This presentation provides an overview (updated through December 2011) of the 2010 Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act (also known as health care reform).

1. HEALTH CARE REFORM IN THE UNITED STATES
An overview of the 2010 Patient Protection and Affordable Care Act and
Health Care and Education Reconciliation Act
By Craig B. Garner, Esq.
1
Copyright 2011 Craig B. Garner, Esq.
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2. THE FIRST HOSPITALS IN THE UNITED STATES
Many of America's initial medical services grew
from the desire of charity based organizations
to assist the poor and sick. In 1736, the New
York City Almshouse designated six bedrooms
as a “ward” that would eventually grow to
become Bellevue Hospital, followed closely that
same year by what would later be known as
Charity Hospital in New Orleans, Louisiana.
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3. MEDICINE IN THE NINETEENTH CENTURY
Through the 1800s, access to the delivery of
care rendered by the few elite hospitals (totaling
fewer than 200 in 1873) in cities such as New
York, Boston and Philadelphia went hand-in-
hand with status in society.
The Medical Laboratory, University of Pennsylvania
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4. At the turn of the twentieth century,
hospitals were few and far between, and
their amenities were sparse. With the
l i m i t e d m e di c al t e c h n ol og y an d
crowded, often unsanitary conditions
available in the early 1900s, a hospital
was not a place to be if you were sick.
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5. THE BEGINNING OF THE TWENTIETH CENTURY
By the 1920’s, the hospital had become a national
institution in America, with more than 5,000
facilities appearing in towns across the country.
This trend brought with it advances in
technology, more doctors, and greater quality of
care.
As conditions in health care improved, the
practice of medicine in the United States shifted
from home to hospital. People went to a hospital
to get better, benefitting from these advances.
St.Vincent Hospital, Los Angeles
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6. HOSPITAL AND COMMUNITY WORKING TOGETHER
In 1946, the Hospital Survey and Construction Act
(the Hill Burton Act”) disbursed approximately $3.7
billion to hospitals so they could meet the needs of
the nation. The Hill Burton Act sought to create 4.5
hospital beds per 1,000 people nationwide.
The Hill Burton Act forced hospitals and their
communities to work together, combining federal
funds with local monies to cover expenses.
Lister Hill
Harold H. Burton
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7. By the 1960s, health care in the United States was at a
crossroads. Access to treatment had increased, but so
had the corresponding price tag. With the passage of
Medicare in 1965, our nation solidified its commitment
to government sponsored health care.
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8. Since the creation of Medicare in 1965, health care in the United
States has faced a multitude of challenges on virtually all possible
fronts. Today, critics contend that health care is overregulated,
underfunded, and the system fails to reflect the expectations and
demands of modern society.
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9. As health care expenses in the United States approach 18% of the
nation’s GDP, as many as 50 million Americans are still without health
insurance, and medical bills are one of the leading causes of individual
bankruptcy today. After many failed attempts at reform over the
decades, 2010 marked the year for change.
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10. HEALTH CARE REFORM BY THE NUMBERS*
On March 23, 2010, President Obama signed the Patient Protection
and Affordable Care Act into law (followed by the Health Care and
Education Reconciliation Act).
The Cost: $940 billion over ten years.
Would expand coverage to 32 million Americans who are
currently uninsured.
In 2014, everyone must purchase health insurance or face a $695 annual fine. There
are some exceptions for low-income households.
Expands Medicaid to include more families who did not previously qualify.
* Estimated projections at the time of passage.
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11. WHO PAYS?*
Drug manufacturers would pay a total of $16 billion between 2011 and 2019.
Health insurers would pay $47 billion over this same period.
Medical device manufacturers would pay a 2.9 % excise tax on sales, beginning in
2013.
A 10% tax on indoor tanning services is expected to raise about $2.7 billion.
Starting in 2012, the Medicare Payroll Tax will include a 3.8% tax on investment
income for families making more than $250,000 per year ($200,000 for
individuals).
Beginning in 2018, businesses will pay a 40% excise tax on so-called "Cadillac"
high-end insurance plans worth over $27,500 for families ($10,200 for
individuals).
* Estimated projections at the time of passage.
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12. HEALTH CARE SPENDING
National Health Expenditure Accounts (NHEA) measure
the total annual dollar amount of our nation’s health care
consumption.
This information also tries to identify the amount
invested in the future of health care (such as medical
structures, equipment, research, etc.).
Growth in U.S. National Health Expenditures (NHE)
over the next ten years is expected to be slightly higher
due to PPACA.
Average annual growth in NHE for 2009 through 2019 is
expected to be 6.3%.
NHE as a portion of the nation’s GDP is expected to Source: CMS, Office of the Actuary (April 2010).
be 19.6% by 2019.
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13. HEALTH CARE SPENDING (continued)
The following information was compiled for fiscal year 2009:
■ NHE grew 4.0% to $2.5 trillion, or $8,086 per person, and accounted for 17.6% of GDP.
■ Medicare spending grew 7.9% to $502.3 billion, or 20% of total NHE.
■ Medicaid spending grew 9.0% to $373.9 billion, or 15% of total NHE.
■ Private health insurance spending grew 1.3% to $801.2 billion, or 32% of total NHE.
■ Out of pocket spending grew 0.4% to $299.3 billion, or 12% of total NHE.
■ Hospital expenditures grew 5.1% in 2009.
■ Physician and clinical services expenditures grew 4.0%.
■ Prescription drug spending increased 5.3%.
Source: CMS, Office of the Actuary (April 2010).
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14. HOW WILL PPACA SLOW THIS TREND IN HEALTH CARE SPENDING?
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15. THE HEALTH INSURANCE EXCHANGE
Under Health Care Reform, the health insurance exchange is a
marketplace created to offer affordable, high-quality health insurance
options. The exchange is designed to help families who have no
insurance or do not get adequate insurance at work and cannot afford
to buy it in the costly individual or small group market. It is also for
small businesses that cannot afford small group health insurance.
When federal guidelines were released in the summer of 2011, the
comparison was made between purchasing health insurance online and
employing the Internet to buy airline tickets and make hotel
reservations.
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16. THE HEALTH INSURANCE EXCHANGE (continued)
In 2010, PPACA established temporary, high-risk pools in each state to provide health coverage to
individuals with pre-existing medical conditions and who have been uninsured for at least six months.
By 2014, state-based health insurance exchanges should provide consumers with a variety of private
health insurance plans to consider. This would include comparisons of covered services, premiums, co-
pays and deductibles, as well as out-of-pocket limits on expenses.
Each exchange will focus on individuals and small employers with 50 to 100 employees.
In 2017, states will have the opportunity to opt out of the federal requirements establishing an insurance
exchange if they can show the ability to provide coverage comparable to the new Federal law.
Illegal immigrants will not be eligible to participate in any State exchange..
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17. THE HEALTH INSURANCE EXCHANGE (continued)
FIVE CATEGORIES OF STATE EXCHANGES
Platinum, with coverage at 90% of the full actuarial value of the essential benefits package.
Gold, with coverage at 80% of actuarial value.
Silver, with coverage at 70% of actuarial value.
Bronze, with coverage at 60% of actuarial value.
Catastrophic, a high-deductible plan available to people under age 30 and to people who qualify for an
exemption (because other coverage is not affordable).
17
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18. CALIFORNIA’S PROPOSED HEALTH INSURANCE EXCHANGE
The Exchange will be governed by a five-member board
appointed by California’s Governor and the legislature.
California will also set up the Small Business Health
Options Program, which will assist qualified small employers
in facilitating the enrollment of their employees in qualified
health plans offered.
California will be active in establishing a competitive
process to select participating carriers.
California will require plans to make available to the general
public claims payment policies and practices as well as
periodic financial disclosures. California will also require
public disclosure of data on enrollment, dis-enrollment, and
denied claims, among other things.
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19. HEALTH INSURANCE EXCHANGES IN OTHER STATES
Utah’s e-Find system enables eligibility workers to search multiple
databases through a state “data warehouse” to verify eligibility for
health coverage.
Louisiana renews coverage for a majority of children without
requiring families to submit a renewal form and by checking available
databases to verify continued eligibility. The percentage of children
who lose coverage at renewal has dropped from 16 percent to less
than 1 percent.
Wisconsin is among the 32 states that allow individuals to apply for
health coverage online. The state’s ACCESS system includes the
ability to complete the application with an electronic signature and
features a personal account function so beneficiaries can report
changes and renew coverage.
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20. HEALTH CARE REFORM -- COVERAGE UP TO AGE 26
Dependent (Adult/Child) Coverage to Age 26:
For plans that provide coverage for dependents, the plan must now cover
dependents (adults/children) to age 26 (this is generally tax free to the
employee).
This is effective for plan renewals beginning on or after September 23, 2010.
This also applies to employers with cafeteria plans, as well as self-employed
individuals who qualify for the self-employed health insurance deduction.
“Grandfathered plans” are not required to cover adults/children to the age
of 26 if the adult/child is eligible to enroll in another eligible employer-
sponsored health plan.
This limited exemption ends on the first plan renewal beginning on or after
January 1, 2014.
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21. NEW PROTECTIONS FOR INDIVIDUALS
PPACA ensures that insurance companies and health plans provide simple
summaries of what is covered and for what services individuals must pay
directly.
By March 2012 PPACA will require a uniform glossary of terms commonly
used in health insurance coverage such as “deductible” and “co-pay.”
Federal tax credits and cost-sharing reduction payments will also reduce
the cost of insurance for low income individuals, leading to the expectation
that more people will obtain coverage on their own. In some cases, this
may reduce the need for employer provided health insurance.
The Congressional Budget Office estimates that when PPACA is
completely phased in, the premium tax credit will help 20 million
Americans afford health insurance.
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22. NEW PROTECTIONS FOR INDIVIDUALS (continued)
The Reform Law is designed to make individual health insurance policies more
affordable and available by: (1) mandating “community rating” so that individual
rates can only vary based on location or rating area, age of the insured, and
tobacco use; and (2) by barring the exclusion of coverage for preexisting
conditions.
In 2011, new federal regulations require health insurance companies to disclose
and justify any rate increase of 10% or more. For an insurer to increase rates in
excess of 10% for any insurance product sold to individuals (or small groups), it
must first file a “preliminary justification.” If state or federal officials disagree and
find the increase unreasonable, the insurer must then file a final justification.
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23. THE INSURANCE MANDATE FOR INDIVIDUALS
Individual Penalty for Not Obtaining Coverage:
Individuals who do not obtain or retain qualifying health care coverage will
be required to pay a penalty as part of their income tax returns. Many low
income individuals who are not required to file income taxes are exempt
from the mandate.
In 2014, the penalty is $95 or 1% of the individual’s income, whichever is
greater.
By 2016, the penalty increases to $695 or 2.5% of income.
For families, the maximum penalty is three times the per-person flat-dollar
penalty. The penalty for dependent children without coverage is half the cost
of the individual flat-dollar penalty.
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24. THE INSURANCE MANDATE FOR INDIVIDUALS (continued)
How Individuals Can Meet the Health Insurance Mandate:
By enrolling in a government program such as Medicare, Medicaid, TRICARE,
or Children’s Health Insurance Program (CHIP).
By participating in qualified insurance offered by your employer.
By purchasing a qualified insurance policy through a state exchange or
directly from an insurer.
To be qualified, a plan must cover certain “essential health benefits” at least
up to at least 60% of actuarial value.
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25. IS THE INSURANCE MANDATE CONSTITUTIONAL?
Legal Challenges to the Individual Requirement are Pending:
There is a split between the Circuit Courts of Appeal.
The United States Supreme Court may soon render the final decision.
Stay tuned. The mandate could be replaced with another means to
encourage participation, as universal coverage through insurance is
viewed as central to the program.
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26. BE MINDFUL OF HIGH DEDUCTIBLE PLANS
As many as three million Californians are enrolled in health plans requiring
deductibles in excess of $5,000.
For members enrolled in preferred provider organizations (PPOs), 28%
reported plan deductibles in excess of $1,000, and in health maintenance
organizations (HMOs), the number was 14%.
Many Californians cannot afford higher-premium plans, but the alternative –
high-deductible plans which may cost less initially – can cost thousands of
dollars when health care is needed.
Catastrophic, a high-deductible plan available to people under age 30 and to
people who qualify for an exemption (because other coverage is not
affordable).
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27. HEALTH CARE REFORM FOR BUSINESSES IN 2014
The new law does not require employers to offer health insurance coverage
to their employees.
For “large employers” (those with 50 or more full-time employees) the law
imposes a penalty ($2,000 per employee) if any of their full-time employees
qualify for and receive federal subsidies.
The large employer penalty does not apply for the first 30 employees.
For small businesses that are not required to provide health coverage,
generous new tax credits will be available to those businesses with low-paid
employees to encourage them to provide qualified health insurance for their
employees.
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28. HEALTH CARE REFORM FOR BUSINESSES (continued)
Limitations on Pre-Existing Conditions and Plan Limits
Currently, group health plans are not able to impose pre-existing condition
exclusions on children under age 19.
Additionally, group health plans are not able to impose lifetime or restrictive
annual limits on benefits under the plan.
Beginning in 2014, a group health plan will not be able to impose any annual
limits.
In addition, effective in 2014, group health plans will be completely
prohibited from imposing pre-existing condition exclusions on plan
participants.
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29. HEALTH CARE REFORM FOR BUSINESSES IN 2018
There will be a 40% tax on expensive heath care plans, dubbed "Cadillac
plans."
These high cost health plans are defined as having a value of $10,200 for a
single employee or $27,500 for a family.
There are exclusions for high risk jobs and other special occupations.
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30. SMALL BUSINESS HEALTH CARE TAX CREDIT
The Health Care Insurance Reform legislation seeks to expand coverage by providing
generous tax credits to small businesses with low-paid employees (which historically have
not provided employee health insurance). This change has already led to a significant
increase in the number of such businesses providing insurance.
Must cover at least 50% of the cost of health care coverage for some of its workers
based on the single rate.
Must have less than the equivalent of 25 full-time workers (for example, an employer
with fewer than 50 half-time workers may be eligible).
Must pay average annual wages below $50,000.
The credit is worth up to 35% of a small business’ premium costs in 2010 (25% for tax-
exempt employers). On January 1, 2014, this rate increases to 50% (35% for tax-exempt
employers).
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31. HEALTH INSURANCE PLAN CHOICES FOR SMALL BUSINESSES
In November 2011, the federal government released a new tool for small business
owners to compare the benefits and costs of health plans, and even research locally
available products, so they can choose the best options for their employees.
At www.HealthCare.gov, small business owners can research:
Insurance product choices for a given ZIP code, sorted by out-of-pocket limits,
average cost per enrollee, or other factors.
A summary of cost and coverage for small group products that shows the available
deductibles, range of co-pay options, included and excluded benefits, and benefits
available for purchase at additional cost.
The ability to filter product selection based on whether the plans are Health Savings
Account eligible, have prescription drug, mental health, or maternity coverage, or
allow for domestic partner or same sex coverage.
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32. CHANGES TO FLEXIBLE SPENDING ARRANGEMENTS
Effective January 1, 2011, the cost of over-the-counter medicine or drugs cannot
be reimbursed from Flexible Spending Arrangements or health reimbursement
arrangements unless a prescription is obtained.
This does not affect insulin, even if purchased without a prescription, or other
health care expenses such as medical devices, eyeglasses, contact lenses, co-pays
and deductibles.
A similar rule went into effect on January 1, 2011, for Health Savings Accounts.
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33. HEALTH SAVINGS ACCOUNTS
As of January 2011, more than 11.4 million people have health savings accounts
(up from 10 million in January 2010).
Health Savings Accounts typically include a tax-preferred savings account where
money is set aside by the consumer (employers can also contribute) to pay for
medical expenses and prescription drugs.
Health Savings Accounts also usually include a high-deductible health insurance
plan. In 2012, that deductible will be at least $1,200 for an individual and $2,400
for a family (and as high as $6,050 and $12,100, respectively).
Any adult with a high-deductible health plan and no other form of health care
coverage can establish Health Savings Accounts.
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34. HEALTH SAVINGS ACCOUNTS (continued)
Individual contributions into Health Savings Accounts are tax
deductible.
Employer contributions into Health Savings Accounts are not taxable
income.
At the end of the year, funds in Health Savings Accounts roll over, and
even stay with the individual if he or she changes employment.
Health Savings Accounts can be used for general retirement expenses
when a participant turns 65.
The IRS determines what medical expenses qualify (i.e., the IRS recently
dropped over-the-counter medications from the list).
34
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35. “OPTIONAL” EMPLOYER REPORTING REQUIREMENTS
Starting in tax year 2011, the new law required employers to report the value
of the health insurance coverage they provide employees on each employee’s
annual Form W-2.
However, to provide employers the time they need to implement these
changes, the IRS deferred the reporting requirement for 2011, making it
optional for 2010 filings.
35
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36. THE FUTURE OF HOSPITAL REIMBURSEMENT?
In April 2011, CMS published regulations that provided a roadmap for
the future of hospital reimbursement.
Authorized within PPACA, CMS will start paying hospitals Medicare
“bonuses” based upon overall performance, adherence to quality
measures, and patient satisfaction.
This hospital value-based purchasing program is another step toward
shifting the reimbursement infrastructure from cost-based
to performance-driven.
36
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37. THE FUTURE OF HOSPITAL REIMBURSEMENT (continued)
Beginning in October 2012, hospitals can share
bonus money from an $850 million fund based
upon their performance scores.
The following year, hospitals will face a 1%
reduction overall on Medicare payments under
this system.
By 2015, hospitals with poor performance ratings
may be excluded from the bonus pool and face
additional cuts in reimbursement.
37
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38. THE FUTURE OF HOSPITAL REIMBURSEMENT (continued)
Also effective October 2012, hospitals with the highest rates
of readmission can lose as much as 3% of reimbursements.
"The incentives we're putting into place have created a whole new way to
think about hospital care."
--Jonathan Blum, deputy administrator of CMS
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39. HOSPITAL PERFORMANCE MEASURES
Hospitals must closely track their performance on
various measures of quality, patient experience, and
operations. This includes the following examples:
Readmission rates for cardiac cases
Readmission rates for pneumonia patients
Mortality rates for cardiac and pneumonia patients
Average waiting time in the emergency department
Patients who would recommend a hospital
Patients who were happy with their levels of
communication with doctors and nurses
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40. Bundled Payments for Care Improvement Initiative
In August 2013, CMS released the Bundled Payments for Care Improvement Initiative, a program designed to
encourage a team of providers to work together to treat certain episodes of care for one bundled payment per
patient.
Instead of separating Medicare payments for each service involved in treating a patient, a “bundled system” is a single
payment for a defined group of services, irrespective of the nature of the entity providing the care (i.e., a single
entity, such as a hospital, or several different, multidisciplinary providers).
CMS has defined four models of care:
Model 1 (inpatient stay only)
Model 2 (inpatient stay plus post-discharge services)
Model 3 (post-discharge services only)
Model 4 (inpatient stay only with a prospectively determined bundled payment rate)
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41. HEALTH CARE REFORM AND THE HOSPITAL
The federal government has enlisted individuals to help fight Medicare fraud, and
Medicare beneficiaries are encouraged to report the following:
If you spot unusual or questionable charges, contact your health care provider. It
may just be a mistake.
If your complaint is not resolved by your provider, report the questionable
charges to Medicare.
If you suspect Medicare fraud, contact the Department of Health & Human
Services Office of Inspector General.
If you think someone is misusing your personal information, contact the Federal
Trade Commission.
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42. HEALTH CARE REFORM AND THE HOSPITAL (continued)
The trend of multi-hospital systems replacing freestanding community hospitals picked up speed after 1965. The
five hospital consolidations noted in 1961 ballooned to upwards of 50 per year in the 1970s. By the 1980s, an
estimated thirty percent of the hospital beds in the United States existed within hospital systems. In 2008, the
American Hospital Association estimated that almost half of the nearly 6,000 U.S. hospitals belonged to a hospital
system.
Even many of the non-profit, faith-based hospitals directly descended from the original almshouses and charity
hospitals of the 18th and 19th centuries have come to seek refuge in consolidation. By 1872, there were
approximately 75 Catholic hospitals in the United States. Today, most of these institutions have been incorporated
into regional “systems”.
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43. HEALTH CARE REFORM AND THE PHYSICIAN
In 2015, roughly 750,000 physicians in the Medicare program
will be asked to revalidate their individual enrollment records
during a massive anti-fraud effort mandated by PPACA.
CMA intends to weed out only those people who should not
have billing privileges, but physicians are concerned that
legitimate health professionals may face disruptions in their
practices.
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44. HEALTH CARE REFORM AND THE PHYSICIAN (continued)
The new law also requires a value-based purchasing modifier that would
adjust physician fees based on quality and efficiency measures.
Although the adjustments will not start until 2015, CMS may start
measuring physician performance in 2013.
Although the adjustments will not start until 2015, CMS may start
measuring physician performance in 2013.
2013: CMS may start measuring physician services to determine modifier
adjustments in the future.
2015: CMS starts applying the modifier to specific physicians and groups.
2017: CMS starts applying the modifier to all physicians and groups.
44
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45. ACCOUNTABLE CARE ORGANIZATIONS
In April the Federal Government released anticipated
details defining Accountable Care Organizations (ACOs).
PPACA encourages the formation of ACOs to monitor the
collective quality and efficiency of doctors and hospitals
alike, while at the same time creating an entirely new set of
standards for compensation.
The Pioneer Model released by CMS is designed for health
care organizations that are already experienced in
coordinating care for patients across such care settings.
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46. ACCOUNTABLE CARE ORGANIZATIONS (continued)
The original regulations faced a strong pushback from the health care industry, including concern that ACOs triggered
well-established violations of law without the benefit of any new, expected safe harbor provisions or other comparable
exceptions, especially in California where the corporate practice of medicine is prohibited.
Additionally, proper formation of ACOs under the regulations necessitate a significant capital commitment,
notwithstanding other financial burdens in the health care industry already:
! Electronic health records
! Seismic Safety Standards
! State budget and Medi-Cal
46
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47. ACCOUNTABLE CARE ORGANIZATIONS (continued)
In response, the federal government published revisions governing formation of ACOs in
October 2011. Some of these changes included:
Rather than a retrospective assignment of patients, the modifications focus on a preliminary prospective-assignment
method with beneficiaries identified quarterly (there will still be a final reconciliation after each performance year
based on patients served by the ACO).
33 quality measures in 4 domains rather than the original 65 measures in 5 domains.
Program establishment date is now January 1, 2012, with the first round of applications due in early 2012. In the
beginning, ACOs will also have some flexibility within each of the performance years, rather than the original uniform
3-year agreement based only on a calendar year.
EHR is no longer a mandatory condition of participation, although it is retained as an important quality measure.
Flexibility on marketing guidelines for ACOs.
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48. ACCOUNTABLE CARE ORGANIZATIONS (continued)
In addition to modifications surrounding formation, other federal
agencies have clarified issues of concern in the revised regulations:
The Office of the Inspector General clarified the implications of
physician self referral laws and the federal anti-kickback statutes.
The Federal Trade Commission clarified that entry into the
Shared Savings Program will no longer require mandatory antitrust
review, and there will be an antitrust “safety zone” for ACOs approved
by CMS to participate in the Shared Savings Program.
The Internal Revenue Service clarified the ways in which a
charitable organization can participate in the Shared Savings Program
without compromising its tax exempt status.
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49. HEALTH CARE REFORM AND PREVENTATIVE CARE
“The Affordable Care Act helps stop health problems before
they start.” --HHS Secretary Kathleen Sebelius
PPACA is about:
Pilot Programs
Preventative Health Care Services
Forward Thinking Research
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50. HEALTH CARE REFORM AND PREVENTATIVE CARE (continued)
Last summer’s regulations required all new private health plans to
cover several evidence-based preventive ser vices like
mammograms, colonoscopies, blood pressure checks, and childhood
immunizations without charging a copayment, deductible or
coinsurance.
PPACA also made recommended preventative services free for
Medicare beneficiaries.
Regulations also focused on preventative care for women to ensure
a full range of recommended preventative services and screenings
without cost sharing.
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51. HEALTH CARE REFORM AND PREVENTATIVE CARE (continued)
Beginning in 2014, employers may use up to 30% of their
employees’ health insurance premiums for outcome-based
wellness incentives.
Employees can receive rewards such as a discount or
rebate on a premium, a waiver of a deductible or
copayment, or some additional benefit not included under
the plan.
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52. HEALTH CARE REFORM AND PREVENTATIVE CARE (continued)
PPACA also created the Patient-Centered Outcomes
Research Institute (PCORI) to produce groundbreaking,
evidence based information pertaining to health care that
will be easily accessible to both doctors and patients.
PCORI will focus on several areas of interest, including
ways to deliver health care “without bias” and identify
existing gaps affecting women, low-income populations,
minorities, children, and the elderly, among others.
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53. HEALTH CARE REFORM AND PREVENTATIVE CARE (continued)
This also includes the National Prevention, Health Promotion,
and Public Health Councils, charged with the task of
developing health care prevention strategies for large-scale
future use.
A report issued by the PPACA’s Prevention and Public Health
Fund estimates that a $10 per person investment each year in
community-based, preventative health programs could result in
an annual savings of more than $15 billion over the next five
years.
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Copyright 2011 Craig B. Garner, Esq.
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54. HEALTH CARE REFORM AND PREVENTATIVE CARE (continued)
Regardless of its emphasis on our nation’s future well-
being, PPACA now finds itself in the crosshairs as
Congress tries to repair America’s global credit score.
How will the debt ceiling legislation impact the
government’s ability to fund health care in the future?
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Copyright 2011 Craig B. Garner, Esq.
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55. THE NATION’S HEALTH CARE HIERARCHY
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56. OPERATING DIVISIONS WITHIN HHS
■ Administration for Children and Families (ACF) ■ Health Resources and Services Administration (HRSA)
■ Administration on Aging (AoA) ■ Indian Health Service (IHS)
■ Agency for Healthcare Research and Quality (AHRQ) ■ National Institutes of Health (NIH) and the National Cancer
Institute (NCI)
■ Agency for Toxic Substances and Disease Registry (ATSDR)
■ Substance Abuse and Mental Health Services Administration
■ Centers for Disease Control and Prevention (CDC) (SAMHSA)
■ Centers for Medicare & Medicaid Services (CMS)
■ Food and Drug Administration (FDA)
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Copyright 2011 Craig B. Garner, Esq.
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57. HHS STAFF DIVISIONS
■ Assistant Secretary for Administration (ASA) ■ Assistant Secretary for Planning and Evaluation (ASPE)
■ Assistant Secretary for Financial Resources (ASFR) ■ Assistant Secretary for Preparedness and Response (ASPR)
■ Assistant Secretary for Legislation (ASL) ■ Center for Faith Based and Neighborhood Partnerships (CFBNP)
■ Assistant Secretary for Public Affairs (ASPA) ■ Departmental Appeals Board (DAB)
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Copyright 2011 Craig B. Garner, Esq.
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58. HHS STAFF DIVISIONS (continued)
■ Office of Intergovernmental Affairs (IGA) ■ Office of the Inspector General (OIG)
■ Office of Civil Rights (OCR) ■ Office of Medicare Hearing and Appeals (OMHA)
■ Office on Disability (OD) ■ Office of National Coordinator of Health Information Technology (ONC)
■ Office of the General Counsel (OGC) ■ Office of the Assistant Secretary for Health (ASH)
■ Office of Global Health Affairs (OGHA) ■ The Surgeon General
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Copyright 2011 Craig B. Garner, Esq.
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59. HEALTH CARE OVERSIGHT IN CALIFORNIA
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Copyright 2011 Craig B. Garner, Esq.
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60. MAKING A HOSPITAL “GREEN”
The EPA estimates that hospitals use twice (maybe 2½ times) as much energy per
square foot as regular buildings.
Hospitals in the United States use 836 trillion BTUs of energy yearly (over 2½ times
the energy intensity and CO2 emissions of commercial office buildings), while
producing 28.575 million tons of CO2 and over 30 pounds of CO2 emissions per
square foot on an annual basis.
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Copyright 2011 Craig B. Garner, Esq.
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61. THE DIGITAL MEDICAL RECORD
As our nation continues to increase its drive toward electronic health care records,
including the protections afforded under the Health Insurance Portability and
Accountability Act (HIPAA), we must be mindful of the speed with which
technology changes, as well as the dilution of privacy expectations progressing from
generation to generation.
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Copyright 2011 Craig B. Garner, Esq.
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62. WHAT IS A MEDICAL EMERGENCY?*
Possible Medical Emergency Potential Symptoms
Heart Attack Chest discomfort; discomfort in other areas of the upper body,
including one or both arms; shortness of breath.
Uncontrolled Bleeding Just about all bleeding can be controlled, but shock or even
death may result if left unattended.
Altered Mental Status The individual may be unresponsive. This may include fainting,
unconsciousness or any other sudden change in mental status.
Commonly known as “respiratory distress,” this may include
Difficulty Breathing sudden breathlessness and/or severe shortness of breath.
In some cases, a person makes a sound, followed by unusual
Seizures stiffening, progressing to possible jerking of the arms and legs.
Serious or body-altering physical injury, including blunt force
Physical Trauma trauma to the head, neck, spine and/or abdomen.
*This list is not a substitute for an examination by a medical practitioner. If you
are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately.
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Copyright 2011 Craig B. Garner, Esq.
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63. CALLING 9-1-1 DURING A MEDICAL EMERGENCY*
A few examples of medical emergencies when it is imperative to call
9-1-1:
Anaphylaxis (life-threatening allergic reaction) Stroke
Chest pain Sudden blindness
Drug overdose Serious burns
Heart attack Bleeding that will not stop
Shortness of breath Broken bones with an open wound
A few examples of when 9-1-1 should not be called:
For information To get a ride to a doctor’s appointment
When the power goes out For paying tickets
To report a broken fire hydrant For your pet
When your water pipes burst As a prank
*This list is not a substitute for an examination by a medical practitioner. If you
are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately.
63
Copyright 2011 Craig B. Garner, Esq.
All rights reserved

64. Craig B. Garner
Craig is an attorney and health care consultant, specializing in issues surrounding modern American health care and the
ways it should be managed in its current climate of reform. Between 2002 and 2011, Craig was the Chief Executive Officer
at Coast Plaza Hospital where he was responsible for administration and oversight of this general acute care hospital
providing services to the City of Norwalk and surrounding communities in southeast Los Angeles County.
Craig is also the founder of a health care sustainability non-profit, Not So Much Foundation (www.notsomuch.org). Last
fall, he published his book Hospital Stay: Health Care Made Simple, a guide for patients and family members who find
themselves in the confusing confines of a hospital environment.
Craig serves on the advisory board for the College of Osteopathic Medicine of the Pacific, Western University of Health
Sciences, the Board of Directors of the Los Angeles Opera, and the Board of Visitors of Seaver College at Pepperdine
University.
Craig regularly writes specialized articles for various health care publications, and in January 2012 he will be teaching a
Hospital Law course at Pepperdine University School of Law.
1299 Ocean Avenue, Suite 400
Santa Monica, CA 90401
T. (310) 458-1560
E. craig@craiggarner.com
W. www.craiggarner.com
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Copyright 2011 Craig B. Garner, Esq.
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65. Additional Resources
http://www.healthcare.gov
http://www.cms.gov
http://www.dhcs.ca.gov
http://www.cdph.ca.gov
http://www.calhospital.org
http://www.craiggarner.com
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Copyright 2011 Craig B. Garner, Esq.
All rights reserved