The 10 titles of the Affordable Care Act

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On June 28, 2012, the US Supreme Court upheld the Affordable Care Act (ACA). In a 5-4 opinion, Chief Justice John Roberts and Justices Elena Kagan, Ruth Bader Ginsburg, Stephen Breyer and Sonia Sotomayor voted to uphold the two most contentious provisions of the act, with exceptions. The justices decided that the individual mandate could stand as a tax, meaning that beginning in 2014, Americans who do not purchase health insurance will have to pay a tax of up to $600. On the Medicaid expansion provision, which 26 states objected to, the justices ruled the federal government was within its rights to expand the program; however, it cannot withhold Medicaid funding from the states that do not comply with the expansion effort. The government previously threatened to refuse all Medicaid funding for states that did not comply. Read on to learn what’s really in the ACA.

Title I. Quality, Affordable Health Care for All Americans

This title fundamentally changes the nature and operation of private health insurance in the United States. Beginning in 2014, no health insurer will be able to sell or rate coverage based on an individual’s medical history; most Americans will be required to obtain health insurance; and substantial financial subsidies will be available to low- and moderate-income Americans to help them afford the cost of health insurance. Most states will operate new “health insurance exchanges” to make shopping for health insurance easier. Small businesses and individuals can shop these insurance exchanges for competitive rates. Other important changes in health insurance, including the banning of lifetime and annual benefit limits, were implemented in 2010.

Title II. The Role of Public Programs

This title creates substantial changes to Medicaid, the federal-state program for many low-income persons. Beginning in 2014, all lower-income individuals will be eligible to enroll in their state’s Medicaid program, not just those who fit into categories such as disabled, children, or parents. For the first time, Medicaid will become a more uniform national program with uniform eligibility and enrollment standards as well as quality improvement requirements.

Title III. Improving the Quality and Efficiency of Health Care

This title establishes new mechanisms to improve the quality of medical care in the United States by making it more efficient and effective, and more patient-centered. Medicare will be improved with the addition of new preventive benefits for enrollees; and the Medicare Part D drug benefit will be made more affordable by closing the coverage gap known as the “donut hole.” Medicare’s rate of growth will be lowered to provide about $450 billion in savings between 2010 and 2019, which should fund about half the cost of the ACA.

Title IV. Prevention of Chronic Disease and the Improvement of Public Health

Title IV is the most ambitious law ever passed to promote healthier lifestyles for all Americans and to prevent disease and disability. A National Prevention, Health Promotion and Public Health Council will devise a national prevention strategy, backed up by a $13 billion Trust Fund. Evidence-based clinical preventive services will be provided in most public and private health insurance policies without cost-sharing. Chain restaurants will be required to post the calorie content of their foods.

Title V. Healthcare Workforce

This title establishes a National Healthcare Workforce Commission to analyze and plan for workforce needs and to make recommendations to Congress and the administration. Support is provided to expand the healthcare workforce, especially in primary care. Major expansions for community health centers and the National Health Service Corps are funded.

Title VI. Transparency and Program Integrity

Title VI provides new authority to federal and state agencies to combat fraud and abuse in Medicare, Medicaid, and private health insurance. Drug companies and medical suppliers will report most gifts and other gratuities to physicians for public release on a federal website. The Patient Centered Outcomes Research Institute is established as a public-private entity to support research on comparative clinical effectiveness. New transparency requirements on the nursing home industry will provide information to protect and empower patients and their families. The Elder Justice Act provides a national framework to combat violence, neglect and financial exploitation of senior citizens.

Title VII. Improving Access to Innovative Medical Therapies

This title directs the U.S. Food and Drug Administration to develop a regulatory pathway to permit the development, manufacture, marketing and sale of bio-similar biologic products, generic-like versions of bio-pharmaceutical drugs. It also ends anti-competitive efforts to keep generic drugs off the market, and offers drug discounts to hospitals and communities that serve low-income patients.

Title VIII. CLASS: Community Living Assistance Supports and Services

This title authorizes a new national and voluntary long-term disability insurance program to provide workers with daily cash payments and support if they become permanently and temporarily disabled. People who enroll in CLASS must pay premiums for a minimum of 5 years. The funding is flexible and can be used for a range of services. No tax money will be used to fund this program. Its only permitted financing source — enrollee premiums — must be sufficient for at least 75 years if the Health and Human Services Secretary is to launch the program.

Editor’s Note: The Obama administration announced on October 15 that it was abandoning plans for CLASS. Congress is expected to quickly draft legislation to repeal the provisions of this title.

Title IX. Revenue Provisions

This section covers the financing for slightly less than half the cost of the ACA. Key provisions establish new Medicare taxes on high-income wage earners, as well as new taxes on pharmaceutical manufacturers, health insurance providers and medical device manufacturers. Also included is an excise tax on high-cost, employer-provided health insurance; changes to health savings accounts and other individual health accounts; and a 10% tax on indoor tanning services.

Title X. Strengthening Quality, Affordable Healthcare for All Americans

The final title in the act is the “Manager’s Amendment,” which includes amendments and additions to Titles I-IX, reflecting the unusual legislative process leading to passage of the ACA. Additional changes to Titles I-X were approved in a separate measure called the Health Care and Education Reconciliation Act (HCERA) signed into law by President Obama one week after he signed the base law on March 23, 2010. This title also reauthorizes the Indian Health Care Improvement Act, which provides healthcare to American Indians and Alaskan natives.

Contributor Information: John E. McDonough, DPh, MPA

Professor of Health Policy and Management

Harvard University School of Public Health

Boston, Massachusetts

Between 2008 and 2010, Dr. McDonough served as Senior Advisor on National Health Reform for the U.S. Senate Committee on Health, Education, Labor, and Pensions. In 2010, he was the Joan Tisch Distinguished Fellow in Public Health at Hunter College in New York City. Beginning in January, 2011, he is a professor of public health practice at the Harvard School of Public Health and Director of the Center for Public Health Leadership.

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