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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 affordability and rate of health insurance coverage for Americans, and reducing the overall costs of health care (for individuals and the government). It provides a number of mechanisms — including mandates, subsidies, and tax credits — to employers and individuals to increase the coverage rate and health insurance affordability. The ACA requires insurance companies to cover all applicants within new minimum standards, and offer the same rates regardless of pre-existing conditions or sex. Additional reforms aim to improve healthcare outcomes and streamline the delivery of health care. 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 all individuals not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs, to 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. This was included on the rationale that - without such a mandate, a form of community rating, and coverage standards - the guaranteed issue provision would likely exacerbate adverse selection: if people could not be denied insurance by companies they might put-off insuring themselves until they got sick, causing insurers to resort to larger premium increases on sick individuals and more extensive coverage limits to afford the remaining insured population, which could result in an insurance death spiral. This led to the inclusion of subsidies (see below) so people with low-incomes can comply when the mandate goes into effect.
• 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, 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 (an 'essential health benefits'), 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 the "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.

Provisions by effective date

The ACA is divided into 10 titles 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. Below are some of the key provisions of the ACA. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.

Effective at enactment

• The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.
• The Medicaid drug rebate (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.
• A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research. 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. The bill prohibits the Institute from developing or employing "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 National Institute for Health and Clinical Excellence, which determines cost-effectiveness directly based on quality-adjusted life year valuations.
• 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.
• The Indian Health Care Improvement Act is reauthorized and amended.
• Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request. 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.
• 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.

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. To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months. There is no age requirement. 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.

Effective July 1, 2010

• The President established, within the Department of Health and Human Services (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 Surgeon General shall serve as the Chairperson of the new Council.
• A 10% sales tax on indoor tanning took effect.

Effective September 23, 2010

• Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.
• Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday, and regulations implemented under the ACA 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.
• Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.
• All new insurance plans must cover preventive care and medical screenings rated Level A or B by the U.S. Preventive Services Task Force. Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.
• Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011. The gap will be eliminated by 2020.
• Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.
• Insurers are prohibited from dropping policyholders when they get sick.
• Insurers are required to reveal details about administrative and executive expenditures.
• Insurers are required to implement an appeals process for coverage determination and claims on all new plans.
• Enhanced methods of fraud detection are implemented.
• Medicare is expanded to small, rural hospitals and facilities.
• 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.
• A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.
• A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.
• 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.

Effective January 1, 2011

• 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'.
• The Centers for Medicare and Medicaid Services is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.
• Flexible spending accounts, Health reimbursement accounts and health savings accounts cannot be used to pay for over-the-counter drugs, purchased without a prescription, except insulin.

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.

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. This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010. Reporting is not required for any employer that was required to file fewer than 250 Forms W-2 in the preceding calendar year.

• 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. Before the ACA, businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600. Under the repealed law, reporting of payments to corporations would also be required. Originally it was expected to raise $17 billion over 10 years. The amendments made by Section 9006 of the ACA 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.

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; gestational diabetes screening; human papillomavirus (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; human immunodeficiency virus (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and domestic violence screening and counseling - will be covered without cost sharing. This is also known as the contraceptive mandate.

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). 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.

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. 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.)

• Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.

• 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%.) This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in veterinary medicine.

• 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.

Effective by August 1, 2013

• Religious organizations that were given an extra year to implement the contraceptive mandate 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.

Effective by October 1, 2013

• Individuals can enroll in subsidized health insurance plans offered through state-based health insurance exchanges. Coverage begins on January 1, 2014.

Effective by January 1, 2014

• Insurers are prohibited from discriminating against or charging higher rates for any individual based on pre-existing medical conditions or gender.
• Insurers are prohibited from establishing annual spending caps.
• Under the mandatory coverage provision, 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, whichever is greater; this will rise to a minimum of $695 ($2,085 for families), or 2.5% of income over the filing minimum, by 2016. Exemptions are permitted for religious reasons, members of health care sharing ministries, or for those for whom the least expensive policy would exceed 8% of their income. In 2010, the Commissioner speculated that insurance providers would supply a form confirming essential coverage to both individuals and the IRS; individuals would attach this form to their Federal tax return. Those who aren't covered will be assessed the penalty on their Federal tax return. In the wording of the law, a taxpayer who fails to pay the penalty "shall not be subject to any criminal prosecution or penalty", and cannot have liens or levies placed on their property, but the IRS will be able to withhold future tax refunds from them.
• In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children. The law also provides for a 5% "income disregard", making the effective income eligibility limit 138% of the poverty line. Participating states may choose to increase the income eligibility limit beyond this minimum requirement. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled in National Federation of Independent Business v. Sebelius (2012) 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 April 25, 2013, fifteen states—Alaska, Alabama, Georgia, Idaho, Indiana, Iowa, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, South Carolina, Texas, Wisconsin, and Virginia—were not participating in the Medicaid expansion, with ten more—Kansas, Maine, Michigan, Montana, Missouri, Ohio, Pennsylvania, South Dakota, Utah, and Wyoming—leaning towards not participating.
• Health insurance exchanges 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. Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, refundable tax credit and gives a formula for its calculation. A refundable tax credit is a way to provide government benefits to individuals who may have no tax liability (such as the Earned Income Tax Credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage. The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (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. According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for a family of four will be the following:

• Two federally regulated 'multi-state plan' (MSP) insurers, with one being non-profit and the other being forbidden from providing coverage for abortion services, become partially available. 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.
• 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. 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.
• 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.
• A $2,000 per employee penalty will be imposed on employers with more than 50 full-time employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill). "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. In July 2013, the Obama administration announced this penalty would not be enforced until January 1, 2015.
• 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 Independent Payment Advisory Board), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.
• Revenue is increased from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.
• Members of Congress and their staff are only offered health care plans through the exchanges or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).
• A new excise tax 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 billion in annual revenue.
• 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 billion in annual revenue.
• The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).
• 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.
• The CLASS Act 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. The CLASS Act was repealed January 1, 2013.

Effective by October 1, 2014

• Federal payments to so-called 'disproportionate share hospitals', 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.

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.

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.

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.
• The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.

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. 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. 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. 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. A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, 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. In April 2011 Vermont announced its intention to pursue a waiver to implement the single-payer system enacted in May 2011. In September 2011 Montana announced it would also be seeking a waiver to set up its own single payer healthcare system.
• States may allow large employers and multi-employer health plans to purchase coverage in the Exchange.
• Two federally regulated 'multi-state plan' (MSP) insurers are scheduled to be fully phased-in, becoming available to all states (for more, see: section on provisions effective by January 1, 2014).

Effective by January 1, 2018

• All existing health insurance plans must cover approved preventive care and checkups without co-payment.
• A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill) 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.

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.

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

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 through public insurance (expanded Medicaid eligibility and Medicare coverage) 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 own proposals while the House was still working on its 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 waivers 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.

ACA drafters believed that increasing insurance coverage would not only improve quality of life but also help reduce medical bankruptcies (currently the leading cause of bankruptcy in America) and job lock; in addition, many believed that expanding coverage was necessary to help ensure cost controls function - the reforms to the payment systems that incentivize value over quantity would be more likely to succeed if the costs of health care providers could be reduced by limiting uncompensated emergency care, and if there was a larger risk pool to distribute costs among.

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.

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.

Insurance exchanges and the individual mandate

The ACA has two predominant means for increasing insurance coverage (as summarized above): One involves the expansion of already-existing, public insurance programs: expanding the coverage of Medicare (such as eliminating the 'donut hole'), and increasing the eligibility of the Medicaid program to expand enrollment. The other primary mechanism for providing insurance is the creation of state-based ‘insurance exchanges:’ regulated, virtual marketplaces, administered by either federal or state government, where private insurers may sell plans to individuals and small business starting January 2014. Those purchasing insurance plans may, if eligible, use subsidies provided through the exchanges. These exchanges will take the form of websites where the private plans allowed on sale within them will be regulated and comparable: Consumers will be able to visit these websites, compare the plans on offer, fill out a form to the government that will determine their eligibility for subsidies, and then purchase the insurance of their choice from the options available. (Members of Congress and their staff will participate in this system: they will be required to obtain health insurance through the exchanges (or plans otherwise approved by the bill, such as Medicare), instead of the Federal Employees Health Benefits Program that they currently use.)

The insurance exchanges are a method designed to create a market for private insurance in a way that addresses market failures in the current system (such as the high number of uninsured, medical bankruptcies, coverage limits, unaffordability, inflation, etc.) through regulations: Only approved plans that meet certain standards (see details below) will be allowed to be sold on the exchanges, and insurers will be prohibited from denying insurance, on the basis of pre-existing conditions, to consumers who are willing to and can afford a plan on offer in the exchanges. Several methods will be employed to make these plans affordable: Subsidies will be provided to those eligible. Regulations intended to increase competition (to reduces prices) will make plans and prices more transparent and price comparisons more accessible for consumers with online information; as well as the phase-in of federally-approved, multi-state plans on state exchanges (to help guarantee enough options, given that the number of plans on offer varies by state). And price regulations will be implemented, including a minimum medical loss ratio, and partial community rating that prevents individuals from being priced out of the market by price discrimination (through unaffordable plans for the uninsured, or premium increases on the insured) - namely poor and sick individuals who are more expensive to cover for insurers motivated either by profit maximization and/or the economics of insurance (specifically, the risk of an insurance pool not providing enough net-premiums to offset net-pay-outs).

The aforementioned regulations are enabled to function due to the requirement to buy insurance (the penalty for forgoing insurance known as the ‘individual mandate’), without which healthy people might put-off insuring themselves until they got sick; in such a situation, to afford the remaining (relatively sicker and thus more expensive) population, insurers would have to raise their premiums, which could drive more people to drop their coverage, creating a vicious cycle that could ultimately result in an insurance death spiral. Alternatively, the process could settle at a stable equilibrium relying on relatively high premiums for the insured and less coverage (and thus more illness and medical bankruptcy) for the uninsured. Either way, the absence of the mandate would likely cause the exchanges as a whole to malfunction, and ultimately perform similarly to the current private insurance market, as studies by the CBO, Jonathan Gruber, and Rand Health have concluded. Conversely, the inclusion of the mandate increases the size and diversity of the insured population, broadening the risk pool to spread the cost of insurance in a sustainable manner. Policy experience in New Jersey on the one hand and Massachusetts on the other offers evidence of such divergent outcomes.

Under the law, setting-up an exchange gives a state partial discretion on standards and prices of insurance (beyond those specifics set-out in the ACA): For example, those administering the exchange will be able to determine which plans are sold on or excluded from the exchanges, adjust (through limits on and negotiations with private insurers) the prices on offer, and impose higher or state-specific coverage requirements – including whether plans offered in the state are prohibited from covering abortion (making the procedure an out-of-pocket expense) or mandated to cover abortions that a physician determines to be medically-necessary (in either case, federal subsidies are prohibited from being used to fund the procedure). If a state does not set-up an exchange itself, they lose that discretion; and the responsibility to set-up exchanges for such states defaults to the federal government, whereby the Department of Health and Human Services assumes the authority and legal obligation to operate all functions in these 'federally-facilitated exchanges'. As of May 2013, 23 states and the District of Columbia plan to operate state-based exchanges themselves (7 of which are doing so in partnership with the federal government, an arrangement where they retain discretionary management but the federal government executes various functions), whereas the remaining 27 states default to federally-facilitated exchanges.

The law is also designed to be flexible by allowing states, from 2017 onwards, to apply for a "waiver for state innovation" from the federal government that will enable them to experiment with their own state-based system, on condition that it meets certain criteria. To obtain a waiver, a state must pass legislation setting-up an alternative health system that provides insurance at least as comprehensive and as affordable as that the ACA would, covers at least as many residents, and does not increase the federal deficit. Provided a state meets these conditions; receiving a waiver can exempt states from some of the central requirements of the ACA, including the individual mandate, the provision of an insurance exchange, and the employer mandate. 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, if they cannot be paid out due to the structure of the state plan. So far, only Vermont, in May 2011, has enacted an alternative plan - a state-based single-payer system for which they intend to pursue a waiver to implement.

Change in insurance standards

• Minimum standards for health insurance policies are to be established (an 'essential health benefits'), and annual and lifetime coverage caps will be banned.
• Co-payments, co-insurance, and deductibles are to be eliminated for select health care insurance benefits considered to be part of the "essential benefits package" for Level A or Level B preventive care.

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."

Temporary waivers during implementation, 2010-2011

During the implementation of the law, there were interim regulations 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. The waivers allowed employers to temporarily avoid the regulations ending annual and lifetime limits on coverage, and were put in place to encourage employers and insurers offering mini-med plans not to withdraw medical coverage before those regulations come into force (by which time small employers and individuals will be able to buy non-capped coverage through the exchanges) and were granted only if the employer could show that complying with the limit would mean a significant decrease in employees' benefits coverage or a significant increase in employees' premiums.

By January 26, 2011, HHS said it had 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.

Effects on insurance premiums

Several studies on insurance premiums expect that with the subsidies offered under the ACA, more people will pay less (than they did prior to the reforms) than those who will pay more, and that those premiums will be more stable (even in changing health circumstances) and transparent, thanks to the regulations on competition in the exchanges. As of July 2013, the average monthly premium scheduled to be on offer in the exchanges has come in below CBO expectations which, if it holds up, will not only be cheaper for consumers, but will reduce the overall cost of the subsidies.

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.

Larry Levitt, a health policy analyst from the Kaiser Family Foundation, noted that the individual market compromises just 6% of those under 65 currently, and said, in contrast, "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 are intended to more than offset this effect.

In June 2013, a study by the Kaiser Family Foundation focused on actual experience under the Act as it affected individual market consumers (those buying insurance on their own). The study found that the Medical Loss Ratio provision of the Act had saved this group of consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%. The bulk of the savings were in reduced premiums for individual insurance, but some came from premium rebates paid to consumers by insurance companies that had failed to meet the requirements of the Act.

Health care cost trends (health care cost inflation)

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 Cohn, a noted health policy analyst, commented that:

CBO doesn't produce estimates of how reform will affect overall health care spending--that is, the amount of money our society, as a whole, will devote to health care. But the official actuary for Medicare does. The actuary determined that... the long-term trend is towards less spending: Inflation after ten years would be lower than it is now. And it's the long-term trend that matters most... will reduce the cost of care--not by a lot and not by as much as possible in theory, but as much as is possible in this political universe.

He and fellow The New Republic editor Noam Scheiber further noted the CBO didn't include in its estimate various cost-saving provisions intended to reduce health inflation, and that historically the CBO has consistently underestimated the impact of 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.

The Centers for Medicare and Medicaid Services reported in 2013 that, while costs per capita continue to rise, the rate of increase in annual healthcare costs (health care inflation) has fallen since 2002. Per capita cost increases have averaged 5.4% annually since 2000. Costs relative to GDP, which had been rising, has stagnated since 2009. Several studies have attempted to explain the reduction in the rate of annual increase. Reasons include, among others:

• Higher unemployment due to the 2008-2010 recession, which has limited the ability of consumers to purchase healthcare;
• Out-of-pocket payments and deductibles (the amount a person pays of their health costs before insurance begins to cover claims) have risen, which generally causes less consumption of health care. And the proportion of workers with employer-sponsored health insurance that requires a deductible has climbed to about three-quarters in 2012 from about half in 2006;
• And structural changes from ACA programs and regulations aiming to shift the system from paying-for-quantity to paying-for-quality (like incentives to use electronic medical records, accountable care organizations and bundled payments to coordinate care and prioritize quality over quantity, and reduce hospital infections, etc.), including health care providers acting in anticipation of future implementation of reforms.

Whilst there is uncertainty about which causes are responsible to what extent for the recent reduction in health care inflation (and accompanying reduction in long-term deficit projections due to reduced health care costs), and about the durability of the trend; several studies have found that the temporary effects of the recession can not account for all of the slowdown, and that structural changes therefore likely share (partial) credit. One study estimated the changes to the health system to be responsible for about a quarter of the recent reduction in inflation.

Federal deficit

CBO estimates of impact on deficit

The 2011 comprehensive CBO estimate projected a net-deficit reduction of more than $200 billion during the 2012–2021 period: it calculated the law would result in $604 billion in total outlays (expenditure) offset by $813 billion in total receipts (revenue), resulting in a $210 billion net-reduction in the deficit. The CBO separately noted that whilst most of the spending provisions don't begin until 2014, revenue will still exceed spending in those subsequent years. CBO also 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."

Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the degree of uncertainty involved in the projection) 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".

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 issue that would have existed whether or not the ACA became law - omitting its cost from the ACA is no different than omitting the cost of the Bush tax cuts.

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—reducing the cost estimate by $84 billion. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)

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 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.

Employer mandate and part-time working hours

Not to be confused with the individual mandate

The employer mandate is a penalty that will be incurred by employers with more than 50 employees, if they do not offer health insurance to their full-time workers. This provision was included as a disincentive for employers considering dropping their current insurance plans once the insurance exchanges begin operating as an alternative source of insurance. Proponents of the reform law wanted to address the parts of the health care system they believed to not be working well, whilst causing minimal disruption to those happy with the coverage they have, and the employer mandate was a part of this attempt. Lawmakers recognized that approximately 80% of Americans already have insurance, of whom 54% are covered directly or indirectly through an employer (44% of the total population) – another 29% of those covered (23% of the total population) are covered by the government (mainly Medicare, Medicaid). And 73% of the total population reported themselves satisfied with their insurance situation; however significant minorities (even among those that reported favorably) had medically-related financial troubles and/or dissatisfaction with aspects of their insurance coverage, especially among the poor and sick. The intent of the employer mandate is to help ensure that existing employer-sponsored insurance plans that people like will stay in place.

However, because a company will not face the penalty if it has less than 50 full-time employees, many are concerned that the employer mandate creates a perverse incentive for business to employ people part-time instead of full-time. Several businesses and the State of Virginia have clarified the contracts of their part-time employees by adding a 29-hour a week cap, to reflect the 30-hour threshold for full-time hours, as defined by the law. As of yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis). And labour market experts note that such shifts are not clearly attributable to the implementation of the ACA: pre-existing, long-term trends in working hours, and the effects of the Great Recession correlate with part-time working hour patterns. The impact of this provision on employer’s decision-making is partially offset by other factors: offering health care helps attract and retain employees, while increasing productivity and reducing absenteeism; and to trade a smaller full-time workforce for a larger part-time work force carries costs of training and administration for a business. In addition, the amount of employers with over 50 employees is relatively small, and over 90% of them already offer insurance, so changes in employer plans from this provision are expected to be small. Workers who don’t receive insurance from an employer plan will still be able to purchase insurance on the exchanges.

Regardless of the political rationale (of maintaining existing insurance arrangements for those happy with them), most policy analysts (on both the right and left) are critical of the employer mandate provision on the policy merits. They argue that the perverse incentives regarding part-time hours (even if they don’t change many existing insurance plans) are real and harmful; that the raised marginal cost of the 50th worker for businesses could limit companies’ growth; that the costs of reporting and administration (the paperwork for businesses and the state enforcement) are not worth the trade-off of incentivizing the maintenance of current employer plans; and note that the employer mandate (unlike the individual mandate) is a non-essential part of the law. (At the same time, though, some analysts have noted that it is possible to design an employer mandate that partially avoids these problems, by instead taxing business that don't offer insurance by a percentage of their payroll, known as 'pay-or-play,' rather than using the 50-employee and 30-hour cut-offs). Furthermore, many health care policy analysts think it would be better to transition away from the employer-based system to systems (whether state- or market-based) where insurance is more portable and stable, and hence think that it is a bad idea to even try to maintain existing employer insurance systems. The effects of the provision have also generated vocal opposition from several business and unions.

On July 2, 2013, the Obama Administration announced on the Treasury Department’s website that it would delay the employer mandate for one year, until 2015. In the statement, the Administration said that they were delaying implementation in order to meet two goals: “First, it will allow us to consider ways to simplify the new reporting requirements consistent with the law. Second, it will provide time to adapt health coverage and reporting systems while employers are moving toward making health coverage affordable and accessible for their employees."

The announcement was met with strong criticism by some who claimed that the authority to delay the implementation of the law lay with Congress. Senate Minority Leader Mitch McConnell argued that President Obama’s authorization to delay the provision exceeded the limits of his executive power. House Republicans bought two bills to a vote to draw attention to the issue: The Authority for Mandate Delay Act; and the Fairness for American Families Act, which would apply the same delay to the individual mandate, arguing that the individual mandate should be treated the same way – an action which the Obama Administration opposes.

Constitutional scholar Simon Lazarus countered critics, saying that the delay was a lawful discretion of Executive power: "In effect, the Administration explains the delay as a sensible adjustment to phase-in enforcement, not a refusal to enforce… To be sure, the federal Administrative Procedure Act authorizes federal courts to compel agencies to initiate statutorily required actions that have been ‘unreasonably delayed.’ But courts have found delays to be unreasonable only in rare cases where, unlike this one, inaction had lasted for several years, and the recalcitrant agency could offer neither a persuasive excuse nor a credible end to its dithering." Critics of the House Republicans’ comparison of the employer and individual mandate also pointed out that the two provisions are qualitatively different.

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."

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. A majority (52–34) indicate that they want "Congress to implement or tinker with the law rather than repeal it."

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, Obamacare had become the most common colloquial term to refer to the law by both supporters and opponents (in contrast to the use of 'Patient Protection and Affordable Care Act' or 'Affordable Care Act' in more formal and official use). Use of the term in a positive sense was suggested by Democratic politicians such as John Conyers (D-MI). President Obama endorsed the nickname, saying, "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...". After its debut as a phrase on Capitol Hill, according to an analysis by the Sunlight Foundation, from July 2009 to June 2012 the term "Obamacare" was used nearly 3,000 times in congressional speeches.

Myths

On August 7, 2009, Sarah Palin falsely claimed that the proposed legislation would create death panels that would decide if sick and elderly Americans were "worthy" of medical care. By 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and that 30% of Americans believed the it was true, with three contemporaneous polls finding similar results. The allegation was named PolitiFact's "Lie of the Year", one of FactCheck's "whoppers", and the most outrageous term by the American Dialect Society. The AARP described such rumors as "rife with gross - and even cruel - distortions." A poll in August 2012 found that 39% of Americans still believed the "death panels" claim.

The 'death panel' rumors and comparable myths (similarly false) distort two issues related to the ACA to claim that seniors are either able to be denied care due to their age under the law, or will be advised by the government to end their own lives instead of receiving due care. Such rumors first allude to the Independent Payment Advisory Board, which has the authority to make cost-saving changes to the Medicare program by implementing the adoption of cost-effective treatments, and finding savings in administration of the program. However, the IPAB is also prohibited from limiting what Medicare covers, or raising the costs on beneficiaries. The other related issue concerns advance care planning consultation: a section of an initial House reform proposal would have reimbursed physicians for providing voluntary consultations of Medicare recipients on end-of-life health planning (which is also covered by many private plans), enabling patients to specify, on request, the kind of care they wish to receive in their old age. As described by the site Snopes.com, "This provision would allow patients (if they so choose) to prepare for the day when they might be seriously ill and unable to made medical decisions for themselves by engaging in consultations with doctors to discuss the full range of end-of-life care options available to them, and to have the cost of such consultations covered by Medicare... directives to accept or refuse extreme life-saving measures, selection of hospice care programs, appointment of relatives" to act on the patient's behalf, etc. However, due to the public concern, this provision was not included in the final draft of the bill that was enacted into law.

In 2010, more false rumors spread on the Internet, claiming that the bill would require all Americans or those covered by public insurance to have a microchip implanted. These were sometimes associated with the number of the beast (666) in Christian eschatology. These rumors echo similar 'Big Brother' conspiracy myths, and in this case were based on language in draft bills of the law that would have enabled the Department of Health and Human Services to collect data "about medical devices 'used in or on a patient' (such as pacemakers or hip replacements) for purposes that included tracking the effectiveness of such devices and facilitating the distribution of manufacturer recall notices." These provisions did not mandate or authorize the government to implant devices in patients, and were not included in the final bill that became law.

Opposition and resistance

Efforts to oppose, undermine, and repeal the legislation have drawn support from prominent conservative advocacy groups, Congressional and many State Republicans, certain small business organizations, and the Tea Party movement.

Legal challenges

Opponents of the Patient Protection and Affordable Care Act turned to the federal courts to challenge the constitutionality of the legislation. In National Federation of Independent Business v. Sebelius, decided on June 28, 2012, the Supreme Court upheld most of the law; ruling the individual mandate (5-4) is constitutional on the basis that is a tax rather than being authorized by the Commerce Clause, but determined that States could not be forced to participate in the Medicaid expansion, effectively allowing states to opt out of this provision. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled 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. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.

State rejections of Medicaid expansion

Following the NFIB v. Sebelius ruling, several states with legislatures and governorships controlled by Republicans 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. As of July 17, with the addition of Arizona, 24 states and the District of Columbia have adopted the Medicaid expansion.

The drafters of the ACA had intended for Medicaid to cover individuals and families with incomes up to 133 (138% under certain definitions of income) of the poverty level by expanding Medicaid eligibility and simplifying the CHIP enrollment process. 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);

However the SCOTUS ruling created the potential for a coverage gap: States that choose to reject the Medicaid expansion can maintain the pre-existing Medicaid eligibility thresholds that they have set, which in many states are significantly below 133% of the poverty line (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 between the state Medicaid threshold and the subsidy eligibility threshold. For example, 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.

Studies of the impact of state decisions (as of July 2013) to reject the Medicaid expansion calculate that up to 6.4 million Americans could fall into this coverage gap.

Congressional obstruction

As with all complex legislation, the act contains small errors and provisions which need to be tweaked in order to make the legislation work well in practice and avoid unintended consequences. Strong opposition in Congress by Republicans opposed to the act has resulted in gridlock, preventing these routine adjustments to programs. Many Congressional Republicans and supporters argue that improving the law will weaken the arguments for repeal. In addition to refusing to make routine technical corrections that would improve the law, Republicans have also attempted to defund its implementation, and block appointments to relevant agencies (like the IPAB and CMS).

Repeal efforts

The ACA has been the subject of repeal efforts by Republicans in the 111th, 112th, and 113th Congresses:

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.

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 law. With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, many 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. 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.

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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