a health plan. As the
D.C.
district court put it, “The federal Exchanges would have no
customers,
and no purpose” (Halbig v. Sebelius, No. 13-0623 (D.D.C.
2014)). Adler
and Cannon claim that the limitation on the exchange’s
customers is
“moot” because it appears in a provision governing state
exchanges, not in
e n t a t i o n 5 9 3
the provision governing federally established exchanges. But
federally

established exchanges are state exchanges. And Congress could
not pos-
sibly have meant for those federally established exchanges to be
an empty
gesture.
Elsewhere, the ACA says that states have to maintain their
Medicaid
eligibility standards until “an Exchange established by the
State” is up and
running (42 U.S.C. § 1396a(gg)( 1)). This maintenance-of-effort
provision
was meant to provide stopgap protection for Medicaid
beneficiaries until
the exchanges went live. On Adler and Cannon’s telling,
however, it would
forbid a state that declined to establish an exchange from ever
relaxing its
Medicaid standards. There is zero evidence that Congress meant
the ACA
to freeze state Medicaid programs into perpetuity.
Brushing past these statutory signals, Adler and Cannon aver
that the
phrase “established by the State” appears in a number of places
in the act.
But it doesn't matter how many times Congress used the phrase.
The
question is what Congress meant by the phrase. Its repetition is
perfectly
consistent with the view that Congress— anticipating that
nearly all the
states would establish exchanges— just meant to refer to
exchanges in
general. At a minimum, Congress’s slipshod use of the “by the
State”

language gives rise to ambiguity as to what Congress meant by
it. And
when there’s ambiguity about federal taxes, it’s up to the IRS to
resolve that
ambiguity.
Adler and Cannon nonetheless insist that Congress meant the
“by the
State” language in the tax-credit calculation to serve some
distinct pur-
pose. What purpose do they have in mind? As they see it,
Congress with-
held tax credits from states that declined to create their own
exchanges in
order to goad them into establishing exchanges. Congress was
making a
threat: set up your own exchanges or you’ll lose out on tax
credits.
This claim is quite implausible. To begin with, Congress knows
how to
threaten states with financial consequences when it wants to.
Adler and
Cannon demonstrate as much by identifying a number of other
bills— not
the ACA— that contain clear language conditioning federal
money on
certain forms of state compliance. The absence of any such
clear language
in the ACA is powerful evidence that Congress never meant the
availability
of tax credits to depend on whether a state established an
exchange. After
all, there was no need to bully the states into doing what
everyone assumed
they would gladly do.

More to the point, threats must be communicated. When Vito
Corleone
made the proverbial offer that can’t be refused, he didn’t just
say “sign the
contract.” He had Luca Brasi hold a gun to the head of a guy
and “assured
him that either his brains or his signature would be on the
contract.”
Without the gun, there’s no threat (Bagley 2014). In the ACA,
however, the
threat that Congress supposedly meant to level was so well
hidden that the
states never noticed it. A careful report from the Georgetown
University
Health Policy Institute, documenting what states knew and when
they knew
it, has found no contemporaneous evidence that the availability
of tax
credits played a role in state decisions over whether to establish
exchanges
(Dash, Monahan, and Lucia 2013; Monahan 2014). How can
Adler and
Cannon say that Congress unambiguously threatened the states
if the states
never got the message?
Their reading is anomalous for another reason. In the absence of
tax
credits on federally established exchanges, many healthy people
would

forgo coverage. Those with serious health problems, however,
would likely
remain in the market. The risk pools for exchange plans would
become
skewed toward sicker enrollees, which would in turn increase
the cost of
exchange plans. As costs went up, relatively healthy people
would decline
insurance, leading to sicker risk pools and even higher prices,
which would
drive away still more healthy people. In short, the exchanges
would stop
working. As a just-released study from the RAND Corporation
explains,
“If the ACA’s subsidies are eliminated entirely, our model
predicts a near
death spiral— that is, sharp premium increases and drastic
enrollment
declines in the individual market” (Eibner and Saltzman 2014:
25). Why
construe the ACA to create dysfunctional exchanges when an
alternative
reading would avoid that result?
Legislative In te n t
If Congress did mean to use the three words to threaten the
states, it should
be easy to find evidence of that threat in the legislative record.
Yet there
is none. Adler and Cannon themselves prove the point. Over the
past
few years, they’ve worked tirelessly to sift through the
legislative record,
attentive for any hint that might support their preferred
interpretation. Yet

they’ve found nothing.
Take, for example, the letter they discuss from the eleven Texas
Democrats in the House of Representatives. In the letter, the
Democratic
legislators implored the president not to give the states the
power to cre-
ate their own exchanges. “In Texas,” they explained, “we know
from expe-
rience that the dangers to the uninsured from greater state
authority are
real” (Doggett 2010). Better by far, the legislators argued, to
establish a
national exchange— one that Texas officials couldn’t interfere
with.
e n t a t i o n 5 9 5
Adler and Cannon assert that the legislators were voicing
concerns that
Texas citizens might not get tax credits. Yet the letter says not
one word
about tax credits. Not one. The absence of any mention of tax
credits is the
dog that didn’t bark in the night— a clue that the legislators had
no inkling
of any supposed threat. The legislators were voicing concerns
about
“obstruction” from Texas officials, not about the loss of tax
credits from
the federal government. And they were right to be worried.
Texas not only
declined to establish its own exchange. It also announced that it

wouldn’t
enforce the ACA’s insurance rules (Luthra 2013), imposed
onerous training
requirements on the navigators who help people buy insurance
(Aaronson
2014), and refused to expand Medicaid (Ramshaw 2012).
What else do Adler and Cannon point to? After the ACA was
signed into
law, the House of Representatives passed the Reconciliation Act
to make a
few changes. Among those changes, the House clarified that
territories
were to be treated as states if they chose to establish exchanges.
“It strains
credulity,” Adler and Cannon assert in an amicus brief they
submitted to the
D.C. Circuit, “that Congress . . . would notice and remedy the
bill’s failure
to authorize [tax credits] in territorial Exchanges, but would not
notice its
failure to authorize them in federal Exchanges” (Brief of Amici
Curiae
Jonathan H. Adler and Michael F. Cannon, Halbig v. Burwell,
No. 14-5018
(D.C. Cir. 2014)). But it doesn’t strain credulity at all. It’s only
natural
that Congress wouldn’t notice— much less assign significance
to— three
innocuous words in a dense, hard-to-follow statutory formula.
What is
truly inconceivable is that Congress would extend tax credits to
territorial
exchanges but— without so much as a whisper— deliberately
refuse to
extend them to federal exchanges.

Finally, Adler and Cannon trace the drafting history of the ACA
in an
effort to support their view that Congress meant that three-word
phrase,
“by the State,” to do important work. All they demonstrate,
however, is
that Congress kept using the phrase during the frantic
negotiations over the
ACA. At the time, however, everyone thought that the
exchanges would
be established by the states. Not a shred of evidence supports
Adler
and Cannon’s conjecture that “Senate leaders and White House
officials”
engineered the insertion of the phrase in the tax-credit
calculation in order
to strip tax credits from the citizens of refusal states.
I could go on. I ’ve made my point, however. In poring through
the
legislative history, Adler and Cannon have committed the
cardinal sin of
looking over a crowd to pick out their friends. Only here, they
have no
friends.
5 9 6 J o u rn a l o f H e a lth P o litic s , P o lic y a n d L a
w
Conclusion
Adler and Cannon have offered a strained interpretation of the
ACA that,

if accepted, would make a hash of other provisions of the
statute and
undermine its stated purpose of extending insurance to nearly
all Ameri-
cans. The more natural reading— one that makes far better
sense of the
statute as a whole— is that tax credits are available in both the
states
that established exchanges and those that did not. On this view,
the “by the
State” language just reflects Congress’s assumption,
unchallenged at the
time, that the states would establish their own exchanges.
But even if you think that Adler and Cannon’s claim is
plausible, maybe
even attractive, the contrary interpretation offered by the
government is
at least reasonable. That brings me to the aspect of their
argument that
troubles me the most: their unyielding conviction that they’ve
identified
the only possible construction of the ACA. Nowhere do they so
much as
acknowledge the possibility that maybe, just maybe, they’re
wrong.
That’s because they can’t admit to doubt. Because of the
deference extended
to agency interpretation, doubt means they lose. But their
unwillingness
even to acknowledge ambiguity reflects an important difference
between
legal advocacy and neutral interpretation. To be clear, Adler
and Cannon
deserve immense credit for their lawyerly ingenuity: they’ve

constructed
a facially plausible argument in support of an exceedingly
strange inter-
pretation of the ACA. But the courts would violate their
obligation of
fidelity in statutory construction if they mistook that ingenuity
for genuine
obeisance to congressional will. The latest challenge to the
ACA is polit-
ical activism masquerading as statutory restraint.
Nicholas Bagley is assistant professor o f la w a t th e U n ive
rsity o f M ic h ig a n Law
School. He teaches and w rite s in th e areas o f h e a lth law
, a d m in is tra tiv e law , and
re g u la to ry th e o ry . His w o r k has a p p e a re d in th e
Harvard Law Review, th e Columbia
Law Review, th e New England Journal o f Medicine, a nd th is
jo u rn a l. P rio r to jo in in g
th e fa c u lty a t M ic h ig a n , he w as an a tto rn e y w it h
th e A p p e lla te S ta ff in th e Civil
D ivision a t th e US D e p a rtm e n t o f Justice. He h olds a
JD fr o m N ew Y o rk U n ive rsity
Law School.
B a g l e y ■ R e p o r t o n H e a l t h R e f o r m I m p l e m
e n t a t i o n 5 9 7
R e f e r e n c e s
Aaronson, Becca. 2014. “Texas Finalizes Rules for Health Care

Navigators.” Texas
Tribune, January 21.
Adler, Jonathan H.. and Michael F. Cannon. 2011. “Another
ObamaCare Glitch.” Wall
Street Journal, November 16.
Bagley, Nicholas. 2014. “Halbig Said It Was Applying the Law
as Written: Don’t
Believe It.” Incidental Economist (blog), July 23.
theincidentaleconomist.com
/wordpress/halbig-said-it-was-applying-the-law-as-written-dont-
believe-it.
Dash, Sarah, Christine Monahan, and Kevin Lucia. 2013.
“Implementing the
Affordable Care Act: State Decisions about Health Insurance
Exchange Estab-
lishment.” Washington, DC: Center on Health Insurance
Reforms, Georgetown
University Health Policy Institute,
georgetown.box.com/shared/static/pfmjd22ofj
03z7qes8w3.pdf.
Doggett, Lloyd. 2010. “U.S. Rep. Doggett: Settling for Second-
Rate Health Care
Doesn’t Serve Texans.” My Harlingen News, January 11.
Eibner, Christine, and Evan Saltzman. 2014. “Assessing
Alternative Modifications to
the Affordable Care Act: Impact on Individual Market
Premiums and Insurance
Coverage.” Santa Monica, CA: RAND,
www.rand.org/content/dam/rand/pubs
/research_reports/RR700/RR708/RAND_RR708.pdf.

Levitt, Larry, and Gary Claxton. 2014. "The Potential Side
Effects of Halbig.” Henry
.1. Kaiser Family Foundation, July 31. kff.org/health-
reform/perspective/the
-potential-side-effects-of-halbig.
Levitt, Larry, Gary Claxton, and Anthony Damico. 2014. “How
Much Financial
Assistance Are People Receiving under the Affordable Care
Act?” Henry J. Kaiser
Family Foundation, March 27. kff.org/health-reform/issue-
brief/how-much-financial
-assistance-are-people-receiving-under-the-affordable-care-act.
Luthra, Shefali. 2013. “States to Feds: We Won’t Enforce
Insurance Reforms.” Texas
Tribune, August 7.
Monahan, Christine. 2014. “Halbig v. Sebelius and State
Motivations to Opt for
Federally Run Exchanges.” CHIRblog, Center on Health
Insurance Reforms,
Georgetown University Health Policy Institute, February. 11.
chirblog.org/halbig
-v-sebelius-and-state-motivations-to-opt-for-federally-run-
exchanges.
Pear, Robert. 2012. “ U.S. Officials Brace for Huge Task of
Operating Health
Exchanges.” New York Times, August 4.
Ramshaw, Emily. 2012. “Perry: TX Won’t Implement Key
Elements of Health
Reform.” Texas Tribune, July 9.

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Op-Ed

Health Care Reform and the American
Congress
S E N AT O R D AV E D U R E N B E R G E R
A
s a longtime health policy reformer, I have come to
love Winston Churchill’s observation that American policymak-
ers always get it right, but only after trying everything else. I
am also beholden to my now deceased Alabama Democratic
colleague
Senator Howell Heflin’s explanation of Congressman Claude
Pepper’s
(D-FL) interview with God after Pepper’s death in 1989. In
Heflin’s
telling, Pepper asked God if we would ever get health reform
right in
America, to which God replied, “I have good news and bad
news. The
good news is, yes, Americans will eventually get it right. The
bad news
is, not in my lifetime.”
Even though we have not “tried everything else” (including
single-payer financing), and even though politics in America is
about as
discouraging as it’s been in my lifetime, nearly 50 years of
involvement
in health reform tells me that someday there will be an
affordable
American health system available to all.
The foundation for such a policy reform was established with
the
passage in 2010 of the Affordable Care Act (ACA). At its heart,

the ACA
broadens coverage and changes financing policy from fee-for-
service to
value-based outcomes and population health improvement.
American
communities are building on this foundation and contributing
their
experiences to future policy improvements.
The ACA represents nearly 4 decades of accumulated
experiences
with health care payment policy reform at the state and federal
levels,
bolstered by health services research that has translated these
experiences
into policy. It is this approach, not partisan politics, that has
long been
at the heart of health care policy improvement in America.
As everyone knows, the ACA became law only because a
Democratic
president and Democratic members of Congress seized one of
those “If
not us, who, if not now, when?” moments in our history.
Unfortunately,
every single elected Republican congressman chose to oppose
passage.
The Milbank Quarterly, Vol. 93, No. 4, 2015 (pp. 663-666)
c© 2015 Milbank Memorial Fund. Published by Wiley
Periodicals Inc.
663

664 D. Durenberger
Worse, most of them have opposed the law’s implementation.
Such
obstruction has made implementing the ACA difficult, to say
the least.
As a practical matter, the politics of health care policymaking is
much the same in every developed country. Liberals focus on
universal
coverage and access. Conservatives focus on affordability and
place
cost and quality above coverage, believing that both are best
achieved
through the marketplace and that government should play a
minimal
role. Ironically, the current Republican opposition to the ACA
does not
represent the health policy reform traditions of American
conservatives
or Republicans. Nor does it represent the best interests of much
of
the health care industry, which is currently engaged in the most
“disruptive” systemic innovation in our history.
As an example of the government’s involvement in health
reform, let’s
look at Medicare and Medicaid, which were enacted a little
more than
50 years ago. These programs were built on a fee-for-reasonable
service
chassis in a dysfunctional private system. As a result, these
popular
programs soon began driving health care demand and costs to
the point
that Democrats needed Republicans to help them continue

funding both
programs.
Likewise, Republicans needed Democrats’ support for their
efforts to
contain costs because the public interprets most efforts to
reduce public
financing as limiting access, a response that has not proved to
be good
politics for Republicans. It was within this dynamic that liberals
like
the late Senator Ted Kennedy (D-MA) and conservatives like
Senator
Orrin Hatch (R-UT) found a bipartisan middle ground for a
series of
cost-controlling policy experiments.
During most of my 3 terms in the US Senate (R-MN, 1978-
1995),
as either the chair or the ranking Republican of the Senate
Finance
Committee’s Health Care Subcommittee, it was up to me and my
Democratic colleagues like Senators Max Baucus (D-MT),
George
Mitchell (D-ME), and Jay Rockefeller (D-WV) to work our way
through President Jimmy Carter’s proposal to regulate hospital
budgets, Medicare prospective payment systems like Diagnosis
Related
Groups (DRGs) and Resource-Based Relative Values (RBRVs),
and the
efforts at privatization, which eventually became Medicare
Advantage,
all based on localized experimentation with payment reform.
We passed, by large bipartisan margins, the Medicare
Catastrophic

Act in 1988, which modernized Medicare’s benefit structure and
added
benefits. This law, however, was repealed a year later because
of public
Health Care Reform and the American Congress 665
opposition to a tax to fund new benefits. In 1994, when partisan
Repub-
licans saw an electoral advantage in opposing President Bill
Clinton’s
Health Security Act, senators from both parties active in past
health
reform efforts met weekly as the “Mainstream Group.” Working
in Sena-
tor John Chafee’s (R-RI) Capitol office, we crafted alternative
legislation
to achieve the president’s systemic reform goals and lower its
costs.
Sadly, this bipartisan effort failed to pass and lost to partisan
politics.
By 2009, everybody in the nearly $3 trillion-a-year American
health
care industry realized that things would have to change. Even
the
American Medical Association (AMA), for the first time in its
history,
pledged to make systemic reform successful. Using the work of
members
of Congress from both parties in the years leading up to the
introduction
of the ACA, President Barack Obama leveraged the willingness
of most

of the stakeholders to commit to this “now or maybe never”
task.
A Democratic president and Congress have now set us on a
course to
create a uniquely American health system. Republicans and
Democrats
should think carefully about this opportunity. Indeed,
implementation
of the ACA as it plays out in different American communities
will
undoubtedly teach members of Congress on both sides of the
aisle about
ways to best improve the law.
There are many places in America to which open-minded
conservative
and liberal legislators can go and see this future. Experienced
health care
professionals and state policymakers are currently engaged in
systemic
reform experiments. As Dr. Donald Berwick summarized his
experiences
at the Center for Medicare and Medicaid Services: “This
country is basi-
cally running a series of clinical trials, the success of which
will depend
on local health care leaders, and on the capacity of state
legislatures to
understand the role state government can play in facilitating
change.”
Yet we must realize that we cannot change the behavior and the
expectations of everyone in this vast system overnight.
Changing gener-
ations of dysfunctional doctor-patient relationships and the

unrealistic
financial rewards for specialization, diagnostic tests, drugs, and
medi-
cal devices takes patience. But if the AMA can see that the
financial
rewards for individuals, professionals, and technology must be
aligned
with healthier people and improved health care services, so can
willing
and able conservatives.
It’s true that Americans have not yet “tried everything else,” but
we
no longer need to do so. The experience and good judgment it
will
take to bring conservatives to the task of implementing an ACA
that
666 D. Durenberger
is strengthened by their participation will come from those who
best
understand and explain these “clinical experiments.”
But in order for Congressman Pepper to make another
appointment
with God, the Congress and the White House must first bring
together
the health services researchers who can best translate the
experiences of
all those across this country who are tearing down the barriers
to creating
a more cost-effective system. And then we must act with
intelligence

and alacrity.
I believe that systemic health reform is here to stay. More
important, I
believe that one day we will truly be able to state that the
United States
has the best health care system in the world.
Address correspondence to: Senator Dave Durenberger, 9
Crocus Hill, St. Paul, MN
55102 (email: [email protected]).
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Obamacare vs. AHCA and BCRA.
Lee, Mara
Modern Healthcare (MOD HEALTHC), 6/26/2017; 47(26/27):
0010-
0010. (1p)
Article
English
Patient Protection and Affordable Care Act -- Legislation and
Jurisprudence -- United States

Politics -- United States
Health Care Reform -- Legislation and Jurisprudence -- United
States
United States; Insurance, Health -- Economics -- United States;
Insurance Coverage; State Government; Taxes -- Legislation
and
Jurisprudence -- United States
The article discusses differences in the provisions of the
Affordable Care
Act (ACA), the American Health Care Act (AHCA) of the U.S.
House
and the Better Care Reconciliation Act (BCRA) of the Senate.
The
differences can be observed in several areas, including
Medicaid
expansion and financing, cost-sharing-reductions, essential
health
benefits, medical underwriting, pre-existing conditions and
taxes.
Health Services Administration; USA
0160-7480
NLM UID: 7801798
20170705
20190115
123851375
CINAHL Complete

Obamacare vs. AHCA and BCRA
Some of the big differences between the Affordable Care Act,
the House's American Health Care Act and the
Senate's Better Care Reconciliation Act are:
Medicaid
Medicaid expansion
ACA: Enhanced federal match for expansion population is 95%
this year, 94% next year, 93% in 2019 and
90% in 2020 and beyond
AHCA: Match would remain as described in ACA until 2020,
with the enhanced match until beneficiaries cycle
out of the program.
BCRA: 90% match in 2020; 85% in 2021; 80% in 2022; 75% in
2023. No grandfathering. After 2023, federal
contribution is based on general state match percentage.
Medicaid financing
Current law: States design plans, provider payment levels and
eligibility. Federal match rate varies depending
on the wealth of the state, ranging from 50% to 73%.

AHCA: In 2020, a per capita cap that could grow by either the
medical component of the Consumer Price Index
or medical CPI plus 1 percentage point. The aged and disabled
adults would be under the more generous per
capita cap. Each state's base figure would be based on historic
per enrollee spending.
BCRA: Per capita cap takes effect in 2020, excludes children
who are on disability. In 2025, the cap would
grow at standard inflation, a much lower rate than medical CPI.
States could set the base rate.
Individual market
Cost-sharing-reductions:
Current law: Continue to be paid to insurers.
AHCA: Paid in 2019 and 2020 only.
BCRA: Same as the AHCA.
Subsidies
Current law: Available to persons or families between 138% and
400% of federal poverty level, as long as they
don't have access to affordable plans through work. Are based
on age, income and local cost of insurance.
AHCA: Available for everyone except those insured through
work. Age-based only and more generous than
current law to younger customers.
BCRA: Available to those below 350% of poverty. Based on
age, income and local cost of insurance. Those

age 50 and older, starting at 200% of poverty, receive lower
subsidies than under the ACA; 60- to 64-year-olds
could have to spend as much as 16% of their income on
premiums before subsidies, compared to 9.7% in the
ACA.
Essential health benefits, medical underwriting, pre-existing
conditions
Current law: 10 essential health benefits, such as prescription
drugs, maternity care and mental health care are
mandated. Plans must sell to everyone and cannot charge sick
people more.
AHCA: States may apply for waivers to drop essential benefits
or the rules on charging sick people more, but
those changes only apply to those who did not maintain
continuous coverage.
BCRA: States may apply for waivers, but not for rejecting sick
applicants or charging them more.
Individual and employer mandates
Current law: Everyone must have insurance or face a tax
penalty. Companies with at least 50 employers are
required to offer insurance.

AHCA: Those who don't buy insurance can be charged 30%
more per month for one year when they try to
come back in. No employer mandate.
BCRA: No mandates.
Taxes
Current law: Taxes on insurers, hospitals, medical-device
manufacturers, rich employer-based plans and
investment income, among others, help pay for the expansion.
Some of those taxes, especially the Cadillac tax
on rich employer plans, were so unpopular they were never
implemented. The investment income tax is the
biggest funder.
AHCA: The taxes are repealed, though not all immediately.
BCRA: The taxes are repealed, some retroactively, such as the
investment tax, and some in 2018 and 2023.
The Cadillac tax is temporarily repealed, but returns in 2026.
~~~~~~~~
By Mara Lee
This article is copyrighted. All rights reserved.
Source: Modern Healthcare
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The Center for Consumer Information & Insurance Oversight
Affordable Care Act: Working with States to Protect Consumers
The Affordable Care Act establishes common-sense consumer
protections and requires insurers to operate in a more
transparent manner. Fair rules and transparency help create a
more level playing field between consumers and
insurers. The law also empowers States by putting them in the
driver’s seat in implementing many of these new
consumer protections.
On July 23, 2010, the Departments of Health and Human
Services, Labor, and the Treasury issued an interim final rule
regarding internal claims and appeals and external review
processes for group health plans and health insurance
issuers offering coverage in the group and individual markets.
This rule works to give people in most plans better
information about what their rights are and why their claims
were denied or coverage rescinded. Under the rule,
consumers have the:
Right to information about why a claim or coverage has been
denied. Health plans and insurance companies
have to tell you why they’ve decided to deny a claim or chosen
to end your coverage – and how you can appeal
that decision.
Right to appeal to the insurance company. If you’ve had a
claim denied or had your coverage rescinded, you
have the right to an internal appeals process, a process in which
you ask your insurance company to conduct a full
and fair review of its decision. If the case is urgent, your
insurance company must speed up this process.

Right to an independent review. Often, insurers and their
policyholders can resolve disputes during the internal
appeals process. If you can’t work it out through the internal
appeals process, you now have the right to take your
appeal to an independent third-party for review of the insurer’s
decision. This is called “external review.” This way,
the insurance company no longer gets the final say regarding
your benefits, and patients and doctors get a greater
measure of control over health care
These protections and standards are an important step forward
in reforming the health care system to make sure it
works for consumers, not just insurance companies.
Amended IFR: State Flexibility and Transition to 2014
Today the Departments are amending the July 23, 2010 Interim
Final Rule. Amendments to the IFR maintain the
unprecedented consumer protections provided in the Affordable
Care Act while reflecting comments from stakeholders
and give States the flexibility they need to implement the law.
The July 2010 IFR set forth 16 minimum consumer protections
based on the Uniform Health Carrier External Review
Model Act written by the National Association of Insurance
Commissioners (NAIC) that, if provided by a State external
review process, will result in the States’ process applying in
lieu of a Federal external review process.
Many States have made progress in meeting the minimum
standards laid out in the July 23, 2010 IFR. To give States a
reasonable opportunity to continue to implement these
important consumer protections the amended IFR extends the
transition period for State external review processes to January
1, 2012.

During the transition period (until January 1, 2012), at a
minimum, plans and issuers are expected to follow their State
laws and processes for external review in the States in which
they are operating. Plans and issuers in States and
territories where the HHS-administered Federal external review
process already applies as of the date of this guidance
are expected to continue their participation in the Federally-
administered external review process until HHS determines
otherwise.
In addition, separate guidance being issued contemporaneously
with the publication of this amendment announces
standards under which, until January 1, 2014, a State may
operate an external review process under Federal standards
similar to the required consumer protections outlined in the July
23, 2010 IFR. Under this guidance, if HHS determines
that a State has neither implemented the required consumer
protections nor implemented a process that meets the
Federal standards that are similar to the required consumer
protections, issuers in the State will have the choice of
participating in either the HHS-administered external review
process or contracting with accredited Independent Review
Organizations. This guidance also phases in the use of multiple
Independent Review Organizations for the plans that
use them starting next year as a way of ensuring that the
external review is unbiased.
HHS is adopting this approach to permit States to operate their
external processes under standards established by the
Secretary until January 1, 2014 to avoid unnecessary disruption
while States work to adopt the consumer protections
CCIIO Home > Affordable Care Act: Working with States to
Protect Consumers

https://www.cms.gov/
https://www.cms.gov/CCIIO/index.html
10/16/2019 Affordable Care Act: Working with States to Protect
Consumers - Centers for Medicare & Medicaid Services
https://www.cms.gov/CCIIO/Resources/Files/working_with_stat
es_to_protect_consumers_06222011.html 2/2
A federal government website managed and paid for by the U.S.
Centers for Medicare &
Medicaid Services. 7500 Security Boulevard, Baltimore, MD
21244
set forth in the July 2010 regulations. Starting in 2014, the
appeals process will be more closely aligned across all
types of plans.
Additional Amendments to the IFR:
The amended IFR released today includes details of all of the
changes made from the original IFR. You can find the
text of this amended IFR here .
Additional guidance issued contemporaneously with the
publication of the amended IFR can be found here.
https://www.federalregister.gov/articles/2011/06/24/2011-
15890/group-health-plans-and-health-insurance-issuers-rules-
relating-to-internal-claims-and-appeals-and

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Information/Aboutwebsite/External-Link-Disclaimer.html
https://www.cms.gov/CCIIO/Resources/Regulations-and-
Guidance/index.html

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