The insurance coverage provisions of the Affordable Care Act (ACA) will have a net cost of $1,168 billion over the 2012-2022 period—compared with $1,252 billion projected in March 2012 for that 11-year period—for a net reduction of $84 billion, the Congressional Budget Office (CBO) announced yesterday.

The projected net savings to the federal government is a result from the Supreme Court's decision allowing states to choose whether or not to expand eligibility for coverage under their Medicaid programs. The reductions in spending from lower Medicaid enrollment are expected to more than offset the increase in costs from greater participation in the newly established exchanges. CBO and the Joint Committee on Taxation (JCT) now estimate that fewer people will be covered by the Medicaid program, more people will obtain health insurance through the newly established exchanges, and more people will be uninsured. The magnitude of those changes varies from year to year.

In 2022, for example, Medicaid and the Children's Health Insurance Program (CHIP) are expected to cover about 6 million fewer people than previously estimated, about 3 million more people will be enrolled in exchanges, and about 3 million more people will be uninsured. These estimates are dominated by the movements of people losing eligibility for Medicaid. However, other smaller shifts in coverage also are expected to occur.

Federal spending over the 2012-2022 period for Medicaid and CHIP now is projected to be $289 billion less than previously expected, whereas the estimated costs of tax credits and other subsidies for the purchase of health insurance through the exchanges (and related spending) have risen by $210 billion. Small changes in other components of the budget estimates account for the remaining $5 billion of the difference.

The report issued yesterday does not include the budgetary impact of other provisions of the ACA.

Additionally, CBO and JCT found that the latest repeal bill (HR 6079) would cause a net increase in federal budget deficits of $109 billion over the 2013-2022 period. Specifically, they estimate that HR 6079 would reduce direct spending by $890 billion and reduce revenues by $1 trillion between 2013 and 2022, adding $109 billion to federal budget deficits over that period.

Older adults who have total hip replacement (THR) or total knee replacement (TKR) surgery are at an increased risk of heart attack, say authors of a study that included records of more than 95,000 Danish patients who underwent a primary THR or TKR from January 1, 1998, through December 31, 2007. 

During the first 2 postoperative weeks, the risk of heart attack was substantially increased in THR patients compared with controls (adjusted hazard ratio [HR] 25.5). The risk remained elevated for 2 to 6 weeks after surgery (adjusted HR, 5.05) and then decreased to baseline levels. For patients with TKR the risk of heart attack also was increased during the first 2 weeks (adjusted HR, 30.9) but did not differ from controls after the first 2 weeks. The absolute 6-week risk of heart attack was 0.51% in patients with THR and 0.21% in patients with TKR.

The authors say the association was strongest in patients 80 years or older. They could not detect a significantly increased risk in patients younger than 60 years. Additionally, a history of heart attack in the 6 months before surgery increased the risk of new heart attack during the first 6 weeks after THR and TKR surgery, but it did not affect the relationship between THR or TKR and heart attack.

Free, full text of the article is available in Archives of Internal Medicine.

Evidence is increasingly being used as a prerequisite for reimbursement of services and is an ongoing mandate for rehabilitation clinicians. The use of evidence-based practice also can ensure that the most effective treatments are being provided to patients, which is fundamental to cost-effective, appropriate care. On September 18, CARF International will host a 90-minute webinar that will review easy-to-use, easy-to-access options for accessing evidence for stroke rehabilitative services. Upon completion, webinar participants should be able to:

• Identify reliable research sources on stroke and stroke rehabilitation.

• Discuss the importance and challenges of knowledge translation.

• Identify tools that address the concepts of impairment, activity, and participation.

• Identify tools that clinicians can use to make their patients and clients aware of ongoing clinical trials.

Register today for Medical Rehabilitation Webinar: Current Stroke Research to Access and Use in Clinical Practice, September 18, noon to 1:30 pm, ET.

APTA is a member of CARF's International Advisory Committee.