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Patient Protection and Affordable Care Act

Long title	The Patient Protection and Affordable Care Act
Acronyms (colloquial)	PPACA
Nicknames	Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare
Enacted by	the 111th United States Congress
Effective	March 23, 2010 Most major provisions phased in by January 2014; remaining provisions phased in by 2020
Citations
Public law	111–148
Statutes at Large	124 Stat. 119 through 124 Stat. 1025 (906 pages)
Legislative history
Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009 Committee consideration by Ways and Means Passed the House on October 8, 2009 (416–0) Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39) with amendment House agreed to Senate amendment on March 21, 2010 (219–212) Signed into law by President Barack Obama on March 23, 2010
Major amendments
Health Care and Education Reconciliation Act of 2010 Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011
United States Supreme Court cases
National Federation of Independent Business v. Sebelius

The Patient Protection and Affordable Care Act (PPACA), commonly called Obamacare or the Affordable Care Act (ACA), is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.

The ACA is aimed at increasing the rate of health insurance coverage for Americans and reducing the overall costs of health care. It provides a number of mechanisms—including mandates, subsidies, and tax credits—to employers and individuals to increase the coverage rate. Additional reforms aim to improve healthcare outcomes and streamline the delivery of health care. The ACA requires insurance companies to cover all applicants and offer the same rates regardless of pre-existing conditions or sex. The Congressional Budget Office projected that the ACA will lower both future deficits and Medicare spending.

On June 28, 2012, the United States Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius.

Overview

Provisions

The ACA includes numerous provisions to take effect over several years beginning in 2010. There is a grandfather clause on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies.

• Guaranteed issue will require policies to be issued regardless of any medical condition, and partial community rating will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most pre-existing conditions (excluding tobacco use).
• A shared responsibility requirement, commonly called an individual mandate, requires that all individuals not covered by an employer sponsored health plan, Medicaid, Medicare 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 Internal Revenue Service, or waived in cases of financial hardship.
• Health insurance exchanges 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).
• Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies on a sliding scale 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).
• The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of the poverty level, effectively 138%, and simplifies the CHIP enrollment process. In National Federation of Independent Business v. Sebelius, 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.
• Minimum standards for health insurance policies are to be established and annual and lifetime coverage caps will be banned.
• 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.
• Very small businesses will be able to get subsidies if they purchase insurance through an exchange.
• Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package" for Level A or Level B preventive care.
• Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "bundled payment." 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 ACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened Medicare tax on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% excise tax on "Cadillac" insurance policies. 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. There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal sales tax on indoor tanning services. Offsets are from intended cost savings such as changes in the Medicare Advantage program relative to traditional Medicare.

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 billion
• Charge an annual fee on health insurance providers: $60 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 billion
• Impose an annual fee on manufacturers and importers of branded drugs: $27 billion
• Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20 billion
• Raise the 7.5% Adjusted Gross Income floor on medical expenses deduction to 10%: $15.2 billion
• Limit annual contributions to flexible spending arrangements in cafeteria plans to $2,500: $13 billion
• All other revenue sources: $14.9 billion

Summary of spending offsets: (ten year projection)

• Reduce funding for Medicare Advantage policies: $132 billion
• Reduce Medicare home health care payments: $40 billion
• Reduce certain Medicare hospital payments: $22 billion

Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17 billion, but the provision was repealed.

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Legislative history

Background

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 politically conservative Heritage Foundation as an alternative to single-payer health care. The idea of an individual mandate was championed by Republican politicians as a market-based approach to health-care reform, on the basis of individual responsibility: because the Emergency Medical Treatment and Active Labor Act (EMTALA), passed in 1986 by a bipartisan Congress and signed by Ronald Reagan, 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.

When, in 1993, President Bill Clinton proposed a health-care reform bill which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan. 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. (After failing to obtain a comprehensive reform of the health care system, Clinton did however negotiate a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997).

The 1993 Republican alternative, introduced by Senator John Chafee (R-RI) as the Health Equity and Access Reform Today Act, contained a "Universal Coverage" requirement with a penalty for non-compliance. Advocates for the 1993 bill which contained the individual mandate included prominent Republicans who today oppose the mandate, such as Orrin Hatch (R-UT), Charles Grassley (R-IA), Bob Bennett (R-UT), and Christopher Bond (R-MO). Of the 43 Republicans Senators from 1993, almost half - 20 out of 43 - supported the HEART Act. And in 1994 Senator Don Nickles (R-OK) introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision - 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." 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 George H.W. Bush, 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."

An individual health-insurance mandate was also enacted at the state-level in Massachusetts: In 2006, Republican Mitt Romney, then governor of Massachusetts, signed an insurance expansion bill with an individual mandate into law with strong bipartisan support (including that of Ted Kennedy (D-MA)). Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 Presidential campaign, Senator Jim DeMint (R-SC) 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."

The following year (2007), Senators Bob Bennett (R-UT) and Ron Wyden (D-OR) introduced the Healthy Americans Act, a bill that also featured an individual mandate, and which attracted bipartisan support. Among the Republican co-sponsors still in Congress during the health care debate: Senators Chuck Grassley (R-IA), Lindsey Graham (R-SC), Bob Bennett (R-UT), Mike Crapo (R-ID), Bob Corker (R-TN), Lamar Alexander (R-TN), and Arlen Specter (R-PA).

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; and that it was deliberately patterned after former Republican Governor of Massachusetts Mitt Romney's state healthcare plan (which contains an individual mandate). Jonathan Gruber, 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 ACA.

Health care debate, 2008–2010

Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 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 health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement. During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his top four priorities if he won the presidency.

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. On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform. By July, a series of bills were approved by committees within the House of Representatives. On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee 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 Max Baucus (D-MT), Chuck Grassley (R-IA), Kent Conrad (D-ND), Olympia Snowe (R-ME), Jeff Bingaman (D-NM), and Mike Enzi (R-WY), 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. The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site or at the Committee's own web site.

With universal health insurance as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like Jonathan Gruber and David Cutler argued that guaranteed issue would require both a (partial) community rating and an individual health insurance mandate to prevent either adverse selection and/or free riding from creating an insurance death spiral. They convinced Obama that this was necessary, which persuaded the Administration to accept Congressional proposals that included a mandate. This approach was preferred because the President and Congressional leaders concluded that more liberal plans (such as Medicare-for-all) 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 Howard Baker (R-TN), Bob Dole (R-KS), Tom Daschle (D-SD) and George Mitchell (D-ME) - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.

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. Senate Minority Leader Mitch McConnell (R-KY), 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:

"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."

Republican Senators (including those who had supported previous bills with a similar mandate) began to describe the mandate as "unconstitutional". Writing in The New Yorker, Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition." The New York Times 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."

The reform negotiations also attracted a great deal of attention from lobbyists, 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. The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.

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 Tea Party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills. There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection.

To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals. 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." On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.

Senate

The Senate began work on its on proposals while the House was still working on its own bill (the Affordable Health Care for America Act); it instead took up H.R. 3590, a bill regarding housing tax breaks for service members. As the United States Constitution requires all revenue-related bills to originate in the House, the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill. The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance 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. At the start of the 111th Congress, 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 to 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 Al Franken was sworn into office and by which time Arlen Specter had switched parties – because of disagreements over the substance of the bill, 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, Ted Kennedy – a long-time advocate for health care reform – died, depriving Democrats of their 60th vote. Whilst Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24 (regaining the Democrats' 60th vote); attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.

Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's Joe Lieberman (an independent who caucused with Democrats) and Nebraska's Ben Nelson. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included, even though it had majority support in Congress. There was debate among supporters of the bill about the importance of the public option, although the vast majority of supporters concluded that the it was a minor part of the reform overall, and that Congressional Democrats' fight for it won various concessions (including conditional wavers allowing states to set up state-based public options, for example Vermont's Green Mountain Care).

With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill; they had by this point concluded that "it was a waste of time dealing with " because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform. (Snowe retired at the end of her term, citing partisanship and polarization). 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 Medicaid reimbursement for Nebraska. The latter half of the compromise was derisively referred to as the "Cornhusker Kickback" (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 filibuster 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 (Jim Bunning (R-KY), not voting). The bill was endorsed by the AMA and AARP.

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41".

House

The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. White House Chief of Staff Rahm Emanuel argued the Democrats should scale-back for a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care". Obama remained insistent on comprehensive reform and the news that Anthem Blue Cross in California 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. On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills. He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill. The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.

With Democrats having lost a filibuster-proof supermajority in the Senate, 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 Affordable Health Care for America Act, 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. 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 Health Care and Education Reconciliation Act), which could be passed via the reconciliation process. Unlike the regular order, reconciliation is not subject to a filibuster (which requires 60 votes to break), but the process is limited to budget changes, 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 ACA) in the first place. 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."

The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion 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 Executive Order 13535, reaffirming the principles in the Hyde Amendment. This concession won the support of Stupak and members of his group and assured passage of the bill. 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. The following day, Republicans introduced legislation to repeal the bill. Obama signed the original bill (the ACA) into law on March 23, 2010. 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 million, leaving 23 million uninsured residents in 2019 after the bill's provisions have all taken effect. A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the successful legal challenge to PPACA's expansion of Medicaid.

Among the people in this uninsured group will be:

• Illegal immigrants, estimated to be around eight million – they will be ineligible for insurance subsidies and Medicaid; they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA).
• Citizens not enrolled in Medicaid despite being eligible.
• Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.
• Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.
• 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.

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. 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%. 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. 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.

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. 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. 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 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.

Effects on insurance premiums

For the effect on health insurance premiums, the CBO referred to its November 2009 analysis 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.

The Associated Press reported that, as a result of PPACA's provisions concerning the Medicare Part D coverage gap (between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription drug program), individuals falling in this "donut hole" would save about 40 percent. Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies. The change benefited more than two million people, most of them in the middle class.

The non-partisan Congressional Budget Office estimates that "about 4 million" (3.9 million or 1.2% of the population) will pay the penalty in 2016. In September 2012, the CBO estimated that nearly six million will pay a $1,200 penalty in 2016. Also, nearly 80 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 or less  for an individual and $115,250 or less for a family of four.

In January 2013, the Internal Revenue Service 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.

In March 2013, a report by The Lewin Group subsidiary of UnitedHealth Group, sponsored and published by the Society of Actuaries, predicted that insurers' claims costs in the individual health insurance market could rise an average of 32 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 percent in Ohio and Wisconsin, and 60 percent in California, Idaho, Maryland and Indiana. States such as New York, Vermont, and Massachusetts could see decreases of 13–14 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 Kaiser Family Foundation, 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.

Coverage for contraceptives

The ACA includes a contraceptive coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations made under PPACA rely on the recommendations of the Institute of Medicine, which concluded that access to contraception is medically necessary "to ensure women's health and well-being."

The initial regulations proved controversial among Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds. 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."

Federal deficit and health care costs

CBO deficit reduction estimates

The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021. 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.

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). 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. 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.)

As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143 billion over the first decade, but half of that was due to expected premiums for the C.L.A.S.S. Act, which has since been abandoned. 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 trillion. 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".

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;" A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019; however, the "doc fix" remains a separate piece of legislation. Subject to the same exclusion, the CBO initially estimated the federal government's share of the cost during the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the spending kicks in; with revenue exceeding spending during these six years.

Opinions on CBO projections

There was mixed opinion about the CBO estimates.

Uwe Reinhardt, a health economist 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 Medicare Modernization Act of 2003."

Douglas Holtz-Eakin, 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 billion because, he argued, it front-loaded revenue and back-loaded benefits.

The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (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 preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation; "innovations in the delivery of medical care, like greater use of electronic medical records 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."

David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, 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. The Center on Budget and Policy Priorities 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 years to produce Medicare savings.

Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700 billion in its first 10 years.

Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false and that repeal of the legislation would increase the deficit by $230 billion over the same period, pointing to the CBO's 2011 analysis of the impact of repeal.

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)."

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."

The law created the Center for Medicare and Medicaid Innovation and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run. Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.

The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates 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.

Expenditure estimates

In 2012, the Congressional Budget Office (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.

According to the Centers for Medicare and Medicaid Services, by 2019 PPACA will increase expenditures on Medicaid and individual subsidies by $165 billion annually while reducing Medicare expenditures by $125 billion annually. The United States Department of Health and Human Services reported that the bill would increase "total national health expenditures" by more than $200 billion from 2010 to 2019. 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. 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 ACA."

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. USA Today 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.

Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. FiveThirtyEight, 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." 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.
• 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.
• Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices), limiting malpractice awards, reducing the age to qualify for Medicare, and the public option.

Pollsters probed the reasons for opposition. In a CNN poll, 62% of respondents said they thought the ACA 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. In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen 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." 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.

Following the Supreme Court decision upholding the Act, 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."

Term "Obamacare"

The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to The New York Times, 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 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care,' 'Edwards-care,' and a totally revamped and remodeled 'Hillary-care' from the 1990s", Schulte Scott wrote. 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 The Atlantic magazine. The word was first uttered in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said: "In my state, I worked on health care for some time. 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."

By mid-2012 it was the common term used by both sides. Use of the term in a positive sense was suggested by Democratic politicians such as John Conyers (D-MI). President Obama said subsequently, "I have no problem with people saying Obama cares. I do care." Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased Google advertisements, triggered by the term, to direct people to the official HHS site. In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post Twitter messages that begin, "I like #Obamacare because...". According to an analysis by the Sunlight Foundation, the term "Obamacare" has been used nearly 3,000 times in Congressional speeches since its debut as a phrase on Capitol Hill in July 2009.

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. Florida’s Palm Beach State College, Pennsylvania’s Community College of Allegheny County, Ohio’s Youngstown State University, and New Jersey’s Kean University have instituted similar rules, as have restaurants such as Applebee's, Olive Garden, Denny's, Red Lobster, Papa John's Pizza, and some Wendy's and Taco Bell franchises.

Opposition and resistance

As with all complex legislation the act contains errors and provisions which need to be improved by tweaks or technical corrections in order to make the legislation work well in practice and avoid unintended consequences. Strong opposition in Congress by Republicans opposed to the act resulted in gridlock which prevented these routine adjustments and placed the program in danger.

Refusal to expand Medicaid coverage

A number of conservative and Southern "red" states have opted to reject the expanded Medicaid coverage provided for by the act. Over half of the uninsured live in those states. They include Texas, Florida, Kansas, Georgia, Louisiana, Alabama, and Mississippi. As of May 24, 2013 a number of states had not made final decisions, and lists of states which have opted out or were considering opting out varied, but Alaska,Idaho, South Dakota, Nebraska, Iowa, Wisconsin, Indiana, Pennsylvania, Maine, North Carolina, South Carolina, and Oklahoma seemed to have decided to reject expanded coverage.

Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies on a sliding scale 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); while Medicaid eligibility is expanded to include all individuals and families with incomes up to 133% of the poverty level, effectively 138%, and simplifies the CHIP enrollment process. In National Federation of Independent Business v. Sebelius, 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 will create a coverage gap in those states. In Kansas, where only those able-bodied adults with children with an income below 32% of the poverty line are eligible for Medicaid, those with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) would be ineligible for both Medicaid and federal subsidies to buy insurance. If they have no children, able-bodied adults are not eligible for Medicaid in Kansas.

Legal challenges

Opponents of the Patient Protection and Affordable Care Act have turned to the federal courts to challenge the constitutionality of the legislation. 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.

Repeal efforts

Efforts to oppose and repeal the legislation drew broad support from prominent conservative advocacy groups, certain small business organizations, and the Tea Party movement. It was also the subject of repeal efforts by Republicans in the 111th and 112th Congresses:

111th Congress

Reps. Steve King of Iowa and Michele Bachmann of Minnesota, both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. Jim DeMint in the Senate. 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), 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. In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down. Before votes in both houses of the Congress took place, President Obama stated that he would veto the bill should it pass both chambers. Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program. The Republicans voted down this measure.

On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader Eric Cantor stated that the House would again vote to repeal the law in July when Congress returns from recess. 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. This was the 31st effort by the House of Representatives to repeal the bill in the 112th Congress. With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, Republicans conceded that repeal almost certainly will not occur.

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." 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. However, FactCheck 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.'" PolitiFact also rated the Republican statement as False.

Jonathan Cohn, citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate job-lock: "people who are only working because they desperately need employer-sponsored health insurance will no longer do so." 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" once they have health insurance outside of their jobs.

Effect of repeal proposals on federal budget projections

The non-partisan Congressional Budget Office (CBO) estimated that repealing the entire PPACA (including both its taxing and spending provisions) would increase the net 2011–2021 federal deficit by $210 billion. Republican politicians disagreed, arguing that estimate was based on unrealistic assumptions; House Speaker John Boehner said, "I don't think anyone in this town believes that repealing Obamacare is going to increase the deficit." 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 billion in 2011 but would increase deficits by almost $6 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."

Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R. 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 billion over the 2013–2022 period. Specifically, CBO estimates that H.R. 6079 would reduce direct spending by $890 billion and reduce revenues by $1 trillion between 2013 and 2022, thus adding $109 billion to federal budget deficits over that period.

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, 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.

Among those receiving waivers were employers, large insurers, such as Aetna and Cigna, and union plans covering about one million employees. McDonald's, 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. Referring to the adjustments as "a balancing act", Nancy-Ann DeParle, director of the Office of Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014." On January 26, 2011, HHS said it had to date granted a total of 733 waivers for 2011, covering 2.1 million people, or about 1% of the privately insured population. 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.

See also

• Comparison of the health care systems in Canada and the United States
• Massachusetts health care reform ("RomneyCare")
• Clinton health care plan of 1993
• Universal health care
• National Health Insurance
• U.S. health care compared with 8 other countries in tabular form

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Further reading

• Barr, Donald A. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. JHU Press.
• CCH (2010). Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact. CCH Incorporated. 1183pp
• Feldman, Arthur M. (2011). Understanding Health Care Reform: Bridging the Gap Between Myth and Reality. CRC Press.
• Jacobs, Lawrence R.; Theda Skocpol (2010). Health Care Reform and American Politics. Oxford U.P.
• John E. McDonough (2011). Inside National Health Reform. University of California Press. ISBN 9780520270190. {{cite book}}: Unknown parameter |month= ignored (help)

Preliminary CBO documents

• Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment − 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)
• Base Analysis – H.R. 3590, Patient Protection and Affordable Care Act, − November 18, 2009.
  ↑ (The Additional and/or Related CBO reporting that follows can be accessed from the above link)
  • 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)

Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of P.L. 111-148

• Estimated Financial Effects of the "Patient Protection and Affordable Care Act," as Amended. April 22, 2010.
• Estimated Effects of the "Patient Protection and Affordable Care Act," as Amended, on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts. April 22, 2010.

Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of H.R. 3590

• Estimated Financial Effects of the "Patient Protection and Affordable Care Act of 2009," as Proposed by the Senate Majority Leader on November 18, 2009. December 10, 2009.
• Estimated Effects of the "Patient Protection and Affordable Care Act" on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts. December 10, 2009.

External links

• Video: Obama signs Healthcare Bill
• Supreme Court Ruling on the ACA-June 28, 2012
• Remarks by the President on Supreme Court Ruling on the Affordable Care Act-June 28, 2012
• HealthCare.gov – Department of Health and Human Services website on the law
• Affordable Care Act collected news and commentary at The New York Times
• Template:WSJtopic
• Basics: Health care reform issues as provided by Emily Smith from CNN' June 25, 2012
• Timeline of the health care law as provided by CNN June 17, 2012
• Kaiser Family Foundation: Health Reform Subsidy Calculator – Premium Assistance for Coverage in Exchanges/Gateways
• Three Days of Argument: Obamacare On Trial Audiobook – Complete coverage of the arguments to the Supreme Court regarding Obamacare
• Supreme Court ruling caps a century of American debate over how to get medical care for all An Associated Press timeline published on June 28, 2012 by The Washington Post 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
• HealthReformGPS.org – 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.
• Ambinder, Marc (March 22, 2010). "Has Romney Lost The RomneyCare = ObamaCare Argument?". The Atlantic. Retrieved April 7, 2011.

Copies of the proposed bill hosted online or readily downloadable

• PDF of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111–148) after 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.
• Plain Text or PDF formats of H. R. 3590 (Public Law 111-148), as engrossed or passed by the Senate and printed via FDsys.
• The Patient Protection and Affordable Care Act, full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov)
• Summary of H.R. 3590 (March 23, 2010) via THOMAS.
• Entry for H.R. 3590 at GovTrack
• The law as published by the U.S. Government Printing Office
• "Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional Committee on Oversight and Government Reform February 16, 2012
  • Lines Crossed: Separation of Church and State – Part 1
  • Lines Crossed: Separation of Church and State – Part 2
  • '"Where Are the Women?": Lawmakers Walk Out on Contraception Rule Hearing After Female Witness Barred' Democracy Now! February 17, 2012

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