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| {{Use American English|date=July 2012}}{{Use MDY dates|date=July 2012}} | {{Use American English|date=July 2012}}{{Use MDY dates|date=July 2012}}<!-- Deleted image removed: ] with Ted Kennedy and a bipartisan group of state legislators, April 12, 2006.]] --> | ||
| {{Infobox U.S. legislation | |||
| | name = Patient Protection and Affordable Care Act | |||
| | fullname = The Patient Protection and Affordable Care Act | |||
| | acronym = PPACA, ACA | |||
| | nickname = Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare | |||
| | enacted by = 111th | |||
| | effective date = March 23, 2010<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020 | |||
| | public law url = http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html | |||
| | cite public law = 111–148 | |||
| | cite statutes at large = 124 Stat. 119 ''through'' 124 Stat. 1025 (906 pages) | |||
| | acts amended = | |||
| | title amended = | |||
| | sections created = | |||
| | sections amended = | |||
| | leghisturl = http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@S | |||
| | introducedin = House | |||
| | introducedbill = '''the''' "Service Members Home Ownership Tax Act of 2009" ({{USBill|111|H.R.|3590}}) | |||
| | introducedby = ] (]–]) | |||
| | introduceddate = September 17, 2009 | |||
| | committees = ] | |||
| | passedbody1 = House | |||
| | passedas1 = "Service Members Home Ownership Tax Act of 2009" | |||
| | passeddate1 = October 8, 2009 | |||
| | passedvote1 = | |||
| | passedbody2 = Senate | |||
| | passedas2 = "Patient Protection and Affordable Care Act" | |||
| | passeddate2 = December 24, 2009 | |||
| | passedvote2 = | |||
| | agreedbody3 = House | |||
| | agreeddate3 = March 21, 2010 | |||
| | agreedvote3 = | |||
| | signedpresident = ] | |||
| | signeddate = March 23, 2010 | |||
| | amendments = ]<br />Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 | |||
| | SCOTUS cases = '']'' | |||
| }} | |||
| The '''Patient Protection and Affordable Care Act''' ('''PPACA'''),<ref>{{USPL|111|148}}, {{USStat|124|119}}, codified as amended at scattered sections of the ] and in ]</ref> commonly called '''Obamacare'''<ref name="CNN20120625Obamacare" /><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/article/2012/mar/20/romneycare-and-obamacare-can-you-tell-difference/ |title=RomneyCare & ObamaCare: Can you tell the difference? |last=Holan |first=Angie D. |author= |authorlink= |date=March 20, 2012 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> or the '''Affordable Care Act''' ('''ACA'''), is a ] ] signed into law by ] ] on March 23, 2010. Together with the ], it represents the most significant regulatory overhaul of the ] since the passage of ] and ] in 1965.<ref name=overhaul>{{cite news|url=http://www.reuters.com/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628|title=US top court upholds healthcare law in Obama triumph|publisher=Reuters|author=James Vicini and Jonathan Stempel|date=June 28, 2012}}</ref> | |||
| The ACA aims to increase the quality and affordability of ], lower the ] by expanding ] and ] insurance coverage, and reduce the costs of healthcare for individuals and the government. It provides a number of mechanisms—including ], ], and ]—to increase coverage and affordability.<ref name="nyt-critics">{{cite news |newspaper=] |title= Health Law Critics Prepare to Battle Over Insurance Exchange Subsidies |url=http://www.nytimes.com/2012/07/08/us/critics-of-health-care-law-prepare-to-battle-over-insurance-exchange-subsidies.html |first=Robert |last=Pear |date=July 7, 2012 |accessdate=July 7, 2012}}</ref><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/statements/2010/feb/04/paul-krugman/krugman-calls-senate-health-care-bill-similar-law-/ |title=Krugman calls Senate health care bill similar to law in Massachusetts |last=Krugman |first=Paul |author= |authorlink= |date=January 31, 2010 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> The law also requires insurance companies to ] within new minimum standards and ] regardless of ]s or sex.<ref>{{cite news |title=Supreme Court Upholds Heart of Obama Health Care Law Seeking to Cover 30 Million Uninsured |author=Hearst, Steven R. |url=http://www.montrealgazette.com/news/Supreme+Court+upholds+heart+Obamacare/6854896/story.html |newspaper=The Gazette |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=ObamaCare Survives the Supreme Court: 5 Takeaways |url=http://theweek.com/article/index/229985/obamacare-survives-the-supreme-court-5-takeaways |newspaper=The Week |date=June 28, 2012 |accessdate=June 30, 2012}}</ref> Additional reforms aim to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of healthcare. The ] projected that the ACA will lower both future deficits<ref>{{cite web |url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/121xx/doc12119/03-30-healthcarelegislation.pdf |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |author=Elmendorf, Douglas W. |date=March 30, 2011 |publisher=] |format=PDF |accessdate=July 15, 2012}}</ref> and Medicare spending.<ref>{{cite web |url=http://cbo.gov/sites/default/files/cbofiles/attachments/06-21-Long-Term_Budget_Outlook.pdf |title=CBO's 2011 Long-Term Budget Outlook |author=Elmendorf, Douglas W. |date=June 2011 |page=44 |publisher=] |format=PDF |quote=Through those changes and numerous others, the 2010 legislation significantly decreased Medicare outlays relative to what they would have been under prior law.}}</ref> | |||
| On June 28, 2012, the ] upheld the constitutionality of most of the ACA in the case '']''. However, the Court held that states cannot be forced to participate in the ACA's Medicaid expansion under penalty of losing their current Medicaid funding.<ref>Pg 55–58, slip opinion, ''National Federation of Independent Business v. Sebelius'', U.S. Supreme. Court. (June 28, 2012)</ref><ref>{{cite news |title=Supreme Court Supports Obamacare, Bolsters Obama |last=Barrett |first=Paul M. |url=http://www.businessweek.com/articles/2012-06-28/supreme-court-supports-obamacare-and-bolsters-obama |newspaper=BloombergBusinessweek |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=Obamacare upheld by the U.S. Supreme Court |author=National Post Wire Services |url=http://news.nationalpost.com/2012/06/28/obamacare-upheld-by-the-u-s-supreme-court/ |newspaper=National Post |date=June 28, 2012 |accessdate=June 30, 2012}}, including a major provision that requires all Americans purchase health insurance coverage.</ref> Since the ruling, the law and its implementation have continued to ] in ], in ], and from some ]. | |||
| {{TOC limit|4}} | |||
| ==Overview of provisions== | |||
| {{Main|Provisions of the Patient Protection and Affordable Care Act by effective date}} | |||
| ] | |||
| from ]<ref>] The Henry J. Kaiser Family Foundation</ref>]] | |||
| The ACA includes numerous provisions that take effect between 2010 and 2020. A ] exempts policies issued before 2010 from many of the changes to insurance standards, but are affected by other provisions.<ref>{{cite web|url=https://www.healthcare.gov/what-if-i-have-a-grandfathered-health-plan/|title=What if I have a grandfathered health insurance plan? |publisher=Healthcare.gov }}</ref><ref>{{cite web|author=Bernadette Fernandez |url=http://www.ncsl.org/documents/health/grandfathered.pdf |title=Grandfathered Health Plans Under the Patient Protection and Affordable Care Act (PPACA) |publisher=Congressional Research Service |date=April 27, 2010 }}</ref> The most significant reforms include the following: | |||
| * ] prohibits insurers from denying coverage to individuals regardless of ]s, and a partial ] requires 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 ] use).<ref name="Blue Cross Blue Shield of Michigan">{{cite press release|url=http://www.bcbsm.com/healthreform/pubs/ppaca_insurance_reform_2014.pdf |title=2014 Insurance Reforms under the Patient Protection and Affordable Care Act (PPACA) |publisher=Blue Cross Blue Shield of Michigan |date= |accessdate=2012-04-09}}</ref><ref name="Pool">{{cite web|last=Pool |first=Gentrie |url=http://www.asjonline.com/Exclusives/2010/10/Pages/After-PPACA-The-Future-of-the-Health-Insurance-Underwriter.aspx |title=After PPACA: The Future of the Health Insurance Underwriter | LifeHealthPro |publisher=Asjonline.com |date=2010-10-07 |accessdate=2012-04-09}}</ref><ref name="Nursingworld.org">{{cite web|title=Selected Patient Protection and Affordable Care Act (PPACA) implementation dates of interest to RNs as caregivers, RNs as patients, and RNs as employees |url=http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Health-Care-Reform-Legislation-Timeline.pdf |publisher=Nursingworld.org |date= |accessdate=2012-04-09}}</ref> | |||
| * ] are established.<ref name=CohnInsuranceStandards>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113440/obamacare-rate-shock-higher-prices-can-mean-better-benefits|title=You Call This Insurance? |publisher=The New Republic |date=June 12, 2013 }}</ref><ref name=essential>{{cite web|url=http://www.healthcare.gov/glossary/e/essential.html |title=Essential Health Benefits – Glossary |publisher=Healthcare.gov |date=September 23, 2010|accessdate=January 9, 2012}}</ref><ref name="Hhs.gov">{{cite press release|url=http://www.hhs.gov/news/press/2011pres/07/20110711a.html |title=HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress |publisher=Hhs.gov |date=2011-07-11 |accessdate=2012-04-09}}</ref><ref name="naic.org">{{cite web|url=http://www.naic.org/documents/committees_b_Exchanges.pdf |title=Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges |publisher=National Association of Insurance Commissioners |date=2010-04-20 |accessdate=2012-04-09}}</ref><ref name="FamiliesUSA">{{cite press release|url=http://www.familiesusa.org/health-reform-central/september-23/Annual-and-Lifetime-Limits.pdf |title=The Patients' Bill of Rights: Ending annual and lifetime limits |publisher=FamiliesUSA |date=2010-09 |accessdate=2012-04-09}}</ref> | |||
| * An ]<ref name=AHPAMandate>{{cite web|title=Minimum Coverage Provision ("individual mandate") |url=http://www.apha.org/advocacy/Health+Reform/ACAbasics/MC_provision.htm |work=American Public Health Association (APHA)}}</ref><ref name="Perkinsaccounting.com">{{cite press release|url=http://www.perkinsaccounting.com/our-story/litigation-support-accounting-firm-newsroom/perkins-news-bulletin/health-insurance-legislation/health-insurance-legislation-mandates.html |title=Perkins Accounting Firm Newsroom Bulletin Health Insurance Legislation Mandates |publisher=Perkinsaccounting.com |date= |accessdate=2012-04-09}}</ref> requires all individuals not covered by an ], ], ] or other public insurance programs (such as ]) 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 ] or has a financial hardship.<ref name="ksr_hlth" >{{cite news|url=http://www.kaiserhealthnews.org/Stories/2010/March/22/consumers-guide-health-reform.aspx|first=Phil |last=Galewitz|title=Consumers Guide To Health Reform|date=March 26, 2010|newspaper=Kaiser Health News}}</ref> For more details, see the ]. Congress also included ] so that people with low-incomes can comply when the mandate goes into effect.<ref name="Tami Luhby">{{cite web|author=Tami Luhby |url=http://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html |title=Millions eligible for Obamacare subsidies, but most don't know it |work=]|date=April 23, 2013|accessdate=June 22, 2013}}</ref> | |||
| * ]s will commence operation in every state. Each exchange will serve as an online marketplace where individuals and small businesses can compare policies and buy insurance (with a government subsidy if eligible).<ref name=HealthCareGov>{{cite web|title=Welcome to the Marketplace|url=https://www.healthcare.gov/marketplace/individual/|publisher=HealthCare.Gov, managed by the ] }}<br />{{cite web|title=What is the Health Insurance Marketplace?|url=https://www.healthcare.gov/what-is-the-health-insurance-marketplace/ |publisher=HealthCare.Gov, managed by the ] }}</ref> | |||
| * Low-income individuals and families whose income is above 100% and up to 400% of the ] will receive ] on a ] if they purchase insurance via an exchange.<ref name="Kaiser Family">{{cite web|url=http://www.kff.org/healthreform/upload/7962-02.pdf |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |publisher=Kaiser Family Foundation |month=April|year=2010 |accessdate=April 1, 2012}}</ref> Those from 133% to 150% of the poverty level will be subsidized such that their premium costs will be 3% to 4% of income.<ref name="Peter Grier">{{cite web|author=Peter Grier |url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance |title=Health care reform bill 101: Who gets subsidized insurance? |work=]|date=March 20, 2010|accessdate=January 9, 2012}}</ref> In 2013, the subsidy would apply for incomes up to $45,960 for an individual or $94,200 for a family of four; consumers can choose to receive their tax credits in advance, and the exchange will send the money directly to the insurer every month.<ref>Michelle Andrews, "", ], August 27, 2013.</ref> Small businesses will also be eligible for subsidies.<ref name="IRSBusinessSubsidy">{{cite web|url=http://www.irs.gov/newsroom/article/0,,id=223666,00.html |title=Small Business Health Care Tax Credit for Small Employers |publisher=Internal Revenue Service|date=December 13, 2011 |accessdate=January 9, 2012}}</ref> | |||
| * ] eligibility is expanded to include individuals and families with incomes up to 133% of ], and the ] enrollment process is simplified.<ref>{{cite web|url=http://kff.org/medicaid/fact-sheet/where-are-states-today-medicaid-and-chip/ |title=Where are States Today? Medicaid and CHIP Eligibility Levels for Children and Non-Disabled Adults |publisher=Kaiser Family Foundation |date=March 28, 2013 }}</ref> However, in '']'', the Supreme Court effectively ruled that states may opt-out of the Medicaid expansion, and ]. | |||
| * Reforms to the Medicare payment system are meant to promote greater efficiency in the healthcare delivery system by restructuring Medicare reimbursements from ] to ]s.<ref>{{cite web|url=http://www.medscape.com/viewarticle/748502 |title=Access |publisher=Medscape |date= |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.huronconsultinggroup.com/researchdetails.aspx?articleId=2577 |title=Key Healthcare Reform Initiatives: Medicare Bundled Payment Pilots |publisher=Huron Consulting Group |date=November 19, 2010 |accessdate=January 9, 2012}}</ref> Under the new payment system, a single payment is paid to a hospital and a physician group for a defined episode of care (such as a hip replacement) rather than individual payments to individual service-providers. | |||
| * 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 healthcare, usually through tax deductions. This is commonly known as the ].<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7907.pdf |title=Explaining Health Care Reform: What is Employer 'Pay-or-Play' Requirement?|year=2009|month=May|publisher=]|accessdate=January 9, 2012}}</ref><ref name=WSJ-mar25>{{cite news |title=What Health Overhaul Means for Small Businesses |author=McNamara, Kristen |url=http://online.wsj.com/article/SB10001424052748703312504575141533342803608.html |newspaper=The Wall Street Journal |date=March 25, 2010}}</ref> | |||
| ==Legislative history== | |||
| ===Background=== | |||
| {{Main|Health care reform in the United States|Health care reform debate in the United States}} | |||
| The Patient Protection and Affordable Care Act consists of a combination of measures to control healthcare costs, and an expansion of coverage through public and private insurance: broader Medicaid eligibility and Medicare coverage, and subsidized, regulated private insurance. An individual mandate coupled with subsidies for private insurance as a means for ] was considered the best way to win the support of the Senate because it had been included in prior bipartisan reform proposals. The idea goes back as far as 1989, when it was initially proposed by the ] ] as an alternative to ].<ref name="forbes1">{{cite news | work = Forbes Magazine | title= The Tortuous History of Conservatives and the Individual Mandate | first = Avik | last = Roy | date = February 7, 2012 | url = http://www.forbes.com/sites/aroy/2012/02/07/the-tortuous-conservative-history-of-the-individual-mandate/}}</ref> It was championed by many ] politicians as a market-based approach to healthcare reform on the basis of individual responsibility. Specifically, because the ] (EMTALA), passed in 1986 by a bipartisan Congress and signed by ], requires any hospital participating in Medicare (which nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.<ref name=CommonSense>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |publisher=The New Republic |date=April 9, 2010 }}</ref><ref name="nyt-mandate">{{cite news | work = ] | title= Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later | first = Michael | last = Cooper | date = February 14, 2012 | accessdate= July 2, 2012 | url = http://www.nytimes.com/2012/02/15/health/policy/health-care-mandate-was-first-backed-by-conservatives.html}}</ref><ref name="new-yorker-klein"/> | |||
| When, in 1993, President ] ] that included a mandate for employers to provide health insurance to all employees through a regulated marketplace of ]s, Republican Senators proposed an alternative that would have required individuals, but not employers, to buy insurance.<ref name="nyt-mandate"/> Ultimately the Clinton plan failed due to concerns that it was overly complex, amid an unprecedented barrage of negative advertising funded by politically conservative groups and the health insurance industry.<ref name="newsweek-clinton">{{cite news | work = ] | title = The Lost Chance | first = Bob | last= Cohn | coauthors = Eleanor Clift | date = September 18, 1994 | accessdate= July 2, 2012 | url =http://www.thedailybeast.com/newsweek/1994/09/18/the-lost-chance.print.html}}</ref> After failing to obtain a comprehensive reform of the healthcare system, Clinton negotiated a compromise with the ] to instead enact the ] in 1997.<ref>{{cite news | url=http://www.newsmax.com/insidecover/hillary_health_care/2007/10/05/38601.html | title=Hillary Claims Credit for Child Program | agency=] for ] | author=Beth Fouhy | date=October 5, 2007 |archiveurl = http://web.archive.org/web/20080123174618/http://www.newsmax.com/insidecover/hillary_health_care/2007/10/05/38601.html <!-- Bot retrieved archive --> |archivedate = January 23, 2008}}</ref> | |||
| The 1993 Republican alternative, introduced by Senator ] as the Health Equity and Access Reform Today Act, contained a "universal coverage" requirement with a penalty for non-compliance—an individual mandate.<ref name="kaiserhealthnews1993">{{cite web|url=http://www.kaiserhealthnews.org/Graphics/2010/022310-Bill-comparison.aspx |title=Chart: Comparing Health Reform Bills: Democrats and Republicans 2009, Republicans 1993 |publisher=Kaiserhealthnews.org |date= |accessdate=July 29, 2012}}<br />{{cite web|author=|url=http://www.kaiserhealthnews.org/Stories/2010/February/23/GOP-1993-health-reform-bill.aspx |title=Summary Of A 1993 Republican Health Reform Plan |publisher=Kaiserhealthnews.org |date=February 23, 2010 |accessdate=July 29, 2012}}</ref> Advocates for the 1993 bill included prominent Republicans who today oppose a mandate, such as Senators ], ], ], and ].<ref>{{cite web|url=http://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |title=In 1993, Republicans Proposed A Mandate First |publisher=NPR |date=March 31, 2012}}</ref><ref>{{cite web|url=http://healthcarereform.procon.org/view.resource.php?resourceID=004182 |title=History of the Individual Health Insurance Mandate, 1989-2010 Republican Origins of Democratic Health Care Provision |publisher=ProCon.org |date=February 9, 2012}}</ref> Of the 43 Republicans Senators from 1993, almost half - 20 out of 43 - supported the HEART Act.<ref name="forbes1"/><ref name="politifact1993">{{cite web|author=|url=http://www.politifact.com/truth-o-meter/statements/2012/apr/19/facebook-posts/facebook-post-says-republicans-embraced-individual/ |title=Facebook post says Republicans embraced individual mandate in 1993 |publisher=PolitiFact |date=April 19, 2012 }}</ref> Also in 1994, Senator ] introduced the Consumer Choice Health Security Act, which also contained an individual mandate with a penalty provision;<ref>{{cite web|url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |publisher=Coloradostatesman.com |date= |accessdate=July 29, 2012}}</ref> however, he subsequently removed the mandate from the bill, stating he had decided "that government should not compel people to buy health insurance."<ref>{{cite news| url=http://www.nytimes.com/2012/02/27/opinion/gop-and-health-mandate.html?_r=2&adxnnl=1&adxnnlx=1333652503-360xnkv/rpzNURZGZh5Vdw | work=The New York Times | title=G.O.P. and Health Mandate | date=February 26, 2012}}</ref> At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for ], remarked, "I don’t remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax."<ref name="forbes1"/> | |||
| <!-- Deleted image removed: ] with Ted Kennedy and a bipartisan group of state legislators, April 12, 2006.]] --> | |||
| An individual health insurance mandate was also enacted at the state-level in Massachusetts. In 2006, Republican ], then governor of Massachusetts, signed ] with an individual mandate into law with strong bipartisan support, including that of ]. Romney's success in installing an individual mandate in Massachusetts was at first lauded by Republicans. During ], Senator ] praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured." Romney himself said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."<ref name="new-yorker-lizza"/> | |||
| In 2007, a year after the Massachusetts reform, Senators Bennett and ] introduced the ], a bill that also featured an individual mandate, and it attracted bipartisan support.<ref name="new-yorker-klein">{{cite news | work = ] | first = Ezra | last = Klein | authorlink = Ezra Klein | title = Unpopular Mandate | accessdate = June 19, 2012 | date = June 25, 2012 | url = http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein}}</ref><ref name="new-yorker-lizza">{{cite news | work = ] | title= Romney's dilemma | url = http://www.newyorker.com/reporting/2011/06/06/110606fa_fact_lizza | first = Ryan | last = Lizza | authorlink = Ryan Lizza | accessdate = June 19, 2012 | date = June 6, 2011}}</ref> The Republican co-sponsors who remained in Congress during the 2008 healthcare debate included Senators Grassley, Bennett, ], ], ], ], and ].<ref> from the ] ] website</ref><ref>, from Senator Wyden's website</ref> | |||
| Given the history of bipartisan support for the idea of an individual mandate and its perceived success in Massachusetts, by 2008 Democrats were considering using an individual mandate as the basis for comprehensive, national healthcare reform. Experts have pointed out that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill<ref name="kaiserhealthnews1993"/> and that it was deliberately patterned after former Governor Romney's state healthcare plan, which also contains an individual mandate.<ref></ref> ], a key architect of the Massachusetts reform who advised the Clinton and Obama Presidential campaigns on their healthcare proposals, served as a technical consultant to the Obama Administration and helped Congress draft the ACA.<ref>{{cite web|title=Jonathan Gruber |url=http://economics.mit.edu/faculty/gruberj |publisher=MIT Department of Economics |accessdate=September 02, 2013 }}<br />{{cite web|title=Jonathan Gruber - Short Biography |url=http://economics.mit.edu/files/7840 |publisher=MIT Department of Economics |accessdate=September 02, 2013 }}</ref> | |||
| ===Healthcare debate, 2008–2010=== | |||
| {{See also|Health care reforms proposed during the Obama administration}} | |||
| Healthcare reform was a major topic of discussion during the ]. As the race narrowed, attention focused on the plans presented by the two leading candidates, ] Senator ] and the eventual nominee, ] Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's plan would have required all Americans obtain coverage (in effect, an individual ]), while Obama's provided a ] but did not include a mandate. During the ], Obama said that fixing healthcare would be one of his top four priorities if he won the presidency.<ref name="Sep2008FirstPresidentialDebate">{{Cite news | url = http://elections.nytimes.com/2008/president/debates/transcripts/first-presidential-debate.html | title = The First Presidential Debate | date = September 26, 2008 | work = The New York Times }}</ref> | |||
| ], September 9, 2009.]] | |||
| After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.<ref name="Feb2009JointSessionAddress">{{Cite news | url = http://www.whitehouse.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress | title = Remarks of President Barack Obama – Address to Joint Session of Congress | date = February 24, 2009 | publisher = The White House | accessdate = March 24, 2010 }}</ref><ref name="reuterstimeline">{{cite news | url = http://www.reuters.com/article/idUSTRE62L0JA20100322 | publisher = Reuters | title = Timeline: Milestones in Obama's quest for healthcare reform | accessdate = March 22, 2010 | date=March 22, 2010 }}</ref> By July, a series of bills were approved by committees within the ].<ref name="EdLaborJul2009">{{Cite news | url = http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml | title = Affordable Health Care for America Act | last = Kruger | first = Mike | date = October 29, 2009 | publisher = ] | accessdate = March 24, 2010 |archiveurl=http://web.archive.org/web/20100106013943/http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml |archivedate= January 6, 2010 }}</ref> On the Senate side, from June through to September, the ] held a series of 31 meetings to develop of a healthcare reform bill. This group - in particular, Senators ], ], ], ], ], and ] - met for more than 60 hours, and the principles that they discussed, in conjunction with the other Committees, became the foundation of the Senate's healthcare reform bill.<ref>{{cite web|title=Health Care Reform from Conception to Final Passage|accessdate=November 23, 2010 |url=http://finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65}}</ref><ref>{{cite web|url=http://www.c-spanvideo.org/videoLibrary/search-results.php?organization=%22Finance%22&organization=%22Senate+Committee%22&date-from=01%2F06%2F2009&date-to=01%2F02%2F2011 |title=Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN |publisher=C-SPAN}}</ref><ref>{{cite web|url=http://finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |title=Senate Finance Committee hearings for 111th Congress |publisher=Finance.Senate.Gov |date= |accessdate=April 1, 2012}}</ref> | |||
| With ] as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like ] and ] argued that ] would require both a ] and an ] to prevent either ] and/or ] from creating an ];<ref name=HowTheyDidIt>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/75077/how-they-did-it |title=How They Did It |publisher=The New Republic |date=21 May 2010 }}</ref> they convinced Obama that this was necessary, persuading him to accept Congressional proposals that included a mandate.<ref name=Mandate2>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/the-top-ten-things-worth-fighting |title=The Top Ten Things Worth Fighting For |publisher=The New Republic |date=October 13, 2009 }}</ref> This approach was preferred because the President and Congressional leaders concluded that more liberal plans, such as ], could not win ] in the Senate. By deliberately drawing on bipartisan ideas - the same basic outline was supported by former Senate Majority Leaders ], ], ] and ] - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/party-is-such-sweet-sorrow |title=Party Is Such Sweet Sorrow |publisher=The New Republic |date=September 4, 2009 }}</ref><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |title=Obama's Moderate Health Care Plan |publisher=The New Republic |date=April 22, 2010 }}<br />{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |publisher=The New Republic |date=December 19, 2009 }}</ref> | |||
| However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to ] any bills that contained it.<ref name="forbes1"/> Senate Minority Leader ], who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections:<ref name=ChaitLegislativeStrategy>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |publisher=The New Republic |date=December 19, 2009 }}</ref>{{cquote|It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out.<ref>{{cite news|author=Carl Hulse and Adam Nagourney |url=http://www.nytimes.com/2010/03/17/us/politics/17mcconnell.html?pagewanted=1&hp |title=Senate G.O.P. Leader Finds Weapon in Unity |publisher=The New York Times |date=March 16, 2010 }}</ref>}} | |||
| <nowiki> </nowiki>Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". Writing in '']'', Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."<ref name="new-yorker-klein"/> The '']'' subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's healthcare law requiring all Americans to buy health insurance has its roots in conservative thinking."<ref name="nyt-mandate"/><ref name="politifact1993"/> | |||
| ], September 12, 2009.]] | |||
| The reform negotiations also attracted a great deal of attention from ],<ref>{{cite news|last=Eaton |first=Joe |coauthors=M.B. Pell, Aaron Mehta |url=http://www.npr.org/templates/story/story.php?storyId=125170643 |title=Lobbying Giants Cash In On Health Overhaul |publisher=NPR |date=March 26, 2010 |accessdate=April 9, 2012 }}</ref> including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/politics/drug-deal |title=Drug Deal |publisher=The New Republic |date=August 25, 2009}}</ref><ref>{{cite news| url=http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html | work=Huffington Post | first=Ryan | last=Grim | title=Internal Memo Confirms Big Giveaways In White House Deal With Big Pharma | date=August 13, 2009}}</ref> The ] documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.<ref>{{cite web|url=http://sunlightfoundation.com/projects/2009/healthcare_lobbyist_complex |title=Visualizing The Health Care Lobbyist Complex |publisher=Sunlight Foundation |date=July 22, 2009 |accessdate=April 1, 2012}}</ref> | |||
| During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the ] organized protests and many ] groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.<ref name="reuterstimeline"/> There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection.<ref name=WashPost-04092010>{{cite news | title=Anger over health-care reform spurs rise in threats against Congress members |last=Horwitz|first=Sari|last2=Pershing|first2=Ben| date=April 9, 2010 | url = http://www.washingtonpost.com/wp-dyn/content/article/2010/04/08/AR2010040805476.html?nav=hcmodule | work =] | accessdate = April 9, 2010 }}</ref> | |||
| To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 ] supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.<ref name="Sep2009JointAddress">{{cite web | url = http://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care | title = Remarks by the President to a Joint Session of Congress on Health Care | date = September 10, 2009 | publisher = The White House | accessdate = March 24, 2010}}</ref> In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."<ref>{{cite web |last=Kennedy |first=Edward M. |authorlink=Ted Kennedy |title=Text of letter to the President from Senator Edward M. Kennedy |url=http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/ |date=May 12, 2009 |work= |publisher=] |accessdate=September 10, 2009 | archiveurl= http://web.archive.org/web/20090910065606/http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/| archivedate= September 10, 2009 <!--DASHBot-->| deadurl= no}}</ref> On November 7, the House of Representatives passed the ] on a 220–215 vote and forwarded it to the Senate for passage.<ref name="reuterstimeline"/> | |||
| ====Senate==== | |||
| The Senate began work on its own proposals while the House was still working on the ]. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.<ref name="ServicemembersHomeOwnershipTaxAct">{{Cite news | title = House OKs tax breaks for military homeowners | first = Rick | last = Maze | url = http://www.airforcetimes.com/news/2009/10/military_homeownerhelp_taxfree_100809w/ | newspaper = ] | date = October 8, 2009 | accessdate = March 24, 2010 }}</ref> As the ] requires all revenue-related bills to originate in the House,<ref name="Const-Revenue">] art. I, § 7, cl. 1.</ref> the Senate took up this bill since it was first passed by the House as a revenue-related modification to the ]. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.<ref>{{USBill|111|S.AMDT.|2786}}</ref> The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate ] and ] committees. | |||
| With the Republican minority in the Senate vowing to ] any bill that they did not support, requiring a ] to end debate, ] would be necessary to get passage in the Senate.<ref>{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/why-reform-survived-august |title=Why Reform Survived August |publisher=The New Republic |date=September 7, 2009 }}</ref> At the start of the ], Democrats had only 58 votes; ] that would be won by ] was still undergoing a recount, and ] 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 ], ], ], and ]. 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 healthcare reform—died, depriving Democrats of their 60th vote. Before the seat was filled, attention was drawn to ] 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.<ref name=HowTheyDidIt /> ] was appointed as Senator Kennedy's temporary replacement on September 24. | |||
| 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. ] focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's ], an independent who caucused with Democrats, and Nebraska's ]. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a ]; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included,<ref name=HowTheyDidIt /><ref name=HackerReform>{{cite news|author=Jacob S. Hacker |url=http://www.newrepublic.com/blog/the-treatment/why-i-still-believe-bill |title=Why I Still Believe in This Bill |publisher=The New Republic|date=December 20, 2009 }}</ref> even though it had majority support in Congress.<ref name=PublicOption>{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/the-public-option-still-dead |title=The Public Option, Still Dead |work=The New Republic|date=March 12, 2010 }}</ref> There was debate among supporters of the bill about the importance of the public option,<ref>{{cite news|url=http://www.huffingtonpost.com/marcia-angell-md/is-the-house-health-care_b_350190.html |title=Is the House Healthcare Bill Better Than Nothing? |work=The Huffington Post |accessdate=January 12, 2012 |date=November 9, 2009}}</ref> although the vast majority of supporters concluded that it was a minor part of the reform overall,<ref name=HackerReform /> and that Congressional Democrats' fight for it won various concessions; this included conditional waivers allowing states to set up state-based public options,<ref name=PublicOption /> for example Vermont's ].<ref>{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/what-public-option-supporters-won |title=What Public Option Supporters Won |publisher=The New Republic |date=December 15, 2009 }}</ref> | |||
| [[File:111th Congress 1st session Senate roll call 396.svg|thumb|300px|'''Senate vote by state.''' | |||
| {{legend|#008|Democratic yea}} | |||
| {{legend|#888|Independent yea}} | |||
| {{legend|#800|Republican nay}} | |||
| {{legend|#F55|Republican not voting}}]] | |||
| 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 ] for the bill;<ref>{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/ben-nelson-still-big-problem |title=Ben Nelson, Still a Big Problem (Updated) |publisher=The New Republic |date=December 17, 2009 }}</ref> they had by this point concluded that "it was a waste of time dealing with "<ref>{{cite news|author= Manu Raju |url=http://www.politico.com/news/stories/0110/31730.html |title=Olympia Snowe puzzled by Harry Reid comments |work=Politico|date=January 20, 2010 }}</ref> 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.<ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |publisher=The New Republic |date=December 19, 2009 }}<br />{{cite news|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/revisiting-snowes-lay-down |title=Revisiting Snowe's Lay Down |publisher=The New Republic |date=January 19, 2010 }}<br />{{cite news|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/nonsense-snowe |title=(Non)sense of Snowe |publisher=The New Republic |date=March 16, 2010}}</ref> (Snowe retired at the end of her term, citing partisanship and polarization).<ref>{{cite news|author=Susan Davis |url=http://content.usatoday.com/communities/onpolitics/post/2012/02/olympia-snowe-senate-retirement-maine/1?csp=34news#.UV6DlFewdEJ |title=Maine GOP Sen. Olympia Snowe won't seek re-election |work=USA Today |date=February 28, 2012}}</ref> After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges," which would require consumers to pay for the procedure out-of-pocket if the state so decided; and an amendment to offer a higher rate of ] reimbursement for Nebraska.<ref name="reuterstimeline"/><ref>{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/breaking-nelson-says-yes-makes-60 |title=BREAKING: Nelson Says Yes; That Makes 60 |publisher=The New Republic |date=December 19, 2009 }}</ref> The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"<ref>{{cite news|title={{-'}}Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment|url=http://www.foxnews.com/politics/2010/03/18/cornhusker-kickback-gets-boot-health/|date=March 19, 2010|publisher=]|accessdate=April 26, 2010}}</ref> and was later repealed by the subsequent reconciliation amendment bill. | |||
| On December 23, the Senate voted 60–39 to end debate on the bill: a ] to end the ] by opponents. The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against except one (], not voting).<ref name="USS RC 2009-396">{{cite web|url=http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396 |title=Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended) |publisher=U.S. Senate |date= |accessdate=January 9, 2012}}</ref> The bill was endorsed by the ] and ].<ref>. ''The Huffington Post''.</ref> | |||
| Several weeks after the vote, on January 19, 2010, ] Republican ] was elected to the Senate in ], having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41."<ref name="reuterstimeline"/><ref>{{cite news|author=J. Scott Applewhite|agency=Associated Press |url=http://www.cleveland.com/nation/index.ssf/2010/01/senator-elect_scott_brown_welc.html |title=Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts |publisher=McClatchy-Tribune News Service |date= |accessdate=April 19, 2012}}</ref><ref>{{cite press release|url=http://www.votesmart.org/public-statement/477580/scott-brown-responds-to-martha-coakleys-misleading-health-care-distortions |title=Public Statements – Project Vote Smart |publisher=Votesmart.org |date=January 13, 2010 |accessdate=April 9, 2012}}</ref> The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: the symbolic importance of losing the ] formerly held by Ted Kennedy, a staunch support of reform, made many Congressional Democrats concerned about the political cost of passing a bill.<ref>{{cite web|author=Nate Silver |url=http://www.fivethirtyeight.com/2010/01/will-base-abandon-hope.html |title=Will the Base Abandon Hope? |publisher=] |date=January 21, 2010 }}</ref><ref name=BillPassageOptions>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/what-do-if-coakley-loses-contd |title=How to Pass the Bill--Whatever Happens Tuesday |publisher=The New Republic |date=January 17, 2010}}</ref> The second effect was more practical: the loss of the Democrat's ] complicated the legislative strategy of reform proponents.<ref name=BillPassageOptions /> | |||
| ====House==== | |||
| [[File:111th Congress roll call 165.svg|thumb|300px|'''House vote by congressional district.''' | |||
| {{legend|#000080|Democratic yea}} | |||
| {{legend|#5050FF|Democratic nay}} | |||
| {{legend|#800000|Republican nay}} | |||
| {{legend|#C8C8C8|No representative seated}}]] | |||
| <!-- Deleted image removed: ] --> | <!-- Deleted image removed: ] --> | ||
| <!-- I'm trying to source a better image; in the meantime I've put this here as a temporary one --> |
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| The election of Scott Brown meant Democrats could no longer ] in the Senate. In response, ] ] argued the Democrats should scale-back for a less ambitious bill; ] ] pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."<ref name="nytimesjourney">{{Cite news | title = Health Vote Caps a Journey Back From the Brink | first = Sheryl | last = Stolberg | author2 = Jeff Zeleny | author3 = Carl Hulse | url = http://www.nytimes.com/2010/03/21/health/policy/21reconstruct.html | newspaper = ] | date = March 20, 2010 | accessdate = March 23, 2010}}</ref><ref name="PoliticoPelosi">{{Cite news | title = Pelosi steeled W.H. for health push | first = Carrie | last = Brown | author2 = Glenn Thrush | url = http://www.politico.com/news/stories/0310/34753.html | newspaper = ] | date = March 20, 2010 | accessdate = March 23, 2010}}</ref> Obama also remained insistent on comprehensive reform, and the news that ] in ] intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.<ref name="nytimesjourney"/><ref name="PoliticoPelosi"/> On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.<ref>{{cite web|author= |url=http://www.kaiserhealthnews.org/Daily-Reports/2010/February/22/President-Obama-Health-Care-Reform-Plan.aspx |title=White House Unveils Revamped Reform Plan, GOP And Industry React |publisher=Kaiserhealthnews.org |date=February 22, 2010 |accessdate=June 29, 2012}}</ref> He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.<ref name="reuterstimeline"/> The summit proved successful in shifting the political narrative away from the Massachusetts loss back to healthcare policy.<ref name="PoliticoPelosi"/> | |||
| With Democrats ] a ] in the Senate, but having already passed the Senate bill with 60 votes on December 24, the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the ], and pass the Senate's bill, The Patient Protection and Affordable Care Act, instead. Various health policy experts encouraged the House to pass the Senate version of the bill.<ref>{{cite web|author=Harold Pollack |url=http://www.tnr.com/blog/the-treatment/47-health-policy-experts-including-me-say-sign-the-senate-bill |title=47 (Now 51) Health Policy Experts (Including Me) Say "Sign the Senate bill." |publisher=The New Republic |accessdate=January 12, 2012}}</ref> However, House Democrats were not happy with the content of the Senate bill, and had expected to be able to negotiate changes ] before passing a final bill.<ref name=BillPassageOptions /> 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; most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.<ref name=BillPassageOptions /> They drafted the ], which could be passed via the ].<ref name="nytimesjourney"/><ref name="Reconciliationprimer">{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/brief-reconciliation-primer |title=A Brief Reconciliation Primer |publisher=The New Republic |date=February 20, 2010 }}</ref><ref name=538Paths218>{{cite web|author=Nate Silver |url=http://www.fivethirtyeight.com/2009/12/in-house-many-paths-to-218.html |title=For Pelosi, Many Paths to 218 |publisher=] |date=December 26, 2009 }}</ref> Unlike rules under regular order, as per the ] reconciliation cannot be subject to a ], which requires ], but the process is ]; this is why the procedure was never able to be used to pass a comprehensive reform bill in the first place, such as the ACA, due to inherently non-budgetary regulations.<ref>{{cite web|author=Nate Silver |url=http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |title=1. Reconciliation! 2. ??? 3. Profit! |publisher=] |date=January 21, 2010 }}</ref><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |title=Reconciliation: Why Most Dems Don't Want to Go There |publisher=The New Republic |date=September 21, 2009 }}</ref> Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."<ref name="Reconciliationprimer"/> | |||
| The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman ]. The group found the possibility of federal funding for ] would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued ], reaffirming the principles in the ].<ref name="EO13535">] of March 24, 2010 – ''Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act'', Vol. 75, No. 59, {{USFedReg|75|15599}}, March 29, 2010.</ref> This concession won the support of Stupak and members of his group and assured passage of the bill.<ref name=538Paths218 /><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/stupak-makes-deal-reform-pass |title=Stupak Makes A Deal, Reform To Pass |publisher=The New Republic |date=March 21, 2010 }}</ref> The House passed the Senate bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.<ref name="USH RC 2010-165">{{cite web|url=http://clerk.house.gov/evs/2010/roll165.xml |title=Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act) |publisher=Office of the Clerk: House of Representatives |date=March 21, 2010 |accessdate=April 9, 2012}}</ref> The following day, Republicans introduced legislation to repeal the bill.<ref name="PelosiSawyer">{{Cite news | title = Pelosi Defends Health Care Fight Tactics | first = Margaret | last = Aro | author2 = Mark Mooney | url = http://abcnews.go.com/WN/Politics/house-speaker-nancy-pelosis-exclusive-interview-diane-sawyer/story?id=10172685 | newspaper = ] | date = March 22, 2010 | accessdate = March 23, 2010}}</ref> Obama signed the ACA into law on March 23, 2010.<ref>{{Cite news | title = Obama Signs Health Care Overhaul Bill, With a Flourish | first = Sheryl | last = Stolberg | author2 = Robert Pear | url = http://www.nytimes.com/2010/03/24/health/policy/24health.html | newspaper = The New York Times | date = March 23, 2010 | accessdate = March 24, 2010}}</ref> The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30. | |||
| ==Impact== | |||
| ===Public policy=== | |||
| ====Change in number of uninsured==== | |||
| {{See also|Health insurance coverage in the United States}} | |||
| 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.<ref name="cbouninsured">{{cite web|url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf|title=Cost Estimate for Pending Health Care Legislation|date=March 20, 2010|publisher=]|accessdate=March 28, 2010}}</ref><ref name="CBO43090">{{cite web|url=http://www.cbo.gov/publication/43090 |title=The Effects of the Affordable Care Act on Employment-Based Health Insurance |publisher=Congressional Budget Office |date=March 15, 2012 |accessdate= |quote=''Highlights and Key Findings'' , March 23, 2012 }}</ref><ref name=fewer/><ref name="CBO43076">{{cite web |url=http://www.cbo.gov/publication/43076 |title=Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 13, 2012 |accessdate=April 6, 2012}}</ref> With the elderly covered by Medicare; the CBO estimate projected that the law would raise the proportion of insured, non-elderly citizens from 83% to 94%.<ref name="cbouninsured" /> A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting ] to the ACA's expansion of Medicaid.<ref name=cbooptout>{{cite web| url= http://www.cbo.gov/publication/43472 | title= Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision|date=July 24, 2012 | publisher= CBO | accessdate=February 23, 2012}}</ref><ref name=optout>{{cite web| url= http://money.cnn.com/2012/07/23/news/economy/health-reform/ | title= 6 million will lose out on Medicaid expansion| first=Emily Jane|last= Fox |work=CNNMoney |date=July 24, 2012 | publisher= CNN | accessdate=July 25, 2012}}</ref> | |||
| Among the people in this uninsured group will be: | |||
| * ], estimated at around eight million <!--almost a third of the 25 million --> – they will be ineligible for insurance ] and Medicaid;<ref name="cbouninsured"/><ref name=PPACANoncitizens>{{Cite journal|title=Treatment of Noncitizens Under the Patient Protection and Affordable Care Act|url=http://www.ciab.com/WorkArea/DownloadAsset.aspx?id=2189|date=March 22, 2011|first=Alison|last=Siskin|publisher=]|accessdate=October 14, 2011|id=R41714}}</ref><ref>{{Cite journal|title=PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges|url=http://www.nationalaglawcenter.org/assets/crs/R41664.pdf|date=March 2, 2011|first=Hinda|last=Chaikind|publisher=]|first2=Curtis W.|last2=Copeland|first3=C. Stephen| last3=Redhead| first4=Jennifer| last4=Staman| accessdate=October 14, 2011|id=R41664}}</ref> they will also be exempt from the ], but will remain eligible for emergency services under the 1986 ] (EMTALA). | |||
| *Citizens not enrolled in Medicaid despite being eligible.<ref name="notcovered">{{cite news| url= http://www.csmonitor.com/USA/2010/0323/Obama-signs-health-care-bill-Who-won-t-be-covered| title= Obama signs health care bill: Who won't be covered?|last=Trumbull|first=Mark|date=March 23, 2010|work=]|accessdate=March 24, 2010}}</ref> | |||
| *Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.<ref name="notcovered"/> | |||
| *Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.<ref name="notcovered"/> | |||
| *Citizens who live in ] and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.<ref name=optout/> | |||
| ACA drafters believed that increasing insurance coverage would not only improve quality of life but also help reduce ] (currently the leading cause of bankruptcy in America<ref>{{cite news |url= http://www.cbsnews.com/stories/2009/06/05/earlyshow/health/main5064981.shtml|title= Medical Debt Huge Bankruptcy Culprit - Study: It's Behind Six-In-Ten Personal Filings |publisher= ] |date =June 5, 2009 |accessdate=June 22, 2009}}</ref>) and ];<ref>{{cite web|author=Jonathan Cohn |title= Why Today's Vote Matters|url=http://www.newrepublic.com/blog/jonathan-cohn/81838/why-todays-vote-matters |publisher=The New Republic|date=January 19, 2011}}<br />{{cite web|author=Jonathan Cohn|title=Obamacare, Good for the Economy.|url=http://www.newrepublic.com/blog/plank/104035/obamacare-romney-economy-benefit-job-regulation-noam |publisher=The New Republic|date=June 13, 2012}}<br />{{cite web|author=Jonathan Cohn|title=Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs.|url=http://www.newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs |publisher=The New Republic|date=February 11, 2011}}</ref> 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 healthcare providers could be reduced by limiting uncompensated emergency care, and if there was a larger ] to distribute costs among.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |publisher=The New Republic |date=April 9, 2010 }}<br />{{cite web|author=Jonathan Cohn|title= What, You Have a Better Idea for Cost Control?|url= http://www.newrepublic.com/blog/the-treatment/what-you-have-better-idea-cost-control |publisher=The New Republic|date=March 7, 2010}}</ref> | |||
| Due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26, several insurance companies announced that they would end the issuance of new child-only policies.<ref>, CBS News, September 22, 2010</ref><ref>, ''Los Angeles Times'', September 21, 2010</ref><ref name=ChildOnlySenateHELP>{{Cite press release|url=http://help.senate.gov/newsroom/press/release/?id=141b967c-935c-43d7-8565-147d7a64c70e&groups=Ranking|title=Report: Access to Child-Only Health Plans Declines Under New Health Care Law|date=August 2, 2011|publisher=]}}</ref> Since children would now be covered by their parents plans, the Census Bureau found at the same time that the number of uninsured 19- to 25-year-olds had declined by 393,000, or 1.6% by 2011.<ref>{{Cite journal|title=Income, Poverty, and Health Insurance Coverage in the United States: 2010|url=http://www.census.gov/prod/2011pubs/p60-239.pdf| month=September|year=2011|publisher=]| first= Carmen| last= DeNavas-Walt|last2=et al.|pages=26–27|accessdate=October 15, 2011}}</ref> | |||
| In January 2013, the ] ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the worker’s household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. ''The New York Times'' said this could leave 2–4 million Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies to buy coverage elsewhere.<ref> ''New York Times'', February 2, 2013</ref> For those unable to afford insurance under any of the available options from employers, the government, or the exchanges, ]. | |||
| ====Insurance exchanges and the individual mandate==== | |||
| {{main|Health insurance marketplace}} | |||
| {{Details|Individual mandate|individual mandates}} | |||
| One of the ACA's two primary mechanisms for ] involves the expansion of public insurance programs: increasing the coverage of ], by eliminating the ] for example, and increasing the eligibility of the ] to expand enrollment. The other is the creation of state-based ‘insurance exchanges:’ regulated, virtual marketplaces, administered by either federal or state government, where individuals and small business can purchase private insurance plans, starting January 2014.<ref name=HealthCareGov /><ref>{{cite web|title=Insurance Exchanges|url=http://www.apha.org/advocacy/Health+Reform/ACAbasics/insurance.htm |work=American Public Health Association (APHA)}}</ref><ref name=CohnExchanges>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/112259/obamacare-sticker-shock-not-very-shocking |title=Obamacare Sticker Shock: Not Very Shocking |publisher=The New Republic |date=April 29, 2013 }}</ref> Those purchasing insurance plans may, if eligible, use subsidies provided by the government.<ref name="Tami Luhby" /> | |||
| The 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 or ring a call center, 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 during limited open enrollment periods.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113075/obamacare-implementation-revised-application-much-simpler-easier |title=Obamacare's New Paperwork Is Simpler than Private Insurers' |publisher=The New Republic |date=April 30, 2013 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113049/obamacare-implementation-2013-busting-myths |title=Why Obamacare Is Not a 'Train Wreck' (Again) |publisher=The New Republic |date=April 29, 2013 }}</ref> The first open enrollment period will last from October 1, 2013, through to March 31, 2014, after which time uninsured individuals generally may not purchase insurance through an exchange until the following open enrollment period; in subsequent years, the open enrollment period will start on October 1 and end on December 7.<ref name=LimitedOEForbes >{{cite news|last=McClanahan|first=Carolyn|title=Reader's Questions About Obamacare -- Misinformation Abounds|url=http://www.forbes.com/sites/carolynmcclanahan/2013/08/04/readers-questions-about-obamacare-misinformation-abounds/|accessdate=15 August 2013|newspaper=Forbes|date=4 August 2013}}</ref><ref name=CohnOE >{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/114163/limited-enrollment-periods-obamacare-means-young-people-cant-wait |title=Burn Your Obamacare Card, Burn Yourself |publisher=The New Republic |date=August 5, 2013 }}</ref> (], Members of Congress and their staff will participate in this system: they are required to obtain health insurance through the exchanges - or plans otherwise approved by the bill, such as Medicare - instead of the ] that they currently use.<ref name=CongressionalInsurance >, section 1312: "... the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."</ref>) | |||
| The insurance exchanges are a method designed to create a market for private insurance in a way that addresses ]s in the current system (such as the ], ], ], unaffordability, ], etc.<ref>{{cite web|title=ACA Basics and Background|url=http://www.apha.org/APHA/CMS_Templates/ChannelDefault.aspx?NRMODE=Published&NRNODEGUID={AB761237-3543-40C9-8A4B-FC912734A816}&NRORIGINALURL=%2fadvocacy%2fHealth%2bReform%2fACAbasics%2f&NRCACHEHINT=NoModifyGuest#Basics3 |work=American Public Health Association (APHA)|accessdate=25 July 2013|location=3. Why do we need the ACA?}}</ref>) through regulations:<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/81678/repeal-government-takeover-health-care |title=More Government in Health Care? Yes. You Got a Problem With That? |publisher=The New Republic |date=January 18, 2011 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/86841/ryan-obama-brooks-health-choice-competition-exchange |title=When Republicans Oppose Competition |publisher=The New Republic |date=April 15, 2011 }}</ref><ref name=HackerReform /> Only approved plans that meet ] will be allowed to be sold on the exchanges, and insurers will be ] to consumers on the basis of ]s.<ref name="Blue Cross Blue Shield of Michigan" /><ref name="Pool" /> Several methods will be employed to make these plans affordable: Subsidies will be provided to those eligible.<ref name="Kaiser Family" /><ref name="IRSBusinessSubsidy" /> Regulations intended to reduce prices through ] will make plans and prices more transparent and price comparisons more accessible for consumers with online information;<ref>{{cite web|title=Summary of Benefits and Coverage |url=https://www.healthcare.gov/how-does-the-health-care-law-protect-me/#part=4 |publisher=HealthCare.Gov, managed by the ] }}</ref><ref>{{cite news| url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/30/are-obamacares-exchanges-competitive-heres-what-the-experts-say/ | publisher=The Washington Post | author=Sarah Kliff| title=Are Obamacare's Exchanges Competitive? Here's What The Experts Say | date=May 30, 2013}}</ref><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113346/obamacare-insurance-options-looks-exchanges-will-have-plenty |title=Another Obamacare Train Wreck Not Happening |publisher=The New Republic |date=May 31, 2013 }}</ref><ref>{{cite web|author=Joe Conason |url=http://www.realclearpolitics.com/articles/2013/07/25/if_republicans_love_competition_why_do_they_still_hate_obamacare_119365.html |title=If Republicans Love Competition, Why Do They Still Hate Obamacare? |publisher=RealClearPolitics |date=July 25, 2013 }}</ref> and federally approved, multi-state plans will be phased-into state exchanges<ref name=Multi-StatePlans >{{cite web|url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf | title= Multi-State Plans Under the Affordable Care Act |author1=Trish Riley |author2=Jane Hyatt Thorpe |publisher=George Washington University Medical Center, Department of Health Policy}}</ref> to help guarantee enough options.<ref>{{cite news |newspaper=] |title= Choice of Health Plans to Vary Sharply From State to State |url=http://www.nytimes.com/2013/06/17/health/choice-of-health-plans-to-vary-sharply-from-state-to-state.html |author=Reed Abelson |date=June 16, 2013 }}</ref> And price regulations will be implemented, including a minimum ],<ref name=KaiserMLR>{{cite web | last = Cox | first = Cynthia | coauthors = Gary Claxton, Larry Levitt| title = Beyond Rebates: How Much Are Consumers Saving from the ACA’s Medical Loss Ratio Provision? | publisher = ] | date = June 6, 2013 | url = http://kff.org/health-reform/perspective/beyond-rebates-how-much-are-consumers-saving-from-the-acas-medical-loss-ratio-provision/ | accessdate = 2013-06-09}}</ref> and partial ] that prevents ] from ] through unaffordable plans or premium increases on the insured<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/112259/obamacare-sticker-shock-not-very-shocking |title=Obamacare Sticker Shock: Not Very Shocking |publisher=The New Republic |date=April 29, 2013 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/101948/supreme-court-mandate-new-jersey-insurance-reform |title=Reform With No Mandate? Ask New Jersey About That |publisher=The New Republic and Kaiser Health News |date=March 21, 2012 }}</ref> - ] who are more expensive to cover for insurers motivated either by ] and/or the economics of insurance; specifically, the risk of an insurance pool ].<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/81678/repeal-government-takeover-health-care |title=More Government in Health Care? Yes. You Got a Problem With That? |publisher=The New Republic |date=January 18, 2011 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113851/obamacare-individual-mandate-republicans-push-delay |title=Obamacare's Individual Mandate Can't Wait |publisher=The New Republic |date=July 15, 2013 }}</ref> | |||
| The aforementioned regulations are enabled to function due to the ]<ref name=AHPAMandate /> - the requirement to buy insurance or pay a penalty - and the limits on open enrollment,<ref name=LimitedOEForbes /><ref name=CohnOE /> without which healthy people might ]; in such a situation, to afford the remaining (relatively sicker and thus more expensive) population, insurers would have to raise their premiums,<ref name=AHPAMandate /><ref name=ReformWithoutTheMandate>{{cite web|author=Nathan Pippenger |url=http://www.newrepublic.com/blog/the-study/102118/health-care-reform-without-the-mandate |title=Health Care Reform Without The Mandate? |publisher=The New Republic |date=March 28, 2012 }}</ref><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |publisher=The New Republic |date=April 9, 2010 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |title=What If the Mandate Goes? |publisher=The New Republic |date=April 2, 2012 }}</ref> which could drive more people to drop their coverage, creating a ] that could ultimately result in ].<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113851/obamacare-individual-mandate-republicans-push-delay |title=Obamacare's Individual Mandate Can't Wait |publisher=The New Republic |date=July 15, 2013 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |title=What If the Mandate Goes? |publisher=The New Republic |date=April 2, 2012 }}</ref> Alternatively, the process could settle at a stable equilibrium relying on relatively ] (and thus more illness and medical bankruptcy) for the uninsured.<ref name=ReformWithoutTheMandate /><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/101948/supreme-court-mandate-new-jersey-insurance-reform |title=Reform With No Mandate? Ask New Jersey About That |publisher=The New Republic and Kaiser Health News |date=March 21, 2012 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/plank/103875/obamacare-supreme-court-mandate-contingency-survive |title=Just in Case: How Reform Might Survive Without the Mandate |publisher=The New Republic |date=June 8, 2012 }}</ref> 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,<ref name=WhatIftheMandateGoes>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |title=What If the Mandate Goes? |publisher=The New Republic |date=April 2, 2012 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/plank/103875/obamacare-supreme-court-mandate-contingency-survive |title=Just in Case: How Reform Might Survive Without the Mandate |publisher=The New Republic |date=June 8, 2012 }}</ref><ref>{{cite web|author=Paul Krugman |url=http://krugman.blogs.nytimes.com/2010/01/08/one-health-care-reform-indivisible/ |title=One Health Reform, Indivisible |publisher=New York Times |date=January 8, 2010 }}</ref> as studies by the ], ], and Rand Health have concluded.<ref>{{cite web|author=Jessica Banthin |url=http://www.slideshare.net/cbo/effects-of-eliminating-the-individual-mandate-to-obtain-health-insurance |title=Effects of Eliminating the Individual Mandate to Obtain Health Insurance |publisher=CBO |date=March 20, 2012 }}</ref><ref name=GruberMandate>{{cite web|author=Jonathan Gruber |url=http://www.americanprogress.org/issues/2011/02/pdf/gruber_mandate.pdf |title=Health Care Reform without the Individual Mandate |publisher=Center for American Progress |date=February 2011 }}</ref><ref>{{cite web|author1=Christine Eibner |author2=Carter Price |publisher=Rand Health |url=http://www.rand.org/content/dam/rand/pubs/technical_reports/2012/RAND_TR1221.pdf |title=The Effect of the Affordable Care Act on Enrollment and Premiums, With and Without the Individual Mandate |year=2012 }}</ref> Conversely, the inclusion of the mandate increases the size and diversity of the insured population, broadening the ] to spread the cost of insurance in a sustainable manner.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |title=Common Sense |publisher=The New Republic |date=April 9, 2010 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |title=What If the Mandate Goes? |publisher=The New Republic |date=April 2, 2012 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/98928/individual-mandate-mistake-health-reform-starr-cbo-ppaca |title=Was the Mandate a Mistake? |publisher=The New Republic |date=December 26, 2011 }}</ref> Policy experience in New Jersey on the one hand and Massachusetts on the other offers evidence of such divergent outcomes.<ref name=GruberMandate /><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/101948/supreme-court-mandate-new-jersey-insurance-reform |title=Reform With No Mandate? Ask New Jersey About That |publisher=The New Republic and Kaiser Health News |date=March 21, 2012 }}<br />{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/98928/individual-mandate-mistake-health-reform-starr-cbo-ppaca |title=Was the Mandate a Mistake? |publisher=The New Republic |date=December 26, 2011 }}</ref> In September 2012, the ] estimated that nearly six million will pay the penalty in 2016.<ref>{{cite news|last=Alonso-Zaldivar|first=Ricardo|title=Tax penalty to hit nearly 6M uninsured people|agency=Associated Press|date=September 19, 2012|url=http://www.google.com/hostednews/ap/article/ALeqM5jmIII4FgDvIW-bij_fdHF4v0Whbw?docId=48328c71af0241c39aef95fda77612f7|archiveurl=http://www.webcitation.org/6ApAsoQ8h|archivedate=September 20, 2012|deadurl=no }}</ref><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/114103/obamacare-and-hipsters-6-reasons-theyll-proabably-enroll |title=Six Reasons Hipsters Will Bite on Obamacare |publisher=The New Republic |date=August 1, 2013 }}</ref> For more details on the mandate, see the ]. | |||
| [[File:ACA health insurance exchanges by state.svg|thumb|300px|Health insurance exchanges by state.<ref name=KaiserExchanges /> | |||
| {{legend|#232|Creating state-operated exchanges}} | |||
| {{legend|#898|Establishing state-federal partnership exchanges}} | |||
| {{legend|#C8C8C8|Defaulting to federal exchange}}]] | |||
| Under the law, setting-up an exchange gives a state partial discretion on standards and prices of insurance, aside from those specifics set-out in the ACA:<ref name=KaiserExchangesNotes>{{cite web|title=State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Notes|url=http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#notes |publisher=Kaiser Family Foundation |date=May 28, 2013 }}</ref><ref>{{cite web|title=State Health Insurance Exchange Laws: The First Generation|url=http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jul/State-Health-Insurance-Exchange-Laws.aspx?omnicid=20 |work=The Common Wealth Fund |date=July 25, 2012 }}</ref> 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 is medically necessary; in either case, federal subsidies are ].<ref>{{Cite news | title = The Question of Abortion Coverage in Health Exchanges | author = Rebecca Adams | url = http://www.rollcall.com/news/the_question_of_abortion_coverage_in_health_exchanges-226547-1.html | publisher= ] | date = July 22, 2013 }}</ref> 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 ] assumes the authority and legal obligation to operate all functions in these 'federally facilitated exchanges'.<ref name=KaiserExchangesNotes /> As of May 2013, 23 states and the District of Columbia plan to operate state-based exchanges themselves, (seven 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.<ref name=KaiserExchanges>{{cite web|title=State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Table|url=http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#table |publisher=Kaiser Family Foundation |date=May 28, 2013 }}<br />{{cite web|title=State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Map|url=http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#map |publisher=Kaiser Family Foundation |date=May 28, 2013 }}</ref> | |||
| 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 allows them to experiment with their own state-based system, on condition that it meets certain criteria.<ref name=GPOStateWaiver>{{cite web|url=http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm |title=Public Law 111 – 148, section 1332 |publisher=Gpo.gov |date= |accessdate=June 29, 2012}}</ref> 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.<ref name=StateWaiverConditions>{{cite web|url=http://www.healthcare.gov/news/factsheets/stateinnovation03102011a.html |title=Preparing for Innovation: Proposed Process for States to Adopt Innovative Strategies to Meet the Goals of the Affordable Care Act |publisher=U.S. Department of Health & Human Services |date=November 16, 2011 |accessdate=April 1, 2012}}</ref> 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 ].<ref name=WaPoWaiverFlexibility >{{cite news| url=http://www.washingtonpost.com/wp-dyn/content/article/2011/02/28/AR2011022806535.html | work=The Washington Post | first1=Amy | last1=Goldstein | first2=Dan | last2=Balz | title=Obama offers states more flexibility in health-care law | date=March 1, 2011}}</ref> 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.<ref name=GPOStateWaiver /> So far, only Vermont, in May 2011, has enacted ] - a state-based ] for which they intend to pursue a waiver to implement.<ref name=VermontGMC1>{{cite web|url=http://governor.vermont.gov/http%3A/%252Fgovernor.vermont.gov/node/add/media-federal-rules |title=Gov. Shumlin issued the following statement on health care rules |publisher=Governor.vermont.gov |date=March 14, 2011 |accessdate=April 1, 2012}}</ref><ref name=VermontGMC2>{{cite web|last=Estes |first=Adam Clark |url=http://www.theatlanticwire.com/national/2011/05/vermont-becomes-first-state-pass-single-payer-health-care/38207/ |title=Vermont Becomes First State to Enact Single-Payer Health Care |work=The Atlantic |date=May 26, 2011 |accessdate=April 1, 2012}}</ref><ref name=VermontGMC3>{{cite news| url=http://www.huffingtonpost.com/2011/05/26/vermont-health-care-reform-law-single-payer_n_867573.html | work=The Huffington Post | first=Nicholas | last=Wing | title=Vermont Single-Payer Health Care Law Signed By Governor | date=May 26, 2011}}</ref> | |||
| ====Change in insurance standards==== | |||
| The ACA includes regulations that set standards for insurance,<ref name=CohnInsuranceStandards /> some specified in the law, others subsequently established by the ]. Among these new standards are a ban on the ability to ],<ref name='Top 18' /> a ban on ] on the basis of ]s or sex through a partial ],<ref name="New Hampshire Insurance Department">{{cite web|url=http://www.nh.gov/insurance/consumers/documents/naic_faq.pdf|title=I have been denied coverage because I have a pre-existing condition. What will this law do for me?|publisher=New Hampshire Insurance Department|work=Health Care Reform Frequently Asked Questions|accessdate=June 28, 2012|page=2}}</ref> and allowing children and dependents to remain on their parents' insurance plan until their 26th birthday.<ref name="H.R. 3590 Enrolled">, section 1001 (adding section 2714 to the ]): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age."</ref><ref name="Pear">{{cite news | title= Rules Let Youths Stay on Parents' Insurance | newspaper= The New York Times | date=May 10, 2010 | url= http://www.nytimes.com/2010/05/11/health/policy/11health.html | first=Robert | last=Pear}}</ref><ref name="whitehouse.gov">{{cite press release | title= Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Families and Businesses | publisher= ] | url= http://www.whitehouse.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf }}</ref> | |||
| Under the law's authorization, Secretary of Health ] issued a set of defined 'essential health benefits'<ref name="essential"/> that all new insurance plans have to include. Insurers will be prohibited from imposing annual or lifetime coverage caps on these essential benefits,<ref name='Top 18' >{{cite news | first=Jeremy | last=Binckes | coauthors= Nick Wing |authorlink= | title=The Top 18 Immediate Effects Of The Health Care Bill | date=March 22, 2010 | url =http://www.huffingtonpost.com/2010/03/22/the-top-18-immediate-effe_n_508315.html#s75147 | work =The Huffington Post | accessdate =March 22, 2010 }}</ref><ref name="ReferenceA">{{cite web|url=http://www.healthcare.gov/law/about/order/byyear.html |title=Provisions of the Affordable Care Act, By Year |publisher=HealthCare.gov |date= |accessdate=January 9, 2012}}</ref> which cover: "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care."<ref name=KaiserEHB>{{cite web|url=http://kff.org/health-reform/perspective/questions-about-essential-health-benefits/ |title=Questions About Essential Health Benefits |publisher=Kaiser Family |coauthors=Larry Levitt, Gary Claxton, Karen Pollitz |date=October 18, 2011 }}</ref><ref>{{cite web|title=Essential Health Benefits |url=https://www.healthcare.gov/glossary/essential-health-benefits/ |publisher=HealthCare.Gov, managed by the ] }}<br />{{cite web|title=What does Marketplace health insurance cover? |url=https://www.healthcare.gov/what-does-marketplace-health-insurance-cover/ |publisher=HealthCare.Gov, managed by the ] }}</ref> In determining what qualified as an essential benefit, the law required that the scope of standard benefits should equal that of a "typical employer plan"<ref name=KaiserEHB /> States have some discretion in determining what should be considered the benchmark plan within the requirements of the law, and may include services beyond those set-out by the Secretary.<ref>{{cite web|url=http://kff.org/health-reform/fact-sheet/quick-take-essential-health-benefits-what-have-states-decided-for-their-benchmark/ |title=Quick Take: Essential Health Benefits: What Have States Decided for Their Benchmark? |publisher=Kaiser Family |date=December 7, 2012 }}</ref> | |||
| Among the essential health benefits; preventive care, childhood immunizations and adult vaccinations, and medical screenings<ref name=KaiserSummary>{{cite news|url=http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf|title=Summary of the Affordable Care Act|date=April 23, 2013|newspaper=Kaiser Family Foundation }}</ref><ref name="healthcare.gov">{{cite web | title=Health Insurance Market Reforms: Prevention | url=https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Prevention.html |publisher=Centers for Medicare and Medicaid Services |date=December 21, 2010 |accessdate=September 8, 2013 }}</ref> will have ], ], and ]s eliminated - these services will be covered by an insurance plan's premiums.<ref name=essential /><ref name="SHNS">{{cite news | first=Lee | last=Bowman | title=Health reform bill will cause several near-term changes | date=March 22, 2010 | url =http://public.shns.com/node/52359 | agency =Scripps Howard News Service | accessdate =March 23, 2010}}</ref><ref name="ReferenceC">{{cite web | title=The Affordable Care Act and Immunization | url=http://www.healthcare.gov/news/factsheets/2010/09/affordable-care-act-immunization.html|publisher=U.S. Department of Health & Human Services|accessdate=September 15, 2012}}</ref> Such services include mammograms and colonoscopies, wellness visits, ] screening, ] testing, ] counseling, ] screening and counseling, FDA-approved contraceptive methods, breastfeeding support and supplies, and ] screening and counseling.<ref name="Schiff Hardin LLP">{{cite web |title=Next Steps to Comply with Health Care Reform |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |publisher=] LLP |work=The National Law Review|date=October 10, 2012|accessdate=October 10, 2012}}</ref> | |||
| In addition, the law establishes four tiers of coverage: bronze, silver, gold, and platinum. All categories offer the same set of essential health benefits. What the categories specify is the division of premiums and out-of-pocket costs: bronze plans will have the lowest monthly premiums and higher out-of-pocket costs, and vice versa for platinum plans.<ref name=KaiserEHB /><ref>{{cite web|title=How do I choose Marketplace insurance? |url=https://www.healthcare.gov/how-do-i-choose-marketplace-insurance/ |publisher=HealthCare.Gov, managed by the ] }}</ref> The percentages of care that plans are expected to cover through premiums (as opposed to out-of-pocket costs) are, on average: 60% (Bronze), 70% (Silver), 80% (Gold), and 90% (Platinum).<ref>{{cite web|title=Health Plan Categories |url=https://www.healthcare.gov/glossary/health-plan-categories/ |publisher=HealthCare.Gov, managed by the ] }}</ref> | |||
| Insurers are required to implement an ]s process for coverage determination and claims on all new plans.<ref name='Top 18' /> And they are required to ] on health costs and claims, as opposed to administrative costs and profits, and rebates must be issued to ]s if this is violated.<ref>{{cite web|url=http://www.healthcare.gov/news/factsheets/medical_loss_ratio.html |title=Medical Loss Ratio: Getting Your Money's Worth on Health Insurance |publisher=U.S. Department of Health & Human Services |date= |accessdate=April 1, 2012}}</ref><ref name="Federal Register">{{cite web|url=https://www.federalregister.gov/articles/2011/12/07/2011-31289/medical-loss-ratio-requirements-under-the-patient-protection-and-affordable-care-act |title=Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act |publisher=Federal Register |date= |accessdate=April 1, 2012}}</ref><ref name="Pecquet">{{cite web|last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-insurance/211225-obama-administration-denies-one-states-health-law-waiver-partially-approves-another |title=Obama administration concludes healthcare law waiver review |work=The Hill |date=February 16, 2012 |accessdate=April 1, 2012}}</ref> | |||
| =====Coverage for contraceptives===== | |||
| {{main|Contraceptive mandate (United States)}} | |||
| One provision in the law is the ] coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions.<ref>{{cite web | title=Women’s Preventive Services Coverage and Non-Profit Religious Organizations | url=http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013.html |publisher=Centers for Medicare and Medicaid Services |accessdate=September 8, 2013 }}</ref><ref name="Kliff">{{cite news|last=Kliff|first=Sarah|title=Five facts about the health law’s contraceptive mandate|url=http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/01/five-facts-about-the-health-laws-contraceptive-mandate/|accessdate=29 November 2012|newspaper=The Washington Post|date=1 August 2012}}</ref> These regulations<ref name="Final Rule">{{cite web|title=Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules|url=http://www.gpo.gov/fdsys/granule/FR-2012-02-15/2012-3547/content-detail.html|publisher=Federal Register, GPO|accessdate=February 15, 2012|author=Dept. Health and Human Services|format=77 FR 8725|date=February 10, 2012|quote=Summary: ''These regulations finalize, without change, interim final regulations authorizing the exemption of group health plans and group health insurance coverage sponsored by certain religious employers from having to cover certain preventive health services under provisions of the Patient Protection and Affordable Care Act''.}}</ref> were included on the recommendations of the ], which concluded that access to contraception is medically necessary "to ensure women's health and well-being."<ref>{{cite news | publisher = CNN | title = Birth control should be fully covered under health plans, report says | first = Madison | last = Park | url = http://www.cnn.com/2011/HEALTH/07/19/birth.control.iom/index.html | date = July 19, 2011 | accessdate = August 27, 2012}}</ref> | |||
| The initial regulations proved controversial among Christian hospitals, ], ], and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds.<ref>{{cite web|author=Jonathan Cohn|title=Religious Institutions Matter. So Do Their Employees.|url=http://www.newrepublic.com/blog/jonathan-cohn/100521/contraception-obamacare-catholic-religious-institutions |publisher=The New Republic |date=February 8, 2012}}</ref> To accommodate those concerns whilst still guaranteeing access to contraception, the regulations were adjusted to "allow religious organizations to opt out of the requirement to include birth control coverage in their employee insurance plans. In those instances, the insurers themselves will offer contraception coverage to enrollees directly, at no additional cost."<ref>{{cite web|author=Jonathan Cohn|title=Obama’s Deal on Birth Control Coverage|url=http://www.newrepublic.com/blog/jonathan-cohn/100636/obama-announces-contraception-accommodation-bishops-catholic-hospital-exemption |publisher=The New Republic |date=February 10, 2012}}</ref> | |||
| ====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 insurance.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/112259/obamacare-sticker-shock-not-very-shocking |title=Obamacare Sticker Shock: Not Very Shocking |publisher=The New Republic |date=April 29, 2013 }}<br />{{cite web|author=Jonathan Cohn |title=Un-rigging the Rate-Shock Debate |url=http://www.newrepublic.com/article/113392/obamacare-rate-shock-debate-subsidies-make-huge-difference |date=June 5, 2013 |publisher=The New Republic }}</ref><ref>{{cite web|author=Jonathan Chait|title=Is Obamacare a War on Bros? |url=http://nymag.com/daily/intelligencer/2013/06/obamacare-a-war-on-bros.html |date=June 5, 2013 |publisher=New York Magazine }}</ref> The ] has calculated that about half the people who currently buy insurance on their own today will be eligible for subsidies. Among those receiving subsidies (excluding those with incomes above four times the poverty line, about $94,000), the subsidies are projected to be worth an average of $5,548 per household, which would effectively discount the projected price of insurance by two-thirds.<ref>{{cite web|author=Jonathan Cohn |title=The Big Savings Obamacare Critics Miss |url=http://www.newrepublic.com/article/114302/kaiser-study-obamacare-tax-credits-worth-thousands-lots-people |publisher=The New Republic |date=August 14, 2013 }}</ref> As of September 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 also save the government money by reducing the overall cost of the subsidies.<ref>{{cite web|author=Jonathan Cohn |title=The Obamacare Train Still Hasn't Wrecked |url=http://www.newrepublic.com/article/113935/obamacare-insurance-premiums-rate-shock-or-rate-joy |date=July 18, 2013 |publisher=The New Republic }}</ref><ref>{{cite web|author=Teagan Goddard |title=(Kaiser Family Foundation) Study Finds ‘Lower Than Expected’ Obamacare Premiums |url=http://wonkwire.rollcall.com/2013/09/05/study-finds-lower-expected-obamacare-premiums/ |date=September 5, 2013 |publisher=Teagan Goddard's Wonkwire }}</ref><ref>{{cite web| last = Mukherjee| first = Sy| title = Major New Study On Obamacare Premiums Should End The ‘Rate Shock’ Hysteria Once And For All| publisher = ]| date =September 5, 2013| url = http://thinkprogress.org/health/2013/09/05/2575601/obamacare-premiums-expected-kaiser/| accessdate =September 5, 2013 }}</ref> | |||
| For the effect on health insurance premiums, the CBO referred<ref name="CBO-Reid-Dec2009"/> to its November 2009 analysis<ref name=CBOPremiumEffect>{{cite web|url=http://www.cbo.gov/doc.cfm?index=10781&type=1 |title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act |publisher=Cbo.gov |date=November 30, 2009 |accessdate=June 29, 2012}}</ref> and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.<ref name=CBOPremiumEffect/> | |||
| The ] reported that, as a result of ACA's provisions concerning the ] (between the ''initial coverage limit'' and the ''catastrophic coverage threshold'' in the ]), individuals falling in this "donut hole" would save about 40 percent.<ref name="shrinks">{{cite web| last = Alonso-Zaldivar | first = Ricardo| title = AP Newsbreak: Medicare's drug coverage gap shrinks| publisher = ]| date = November 27, 2011| url = http://www.businessweek.com/ap/financialnews/D9R93OMO3.htm| accessdate = October 25, 2012}}</ref> Almost all of the savings came because, with regard to brand-name drugs, ACA secured a discount from pharmaceutical companies.<ref name="shrinks"/> The change benefited more than two million people, most of them in the middle class.<ref name="shrinks"/> | |||
| Larry Levitt, a health policy analyst from the ], 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 ] 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.<ref>{{cite news|last=Aigner-Treworgy|first=Adam|date=March 27, 2013|title=Health care law will raise insurers' costs, actuaries say|work=CNN politicalticker... blog|publisher=]|url=http://politicalticker.blogs.cnn.com/2013/03/27/health-care-law-will-raise-insurers-costs-actuaries-say/|accessdate=April 12, 2013}}<br/>{{cite web|last=Robertson|first=Lori|date=April 5, 2013|title=Health insurance premium spin|location=Philadelphia|publisher=]|url=http://www.factcheck.org/2013/04/insurance-premium-spin/|accessdate=April 12, 2013}}</ref> | |||
| 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%.<ref name=KaiserMLR /> 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. | |||
| ====Healthcare cost inflation==== | |||
| In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:{{cquote|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.}} | |||
| <nowiki> </nowiki>CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."<ref>{{cite web|url=http://www.cbo.gov/ftpdocs/115xx/doc11544/Presentation5-26-10.pdf |title=Health Costs and the Federal Budget |publisher=Congressional Budget Office |date=May 28, 2010 |accessdate=April 1, 2012}}</ref> | |||
| ], a noted health policy analyst, commented that: {{cquote|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 ] 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.<ref>{{cite web|author=Jonathan Cohn|title=What, You Have a Better Idea for Cost Control?|url= http://www.newrepublic.com/blog/the-treatment/what-you-have-better-idea-cost-control |publisher=The New Republic|date=March 7, 2010}}<br />{{cite news |title=New Cost Estimate on Senate Bill |author=Jonathan Cohn |publisher=The New Republic |date=December 11, 2009 |url=http://www.tnr.com/blog/the-treatment/breaking-new-cost-estimate-senate-bill }}</ref>}} | |||
| <nowiki> </nowiki>He and fellow '']'' editor ] further noted the CBO didn't include in its estimate various cost-saving provisions intended to reduce health inflation.<ref name=CBOMethodology>{{cite news |title=The GOP's Trick Play |author=Jonathan Cohn |publisher=The New Republic |date=January 21, 2011 |url=http://www.tnr.com/blog/jonathan-cohn/81941/trick-play }}</ref> They also noted the CBO has a history of consistently underestimating the impact of health legislation.<ref name=CBOTrackRecord>{{cite news |title=Is the CBO Biased Against Health Care Reform? |author=Noam Scheiber |publisher=The New Republic |date=September 17, 2009 |url=http://www.tnr.com/blog/the-stash/the-cbo-biased-against-health-care-reform }}</ref> | |||
| ], an influential consultant who helped develop both the ACA and the Massachusetts healthcare reform that preceded it, acknowledges that the ACA is not ''guaranteed'' to significantly "bend the curve" of rising healthcare costs:<ref>{{cite book|last=Gruber|first=Jonathan|title=Health Care Reform: What It Is, Why It's Necessary, How It Works|year=2011|publisher=Hill and Wang|location=United States|isbn=978-0-8090-5397-1|page=101}}</ref>{{cquote|The real question is how far the ACA will go in slowing cost growth. Here, there is great uncertainty—mostly because there is such uncertainty in general about how to control cost growth in health care. There is no shortage of good ideas for ways of doing so... There is, however, a shortage of evidence regarding which approaches will actually work—and therefore no consensus on which path is best to follow. In the face of such uncertainty, the ACA pursued the path of considering a range of different approaches to controlling health care costs... Whether these policies by themselves can fully solve the long run health care cost problem in the United States is doubtful. They may, however, provide a first step towards controlling costs—and understanding what does and does not work to do so more broadly.<ref>{{cite web|url=http://economics.mit.edu/files/6829 |last=Gruber|first=Jonathan|title=The Impacts Of The Affordable Care Act: How Reasonable Are The Projections?}}</ref>}} | |||
| The law created the ] and requires numerous pilot programs and demonstrations that may affect healthcare costs.<ref>Kuraitis V. (2010). . e-CareManagement.com.</ref> Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate except ].<ref name="NewYorker-Gawande">{{Cite journal | author = ] | month = December | year = 2009 | url = http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all| title = Testing, Testing | journal = ]| accessdate = March 22, 2010}}</ref> | |||
| The ], an association of ], commissioned a report from the ] ] that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.<ref>{{cite news|url=http://www.politifact.com/truth-o-meter/statements/2010/mar/19/barack-obama/obama-says-health-reform-legislation-could-reduce-/|title=Obama says health reform legislation could reduce costs in employer plans by up to $3,000|last=Farley|first=Robert|date=March 19, 2010|publisher=PolitiFact.com|accessdate=April 7, 2010}}</ref> | |||
| 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 has fallen since 2002. Per capita cost increases have averaged 5.4% annually since 2000. Costs relative to GDP, which had been rising, have stagnated since 2009.<ref></ref> Several studies have attempted to explain the reduction in the rate of annual increase. Reasons include, among others: | |||
| *Higher unemployment due to the ], which has limited the ability of consumers to purchase healthcare; | |||
| *Out-of-pocket payments, and deductibles, which constitute the amount an individual pays for their health costs before insurance begins to cover claims, have risen. These rising costs generally cause less consumption of healthcare services.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/86554/ryan-medicare-high-deductible-insurance |title=More Skin in the Game--for Seniors? |publisher=The New Republic and Kaiser Health News |date=April 12, 2011 }}</ref> 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.<ref name="NYTLowrey1">{{Cite journal | author = Annie Lowrey | month = May | year = 2013 | url = http://www.nytimes.com/2013/05/07/business/slowdown-in-rise-of-health-care-costs-may-persist.html| title = Slowdown in Rise of Healthcare Costs May Persist | journal = ]| accessdate = June 10, 2013}}</ref><ref name="NROLevin1">{{Cite journal | author = Yuval Levin | month = May| year = 2013 | url = http://www.nationalreview.com/corner/349295/health-costs-and-budget| title = Healthcare Costs and Budget | journal = ]| accessdate = June 10, 2013}}</ref> | |||
| *Structural changes<ref name="NYTLowrey1"/> in the healthcare system made by the ACA that aim to shift the healthcare system from paying-for-quantity to paying-for-quality. Examples include incentives to ] and to use ]s, ]s, and ]s to coordinate care and prioritize quality over quantity.<ref name="NYMagChait2">{{cite news |title=Yuval Levin Dissembles Madly |author=Jonathan Chait |publisher=New York Magazine |date=May 29, 2013 |url=http://nymag.com/daily/intelligencer/2013/05/yuval-levin-dissembles-madly.html }}</ref> Some of these changes have occurred due to healthcare providers acting in anticipation of future implementation of reforms.<ref name=ChaitHCRInflation>{{cite news |title=Yuval Levin Dissembles Madly |author=Jonathan Chait |publisher=New York Magazine |date=May 29, 2013 |url=http://nymag.com/daily/intelligencer/2013/05/yuval-levin-dissembles-madly.html }}<br />{{cite news |title=The Facts Are In and Paul Ryan Is Wrong |author=Jonathan Chait |publisher=New York Magazine |date=May 10, 2013 |url=http://nymag.com/daily/intelligencer/2013/05/facts-are-in-and-paul-ryan-is-wrong.html }}</ref> | |||
| Uncertainty exists about the extent to which each factor is responsible for the recent reduction in health inflation, and about the durability of the overall trend, including the accompanying reduction in long-term deficit projections due to reduced healthcare costs. However, several studies have found that the temporary effects of the recession cannot account for the entirety of the slowdown and that structural changes likely share at least partial credit.<ref name="NYTLowrey1"/><ref name=ChaitHCRInflation /><ref>{{cite web | title = Health Cost Growth Slows Further Even as Economy Rebounds | publisher = Bloomberg | author = Alex Wayne | date = June 18, 2013 | url = http://www.bloomberg.com/news/print/2013-06-18/health-cost-growth-slows-further-even-as-economy-rebounds.html }}</ref> One study estimated that the changes to the health system are responsible for about a quarter of the recent reduction in inflation.<ref>{{cite web | title = Assessing the Effects of the Economy on the Recent Slowdown in Health Spending | publisher = ] | date = April 22, 2013 | url = http://kff.org/health-costs/issue-brief/assessing-the-effects-of-the-economy-on-the-recent-slowdown-in-health-spending-2/ }}</ref> Even if the cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly ].<ref>{{cite web | title = In Spending Debate, Baby Boomer Issue Remains a Headache for Legislators | publisher = Roll Call | author = Paul Krawzak | date = June 14, 2013 | url = http://www.rollcall.com/news/in_spending_debate_baby_boomer_issue_remains_a_headache_for_legislators-225650-1.html }}</ref> | |||
| {{Gallery | |||
| |title='''U.S. Healthcare Costs - Centers for Medicare and Medicaid Services''' | |||
| |width=500 | height=375 | lines=2 | |||
| |align=center | |||
| |File:U.S. Healthcare Costs as a Percentage of GDP.png | |||
| |alt1=U.S. HC %GDP | |||
| |Healthcare Costs as a Percentage of GDP 2000-2011 | |||
| |File:U.S. National Healthcare Expenditures - Annual Percent Change.png | |||
| |alt2=U.S. HC Inflation | |||
| |Healthcare Cost Inflation 2000-2011 | |||
| }} | |||
| {{-}} | |||
| ====Federal deficit==== | |||
| =====CBO estimates of impact on deficit===== | |||
| {{See also|United States public debt|Provisions of the Patient Protection and Affordable Care Act by effective date}} | |||
| ] | |||
| The 2011 comprehensive CBO estimate projected a net-deficit reduction of more than $200 billion during the 2012–2021 period:<ref name="CBO22077">{{cite web|url=http://www.cbo.gov/publication/22077 |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |publisher=Congressional Budget Office |date=March 30, 2011 |accessdate=April 6, 2012}}</ref><ref name="CBO43104">{{cite web |url=http://www.cbo.gov/publication/43104 |title=Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 16, 2012 |accessdate=April 6, 2012}}</ref> 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.<ref name="CBO22077"/> The CBO separately noted that whilst most of the spending provisions don't begin until 2014,<ref name="CBO-Pelosi">{{cite web | url = http://www.cbo.gov/ftpdocs/113xx/doc11355/hr4872.pdf | title = H.R. 4872, Reconciliation Act of 2010 | format = PDF | publisher = Congressional Budget Office | date = March 18, 2010 | accessdate = March 22, 2010}}</ref><ref name="RollCallCBO">{{Cite news | title = CBO: Health Care Overhaul Would Cost $940 Billion | first = Steven | last = Dennis | url = http://www.rollcall.com/news/44347-1.html | newspaper = ] | publisher = ] | date = March 18, 2010 | accessdate = March 22, 2010}}</ref> revenue will still exceed spending in those subsequent years.<ref name="CBO-Pelosi2">{{Cite news | title = What does the health-care bill do in its first year? | first = Ezra | last = Klein | url = http://voices.washingtonpost.com/ezra-klein/2010/03/what_does_the_health-care_refo.html | newspaper = ] | date = March 22, 2010}}</ref> 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"<ref name="CBO-Reid-Dec2009">{{cite web | url = http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-Reid_Letter_Managers_Correction_Noted.pdf | title = Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act | format = PDF | publisher = Congressional Budget Office | date = December 19, 2009 | accessdate = March 22, 2010}}</ref> - ultimately extending the solvency of the ] by 8 years.<ref>{{cite news|author1=Judith Solomon|author2=Paul N. Van de Water|url=http://www.cbpp.org/cms/?fa=view&id=3746 |title=Letter: Improving the Strength and Solvency of Medicare |publisher=The Center on Budget and Policy Priorities |date=April 18, 2012 }}</ref> | |||
| However, this estimate was made prior to the ] on the ACA,<ref name="CBO43076" /> which enabled states to ], thereby forgoing the federal funding. The ] and ] subsequently updated the budget projection, estimating the impact of the ruling would reduce the cost estimate of the insurance coverage provisions by $84 billion.<ref name=fewer>{{cite web|last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/215795-cbo-health-law-to-cost-less-cover-fewer-people-than-first-thought |title=CBO: Obama's health law to cost less, cover fewer people than first thought – The Hill's Healthwatch |publisher=Thehill.com |date=March 13, 2012 |accessdate=June 29, 2012}}</ref><ref name="CBO43472">{{cite web|url=http://www.cbo.gov/publication/43472 |title=CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=August 6, 2012}}</ref><ref>{{cite news|last=Sahadi |first=Jeanne |url=http://money.cnn.com/2012/03/13/news/economy/health-reform-costs |title=Health reform coverage cost falls slightly – Mar. 13, 2012 |publisher=Money.cnn.com |date= March 13, 2012|accessdate=June 29, 2012}}</ref> | |||
| Major sources of deficit reduction include:<ref name=KaiserSummary /> higher ] on the wealthy; new annual fees on health insurance providers; similar fees on the healthcare industry such as manufacturers and importers of brand-name ]s and certain ]s; limits on ] and ]s; a new 40% ] on ] - plans with annual insurance premiums in excess of $10,200 for an individual or $27,500 for a family; revenue from mandate penalty payments; a 10% federal ] on ]; and spending offsets such as a reduction in Medicare reimbursements to insurers and drug companies for private ] policies that the ] and ] found to be overpaid (relative to government Medicare); and reductions in Medicare reimbursements to hospitals that do not meet standards of efficiency and care. | |||
| 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.<ref name="CBO-Reid-Dec2009"/><ref name="CNN-Mar18">{{Cite news | url = http://www.cnn.com/2010/POLITICS/03/18/health.care.latest/index.html | publisher = CNN | title = Where does health care reform stand? | date = March 18, 2010 | accessdate = May 12, 2010}}</ref> CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".<ref>{{cite news|url=http://www.politifact.com/truth-o-meter/statements/2010/mar/18/nancy-pelosi/pelosi-cbo-says-health-reform-bill-would-cut-defic/|title=Pelosi: CBO says health reform bill would cut deficits by $1.2 trillion in second decade|last=Farley|first=Robert|date=March 18, 2010|publisher=]|accessdate=April 7, 2010}}</ref> | |||
| A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "]" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019.<ref>{{cite web|url=http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |title=Sen. Tom Coburn: Obamacare PR campaign anchored in spin, not reality |work=The Washington Examiner |date=July 8, 2006 |accessdate=April 1, 2012}}</ref><ref>{{cite news| url=http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta |title=Obamacare’s Cooked Books and the ‘Doc Fix’ |publisher=National Review |author= James Capretta}}</ref><ref>{{cite web|last=Hogberg |first=David |url=http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |title=GOP Might Target ObamaCare As Part Of A Medicare 'Doc Fix' |work=Investor's Business Daily |date=November 22, 2010 |accessdate=April 1, 2012}}</ref> 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 ].<ref>{{cite web|url=http://www.cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |title=Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010 |publisher=Congressional Budget Office |date=March 19, 2010 |accessdate=April 1, 2012}}</ref><ref>{{cite news|author=Jonathan Chait|url=http://www.newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |title=The Doc Fix Myth And The Right's Misinformation Feedback Loop |publisher=The New Republic |date=March 24, 2010 }}</ref><ref>{{cite web|last=Van de Water|first=Peter|title=Debunking False Claims About Health Reform, Jobs, and the Deficit|url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3366|publisher=Center for Budget and Policy Priorities}}</ref> | |||
| =====Opinions on CBO projections===== | |||
| There was mixed opinion about the CBO estimates. | |||
| ], a ] at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the ]."<ref>{{cite news |title=Wrapping Your Head Around the Health Bill |author=] |newspaper=The New York Times |date=March 24, 2010 |url=http://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill/ |accessdate=October 9, 2010}}</ref> | |||
| ], CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.<ref>{{cite news| url=http://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html | work=The New York Times | title=The Real Arithmetic of Health Care Reform | first=Douglas | last=Holtz-Eakin | date=March 21, 2010}}</ref> | |||
| '']'' editors ] (an economist) and ] (a healthcare policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from ], and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;<ref name=CBOMethodology /><ref name=CBOTrackRecord /> "innovations in the delivery of medical care, like greater use of ]s<ref>{{cite web|url=http://www.medicalrecords.com/physicians/electronic-medical-records-deadline |title=Electronic Medical Records (Health Information Technology)}}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another – and that meant there wasn't much hard data to prove the savings would materialize."<ref name=CBOMethodology /> | |||
| ], former ] now working for ], has stated that the CBO estimates are not likely to be accurate, because they are based on the assumption that Congress is going to do everything they say they're going to do.<ref name="deficit_david_walker_cbo_innacurate">{{cite news|url=http://www.npr.org/blogs/thetwo-way/2010/03/health_overhaul_another_promis.html|title=Health Overhaul Another Promise U.S. Can't Afford: Expert|last=James|first=Frank|date=March 19, 2010|publisher=]|accessdate=April 7, 2010}}</ref> The ] objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings.<ref>{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |title=Congress Has Good Record of Implementing Medicare Savings |publisher=CBPP |accessdate=March 28, 2010 }}</ref><ref>{{cite news |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |work=The Washington Post |accessdate=March 28, 2010 }}</ref> | |||
| ====Employer mandate and part-time working hours==== | |||
| :''Not to be confused with the ]''<ref name=ChaitNotCollapsing>{{cite web| author=Jonathan Chait|title=Obamacare Still Not Collapsing |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |publisher=New York Magazine |date=July 3, 2013}}</ref><ref name=Mandate3>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113851/obamacare-individual-mandate-republicans-push-delay |title=Obamacare's Individual Mandate Can't Wait |publisher=The New Republic |date=July 15, 2013 }}</ref> | |||
| {{Details|Health insurance mandate|health insurance mandates}} | |||
| 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.<ref name=GPO>{{cite web|url=http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleD-chap43-sec4980H.pdf|title=Title 26 - Internal Revenue Code|author=Government Printing Office}}</ref> 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.<ref name="http">{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113257/low-wage-employers-try-avoid-obamacare-mandate |title=Weaseling Out of Obamacare |publisher=The New Republic |date=May 21, 2013 }}</ref> Proponents of the reform law wanted to address the parts of the healthcare 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.<ref name=KaiserSatisfication>{{cite web|title=Data Note: Americans’ Satisfaction with Insurance Coverage|url=http://kff.org/health-reform/issue-brief/data-note-americans-satisfaction-with-insurance-coverage/ |publisher=Kaiser Family Foundation |date=August 31, 2009 }}<br />{{cite web|title=Data Note: Americans’ Satisfaction with Insurance Coverage, Poll PDF |url=http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7979.pdf |publisher=Kaiser Family Foundation |date=September, 2009 }}</ref><ref name="http"/> 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).<ref>{{cite web|title=Health Coverage & Uninsured|url=http://kff.org/state-category/health-coverage-uninsured/ |publisher=Kaiser Family Foundation |date=June 20, 2013 }}<br />{{cite web|title=Health Insurance Coverage of the Total Population |url=http://kff.org/other/state-indicator/total-population/ |publisher=Kaiser Family Foundation |date=June 20, 2013 }}</ref><ref>{{cite web|title=Pg 14 of ‘Kaiser Health Tracking Poll: June 2013’|url=http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8451-t.pdf |publisher=Kaiser Family Foundation |date=June 2013 }}</ref> 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.<ref name=KaiserSatisfication /> The intent of the employer mandate (along with a ] in the ACA) 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 ] ] for business to employ people part-time instead of full-time.<ref name=ChaitNotWreck>{{cite web| author=Jonathan Chait |title=Obama Employer Mandate Delay Train Wreck! Or Not |url=http://nymag.com/daily/intelligencer/2013/07/obama-employer-mandate-delay-train-wreck-or-not.html |publisher=New York Magazine |date=July 3, 2013}}</ref><ref name=KliffPartTime>{{cite news |title= Will Obamacare lead to millions more part-time workers? Companies are still deciding. |author=Sarah Kliff |url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/06/will-obamacare-lead-to-millions-more-part-time-workers-companies-are-still-deciding/ |newspaper=Washington Post |date= May 6, 2013}}</ref> Several businesses and the State of Virginia have clarified the contracts of their part-time employees by adding a 29-hour a week cap,<ref>{{cite web|url=http://hamptonroads.com/2013/02/state-workers-parttime-hours-capped-due-health-law |title=Va. workers' part-time hours capped due to health law |author=Bill Sizemore |publisher=The Virginian-Pilot |date=February 8, 2013 }}<br />{{cite web|url=http://thinkprogress.org/health/2013/02/11/1568291/virginia-employees-obamacare/ |title=Virginia Cuts State Employees’ Hours To Avoid Providing Obamacare Coverage |author=Annie-Rose Strasser |publisher=''ThinkProgress'' |date=February 11, 2013 }}</ref><ref>{{cite web|url=http://tv.msnbc.com/2013/01/14/colleges-roll-back-faculty-hours-in-response-to-obamacare/ |title=Colleges roll back faculty hours in response to Obamacare |author=Ned Resnikoff |publisher=''MSNBC'' |date=January 14, 2013 }}<br />{{cite web|url=http://thinkprogress.org/health/2013/01/14/1445301/four-public-colleges-obamacare/ |title=Four Public Colleges Will Cut Adjunct Faculty Hours To Avoid Providing Health Coverage Under Obamacare |author=Sy Mukherjee |publisher=''ThinkProgress'' |date=January 14, 2013 }}</ref> to reflect the 30-hour threshold for full-time hours, as defined by the law.<ref name=GPO/> 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).<ref name=KliffPartTime /> 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,<ref name=NPRPartTime>{{cite news |title=As Health Law Changes Loom, A Shift To Part-Time Workers |url=http://www.npr.org/2013/04/29/179864601/as-health-law-changes-loom-a-shift-to-part-time-workers |publisher=NPR |date= April 29, 2013}}</ref> and the effects of the ] correlate with part-time working hour patterns.<ref>{{cite news |author=Jared Bernstein|title=Stop Blaming Obamacare for Part-Time Workers |url=http://wonkwire.rollcall.com/2013/09/04/stop-blaming-obamacare-part-time-workers/ |publisher=Teagan Goddard's Wonkwire |date= September 4, 2013}}</ref><ref>{{cite news |author=Matthew Yglesias|title=Obamacare's Not To Blame For Increasing Part-time Work |url=http://www.slate.com/blogs/moneybox/2013/07/15/obamacare_part_time_work.html |publisher=Slate |date= July 15, 2013}}</ref> The impact of this provision on employer’s decision-making is partially offset by other factors: offering healthcare 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.<ref name=KliffPartTime /><ref name=NPRPartTime /><ref>{{cite news |author=Timothy Jost|title=Implementing Health Reform: A One-Year Employer Mandate Delay|url=http://healthaffairs.org/blog/2013/07/02/implementing-health-reform-a-one-year-employer-mandate-delay/ |publisher=Health Affairs |date= July 2, 2013}}</ref> In addition, the amount of employers with over 50 employees is relatively small,<ref name=KliffPartTime /> and over 90% of them already offer insurance,<ref name=CohnDelay /> so changes in employer plans from this provision are expected to be small.<ref name=ChaitNotWreck /> 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.<ref name=ChaitNotWreck /><ref name=CohnDelay /> 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 ] 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 ] 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.<ref name=CBPPEmpMand.>{{cite web|url=http://www.cbpp.org/cms/index.cfm?fa=view&id=2921|title= Finance Committee Makes Flawed Employer Requirement in Health Reform Bill Still More Problematic |author= Robert Greenstein and Judith Solomon |publisher= ] |date=July 3, 2013}}</ref><ref name=MandateRepeal>{{cite news |title= Will Obamacare lead to millions more part-time workers? Companies are still deciding. |author=Ezra Klein |url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/07/02/obamacares-employer-mandate-shouldnt-be-delayed-it-should-be-repealed/ |newspaper=Washington Post |date= July 2, 2013}}</ref><ref>{{cite news |author=Matthew Yglesias|title=Delaying Employer Responsibility Fines Is a Good Idea—the Real Problem Comes Later|url=http://www.slate.com/blogs/moneybox/2013/07/03/obamacare_delayed_a_good_idea_covering_up_a_big_problem.html |publisher=Slate |date= July 3, 2013}}</ref><ref>{{cite web|author=Jonathan Chait |title=Obamacare Haters Struggling to Understand What ‘Nonessential’ Means |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-haters-struggle-to-get-nonessential.html |publisher=New York Magazine |date=July 3, 2013}}<br />{{cite web| author=Jonathan Chait|title=Obamacare Still Not Collapsing |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |publisher=New York Magazine |date=July 3, 2013}}</ref><ref name=Mandate3 /> (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).<ref name=ChaitNotWreck /><ref name=CBPPEmpMand. /> Furthermore, many healthcare 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.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113773/obamacare-employer-mandate-liberals-v-conservatives |title=An Obamacare Debate We Should Be Having |publisher=The New Republic |date=July 8, 2013 }}</ref> The effects of the provision have also generated vocal opposition from several business and unions.<ref name=MandateRepeal /><ref>, Wall St. Journal, July 12, 2013</ref> | |||
| On July 2, 2013, the ] announced on the ] website that it would ], until 2015.<ref name=CohnDelay>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/113745/obamacare-employer-mandate-delayed-not-what-doctor-ordered |title=Some Bad News About Obamacare That Isn't Bogus |publisher=The New Republic |date=July 2, 2013 }}</ref><ref name=treasurystatement>{{cite web|last=Mazur|first=Mark|title=Continuing to Implement the ACA in a Careful, Thoughtful Manner|url=http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx|publisher=United States Department of the Treasury|accessdate=16 July 2013}}</ref> | |||
| ===Political=== | |||
| ====Public opinion==== | |||
| Polls indicate support of healthcare reform in general, but became more negative in regards to specific plans during the legislative debate over 2009 and 2010, and the Act that was ultimately signed in 2010 remains controversial with opinions falling along party lines: Democrats favor the law, while Republicans and most Independents do not. Polling averages show a plurality with negative opinions of the law, with those in favor trailing by single digits.<ref name="swanson">{{cite news| url=http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html | work=Pollster.com | first=Emily | last=Swanson | title=Health Care Plan: Favor / Oppose | date=July 30, 2009}}</ref><ref name="rcp">{{cite web|url=http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html |title=Obama and Democrats' Health Care Plan |publisher=RealClearPolitics |date= |accessdate=April 1, 2012}}</ref> '']'' found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.<ref>{{cite news|url=http://www.usatoday.com/news/washington/2010-03-23-health-poll-favorable_N.htm|title=Poll: Health care plan gains favor|last=Page|first=Susan|date=March 24, 2010|work=USA Today|accessdate=2010-03-24}}</ref> | |||
| Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. '']'', describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."<ref name=538ACAPolls>{{cite news|author=Micah Cohen |url=http://fivethirtyeight.blogs.nytimes.com/2013/05/01/uncertainty-still-clouds-health-care-law/ |title=Uncertainty Still Clouds Health Care Law |date=May 1, 2013|work=FiveThirtyEight}}</ref><ref name=538InfoGap>{{cite web|author=Nate Silver |url=http://www.fivethirtyeight.com/2010/01/health-care-polls-opinion-gap-or.html |title=Health Care Polls: Opinion Gap or Information Gap? |publisher=] |date=January 23, 2010 }}</ref> For example, a Reuters-Ipsos poll during June 2012 indicated the following: | |||
| *44% of Americans supported the law, with 56% against. 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. | |||
| *39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.<ref name=most>{{cite news|last=Zengerle |first=Patricia |url=http://www.reuters.com/article/2012/06/24/us-usa-campaign-healthcare-idUSBRE85N01M20120624 |title=Reuters-Most Americans Oppose Health Law But Like the Provisions|publisher=Reuters.com |date= June 24, 2012 |accessdate=June 28, 2012}}</ref> | |||
| *Other polls showed additional provisions receiving majority support include: the creation of insurance exchanges, pooling small businesses and the uninsured with other consumers, so all can take advantage of large group pricing benefits (the community rating); and providing subsidies to individuals and families to make health insurance more affordable.<ref>{{cite news|url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does/ |title=Washington Post-Republicans hate ‘Obamacare,’ but like most of what it does|publisher=Washingtonpost.com |author=Ezra Klein |date= June 26, 2012|accessdate=June 28, 2012}}</ref><ref>{{cite news|author=Greg Sargent |url=http://www.washingtonpost.com/blogs/plum-line/post/republicans-support-obamas-health-reforms--as-long-as-his-name-isnt-on-them/2012/06/25/gJQAq7E51V_blog.html |title=Republicans Support Obama's Health Reforms - As Long As His Name Isn't On Them |publisher=The Washington Post |date=June 25, 2012 |accessdate=June 28, 2012}}</ref> | |||
| *Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),<ref>{{cite news|author=Uwe E. Reinhardt |url=http://economix.blogs.nytimes.com/2009/12/18/reimporting-american-drugs-from-canada/ |title=Reimporting American Drugs From Canada |date=December 18, 2009|work=Economix}}</ref> ], reducing the age to qualify for Medicare, and the ].<ref name=NEJMPublicOpinion>{{cite journal |author=Blendon RJ, Benson JM |title=Public opinion at the time of the vote on health care reform |journal=N. Engl. J. Med. |volume=362 |issue=16 |pages=e55 |year=2010 |month=April |pmid=20375397 |doi=10.1056/NEJMp1003844 |url=}}</ref> | |||
| Pollsters probed the reasons for opposition.<ref>{{cite news| url=http://facts.kff.org/chart.aspx?ch=1683 | publisher=Kaiser Family Foundation | title=Negative Views Driven By Many Factors }}</ref> In a ] ], 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.<ref>{{cite news| url=http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf |title=CNN Opinion Research Poll |publisher=CNN |date=March 22, 2010 }}</ref> Other polls found that people were concerned that the law would cost more than projected, and wouldn't do enough to control the cost of health care affecting their families.<ref>{{cite news| url=http://online.wsj.com/article/SB10001424052748704784904575111993559174212.html | work=The Wall Street Journal | first1=Scott | last1=Rasmussen | first2=Doug | last2=Schoen | title=Why Obama Can't Move the Health-Care Numbers | date=March 9, 2010}}</ref> | |||
| However, part of the opposition to the law is because some Americans believe the reform did not go far enough: A Reuters-Ipsos poll indicated that, for those opposed to the bill, 71% of Republican opponents reject it overall while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the relatively much smaller group of Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.<ref name=most/> | |||
| Many Democrats believe that the ACA will grow more popular over time, like Medicare did after its implementation,<ref>{{cite web|url=http://www.people-press.org/2011/07/07/public-wants-changes-in-entitlements-not-change-in-benefits/ |title=Public Wants Changes in Entitlements, Not Changes in Benefits |publisher=Pew Research Center |date=July 7, 2011 }}</ref> as the benefits of the law take effect and close the information gap about the contents of the bill.<ref name=538ACAPolls /><ref name=538InfoGap /><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/101993/obamacare-anniversary-coverage-payment-reform-cost |title=Obamacare's (Somewhat) Happy Birthday |publisher=The New Republic |date=March 23, 2012 }}</ref> | |||
| A majority of the public (52–34) indicate that they want "Congress to implement or tinker with the law rather than repeal it."<ref>{{cite news|author=Jonathan Chait |url=http://nymag.com/daily/intelligencer/2013/06/obamacare-and-conservative-self-delusion.html |title=Obamacare, Public Opinion, and Conservative Self-Delusion |date=June 13, 2013|work=New York Magazine}}</ref> Following the ], a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."<ref>Jackson, David. ''USA Today.'' Retrieved: 8 July 2012.</ref> | |||
| ====Term "Obamacare"==== | |||
| The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to '']'', the term was first put in print in March 2007, when healthcare lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a ']-care' and 'Obama-care' to go along with ']-care,' ']-care,' and a totally revamped and remodeled ']-care' ]", Schulte Scott wrote.<ref name="CNN20120625Obamacare" /><ref name="NYT20120325">{{cite news|title=Fighting to Control the Meaning of ‘Obamacare’|url=http://www.nytimes.com/interactive/2012/03/25/us/politics/fighting-to-control-the-meaning-of-obamacare.html|accessdate=June 29, 2012|newspaper=The New York Times|date=March 25, 2012|author=Amanda Cox, Alicia Desantis and Jeremy White}}</ref> The expression Obamacare first was used in early 2007 generally by writers describing the candidate’s proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at ] magazine.<ref name="NYT20120803" /> The word was first uttered in a political campaign by ] in May 2007 in ], ]. Romney said: "] We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over healthcare'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."<ref name="CNN20120625Obamacare" /> | |||
| By mid-2012, Obamacare had become the most common ] 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.<ref name="NYT20120803">{{cite news|last=Baker|first=Peter|title=Democrats Embrace Once Pejorative ‘Obamacare’ Tag|url=http://www.nytimes.com/2012/08/04/health/policy/democrats-embrace-once-pejorative-obamacare-tag.html?_r=1|accessdate=6 August 2012|newspaper=The New York Times|date=3 August 2012}}</ref> Use of the term in a positive sense was suggested by Democratic politicians such as ] (D-MI).<ref>{{cite web|last=Nelson |first=Steven |url=http://dailycaller.com/2011/06/08/democratic-leader-wants-to-reclaim-obamacare-make-it-a-compliment/ |title=Democratic Rep. John Conyers wants to reclaim 'ObamaCare', make it a compliment |work=The Daily Caller |date=June 8, 2011 |accessdate=April 1, 2012}}</ref> President Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."<ref>{{cite news| url=http://www.cbsnews.com/8301-503544_162-20092578-503544.html | publisher=CBS News | title=On bus tour, Obama embraces 'Obamacare', says 'I do care{{'-}}}}</ref> Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased ] ], triggered by the term, to direct people to the official HHS site.<ref name=smith20101217>{{cite news|url=http://www.politico.com/blogs/bensmith/1210/HHS_buys_ObamaCare.html|work=Politico|title=HHS Buys 'ObamaCare{{'-}}|first=Ben|last=Smith|date=December 17, 2010|accessdate=February 9, 2011}}</ref> In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post ] messages that begin, "I like #Obamacare because...".<ref name=thehill>{{cite web | last = Strauss | first = Daniel | title = Obama camp's pitch to supporters: 'Hell yeah, I'm for Obamacare{{'-}} | work = ] | date = March 23, 2012 | url = http://thehill.com/blogs/blog-briefing-room/news/217893-obama-reelection-campaign-urges-supporters-to-say-im-for-obamacare | accessdate = March 27, 2012}}</ref> After its debut as a phrase on ], according to an analysis by the ], from July 2009 to June 2012 the term "Obamacare" was used nearly 3,000 times in congressional speeches.<ref name="CNN20120625Obamacare">{{cite news|last=Wallace|first=Gregory|title={{-'}}Obamacare': The word that defined the health care debate|url=http://articles.cnn.com/2012-06-25/politics/politics_obamacare-word-debate_1_health-reform-law-health-care-affordable-care-act?_s=PM:POLITICS|publisher=CNN|accessdate=September 4, 2012|date=June 25, 2012}}</ref> | |||
| ====Myths==== | |||
| {{Details|Death panel|the "death panels" myth}} | |||
| On August 7, 2009, ] falsely claimed that the proposed legislation would create "]s" that would decide if sick and elderly Americans were "worthy" of medical care.<ref name="Not so">{{cite news |title=Sarah Palin falsely claims Barack Obama runs a 'death panel' |author= |newspaper=] |date=August 10, 2009 |url=http://www.politifact.com/truth-o-meter/statements/2009/aug/10/sarah-palin/sarah-palin-barack-obama-death-panel/}}</ref> By 2010, the ] reported that 85% of Americans were familiar with the claim, and that 30% of Americans believed it was true, with three contemporaneous polls finding similar results.<ref>{{Cite journal |author=] |title=Why the "Death Panel" Myth Wouldn't Die: Misinformation in the Health Care Reform Debate |journal=The Forum |publisher=] |volume=8 |issue=1 |year=2010 |doi=10.2202/1540-8884.1354 |url=http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf}}</ref> The allegation was named ]'s "Lie of the Year",<ref name="Not so"/><ref>{{Cite news |title=PolitiFact's Lie of the Year: 'Death panels' |work=PolitiFact |date=December 19, 2009 |url=http://politifact.com/truth-o-meter/article/2009/dec/18/politifact-lie-year-death-panels/|author=Angie Drobnic Holan |accessdate=November 19, 2010}}</ref> one of ]'s "whoppers",<ref>{{Cite news |title=False Euthanasia Claims |author=Jess Henig, with Lori Robertson |newspaper=] |date=July 29, 2010 |url=http://www.factcheck.org/2009/07/false-euthanasia-claims/}}</ref><ref>{{cite web|title=Whoppers of 2009—We review the choicest falsehoods from a year that kept us busy|date=December 24, 2009|author=FactCheck staff|accessdate=April 28, 2011|location=University of Pennsylvania |url=http://www.factcheck.org/2009/12/whoppers-of-2009/|work=FactCheck|publisher=Annenberg Public Policy Center}}</ref> and the most outrageous term by the ].<ref>{{cite web |url=http://www.americandialect.org/2009-Word-of-the-Year-PRESS-RELEASE.pdf |title='Tweet' 2009 Word of the Year, 'Google' Word of the Decade, as voted by American Dialect Society |date=January 8, 2010 |publisher=] |accessdate=October 8, 2010}}</ref> The AARP described such rumors as "rife with gross - and even cruel - distortions."<ref name="snopes1">{{cite web|url=http://snopes.com/politics/medical/euthanasia.asp |title=Euthanasia Counseling|publisher=Snopes.com|date=August 13, 2009}}</ref> A poll in August 2012 found that 39% of Americans still believed the "death panels" claim.<ref>{{cite news|url=http://thehill.com/blogs/healthwatch/health-reform-implementation/258753-poll-four-in-10-believe-in-health-law-death-panels|title=Poll: Four in 10 believe in Obama healthcare law ‘death panels’|publisher=The Hill|date=September 26, 2012|first=Elise|last=Viebeck}}</ref> | |||
| The 'death panel' rumors and comparable myths distort two issues related to the ACA to claim that seniors can either be denied care due to their age under the law,<ref>{{cite web|url=http://snopes.com/politics/medical/over75.asp|title=Seniors Beware|publisher=Snopes.com|date=August 23, 2012}}</ref> and/or that the government will advise them to end their own lives instead of receiving due care.<ref name="snopes1"/> Such rumors first allude to the Independent Payment Advisory Board (IPAB), 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 Medicare eligibility or coverage, or raising the costs on beneficiaries.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/jonathan-cohn/87102/ipab-medicare-commission-repeal-ryan-schwartz |title=Here We Go Again, With the Death Panels |publisher=The New Republic |date=April 20, 2011 }}</ref> The other related issue concerns advance care planning consultation: ] 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.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/mandatory-death-counseling-exposed |title=Mandatory Death Counseling--exposed! |publisher=The New Republic |date=August 13, 2009 }}</ref> As described by the site ], "This provision would allow patients (''if they so choose'') to prepare for the day when they might be seriously ill and unable to make 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" ], etc.<ref name="snopes1"/> However, due to the public concern, this provision was not included in the final draft of the bill that was enacted into law.<ref name="SenateCommittee">{{cite news |title=Senate committee scraps healthcare provision that gave rise to 'death panel' claims; Though the claims are widely discredited, the Senate Finance Committee is withdrawing from its bill the inclusion of advance care planning consultations, calling them too confusing |authors=Christi Parsons and Andrew Zajac |newspaper=Los Angeles Times |date=August 14, 2009 |url=http://articles.latimes.com/2009/aug/14/nation/na-health-end-of-life14}}</ref> | |||
| Two other prominent myths about the ACA are that Congress is 'exempt' from the reforms, and that illegal immigrants will receive free healthcare under the law. Both claims are false. The ACA requires that Members of Congress and other federal employees obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the current government program (the ]); and the federal government will, like large private employers, maintain its contributions to the new health insurance plans of federal employees.<ref name=CongressionalInsurance /><ref>{{cite web|author=Jonathan Chait |url=http://nymag.com/daily/intelligencer/2013/08/congress-exempt-from-obamacare-or-something.html |title=Congress Exempts Itself From Obamacare! Or Something! |publisher=New York Magazine |date=August 6, 2013 }}</ref><ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/114284/congress-exempt-obamacare-latest-lie-wont-die |title=The Latest Obamacare Lie That Just Won't Die |publisher=The New Republic |date=August 13, 2013 }}</ref><ref>{{Cite news |title=Sen. Ted Cruz says Obama 'just granted all of Congress an exception' to Obamacare |work=PolitiFact |date=August 14, 2013 |url=http://www.politifact.com/truth-o-meter/statements/2013/aug/14/ted-cruz/sen-ted-cruz-says-obama-just-granted-all-congress-/ |author=Becky Bowers |accessdate=August 19, 2013}}</ref><ref>{{Cite news |title=Congress Exempt from Health Bill? |author=Lori Robertson |newspaper=] |date= January 20, 2010 |url=http://www.factcheck.org/2010/01/congress-exempt-from-health-bill/}}</ref> The other rumor, regarding illegal immigrants, most ],<ref>{{Cite news |title=The Democrats' health care bills would provide "free health care for illegal immigrants." |work=PolitiFact |date=January 21, 2010 |url=http://www.politifact.com/truth-o-meter/statements/2010/jan/21/chain-email/chain-e-mail-claims-health-care-bills-congress-wou/ |author=Robert Farley |accessdate=August 19, 2013}}</ref> is also ], as the law explicitly ].<ref name=PPACANoncitizens /> | |||
| 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 ].<ref name="snopes2">{{cite web|url=http://www.snopes.com/politics/medical/microchip.asp|title=Microchip Off the Block|publisher=Snopes.com|date=February 7, 2013}}</ref> These were sometimes associated with the ] in ].<ref>E.g. {{cite web|url=http://www.tldm.org/news4/markofthebeast.htm|title=Will the Mandatory Microchip in Obamacare End Up Being the Mark of the Beast?|date=February 13, 2013|publisher=These Last Days News}}</ref> 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."<ref name="snopes2"/> 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.<ref name="snopes2" /> | |||
| ==Opposition and resistance== | |||
| Efforts to oppose, undermine, and repeal the legislation have drawn support from prominent ] advocacy groups, Congressional and many State Republicans, certain small business organizations, and the ].<ref>{{cite news|last=Peters |first=Jeremy |title=Conservatives’ Aggressive Ad Campaign Seeks to Cast Doubt on Health Law |url=http://www.nytimes.com/2013/07/07/us/politics/conservatives-aggressive-ad-campaign-seeks-to-cast-doubt-on-health-law.html | publisher=The New York Times | date = January 20, 2011}}</ref> These groups believe the law will lead to disruption of existing health plans, increased costs from new insurance standards, and that it will increase the deficit.<ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/article/113994/obamacare-implementation-conservatives-brace-it-working |title=Conservatives Brace for the Possibility Obamacare Won't Totally Suck |publisher=The New Republic |date=July 23, 2013 }}</ref> Some also are against the idea of ], viewing insurance as similar to other commodities to which people are not entitled.<ref>{{cite web|author=Michael Cannon |url=http://www.cato.org/blog/anti-universal-coverage-club-manifesto |title=The Anti-Universal Coverage Club Manifesto |publisher=Cato Institute|date=July 6, 2007 }}</ref><ref>{{cite web|author=Jonathan Chait |url=http://nymag.com/daily/intelligencer/2012/06/health-care-as-privilege-what-gop-wont-admit.html |title=Health Care As a Privilege: What the GOP Won’t Admit |publisher=New York Magazine|date=June 25, 2012 }}</ref> | |||
| ===Legal challenges=== | |||
| {{main|Constitutional challenges to the Patient Protection and Affordable Care Act}} | |||
| Opponents of the Patient Protection and Affordable Care Act turned to the federal courts to challenge the constitutionality of the legislation.<ref>{{cite web|last=Cauchi|first=Richard|title=State Legislation and Actions Challenging Certain Health Reforms, 2011–2012|url=http://www.ncsl.org/issues-research/health/state-laws-and-actions-challenging-aca.aspx|publisher=National Conference of State Legislatures|accessdate=June 30, 2012|date=June 28, 2012}}</ref><ref>{{cite web|title=Legal Challenges to the Affordable Care Act|url=http://www.hfma.org/Templates/Print.aspx?id=24263|work=Healthcare Financial Management Association|publisher=Healthcare Financial Management Association|accessdate=June 30, 2012}}</ref> In '']'', decided on June 28, 2012, the Supreme Court upheld most of the law: it ruled that 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 ACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.<ref>{{cite web |title=Analysis: U.S. Supreme Court Upholds the Affordable Care Act: Roberts Rules? |url=http://www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules |publisher=von Briesen & Roper, S.C. |work=The National Law Review|date=June 29, 2012|accessdate=July 2, 2012}}</ref> | |||
| ===State rejections of Medicaid expansion=== | |||
| [[File:ACA Medicaid expansion by state.svg|thumb|300px|Medicaid expansion by state.<ref name=KaiserMedicaid>{{cite web|title=Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013 - Table|url=http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#table |publisher=Kaiser Family Foundation |date=June 20, 2013 }}<br />{{cite web|title=Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013 - Map|url=http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/#map|publisher=Kaiser Family Foundation |date=June 20, 2013 }}</ref> | |||
| {{legend|#232|Expanding Medicaid}} | |||
| {{legend|#C8C8C8|Not expanding Medicaid}} | |||
| {{legend|#898|Still debating Medicaid expansion}}]] | |||
| Following the Supreme Court ruling in '']'', several states with legislatures or governorships controlled by Republicans have opted to reject the expanded Medicaid coverage provided for by the Act. Over half of the national uninsured population lives in those states.<ref name=NTY52413 /> As of September 2013, with the addition of ],<ref name=NYT90313>{{cite news|title=Michigan: State Ready to Expand Medicaid|url=http://www.nytimes.com/2013/09/04/us/michigan-state-ready-to-expand-medicaid.html|accessdate=September 4, 2013|newspaper=The New York Times|date=September 3, 2013|agency=Associated Press}}</ref> 25 states and the District of Columbia have adopted the Medicaid expansion; a few states remain undecided.<ref name="KaiserMedicaid"/><ref name=WP5513>{{cite news|title=Florida rejects Medicaid expansion, leaves 1 million uninsured|url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/05/florida-rejects-medicaid-expansion-leaves-1-3-million-uninsured/|accessdate=May 24, 2013|newspaper=The Washington Post|date=May 5, 2013|author=Sarah Kliff}}</ref><ref name="State stands">{{cite web|title=Beyond the pledges: Where the states stand on Medicaid|url=http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMap|publisher=The Advisory Board Company|date=July 26, 2013|accessdate=August 27, 2013}}</ref> States that decline to expand Medicaid before 2014 may choose to opt-in at a later time.<ref name=CNNMedicaid /> | |||
| The drafters of the ACA had intended for Medicaid to cover individuals and families with incomes up to 133% (138% ]<ref name="APHA138">{{cite web|title=Medicaid Expansion|url=http://www.apha.org/APHA/CMS_Templates/GeneralArticle.aspx?NRMODE=Published&NRNODEGUID=%7bD5E1C04A-0438-4FD4-A423-CEFDA0D9878D%7d&NRORIGINALURL=%2fadvocacy%2fHealth%2bReform%2fACAbasics%2fmedicaid%2ehtm|work=American Public Health Association (APHA)|accessdate=24 July 2013|location=Is Medicaid eligibility expanding to 133 or 138 percent FPL, and what is MAGI?}}</ref>) of ] by expanding Medicaid eligibility and simplifying the ] enrollment process. Low-income individuals and families above 100% and up to 400% of the ] will receive federal ]<ref name="Kaiser Family"/> on a ] if they choose to purchase insurance via an exchange. For example, individuals with incomes between 133% and 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of their income.<ref name="Peter Grier"/> | |||
| However, the Supreme Court ruling created the potential for a coverage gap. States that choose to reject the Medicaid expansion can maintain the pre-existing Medicaid eligibility thresholds they have set; which in many states are significantly below 133% of the poverty line for most individuals. Furthermore, 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.<ref name="Kliff, Sarah">{{cite web |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart/ |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |publisher=The Washington Post |accessdate=July 15, 2012}}</ref><ref name="HealthCare Reform Magazine">{{cite web|url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and MedicaidExpansion|publisher=HealthCare Reform Magazine|date=July 13, 2010 |accessdate=January 9, 2012}}</ref><ref name="Families USA">{{cite web|url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf|title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |date= |accessdate=April 1, 2012}}</ref><ref>{{cite web|title=Analyzing the Impact of State Medicaid Expansion Decisions|url=http://kff.org/medicaid/issue-brief/analyzing-the-impact-of-state-medicaid-expansion-decisions/ |publisher=Kaiser Family Foundation |date=July 17, 2013 }}</ref> 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.<ref name=NTY52413>{{cite news|title=States’ Policies on Health Care Exclude Some of the Poorest|url=http://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html|accessdate=May 25, 2013|newspaper=The New York Times|date=May 24, 2013|author=Robert Pear|quote=In most cases, , said adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) "will have no assistance."}}</ref> Studies of the impact of state decisions to reject the Medicaid expansion, as of July 2013, calculate that up to 6.4 million Americans could fall into this coverage gap.<ref>{{cite news |title=We Don't Know Everything About Obamacare. But We Know Who's Trying to Sabotage It. |author=Jonathan Cohn |publisher=The New Republic |date=July 19, 2013 |url=http://www.newrepublic.com/article/113947/obamacare-implementation-and-role-state-officials }}</ref> | |||
| For states that do expand Medicaid, the law provides that the federal government will pay for 100% of the expansion for the first three years and then gradually reduce its subsidy to 90% by 2020.<ref name=CNNMedicaid>{{cite web|url=http://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html|title=States forgo billions by opting out of Medicaid expansion |author=Tami Luhby |publisher=]|date=July 1, 2013 }}</ref> Several opposing states argue that the 10% of the funding of the expansion that they will be responsible for will be too much for their states' budgets.<ref name=CNNMedicaid /><ref name=Medicaiddeal>{{cite web|url=http://www.usnews.com/debate-club/is-medicaid-expansion-good-for-the-states|title=Is Medicaid Expansion Good for the States?|publisher=USNews }}</ref> However, studies suggest that rejecting the expansion will cost states more than expanding Medicaid due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage.<ref>{{cite news|title=Wonkbook: The terrible deal for states rejecting Medicaid |url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/06/04/wonkbook-the-terrible-deal-for-states-rejecting-medicaid/ |date=June 4, 2013 |newspaper=The Washington Post|author1=Ezra Klein|author1=Evan Soltas}}</ref> | |||
| ===Noncooperation=== | |||
| Republican officials in several states have decided to oppose elements of the ACA's implementation that they have discretion over.<ref>{{cite web|author=Sandhya Somashekhar|title=States find new ways to resist health law |url=http://www.washingtonpost.com/national/health-science/states-find-new-ways-to-resist-health-law/2013/08/28/c63f8498-0a93-11e3-8974-f97ab3b3c677_story.html?hpid=z3 |publisher=The Washington Post|date=August 29, 2013}}</ref><ref name=Ornstein>{{cite web|author=Norm Ornstein|title=The Unprecedented and Contemptible Attempts to Sabotage Obamacare |url=http://www.nationaljournal.com/columns/washington-inside-out/the-unprecedented-and-contemptible-attempts-to-sabotage-obamacare-20130724 |publisher=National Journal|date=July 24, 2013}}</ref><ref name=BoycottDefundShutdown>{{cite web|author=Jonathan Chait|title=The GOP’s Insane Obamacare Boycott |url=http://nymag.com/daily/intelligencer/2013/08/gops-insane-obamacare-boycott.html |publisher=New York Magazine|date=August 7, 2013}}</ref> For example, Missouri has not only declined to expand Medicaid or ] but is also engaged in an active program of ], having enacted a statute forbidding any state or local official to render any aid not specifically required by federal law to functioning of the Affordable Care Act.<ref name=NYT80213>{{cite news|title=Missouri Citizens Face Obstacles to Coverage|url=http://www.nytimes.com/2013/08/03/us/missouri-citizens-face-obstacles-to-coverage.html|accessdate=August 3, 2013|newspaper=The New York Times|date=August 2, 2013|author=Robert Pear}}</ref> Other Republican politicians have tried to discourage efforts to advertise the benefits of the law, and some conservative political groups have launched ad campaigns to discourage enrollment.<ref>{{cite news |title=The Right's Latest Scheme to Sabotage Obamacare |author=Jonathan Cohn |publisher=The New Republic |date=July 25, 2013 |url=http://www.newrepublic.com/article/114028/obamacare-sabotage-watch-conservative-campaign-gets-real }}</ref><ref>{{cite news |title=Inside the Obamacare Resistance |author=Sarah Kliff |publisher=The Washington Post |date=August 1, 2013 |url=http://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/01/inside-the-obamacare-resistance/ }}</ref> | |||
| ===Congressional opposition=== | |||
| As with such complex legislation, the act contains errors and provisions that must be tweaked to attempt to make the legislation work well in practice, and avoid ]. Strong opposition in Congress by Republicans opposed to the act has resulted in ], preventing these adjustments to programs.<ref name=Ornstein /><ref name=NYT52613>{{cite news|title=Partisan Gridlock Thwarts Effort to Alter Health Law|url=http://www.nytimes.com/2013/05/27/us/politics/polarized-congress-thwarts-changes-to-health-care-law.html|accessdate=May 27, 2013|newspaper=The New York Times|date=May 26, 2013|author=Jonathan Weisman|author2=Robert Pear|quote=we cannot use any of the normal tools to resolve ambiguities or fix problems}}</ref> Many Congressional Republicans and supporters argue against modifications to the law on the grounds that it will weaken the arguments for repeal.<ref>{{cite web| author=Jonathan Chait|title=Obamacare Still Not Collapsing |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |publisher=New York Magazine |date=July 3, 2013}}<br />{{cite web|author=Jonathan Chait|title=The GOP’s Insane Obamacare Boycott |url=http://nymag.com/daily/intelligencer/2013/08/gops-insane-obamacare-boycott.html |publisher=New York Magazine|date=August 7, 2013}}</ref><ref name=MandateRepeal /> In addition to refusing to make modifications; Republicans have also attempted to defund its implementation<ref name=Ornstein /><ref>{{cite web|author=Jonathan Cohn|title=What Defunding Health Reform Would Do |url=http://www.newrepublic.com/blog/jonathan-cohn/80411/what-defunding-health-reform-would-do |publisher=The New Republic|date=December 23, 2010}}</ref>,<ref name=BoycottDefundShutdown/><ref>{{cite web|author=Jonathan Cohn|title=Tea Party to Republicans: Shut Down the Government, or You're a Sellout |url=http://www.newrepublic.com/article/114229/tea-party-wants-government-shutdown-over-obamacare |publisher=The New Republic|date=August 7, 2013}}</ref> and block appointments to relevant agencies (like the ]<ref>{{cite web|last=Goddard|first=Teagan|title=Blocking the Medicare Reform Board Won’t Stop Reform |url=http://wonkwire.rollcall.com/2013/05/17/blocking-the-medicare-reform-board-wont-stop-reform/ |publisher=WonkWire.RollCall.com|date=May 17, 2013}}</ref> and ]<ref>{{cite web|last=Cohn|first=Jonathan|title=Save Donald |url=http://www.newrepublic.com/article/politics/75324/save-donald |publisher=The New Republic|date=May 24, 2010}}<br />{{cite web|last=Cohn|first=Jonathan|title=Meet The Don |url=http://www.newrepublic.com/blog/jonathan-cohn/76076/meet-the-don |publisher=The New Republic|date=July 6, 2010}}</ref>). | |||
| ===Repeal efforts=== | |||
| The ACA has been the subject of repeal efforts by ] in the ], ], and ] Congresses: | |||
| Representatives ] and ] introduced bills in the House to repeal the ACA the day after it was signed, as did Senator ] in the Senate.<ref>{{cite web|last=O'Brien |first=Michael |url=http://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |title=GOP quick to release 'repeal' bills |work=The Hill |date=March 22, 2010 |accessdate=April 1, 2012}}</ref> None of the bills were considered by either body. | |||
| In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2), which the House passed on a vote of 245–189.<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002:|title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=] |date=January 19, 2011}}</ref> All Republicans and 3 Democrats voted for repeal.<ref>{{cite web |url=http://clerk.house.gov/evs/2011/roll014.xml |title=Final Vote Results for passage of Repealing the Job-Killing Health Care Law Act (H.R. 2) |publisher=] |date=January 19, 2011}}</ref> House Democrats proposed an amendment that repeal not take effect until a majority of the Senators and Representatives had opted out of the ]; Republicans voted down the measure.<ref>{{cite web| last = Beutler| first = Brian | title = Dems Press GOPers To Repeal Their Own Benefits Along With Health Care Law| work = ]| date = January 19, 2011| url = http://tpmdc.talkingpointsmemo.com/2011/01/dems-press-gopers-to-repeal-their-own-benefits-along-with-health-care-law.php?ref=dcblt | accessdate =January 21, 2011}}</ref> In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down.<ref>{{cite web|url=http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=112&session=1&vote=00009 |title=Motion to Waive All Applicable Budgetary Discipline Re: McConnell Amdt. No. 13 |publisher=U.S. Senate |date=February 2, 2011 |accessdate=April 1, 2012}}</ref> President Obama had stated that he would have ] the bill even had it passed both chambers of Congress.<ref>{{cite web |url=http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994/ |title=House Passes Health Care Repeal 245–189 |publisher=] |date=January 19, 2011}}</ref> | |||
| Following the ] upholding the ACA as constitutional, Republicans held another vote to repeal the law on July 11:<ref>{{cite news |url=http://online.wsj.com/article/SB10001424052702303561504577494682627914026.html |title=Romney, GOP Pledge to Repeal Health Law |last=Boles |first=Corey |newspaper=The Wall Street Journal |date=June 28, 2012 |accessdate=June 29, 2012}}</ref> the House of Representatives voted with all 239 Republicans and 5 Democrats in favor of repeal - it marked the 31st repeal attempt.<ref name="thirtythree">{{cite news| url=http://abcnews.go.com/blogs/politics/2012/07/house-obamacare-repeal-thirty-third-times-the-charm/ | publisher=ABC News | title=House Obamacare Repeal: Thirty-Third Time’s the Charm? | date=July 11, 2012}}</ref><ref name="thirtyone">{{cite web |url=http://articles.baltimoresun.com/2012-07-11/health/bal-republicans-repeal-health-reform_1_house-votes-repeal-care-reform-bill |title=House of representatives votes to repeal health reform for the 31st time |last1=Walker |first1=Andrea K. |work=Baltimore Sun |date=July 11, 2012 |accessdate=July 12, 2012}}</ref> With President Obama's reelection and the Democrats expanding their majority in the Senate following the ], many Republicans conceded that repeal almost certainly will not occur.<ref>Baker, Sam. (2012-11-07) . Thehill.com. Retrieved on 2013-07-17.</ref> | |||
| ====Job consequences of repeal==== | |||
| The House Republican leadership put forth the argument in favor of repeal that "this is a job-killing law, period."<ref name="jobkilling"/> They contended that the ACA would lead to a loss of 650,000 jobs, attributing the figure to a report by the Congressional Budget Office.<ref name="jobkilling">{{cite web | last = Jackson | first = Brooks | coauthors = Lori Robertson| title = A 'Job-Killing' Law?| publisher = ] | date = January 7, 2011| url = http://factcheck.org/2011/01/a-job-killing-law/ | accessdate =January 23, 2011 }}</ref> However, ] noted the 650,000 figure was not included in the CBO report referred to, saying that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect 'will probably be small.'"<ref name="jobkilling"/> ] also rated the Republican statement as False.<ref>{{cite web | last = Farley | first = Robert | coauthors = Angie Drobnic Holan | title = The health care law a 'job killer'? The evidence falls short | publisher = ] | date = January 20, 2011 | url = http://www.politifact.com/truth-o-meter/statements/2011/jan/20/eric-cantor/health-care-law-job-killer-evidence-falls-short/ | accessdate = January 23, 2011 }}</ref> | |||
| ], citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate ]: "people who are only working because they desperately need employer-sponsored health insurance will no longer do so."<ref name=CBOjobs>{{cite web|author=Jonathan Cohn|title=Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs.|url=http://www.newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs |publisher=The New Republic|date=February 11, 2011}}</ref> He concluded that "reform’s only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire"<ref name=ACAEconomyCohn>{{cite web|author=Jonathan Cohn|title=Obamacare, Good for the Economy.|url=http://www.newrepublic.com/blog/plank/104035/obamacare-romney-economy-benefit-job-regulation-noam |publisher=The New Republic|date=June 13, 2012}}</ref> once they have health insurance outside of their jobs. | |||
| ====Impact of repeal on federal budget projections==== | |||
| In May 2011, the non-partisan ] (CBO) analyzed proposals to repeal the law. Mirroring ], the CBO estimated that repealing the entire law (both its taxing and spending provisions) would increase the net 2011–2021 federal deficit by $210 billion.<ref name=autogenerated2>Heavey, Susan (February 18, 2011), , Reuters, retrieved March 13, 2011</ref><ref name="CBO41472">{{cite web|url=http://cbo.gov/publication/41472 |title = Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010 |publisher=Congressional Budget Office |date=May 26, 2011 |accessdate=April 1, 2012}}</ref> Revised CBO accounting, following the July 11, 2012 House repeal vote (H.R. 6079), and ], was consistent with its previous estimate: that repeal would cause a net increase in federal budget deficits of $109 billion over the 2013–2022 period.<ref name="CBO43471">{{cite web |url=http://cbo.gov/publication/43471 |title=Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=July 27, 2012}}</ref> | |||
| ==See also== | |||
| *] | |||
| *] | |||
| *] | |||
| *] | |||
| *] | |||
| *U.S. ] with 8 other countries in tabular form | |||
| *] ("Class Act") | |||
| ==References== | |||
| {{reflist|30em}} | |||
| ==Further reading== | |||
| * {{cite book|author=Barr, Donald A. |title=Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America|url=http://books.google.com/books?id=yZLJrmNoEzkC|year= 2011|publisher=JHU Press}} | |||
| * {{cite book|author=CCH|title=Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact|url=http://books.google.com/books?id=tCTt0sq2vaEC|year=2010|publisher=CCH Incorporated}} 1183pp | |||
| * {{cite book|author= Feldman, Arthur M.|title=Understanding Health Care Reform: Bridging the Gap Between Myth and Reality|url=http://books.google.com/books?id=dSszUQPKSZIC|year=2011|publisher=CRC Press}} | |||
| * {{cite book|author1=Jacobs, Lawrence R. |author2=Theda Skocpol|title=Health Care Reform and American Politics |url=http://books.google.com/books?id=VcsmJybD32wC|year=2010|publisher=Oxford U.P. }} | |||
| * {{cite book | author = John E. McDonough | title = Inside National Health Reform | publisher = University of California Press | year = 2011 | month = September | isbn = 9780520270190 }} | |||
| * | |||
| ;Preliminary CBO documents | |||
| * − December 19, 2009 | |||
| ** Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009) | |||
| ** Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009) | |||
| * , − November 18, 2009.<br />↑ <small>(The Additional and/or Related CBO reporting that follows can be accessed from the above link)</small> | |||
| ** Estimated Distribution Of Individual Mandate Penalties (November 20, 2009) | |||
| ** Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009) | |||
| ** Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009) | |||
| ** Estimated Average Premiums Under Current Law (December 5, 2009) | |||
| ** Additional Information About Employment-Based Coverage (December 7, 2009) | |||
| ** Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009) | |||
| ;] (CMS) Estimates of the impact of P.L. 111-148 | |||
| *. April 22, 2010. | |||
| *. April 22, 2010. | |||
| ;] (CMS) Estimates of the impact of H.R. 3590 | |||
| *. December 10, 2009. | |||
| *. December 10, 2009. | |||
| ;Senate Finance Committee Meetings | |||
| *; also available from | |||
| ==External links== | |||
| {{Sister project links | |||
| | wikt = no | |||
| | b = no | |||
| | q = no | |||
| | commons = Category:Patient Protection and Affordable Care Act | |||
| | n = U.S. Senate passes landmark health care reform bill | |||
| | v = no}} | |||
| * | |||
| * | |||
| * | |||
| * – Department of Health and Human Services website on the law | |||
| *{{NYTtopic|organizations/s/supreme_court/affordable_care_act/|Affordable Care Act}} | |||
| *{{WSJtopic|subject/H/health-reform/1662|Health Reform}} | |||
| * as provided by Emily Smith from '']''' June 25, 2012 | |||
| * as provided by '']'' June 17, 2012 | |||
| * Kaiser Family Foundation: | |||
| * – Complete coverage of the arguments to the Supreme Court regarding Obamacare | |||
| * An ] timeline published on June 28, 2012, by ] about key events in a century of debate over what role the government should play in helping people in the United States afford medical care | |||
| * – Tracking and explanation of the law – as it is implemented – by analysts at the Hirsh Health Law and Policy program of the George Washington University School of Public Health and Health Services. | |||
| * {{cite news|url=http://www.theatlantic.com/politics/archive/2010/03/has-romney-lost-the-romneycare-obamacare-argument/37842/|title=Has Romney Lost The RomneyCare = ObamaCare Argument?|author=Ambinder, Marc |work=The Atlantic|date=March 22, 2010|accessdate=2011-04-07}} | |||
| ; Copies of the proposed bill hosted online or readily downloadable | |||
| * of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111–148) ''<u>after</u>'' consolidating the amendments made by Title X of PPACA itself and by the Health Care and Education Reconciliation Act of 2010 ("HCERA"; Public Law 111–152) into one revision. | |||
| * , as engrossed or passed by the Senate and printed via ]. | |||
| * The , full text, summary, background, provisions and more, via Democratic Policy Committee (Senate.gov) | |||
| * (March 23, 2010) via ]. | |||
| * at ] | |||
| * | |||
| *"Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional ] February 16, 2012 | |||
| ** | |||
| ** | |||
| ** '']'' February 17, 2012 | |||
| {{Portal bar|Government of the United States|Health and fitness|Law|Medicine}} | |||
| {{Use mdy dates|date=July 2012}} | |||
| {{DEFAULTSORT:Patient Protection And Affordable Care Act}} | {{DEFAULTSORT:Patient Protection And Affordable Care Act}} | ||
Revision as of 00:02, 22 September 2013
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