Misplaced Pages

Affordable Care Act: Difference between revisions

Article snapshot taken from Wikipedia with creative commons attribution-sharealike license. Give it a read and then ask your questions in the chat. We can research this topic together.
Browse history interactively← Previous editNext edit →Content deleted Content addedVisualWikitext
Revision as of 12:04, 8 May 2013 view sourceFamspear (talk | contribs)Extended confirmed users, Rollbackers31,315 editsm Reverted edits by 204.38.187.17 (talk) to last version by Yobot← Previous edit Revision as of 00:55, 10 May 2013 view source Marinac789 (talk | contribs)1 editm UGHTag: blankingNext edit →
Line 1: Line 1:
OBAMACARE IS STUPID
{{Use American English|date=July 2012}}{{Use MDY dates|date=July 2012}}
{{Merge from|Health care reform in the United States|discuss=Talk:Patient Protection and Affordable Care Act#Health care reform in the United States article and this article|date=March 2013}}
{{Infobox U.S. legislation
| name = Patient Protection and Affordable Care Act
| fullname = The Patient Protection and Affordable Care Act
| acronym = PPACA
| nickname = Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare
| enacted by = 111th
| effective date = March 23, 2010<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020
| public law url = http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html
| cite public law = 111–148
| cite statutes at large = 124 Stat. 119 ''through'' 124 Stat. 1025 (906 pages)
| acts amended =
| title amended =
| sections created =
| sections amended =
| leghisturl = http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@S
| introducedin = House
| introducedbill = '''the''' "Service Members Home Ownership Tax Act of 2009" ({{USBill|111|H.R.|3590}})
| introducedby = ] (]–])
| introduceddate = September 17, 2009
| committees = ]
| passedbody1 = House
| passedas1 = "Service Members Home Ownership Tax Act of 2009"
| passeddate1 = October 8, 2009
| passedvote1 =
| passedbody2 = Senate
| passedas2 = "Patient Protection and Affordable Care Act"
| passeddate2 = December 24, 2009
| passedvote2 =
| agreedbody3 = House
| agreeddate3 = March 21, 2010
| agreedvote3 =
| signedpresident = ]
| signeddate = March 23, 2010
| amendments = ]<br />Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011
| SCOTUS cases = '']''
}}


IT IS POINTLESS
The '''Patient Protection and Affordable Care Act''' ('''PPACA'''),<ref>{{USPL|111|148}}, {{USStat|124|119}}, to be codified as amended at scattered sections of the ] and in ]</ref> commonly called '''Obamacare'''<ref name="CNN20120625Obamacare" /><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/article/2012/mar/20/romneycare-and-obamacare-can-you-tell-difference/ |title=RomneyCare & ObamaCare: Can you tell the difference? |last=Holan |first=Angie D. |author= |authorlink= |date=March 20, 2012 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> or the '''Affordable Care Act''', is a ] ] signed into law by ] ] on March 23, 2010. Together with the ], it represents the most significant government expansion and regulatory overhaul of the ] since the passage of ] and ] in 1965.<ref name=overhaul>{{cite news|url=http://www.reuters.com/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628|title=US top court upholds healthcare law in Obama triumph|publisher=Reuters|author=James Vicini and Jonathan Stempel|date=June 28, 2012}}</ref>


The PPACA is aimed at increasing ] and reducing the overall costs of health care. It provides a number of mechanisms—including ], ], and ]—to employers and individuals to increase the coverage rate.<ref name="nyt-critics">{{cite news |newspaper=] |title= Health Law Critics Prepare to Battle Over Insurance Exchange Subsidies |url=http://www.nytimes.com/2012/07/08/us/critics-of-health-care-law-prepare-to-battle-over-insurance-exchange-subsidies.html |first=Robert |last=Pear |date=July 7, 2012 |accessdate=July 7, 2012}}</ref><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/statements/2010/feb/04/paul-krugman/krugman-calls-senate-health-care-bill-similar-law-/ |title=Krugman calls Senate health care bill similar to law in Massachusetts |last=Krugman |first=Paul |author= |authorlink= |date=January 31, 2010 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> Additional reforms aim to improve healthcare outcomes and streamline the delivery of health care. The PPACA requires insurance companies to ] and ] regardless of ]s or sex.<ref>{{cite news |title=Supreme Court Upholds Heart of Obama Health Care Law Seeking to Cover 30 Million Uninsured |author=Hearst, Steven R. |url=http://www.montrealgazette.com/news/Supreme+Court+upholds+heart+Obamacare/6854896/story.html |newspaper=The Gazette |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=ObamaCare Survives the Supreme Court: 5 Takeaways |url=http://theweek.com/article/index/229985/obamacare-survives-the-supreme-court-5-takeaways |newspaper=The Week |date=June 28, 2012 |accessdate=June 30, 2012}}</ref> The ] projected that the PPACA will lower both future deficits<ref>{{cite web |url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/121xx/doc12119/03-30-healthcarelegislation.pdf |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |author=Elmendorf, Douglas W. |date=March 30, 2011 |publisher=] |format=PDF |accessdate=July 15, 2012}}</ref> and ] spending.<ref>{{cite web |url=http://cbo.gov/sites/default/files/cbofiles/attachments/06-21-Long-Term_Budget_Outlook.pdf |title=CBO's 2011 Long-Term Budget Outlook |author=Elmendorf, Douglas W. |date=June 2011 |page=44 |publisher=] |format=PDF |quote=Through those changes and numerous others, the 2010 legislation significantly decreased Medicare outlays relative to what they would have been under prior law.}}</ref>


On June 28, 2012, the ] upheld the constitutionality of most of the PPACA in the case '']''.<ref>{{cite news |title=Supreme Court Supports Obamacare, Bolsters Obama |last=Barrett |first=Paul M. |url=http://www.businessweek.com/articles/2012-06-28/supreme-court-supports-obamacare-and-bolsters-obama |newspaper=BloombergBusinessweek |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=Obamacare upheld by the U.S. Supreme Court |author=National Post Wire Services |url=http://news.nationalpost.com/2012/06/28/obamacare-upheld-by-the-u-s-supreme-court/ |newspaper=National Post |date=June 28, 2012 |accessdate=June 30, 2012}}, including a major provision which requires all Americans purchase health insurance coverage.</ref>


==Overview==


===Provisions===
]
]
]<ref name="private_pp" /> (Source: ])]]


The PPACA includes numerous provisions to take effect over several years ]. There is a ] on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies.
* ] will require policies to be issued regardless of any medical condition, and partial ] will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most ]s (excluding ] use).<ref>{{cite press release|url=http://www.bcbsm.com/healthreform/pubs/ppaca_insurance_reform_2014.pdf |title=2014 Insurance Reforms under the Patient Protection and Affordable Care Act (PPACA) |publisher=Blue Cross Blue Shield of Michigan |date= |accessdate=2012-04-09}}</ref><ref>{{cite web|last=Pool |first=Gentrie |url=http://www.asjonline.com/Exclusives/2010/10/Pages/After-PPACA-The-Future-of-the-Health-Insurance-Underwriter.aspx |title=After PPACA: The Future of the Health Insurance Underwriter &#124; LifeHealthPro |publisher=Asjonline.com |date=2010-10-07 |accessdate=2012-04-09}}</ref><ref>{{cite web|title=Selected Patient Protection and Affordable Care Act (PPACA) implementation dates of interest to RNs as caregivers, RNs as patients, and RNs as employees |url=http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Health-Care-Reform-Legislation-Timeline.pdf |publisher=Nursingworld.org |date= |accessdate=2012-04-09}}</ref>
* A shared responsibility requirement, commonly called an ],<ref>{{cite press release|url=http://www.perkinsaccounting.com/our-story/litigation-support-accounting-firm-newsroom/perkins-news-bulletin/health-insurance-legislation/health-insurance-legislation-mandates.html |title=Perkins Accounting Firm Newsroom Bulletin Health Insurance Legislation Mandates |publisher=Perkinsaccounting.com |date= |accessdate=2012-04-09}}</ref><ref>{{cite news|last=Keely |first=Cheryl |url=http://www.lexisnexis.com/community/emergingissues/blogs/spotlightonhealthcarereform/archive/2010/12/13/federal-judge-rejects-commerce-clause-argument-finds-ppaca-health-insurance-individual-mandate-is-unconstitutional.aspx |title=Federal Judge Rejects Commerce Clause Argument, Finds PPACA Health Insurance Individual Mandate is Unconstitutional |publisher=Lexisnexis.com |date=2010-12-13 |accessdate=2012-04-09}}</ref> requires that all individuals not covered by an ], ], ] or other public insurance programs, secure an approved private-insurance policy or pay a penalty, unless the applicable individual is a member of a recognized religious sect exempted by the ], or waived in cases of financial hardship.<ref name="ksr_hlth" />
* ]s will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).<ref>{{cite web|url=http://www.healthcare.gov/law/provisions/exchanges/index.html |title=Affordable Insurance Exchanges |publisher=HealthCare.gov |date=August 18, 2011|accessdate=January 9, 2012}}</ref>
* Low-income individuals and families above 100% and up to 400% of the ] will receive ]<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7962-02.pdf |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |publisher=Kaiser Family |month=April|year=2010 |accessdate=April 1, 2012}}</ref> on a ] if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income).<ref>{{cite web|author=Peter Grier |url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance |title=Health care reform bill 101: Who gets subsidized insurance? |work=]|date=March 20, 2010|accessdate=January 9, 2012}}</ref>
* The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of ], effectively 138%, and simplifies the ] enrollment process. In '']'', the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this may create a coverage gap in those states.<ref>{{cite web |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart/ |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |publisher=The Washington Post |accessdate=July 15, 2012}}</ref><ref>{{cite web|url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and Medicaid Expansion|publisher=HealthCare Reform Magazine|date=July 13, 2010 |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf|title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |date= |accessdate=April 1, 2012}}</ref>
* Minimum standards for health insurance policies are to be established and annual and lifetime coverage caps will be banned.<ref>{{cite press release|url=http://www.hhs.gov/news/press/2011pres/07/20110711a.html |title=HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress |publisher=Hhs.gov |date=2011-07-11 |accessdate=2012-04-09}}</ref><ref>{{cite web|url=http://www.naic.org/documents/committees_b_Exchanges.pdf |title=Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges |publisher=National Association of Insurance Commissioners |date=2010-04-20 |accessdate=2012-04-09}}</ref><ref>{{cite press release|url=http://www.familiesusa.org/health-reform-central/september-23/Annual-and-Lifetime-Limits.pdf |title=The Patients' Bill of Rights: Ending annual and lifetime limits |publisher=FamiliesUSA |date=2010-09 |accessdate=2012-04-09}}</ref>
* Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7907.pdf |title=Explaining Health Care Reform: What is Employer 'Pay-or-Play' Requirement?|year=2009|month=May|publisher=]|accessdate=January 9, 2012}}</ref><ref name=WSJ-mar25>{{cite news |title=What Health Overhaul Means for Small Businesses |author=McNamara, Kristen |url=http://online.wsj.com/article/SB10001424052748703312504575141533342803608.html |newspaper=The Wall Street Journal |date=March 25, 2010}}</ref>
* Very small businesses will be able to get subsidies if they purchase insurance through an exchange.<ref>{{cite web|url=http://www.irs.gov/newsroom/article/0,,id=223666,00.html |title=Small Business Health Care Tax Credit for Small Employers |publisher=Internal Revenue Service|date=December 13, 2011 |accessdate=January 9, 2012}}</ref>
* ], ], and ]s are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package"<ref>{{cite web|url=http://www.healthcare.gov/glossary/e/essential.html |title=Essential Health Benefits – Glossary |publisher=HealthCare.gov |date=September 23, 2010|accessdate=January 9, 2012}}</ref> for Level A or Level B ].<ref>
{{cite web |url=http://www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |title=Reform Law Will Require New Plans to Cover Preventive Care and Limit Out-of-Pocket Expenses |accessdate=April 4, 2010|date=April 2, 2010|publisher=Society for Human Resource Management |archiveurl=http://webcache.googleusercontent.com.nyud.net/search?q=cache:OL8orVWxAhIJ:www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |archivedate=March 28, 2012}}{{dead link|date=June 2012}}</ref><ref>
{{cite web |url=http://www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |title=Understanding health reform's Essential Benefits |accessdate=April 4, 2012|date=April 4, 2012|publisher=HealthInsurance.org}}</ref>
* Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "]."<ref>{{cite web|url=http://www.medscape.com/viewarticle/748502 |title=Access |publisher=Medscape |date= |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.huronconsultinggroup.com/researchdetails.aspx?articleId=2577 |title=Key Healthcare Reform Initiatives: Medicare Bundled Payment Pilots |publisher=Huron Consulting Group |date=November 19, 2010 |accessdate=January 9, 2012}}</ref> A single payment is paid to a hospital and a physician group, for example, for a defined episode of care (such as a hip replacement), rather than individual payments to individual service-providers.


===Funding===
The PPACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened ] on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% ] on ]. The income levels are not adjusted for inflation, leaving the possibility of increased taxes on incomes over 250,000 inflation-adjusted dollars after more than two decades without indexing through.<ref>, ''Wall Street Journal'' November 6, 2009.</ref> There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal ] on ]. Offsets are from intended cost savings such as changes in the ] program relative to traditional Medicare.<ref>{{cite web |url=http://www.csmonitor.com/USA/Politics/2010/0321/Health-care-reform-bill-101-Who-will-pay-for-reform |title=Health care reform bill 101: Who Will Pay for Reform? |author=Grier, Peter |date=March 21, 2010 |publisher=]}}</ref>


Summary of tax increases: (ten-year projection)
* Increase Medicare tax rate by .9% and impose added tax of 3.8% on unearned income for high-income taxpayers: $210.2&nbsp;billion
* Charge an annual fee on health insurance providers: $60&nbsp;billion
* Impose a 40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family: $32&nbsp;billion
* Impose an annual fee on manufacturers and importers of branded drugs: $27&nbsp;billion
* Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20&nbsp;billion
* Raise the 7.5% ] floor on ] to 10%: $15.2&nbsp;billion
* Limit annual contributions to ] in ]s to $2,500: $13&nbsp;billion
* All other revenue sources: $14.9&nbsp;billion
Summary of spending offsets: (ten year projection)
* Reduce funding for Medicare Advantage policies: $132&nbsp;billion
* Reduce Medicare home health care payments: $40&nbsp;billion
* Reduce certain Medicare hospital payments: $22&nbsp;billion


Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17&nbsp;billion, but the provision was repealed.<ref>{{cite news|last=Rubin |first=Richard |url=http://www.bloomberg.com/news/2011-04-14/obama-signs-law-repealing-business-tax-reporting-mandate-1-.html |title=Obama Signs Law Repealing Business Tax Reporting Mandate |publisher=Bloomberg |date=April 14, 2011 |accessdate=April 1, 2012}}</ref>


==Provisions by effective date==
The PPACA is divided into 10 titles<ref>] from Wikisource.</ref> and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020.<ref name='Kypost'>{{cite news|url=http://www.kypost.com/mostpopular/story/Key-Points-Of-The-Health-Care-Reform-Bill/GYwbvispwEy36LI05K_9Cg.cspx |title=Key Points Of The Health Care Reform Bil|accessdate=2010-03-22|newspaper=The Kentucky Post}}{{Dead link|date=March 2011}}</ref><ref name='Top 18'>{{cite news | first=Jeremy | last=Binckes | coauthors= Nick Wing |authorlink= | title=The Top 18 Immediate Effects Of The Health Care Bill | date=2010-03-22 | url =http://www.huffingtonpost.com/2010/03/22/the-top-18-immediate-effe_n_508315.html#s75147 | work =The Huffington Post | pages = | accessdate = 2010-03-22 | language = }}</ref> Below are some of the key provisions of the PPACA. For simplicity, the amendments in the ] are integrated into this timeline.<ref>{{Cite news |url=http://www.nytimes.com/interactive/2009/11/19/us/politics/1119-plan-comparison.html |title=Comparing the House and the Senate Health Care Proposals |newspaper=The New York Times |date=March 23, 2010 | first1=Farhana | last1=Hossain | first2=Archie | last2=Tse | accessdate=May 21, 2010}}</ref><ref name="CRFB">{{cite web |url=http://crfb.org/blogs/updated-health-care-charts |title=Updated Health Care Charts |publisher=Committee for a Responsible Federal Budget |date=November 19, 2009 }}</ref>


===Effective at enactment===


* The ] is now authorized to approve generic versions of ] drugs and grant biologics manufacturers 12&nbsp;years of exclusive use before generics can be developed.<ref name='ksr_list1'>{{cite web|url=http://www.kff.org/healthreform/8060.cfm|title=Health Reform Implementation Timeline|accessdate=2010-03-30|publisher=Kaiser Family Foundation}}</ref>
* The Medicaid drug ] (paid by drug manufacturers to the states) for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.<ref name='ksr_list1' />
* A non-profit ] is established, independent from government, to undertake ].<ref name='ksr_list1' /> This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.<ref>{{cite web|url=http://today.msnbc.msn.com/id/36135106/ns/health-health_care/ |title=True or false? Top 7 health care fears - TODAY Health - TODAY.com |publisher=msnbc.com |date=2010-02-04 |accessdate=2012-01-09}}</ref> The bill forbids the Institute to develop or employ "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's ].
* Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.<ref name='ksr_list1' />
* The Indian Health Care Improvement Act is reauthorized and amended.<ref name='ksr_list1' />
* ] restaurants and food vendors with 20 or more locations are required to display the ] of their foods on menus, drive-through menus, and vending machines. Additional information, such as ], ], and ] content, must also be made available upon request.<ref name='Nutrition'>{{cite news | first=Jean | last=Spencer | title=Menu Measure: Health Bill Requires Calorie Disclosure | date=2010-03-22 | work =The Wall Street Journal | url =http://blogs.wsj.com/washwire/2010/03/22/menu-measure-health-bill-requires-calorie-disclosure/|accessdate = 2010-03-23}}</ref> But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.{{update after|2013}}<ref name='Nutrition' />
* States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.<ref name="thenationalcampaign.org">{{cite web|url=http://www.thenationalcampaign.org/policymakers/PDF/SummaryProvisions_TUO_HealthReform.pdf |title=Provisions Related to Teen and Unplanned Pregnancy}}</ref><ref>{{cite web|url=http://www.thenationalcampaign.org/resources/pdf/Briefly_Policy%20Brief_ExpandingMedicaid.pdf|title=Expanding Medicaid Family Planning}}</ref><ref>{{cite web|url=http://www.prochoiceamerica.org/what-is-choice/fast-facts/low-income-fp-access.html|title=LOW-INCOME WOMEN'S ACCESS TO FAMILY PLANNING}}</ref>


===Effective June 21, 2010===


* Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.<ref name='Top 18' /><ref>{{cite web|url=http://www.csmonitor.com/USA/Politics/2010/0324/Health-care-reform-bill-101-rules-for-preexisting-conditions|title=Health care reform bill 101: rules for preexisting conditions|last=Grier|first=Peter|work=The Christian Science Monitor|date=2010-03-24|accessdate=2010-03-25}}</ref> To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.<ref name=wjs_ret /> There is no age requirement.<ref name=wjs_ret>{{cite news|url=http://online.wsj.com/article/SB127570667448201583.html?KEYWORDS=high-risk+pool+health+insurance|title=Insurance Relief for Early Retirees | work=The Wall Street Journal | first=Anne | last=Tergesen | date=June 5, 2010}}</ref> The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.<ref name=wjs_ret /><ref>{{cite web|url=http://www.kff.org/healthreform/upload/8066.pdf|title=Kaiser: High-Risk Pool Provisions under the Health Reform Law}}</ref><ref>{{cite news|url=http://www.washingtonpost.com/wp-dyn/content/article/2010/05/03/AR2010050304072.html|title=18 states refuse to run insurance pools for those with preexisting conditions | work=The Washington Post | first=David S. | last=Hilzenrath | date=May 4, 2010}}</ref>


===Effective July 1, 2010===


* The President established, within the ] (HHS), a council to be known as the ''National Prevention, Health Promotion and Public Health Council'' to help begin to develop a National Prevention and Health Promotion Strategy. The ] shall serve as the Chairperson of the new Council.<ref name=sec4001>{{cite web|url=http://en.wikisource.org/Patient_Protection_and_Affordable_Care_Act/Title_IV#Subtitle_A|title=Patient Protection and Affordable Care Act/Title IV/Subtitle A/Sec. 4001. National Prevention, Health Promotion and Public Health Council}}</ref><ref name="EO13544">] – ''Establishing the National Prevention, Health Promotion, and Public Health Council'', June 10, 2010, Vol.&nbsp;75, No.&nbsp;114,&nbsp;{{USFedReg|75|33983}}</ref>
* A 10% sales tax on indoor tanning took effect.<ref>{{cite news|url=http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aa32kl.M09T4|title=Health-Care Changes to Start Taking Effect This Year | publisher=Bloomberg | date=March 24, 2010}}</ref>


===Effective September 23, 2010===


* Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.<ref>{{cite web|url=http://www.healthcare.gov/law/about/order/byyear.html |title=Provisions of the Affordable Care Act, By Year |publisher=HealthCare.gov |date= |accessdate=2012-01-09}}</ref>
* Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday,<ref>, section 1001 (adding section 2714 to the ]): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26&nbsp;years of age."</ref> and regulations implemented under the PPACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.<ref>{{cite news | title= Rules Let Youths Stay on Parents' Insurance | newspaper= The New York Times | date= May 10, 2010 | url= http://www.nytimes.com/2010/05/11/health/policy/11health.html | first=Robert | last=Pear}}</ref><ref>{{cite press release | title= Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Families and Businesses | publisher= ] | url= http://www.whitehouse.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf }}</ref>
* Insurers are prohibited from excluding pre-existing medical conditions (except in ] individual health insurance plans) for children under the age of 19.<ref>Note: Language in the law concerning this provision has been described as ambiguous, but representatives of the insurance industry have indicated they will comply with regulations to be issued by the ] reflecting this interpretation.
* {{cite news|title=Coverage Now for Sick Children? Check Fine Print|url=http://www.nytimes.com/2010/03/29/health/policy/29health.html|date=March 28, 2010|last=Pear|first=Robert|work=]|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|title=Obama administration has blunt message for insurers|url=http://www.reuters.com/article/idUSN2017888120100329|date=March 29, 2010|last=Holland|first=Steve|publisher=Reuters|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|title=Insurers to Comply With Rules on Children|url=http://www.nytimes.com/2010/03/31/health/policy/31health.html|date=March 30, 2010|last=Pear|first=Robert|work=The New York Times|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|url=http://abcnews.go.com/Business/wireStory?id=10186800|title=Gap in Health Care Law's Protection for Children|last=Alonso-Zaldivar|first=Ricardo|date=March 24, 2010|publisher=ABC News|accessdate=April 8, 2010|agency=Associated Press}}</ref><ref name="FR June 28, 2010">{{cite journal |author=U.S. Department of Health and Human Services |date=June 28, 2010 |title=Patient Protection and Affordable Care Act; Requirements for Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule |journal=] |volume=75 |issue=123 |pages=37187–37241 |url=http://edocket.access.gpo.gov/2010/2010-15278.htm |accessdate=July 26, 2010}}</ref>
* All new insurance plans must cover preventive care and medical screenings<ref name="healthcare.gov">{{cite web | title=Preventive Services Covered Under the Affordable Care Act | url=http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html}}</ref> rated by the ].<ref>http://www.shrm.org/publications/hrnews/pages/coverpreventivecare.aspx</ref> Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.<ref name='SHNS'>{{cite news | first=Lee | last=Bowman | title=Health reform bill will cause several near-term changes | date=2010-03-22 | url =http://public.shns.com/node/52359 | agency =Scripps Howard News Service | accessdate = 2010-03-23}}</ref>
* Individuals affected by the ] will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.<ref name='80beats'>{{cite news | first=Smriti | last=Rao | title=Health-Care Reform Passed. So What Does It Mean? | date=2010-03-22 | work=] | url =http://blogs.discovermagazine.com/80beats/2010/03/22/health-care-reform-passed-so-what-does-it-mean/| pages = | accessdate = 2010-03-23 | language = }}</ref> The gap will be eliminated by 2020.
* Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.<ref name='Top 18' />
* Insurers are prohibited from dropping ]s when they get sick.<ref name='Top 18' />
* Insurers are required to reveal details about administrative and executive expenditures.<ref name='Top 18' />
* Insurers are required to implement an ]s process for coverage determination and claims on all new plans.<ref name='Top 18' />
* Enhanced methods of ] detection are implemented.<ref name='Top 18' />
* Medicare is expanded to small, rural hospitals and facilities.<ref name='Top 18' />
* Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses.
* Companies which provide early retiree benefits for individuals aged 55–64 are eligible to participate in a temporary program which reduces premium costs.<ref name='Top 18' />
* A new website installed by the ] will provide consumer insurance information for individuals and small businesses in all states.<ref name='Top 18' />
* A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.<ref name='Top 18' />
* All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.<ref>{{cite web | title=The Affordable Care Act and Immunization | url=http://www.healthcare.gov/news/factsheets/2010/09/affordable-care-act-immunization.html|publisher=U.S. Department of Health & Human Services|accessdate=September 15, 2012}}</ref>


===Effective January 1, 2011===


IT IS THE REASON AMERICA IS IN SO MUCH DEBT WITH CHINA
* Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.<ref>{{cite web|url=http://www.healthcare.gov/news/factsheets/medical_loss_ratio.html |title=Medical Loss Ratio: Getting Your Money's Worth on Health Insurance |publisher=U.S. Department of Health & Human Services |date= |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=https://www.federalregister.gov/articles/2011/12/07/2011-31289/medical-loss-ratio-requirements-under-the-patient-protection-and-affordable-care-act |title=Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act |publisher=Federal Register |date= |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-insurance/211225-obama-administration-denies-one-states-health-law-waiver-partially-approves-another |title=Obama administration concludes healthcare law waiver review |work=The Hill |date=February 16, 2012 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://companyprofiles.healthcare.gov/MlrQA |title=Medical Loss Ratio}}</ref>
* The ] is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.<ref>{{cite web|url=http://healthreformgps.org/resources/center-for-medicare-and-medicaid-innovation/ |title=Center for Medicare and Medicaid Innovation – Health Reform GPS: Navigating the Implementation Process |publisher=Healthreformgps.org |date= |accessdate=2012-06-29}}</ref>
* ]s, ]s and ]s cannot be used to pay for over-the-counter drugs, purchased without a prescription, except ].<ref name="IR-2010-95">{{cite web
|url=http://www.irs.gov/newsroom/article/0,,id=227301,00.html
|title=IRS Issues Guidance Explaining 2011 Changes to Flexible Spending Arrangements
|publisher=Internal Revenue Service
|date=2010-09-03
|accessdate=2010-09-15
}}</ref>

===Effective September 1, 2011===

* All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.<ref>{{cite web|url=http://companyprofiles.healthcare.gov/RateReviewInfo |title=Promoting Transparency: Rate Increase Reviews}}</ref><ref>{{cite web|url=http://cciio.cms.gov/programs/marketreforms/rates/index.html |title=Review of Insurance Rates}}</ref>

===Effective January 1, 2012===

* Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employee's annual Form W-2's.<ref>{{cite news|url=http://www.reuters.com/article/idUSN1914020220100319|title=FACTBOX-US healthcare bill would provide immediate benefits | publisher=Reuters | first=Donna | last=Smith | date=March 19, 2010}}</ref> This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010.<ref>{{cite web|url=http://www.irs.gov/pub/irs-drop/n-2010-69.pdf |title=Interim Relief with Respect to Form W-2 Reporting of the Cost of Coverage of Group Health Insurance Under § 6051(a)(14) |publisher=Internal Revenue Service |date= |accessdate=2012-04-01}}</ref> Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.<ref>{{cite web |title=Notice 2012-9: Interim Guidance on Informational Reporting to Employees of the Cost of Their Group Health Insurance Coverage |work= Internal Revenue Service |date= January 4, 2012 |format= PDF |url= http://www.irs.gov/pub/irs-drop/n-12-09.pdf }}</ref>

* New tax reporting changes were to come in effect. Lawmakers originally felt these changes would help prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses.<ref>{{cite web|url=http://www.whitehouse.gov/blog/2011/04/14/repealing-1099-reporting-requirement-big-win-small-business|title=Repealing the 1099 Reporting Requirement: A Big Win for Small Business}}</ref><ref name="repeal">{{cite news|url=http://www.bloomberg.com/news/2011-04-14/obama-signs-law-repealing-business-tax-reporting-mandate-1-.html|title=Obama Signs Law Repealing Business Tax Reporting Mandate | publisher=Bloomberg | first=Richard|last=Rubin|date=April 14, 2011}}</ref> Before the PPACA, businesses were required to notify the IRS on ] of certain payments to individuals for certain services or property over a reporting threshold of $600.<ref name=irs1099>{{cite web|url=http://www.irs.gov/pub/irs-pdf/i1099msc.pdf|title=Instructions for Form 1099-MISC| publisher = Internal Revenue Service }}</ref><ref name="U.S. Government Printing Office">{{cite web|url=http://www.gpo.gov:80/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm|title=U.S. Government Printing Office}}</ref> Under the repealed law, reporting of payments to corporations would also be required.<ref>{{cite web|url=http://www.ppbmag.com/Article.aspx?id=5436|title=Healthcare Law Includes Tax Credit, Form 1099 Requirement}}</ref><ref>{{cite web|url=http://www.theapchannel.com/accounts-payable/node/522|title=Health Care Bill Brings Major 1099 Changes}}</ref> Originally it was expected to raise $17&nbsp;billion over 10&nbsp;years.<ref>{{cite web|url=http://www.accountingweb.com/topic/tax/costly-changes-1099-reporting-health-care-bill|title=Costly changes to 1099 reporting in health care law}}</ref> The amendments made by Section 9006 of the PPACA were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.<ref name="repeal" /><ref name="U.S. Government Printing Office"/>

===Effective August 1, 2012===

* All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services – including: well-woman visits; ] screening; ] (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; ] (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and ] screening and counseling - will be covered without cost sharing.<ref>{{cite web |title=Next Steps to Comply with Health Care Reform |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |publisher=] LLP |work=The National Law Review|date=2012-10-10|accessdate=2012-10-10}}</ref> This is also known as the ].<ref name="healthcare.gov"/><ref>{{cite web | title=Affordable Care Act Rules on Expanding Access to Preventive Services for Women | url=http://www.healthcare.gov/news/factsheets/2011/08/womensprevention08012011a.html}}</ref><ref>{{cite news|last=Kliff|first=Sarah|title=Five facts about the health law’s contraceptive mandate|url=http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/01/five-facts-about-the-health-laws-contraceptive-mandate/|accessdate=29 November 2012|newspaper=The Washington Post|date=1 August 2012}}</ref>

===Effective October 1, 2012===

* The Centers for Medicare & Medicaid Services (CMS) will begin the Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (§412.150 through §412.154).<ref>{{cite web|url=http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html|title=Readmissions Reduction Program}}</ref> Starting in October, an estimated total of 2,217 hospitals across the nation will be penalized; however, only 307 of these hospitals will receive this year's maximum penalty, i.e., 1 percent off their base Medicare reimbursements. The penalty will be deducted from reimbursements each time a hospital submits a claim starting Oct. 1. The maximum penalty will increase after this year, to 2 percent of regular payments starting in October 2013 and then to 3 percent the following year. As an example, if a hospital received the maximum penalty of 1 percent and it submitted a claim for $20,000 for a stay, Medicare would reimburse it $19,800. Together, these 2,217 hospitals will forfeit more than $280 million in Medicare funds over the next year, i.e., until October 2013, as Medicare and Medicaid begin a wide-ranging push to start paying health care providers based on the quality of care they provide. The $280 million in penalties comprises about 0.3 percent of the total amount hospitals are paid by Medicare.<ref>{{cite web|url=http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx|title=Medicare To Penalize 2,217 Hospitals For Excess Readmissions}}</ref>

===Effective January 1, 2013===

* Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.<ref>{{cite web|url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf|title=PPACA, section 9015 as modified by section 10906}}</ref> In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.)<ref>{{cite web|url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr4872enr/pdf/BILLS-111hr4872enr.pdf|title=HCERA section 1402}}</ref>

* Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.<ref>{{cite web|url=http://www.foley.com/files/PPACASummary.pdf|title=PPACA Summary (Foley.com)}}</ref><ref>{{cite web|url=http://www.lifehealthpro.com/2012/09/12/8-things-you-might-not-know-about-ppaca?page=9|title=What You Might Not Know About PPACA}}</ref><ref>{{cite web|url=http://www.irs.gov/pub/irs-drop/n-12-40.pdf|title=IRS Notice 2012-40}}</ref>

* Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.)<ref>{{cite web|url=http://www.healthcare.gov/center/authorities/reconciliation_law.pdf|title=Health Care reform Reconciliation Act}}</ref> This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in ].<ref name="Dotzenrod">{{cite news |title=IRS releases final rule on medical device tax |author=Constance Fore Dotzenrod |author2=Gregory C Sicilian |url=http://www.lexology.com/library/detail.aspx?g=9e5a8e7b-9383-4fe9-98c5-4961b16c1499 |newspaper=Lexology |date=December 10, 2012 |accessdate=December 13, 2012}}</ref>

* Insurance companies are required to use simpler, more standardized paperwork, with the intention of helping consumers make apples-to-apples comparisons between the prices and benefits of different health plans.<ref>{{cite news|last=Doyle|first=Brion B.|title=Understanding the Impacts of the Patient Protection and Affordable Care Act|url=http://www.natlawreview.com/article/understanding-impacts-patient-protection-and-affordable-care-act|accessdate=17 April 2013|newspaper=The ]|date=March 5, 2013|author2=Varnum LLP}}</ref>

===Effective by August 1, 2013===

* Religious organizations that were given an extra year to implement the ] are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.<ref>{{cite web |title=Next Steps to Comply with Health Care Reform |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |publisher=Schiff Hardin LLP |work=The ]|date=2012-10-10|accessdate=2012-10-10}}</ref>

===Effective by October 1, 2013===

* Starting in October 2013, those looking to buy individual health insurance can enroll in subsidized plans offered through state-based exchanges (see below), with coverage beginning in January 2014.<ref>{{cite web|url=http://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html?hpt=hp_t5|title=Millions eligible for Obamacare subsidies, but most don't know it|author=]}}</ref><ref>{{cite web|url=http://www.kff.org/healthreform/upload/8213-2.pdf|title=ESTABLISHING HEALTH INSURANCE EXCHANGES: AN OVERVIEW OF STATE EFFORTS}}</ref><ref>{{cite web|url=http://www.healthcare.gov/marketplace/get-ready/index.html|title=Enrollment in the Marketplace starts in October 2013.}}</ref>

===Effective by January 1, 2014===

] and ].<ref name="private_pp" /> (Source: ])]]

* Insurers are prohibited from discriminating against or charging higher rates for any individual based on gender or pre-existing medical conditions.<ref>{{cite web|url=http://www.nh.gov/insurance/consumers/documents/naic_faq.pdf|title=I have been denied coverage because I have a pre-existing condition. What will this law do for me?|publisher=New Hampshire Insurance Department|work=Health Care Reform Frequently Asked Questions|accessdate=2012-06-28|page=2}}</ref>
* Insurers are prohibited from establishing annual spending caps.<ref name='Top 18' />
* Individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of income over the filing minimum,<ref name=jct>"Generally, in 2010, the filing threshold is $9,350 for a single person or a married person filing separately and is $18,700 for married filing jointly." - Congress of the United States The Joint Committee on Taxation, "," March 21, 2010.</ref> whichever is greater; this will rise to a minimum of $695 ($2,085 for families),<ref>{{cite news|last=Doyle|first=Brion B.|title=Understanding the Impacts of the Patient Protection and Affordable Care Act|url=http://www.natlawreview.com/article/understanding-impacts-patient-protection-and-affordable-care-act|accessdate=17 April 2013|newspaper=The National Law Review|date=March 5, 2013|author2=Varnum LLP}}</ref> or 2.5% of income over the filing minimum,<ref name="jct" /> by 2016.<ref name="ksr_hlth" /><ref name = bglobetaximp>{{cite news|url=http://www.boston.com/business/personalfinance/managingyourmoney/archives/2010/03/tax_implication.html|title=Tax implications of health care reform legislation|author=Downey, Jamie|date=March 24, 2010|newspaper=]|accessdate=2010-03-25}}</ref> Exemptions to the ] and penalty are permitted for religious reasons, members of ], or for those for whom the least expensive policy would exceed 8% of their income.<ref>{{cite news|url=http://www.washingtonpost.com/blogs/ezra-klein/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html|title=Individual mandate 101: What it is, why it matters |publisher=Wonkblog at the Washington Post|coauthors=Sarah Kliff; Ezra Klein|date=March 27, 2012|accessdate=July 2, 2012}}</ref>
* In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the ] qualify for coverage, including adults without dependent children.<ref name="ksr_hlth">{{cite news|url=http://www.kaiserhealthnews.org/Stories/2010/March/22/consumers-guide-health-reform.aspx|first=Phil |last=Galewitz|title=Consumers Guide To Health Reform|date=March 26, 2010|newspaper=Kaiser Health News}}</ref><ref name="cnn_ref1">{{cite news|url=http://www.cnn.com/2010/HEALTH/03/25/health.care.law.basics/index.html|title=5 key things to remember about health care reform|publisher=CNN|date=March 25, 2010 | accessdate=May 21, 2010}}</ref> As written, the PPACA withheld ''all'' Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled, in '']'', that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing ''pre-existing'' Medicaid funding from the federal government. As of February 26, 2013, ten states&mdash;], ], ], ], ], ], ], ], ], and ]&mdash;had announced that they would decline to participate in the Medicaid expansion, and four more&mdash;], ], ], and ]&mdash;were leaning towards declining.<ref>http://www.usatoday.com/story/news/nation/2013/02/04/medicaid-expansion-ohio/1891205/</ref><ref>http://www.slate.com/blogs/the_slatest/2013/02/26/chris_christie_medicaid_gop_governor_pushes_plan_to_expand_medicaid.html</ref>
*]s are established, and subsides for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage.<ref name="cnn_ref1" /><ref>{{cite web|title=Health Insurance Premium Credits Under PPACA (P.L. 111-148)|url=http://liberalarts.iupui.edu/economics/uploads/docs/jeanabrahamcrscredits.pdf|publisher=Congressional Research Service|author=Chris L. Peterson, Thomas Gibe|date=April 6, 2010}}</ref><ref name='Galewitz'>{{cite news | first=Phil | last=Galewitz | title=Health reform and you: A new guide | date=2010-03-22 | publisher=] | url =http://today.msnbc.msn.com/id/34609984/ns/health-health_care/ | accessdate = 2010-03-23 }}</ref><ref>{{cite web|url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance|title=Health Care Reform Bill 101|work=]}}</ref> Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, ]<ref name=sec1401>{{cite web|url=http://en.wikisource.org/Patient_Protection_and_Affordable_Care_Act/Title_I/Subtitle_E/Part_I/Subpart_A|title=Patient Protection and Affordable Care Act/Title I/Subtitle E/Part I/Subpart A}}</ref> and gives a formula for its calculation.<ref name=sec1401_p>]</ref> A ] is a way to provide government benefits to individuals who may have no tax liability<ref>{{cite web|url=http://hungerreport.org/2010/report/chapters/two/taxes/refundable-tax-credits|title=Refundable Tax Credit}}</ref> (such as the ]). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. The ] (DHHS) and ] (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.<ref>{{cite web|url=http://www.gpo.gov/fdsys/pkg/FR-2012-05-23/pdf/2012-12421.pdf|title=Health Insurance Premium Tax Credit – from DHHS and IRS}}</ref><ref name="treasury_12">{{cite web|url=http://www.treasury.gov/press-center/Documents/36BFactSheet.PDF|title=Treasury Lays the Foundation to Deliver Tax Credits}}</ref> According to ] and ], in 2014 the income-based premium caps for a ] for a family of four will be the following:
{| class="wikitable" style="margin: 1em auto 1em auto"
|+ Health Insurance Premiums and Cost Sharing under PPACA for Average Family of 4<ref name="private_pp">{{cite web|url=http://bingaman.senate.gov/policy/crs_privhins.pdf|title=Private Health Insurance Provisions in PPACA (P.L. 111-148)|publisher=]|date=April 15, 2010}}</ref><ref name="treasury_12" /><ref name="hip-dhhs">http://www.healthcare.gov/law/resources/reports/premiums01282011a.pdf</ref><ref>{{cite web|author=by Administrator |url=http://www.samhsa.gov/Financing/post/Health-Insurance-Premiums-Past-High-Costs-Will-Become-the-Present-and-Future-Without-Health-Reform.aspx |title=Financing Center of Excellence &#124; SAMHSA &#124; Health Insurance Premiums: Past High Costs Will Become the Present and Future Without Health Reform |publisher=Samhsa.gov |date=2011-03-14 |accessdate=2012-06-29}}</ref><ref name="hipc">{{cite web|url=http://hrsa.dshs.wa.gov/MedicaidHealthCareReform/CRS/HealthInsurancePremiumCredits.pdf|title=Health Insurance Premium Credits Under PPACA|publisher=]|archiveurl=http://web.archive.org/web/20101027220254/http://hrsa.dshs.wa.gov/MedicaidHealthCareReform/CRS/HealthInsurancePremiumCredits.pdf|archivedate=October 27, 20120|date=April 28, 2010}}</ref>
|-
! Income % of ]
! Premium Cap as a Share of Income
! Income $ (family of 4){{ref|fedpovlevel|a}}
! Max Annual Out-of-Pocket Premium
! Premium Savings{{ref|fedpovlevelb|b}}
! Additional Cost-Sharing Subsidy
|-
| 133%
| 3% of income
| $31,900
| $992
| $10,345
| $5,040
|-
| 150%
| 4% of income
| $33,075
| $1,323
| $9,918
| $5,040
|-
| 200%
| 6.3% of income
| $44,100
| $2,778
| $8,366
| $4,000
|-
| 250%
| 8.05% of income
| $55,125
| $4,438
| $6,597
| $1,930
|-
| 300%
| 9.5% of income
| $66,150
| $6,284
| $4,628
| $1,480
|-
| 350%
| 9.5% of income
| $77,175
| $7,332
| $3,512
| $1,480
|-
| 400%
| 9.5% of income
| $88,200
| $8,379
| $2,395
| $1,480
|-
| colspan="6" style="text-align:left; background:white; border-top:1px solid black; padding:0 1em;"|
<small>a.{{note|fedpovlevel}}Note: In 2016, the ] is projected to equal about $11,800 for a single person and about $24,000 for family of four.<ref name="cbo_est">{{cite web|url=http://www.cbo.gov/doc.cfm?index=10781|title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act}}</ref><ref name=whitehouse>{{cite web|url=http://www.whitehouse.gov/health-care-meeting/proposal/whatsnew/affordability|title=Policies to Improve Affordability and Accountability|publisher=The White House}}</ref> See Subsidy Calculator for specific dollar amount.<ref name="kaiser_c">{{cite web|url=http://healthreform.kff.org/SubsidyCalculator.aspx|title=Kaiser Family Foundation:Health Reform Subsidy Calculator – Premium Assistance for Coverage in Exchanges/Gateways}}</ref>
b.{{note|fedpovlevelb}}] and ] estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the reform.<ref name="hip-dhhs" /></small>
|}
* Section 2708 to the Public Health Service Act becomes effective, which prohibits patient eligibility waiting periods in excess of 90 days for group health plan coverage. The 90-day rule applies to all grandfathered and non-grandfathered group health plans and group health insurance issuers, including multiemployer health plans and single-employer group health plans pursuant to collective bargaining arrangements.<ref>{{cite journal|last=Gordon|first=Amy|coauthors=Megan Mardy, Jamie A. Weyeneth|title=Patient Protection and Affordable Care Act (ACA) Guidance on 90-Day Waiting Periods and Certificates of Creditable Coverage|journal=The National Law Review|date=April 12, 2013|url=http://www.natlawreview.com/article/patient-protection-and-affordable-care-act-aca-guidance-90-day-waiting-periods-and-c|accessdate=17 April 2013|publisher=McDermott Will & Emery}}</ref> Plans will still be allowed to impose eligibility requirements based on factors other than the lapse of time; for example, a health plan can restrict eligibility to employees who work at a particular location or who are in an eligible job classification. The waiting period limitation means that coverage must be effective no later than the 91st day after the employee satisfies the substantive eligibility requirements.<ref>{{cite journal|last=Davis II|first=Hugh W.|coauthors=Poyner Spruill LLP|title=Health Reform - New Guidance On Eligibility Waiting Periods (or, when is 90 days not 90 days?)|journal=The National Law Review|date=April 16, 2013|url=http://www.natlawreview.com/article/health-reform-new-guidance-eligibility-waiting-periods-or-when-90-days-not-90-days|accessdate=20 April 2013}}</ref>
* Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.<ref>{{Cite book|title=Summary of Small Business Health Insurance Tax Credit Under PPACA (P.L. 111-148)|url=http://healthreform.kff.org/~/media/Files/KHS/docfinder/crssmallbusinesscredit.pdf|date=April 20, 2010|first=Chris L.|last=Peterson|publisher=]|page=3 (Table 2)|first2=Hinda|last2=Chaikind|separator=,|lastauthoramp=yes|postscript=|accessdate=February 23, 2011|archiveurl=http://web.archive.org/web/20101008065416/http://healthreform.kff.org/~/media/Files/KHS/docfinder/crssmallbusinesscredit.pdf|archivedate=October 8, 2010}}</ref>
* A $2,000 per employee penalty will be imposed on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).<ref name="WSJ-mar25"/> "Full-time" is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.<ref>http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleD-chap43-sec4980H.pdf</ref>
* For employer-sponsored plans, a $2,000 maximum annual deductible is established for any plan covering a single individual or a $4,000 maximum annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
* To finance part of the new spending, spending and coverage cuts are made to Medicare Advantage, the growth of Medicare provider payments are slowed (in part through the creation of a new ]), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.<ref name="CRFB" /><ref>{{cite news|url=http://online.wsj.com/public/resources/documents/st_healthcareproposals_20090912.html|title=Health Reform, Point by Point – Bills Compared|date=March 22, 2010|newspaper=]|accessdate=2010-04-07}}</ref>
* Revenue is increased from a new $2,500 limit on tax-free contributions to ]s (FSAs), which allow for payment of health costs.<ref>{{cite web |work=] |url=http://newsok.com/medical-expense-accounts-could-be-limited-to-2500/article/3415512 |title=Medical Expense Accounts Could be Limited to $2,500 |date=November 8, 2009 |first=Paula |last=Burkes}}</ref>
* Members of Congress and their staff are only offered health care plans through the exchange or plans otherwise established by the bill (instead of the ] that they currently use).<ref>, section 1312: "... the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."</ref>
* A new ] goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5&nbsp;billion in annual revenue.<ref name = bglobetaximp/>
* Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3&nbsp;billion in annual revenue.<ref name = bglobetaximp/>
* The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).<ref>{{cite news| url=http://www.usatoday.com/money/perfi/taxes/2010-03-24-investtax24_ST_N.htm|title=Highlights of the Tax Provisions in Health Care Reform|publisher=Accuracy in Media | first=Matt | last=Krantz | date=March 24, 2010 | accessdate=May 21, 2010}}</ref>
* Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.<ref>{{cite web|url=http://www.healthcare.gov/law/features/choices/co-op/index.html|title=Consumer Operated and Oriented Plans (CO-OPs)}}</ref>
* The ] provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped.<ref>{{cite news| url=http://www.boston.com/news/nation/washington/articles/2011/10/17/ruling_could_speed_repeal_of_long_term_care_plan/ | work=The Boston Globe | first=Ricardo | last=Alonso-Zaldivar | title=White House waffling on long-term care plan? | date=October 17, 2011}}</ref> The CLASS Act was repealed January 1, 2013.<ref>{{cite web|url=http://www.forbes.com/sites/howardgleckman/2013/01/01/fiscal-cliff-deal-repeals-class-act-creates-long-term-care-commission/|title=Fiscal Cliff Deal Repeals CLASS Act -- Creates Long Term Care Commission|publisher=Forbes|date=January 1, 2013}}</ref>
<!-- The provision of the PPACA regarding free choice vouchers was repealed by Section 1858 of the Department of Defense and Full-Year Continuing Appropriations Act, 2011. See http://thomas.gov/cgi-bin/bdquery/z?d112:HR01473:@@@D&summ2=m& and http://www.gpo.gov/fdsys/pkg/PLAW-112publ10/pdf/PLAW-112publ10.pdf * Employed individuals who pay more than 9.5% of their income on health insurance premiums will be permitted to purchase subsidized private insurance through the exchanges.<ref>{{Cite news|title=How the Health Care Overhaul Could Affect You|url=http://www.nytimes.com/interactive/2010/03/21/us/health-care-reform.html|date=March 21, 2010|first=Farhana|last=Hosssain|work=The New York Times|first2=Kevin|last2=Quealy|separator=,|lastauthoramp=yes|postscript=|accessdate=March 22, 2011}}</ref> If the employer provides an employer sponsored plan but the individual earns less than 400% of the Federal Poverty level and could qualify for a government subsidy, the employee is entitled to obtain a "free choice voucher" from the employer of equivalent value to the employer's offering, which can be spent in the exchange to buy a subsidized policy of his own choosing.<ref>Section 10108 FREE CHOICE VOUCHERS</ref> --->

===Effective by October 1, 2014===

* Federal payments to so-called ']s', which treat large numbers of indigent patients, are to be reduced and subsequently allowed to rise based on the percentage of the population that is uninsured in each state.<ref name="commonwealthfund.org">{{cite web|url=http://www.commonwealthfund.org/Newsletters/Washington-Health-Policy-in-Review/2012/Jul/July-16-2012/Whats-in-Effect.aspx/ |title= Washington Health Policy Week in Review What's in Effect, What's Ahead Under Health Care Overhaul}}</ref>

===Effective by January 1, 2015===

* CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.<ref>{{cite web|url=http://www.healthcare.gov/law/timeline/ |title= Implementation Timeline}}</ref>

===Effective by October 1, 2015===

* States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.<ref name="commonwealthfund.org"/>

===Effective by January 1, 2016===

* States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.<ref name="commonwealthfund.org"/>
* The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.<ref>{{cite web|url=http://www.onclive.com/media/pdf/654be33e20de6bf0d83f2bdfeb25284f.pdf |title= How will health care reform affect you?}}</ref>

===Effective by January 1, 2017===

* A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.<ref name=autogenerated4>{{cite web|url=http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm |title=Public Law 111 – 148, section 1332 |publisher=Gpo.gov |date= |accessdate=2012-06-29}}</ref> A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.<ref name=autogenerated1>{{cite news| url=http://www.washingtonpost.com/wp-dyn/content/article/2011/02/28/AR2011022806535.html | work=The Washington Post | first1=Amy | last1=Goldstein | first2=Dan | last2=Balz | title=Obama offers states more flexibility in health-care law | date=March 1, 2011}}</ref><ref name="WydenHuffingtonPostinterview">{{cite news
| url = http://www.huffingtonpost.com/2010/03/24/wyden-health-care-lawsuit_n_511748.html
| title = Wyden: Health Care Lawsuits Moot, States Can Opt Out Of Mandate
| date = March 24, 2010
| work= The Huffington Post
| accessdate = March 27, 2010
| first=Sam
| last=Stein
}}</ref> The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.<ref name=autogenerated4 /> To qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.<ref>{{cite web|url=http://www.healthcare.gov/news/factsheets/stateinnovation03102011a.html |title=Preparing for Innovation: Proposed Process for States to Adopt Innovative Strategies to Meet the Goals of the Affordable Care Act |publisher=U.S. Department of Health & Human Services |date=November 16, 2011 |accessdate=April 1, 2012}}</ref> A bipartisan bill sponsored by Senators ] and ], and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.<ref name=autogenerated1 /> In April 2011 ] announced its intention to pursue a waiver to implement the ] enacted in May 2011.<ref>{{cite web|url=http://governor.vermont.gov/http%3A/%252Fgovernor.vermont.gov/node/add/media-federal-rules |title=Gov. Shumlin issued the following statement on health care rules |publisher=Governor.vermont.gov |date=March 14, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://www.bipartisanpolicy.org/blog/2011/03/health-reform-flexibility-and-wyden-brown-waiver-state-innovation |title=Health Reform Flexibility and the Wyden-Brown Waiver for State Innovation |publisher=Bipartisan Policy Center |date=March 4, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Estes |first=Adam Clark |url=http://www.theatlanticwire.com/national/2011/05/vermont-becomes-first-state-pass-single-payer-health-care/38207/ |title=Vermont Becomes First State to Enact Single-Payer Health Care |work=The Atlantic |date=May 26, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite news| url=http://www.huffingtonpost.com/2011/05/26/vermont-health-care-reform-law-single-payer_n_867573.html | work=The Huffington Post | first=Nicholas | last=Wing | title=Vermont Single-Payer Health Care Law Signed By Governor | date=May 26, 2011}}</ref> In September 2011 ] announced it would also be seeking a waiver to set up its own single payer healthcare system.<ref>{{cite web|url=http://www.dailykos.com/story/2011/09/30/1021603/-Gov-Schweitzer-pushing-single-payer-in-Montana-ahead-of-Affordable-Care-Act | title= Single payer in Montana}}</ref>
* States may allow large employers and multi-employer health plans to purchase coverage in the Exchange.
* Two federally regulated 'multi-state plan' (MSP) insurers, with one being non-profit and the other being forbidden from providing coverage for abortion services, will be available to all states. They will have to abide by the same federal regulations as required by individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016 with full national coverage in 2017.<ref>{{cite web|url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf | title= Multi-State Plans Under the Affordable Care Act}}</ref>

===Effective by January 1, 2018===

* All ''existing'' health insurance plans must cover approved preventive care and checkups without co-payment.<ref name='Top 18' />
* A 40% ] on high cost ] is introduced. The tax (as amended by the reconciliation bill)<ref name=Gold>{{cite web
|url=http://www.kaiserhealthnews.org/Stories/2010/March/18/Cadillac-Tax-Explainer-Update.aspx
|title='Cadillac' Insurance Plans Explained
|first=Jenny
|last=Gold
|publisher=]
|date=2010-01-15}}</ref> is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.<ref name = bglobetaximp/><ref>{{cite web|url=http://docs.house.gov/energycommerce/TIMELINE.pdf|title=H.R. 4872, The Health Care & Education Affordability Reconciliation Act of 2010 Implementation Timeline|date=March 18, 2010|publisher=U.S. House Committees on Ways & Means, Energy & Commerce, and Education & Labor|page=7|accessdate=March 24, 2010}}</ref>
<!-- * Various new taxes are introduced -- commented out until concrete citations are provided -->

===Effective by January 1, 2019===

* Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old<ref name="thenationalcampaign.org"/>

===Effective by January 1, 2020===

* The Medicare Part D coverage gap (a.k.a., "donut hole") will be completely phased out and hence closed.

==Legislative history==

===Background===
{{Main|Health care reform in the United States|Health care reform debate in the United States}}

The plan that ultimately became the Patient Protection and Affordable Care Act consists of a combination of measures to control health care costs and an insurance expansion thought public insurance (expanded Medicaid eligibility and Medicare coverage expansion) and subsidized, regulated private insurance. The latter of these ideas forms the core of the law's insurance expansion, and it has been included in bipartisan reform proposals in the past. In particular, the idea of an individual mandate coupled with subsidies for private insurance, as an alternative to public insurance, was considered a way to get Universal Health Insurance that could win the support of the Senate. Many healthcare policy experts have pointed out that the individual mandate requirement to buy health insurance was contained in many previous proposals by Republicans for healthcare legislation, going back as far as 1989, when it was initially proposed by the ] ] as an alternative to ].<ref name="forbes1"></ref> The idea of an individual mandate was championed by ] politicians as a market-based approach to health-care reform, on the basis of individual responsibility: because the ], passed in 1986 by a bipartisan Congress and signed by ], requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |publisher=The New Republic |date=2010-04-09 }}</ref><ref name="nyt-mandate">{{cite news | work = ] | title= Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later | first = Michael | last = Cooper | date = February 14, 2012 | accessdate= July 2, 2012 | url = http://www.nytimes.com/2012/02/15/health/policy/health-care-mandate-was-first-backed-by-conservatives.html}}</ref><ref name="new-yorker-klein"/>

When, in 1993, President ] ] which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of ]s, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan.<ref name="nyt-mandate"/> Ultimately the Clinton plan failed amid concerns that it was overly complex or unrealistic, and in the face of an unprecedented barrage of negative advertising funded by politically conservative groups and the health-insurance industry.<ref name="newsweek-clinton">{{cite news | work = ] | title = The Lost Chance | first = Bob | last= Cohn | coauthors = Eleanor Clift | date = September 18, 1994 | accessdate= July 2, 2012 | url =http://www.thedailybeast.com/newsweek/1994/09/18/the-lost-chance.print.html}}</ref> (After failing to obtain a comprehensive reform of the health care system, Clinton did however negotiate a compromise with the ] to instead enact the ] in 1997).

The 1993 Republican alternative, introduced by Senator ] as the Health Equity and Access Reform Today Act, contained a "Universal Coverage" requirement with a penalty for non-compliance.<ref>{{cite web|author=|url=http://www.kaiserhealthnews.org/Stories/2010/February/23/GOP-1993-health-reform-bill.aspx |title=Summary Of A 1993 Republican Health Reform Plan |publisher=Kaiserhealthnews.org |date=2010-02-23 |accessdate=2012-06-29}}</ref><ref name="kaiserhealthnews1993">{{cite web|url=http://www.kaiserhealthnews.org/Graphics/2010/022310-Bill-comparison.aspx |title=Chart: Comparing Health Reform Bills: Democrats and Republicans 2009, Republicans 1993 |publisher=Kaiserhealthnews.org |date= |accessdate=2012-06-29}}</ref> Advocates for the 1993 bill which contained the individual mandate included prominent Republicans who today oppose the mandate, such as ], ], ], and ].<ref></ref><ref>{{cite web|url=http://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |title=In 1993 Republicans Proposed A Mandate First |publisher=NPR }}</ref> Of the 43 Republicans Senators from 1993, almost half - 20 out of 43 - supported the HEART Act.<ref name="forbes1"/><ref name="politifact1993">{{cite web|author=|url=http://www.politifact.com/truth-o-meter/statements/2012/apr/19/facebook-posts/facebook-post-says-republicans-embraced-individual/ |title=Facebook post says Republicans embraced individual mandate in 1993 |publisher=PolitiFact |date=2012-04-19 }}</ref> And in 1994 Senator ] introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision<ref>{{cite web|url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |publisher=Coloradostatesman.com |date= |accessdate=2012-06-29}}</ref> - however, subsequently, he did remove the mandate from the act after introduction stating that they had decided "that government should not compel people to buy health insurance."<ref>{{cite news| url=http://www.nytimes.com/2012/02/27/opinion/gop-and-health-mandate.html?_r=2&adxnnl=1&adxnnlx=1333652503-360xnkv/rpzNURZGZh5Vdw | work=The New York Times | title=G.O.P. and Health Mandate | date=February 26, 2012}}</ref> At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for ], remarked, "I don’t remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax... So I’ve been surprised by that argument."<ref name="forbes1"/>

] with Ted Kennedy and a bipartisan group of state legislators, April 12, 2006.]]

An individual health-insurance mandate was also enacted at the state-level in Massachusetts: In 2006, Republican ], then governor of Massachusetts, signed ] with an individual mandate into law with strong bipartisan support (including that of ]). Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During ], Senator ] praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured." Romney himself said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."<ref name="new-yorker-lizza"/>

The following year (2007), Senators ] and ] introduced the
], a bill that also featured an individual mandate, and which attracted bipartisan support.<ref name="new-yorker-klein">{{cite news | work = ] | first = Ezra | last = Klein | authorlink = Ezra Klein | title = Unpopular Mandate | accessdate = June 19, 2012 | date = June 25, 2012 | url = http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein}}</ref><ref name="new-yorker-lizza">{{cite news | work = ] | title= Romney's dilemma | url = http://www.newyorker.com/reporting/2011/06/06/110606fa_fact_lizza | first = Ryan | last = Lizza | authorlink = Ryan Lizza | accessdate = June 19, 2012 | date = June 6, 2011}}</ref> Among the Republican co-sponsors still in Congress during the health care debate: Senators ], ], ], ], ], ], and ].<ref> from the ] ] website</ref><ref>, from Senator Wyden's website</ref>

Given the history of bipartisan support for the idea, and its track record in Massachusetts; by 2008 Democrats were considering it as a basis for comprehensive, national health care reform: Experts have pointed out that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill;<ref name="kaiserhealthnews1993"/> and that it was deliberately patterned after former Republican Governor of Massachusetts Mitt Romney's ] (which contains an individual mandate).<ref></ref> ], a key architect of the Massachusetts reform, advised the Clinton and Obama Presidential campaigns on their health care proposals, served as a technical consultant to the Obama Administration, and helped Congress draft the PPACA.

===The Health Care Debate, 2008-2010===
{{Main|Health care reforms proposed during the Obama administration}}

Health care reform was a major topic of discussion during the ]. As the race narrowed, attention focused on the plans presented by the two leading candidates, ] Senator ] and the eventual nominee, ] Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45&nbsp;million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual ]), while Obama's was to provide a ] but not create a direct requirement. During the ] campaign between Obama and the Republican nominee, ] Senator ], Obama said that fixing health care would be one of his top four priorities if he won the presidency.<ref name="Sep2008FirstPresidentialDebate">{{Cite news | url = http://elections.nytimes.com/2008/president/debates/transcripts/first-presidential-debate.html | title = The First Presidential Debate | date = September 26, 2008 | work = The New York Times }}</ref>

], September 9, 2009.]]

After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.<ref name="Feb2009JointSessionAddress">{{Cite news | url = http://www.whitehouse.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress | title = Remarks of President Barack Obama – Address to Joint Session of Congress | date = February 24, 2009 | publisher = The White House | accessdate = March 24, 2010 }}</ref> On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform.<ref name="reuterstimeline">{{cite news | url = http://www.reuters.com/article/idUSTRE62L0JA20100322 | publisher = Reuters | title = Timeline: Milestones in Obama's quest for healthcare reform | accessdate = March 22, 2010 | date=March 22, 2010 }}</ref> By July, a series of bills were approved by committees within the ].<ref name="EdLaborJul2009">{{Cite news | url = http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml | title = Affordable Health Care for America Act | last = Kruger | first = Mike | date = October 29, 2009 | publisher = ] | accessdate = March 24, 2010 |archiveurl=http://web.archive.org/web/20100106013943/http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml |archivedate= January 6, 2010 }}</ref> On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican ] Members met for a series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators ], ], ], ], ], and ], met for more than 60 hours, and the principles that they discussed (in conjunction with the other Committees) became the foundation of the Senate's health care reform bill.<ref>{{cite web|title=Health Care Reform from Conception to Final Passage|accessdate=2010-11-23|url=http://finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65}}</ref> The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site<ref> Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN</ref> or at the Committee's own web site.<ref>{{cite web|url=http://finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |title=Senate Finance Committee hearings for 111th Congress |publisher=Finance.senate.gov |date= |accessdate=April 1, 2012}}</ref>

With ] as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like ] and ] argued that ] would require both a (partial) ] and an ] to prevent either ] and/or ] from creating an ].<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/75077/how-they-did-it |title=How They Did It |publisher=The New Republic |date=2010-05-21 }}</ref> They convinced Obama that this was necessary, which persuaded the Administration to accept Congressional proposals that included a mandate.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/the-top-ten-things-worth-fighting |title=The Top Ten Things Worth Fighting For |publisher=The New Republic |date=2009-10-13 }}</ref> This approach was preferred because the President and Congressional leaders concluded that more liberal plans (such as ]) could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas - the same basic outline was supported by former Senate Majority Leaders ], ], ] and ] - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/party-is-such-sweet-sorrow |title=Party Is Such Sweet Sorrow |publisher=The New Republic |date=2009-09-04 }}</ref><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |title=Obama's Moderate Health Care Plan |publisher=The New Republic |date=2010-04-22 }}</ref><ref name="newrepublic1">{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |publisher=The New Republic |date=2009-12-19 }}</ref>

However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to filibuster any bills that contained it.<ref name="forbes1"/> Senate Minority Leader ], who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections:<ref name="newrepublic1"/>
:"It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out."<ref>{{cite news|author=Carl Hulse and Adam Nagourney |url=http://www.nytimes.com/2010/03/17/us/politics/17mcconnell.html?pagewanted=1&hp |title=Senate G.O.P. Leader Finds Weapon in Unity |publisher=The New York Times |date=2010-03-16 }}</ref>
Republican Senators (including those who had supported previous bills with a similar mandate) began to describe the mandate as "unconstitutional". Writing in '']'', Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."<ref name="new-yorker-klein"/> The '']'' subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's health care law requiring all Americans to buy health insurance has its roots in conservative thinking."<ref name="nyt-mandate"/><ref name="politifact1993"/>

], September 12, 2009.]]

The reform negotiations also attracted a great deal of attention from ],<ref>{{cite news|last=Eaton |first=Joe |coauthors=M.B. Pell, Aaron Mehta |url=http://www.npr.org/templates/story/story.php?storyId=125170643 |title=Lobbying Giants Cash In On Health Overhaul |publisher=NPR |date=2010-03-26 |accessdate=2012-04-09}}</ref> including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/politics/drug-deal |title=Drug Deal |publisher=The New Republic |date=2009-08-25 }}</ref><ref>{{cite news| url=http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html | work=Huffington Post | first=Ryan | last=Grim | title=Internal Memo Confirms Big Giveaways In White House Deal With Big Pharma | date=August 13, 2009}}</ref> The ] documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.<ref>{{cite web|url=http://sunlightfoundation.com/projects/2009/healthcare_lobbyist_complex |title=Visualizing The Health Care Lobbyist Complex |publisher=Sunlight Foundation |date=July 22, 2009 |accessdate=April 1, 2012}}</ref>

During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the ] organized protests and many ] groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.<ref name="reuterstimeline"/> There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection.<ref name=WashPost-04092010>{{cite news | title=Anger over health-care reform spurs rise in threats against Congress members |last=Horwitz|first=Sari|last2=Pershing|first2=Ben| date=April 9, 2010 | url = http://www.washingtonpost.com/wp-dyn/content/article/2010/04/08/AR2010040805476.html?nav=hcmodule | work =] | accessdate = April 9, 2010 }}</ref>

To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 ] supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.<ref name="Sep2009JointAddress">{{cite web | url = http://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care | title = Remarks by the President to a Joint Session of Congress on Health Care | date = September 10, 2009 | publisher = The White House | accessdate = March 24, 2010}}</ref> In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."<ref>{{cite web |last=Kennedy |first=Edward M. |authorlink=Ted Kennedy |title=Text of letter to the President from Senator Edward M. Kennedy |url=http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/ |date=2009-05-12 |work= |publisher=] |accessdate=2009-09-10| archiveurl= http://web.archive.org/web/20090910065606/http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/| archivedate= 10 September 2009 <!--DASHBot-->| deadurl= no}}</ref> On November 7, the House of Representatives passed the ] on a 220–215 vote and forwarded it to the Senate for passage.<ref name="reuterstimeline"/>

===Senate===

The Senate began work on its on proposals while the House was still working on ]; it instead took up H.R. 3590, a bill regarding housing tax breaks for service members.<ref name="ServicemembersHomeOwnershipTaxAct">{{Cite news | title = House OKs tax breaks for military homeowners | first = Rick | last = Maze | url = http://www.airforcetimes.com/news/2009/10/military_homeownerhelp_taxfree_100809w/ | newspaper = ] | date = October 8, 2009 | accessdate = March 24, 2010 }}</ref> As the ] requires all revenue-related bills to originate in the House,<ref name="Const-Revenue">] art. I, § 7, cl. 1.</ref> the Senate took up this bill since it was first passed by the House as a revenue-related modification to the ]. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.<ref>{{USBill|111|S.AMDT.|2786}}</ref> The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate ] and ] committees.

With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/why-reform-survived-august |title=Why Reform Survived August |publisher=NewRepublic.com |date=2009-09-07 }}</ref> Initially, at the start of the ], Democrats had only 58 votes (the Senate seat in Minnesota that would be won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican). To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try and bring aboard several Republican Senators (particular attention was given to Bob Bennett, Chuck Grassley, Mike Enzi, and Olympia Snowe). Negotiations continued even after July 7 - when ] was sworn into the Senate and by which time ] had switched parties - because of disagreements over the bill's substance (which was still being drafted in Committee), and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, ] (a staunch and long-time advocate for Health Care Reform) succumbed to his terminal brain cancer, depriving Democrats of a crucial 60th vote. Attention was drawn to ] as the potential replacement because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly warned that this did not mean she would support the final bill.<ref name="Jonathan Cohn">{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/75077/how-they-did-it |title=How They Did It |publisher=NewRepublic.com |date=2010-05-21 }}</ref>

When ] was appointed as Senator Kennedy's temporary replacement on September 24, regaining Democrat's 60th vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. ] focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut ] (an independent who caucused with Democrats) and Nebraska ]. Senator Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a ]; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was removed.<ref name="Jonathan Cohn"/> To win filibuster-proof support for the overall bill, the provision was not included (even though it had majority support in Congress).<ref name="newrepublic2">{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/the-public-option-still-dead |title=The Public Option, Still Dead |publisher=NewRepublic.com |date=2010-03-12 }}</ref> There was debate among supporters of the bill about the importance of the public option,<ref>{{cite news|url=http://www.huffingtonpost.com/marcia-angell-md/is-the-house-health-care_b_350190.html |title=Is the House Healthcare Bill Better Than Nothing? |work=Huffington Post |accessdate=January 12, 2012 |date=November 9, 2009}}</ref> although the vast majority of supporters concluded that the it was a minor part of the reform overall,<ref>{{cite web|author=Jacob S. Hacker |url=http://www.newrepublic.com/blog/the-treatment/why-i-still-believe-bill |title=Why I Still Believe in This Bill |publisher=NewRepublic.com |date=2009-12-20 }}</ref> and that Congressional Democrats' fight for it won various concessions (including conditional wavers allowing states to set up state-based public options,<ref name="newrepublic2"/> for example Vermont's ]).<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/what-public-option-supporters-won |title=What Public Option Supporters Won |publisher=NewRepublic.com |date=2009-12-15 }}</ref>

[[File:111th Congress 1st session Senate roll call 396.svg|thumb|300px|Senate vote by state.
{{legend|#000080|Two Democratic yeas}}
{{legend|#800080|One Democratic yea, one Republican nay}}
{{legend|#FF5050|One Republican nay, one Republican not voting}}
{{legend|#800000|Two Republican nays}}]]

With every other Democrat now in favour and every other Republican now overtly opposed, The White House and Reid moved on to addressing Senator Nelson's concerns;<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/ben-nelson-still-big-problem |title=Ben Nelson, Still a Big Problem (Updated) |publisher=NewRepublic.com |date=2009-12-17 }}</ref> they had by this point concluded that "it was a waste of time dealing with "<ref>{{cite web|author= Manu Raju |url=http://www.politico.com/news/stories/0110/31730.html |title=Olympia Snowe puzzled by Harry Reid comments |publisher=Politico.com |date=2010-01-20 }}</ref> because, after her vote for the draft bill in the Finance Committee, Senator Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform.<ref name="newrepublic1"/><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/revisiting-snowes-lay-down |title=Revisiting Snowe's Lay Down |publisher=NewRepublic.com |date=2010-01-19 }}</ref><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/nonsense-snowe |title=(Non)sense of Snowe |publisher=NewRepublic.com |date=2010-03-16 }}</ref> (Snowe choose to retire at the end of her term citing partisanship and polarization).<ref>{{cite web|author=Susan Davis |url=http://content.usatoday.com/communities/onpolitics/post/2012/02/olympia-snowe-senate-retirement-maine/1?csp=34news#.UV6DlFewdEJ |title=Maine GOP Sen. Olympia Snowe won't seek re-election |publisher=USA Today |date=2012-02-28 }}</ref> After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges" (requiring consumers to pay for the procedure out-of-pocket, if the state decided it); and an amendment to offer a higher rate of ] reimbursement for Nebraska.<ref name="reuterstimeline"/><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/breaking-nelson-says-yes-makes-60 |title=BREAKING: Nelson Says Yes; That Makes 60 |publisher=NewRepublic.com |date=2009-12-19 }}</ref> The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"<ref>{{cite news|title='Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment|url=http://www.foxnews.com/politics/2010/03/18/cornhusker-kickback-gets-boot-health/|date=March 19, 2010|publisher=]|accessdate=April 26, 2010}}</ref> (and was later repealed by the subsequent reconciliation amendment bill).

On December 23, the Senate voted 60–39 to end debate on the bill (a cloture vote to end the ] by opponents). The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two Independents voting for, and all Republicans voting against except one Republican senator (], R-Ky.) not voting.<ref name="USS RC 2009-396">{{cite web|url=http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396 |title=Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended) |publisher=U.S. Senate |date= |accessdate=2012-01-09}}</ref> The bill was endorsed by the ] and ].<ref>. Huffington Post.</ref>

On January 19, 2010, ] Republican ] was elected to the Senate in a special election to replace Senator Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even famously signing autographs as "Scott 41."<ref name="reuterstimeline"/><ref>{{cite web|author=J. Scott Applewhite, Associated Press |url=http://www.cleveland.com/nation/index.ssf/2010/01/senator-elect_scott_brown_welc.html |title=Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts |publisher=cleveland.com |date= |accessdate=2012-04-09}}</ref><ref>{{cite press release|url=http://www.votesmart.org/public-statement/477580/scott-brown-responds-to-martha-coakleys-misleading-health-care-distortions |title=Public Statements – Project Vote Smart |publisher=Votesmart.org |date=2010-01-13 |accessdate=2012-04-09}}</ref>

===House===
[[File:111th Congress roll call 165.svg|thumb|300px|House vote by congressional district.
{{legend|#000080|Democratic yea}}
{{legend|#5050FF|Democratic nay}}
{{legend|#800000|Republican nay}}
{{legend|#C8C8C8|No representative seated}}]]
]
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. ] ] argued the Democrats should scale-back for a less ambitious bill; ] ] pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care".<ref name="nytimesjourney">{{Cite news
| title = Health Vote Caps a Journey Back From the Brink
| first = Sheryl
| last = Stolberg
| author2 = Jeff Zeleny
| author3 = Carl Hulse
| url = http://www.nytimes.com/2010/03/21/health/policy/21reconstruct.html
| newspaper = ]
| date = March 20, 2010
| accessdate = March 23, 2010
}}</ref><ref name="PoliticoPelosi">{{Cite news
| title = Pelosi steeled W.H. for health push
| first = Carrie
| last = Brown
| author2 = Glenn Thrush
| url = http://www.politico.com/news/stories/0310/34753.html
| newspaper = ]
| date = March 20, 2010
| accessdate = March 23, 2010
}}</ref> Obama remained insistent on comprehensive reform and the news that ] in ] intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.<ref name="nytimesjourney"/><ref name="PoliticoPelosi"/> On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.<ref>{{cite web|author= |url=http://www.kaiserhealthnews.org/Daily-Reports/2010/February/22/President-Obama-Health-Care-Reform-Plan.aspx |title=White House Unveils Revamped Reform Plan, GOP And Industry React |publisher=Kaiserhealthnews.org |date=2010-02-22 |accessdate=2012-06-29}}</ref> He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.<ref name="reuterstimeline"/> The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.<ref name="PoliticoPelosi"/>

With Democrats having ], but having already passed the Senate bill with 60 votes on December 23; the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the ], and pass the Senate's bill (The Patient Protection and Affordable Care Act) instead. Various health policy experts encouraged the House to pass the Senate version of the bill.<ref>{{cite web|url=http://www.tnr.com/blog/the-treatment/47-health-policy-experts-including-me-say-sign-the-senate-bill |title=Pollack-The New Republic-January 22, 2010 |publisher=Tnr.com |accessdate=January 12, 2012}}</ref> However, House Democrats were not happy with the content of the Senate bill and had expected to be able to negotiate changes in a (House-Senate) Conference before passing a final bill. With that option off the table (as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster); the House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill (ultimately the ]), which could be passed via the ] process.<ref name="nytimesjourney"/><ref name="Reconciliationprimer">{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/brief-reconciliation-primer |title=A Brief Reconciliation Primer |publisher=NewRepublic.com |date=2010-02-20 }}</ref> Unlike the regular order, reconciliation is not subject to a ] (which requires 60 votes to break), but the process is ] which is why it was never able to be used to pass a comprehensive reform bill (with its inherently non-budgetary regulations as in the PPACA) in the first place.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |title=Reconciliation: Why Most Dems Don't Want to Go There |publisher=NewRepublic.com |date=2009-09-21 }}</ref> Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."<ref name="Reconciliationprimer"/>

The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman ]. The group found the possibility of federal funding for ] would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued ], reaffirming the principles in the ]. This concession won the support of Stupak and members of his group and assured passage of the bill.<ref name="EO13535">] of March 24, 2010 – ''Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act'', Vol.&nbsp;75, No.&nbsp;59,&nbsp;{{USFedReg|75|15599}}, March 29, 2010.</ref> The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.<ref name="USH RC 2010-165">{{cite web|url=http://clerk.house.gov/evs/2010/roll165.xml |title=Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act) |publisher=Office of the Clerk: House of Representatives |date=2010-03-21 |accessdate=2012-04-09}}</ref> The following day, Republicans introduced legislation to repeal the bill.<ref name="PelosiSawyer">{{Cite news
| title = Pelosi Defends Health Care Fight Tactics
| first = Margaret
| last = Aro
| author2 = Mark Mooney
| url = http://abcnews.go.com/WN/Politics/house-speaker-nancy-pelosis-exclusive-interview-diane-sawyer/story?id=10172685
| newspaper = ]
| date = March 22, 2010
| accessdate = March 23, 2010
}}</ref> Obama signed the original bill (the PPACA) into law on March 23, 2010.<ref>{{Cite news
| title = Obama Signs Health Care Overhaul Bill, With a Flourish
| first = Sheryl
| last = Stolberg
| author2 = Robert Pear
| url = http://www.nytimes.com/2010/03/24/health/policy/24health.html
| newspaper = The New York Times
| date = March 23, 2010
| accessdate = March 24, 2010}}</ref> The amendment bill (the Health Care and Education Reconciliation Act) was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.

==Impact==

===Public policy===

====Change in number of uninsured====
CBO originally estimated the legislation will reduce the number of uninsured residents by 32&nbsp;million, leaving 23&nbsp;million uninsured residents in 2019 after the bill's provisions have all taken effect.<ref name="cbouninsured">{{cite web|url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf|title=Cost Estimate for Pending Health Care Legislation|date=March 20, 2010|publisher=]|accessdate=March 28, 2010}}</ref><ref name="CBO43090">{{cite web|url=http://www.cbo.gov/publication/43090 |title=The Effects of the Affordable Care Act on Employment-Based Health Insurance |publisher=Congressional Budget Office |date=March 15, 2012 |accessdate= |quote=''Highlights and Key Findings'' , March 23, 2012 }}</ref><ref name=fewer/><ref name="CBO43076">{{cite web |url=http://www.cbo.gov/publication/43076 |title=Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 13, 2012 |accessdate=April 6, 2012}}</ref> A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the ] to PPACA's expansion of Medicaid.<ref name=cbooptout>{{cite web| url= http://www.cbo.gov/publication/43472 | title= Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision|date=July 24, 2012 | publisher= CBO | accessdate= 2012-02-23}}</ref><ref name=optout>{{cite web| url= http://money.cnn.com/2012/07/23/news/economy/health-reform/ | title= 6 million will lose out on Medicaid expansion| first=Emily Jane|last= Fox |work=CNNMoney |date=July 24, 2012 | publisher= CNN | accessdate= 2012-07-25}}</ref>

Among the people in this uninsured group will be:
* ], estimated to be around eight million <!--almost a third of the 25&nbsp;million --> – they will be ineligible for insurance ] and Medicaid;<ref name="cbouninsured"/><ref>{{Cite journal|title=Treatment of Noncitizens Under the Patient Protection and Affordable Care Act|url=http://www.ciab.com/WorkArea/DownloadAsset.aspx?id=2189|date=March 22, 2011|first=Alison|last=Siskin|publisher=]|accessdate=October 14, 2011|id=R41714}}</ref><ref>{{Cite journal|title=PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges|url=http://www.nationalaglawcenter.org/assets/crs/R41664.pdf|date=March 2, 2011|first=Hinda|last=Chaikind|publisher=]|first2=Curtis W.|last2=Copeland|first3=C. Stephen| last3=Redhead| first4=Jennifer| last4=Staman| accessdate=October 14, 2011|id=R41664}}</ref> they will also be exempt from the ] and will remain eligible for emergency services under the 1986 ] (EMTALA).
*Citizens not enrolled in Medicaid despite being eligible.<ref name="notcovered">{{cite news| url= http://www.csmonitor.com/USA/2010/0323/Obama-signs-health-care-bill-Who-won-t-be-covered| title= Obama signs health care bill: Who won't be covered?|last=Trumbull|first=Mark|date=March 23, 2010|work=]|accessdate=March 24, 2010}}</ref>
*Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.<ref name="notcovered"/>
*Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.<ref name="notcovered"/>
*Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.<ref name=optout/>

Early experience under PPACA was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.<ref>{{Cite news | last = Levey| first = Noam N.| title = More small businesses are offering health benefits to workers| newspaper = ]| date = December 27, 2010 | url = http://www.latimes.com/health/healthcare/la-fi-health-coverage-20101227,0,5024491.story}}</ref> On September 13, 2011, the Census Bureau released a report showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.<ref>{{Cite journal|title=Income, Poverty, and Health Insurance Coverage in the United States: 2010|url=http://www.census.gov/prod/2011pubs/p60-239.pdf| month=September|year=2011|publisher=]| first= Carmen| last= DeNavas-Walt|last2=et al.|pages=26–27|accessdate=October 15, 2011}}</ref> A later report from the Government Accountability Office in 2012 found that of the 4 million small businesses that were offered the tax credit only 170,300 businesses claimed it.<ref>Ellmers, R. (2012, May 31). Small business subcommittee on healthcare & technology chairwoman Renee Ellmers: Need a job: support small businesses. Congressional Documents and Publications. Retrieved online from http://www.dowjones.com/factiva</ref><ref>Lawrimore, E. (2012, June 27). Barraso’s 2nd opinion: Obamacare small business tax credit is a bust. Congressional Documents and Publications. Retrieved from http://www.dowjones.com/factiva</ref> Due to the effect of the U.S. Supreme court ruling, states can opt-in or out of the expansion of Medicaid. Arkansas, California, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont, and Washington are implementing the expansion; Florida, Louisiana, Mississippi, Georgia, South Carolina, and Texas are not.<ref>{{cite news |title=How States are using their flexibility |author=U-T San Diego Editorial Board |url=http://www.utsandiego.com/news/2012/aug/12/tp-how-states-are-using-their-flexibility/ |newspaper=] |date=12 August 2012 |accessdate=27 August 2012}}
</ref><ref>{{cite news |title=States opting out of Medicaid expansion could leave many uninsured |author=Stephanie Condon |url=http://www.cbsnews.com/8301-503544_162-57465110-503544/states-opting-out-of-medicaid-expansion-could-leave-many-uninsured/ |newspaper=CBS News |date=2 August 2012 |accessdate=27 August 2012}}</ref><ref>{{cite news |title=The backlash begins: States start opting out of Medicaid expansion |author=Sarah Kliff |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/02/the-backlash-begins-states-start-opting-out-of-medicaid-expansion/ |newspaper=Washington Post |date=2 July 2012 |accessdate=27 August 2012}}</ref><ref>{{cite news |title=Fifteen governors reject or leaning against expanded Medicaid program |author=Elise Viebeck |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/236033-fifteen-governors-reject-or-leaning-against-expanded-medicaid-program |newspaper=The Hill |date=3 July 2012 |accessdate=27 August 2012}}</ref>

Also, in part due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26; in September 2010 some insurance companies announced that in response to the law, they would end the issuance of new child-only policies.<ref>, CBS News, September 22, 2010</ref><ref>, ''Los Angeles Times'', September 21, 2010</ref> Kentucky Insurance Commissioner Sharon Clark said the decision by insurers to stop offering such policies was a violation of state law and ordered insurers to offer an open enrollment period in January 2011 for Kentuckians under 19.<ref>{{cite web|last=Truman |first=Cheryl |url=http://www.kentucky.com/2010/11/19/1530685/state-orders-health-insurers-to.html |title=State orders health insurers to offer child-only policies|publisher=Kentucky.com |date=2010-11-19 |accessdate=2012-06-28}}</ref> An August 2011 Congressional report found that passage of the health care law prompted health insurance carriers to stop selling new child-only health plans in many states. Of the 50&nbsp;states, 17 reported that there were currently no carriers selling child only health plans to new enrollees. Thirty-nine states indicated at least one insurance carrier exited the child-only market following enactment of the health care laws.<ref>{{Cite press release|url=http://help.senate.gov/newsroom/press/release/?id=141b967c-935c-43d7-8565-147d7a64c70e&groups=Ranking|title=Report: Access to Child-Only Health Plans Declines Under New Health Care Law|date=August 2, 2011|publisher=]}}</ref>

====Effects on insurance premiums====

For the effect on health insurance premiums, the CBO referred<ref name="CBO-Reid-Dec2009"/>{{Rp|15}} to its November 2009 analysis<ref name=CBOPremiumEffect>{{cite web|url=http://www.cbo.gov/doc.cfm?index=10781&type=1 |title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act |publisher=Cbo.gov |date=2009-11-30 |accessdate=2012-06-29}}</ref> and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.<ref name=CBOPremiumEffect/>

The ] reported that, as a result of PPACA's provisions concerning the ] (between the ''initial coverage limit'' and the ''catastrophic coverage threshold'' in the ] ] program), individuals falling in this "donut hole" would save about 40 percent.<ref name="shrinks">{{cite web| last = Alonso-Zaldivar | first = Ricardo| title = AP Newsbreak: Medicare's drug coverage gap shrinks| publisher = ]| date = November 27, 2011| url = http://www.businessweek.com/ap/financialnews/D9R93OMO3.htm| accessdate = October 25, 2012}}</ref> Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies.<ref name="shrinks"/> The change benefited more than two million people, most of them in the middle class.<ref name="shrinks"/>

The non-partisan ] estimates that "about 4 million" (3.9 million or 1.2% of the ]) will pay the penalty in 2016.<ref>Congressional Budget Office, "," Congress of the United States, December 2010, pp 71,73.</ref> In September 2012, the CBO estimated that nearly six million will pay a $1,200&nbsp;penalty in 2016. Also, nearly 80&nbsp;percent of those who will face the penalty would be making up to or less than five times the federal poverty level. This would work out to $55,850&nbsp;or less &nbsp;for an individual and $115,250&nbsp;or less for a family of four.<ref>{{cite news|last=Alonso-Zaldivar|first=Ricardo|title=Tax penalty to hit nearly 6M uninsured people|agency=Associated Press|date=2012-09-19|url=http://www.google.com/hostednews/ap/article/ALeqM5jmIII4FgDvIW-bij_fdHF4v0Whbw?docId=48328c71af0241c39aef95fda77612f7|archiveurl=http://www.webcitation.org/6ApAsoQ8h|archivedate=2012-09-20|deadurl=no }}</ref>

In January 2013, the ] ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the worker’s household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. ''The New York Times'' said this could leave millions of Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies to buy coverage elsewhere.<ref> ''New York Times'', February 2, 2013</ref>

In March 2013, a report by The Lewin Group subsidiary of ], sponsored and published by the ], predicted that insurers' claims costs in the individual health insurance market could rise an average of 32&nbsp;percent nationally by 2017. Insurers in some states could see claims costs in the individual health insurance market go up higher than that with increases estimated at 80&nbsp;percent in Ohio and Wisconsin, and 60&nbsp;percent in California, Idaho, Maryland and Indiana. States such as New York, Vermont, and Massachusetts could see decreases of 13–14&nbsp;percent in insurers' claims costs in the individual health insurance market, however. The effect on insurance premiums was outside the scope of the study and was not addressed in the report. Larry Levitt, a health policy analyst from the ], cautioned that the Lewin Group study did not factor in efforts in the reform to control costs, and assumes huge increases in the individual market (which compromises just 6% of those under 65 currently); in contrast, Levitt said "I don't think anyone expects significant increases in the employer market," where the majority of Americans get their health insurance. Secretary of Health and Human Services Kathleen Sebelius also indicated that some cost increase in the individual market was expected because the standard of insurance allowed in the health care exchanges (run by the states or the federal government) would be higher quality than that generally available currently (and thus more expensive), and that the government subsidies provided to make insurance affordable weren't included in the Lewin Group estimates.<ref name="Haught 2013">{{cite web|author=Haught, Randy (]); Aherns, John (])|date=March 26, 2013|title=Cost of the future newly insured under the Affordable Care Act (ACA)|location=Schaumburg|publisher=]|url=http://cdn-files.soa.org/web/research-cost-aca-report.pdf|accessdate=April 12, 2013}}<br/>{{cite news|last=Aigner-Treworgy|first=Adam|date=March 27, 2013|title=Health care law will raise insurers' costs, actuaries say|work=CNN politicalticker... blog|publisher=]|url=http://politicalticker.blogs.cnn.com/2013/03/27/health-care-law-will-raise-insurers-costs-actuaries-say/|accessdate=April 12, 2013}}<br/>{{cite web|last=Robertson|first=Lori|date=April 5, 2013|title=Health insurance premium spin|location=Philadelphia|publisher=]|url=http://www.factcheck.org/2013/04/insurance-premium-spin/|accessdate=April 12, 2013}}</ref>

====Coverage for contraceptives====
{{main|Contraceptive mandate (United States)}}
The PPACA includes a ] coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations<ref name="Final Rule">{{cite web|title=Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules|url=http://www.gpo.gov/fdsys/granule/FR-2012-02-15/2012-3547/content-detail.html|publisher=Federal Register, GPO|accessdate=February 15, 2012|author=Dept. Health and Human Services|format=77 FR 8725|date=February 10, 2012|quote=Summary: ''These regulations finalize, without change, interim final regulations authorizing the exemption of group health plans and group health insurance coverage sponsored by certain religious employers from having to cover certain preventive health services under provisions of the Patient Protection and Affordable Care Act''.}}</ref> made under PPACA rely on the recommendations of the ], which concluded that access to contraception is medically necessary "to ensure women's health and well-being."<ref>{{cite news | publisher = CNN | title = Birth control should be fully covered under health plans, report says | first = Madison | last = Park | url = http://www.cnn.com/2011/HEALTH/07/19/birth.control.iom/index.html | date = July 19, 2011 | accessdate = August 27, 2012}}</ref>

The initial regulations proved controversial among Christian hospitals, ], ], and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds.<ref>{{cite web|last=Cohn|first=Jonathan|title=Religious Institutions Matter. So Do Their Employees.|url=http://www.newrepublic.com/blog/jonathan-cohn/100521/contraception-obamacare-catholic-religious-institutions }}</ref> To accommodate those concerns whilst still guaranteeing access to contraception, the regulations were adjusted to "allow religious organizations to opt out of the requirement to include birth control coverage in their employee insurance plans. In those instances, the insurers themselves will offer contraception coverage to enrollees directly, at no additional cost."<ref>{{cite web|last=Cohn|first=Jonathan|title=Obama’s Deal on Birth Control Coverage.|url=http://www.newrepublic.com/blog/jonathan-cohn/100636/obama-announces-contraception-accommodation-bishops-catholic-hospital-exemption }}</ref>

===Federal deficit and health care costs===
{{See also|United States public debt}}

====CBO deficit reduction estimates====
]
The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021.<ref name="CBO22077">{{cite web|url=http://www.cbo.gov/publication/22077 |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |publisher=Congressional Budget Office |date=March 30, 2011 |accessdate=April 6, 2012}}</ref><ref name="CBO43104">{{cite web |url=http://www.cbo.gov/publication/43104 |title=Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 16, 2012 |accessdate=April 6, 2012}}</ref> CBO estimated in March 2011 that for the 2012–2021 period, the law would result in net receipts of $813 billion, offset by $604 billion in outlays, resulting in a $210 billion reduction in the deficit.<ref name="CBO22077"/>

In 2012, the CBO updated its cost estimates for a portion of the bill, but did not update its estimate of the net deficit impact of the whole bill (which was still estimated to reduce budget deficits overall).<ref name="CBO43080"/> The ACA's provisions related to insurance coverage were projected earlier in 2012 to have a net cost of $1,252 billion over the 2012–2022 period; that amount represented a gross cost to the federal government of $1,762 billion, offset in part by $510 billion in receipts and other budgetary effects (primarily revenues from penalties and other sources). The addition of 2022 to the projection period had the effect of increasing the costs of the coverage provisions of the ACA relative to those projected in March 2011 for the 2012-2021 period because that change added a year in which the expansion of eligibility for Medicaid and the subsidies for health insurance purchased through the exchanges would have been in effect. This estimate was made prior to the Supreme Court's ruling regarding the expansion of Medicaid program to the individual states however.<ref name="CBO43076" /> CBO and JCT now estimate that the insurance coverage provisions of the 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. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)<ref name="CBO43472">{{cite web|url=http://www.cbo.gov/publication/43472 |title=CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=August 6, 2012}}</ref>

As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143&nbsp;billion<ref name="CBO21351">{{cite web |url=http://www.cbo.gov/publication/21351 |title=Cost Estimates for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation) |publisher=Congressional Budget Office |date=March 20, 2010 |accessdate=April 6, 2012}}</ref> over the first decade, but half of that was due to expected premiums for the ], which has since been abandoned.<ref>{{cite news| url=http://www.bloomberg.com/news/2011-10-14/u-s-won-t-start-class-long-term-care-insurance-sebelius-says.html | publisher=Bloomberg | first1=Alex | last1=Wayne | first2=Drew | last2=Armstrong | title=U.S. Won't Start Long-Term Care Insurance | date=October 14, 2011}}</ref> Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the great degree of uncertainty involved in the data) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2&nbsp;trillion.<ref name="CBO-Reid-Dec2009"/><ref name="CNN-Mar18">{{Cite news
| url = http://www.cnn.com/2010/POLITICS/03/18/health.care.latest/index.html
| publisher = CNN
| title = Where does health care reform stand?
| date = March 18, 2010
| accessdate = May 12, 2010
}}</ref>
CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".<ref>{{cite news|url=http://www.politifact.com/truth-o-meter/statements/2010/mar/18/nancy-pelosi/pelosi-cbo-says-health-reform-bill-would-cut-defic/|title=Pelosi: CBO says health reform bill would cut deficits by $1.2 trillion in second decade|last=Farley|first=Robert|date=March 18, 2010|publisher=]|accessdate=2010-04-07}}</ref>

CBO also initially stated that the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs;"<ref name="CBO-Reid-Dec2009">{{cite web | url = http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-Reid_Letter_Managers_Correction_Noted.pdf | title = Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act | format = PDF | publisher = Congressional Budget Office | date = December 19, 2009 | accessdate = March 22, 2010}}</ref> A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "]" legislation that would increase Medicare payments by more than $200&nbsp;billion from 2010 to 2019;<ref>{{cite web|url=http://www.cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |title=Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010 |publisher=Congressional Budget Office |date=March 19, 2010 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |title=Sen. Tom Coburn: Obamacare PR campaign anchored in spin, not reality |work=The Washington Examiner |date=July 8, 2006 |accessdate=April 1, 2012}}</ref><ref>{{cite news| url=http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta }}</ref><ref>{{cite web|last=Hogberg |first=David |url=http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |title=GOP Might Target ObamaCare As Part Of A Medicare 'Doc Fix' |work=Investor's Business Daily |date=November 22, 2010 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://www.heritage.org/Research/Reports/2009/12/An-Analysis-of-the-Senate-Democrats-Health-Care-Bill |title=An Analysis of the Senate Democrats' Health Care Bill |publisher=The Heritage Foundation |date=December 18, 2009 |accessdate=April 1, 2012}}</ref> however, the "doc fix" remains a separate piece of legislation.<ref>{{cite web|last=Van de Water|first=Peter|title=Debunking False Claims About Health Reform, Jobs, and the Deficit|url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3366|publisher=Center for Budget and Policy Priorities}}</ref> Subject to the same exclusion, the CBO initially estimated the federal government's share of the cost during the first decade at $940&nbsp;billion, $923&nbsp;billion of which takes place during the final six years (2014–2019) when the spending kicks in;<ref name="CBO-Pelosi">{{cite web
| url = http://www.cbo.gov/ftpdocs/113xx/doc11355/hr4872.pdf
| title = H.R. 4872, Reconciliation Act of 2010
| format = PDF
| publisher = Congressional Budget Office
| date = March 18, 2010
| accessdate = March 22, 2010
}}</ref><ref name="RollCallCBO">{{Cite news
| title = CBO: Health Care Overhaul Would Cost $940&nbsp;Billion
| first = Steven
| last = Dennis
| url = http://www.rollcall.com/news/44347-1.html
| newspaper = ]
| publisher = ]
| date = March 18, 2010
| accessdate = March 22, 2010
}}</ref> with revenue exceeding spending during these six years.<ref name="CBO-Pelosi2">{{Cite news
| title = What does the health-care bill do in its first year?
| first = Ezra
| last = Klein
| url = http://voices.washingtonpost.com/ezra-klein/2010/03/what_does_the_health-care_refo.html
| newspaper = ]
| date = March 22, 2010
}}</ref>

====Opinions on CBO projections====
There was mixed opinion about the CBO estimates.

], a ] at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the ]."<ref>{{cite news |title=Wrapping Your Head Around the Health Bill |author=] |newspaper=The New York Times |date=March 24, 2010 |url=http://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill/ |accessdate=October 9, 2010}}</ref>

], CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562&nbsp;billion because, he argued, it front-loaded revenue and back-loaded benefits.<ref>{{cite news| url=http://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html | work=The New York Times | title=The Real Arithmetic of Health Care Reform | first=Douglas | last=Holtz-Eakin | date=March 21, 2010}}</ref>

'']'' editors ] (an economist) and ] (a noted health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from ], and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;<ref>{{cite news |title=Is the CBO Biased Against Health Care Reform? |author=Noam Scheiber |work=The New Republic |date=September 17, 2009 |url=http://www.tnr.com/blog/the-stash/the-cbo-biased-against-health-care-reform }}</ref><ref name=autogenerated3>{{cite news |title=The GOP's Trick Play |author=Jonathan Cohn |work= The New Republic |date=January 21, 2011 |url=http://www.tnr.com/blog/jonathan-cohn/81941/trick-play }}</ref> "innovations in the delivery of medical care, like greater use of ]s<ref>{{cite web|url=http://www.medicalrecords.com/physicians/electronic-medical-records-deadline |title=Electronic Medical Records (Health Information Technology)}}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another – and that meant there wasn't much hard data to prove the savings would materialize."<ref name=autogenerated3 />

], former ] now working for ], has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.<ref name="deficit_david_walker_cbo_innacurate">{{cite news|url=http://www.npr.org/blogs/thetwo-way/2010/03/health_overhaul_another_promis.html|title=Health Overhaul Another Promise U.S. Can't Afford: Expert|last=James|first=Frank|date=March 19, 2010|publisher=]|accessdate=2010-04-07}}</ref> The ] objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20&nbsp;years to produce Medicare savings.<ref>{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |title=Congress Has Good Record of Implementing Medicare Savings |publisher=CBPP |accessdate=2010-03-28 }}</ref><ref>{{cite news |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |work=The Washington Post |accessdate=2010-03-28 }}</ref>

Republican ] leadership and the Republican majority on the ] estimate the law would increase the deficit by more than $700&nbsp;billion in its first 10&nbsp;years.<ref>{{cite web|last=Ryan |first=Paul |url=http://budget.house.gov/healthcare/ |title=The Budgetary Consequences of the President's Health Care Overhaul |publisher=House of Representatives Committee on the Budget |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Seymour |first=Don |url=http://www.speaker.gov/Blog/?postid=219211 |title=Repealing Job-Killing Health Care Law "First Step Toward Fiscal Sanity" |publisher=Speaker of the House John Boehner |date=January 6, 2011 |accessdate=April 1, 2012}}</ref>

Democratic ] leadership and the Democratic minority on the ] say the claims of budget gimmickry are false<ref>{{cite web|url=http://democrats.budget.house.gov/press-release/mythbuster-cms-actuary-debunks-gop-talking-point-health-reform-and-deficit |title=MYTHBUSTER – CMS Actuary Debunks GOP Talking Point on Health Reform and the Deficit |publisher=Committee on the Budget &#124; United States House of Representatives |date=January 26, 2011 |accessdate=April 1, 2012}}</ref> and that repeal of the legislation would increase the deficit by $230&nbsp;billion over the same period,<ref> Committee on the Budget | United States House of Representatives</ref> pointing to the CBO's 2011 analysis of the impact of repeal.<ref name=autogenerated2>Heavey, Susan (February 18, 2011), , Reuters, retrieved March 13, 2011</ref>

====Effect on health care cost trends====
In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:
:Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."<ref>{{cite web|url=http://www.cbo.gov/ftpdocs/115xx/doc11544/Presentation5-26-10.pdf |title=Health Costs and the Federal Budget |publisher=Congressional Budget Office |date=May 28, 2010 |accessdate=April 1, 2012}}</ref>

Jonathan Gruber, an influential consultant who helped develop both the Affordable Care Act and the Massachusetts Health Care reform that preceded it, acknowledges that the Affordable Care Act is not ''guaranteed'' to significantly 'bend the curve' of rising health care costs:
:"The real question is how far the ACA will go in slowing cost growth. Here, there is great uncertainty—mostly because there is such uncertainty in general about how to control cost growth in health care. There is no shortage of good ideas for ways of doing so... There is, however, a shortage of evidence regarding which approaches will actually work—and therefore no consensus on which path is best to follow. In the face of such uncertainty, the ACA pursued the path of considering a range of different approaches to controlling health care costs... Whether these policies by themselves can fully solve the long run health care cost problem in the United States is doubtful. They may, however, provide a first step towards controlling costs—and understanding what does and does not work to do so more broadly."<ref>{{cite web|url=http://economics.mit.edu/files/6829 |last=Gruber|first=Jonathan|title=The Impacts Of The Affordable Care Act: How Reasonable Are The Projections?}}</ref><ref>{{cite book|last=Gruber|first=Jonathan|title=Health Care Reform: What It Is, Why It's Necessary, How It Works|year=2011|publisher=Hill and Wang|location=United States|isbn=978-0-8090-5397-1|page=101}}</ref>

The law created the ] and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run.<ref>Kuraitis V. (2010). . e-CareManagement.com.</ref> Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/].<ref name="NewYorker-Gawande">{{Cite journal | author = ] | month = December | year = 2009 | url = http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all| title = Testing, Testing | journal = ]| accessdate = March 22, 2010}}</ref>

The ], an association of ], commissioned a report from the ] ] that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.<ref>{{cite news|url=http://www.politifact.com/truth-o-meter/statements/2010/mar/19/barack-obama/obama-says-health-reform-legislation-could-reduce-/|title=Obama says health reform legislation could reduce costs in employer plans by up to $3,000|last=Farley|first=Robert|date=March 19, 2010|publisher=PolitiFact.com|accessdate=2010-04-07}}</ref>

====Expenditure estimates====
In 2012, the ] (CBO) projected PPACA will require more than $1.7 trillion in gross federal spending over the period 2012–2022, some of which will be offset by penalties and tax increases related to coverage, resulting in net spending of more than $1.2 trillion for the insurance portion of the bill. However, this is only a partial accounting for the impact of the bill, excluding some offsetting expense reductions and revenue increases that result in a net deficit reduction.<ref name=fewer>{{cite web|last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/215795-cbo-health-law-to-cost-less-cover-fewer-people-than-first-thought |title=CBO: Obama's health law to cost less, cover fewer people than first thought – The Hill's Healthwatch |publisher=Thehill.com |date=2012-03-13 |accessdate=2012-06-29}}</ref><ref name="CBO43076" /><ref name="CBO43080">{{cite web|url=http://www.cbo.gov/publication/43080 |title=CBO Releases Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 13, 2012 |accessdate= |quote=''Supplemented by'' , March 16, 2012 }}</ref><ref>{{cite news|last=Sahadi |first=Jeanne |url=http://money.cnn.com/2012/03/13/news/economy/health-reform-costs |title=Health reform coverage cost falls slightly – Mar. 13, 2012 |publisher=Money.cnn.com |date= March 13, 2012|accessdate=2012-06-29}}</ref>

According to the ], by 2019 PPACA will increase expenditures on Medicaid and individual subsidies by $165&nbsp;billion annually while reducing Medicare expenditures by $125&nbsp;billion annually.<ref>http://heartland.org/sites/all/modules/custom/heartland_migration/files/pdfs/27696.pdf</ref> The ] reported that the bill would increase "total national health expenditures" by more than $200&nbsp;billion from 2010 to 2019.<ref name="autogenerated5">{{cite web|url=https://www.cms.gov/ActuarialStudies/Downloads/S_PPACA_2009-12-10.pdf |title=Estimated Financial Effects of the Patient Protection and Affordable Care Act of 2009 |publisher=Centers for Medicare and Medicaid Services |date=December 10, 2009 |accessdate=April 1, 2012}}</ref><ref>http://www.politico.com/static/PPM110_091211_financial_impact.html</ref> The report also cautioned that the increases could be larger, because the Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back: They projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors.<ref>{{dead link|date=March 2012}} ], April 23, 2010</ref> The Medicare Actuary report still concluded that "Additional Federal revenues would further offset the coverage costs; however, the Office of the Actuary does not have the expertise necessary to estimate all such impacts. The Congressional Budget Office and the Joint Committee on Taxation have estimated an overall reduction in the Federal Budget deficit through 2019 under the PPACA."<ref>Richard S. Foster, , ], April 22, 2010</ref>

===Political===

====Public opinion====
Polls indicate support of health care reform in general, but became more negative in regards to specific plans during the legislative debate over 2009 and 2010, and the Act that was ultimately signed in 2010 remains controversial with opinions falling along party lines: Democrats favor the law, while Republicans and most Independents do not. Polling averages show a plurality with negative opinions of the law, with those in favor trailing by single digits.<ref name="swanson">{{cite news| url=http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html | work=Pollster.com | first=Emily | last=Swanson | title=Health Care Plan: Favor / Oppose | date=July 30, 2009}}</ref><ref name="rcp">{{cite web|url=http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html |title=Obama and Democrats' Health Care Plan |publisher=RealClearPolitics |date= |accessdate=April 1, 2012}}</ref> '']'' found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.<ref>{{cite news|url=http://www.usatoday.com/news/washington/2010-03-23-health-poll-favorable_N.htm|title=Poll: Health care plan gains favor|last=Page|first=Susan|date=March 24, 2010|work=USA Today|accessdate=2010-03-24}}</ref>

Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. '']'', describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."<ref>{{cite news|author=Micah Cohen |url=http://fivethirtyeight.blogs.nytimes.com/2013/05/01/uncertainty-still-clouds-health-care-law/ |title=Uncertainty Still Clouds Health Care Law |date=May 1, 2013|work=FiveThirtyEight}}</ref> For example, a Reuters-Ipsos poll during June 2012 indicated the following:
*56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall.
*82% favored banning insurance companies from denying coverage to people with pre-existing conditions.
*61% favored allowing children to stay on their parents' insurance until age 26.
*72% supported requiring companies with more than 50 employees to provide insurance for their employees.
*61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.<ref name=most>{{cite news|last=Zengerle |first=Patricia |url=http://www.reuters.com/article/2012/06/24/us-usa-campaign-healthcare-idUSBRE85N01M20120624 |title=Reuters-Most Americans Oppose Health Law But Like the Provisions|publisher=Reuters.com |date= June 24, 2012 |accessdate=2012-06-28}}</ref>
*Other polls showed additional provisions receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.<ref>{{cite news|url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does/ |title=Washington Post-Republicans hate ‘Obamacare,’ but like most of what it does|publisher=Washingtonpost.com |date= June 26, 2012|accessdate=2012-06-28}}</ref><ref>{{cite news|last=Sargent |first=Greg |url=http://www.washingtonpost.com/blogs/plum-line/post/republicans-support-obamas-health-reforms--as-long-as-his-name-isnt-on-them/2012/06/25/gJQAq7E51V_blog.html |title=Washington Post-Greg Sargent-The Plum Line|publisher=Washingtonpost.com |date=June 25, 2012 |accessdate=2012-06-28}}</ref>
*Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),<ref>{{cite news|author=Uwe E. Reinhardt |url=http://economix.blogs.nytimes.com/2009/12/18/reimporting-american-drugs-from-canada/ |title=Reimporting American Drugs From Canada |date=December 18, 2009|work=Economix}}</ref> ], reducing the age to qualify for Medicare, and the ].<ref name=NEJMPublicOpinion>{{cite journal |author=Blendon RJ, Benson JM |title=Public opinion at the time of the vote on health care reform |journal=N. Engl. J. Med. |volume=362 |issue=16 |pages=e55 |year=2010 |month=April |pmid=20375397 |doi=10.1056/NEJMp1003844 |url=}}</ref>

Pollsters probed the reasons for opposition.<ref>{{cite news| url=http://facts.kff.org/chart.aspx?ch=1683 | work=Kaiser Family Foundation | title=Negative Views Driven By Many Factors}}</ref> In a ] ], 62% of respondents said they thought the PPACA would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they thought they and their families would be better off with the legislation.<ref>http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf</ref> In '']'', pollsters ] and ] wrote, "81% of voters say it's likely the plan will end up costing more than projected say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care. For these voters, the notion that you need to spend an additional trillion dollars doesn't make sense."<ref>{{cite news| url=http://online.wsj.com/article/SB10001424052748704784904575111993559174212.html | work=The Wall Street Journal | first1=Scott | last1=Rasmussen | first2=Doug | last2=Schoen | title=Why Obama Can't Move the Health-Care Numbers | date=March 9, 2010}}</ref> However, a June 2012 Reuters-Ipsos poll indicated that part of the opposition to the law was because some Americans did not believe the reform went far enough and wanted more done, not less. Among those opposed to the bill, 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among (the relative much smaller group of) Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.<ref name=most/>

Following ], a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."<ref>Jackson, David. ''USA Today.'' Retrieved: 8 July 2012.</ref>

====Term "Obamacare"====

The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to '']'', the term was first put in print in March 2007, when health care lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a ']-care' and 'Obama-care' to go along with ']-care,' ']-care,' and a totally revamped and remodeled ']-care' ]", Schulte Scott wrote.<ref name="CNN20120625Obamacare" /><ref name="NYT20120325">{{cite news|title=Fighting to Control the Meaning of ‘Obamacare’|url=http://www.nytimes.com/interactive/2012/03/25/us/politics/fighting-to-control-the-meaning-of-obamacare.html|accessdate=June 29, 2012|newspaper=The New York Times|date=March 25, 2012|author=Amanda Cox, Alicia Desantis and Jeremy White}}</ref> The expression Obamacare first was used in early 2007 generally by writers describing the candidate’s proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at ] magazine.<ref name="NYT20120803" /> The word was first uttered in a political campaign by ] in May 2007 in ], ]. Romney said: "] We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over health care'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."<ref name="CNN20120625Obamacare" />

By mid-2012 it was the common term used by both sides.<ref name="NYT20120803">{{cite news|last=Baker|first=Peter|title=Democrats Embrace Once Pejorative ‘Obamacare’ Tag|url=http://www.nytimes.com/2012/08/04/health/policy/democrats-embrace-once-pejorative-obamacare-tag.html?_r=1|accessdate=6 August 2012|newspaper=The New York Times|date=3 August 2012}}</ref> Use of the term in a positive sense was suggested by Democratic politicians such as ] (D-MI).<ref>{{cite web|last=Nelson |first=Steven |url=http://dailycaller.com/2011/06/08/democratic-leader-wants-to-reclaim-obamacare-make-it-a-compliment/ |title=Democratic Rep. John Conyers wants to reclaim 'ObamaCare', make it a compliment |work=The Daily Caller |date=June 8, 2011 |accessdate=April 1, 2012}}</ref> President Obama said subsequently, "I have no problem with people saying Obama cares. I do care."<ref>{{cite news| url=http://www.cbsnews.com/8301-503544_162-20092578-503544.html | publisher=CBS News | title=On bus tour, Obama embraces 'Obamacare', says 'I do care{{'-}}}}</ref> Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased ] ], triggered by the term, to direct people to the official HHS site.<ref name=smith20101217>{{cite news|url=http://www.politico.com/blogs/bensmith/1210/HHS_buys_ObamaCare.html|work=Politico|title=HHS Buys 'ObamaCare{{'-}}|first=Ben|last=Smith|date=December 17, 2010|accessdate=February 9, 2011}}</ref> In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post ] messages that begin, "I like #Obamacare because...".<ref name=thehill>{{cite web | last = Strauss | first = Daniel | title = Obama camp's pitch to supporters: 'Hell yeah, I'm for Obamacare{{'-}} | work = ] | date = March 23, 2012 | url = http://thehill.com/blogs/blog-briefing-room/news/217893-obama-reelection-campaign-urges-supporters-to-say-im-for-obamacare | accessdate = March 27, 2012}}</ref> According to an analysis by the ], the term "Obamacare" has been used nearly 3,000 times in Congressional speeches since its debut as a phrase on ] in July 2009.<ref name="CNN20120625Obamacare">{{cite news|last=Wallace|first=Gregory|title={{-'}}Obamacare': The word that defined the health care debate|url=http://articles.cnn.com/2012-06-25/politics/politics_obamacare-word-debate_1_health-reform-law-health-care-affordable-care-act?_s=PM:POLITICS|publisher=CNN|accessdate=September 4, 2012|date=June 25, 2012}}</ref>

===Working hours for part-time employees===
In 2013, the State of Virginia limited all part-time employees, from janitors to adjunct professors, to working no more than 29 hours per week so that they would not qualify for mandatory health insurance coverage under the law.<ref> ''The Virginian-Pilot'', February 8, 2013</ref> Florida’s ], Pennsylvania’s ], Ohio’s ], and New Jersey’s ] have instituted similar rules,<ref></ref> as have restaurants such as ], ], ],<ref> ''ThinkProgress'', February 11, 2013</ref> ], ], and some ] and ] franchises.<ref></ref>

==Legal challenges==
{{main|Constitutional challenges to the Patient Protection and Affordable Care Act}}
Opponents of the Patient Protection and Affordable Care Act have turned to the federal courts to challenge the constitutionality of the legislation.<ref>{{cite web|last=Cauchi|first=Richard|title=State Legislation and Actions Challenging Certain Health Reforms, 2011–2012|url=http://www.ncsl.org/issues-research/health/state-laws-and-actions-challenging-aca.aspx|publisher=National Conference of State Legislatures|accessdate=June 30, 2012|date=June 28, 2012}}</ref><ref>{{cite web|title=Legal Challenges to the Affordable Care Act|url=http://www.hfma.org/Templates/Print.aspx?id=24263|work=Healthcare Financial Management Association|publisher=Healthcare Financial Management Association|accessdate=June 30, 2012}}</ref> The Supreme Court upheld the individual mandate (5-4) on the basis that it is a tax rather than protection under the Commerce Clause, but determined that States could not be forced to participate in the expansion of Medicaid. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.<ref>{{cite web |title=Analysis: U.S. Supreme Court Upholds the Affordable Care Act: Roberts Rules? |url=http://www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules |publisher=von Briesen & Roper, S.C. |work=The National Law Review|date=2012-06-29|accessdate=2012-07-02}}</ref>

==Repeal efforts==

===111th Congress===
Reps. ] of ] and ] of ], both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. ] in the Senate.<ref>{{cite web|last=O'Brien |first=Michael |url=http://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |title=GOP quick to release 'repeal' bills |work=The Hill |date=March 22, 2010 |accessdate=April 1, 2012}}</ref> None of the three bills were considered by either body.

===112th Congress===
In 2011, the Republican-controlled House of Representatives voted 245–189 to approve a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2),<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002:|title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=] |date=2011-01-19}}</ref> which, if enacted, would repeal the Patient Protection and Affordable Care Act and the health care-related text of the Health Care and Education Reconciliation Act of 2010. All Republicans and 3 Democrats voted for repeal.<ref>{{cite web |url=http://clerk.house.gov/evs/2011/roll014.xml |title=Final Vote Results for passage of Repealing the Job-Killing Health Care Law Act (H.R. 2) |publisher=] |date=2011-01-19}}</ref> In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down.<ref>{{cite web|url=http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=112&session=1&vote=00009 |title=Motion to Waive All Applicable Budgetary Discipline Re: McConnell Amdt. No. 13 |publisher=U.S. Senate |date=February 2, 2011 |accessdate=April 1, 2012}}</ref> Before votes in both houses of the Congress took place, President Obama stated that he would ] the bill should it pass both chambers.<ref>{{cite web |url=http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994/ |title=House Passes Health Care Repeal 245–189 |publisher=] |date=2011-01-19}}</ref> Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the ]. The Republicans voted down this measure.<ref>{{cite web| last = Beutler| first = Brian | title = Dems Press GOPers To Repeal Their Own Benefits Along With Health Care Law| work = ]| date = January 19, 2011| url = http://tpmdc.talkingpointsmemo.com/2011/01/dems-press-gopers-to-repeal-their-own-benefits-along-with-health-care-law.php?ref=dcblt | accessdate = 2011-01-21}}</ref>

On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader ] stated that the House would again vote to repeal the law in July when Congress returns from recess.<ref>{{cite news |url=http://www.usatoday.com/news/washington/story/2012-06-28/health-care-romney-obama/55893858/1?csp=34news |title=Romney, GOP leaders pledge to repeal health care law |newspaper=USA Today |last=Kucinich |first=Jackie |date=June 28, 2012 |accessdate=June 29, 2012}}</ref><ref>{{cite news |url=http://online.wsj.com/article/SB10001424052702303561504577494682627914026.html |title=Romney, GOP Pledge to Repeal Health Law |last=Boles |first=Corey |newspaper=The Wall Street Journal |date=June 28, 2012 |accessdate=June 29, 2012}}</ref><ref>{{cite web |url=http://www.politico.com/news/stories/0612/77939.html |title=Health care decision: House GOP to renew repeal effort |last1=Sherman |first1=Jake |last2=Raju |first2=Manu |last3=Kim |first3=Seung Min |work=Politico |date=June 28, 2012 |accessdate=June 29, 2012}}</ref> On July 11, 2012, the House of Representatives voted to repeal the law with 5 Democrats and all 239 Republicans voting in favor of the repeal.<ref name="H.R.6079">{{cite news| url=http://www.foxnews.com/politics/2012/07/11/house-approves-obamacare-repeal-in-first-vote-since-court-ruling/ | publisher=FoxNews | title=House approves ObamaCare repeal in first vote since Supreme Court ruling| date=July 11, 2012}}</ref><ref name="thirtythree">{{cite news| url=http://abcnews.go.com/blogs/politics/2012/07/house-obamacare-repeal-thirty-third-times-the-charm/ | publisher=ABC News | title=House Obamacare Repeal: Thirty-Third Time’s the Charm? | date=July 11, 2012}}</ref> This was the 31st effort by the House of Representatives to repeal the bill in the 112th Congress.<ref name="thirtyone">{{cite web |url=http://articles.baltimoresun.com/2012-07-11/health/bal-republicans-repeal-health-reform_1_house-votes-repeal-care-reform-bill |title=House of representatives votes to repeal health reform for the 31st time |last1=Walker |first1=Andrea K. |work=Baltimore Sun |date=July 11, 2012 |accessdate=July 12, 2012}}</ref> With President Obama's reelection and the Democrats expanding their majority in the Senate following the ], Republicans conceded that repeal almost certainly will not occur.<ref>http://thehill.com/blogs/healthwatch/health-reform-implementation/266689-conservatives-are-begin-to-admit-defeat-in-their-three-year-war-against-obamacare</ref>

====Job consequences of repeal====
One argument put forth in favor of repeal was that, as stated by a spokesman for House Majority Leader Eric Cantor, "This is a job-killing law, period."<ref name="jobkilling"/> The House Republican leadership justified its use of the term "job killing" by contending that PPACA would lead to a loss of 650,000 jobs, and attributing that figure to a report by the Congressional Budget Office.<ref name="jobkilling">{{cite web | last = Jackson | first = Brooks | coauthors = Lori Robertson| title = A 'Job-Killing' Law?| publisher = ] | date = January 7, 2011| url = http://factcheck.org/2011/01/a-job-killing-law/ | accessdate = 2011-01-23}}</ref> However, ] noted the 650,000 figure was not included in the CBO report that was referred to, and said that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect 'will probably be small.'"<ref name="jobkilling"/> ] also rated the Republican statement as False.<ref>{{cite web | last = Farley | first = Robert | coauthors = Angie Drobnic Holan | title = The health care law a 'job killer'? The evidence falls short | publisher = ] | date = January 20, 2011 | url = http://www.politifact.com/truth-o-meter/statements/2011/jan/20/eric-cantor/health-care-law-job-killer-evidence-falls-short/ | accessdate = 2011-01-23}}</ref>

], citing the projections of the CBO, summarized that the primary employment effect of the PPACA is to alleviate job-lock: "people who are only working because they desperately need employer-sponsored health insurance will no longer do so."<ref>{{cite web|last=Cohn|first=Jonathan|title=Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs.|url=http://www.newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs }}</ref> He concluded that "reform’s only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire"<ref>{{cite web|last=Cohn|first=Jonathan|title=Obamacare, Good for the Economy.|url=http://www.newrepublic.com/blog/plank/104035/obamacare-romney-economy-benefit-job-regulation-noam }}</ref> once they have health insurance outside of their jobs.

====Effect of repeal proposals on federal budget projections====
The non-partisan ] (CBO) estimated that repealing the entire PPACA (including both its taxing and spending provisions) would increase the net 2011–2021 federal deficit by $210&nbsp;billion.<ref name=autogenerated2 /> Republican politicians disagreed, arguing that estimate was based on unrealistic assumptions; House Speaker ] said, "I don't think anyone in this town believes that repealing Obamacare is going to increase the deficit."<ref>{{cite news| url=http://www.cnn.com/2011/POLITICS/01/06/health.care/index.html | publisher=CNN | title=Analysis: Health care repeal will cost $230&nbsp;billion | date=January 6, 2011}}</ref> In May 2011, CBO analyzed proposals to prevent the use of appropriated funds to implement the legislation, and wrote that "a temporary prohibition, extending through the remainder of fiscal year 2011, would reduce the budget deficit by about $1.4&nbsp;billion in 2011 but would increase deficits by almost $6&nbsp;billion over the 2011–2021 period... CBO cannot determine whether changes in spending under a permanent prohibition would produce net costs or net savings relative to its baseline projection, which assumes full implementation."<ref name="CBO41472">{{cite web|url=http://cbo.gov/publication/41472 |title = Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010 |publisher=Congressional Budget Office |date=May 26, 2011 |accessdate=April 1, 2012}}</ref>

Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R.&nbsp;6079) on July 11, 2012 and taking into account the Supreme Court's ruling concerning the expansion of Medicaid by the States, that, on balance, the direct spending and revenue effects of enacting the ''Repeal of Obamacare Act'' legislation would cause a net increase in federal budget deficits of $109&nbsp;billion over the 2013–2022 period. Specifically, CBO estimates that H.R.&nbsp;6079 would reduce direct spending by $890&nbsp;billion and reduce revenues by $1&nbsp;trillion between 2013 and 2022, thus adding $109&nbsp;billion to federal budget deficits over that period.<ref name="H.R.6079" /><ref name="CBO43471">{{cite web |url=http://cbo.gov/publication/43471 |title=Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=July 27, 2012}}</ref>

==Temporary waivers==
Interim regulations have been put in place for a specific type of employer-funded insurance, the so-called "mini-med" or limited-benefit plans, which are low-cost to employers who buy them for their employees, but cap coverage at a very low level. Such plans are sometimes offered to low-paid and part-time workers, for example in fast food restaurants or purchased direct from an insurer. Most company-provided health insurance policies starting on or after September 23, 2010 and before September 23, 2011 may not set an annual coverage cap lower than $750,000,<ref name="ELYB"> HHS web site</ref> a lower limit that is raised in stages until 2014, by which time no insurance caps are allowed at all. By 2014, no health insurance, whether sold in the individual or group market, will be allowed to place an annual cap on coverage. The waivers have been put in place to encourage employers and insurers offering mini-med plans not to withdraw medical coverage before the full regulations come into force (by which time small employers and individuals will be able to buy non-capped coverage through the exchanges) and are granted only if the employer can show that complying with the limit would mean a significant decrease in employees' benefits coverage or a significant increase in employees' premiums.<ref name="ELYB" />

Among those receiving waivers were employers, large insurers, such as ] and ], and union plans covering about one million employees. ], one of the employers that received a waiver, has 30,000 hourly employees whose plans have annual caps of $10,000. The waivers are issued for one year and can be reapplied for.<ref name="nytimes.com">{{cite news| url=http://www.nytimes.com/2010/10/07/business/07insure.html | work=The New York Times | first=Reed | last=Abelson | title=U.S. Waivers After Threats of Lost Health Coverage | date=October 6, 2010}}</ref><ref>{{cite news| url=http://www.suntimes.com/business/2782232,Waivers-on-healthreform.article | work=] | title=30 Companies Get One-Year Waiver From Health Reform Rule | date=October 7, 2010}}</ref> Referring to the adjustments as "a balancing act", ], director of the Office of Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014."<ref name="nytimes.com"/> On January 26, 2011, HHS said it had to date granted a total of 733 waivers for 2011, covering 2.1&nbsp;million people, or about 1% of the privately insured population.<ref>"", HHS-CMS-CCIIO, see section "Applications for Waiver of the Annual Limits Requirements"</ref> In June 2011, the Obama Administration announced that all applications for new waivers and renewals of existing ones have to be filed by September 22 of that year, and no new waivers would be approved after this date.<ref>{{cite news|url=http://www.msnbc.msn.com/id/43445375/ns/politics/ |title=Obama administration to end health care waivers |agency=Associated Press |publisher=msnbc.com |date=June 17, 2011 |accessdate=April 1, 2012}}</ref>

==See also==
*]
*] ("RomneyCare")
*]
*]
*]
*U.S. ] with 8 other countries in tabular form

==References==
{{reflist|30em}}

==Further reading==
* {{cite book|author=Barr, Donald A. |title=Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America|url=http://books.google.com/books?id=yZLJrmNoEzkC|year= 2011|publisher=JHU Press}}
* {{cite book|author=CCH|title=Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact|url=http://books.google.com/books?id=tCTt0sq2vaEC|year=2010|publisher=CCH Incorporated}} 1183pp
* {{cite book|author= Feldman, Arthur M.|title=Understanding Health Care Reform: Bridging the Gap Between Myth and Reality|url=http://books.google.com/books?id=dSszUQPKSZIC|year=2011|publisher=CRC Press}}
* {{cite book|author1=Jacobs, Lawrence R. |author2=Theda Skocpol|title=Health Care Reform and American Politics |url=http://books.google.com/books?id=VcsmJybD32wC|year=2010|publisher=Oxford U.P. }}
* {{cite book | author = John E. McDonough | title = Inside National Health Reform | publisher = University of California Press | year = 2011 | month = September | isbn = 9780520270190 }}
*
;Preliminary CBO documents
* − December 19, 2009
** Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
** Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
* , − November 18, 2009.<br />↑ <small>(The Additional and/or Related CBO reporting that follows can be accessed from the above link)</small>
** Estimated Distribution Of Individual Mandate Penalties (November 20, 2009)
** Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009)
** Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009)
** Estimated Average Premiums Under Current Law (December 5, 2009)
** Additional Information About Employment-Based Coverage (December 7, 2009)
** Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009)

;] (CMS) Estimates of the impact of P.L. 111-148
*. April 22, 2010.
*. April 22, 2010.

;] (CMS) Estimates of the impact of H.R. 3590
*. December 10, 2009.
*. December 10, 2009.

==External links==
{{Sister project links
| wikt = no
| b = no
| q = no
| commons = Category:Patient Protection and Affordable Care Act
| n = U.S. Senate passes landmark health care reform bill
| v = no}}
*
*
*
* – Department of Health and Human Services website on the law
*{{NYTtopic|organizations/s/supreme_court/affordable_care_act/|Affordable Care Act}}
*{{WSJtopic|subject/H/health-reform/1662|Health Reform}}
* as provided by Emily Smith from '']''' June 25, 2012
* as provided by '']'' June 17, 2012
* Kaiser Family Foundation:
* – Complete coverage of the arguments to the Supreme Court regarding Obamacare
* An ] timeline published on June 28, 2012 by ] about key events in a century of debate over what role the government should play in helping people in the United States afford medical care
* – Tracking and explanation of the law – as it is implemented – by analysts at the Hirsh Health Law and Policy program of the George Washington University School of Public Health and Health Services.
* {{cite news|url=http://www.theatlantic.com/politics/archive/2010/03/has-romney-lost-the-romneycare-obamacare-argument/37842/|title=Has Romney Lost The RomneyCare = ObamaCare Argument?|author=Ambinder, Marc |work=The Atlantic|date=March 22, 2010|accessdate=2011-04-07}}
; Copies of the proposed bill hosted online or readily downloadable
* of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111–148) ''<u>after</u>'' consolidating the amendments made by Title X of PPACA itself and by the Health Care and Education Reconciliation Act of 2010 ("HCERA"; Public Law 111–152) into one revision.
* , as engrossed or passed by the Senate and printed via ].
* The , full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov)
* (March 23, 2010) via ].
* at ]
*
*"Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional ] February 16, 2012
**
**
** '']'' February 17, 2012
{{Portal bar|Government of the United States|Health and fitness|Law|Medicine}}
{{Use mdy dates|date=July 2012}}

{{DEFAULTSORT:Patient Protection And Affordable Care Act}}
]
]
]
]
]
]
]
]
]
]
]
]
]

Revision as of 00:55, 10 May 2013

OBAMACARE IS STUPID

IT IS POINTLESS










IT IS THE REASON AMERICA IS IN SO MUCH DEBT WITH CHINA