In the area of long-term care, this creates a voluntary and national long-term care insurance program to help purchase services. In addition, this provides support for people who have functional limitations. This is done in order to help them maintain their personal and financial independence (CLASS program). PPACA requires that this be financed through voluntary payroll deductions (ibid 3-4). In the area of Medicaid and CHIP, PPACA expands Medicaid to all individuals under the age of 65 years of age to include incomes up to 133% of the federal poverty level. We will examine how this affects individual providers below. This will provides 100% federal funding to the states for the costs of newly eligible individuals for fiscal years 2014-2016. The Bill will increase the payments for primary care services that are provided by primary care physicians up to 100% of the Medicare payment rates for fiscal years 2013 and 2014. States will receive 100% of federal funding for increased payment rates if they maintain the current structure of the CHIP program. This will increase by 23% in the match rate in fiscal years 2015 through 2019 (ibid).

PPACA will have individual mandates that require most individuals to have a minimum acceptable coverage or the will be required to pay a tax penalty to begin in fiscal year 2014. The Bill allows exemptions for those who cannot afford this coverage (ibid, 2-11).

Under PPACA Employer mandates that employers with more than 50 full-time employees provide health care coverage or pay a penalty. The Act requires that employers offer coverage and make a contribution or to provide free choice vouchers to qualified employees for the purchase of qualified health plans through the exchanges (ibid).

PPACA mandates that there be premium subsidies to individuals and that there be refundable, advanceable and that there be sliding-scale premium credits for individuals and families with modified gross incomes up to 400% of the federal poverty level. The Act provides for small employer tax credits for 25 or fewer full-time employees. The average annual wages of their employees can be no more than $50,000 (ibid).

As PPACA has unfolded over the last two years, the incentives have decreased and the penalties have increased. The interplay of quality and cost is a focus of PPACA. The projection is that the PPACA will eventually be a cost-saving measure is rooted largely in the belief that high quality care costs less. PPACA expanded the PQRI initiative and most notably, will transform the incentive structure from a positive to negative feedback. Bonus payments for quality reporting will be reduced to 1% in 2011, and 0.5% in 2012 through 2014. Beginning in 2015, providers who do not meet reporting requirements will see a 1.5% reduction in Medicare reimbursement. That penalty will increase to 2% in 2016 and beyond (Mathe, Hettrich & Nunley, 2011). PPACA is not the only legislation that will affect health care providers. The American Recovery and Reinvestment Act of 2009 included in its body the Health Information Technology for Economic and Clinical Health (HITECH) Act. This law provides for incentive payments to healthcare providers who employ the "meaningful use" of certified EHR technology. This could prove to be as much as $18,000 (ibid).

PPACA also aims to increase the use of EHRs and other HI technologies, not only to healthcare reduce costs over the long-term. However, the aim is also to make quality reporting easier. An incentive structure was instituted to provide encouragement for the adoption of EHRs by healthcare providers. The PPACA also explicitly requires that the Secretary of the Department of Health and Human Services integrate reporting mechanisms for the PQRI into a meaningful use criteria. Meaningful use criteria will provide structure to the use of EHRs by healthcare providers (ibid).

The PPACA extends the incentives for EHR adoption and for meaningful use criteria adherence. In 2011 and 2012, providers will be able to earn up to a 1.5% bonus. This will decrease to 1% through 2014. Starting in 2015, there will be a 1% reduction in payments that will be applied for healthcare non-adopters. This will increase to 2% in 2016 and 3% in 2017. The total reduction in payments under PQRI and EHR provisons are not allowed to exceed 5% (ibid).

Obviously, these measures are meant to provide an incentive for patients and healthcare providers to spend less According to a Reuters/HCPlexus survey of 2958 doctors, 65% of them feel that the quality of U.S. healthcare will get worse over the next five years. Only 18% thought it would improve. According to their analysis, this translates into more work for already stressed out healthcare workers, less pay and logically However, according to More work, less pay and naturally worse care. That seems to be doctors' diagnosis of U.S. president Barack Obama's health care reform law, according to a new Thompson Reuters poll ("Mds fear healthcare," 2011) .

Doctors are were very pessimistic, to say the least about the PPACA's impact on their practices. In the poll, 78% of doctors said the PPACA has a negative impact on physician practices while only 8% said it has "positive" benefits. A mere 14% said that the PPACA would have a "neutral" effect on their practices. When it came to the patient care, 57% of physicians said that the PPACA would have a negative effect and only 27% believed the effect would be "positive." 15% believed the effect of the reform law would be "neutral" overall. The poll noted that the most optimistic groups were psychiatrists and pediatricians, with half in each believing in a positive outcome. Surgeons and ophthalmologists were the most pessimistic with both having the least positive responses and most negative responses. 74% believe the reforms of the ACA will make the reimbursement practices less fair with doctors and nurse practitioners getting closer levels of compensation in spite of differences in medical education levels between the jobs. Over 55% of physicians said that anyone newly insured would more likely be treated by nurse practitioners or physician assistants rather than by a primary care physician (ibid).

So, how well do the fears reflect present reality in the second year of PPACA? The Galen Institute, a research institute that favors free market healthcare published a study in April 2011. Almost every physician bemoans underpayments from insurance companies, Medicare and Medicaid and convoluted compensation schemes. Medicare's propensity to leverage its size to lower fees with providers is legendary and is touted as its hallmark advantage. Unfortunately, there is nothing free. These effects of these underpayments are shifted to patients in the form of shorter visits, reduced face time, shorter hospital stays and lower quality care. In essence, the Galen Institute is maintaining that rather than reforming the government's reimbursement system, PPACA merely expands its scope

("The new health," 2011, 1).

Logically, Medicare and Medicaid issues hit long-term care facilities such as nursing homes significantly. Therefore, they put more pressure on such facilities (as well as hospitals) that take large numbers of patients whose insurance baskets are made up partially or totally with Medicaid and Medicare as part of the coverage. Obviously, the effect upon family physicians will be marked with shorter visits and larger case loads. Family doctors responsible for writing patient discharge orders now feel even more pressure from social workers, case coordinators, department chiefs nurses and even hospital administrators. Specialized physicians will have less coverage for costly procedures and may have some of their services as written off as part of larger capitation fees. The present picture provided in the Galen Institute report essentially reflects the fears of the doctors in the Reuters poll. Medicare currently reimburses hospitals and doctors, approximately 71% and 81%, respectively, of private rates. Medicaid reimburses doctors even less, on average 56% of private rates (ibid, 3-5).

The above tendencies are even more so under PPACA. This is due to PPACA enrolling more people into the Medicaid system by increasing the threshold to 133% of poverty level ($29,327 for a family of four) (ibid, 9). Sections 110-1103 of Public law 111 -- 152 (Immediate Actions to Preserve and Expand Coverage) expands upon the insured pool

. This will put even more pressures upon physicians by expanding the pool to include drastically (Public law 111 -- 152, 2010).

In terms of hospitals, one of the most affected physician specialties will be internal medicine, due to the huge number of internists in the market across…