Beyond Structured Settlements

Single-Claimant QSFs Revisited

Single-claimant qualified settlement funds (SCQSFs) represent one of the two most politically divisive issues within the structured settlement industry - with the National Structured Settlement Trade Association (NSSTA) opposing and the Society of Settlement Planners (SSP) promoting SCQSF use.

Tax expert Robert W. Wood , a prolific author, whose specialties include structured settlements and personal injury settlement planning, has published a new article in the June 23, 2014 of "Tax Notes" titled "Reprising Single-Claimant Qualified Settlement Funds".

QSFs, or section 468B funds, as explained in Wood's article, are designed to resolve litigation. "Their primary objective is to gather and administer cash or assets and determine the amounts and exact nature of payments that the plaintiffs, attorneys, and other claimants will receive..... QSFs benefit both plaintiffs and defendants alike. They are separate entities for federal income tax purposes and are flexible and easy to establish."

The benefits of QSFs are summarized in Section 3.08B of "Structured Settlements and Periodic Payment Judgments" (S2P2J): "defendants obtain a binding release from liability by making a currently-deductible payment into a court or government-approved Fund; while claimants, who have no tax consequence as a result of this payment into a Fund, are then afforded as much time as they need to sort out important issues of their own, such as allocating settlement shares, obtaining court approvals for minors or other legally-disabled claimants, resolving liens (which sometimes involve complex pay-back and set-aside issues as to Medicaid and Medicare), and deciding on forms of distribution (whether cash, structured settlements, or special needs trusts that may be used to preserve eligibility for certain government benefits)."

Wood has previously addressed SCQSF issues in multiple articles and conference presentations and, most significantly, in his 2009 legal textbook titled "Qualified Settlement Funds and Section 468B" . For background concerning Wood's views on SCQSFs, see these prior S2KM blog posts;

• Robert Wood and 468B Funds
• Robert Wood QSF Interview
• Robert Wood and 468B Funds - 2

Having surveyed the debate and framed the issues five years ago, at which time Wood concluded the proponents of SCQSFs had the better argument, Wood prefaces his new article by asking: "Has Anything Changed?"

Wood's new article:

• Reviews the legal background and arguments favoring and opposing SCQSFs as well as the requirements and advantages of QSFs.
• Confirms Wood's opinion favoring proponents' arguments for SCQSFs - while cautioning taxpayers to try to set up QSFs with multiple claimants:
  • "The language of the tax code and regulations suggests there should be no controversy."
  • "Reg. section 1.468B-1(c)(2) suggests the possibility of a single claim, mentioning 'one or more contested or uncontested claims' and an event giving rise to 'at least one claim asserting liability.'
  • "With the focus on the claim or claims, not the claimant or claimants, a plurality of claimants seems to be unimportant."
  • "Congress appears to have intended QSFs to operate as a statutory exception to both the economic benefit and constructive receipt doctrines."
• Highlights removal of the SCQSF issue (without IRS explanation) from the IRS priority guidance plan in 2009.
• Predicts the IRS is more likely to "establish some sort of antiabuse rule addressing the inappropriate use of QSFs to defer income rather than establishing a minimum number of plaintiffs or claimants."

Has Anything Changed?

Beyond removal of the issue from the IRS priority guidance plan, however, Wood's new article does not directly address his primary question: "Has Anything Changed" since 2009 that impacts the utilization of SCQSFs?

The answer is "Yes". Most significantly, unlike 2009, no structured settlement annuity providers currently accept SCQSFs. They have effectively shut down this strategic personal injury settlement planning opportunity for a wide scope of actual and/or potential structured settlement cases.

Prudential, for example, sent a communication to its structured settlement agents dated March 19, 2012 stating, in part:

• "Prudential recently reviewed its underwriting criteria with respect to single claimant QSF cases. As a result, effective immediately, we will no longer write cases stemming from a single claimant QSF."
• "Prudential defines a single claimant QSF as a fund either established for the benefit of a single claimant or, for multiple claimants who do not have “competing interests” (e.g., plaintiff family members). Prudential will not provide for “derivative” claims from the injured party, i.e., a loss of consortium or an emotional distress claim by the parents and/or siblings for the personal injury victim."
• "It is Prudential’s position that when the funds are deposited into a QSF for a single claimant, and there are no other factors to be negotiated under the settlement, the claimant has received economic benefit of the assets. Prudential does not consider lien holders or other non-claimant creditors (attorneys, medical providers, Medicare or Medicaid) as substantial additional obligations to be satisfied prior to the claimant’s ownership of the assets transferred to the QSF."

Despite the current closure of the SCQSF structured settlement market, SCQSF analysis and debate has expanded since 2009 - thanks significantly to Wood's SCQSF writing and speaking. Examples:

• Jeremy Babener's QSF Paper: "Structured Settlements and Single-Claimant Qualified Settlement Funds: Regulating in Accordance with Structured Settlement History". See:
  • Jeremy Babener's QSF Paper
  • S2KM Reviews Jeremy Babener's QSF Paper-1
  • S2KM Reviews Jeremy Babener's QSF Paper-2
  • Jeremy Babener Interview-2
• Martin Jacobson's QSF Presentation titled "The Ins and Outs of 468B Funds" at the NSSTA 2011 Annual Meeting wherein Jacobson identified what he termed "the real SCQSF questions":
  • Does a single claimant have economic benefit of the funds placed in the QSF?
  • Does the single claimant have "unqualified availability" of those funds?
  • Has IRC Section 130(c) been satisfied?
  • Is there going to be an IRS ruling applicable to single claimant QSFs?
  • In the continuing absence of such an IRS ruling, Jacobson quoted Robert Wood to "avoid the single claimant controversy" by establishing QSFs with multiple claimants.
• The Qualified Settlement Fund Symposium - For S2KM's reporting from the 2012 QSF Symposium, see these prior blog posts:
  • Part 1
  • Part 2

Opponents' Objections

Why do opponents object to SCQSFs - and why do they continue to broaden the scope of SCQSFs to encompass arguably multiple claims by family members, plaintiff attorneys, lien holders and creditors?

• Without more definitive tax clarification, structured settlement annuity providers are concerned about the original legislative intent of IRC section 468B, related economic benefit issues, and the potential litigation impact from lawsuits that could arise if SCQSFs are ruled invalid.
• Defendants and their insurers view structured settlements as valuable "needs analysis" and "bridge-the-gap" negotiating tools they would lose if single event personal injury cases were routinely resolved using QSFs.
• Defense brokers argue that SCQSFs will: 1) reduce the structured settlement market by eliminating defense incentive to promote structured settlements; and 2) eliminate defense broker commissions.

Although Robert Wood's most recent SCQSF article does not attempt to resolve these SCQSF objections (and they may not be resolvable), his SCQSF "reprising" hopefully will help motivate structured settlement and settlement planning stakeholders to better identify shared SCQSF interests and to seek further SCQSF tax clarification including what constitutes multiple claimants for purposes of IRC section 468B.

Government Medicaid Reports

Despite continuing evidence and predictions of expanded enrollment for private health insurance pursuant to the Patient Protection and Affordable Care Act (ACA), Medicaid planning, especially for long-term care costs, continues to represent a settlement priority for many past and present personal injury victims.

Medicaid is a means-tested program jointly funded by the Federal government and the states that provides health insurance to eligible low-income individuals. Each state manages its own Medicaid program with flexibility to determine eligibility and other criteria.

Two recent government reports addressing Medicaid issues should interest settlement planners and structured settlement consultants, as well as special needs and elder law attorneys.

CEA Medicaid Expansion Report

In addition to expanding private health insurance, the ACA also expanded eligibility for Medicaid by offering financial support to states that expand Medicaid eligibility to non-elderly individuals in families with incomes below 133 percent of the Federal Poverty Level. Through 2016, the Federal government has committed to paying participating states 100 percent of the related costs reducing to 90 percent in 2020 and subsequent years.

The U.S. Supreme Court ruled in 2012 that the Federal government could give states a choice to accept Medicaid expansion but could not require them to do so. To date, 26 states and D.C. have expanded Medicaid and 24 states have not. A political battle continues between President Obama's administration and states that have declined to expand Medicaid.

To promote further Medicaid expansion, the Council of Economic Advisers (CEA) published a report this month titled "Missed Opportunities: The Consequences of State Decisions Not to Expand Medicaid" (CEA report). The report states that 5.2 million people have gained Medicaid or CHIP coverage in states that have expanded Medicaid. It also cites an Urban Institute estimate that 5.7 million people will be deprived of health insurance coverage in 2016 if the other 24 states do not.

The CEA report concludes: "by expanding their Medicaid programs, States can improve access to essential medical care, reduce financial hardship, improve their citizens' mental health and longevity, and claim billions of dollars in Federal funding that could boost their economies today."

To quantify the benefits of expanded Medicaid to newly insured individuals, the CEA report relies on estimates from the Oregon Health Insurance Experiment (OHIE). The OHIE, which the CEA characterizes as "a unique research opportunity", resulted from Oregon's 2008 decision to allocate Medicaid coverage by lottery.

Acknowledging "[t]he limited sample size of the OHIE makes it more difficult to reach firm conclusions about the effect of Medicaid on objective measures of physical health", the CEA report also relies on parallel research literature that uses "quasi-experiments created by past policy changes."

The CEA report quantifies the following purported benefits for newly insured individuals on a state-by-state basis with supporting maps and tables:

• Improved access to care
• Greater financial security
• Better mental and overall health

In addition, the CEA report utilizes data from the Congressional Budget Office and Urban Institute to quantify the following projected benefits of expanding Medicaid for state economies with supporting state-specific maps and tables:

• Additional Federal funds
• Increased employment
• Greater overall economic activity

CEA Report Criticism

Perhaps predictably, given the political debate that surrounds the ACA and Medicaid expansion, many commentators have criticized the CEA report. One example is Robert Samuelson, whose op-ed titled "The Real Medicaid Problem" appeared in the July 14, 2014 issue of the Washington Post.

Samuelson questions whether the promised 90 percent Federal reimbursement rate will remain permanent. He quotes Matt Salo of the National Association of Medicaid Directors: “The ACA says what it says. Future Congresses can repeal or modify it.”

Samuelson also points out how demographic trends ("ignored by the [CEA] report") could become a financial albatross for the states. As one result of rising Medicaid costs, according to Samuelson, "[t]he competition between nursing homes and home health care — on the one hand — and classroom teachers, higher education, police and other governmental services — on the other — will intensify."

In a similar critique, a July 11, 2014 Wall Street Journal article , written by Chris Jacobs and titled "Why States are Hesitating to Expand Medicaid", highlights a recent study of "State Healthcare Spending on Medicaid" sponsored by the Pew Charitable Trusts and findings by the Commerce Department’s Bureau of Economic Development to explain why many states have not rushed to expand Medicaid.

For a state-specific example (Virginia) of opposing political viewpoints concerning Medicaid expansion, compare this July 11, 2014 Wall Street Journal op-ed by Fred Barnes with this July 11, 2014 Washington Post editorial.

GAO Medicaid Report

The Government Accountability Office (GAO) has also published a recent Medicaid report titled "Medicaid: Financial Characteristics of Approved Applicants and Methods Used to Reduce Assets to Qualify for Nursing Home Coverage" which may prove cause for concern among special needs and elder law attorneys.

As justification for its study, which was requested by Senators Tom Coburn (R-OK) and Richard Burr (R-NC) and Representatives Darrell Issa (R-CA) and Trey Gowdy (R-SC), the GAO points out:

• "Medicaid paid for nearly one-third of the nation’s $158 billion in nursing home expenditures in 2012"; and
• Many individuals utilize various planning techniques to reduce their assets and qualify for Medicaid - despite continuing efforts by Congress to discourage such activity and to address financial eligibility requirements for Medicaid coverage of nursing home care. See, for example "The Deficit Reduction Act of 2005".

Historically, many special needs and elder law attorneys have devised these asset reduction techniques and advised their clients when and how to utilize them.

In responding to the Congressional request for information about the extent of asset reduction techniques to qualify for Medicaid nursing home coverage, the GAO report:

• Examined financial characteristics of applicants approved for Medicaid nursing home coverage in selected states; and
• Identified methods used to reduce countable assets to qualify for Medicaid as well as information state Medicaid workers consider most useful in assessing an applicants’ financial eligibility.

Among its findings, the GAO report identifies four main methods used by applicants to reduce their countable assets (income and resources) and qualify for Medicaid coverage:

• "Spending countable resources on goods and services that are not countable towards financial eligibility, such as prepaid funeral arrangements;
• "Converting countable resources into noncountable resources that generate an income stream for the applicant, such as an annuity or promissory note;
• "Giving away countable assets as a gift to another individual—such gifts could lead to a penalty period that delays Medicaid nursing home coverage; and
• "For married applicants, increasing the amount of assets a spouse remaining in the community can retain, such as through the purchase of an annuity."

NAELA Response

Promising a thorough analysis of the GAO report, the National Academy of Elder Law Attorneys (NAELA) has responded with a press release recommending the GAO report as "a starting point for an urgent review of the long-term crises that millions of Americans and their families are facing."

The GAO report, according to NAELA, "highlights the impact of a public policy that requires persons needing long-term services and supports for chronic diseases such as dementia, ALS, and Parkinson's to impoverish themselves to be eligible for treatment under Medicaid while those with heart disease and more acute maladies receive health care coverage through Medicare."

For additional NAELA resources addressing long-term care and Medicaid, see:

• NAELA position paper
• "Myths and Realities about Medicaid Planning"

For additional S2KM reporting about Medicaid and the ACA, see the structured settlement wiki.

 

ACA and Future Medical Expenses - 3

Is the Affordable Care Act (ACA) good or bad for structured settlements? What impact will it have on settlement planning in personal injury cases?

Four years following the ACA's enactment, and two years after the U.S. Supreme Court upheld its primary provisions as constitutional, including the individual mandate and elimination of pre-existing condition restrictions which became effective nationally on January 1, 2014, those questions not only lack definitive unanswers - they have not yet been comprehensively addressed in any public forum.

One primary related issue is what impact the ACA will have upon future medical expenses in personal injury cases. The answer depends, however, not only on the terms and conditions of the ACA, but also on how the ACA interacts with other related laws and legal developments such as Medicaid (including the Bipartisan Budget Act of 2013), Medicare (including WCMSAs , liability MSAs and MMSEA) as well as state specific collateral source and subrogation rules.

To provide a point of reference for future S2KM reporting about the legal interplay involving the ACA, personal injury cases and structured settlements, S2KM is publishing a series of blog posts looking generally at the "ACA and Future Medical Expenses":

• Part 1 reviews an article written by Seth Cardeli, titled "Thwart the Assault on Future Medical Expenses", which appeared in the May 2014 issue of the American Association for Justice (AAJ) Trial Magazine.
• Part 2 summarizes ACA-related analysis by speakers at professional conferences S2KM has previously attended and includes excerpts from prior S2KM reviews of those conferences.
• Part 3 (this post) summarizes similar ACA analysis from articles and papers previously reviewed by S2KM and also features excerpts from those reviews.

Authors of Articles and Papers Addressing ACA Issues

NAELA Journal

NAELA devoted the entire Spring 2011 edition of its "NAELA Journal" to health care reform generally and the ACA more specifically. Available to NAELA members only, this NAELA analysis featured a detailed introduction by NAELA Journal's then Editor-in-Chief William J. Brisk plus eight articles and a supplement of online resources.

• Brisk's introduction addressed why health care reform is "too significant to ignore" and highlighted its most important features. His analysis identified what the ACA actually does and does not accomplish and emphasized the important roles Medicare, Medicaid, private health insurance companies and health maintenance organizations will play in implementing health care reform.
• Additional NAELA Journal topics and authors:
  • Health Care Changes: Challenges to Medicare - Vicki Gottlich, Patricia Nemore, and Alfred J. Chiplin Jr.;
  • The New CLASS Act - Morris Klein;
  • Nursing Home Regulations - Charles Perez Golbert;
  • Health Care Reform’s Impact on Small Businesses and Individuals - Ben A. Neiburger;
  • Health Care Reform and End-of-Life Issues - Fay Blix;
  • The Affordable Care Act’s Changes to Medicaid’s Coverage for Long-Term Services and Supports - Gene Coffey;
  • Health Insurance Reforms: Once In a Lifetime Change or Same as It Ever Was? - Lucinda E. Jesson;
  • Medicaid Expansion Under the 2010 Health Care Reform Legislation: The Continuing Evolution of Medicaid’s Central Role in American Health Care - Renée M. Landers and Patrick A. Leeman;
  • Online Resources Available to Supplement Health Care Reform Discussion - prepared by Claire DeMarco.

Alfred Chiplin, Jr. and Bethany Lilly

In addition to the Spring 2011 edition of the NAELA Journal, NAELA awarded its 2014 John Regan Writing Award, honoring the authors of the best article published in the "NAELA Journal" during the past year, to Alfred Chiplin, Jr. and Bethany Lilly, for their 2013 article titled "Medicare’s Future: Letting the Affordable Care Act Work, While Learning From the Past" analyzing various ACA cost-saving components on Medicare.

Chiplin and Lilly begin their article with an extensive review of the historical debate concerning public health insurance in the United States including a summary of key components of the current Medicare system and current concerns about Medicare solvency.

This historical debate not only defines the current structure of the Medicare program but also, according to Chiplin and Lilly, "the on-going debate ... about the necessary elements of a comprehensive program, including health care financing and accessing the quality of necessary services."

Chiplin and Lilly provide statistical evidence to highlight the negative impact of rising health care costs on Medicare and Medicare beneficiaries as well as the United States economy. Following their historical and statistical summaries, Chiplin and Lilly address the central issue in their article: "how will the ACA reduce health care costs?"

The ACA's cost-containment programs, according to Chiplin and Lilly, are based upon the theory that costs can be reduced by demanding a higher quality of care and greater efficiency from providers and allowing providers to share in the savings. ACA programs the authors highlight include:

• Patient-Centered Medical Home
• Medicare Shared Savings Program
• The Independent Payment Advisory Board
• Quality Review Mechanisms.

Chiplin and Lilly view ACA as "a vast experiment in paying for high-quality health care while preserving the Medicare program and expanding access to health care for other population segments." Implementation will be a tough, but doable challenge so long as we "let the tools of the ACA work".

Among the implementation challenges: the "fiscal cliff", insurance exchanges, and integrating services for "dual-eligibles". Overtime, the authors believe the ACA's spending and cost-containment provisions should at least slow the health care spending curve.

Seth Cardeli

The impact of the ACA on future medical expenses, perhaps the most important ACA-related issue for personal injury stakeholders, including settlement planners and structured settlement professionals, was addressed most recently by plaintiff attorney Seth Cardeli in an article  featured in the May 2014 issue of the AAJ's Trial Magazine, and summarized by S2KM, titled "Thwart the Assault on Future Medical Expenses".

In his article, Cardeli labels as "speculative and misleading" current defense efforts to convince courts the ACA changed how courts should calculate future medical expenses thereby transforming the ACA into "the latest tort 'reform' vehicle." Their efforts should fail, Cardeli maintains, because they wrongly attempt to circumvent states' collateral source and subrogation rules.

Cardeli's article cites cases from several state venues where courts have rejected defendants' attempts to limit plaintiff evidence of future medical expenses or to present their own evidence of ACA-related health care coverage. He urges plaintiff attorneys to aggressively oppose all related motions in limine by arguing:

• The effect of the ACA on a plaintiff's recoverable future medical expenses is speculative.
• Evidence of collateral sources is prejudicial to personal injury plaintiffs.
• Tortfeasors should bear the risk that any future medical expenses will not be covered by medical insurance.

Joshua Congdon-Hohman and Victor Matheson

A 2012 research paper titled "Potential Effects of the Affordable Care Act on the Award of Life Care Expenses" and written by economists Joshua Congdon-Hohman and Victor Matheson provides a notable counter argument to Seth Cardeli's Trial Magazine article. Contrary to Caredi, these economists maintain: "the ACA may well have indirectly resulted in a great deal of tort reform" and, as a result, "awards in personal injury cases could be dramatically impacted".

Their argument:

• When the ACA is fully implemented in 2014, all individuals will be required to purchase health insurance or pay a penalty.
• The ACA provides insurance premium subsidies for low income individuals who do not receive health insurance through the government or from a family member’s employer.
• The ACA prevents price discrimination based on health status and bans annual and lifetime expenditure limits.
• Most individuals will pay the same cost for health insurance before and after an accident.
• The legal maximum out-of-pocket expenses allowable under the ACA is $5,950 per year.
• The goal of tort law is to make the plaintiff "whole".
• Funding of health care through private insurance is a valid methodology for accomplishing this goal now that the ACA makes those markets available to injury victims.
• Therefore, the ACA:
  • Should simplify and reduce calculations of future medical damages;
  • By limiting those costs to "[health insurance] premiums and out-of-pocket limits less any pre-injury expected medical costs and penalties if uninsured."

Similar to Cardeli, and significantly, Congdon-Hohman and Matheson acknowledge a collateral source issue is "at play" and "remains of significant importance". Unlike Cardeli, however, they argue "there is reason to believe the ACA changes the underlying reason of excluding collateral source compensation from inclusion in tort cases."

More specifically, Congdon-Hohman and Matheson maintain: "removing existing health insurance coverage from exclusion under the collateral source rule would not significantly affect health insurance coverage rates reducing the economic rationale for having a collateral source rule in place for health insurance."

As a related result of the ACA, Congdon-Hohman and Matheson believe life care planners will play an increasingly important role in personal injury damage analysis.

• Prior to the ACA, life care planners were tasked with identifying medical and living expenses not otherwise required "but for" the accident.
• Under the ACA, the authors maintain life care planners must also identify which health care and living expenses will, and will not, be covered by the ACA's minimum insurance requirements. And, despite certain minimum federal standards, these requirements may also differ by state.

Rebecca Levenson and Ann Levin

During 2013, S2KM reviewed two law review articles which address whether and how the ACA will impact the collateral source rule (CSR):

• Rebecca Levenson (Levenson), "Allocating the Costs of Harm to Whom They are Due: Modifying the Collateral Source Rule after Health Care Reform" (Levenson article), University of Pennsylvania Law Review, Volume 160.
• Ann S. Levin (Levin), "The Fate of the Collateral Source Rule After Health Care Reform" (Levin article), UCLA Law Review, Volume 60.

Although every state and federal court recognizes the CSR in some form, many states have limited its scope or abolished it completely as a result of tort reform. Plaintiffs in different states and/or different courts therefore can receive widely different damage awards for the same injury because different courts measure medical costs differently.

Levenson and Levin each summarize traditional arguments favoring and opposing the common law CSR. However, neither Levin nor Levenson:

• Directly address whether and/or how the CSR will affect calculations of future medical damages, as opposed to past medical damages.
• Discuss how the ACA's restrictions against pre-existing conditions impact calculations of medical damages.

CSR proponents emphasize the deterrence theory of tort law which seeks to punish tortfeasors and deter them from injuring future plaintiffs:

• Defendants should not be unjustly enriched if a plaintiff purchases medical insurance.
• The CSR incentivizes plaintiffs to purchase medical insurance.
• Collateral sources never fully reimburse plaintiffs.
• Subrogation rights reduce and/or prevent double recoveries.
• The CSR promotes independence of jury determinations.

CSR opponents argue the purpose of tort law is compensation for harm not deterrence. They criticize the CSR for:

• Allowing some plaintiffs to recover twice.
• Generating different damage awards for the same injuries in different cases.
• Adding an unjustified element of punitive damages.
• Inflating awards.
• Encouraging claimants to go to trial.

Both Levenson and Levin agree the ACA's individual mandate weakens the traditional common law CSR rationale and that medical damages should now be calculated differently. However they do so for different reasons and propose different solutions.

• Levin - Levin's primary argument for changing the traditional common law CSR is that it calculates medical damages based on medical provider bills instead of the lower negotiated reimbursement rate paid by most health insurers. To achieve fairness and accuracy post-ACA, Levin maintains courts should calculate medical damages using: 1) the negotiated reimbursement rate; and 2) a portion of the premium payments the plaintiff has paid for medical insurance.
• Levenson - The purpose of changing the CSR after the ACA, according to Levenson, should be to align the CSR's outcome with the underlying goal of the individual mandate. Whether and what changes will occur, however, will vary from jurisdiction to jurisdiction depending upon a number of factors which Levenson identifies including the current status of the CSR in a particular state. Levenson insists any changes in the CSR must account for the different groups affected: insured plaintiffs, willfully uninsured plaintiffs and exempt plaintiffs.

Conclusion

For personal injury and settlement planning professionals who are attempting to understand how the ACA impacts personal injury damage analysis, future medical expenses, negotiation strategy, work product, and funding options, this S2KM blog series hopefully captures some of the complexity of the related laws, issues and perspectives and encourages continuing and more comprehensive analysis.

The impact of the ACA on structured settlements, and settlement planning more generally, depends not only upon the terms and conditions of the ACA itself, but also upon the new and evolving legal construct for future medical expenses in personal injury cases created by the interaction of the ACA with these related laws and legal developments.

For S2KM's continuing coverage of ACA-related issues, see the structured settlement wiki.