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{{short description|U.S. federal statute also known as Obamacare}}
{{Use American English|date=July 2012}}{{Use MDY dates|date=July 2012}}
{{redirect|Obamacare|the song|Obamacare (song)}}
{{pp-semi-indef|small=yes}}
{{pp-move}}
{{Use mdy dates|date=April 2020}}
{{Use American English|date=April 2020}}
{{Infobox U.S. legislation {{Infobox U.S. legislation
| name = Patient Protection and Affordable Care Act
| fullname = The Patient Protection and Affordable Care Act
| acronym = PPACA
| nickname = Affordable Care Act, Health Insurance Reform, Healthcare Reform, Obamacare
| enacted by = 111th | enacted by = 111th
| effective date = March 23, 2010<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020 | effective date = {{start date and age|2010|3|23}}<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020; penalty enforcing individual mandate set at $0 starting 2019
| public law url = http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/content-detail.html
| cite public law = 111–148 | cite public law = 111–148
| cite statutes at large = 124 Stat. 119 ''through'' 124 Stat. 1025 (906 pages) | cite statutes at large = {{USStat|124|119}} ''through'' {{USStat|124|1025}} (906 pages)
| public law url = https://www.govinfo.gov/link/plaw/111/public/148?link-type=details
| acts amended =
| leghisturl = https://www.congress.gov/bill/111th-congress/house-bill/3590/all-actions
| title amended =
| sections created =
| sections amended =
| leghisturl = http://thomas.loc.gov/cgi-bin/bdquery/z?d111:HR03590:@@@S
| introducedin = House | introducedin = House
| introducedbill = '''the''' "Service Members Home Ownership Tax Act of 2009" ({{USBill|111|H.R.|3590}}) | introducedbill = '''the''' "Service Members Home Ownership Tax Act of 2009" ({{USBill|111|H.R.|3590}})
| introducedby = ] (]–]) | introducedby = ] (]–])
| introduceddate = September 17, 2009 | introduceddate = September 17, 2009
| committees = ] | committees = ]
| passedbody1 = House | passedbody1 = House
| passeddate1 = November 7, 2009
| passedas1 = "Service Members Home Ownership Tax Act of 2009"
| passedvote1 =
| passeddate1 = October 8, 2009
| passedvote1 =
| passedbody2 = Senate | passedbody2 = Senate
| passedas2 = "Patient Protection and Affordable Care Act" | passedas2 = "Patient Protection and Affordable Care Act"
| passeddate2 = December 24, 2009 | passeddate2 = December 24, 2009
| passedvote2 = | passedvote2 =
| agreedbody3 = House | agreedbody3 = House
| agreeddate3 = March 21, 2010 | agreeddate3 = March 21, 2010
Line 33: Line 29:
| signedpresident = ] | signedpresident = ]
| signeddate = March 23, 2010 | signeddate = March 23, 2010
| amendments = ]<br />Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 | amendments = ]<br />Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011<br />]
| name = Affordable Care Act
| SCOTUS cases = '']''
| fullname = An Act Entitled The Patient Protection and Affordable Care Act
| acronym = ACA, PPACA
| nickname = Obamacare, Affordable Care Act, Health Insurance Reform, Healthcare Reform
| acts amended = ]
| title amended =
| sections created =
| sections amended =
| SCOTUS cases = {{ubl|'']'', {{ussc|567|519|2012}}|'']'', {{ussc|573|682|2014}}|'']'', {{ussc|576|473|2015}}|'']'', {{ussc|docket=14-1418|volume=578|year=2016}}|'']'', {{ussc|docket=18-1023|volume=590|year=2020}}|'']'', {{ussc|docket=19-431|volume=591|year=2020}}|'']'', {{ussc|docket=19-840|volume=593|year=2021}}|'']'', {{ussc|docket=20-219|volume=596|year=2022}}}}
}} }}


The '''Patient Protection and Affordable Care Act''' ('''PPACA'''),<ref>{{USPL|111|148}}, {{USStat|124|119}}, to be codified as amended at scattered sections of the ] and in ]</ref> commonly called '''Obamacare'''<ref name="CNN20120625Obamacare" /><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/article/2012/mar/20/romneycare-and-obamacare-can-you-tell-difference/ |title=RomneyCare & ObamaCare: Can you tell the difference? |last=Holan |first=Angie D. |author= |authorlink= |date=March 20, 2012 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> or the '''Affordable Care Act''' ('''ACA'''), is a ] ] signed into law by ] ] on March 23, 2010. Together with the ], it represents the most significant government expansion and regulatory overhaul of the ] since the passage of ] and ] in 1965.<ref name=overhaul>{{cite news|url=http://www.reuters.com/article/2012/06/28/usa-healthcare-court-idUSL2E8HS4WG20120628|title=US top court upholds healthcare law in Obama triumph|publisher=Reuters|author=James Vicini and Jonathan Stempel|date=June 28, 2012}}</ref> The '''Affordable Care Act''' ('''ACA'''), formally known as the '''Patient Protection and Affordable Care Act''' ('''PPACA''') and informally as '''Obamacare''', is a landmark ] enacted by the ] and signed into law by President ] on March 23, 2010. Together with the ] amendment, it represents the ]'s most significant regulatory overhaul and expansion of coverage since the enactment of ] and ] in 1965.<ref name="Oberlander2010" /><ref name="Blumenthal2015" /><ref name="CohenEtAl" /><ref name="ReutersSCOTUS" /> Most of the act's provisions are still in effect.


The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered.<ref name="CBO_Subsidy2016" /><ref name="HHS_ASPE16">{{Cite web |url=https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-2010-2016 |first1 = Namrata| first2 = Kenneth |first3 =Emily | last1= Uberoi |last2 =Finegold| last3=Gee |title=Health Insurance Coverage and the Affordable Care Act, 2010–2016| work=ASPE |publisher = U.S. Department of Health and Human Services |department= Assistant Secretary for Planning and Evaluation |access-date=December 7, 2016 | archive-url = https://web.archive.org/web/20211205091604/https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//142146/ACA2010-2016.pdf | archive-date = December 5, 2021|date=March 2, 2016}}</ref> The law also enacted a host of ] reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.<ref name="Kaiser15">{{Cite web |url=http://files.kff.org/attachment/summary-of-findings-2015-employer-health-benefits-survey |title=Employer Health Benefits 2015 |website=] |access-date=November 19, 2016 |archive-date=April 12, 2020 |archive-url=https://web.archive.org/web/20200412005741/http://files.kff.org/attachment/summary-of-findings-2015-employer-health-benefits-survey |url-status=live }}</ref>
The ACA is aimed at increasing ] and reducing the overall costs of health care. It provides a number of mechanisms—including ], ], and ]—to employers and individuals to increase the coverage rate.<ref name="nyt-critics">{{cite news |newspaper=] |title= Health Law Critics Prepare to Battle Over Insurance Exchange Subsidies |url=http://www.nytimes.com/2012/07/08/us/critics-of-health-care-law-prepare-to-battle-over-insurance-exchange-subsidies.html |first=Robert |last=Pear |date=July 7, 2012 |accessdate=July 7, 2012}}</ref><ref>{{cite web |url=http://www.politifact.com/truth-o-meter/statements/2010/feb/04/paul-krugman/krugman-calls-senate-health-care-bill-similar-law-/ |title=Krugman calls Senate health care bill similar to law in Massachusetts |last=Krugman |first=Paul |author= |authorlink= |date=January 31, 2010 |work=PolitiFact.com |publisher=Tampa Bay Times |location= |archiveurl= |archivedate= |deadurl= |accessdate=August 29, 2012 |quote= |ref= }}</ref> Additional reforms aim to improve healthcare outcomes and streamline the delivery of health care. The ACA requires insurance companies to ] and ] regardless of ]s or sex.<ref>{{cite news |title=Supreme Court Upholds Heart of Obama Health Care Law Seeking to Cover 30 Million Uninsured |author=Hearst, Steven R. |url=http://www.montrealgazette.com/news/Supreme+Court+upholds+heart+Obamacare/6854896/story.html |newspaper=The Gazette |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=ObamaCare Survives the Supreme Court: 5 Takeaways |url=http://theweek.com/article/index/229985/obamacare-survives-the-supreme-court-5-takeaways |newspaper=The Week |date=June 28, 2012 |accessdate=June 30, 2012}}</ref> The ] projected that the 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 ] 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>


The increased coverage was due, roughly equally, to an ] and to changes to ] markets. Both received new spending, funded through a combination of new taxes and cuts to Medicare provider rates and ]. Several ] (CBO) reports said that overall these provisions reduced the ], that repealing ACA would increase the deficit,<ref name="CBO50252" /><ref name="CBO22077" /> and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.<ref name="CBO_Dist14"/>
On June 28, 2012, the ] upheld the constitutionality of most of the ACA in the case '']''.<ref>{{cite news |title=Supreme Court Supports Obamacare, Bolsters Obama |last=Barrett |first=Paul M. |url=http://www.businessweek.com/articles/2012-06-28/supreme-court-supports-obamacare-and-bolsters-obama |newspaper=BloombergBusinessweek |date=June 28, 2012 |accessdate=June 30, 2012}}</ref><ref>{{cite news |title=Obamacare upheld by the U.S. Supreme Court |author=National Post Wire Services |url=http://news.nationalpost.com/2012/06/28/obamacare-upheld-by-the-u-s-supreme-court/ |newspaper=National Post |date=June 28, 2012 |accessdate=June 30, 2012}}, including a major provision which requires all Americans purchase health insurance coverage.</ref>


The act largely retained the existing structure of Medicare, Medicaid, and the ], but individual markets were radically overhauled.<ref name="Oberlander2010"/><ref>{{cite journal |last1=Gruber |first1=Jonathan |title=The Impacts of the Affordable Care Act: How Reasonable Are the Projections? |journal=National Tax Journal |date=2011 |volume=64 |issue=3 |pages=893–908 |url=https://economics.mit.edu/files/11416 |archive-url=https://web.archive.org/web/20160620124250/http://economics.mit.edu/files/11416 |url-status=dead |archive-date=2016-06-20 |access-date=July 23, 2017 |doi=10.17310/ntj.2011.3.06 |hdl=1721.1/72971 |s2cid=232213290 |hdl-access=free }}</ref> Insurers were made to ] without charging based on ]s or demographic status (except age). To combat the resultant ], the act ] that individuals buy insurance (or pay a monetary penalty) and that insurers cover a list of "]".
==Overview==


Before and after enactment the ACA faced strong political opposition, calls for repeal and ]. In '']'', the ] ruled that states could choose not to participate in the law's Medicaid expansion, but upheld the law as a whole.<ref name="NatLawReview2012"/> The federal health insurance exchange, ], faced major technical problems at the beginning of its rollout in 2013. Polls initially found that a ] of Americans opposed the act, although its individual provisions were generally more popular.<ref>{{cite web |last1=Kirzinger |first1=Ashley |last2=Sugarman |first2=Elise |last3=Brodie |first3=Mollyann |title=Kaiser Health Tracking Poll: November 2016 |url=http://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-november-2016/ |publisher=] |access-date=July 23, 2017 |date=December 1, 2016 |archive-date=December 1, 2016 |archive-url=https://web.archive.org/web/20161201092513/http://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-november-2016/ |url-status=live }}</ref> By 2017, the law had majority support.<ref>{{cite news |title=Gallup: ObamaCare has majority support for first time |url=https://thehill.com/policy/healthcare/327267-poll-obamacare-has-majority-support-for-first-time/ |access-date=November 18, 2017 |work=] |archive-date=December 1, 2017 |archive-url=https://web.archive.org/web/20171201042959/http://thehill.com/policy/healthcare/327267-poll-obamacare-has-majority-support-for-first-time |url-status=live }}</ref> The ] of 2017 set the ] penalty at $0 starting in 2019 due to its overall unpopularity and to reduce the federal budget deficit.<ref>{{Cite web |date=November 8, 2024 |title=H.R.1 – An Act to provide for reconciliation pursuant to titles II and V of the concurrent resolution on the budget for fiscal year 2018. |url=https://www.congress.gov/bill/115th-congress/house-bill/1/titles |website=Congress.gov}}</ref><ref>{{Cite web |date=2017-11-08 |title=Repealing the Individual Health Insurance Mandate: An Updated Estimate {{!}} Congressional Budget Office |url=https://www.cbo.gov/publication/53300 |access-date=2024-11-08 |website=www.cbo.gov |language=en}}</ref>
===Provisions===
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]
]
]<ref name="private_pp" /> (Source: ])]]


==Provisions==
The ACA includes numerous provisions to take effect over several years ]. There is a ] on policies issued before then that exempt them from many of these provisions, but other provisions may affect existing policies.
{{See also|Provisions of the Patient Protection and Affordable Care Act}}
* ] will require policies to be issued regardless of any medical condition, and partial ] will require insurers to offer the same premium to all applicants of the same age and geographical location without regard to gender or most ]s (excluding ] use).<ref>{{cite press release|url=http://www.bcbsm.com/healthreform/pubs/ppaca_insurance_reform_2014.pdf |title=2014 Insurance Reforms under the Patient Protection and Affordable Care Act (PPACA) |publisher=Blue Cross Blue Shield of Michigan |date= |accessdate=2012-04-09}}</ref><ref>{{cite web|last=Pool |first=Gentrie |url=http://www.asjonline.com/Exclusives/2010/10/Pages/After-PPACA-The-Future-of-the-Health-Insurance-Underwriter.aspx |title=After PPACA: The Future of the Health Insurance Underwriter &#124; LifeHealthPro |publisher=Asjonline.com |date=2010-10-07 |accessdate=2012-04-09}}</ref><ref>{{cite web|title=Selected Patient Protection and Affordable Care Act (PPACA) implementation dates of interest to RNs as caregivers, RNs as patients, and RNs as employees |url=http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/HealthSystemReform/Health-Care-Reform-Legislation-Timeline.pdf |publisher=Nursingworld.org |date= |accessdate=2012-04-09}}</ref>
]
* A shared responsibility requirement, commonly called an ],<ref>{{cite press release|url=http://www.perkinsaccounting.com/our-story/litigation-support-accounting-firm-newsroom/perkins-news-bulletin/health-insurance-legislation/health-insurance-legislation-mandates.html |title=Perkins Accounting Firm Newsroom Bulletin Health Insurance Legislation Mandates |publisher=Perkinsaccounting.com |date= |accessdate=2012-04-09}}</ref><ref>{{cite news|last=Keely |first=Cheryl |url=http://www.lexisnexis.com/community/emergingissues/blogs/spotlightonhealthcarereform/archive/2010/12/13/federal-judge-rejects-commerce-clause-argument-finds-ppaca-health-insurance-individual-mandate-is-unconstitutional.aspx |title=Federal Judge Rejects Commerce Clause Argument, Finds PPACA Health Insurance Individual Mandate is Unconstitutional |publisher=Lexisnexis.com |date=2010-12-13 |accessdate=2012-04-09}}</ref> requires that all individuals not covered by an ], ], ] or other public insurance programs, secure an approved private-insurance policy or pay a penalty, unless the applicable individual is a member of a recognized religious sect exempted by the ], or waived in cases of financial hardship.<ref name="ksr_hlth" />
] and Nancy Pelosi celebrate after the House passes the amended bill on March 21.]]
* ]s will commence operation in each state, offering a marketplace where individuals and small businesses can compare policies and premiums, and buy insurance (with a government subsidy if eligible).<ref>{{cite web|url=http://www.healthcare.gov/law/provisions/exchanges/index.html |title=Affordable Insurance Exchanges |publisher=HealthCare.gov |date=August 18, 2011|accessdate=January 9, 2012}}</ref>
* Low-income individuals and families above 100% and up to 400% of the ] will receive ]<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7962-02.pdf |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |publisher=Kaiser Family |month=April|year=2010 |accessdate=April 1, 2012}}</ref> on a ] if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income).<ref>{{cite web|author=Peter Grier |url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance |title=Health care reform bill 101: Who gets subsidized insurance? |work=]|date=March 20, 2010|accessdate=January 9, 2012}}</ref>
* The text of the law expands Medicaid eligibility to include all individuals and families with incomes up to 133% of ], effectively 138%, and simplifies the ] enrollment process. In '']'', the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this may create a coverage gap in those states.<ref>{{cite web |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart/ |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |publisher=The Washington Post |accessdate=July 15, 2012}}</ref><ref>{{cite web|url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and Medicaid Expansion|publisher=HealthCare Reform Magazine|date=July 13, 2010 |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf|title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |date= |accessdate=April 1, 2012}}</ref>
* Minimum standards for health insurance policies are to be established and annual and lifetime coverage caps will be banned.<ref>{{cite press release|url=http://www.hhs.gov/news/press/2011pres/07/20110711a.html |title=HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress |publisher=Hhs.gov |date=2011-07-11 |accessdate=2012-04-09}}</ref><ref>{{cite web|url=http://www.naic.org/documents/committees_b_Exchanges.pdf |title=Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges |publisher=National Association of Insurance Commissioners |date=2010-04-20 |accessdate=2012-04-09}}</ref><ref>{{cite press release|url=http://www.familiesusa.org/health-reform-central/september-23/Annual-and-Lifetime-Limits.pdf |title=The Patients' Bill of Rights: Ending annual and lifetime limits |publisher=FamiliesUSA |date=2010-09 |accessdate=2012-04-09}}</ref>
* Firms employing 50 or more people but not offering health insurance will also pay a shared responsibility requirement if the government has had to subsidize an employee's health care.<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7907.pdf |title=Explaining Health Care Reform: What is Employer 'Pay-or-Play' Requirement?|year=2009|month=May|publisher=]|accessdate=January 9, 2012}}</ref><ref name=WSJ-mar25>{{cite news |title=What Health Overhaul Means for Small Businesses |author=McNamara, Kristen |url=http://online.wsj.com/article/SB10001424052748703312504575141533342803608.html |newspaper=The Wall Street Journal |date=March 25, 2010}}</ref>
* Very small businesses will be able to get subsidies if they purchase insurance through an exchange.<ref>{{cite web|url=http://www.irs.gov/newsroom/article/0,,id=223666,00.html |title=Small Business Health Care Tax Credit for Small Employers |publisher=Internal Revenue Service|date=December 13, 2011 |accessdate=January 9, 2012}}</ref>
* ], ], and ]s are to be eliminated for select health care insurance benefits considered to be part of an "essential benefits package"<ref>{{cite web|url=http://www.healthcare.gov/glossary/e/essential.html |title=Essential Health Benefits – Glossary |publisher=HealthCare.gov |date=September 23, 2010|accessdate=January 9, 2012}}</ref> for Level A or Level B ].<ref>
{{cite web |url=http://www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |title=Reform Law Will Require New Plans to Cover Preventive Care and Limit Out-of-Pocket Expenses |accessdate=April 4, 2010|date=April 2, 2010|publisher=Society for Human Resource Management |archiveurl=http://webcache.googleusercontent.com.nyud.net/search?q=cache:OL8orVWxAhIJ:www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |archivedate=March 28, 2012}}{{dead link|date=June 2012}}</ref><ref>
{{cite web |url=http://www.shrm.org/Publications/HRNews/Pages/CoverPreventiveCare.aspx |title=Understanding health reform's Essential Benefits |accessdate=April 4, 2012|date=April 4, 2012|publisher=HealthInsurance.org}}</ref>
* Changes are enacted that allow a restructuring of Medicare reimbursement from "fee-for-service" to "]."<ref>{{cite web|url=http://www.medscape.com/viewarticle/748502 |title=Access |publisher=Medscape |date= |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.huronconsultinggroup.com/researchdetails.aspx?articleId=2577 |title=Key Healthcare Reform Initiatives: Medicare Bundled Payment Pilots |publisher=Huron Consulting Group |date=November 19, 2010 |accessdate=January 9, 2012}}</ref> A single payment is paid to a hospital and a physician group, for example, for a defined episode of care (such as a hip replacement), rather than individual payments to individual service-providers.


ACA amended the ] and inserted new provisions on affordable care into ].<ref name="Oberlander2010">{{cite journal |last1=Oberlander |first1=Jonathan |title=Long Time Coming: Why Health Reform Finally Passed |journal=Health Affairs |publisher=Project HOPE |oclc=07760874 |date=June 1, 2010 |volume=29 |issue=6 |pages=1112–1116 |doi=10.1377/hlthaff.2010.0447 |pmid=20530339 |issn=0278-2715|doi-access=free }}</ref><ref name="Blumenthal2015">{{cite journal |last1=Blumenthal |first1=David |last2=Abrams |first2=Melinda |last3=Nuzum |first3=Rachel |title=The Affordable Care Act at 5 Years |journal=New England Journal of Medicine |date=June 18, 2015 |volume=372 |issue=25 |pages=2451–2458 |doi=10.1056/NEJMhpr1503614 |pmid=25946142 |s2cid=28486139 |issn=0028-4793 |doi-access=free }}</ref><ref name="CohenEtAl">{{cite book |last1=Cohen |first1=Alan B. |last2=Colby |first2=David C. |last3=Wailoo |first3=Keith A. |last4=Zelizer |first4=Julian E. |title=Medicare and Medicaid at 50: America's Entitlement Programs in the Age of Affordable Care |date=June 1, 2015 |publisher=Oxford University Press |isbn=978-0-19-023156-9 |url=https://books.google.com/books?id=H9DGBwAAQBAJ}}</ref><ref name="24health">{{cite news |last1=Stolberg |first1=Sheryl Gay |last2=Pear |first2=Robert |title=Obama Signs Health Care Overhaul Bill, With a Flourish |url=https://www.nytimes.com/2010/03/24/health/policy/24health.html |work=] |issn=0362-4331 |oclc=1645522 |access-date=June 22, 2022 |archive-date=March 25, 2010 |archive-url=https://web.archive.org/web/20100325200505/https://www.nytimes.com/2010/03/24/health/policy/24health.html |page=A19 |date=March 23, 2010}}</ref><ref name="ReutersSCOTUS">{{cite news |last1=Vicini |first1=James |last2=Stempel |first2=Jonathan |author-link3=Joan Biskupic |last3=Biskupic |first3=Joan |title=Top court upholds healthcare law in Obama triumph |url=https://www.reuters.com/article/us-usa-healthcare-court-idUSBRE85R06420120628 |work=] |date=June 28, 2017 |access-date=July 1, 2017 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308202215/https://www.reuters.com/article/us-usa-healthcare-court-idUSBRE85R06420120628 |url-status=live }}</ref> The individual insurance market was radically overhauled, and many of the law's regulations applied specifically to this market,<ref name="Oberlander2010" /> while the structure of Medicare, Medicaid, and the ] were largely retained.<ref name="Blumenthal2015" /> Some regulations applied to the employer market, and the law also made delivery system changes that affected most of the health care system.<ref name="Blumenthal2015" />
===Funding===
{{Further|Commission on Key National Indicators}}
The ACA's provisions are funded by a variety of taxes and offsets. Major sources of new revenue include a much-broadened ] on incomes over $200,000 and $250,000, for individual and joint filers respectively, an annual fee on insurance providers, and a 40% ] on ]. The income levels are not adjusted for inflation, leaving the possibility of increased taxes on incomes over 250,000 inflation-adjusted dollars after more than two decades without indexing through.<ref>, ''Wall Street Journal'' November 6, 2009.</ref> There are also taxes on pharmaceuticals, high-cost diagnostic equipment, and a 10% federal ] on ]. Offsets are from intended cost savings such as changes in the ] program relative to traditional Medicare.<ref>{{cite web |url=http://www.csmonitor.com/USA/Politics/2010/0321/Health-care-reform-bill-101-Who-will-pay-for-reform |title=Health care reform bill 101: Who Will Pay for Reform? |author=Grier, Peter |date=March 21, 2010 |publisher=]}}</ref>


===Insurance regulations: individual policies===
Summary of tax increases: (ten-year projection)
All new individual major medical health insurance policies sold to individuals and families faced new requirements.<ref>{{Cite web |url=https://www.healthcare.gov/fees/plans-that-count-as-coverage/ |title=Health insurance that counts as coverage |website=HealthCare.gov |access-date=October 2, 2019 |archive-date=November 4, 2015 |archive-url=https://web.archive.org/web/20151104181707/https://www.healthcare.gov/fees/plans-that-count-as-coverage/ |url-status=live }}</ref> The requirements took effect on January 1, 2014. They include:
* Increase Medicare tax rate by .9% and impose added tax of 3.8% on unearned income for high-income taxpayers: $210.2&nbsp;billion
* ] prohibits insurers from denying coverage to individuals because of ]s.<ref>{{cite web |title=Health benefits & coverage for pre-existing conditions |url=https://www.healthcare.gov/coverage/pre-existing-conditions/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210211230724/https://www.healthcare.gov/coverage/pre-existing-conditions/ |archive-date=February 11, 2021}}</ref>
* Charge an annual fee on health insurance providers: $60&nbsp;billion
* States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
* Impose a 40% excise tax on health insurance annual premiums in excess of $10,200 for an individual or $27,500 for a family: $32&nbsp;billion
* A partial ] allows premiums to vary only by age and location, regardless of preexisting conditions. Premiums for older applicants can be no more than three times those for the youngest.<ref>{{cite web |url=http://www.naifa.org/practice-resources/prp/age-band-rating-(aca) |title=Age Band Rating (ACA) |publisher=] |access-date=September 24, 2016 |archive-date=September 24, 2016 |archive-url=https://web.archive.org/web/20160924202123/http://www.naifa.org/practice-resources/prp/age-band-rating-(aca) |url-status=dead}}</ref>
* Impose an annual fee on manufacturers and importers of branded drugs: $27&nbsp;billion
* ] must be provided. The ] defines the law's "essential health benefits" as "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="Hhs.gov" /><ref name="essential" /> and others<ref>{{Cite web |url=https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ratereview.html |title=ratereview |first1=Centers for |last1=Medicare |first2=Medicaid Services 7500 Security Boulevard |last2=Baltimore |first3=Md21244 |last3=US |date=December 19, 2014 |website=www.cms.gov |access-date=July 24, 2019 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012219/https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ratereview |url-status=live }}</ref> rated Level A or B<ref>{{Cite web |url=http://www.ahrq.gov/prevention/guidelines/index.html |title=Clinical Guidelines and Recommendations |website=www.ahrq.gov |access-date=November 28, 2019 |archive-date=February 23, 2022 |archive-url=https://web.archive.org/web/20220223004545/https://www.ahrq.gov/prevention/guidelines/index.html |url-status=live }}</ref> by the ].<ref name="ReferenceB" /> In determining essential benefits, the law required that standard benefits should offer at least that of a "typical employer plan".<ref name="KaiserEHB" /> States may require additional services.<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? |date=December 7, 2012 |publisher=Kaiser Family |access-date=July 28, 2013 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012159/https://www.kff.org/health-reform/fact-sheet/quick-take-essential-health-benefits-what-have-states-decided-for-their-benchmark/ |url-status=live }}</ref>
* Impose a 2.3% excise tax on manufacturers and importers of certain medical devices:$20&nbsp;billion
* Preventive care and screenings for women.<ref> {{Webarchive|url=https://web.archive.org/web/20210215012146/https://www.govtrack.us/congress/bills/111/hr3590/text |date=February 15, 2021 }}, 2713,(a)(4)</ref> "ll Food and Drug Administration approved ] methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity".<ref> {{Webarchive|url=https://web.archive.org/web/20210215012148/http://www.hrsa.gov/womensguidelines/ |date=February 15, 2021 }} HRSA, U.S. Department of Health and Human Services</ref> This mandate applies to all employers and educational institutions except for religious organizations.<ref name="faqs" /><ref name="Kliff" /> These regulations were included on the recommendations of the ].<ref name="FinalRule" /><ref name="cnncontra" />
* Raise the 7.5% ] floor on ] to 10%: $15.2&nbsp;billion
* Limit annual contributions to ] in ]s to $2,500: $13&nbsp;billion
* All other revenue sources: $14.9&nbsp;billion
Summary of spending offsets: (ten year projection)
* Reduce funding for Medicare Advantage policies: $132&nbsp;billion
* Reduce Medicare home health care payments: $40&nbsp;billion
* Reduce certain Medicare hospital payments: $22&nbsp;billion


] created this summary to explain his view on the act.]]
Original budget estimates included a provision to require information reporting on payments to corporations, which had been projected to raise $17&nbsp;billion, but the provision was repealed.<ref>{{cite news|last=Rubin |first=Richard |url=http://www.bloomberg.com/news/2011-04-14/obama-signs-law-repealing-business-tax-reporting-mandate-1-.html |title=Obama Signs Law Repealing Business Tax Reporting Mandate |publisher=Bloomberg |date=April 14, 2011 |accessdate=April 1, 2012}}</ref>
* Annual and lifetime coverage caps on essential benefits were banned.<ref name="healthcare" /><ref name="hhs" /><ref>{{cite web |title=Health insurance rights & protections: Ending lifetime & yearly limits |url=https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210127070050/https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/ |archive-date=January 27, 2021}}</ref>
* Insurers are forbidden from dropping ]s when they become ill.<ref name="Top 18" /><ref>{{cite web |title=Health insurance rights & protections |url=https://www.healthcare.gov/health-care-law-protections/rights-and-protections/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210129062759/https://www.healthcare.gov/health-care-law-protections/rights-and-protections/ |archive-date=January 29, 2021}}</ref>
* All policies must provide an annual maximum out-of-pocket (MOOP) payment cap for an individual's or family's medical expenses (excluding premiums). After the MOOP payment is reached, all remaining costs must be paid by the insurer.<ref>{{cite web |title=How do out-of-pocket maximums work? |publisher=] |url=http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/out-of-pocket-maximums.html |access-date=September 3, 2016 |archive-date=November 30, 2020 |archive-url=https://web.archive.org/web/20201130182132/https://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/out-of-pocket-maximums.html |url-status=live }}</ref>
* Preventive care, vaccinations and medical screenings cannot be subject to ], ] or ].<ref name="SHNS" /><ref name="KaiserSummary" /><ref name="cmsprev" /> Specific examples of covered services include: ] and ], wellness visits, ] screening, ] testing, ] counseling, ] screening and counseling, contraceptive methods, breastfeeding support/supplies and ] screening and counseling.<ref name="SchiffHardinLLP" />{{anchor|Platinum plan}}
* The law established four tiers of coverage: bronze, silver, gold and platinum. All categories offer essential health benefits. The categories vary in their division of premiums and out-of-pocket costs: bronze plans have the lowest monthly premiums and highest out-of-pocket costs, while platinum plans are the reverse.<ref name="KaiserEHB" /><ref name="choose" /> The percentages of ] 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 |url=https://www.healthcare.gov/glossary/health-plan-categories/ |title=Health Plan Categories |website=HealthCare.Gov |publisher=the ] |access-date=July 28, 2013 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012133/https://www.healthcare.gov/glossary/health-plan-categories/ |url-status=live }}</ref>
* Insurers are required to implement an ]s process for coverage determination and claims on all new plans.<ref name="Top 18" />
* Insurers must ] on health costs; rebates must be issued if this is violated.<ref name="cmsprog" /><ref name="FederalRegister" />


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


The mandate was intended to increase the size and diversity of the insured population, including more young and healthy participants to broaden the ], spreading costs.<ref>{{cite news |url=https://newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |archive-url=https://web.archive.org/web/20131203014925/https://newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |archive-date=December 3, 2013 |title=Why Americans should support individual mandate |website=Common Sense |last=Cohn |first=Jonathan |location=Washington DC |date=April 9, 2010 |issn=2169-2416 |agency=Kaiser Health News |publisher=]}}<br /> {{cite news |url=https://newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |title=What If the Mandate Goes? |archive-url=https://web.archive.org/web/20131203023213/https://newrepublic.com/blog/jonathan-cohn/102285/supreme-court-obamacare-mandate-severability-cbo |archive-date=December 3, 2013 |location=Washington DC |last=Cohn |first=Jonathan |date=April 2, 2012 |issn=2169-2416|magazine=]}}<br /> {{cite news |url=https://newrepublic.com/blog/jonathan-cohn/98928/individual-mandate-mistake-health-reform-starr-cbo-ppaca |title=Was the Mandate a Mistake? |archive-url=https://web.archive.org/web/20131203025039/https://newrepublic.com/blog/jonathan-cohn/98928/individual-mandate-mistake-health-reform-starr-cbo-ppaca |archive-date=December 3, 2013 |location=Washington DC |issn=2169-2416 |last=Cohn |first=Jonathan |date=December 26, 2011 |magazine=]}}</ref>
===Effective at enactment===


Among the groups who were not subject to the individual mandate are:
* The ] is now authorized to approve generic versions of ] drugs and grant biologics manufacturers 12&nbsp;years of exclusive use before generics can be developed.<ref name='ksr_list1'>{{cite web|url=http://www.kff.org/healthreform/8060.cfm|title=Health Reform Implementation Timeline|accessdate=2010-03-30|publisher=Kaiser Family Foundation}}</ref>
* ]. Estimated at 8{{nbsp}}million, roughly a third of the 23 million projection, they are ineligible for insurance ] and Medicaid.<ref name="cbouninsured" /><ref name="Chaikind2011" /> They remain eligible for emergency services.
* The Medicaid drug ] (paid by drug manufacturers to the states) for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.<ref name='ksr_list1' />
* Medicaid-eligible citizens not enrolled in Medicaid.<ref name="notcovered" />
* A non-profit ] is established, independent from government, to undertake ].<ref name='ksr_list1' /> This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.<ref>{{cite web|url=http://today.msnbc.msn.com/id/36135106/ns/health-health_care/ |title=True or false? Top 7 health care fears - TODAY Health - TODAY.com |publisher=msnbc.com |date=2010-02-04 |accessdate=2012-01-09}}</ref> The bill forbids the Institute to develop or employ "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's ].
* Citizens whose insurance coverage would cost more than 8% of household income.<ref name="notcovered" />
* Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.<ref name='ksr_list1' />
* Citizens who live in ] and who qualify for neither existing Medicaid coverage nor subsidized coverage.<ref name="optout" />
* The Indian Health Care Improvement Act is reauthorized and amended.<ref name='ksr_list1' />
* ] restaurants and food vendors with 20 or more locations are required to display the ] of their foods on menus, drive-through menus, and vending machines. Additional information, such as ], ], and ] content, must also be made available upon request.<ref name='Nutrition'>{{cite news | first=Jean | last=Spencer | title=Menu Measure: Health Bill Requires Calorie Disclosure | date=2010-03-22 | work =The Wall Street Journal | url =http://blogs.wsj.com/washwire/2010/03/22/menu-measure-health-bill-requires-calorie-disclosure/|accessdate = 2010-03-23}}</ref> But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.{{update after|2013}}<ref name='Nutrition' />
* States can apply for a 'State Plan Amendment" to expand family planning eligibility to the same eligibility as pregnancy related care (above and beyond Medicaid level eligibility), through a state option rather than having to apply for a federal waiver.<ref name="thenationalcampaign.org">{{cite web|url=http://www.thenationalcampaign.org/policymakers/PDF/SummaryProvisions_TUO_HealthReform.pdf |title=Provisions Related to Teen and Unplanned Pregnancy}}</ref><ref>{{cite web|url=http://www.thenationalcampaign.org/resources/pdf/Briefly_Policy%20Brief_ExpandingMedicaid.pdf|title=Expanding Medicaid Family Planning}}</ref><ref>{{cite web|url=http://www.prochoiceamerica.org/what-is-choice/fast-facts/low-income-fp-access.html|title=LOW-INCOME WOMEN'S ACCESS TO FAMILY PLANNING}}</ref>


The ],<ref name="hatchsays">{{cite news |url=https://www.foxnews.com/opinion/sen-orrin-hatch-repealing-the-individual-mandate-tax-is-the-beginning-of-the-end-of-the-obamacare-era/ |title=Sen. Orrin Hatch: Repealing the individual mandate tax is the beginning of the end of the ObamaCare era |last=Hatch |first=Orrin |date=December 20, 2017 |access-date=December 21, 2017 |publisher=] |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012208/https://www.foxnews.com/opinion/sen-orrin-hatch-repealing-the-individual-mandate-tax-is-the-beginning-of-the-end-of-the-obamacare-era |url-status=live }}</ref> set to $0 the penalty for not complying with the individual mandate, starting in 2019.<ref name="auto">{{cite journal |last1=Eibner |first1=Christine |last2=Nowak |first2=Sarah |year=2018 |title=The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors &#124; Commonwealth Fund |url=https://www.commonwealthfund.org/publications/fund-reports/2018/jul/eliminating-individual-mandate-penalty-behavioral-factors |url-status=live |doi=10.26099/SWQZ-5G92 |archive-url=https://web.archive.org/web/20180715040810/https://www.commonwealthfund.org/publications/fund-reports/2018/jul/eliminating-individual-mandate-penalty-behavioral-factors |archive-date=July 15, 2018 |access-date=July 10, 2019 |website=www.commonwealthfund.org}}</ref>
===Effective June 21, 2010===


===Exchanges===
* Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.<ref name='Top 18' /><ref>{{cite web|url=http://www.csmonitor.com/USA/Politics/2010/0324/Health-care-reform-bill-101-rules-for-preexisting-conditions|title=Health care reform bill 101: rules for preexisting conditions|last=Grier|first=Peter|work=The Christian Science Monitor|date=2010-03-24|accessdate=2010-03-25}}</ref> To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.<ref name=wjs_ret /> There is no age requirement.<ref name=wjs_ret>{{cite news|url=http://online.wsj.com/article/SB127570667448201583.html?KEYWORDS=high-risk+pool+health+insurance|title=Insurance Relief for Early Retirees | work=The Wall Street Journal | first=Anne | last=Tergesen | date=June 5, 2010}}</ref> The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (3:1), geographic area, family composition and tobacco use (1.5:1). Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.<ref name=wjs_ret /><ref>{{cite web|url=http://www.kff.org/healthreform/upload/8066.pdf|title=Kaiser: High-Risk Pool Provisions under the Health Reform Law}}</ref><ref>{{cite news|url=http://www.washingtonpost.com/wp-dyn/content/article/2010/05/03/AR2010050304072.html|title=18 states refuse to run insurance pools for those with preexisting conditions | work=The Washington Post | first=David S. | last=Hilzenrath | date=May 4, 2010}}</ref>
{{main|Health insurance marketplace}}
ACA mandated that health insurance exchanges be provided for each state. The exchanges are regulated, largely online marketplaces, administered by either federal or state governments, where individuals, families and small businesses can purchase private insurance plans.<ref name="HealthCareGov" /><ref name="aphabasics" /><ref name="CohnExchanges" /> Exchanges first offered insurance for 2014. Some exchanges also provide access to Medicaid.<ref>{{Cite web |url=https://www.mass.gov/files/documents/2019/06/28/aca-3-english.pdf |title=Paper MA ACA application (for the MA Health Connector, the state exchange) |date=August 10, 2019 |access-date=August 10, 2019 |archive-date=July 26, 2019 |archive-url=https://web.archive.org/web/20190726160950/https://www.mass.gov/files/documents/2019/06/28/aca-3-english.pdf |url-status=dead}}</ref><ref>{{cite web |url=https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6696-ENG |title=MN ACA application (MNSURE, their state exchange) |date=August 10, 2019 |access-date=August 10, 2019 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012220/https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6696-ENG |url-status=live }}</ref>


States that set up their own exchanges have some discretion on standards and prices.<ref name="KaiserExchangesNotes" /><ref name="cwfstate" /> For example, states approve plans for sale, and thereby influence (through negotiations) prices. They can impose additional coverage requirements—such as abortion.<ref>{{Cite news |url=http://www.rollcall.com/news/the_question_of_abortion_coverage_in_health_exchanges-226547-1.html |title=The Question of Abortion Coverage in Health Exchanges |last=Adams |first=Rebecca |date=July 22, 2013 |work=] |access-date=July 26, 2013 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012224/https://www.rollcall.com/2013/07/22/the-question-of-abortion-coverage-in-health-exchanges/ |url-status=dead }}</ref> Alternatively, states can make the federal government responsible for operating their exchanges.<ref name="KaiserExchangesNotes" />
===Effective July 1, 2010===


===Premium subsidies===
* The President established, within the ] (HHS), a council to be known as the ''National Prevention, Health Promotion and Public Health Council'' to help begin to develop a National Prevention and Health Promotion Strategy. The ] shall serve as the Chairperson of the new Council.<ref name=sec4001>{{cite web|url=http://en.wikisource.org/Patient_Protection_and_Affordable_Care_Act/Title_IV#Subtitle_A|title=Patient Protection and Affordable Care Act/Title IV/Subtitle A/Sec. 4001. National Prevention, Health Promotion and Public Health Council}}</ref><ref name="EO13544">] – ''Establishing the National Prevention, Health Promotion, and Public Health Council'', June 10, 2010, Vol.&nbsp;75, No.&nbsp;114,&nbsp;{{USFedReg|75|33983}}</ref>
Individuals whose household incomes are between 100% and 400% of the ] (FPL) are eligible to receive ] for premiums for policies purchased on an ACA exchange, provided they are not eligible for ], ], the ], or other forms of public assistance health coverage, and do not have access to affordable coverage (no more than 9.86% of income for the employee's coverage) through their own or a family member's employer.<ref name="KaiserFamily" /><ref name="TamiLuhby" /><ref name="hip-dhhs" /> Households below the federal poverty level are not eligible to receive these subsidies. Lawful Residents and some other legally present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for subsidies if they meet all other eligibility requirements.<ref>{{Cite web |url=https://www.healthcare.gov/immigrants/immigration-status/ |title=Find out what immigration statuses qualify for coverage in the Health Insurance Marketplace®. |website=HealthCare.gov |access-date=August 28, 2021 |archive-date=August 28, 2021 |archive-url=https://web.archive.org/web/20210828035037/https://www.healthcare.gov/immigrants/immigration-status/ |url-status=live }}</ref><ref name="KaiserFamily" /> Married people must file taxes jointly to receive subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.
* A 10% sales tax on indoor tanning took effect.<ref>{{cite news|url=http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aa32kl.M09T4|title=Health-Care Changes to Start Taking Effect This Year | publisher=Bloomberg | date=March 24, 2010}}</ref>


The subsidies for an ACA plan purchased on an exchange stop at 400% of the federal poverty level (FPL). According to the Kaiser Foundation, this results in a sharp "discontinuity of treatment" at 400% FPL, which is sometimes called the "subsidy cliff".<ref>{{Cite web |url=https://www.kff.org/health-reform/issue-brief/how-affordable-are-2019-aca-premiums-for-middle-income-people/ |title=How Affordable are 2019 ACA Premiums for Middle-Income People? |last1=Fehr |first1=Rachel |last2=Claxton |first2=Gary |date=March 5, 2019 |website=The Henry J. Kaiser Family Foundation |access-date=October 2, 2019 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012208/https://www.kff.org/health-reform/issue-brief/how-affordable-are-2019-aca-premiums-for-middle-income-people/ |url-status=live }}</ref> After-subsidy premiums for the second lowest cost silver plan (SCLSP) just below the cliff are 9.86% of income in 2019.<ref name=":82">{{Cite web |url=https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/ |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |date=November 20, 2018 |website=The Henry J. Kaiser Family Foundation |access-date=August 10, 2019 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012141/https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health-insurance-subsidies/ |url-status=live }}</ref>
===Effective September 23, 2010===


Subsidies are provided as an advanceable, ].<ref name="sec1401" /><ref name="sec1401_p" />
* Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.<ref>{{cite web|url=http://www.healthcare.gov/law/about/order/byyear.html |title=Provisions of the Affordable Care Act, By Year |publisher=HealthCare.gov |date= |accessdate=2012-01-09}}</ref>
* Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday,<ref>, section 1001 (adding section 2714 to the ]): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26&nbsp;years of age."</ref> and regulations implemented under the ACA include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.<ref>{{cite news | title= Rules Let Youths Stay on Parents' Insurance | newspaper= The New York Times | date= May 10, 2010 | url= http://www.nytimes.com/2010/05/11/health/policy/11health.html | first=Robert | last=Pear}}</ref><ref>{{cite press release | title= Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Families and Businesses | publisher= ] | url= http://www.whitehouse.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf }}</ref>
* Insurers are prohibited from excluding pre-existing medical conditions (except in ] individual health insurance plans) for children under the age of 19.<ref>Note: Language in the law concerning this provision has been described as ambiguous, but representatives of the insurance industry have indicated they will comply with regulations to be issued by the ] reflecting this interpretation.
* {{cite news|title=Coverage Now for Sick Children? Check Fine Print|url=http://www.nytimes.com/2010/03/29/health/policy/29health.html|date=March 28, 2010|last=Pear|first=Robert|work=]|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|title=Obama administration has blunt message for insurers|url=http://www.reuters.com/article/idUSN2017888120100329|date=March 29, 2010|last=Holland|first=Steve|publisher=Reuters|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|title=Insurers to Comply With Rules on Children|url=http://www.nytimes.com/2010/03/31/health/policy/31health.html|date=March 30, 2010|last=Pear|first=Robert|work=The New York Times|postscript=<!--None-->|lastauthoramp=yes|accessdate=April 8, 2010}}
* {{cite news|url=http://abcnews.go.com/Business/wireStory?id=10186800|title=Gap in Health Care Law's Protection for Children|last=Alonso-Zaldivar|first=Ricardo|date=March 24, 2010|publisher=ABC News|accessdate=April 8, 2010|agency=Associated Press}}</ref><ref name="FR June 28, 2010">{{cite journal |author=U.S. Department of Health and Human Services |date=June 28, 2010 |title=Patient Protection and Affordable Care Act; Requirements for Group Health Plans and Health Insurance Issuers Under the Patient Protection and Affordable Care Act Relating to Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections; Final Rule and Proposed Rule |journal=] |volume=75 |issue=123 |pages=37187–37241 |url=http://edocket.access.gpo.gov/2010/2010-15278.htm |accessdate=July 26, 2010}}</ref>
* All new insurance plans must cover preventive care and medical screenings<ref name="healthcare.gov">{{cite web | title=Preventive Services Covered Under the Affordable Care Act | url=http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html}}</ref> rated by the ].<ref>http://www.shrm.org/publications/hrnews/pages/coverpreventivecare.aspx</ref> Insurers are prohibited from charging co-payments, co-insurance, or deductibles for these services.<ref name='SHNS'>{{cite news | first=Lee | last=Bowman | title=Health reform bill will cause several near-term changes | date=2010-03-22 | url =http://public.shns.com/node/52359 | agency =Scripps Howard News Service | accessdate = 2010-03-23}}</ref>
* Individuals affected by the ] will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.<ref name='80beats'>{{cite news | first=Smriti | last=Rao | title=Health-Care Reform Passed. So What Does It Mean? | date=2010-03-22 | work=] | url =http://blogs.discovermagazine.com/80beats/2010/03/22/health-care-reform-passed-so-what-does-it-mean/| pages = | accessdate = 2010-03-23 | language = }}</ref> The gap will be eliminated by 2020.
* Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.<ref name='Top 18' />
* Insurers are prohibited from dropping ]s when they get sick.<ref name='Top 18' />
* Insurers are required to reveal details about administrative and executive expenditures.<ref name='Top 18' />
* Insurers are required to implement an ]s process for coverage determination and claims on all new plans.<ref name='Top 18' />
* Enhanced methods of ] detection are implemented.<ref name='Top 18' />
* Medicare is expanded to small, rural hospitals and facilities.<ref name='Top 18' />
* Medicare patients with chronic illnesses must be monitored/evaluated on a 3-month basis for coverage of the medications for treatment of such illnesses.
* Companies which provide early retiree benefits for individuals aged 55–64 are eligible to participate in a temporary program which reduces premium costs.<ref name='Top 18' />
* A new website installed by the ] will provide consumer insurance information for individuals and small businesses in all states.<ref name='Top 18' />
* A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.<ref name='Top 18' />
* All new insurance plans must cover childhood immunizations and adult vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) without charging co-payments, co-insurance, or deductibles when provided by an in-network provider.<ref>{{cite web | title=The Affordable Care Act and Immunization | url=http://www.healthcare.gov/news/factsheets/2010/09/affordable-care-act-immunization.html|publisher=U.S. Department of Health & Human Services|accessdate=September 15, 2012}}</ref>


The amount of subsidy is sufficient to reduce the premium for the second-lowest-cost silver plan (SCLSP) on an exchange to a sliding-scale percentage of income. The percentage is based on the percent of federal poverty level (FPL) for the household, and varies slightly from year to year. In 2019, it ranged from 2.08% of income (100%-133% FPL) to 9.86% of income (300%-400% FPL).<ref name="hip-dhhs" /> The subsidy can be used for any plan available on the exchange, but not catastrophic plans. The subsidy may not exceed the premium for the purchased plan.
===Effective January 1, 2011===


(In this section, the term "income" refers to modified ].<ref name="KaiserFamily" /><ref>{{Cite web |url=http://laborcenter.berkeley.edu/modified-adjusted-gross-income-under-the-affordable-care-act/ |title=Modified Adjusted Gross Income under the Affordable Care Act |last1=Research |first1=UC Berkeley Center for Labor |last2=Education |date=July 1, 2014 |website=Center for Labor Research and Education |access-date=October 2, 2019 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012211/https://laborcenter.berkeley.edu/modified-adjusted-gross-income-under-the-affordable-care-act/ |url-status=live }}</ref>)
* Insurers must spend 80% (for individual or small group insurers) or 85% (for large group insurers) of premium dollars on health costs and claims, leaving only 20% or 15% respectively for administrative costs and profits, subject to various waivers and exemptions. If an insurer fails to meet this requirement, there is no penalty, but a rebate must be issued to the policy holder. This policy is known as the 'Medical Loss Ratio'.<ref>{{cite web|url=http://www.healthcare.gov/news/factsheets/medical_loss_ratio.html |title=Medical Loss Ratio: Getting Your Money's Worth on Health Insurance |publisher=U.S. Department of Health & Human Services |date= |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=https://www.federalregister.gov/articles/2011/12/07/2011-31289/medical-loss-ratio-requirements-under-the-patient-protection-and-affordable-care-act |title=Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act |publisher=Federal Register |date= |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-insurance/211225-obama-administration-denies-one-states-health-law-waiver-partially-approves-another |title=Obama administration concludes healthcare law waiver review |work=The Hill |date=February 16, 2012 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://companyprofiles.healthcare.gov/MlrQA |title=Medical Loss Ratio}}</ref>
* The ] is responsible for developing the Center for Medicare and Medicaid Innovation and overseeing the testing of innovative payment and delivery models.<ref>{{cite web|url=http://healthreformgps.org/resources/center-for-medicare-and-medicaid-innovation/ |title=Center for Medicare and Medicaid Innovation – Health Reform GPS: Navigating the Implementation Process |publisher=Healthreformgps.org |date= |accessdate=2012-06-29}}</ref>
* ]s, ]s and ]s cannot be used to pay for over-the-counter drugs, purchased without a prescription, except ].<ref name="IR-2010-95">{{cite web
|url=http://www.irs.gov/newsroom/article/0,,id=227301,00.html
|title=IRS Issues Guidance Explaining 2011 Changes to Flexible Spending Arrangements
|publisher=Internal Revenue Service
|date=2010-09-03
|accessdate=2010-09-15
}}</ref>


Small businesses are eligible for a tax credit provided they enroll in the ] Marketplace.<ref name="IRSBusinessSubsidy" />
===Effective September 1, 2011===
{| class="wikitable" style="margin: 1em auto 1em auto"
|+Maximum net premium after subsidies (2019) for family of four<ref name=":82"/>
|-
! Income % of ]
! Premium cap as a share of income
! Income{{ref|fedpovlevel|a}}
! Maximum{{ref|max|b}} annual net premium after subsidy<br />(second-lowest-cost silver plan)
! Maximum out-of-pocket
|-
| 133%
| 3.11% of income
| $33,383
| $1,038
| $5,200
|-
| 150%
| 4.15% of income
| $37,650
| $1,562
| $5,200
|-
| 200%
| 6.54% of income
| $50,200
| $3,283
| $5,200
|-
| 250%
| 8.36% of income
| $62,750
| $5,246
| $12,600
|-
| 300%
| 9.86% of income
| $75,300
| $7,425
| $15,800
|-
| 400%
| 9.86% of income
| $100,400
| $9,899
| $15,800
|-
| colspan="5" style="text-align:left; background:white; border-top:1px solid black; padding:0 1em;" |
<small>a.{{note|fedpovlevel}}In 2019, the federal poverty level was $25,100 for family of four (outside of Alaska and Hawaii).</small>


<small>b.{{note|max}}If the premium for the second lowest cost silver plan (SLCSP) is greater than the amount in this column, the amount of the premium subsidy will be such that it brings the net cost of the SCLSP down to the amount in this column. Otherwise, there will be no subsidy, and the SLCSP premium will (of course) be no more than (usually less than) the amount in this column.</small>
* All health insurance companies must inform the public when they want to increase health insurance rates for individual or small group policies by an average of 10% or more. This policy is known as 'Rate Review'. States are provided with Health Insurance Rate Review Grants to enhance their rate review programs and bring greater transparency to the process.<ref>{{cite web|url=http://companyprofiles.healthcare.gov/RateReviewInfo |title=Promoting Transparency: Rate Increase Reviews}}</ref><ref>{{cite web|url=http://cciio.cms.gov/programs/marketreforms/rates/index.html |title=Review of Insurance Rates}}</ref>


<small>Note: The numbers in the table do not apply for Alaska and Hawaii.</small>
===Effective January 1, 2012===
|}


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


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


As written, ACA mandated that insurers reduce copayments and deductibles for ACA exchange enrollees earning less than 250% of the FPL. Medicaid recipients were not eligible for the reductions.
===Effective August 1, 2012===


So-called cost-sharing reduction (CSR) subsidies were to be paid to insurance companies to fund the reductions. During 2017, approximately $7 billion in CSR subsidies were to be paid, versus $34 billion for premium tax credits.<ref> {{Webarchive|url=https://web.archive.org/web/20210215012210/https://www.cbo.gov/publication/53091 |date=February 15, 2021 }}. United States. Congressional Budget Office. September 14, 2017. (Report).</ref>
* All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services – including: well-woman visits; ] screening; ] (HPV) DNA testing for women age 30 and older; sexually transmitted infection counseling; ] (HIV) screening and counseling; FDA-approved contraceptive methods and contraceptive counseling; breastfeeding support, supplies and counseling; and ] screening and counseling - will be covered without cost sharing.<ref>{{cite web |title=Next Steps to Comply with Health Care Reform |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |publisher=] LLP |work=The National Law Review|date=2012-10-10|accessdate=2012-10-10}}</ref> This is also known as the ].<ref name="healthcare.gov"/><ref>{{cite web | title=Affordable Care Act Rules on Expanding Access to Preventive Services for Women | url=http://www.healthcare.gov/news/factsheets/2011/08/womensprevention08012011a.html}}</ref><ref>{{cite news|last=Kliff|first=Sarah|title=Five facts about the health law’s contraceptive mandate|url=http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/01/five-facts-about-the-health-laws-contraceptive-mandate/|accessdate=29 November 2012|newspaper=The Washington Post|date=1 August 2012}}</ref>


The latter was defined as ] that does not require an annual Congressional appropriation. CSR payments were not explicitly defined as mandatory. This led to litigation and disruption later.{{explain|date=July 2022}}
===Effective October 1, 2012===


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


ACA implemented multiple approaches to helping mitigate the disruptions to insurers that came with its many changes.
===Effective January 1, 2013===


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


The ] program was a temporary risk management device.<ref>{{citation |url=http://www.rubio.senate.gov/public/_cache/files/1dc92ef8-c340-4cfd-95c0-67369a557f1e/2AA5EF8F125279800BFABC8B8BA37072.05.24.2016-crs-rubio-memo-risk-corridors-1-5-16-1-redacted.pdf |title=Lawsuits to Recover Payments under the Risk Corridors Program of the Affordable Care Act |date=January 5, 2016 |access-date=February 11, 2017 |author=Legislative Attorneys, American Law Division |publisher=] |page=6 |archive-date=February 24, 2021 |archive-url=https://web.archive.org/web/20210224021300/https://www.rubio.senate.gov/public/_cache/files/1dc92ef8-c340-4cfd-95c0-67369a557f1e/2AA5EF8F125279800BFABC8B8BA37072.05.24.2016-crs-rubio-memo-risk-corridors-1-5-16-1-redacted.pdf |url-status=live }}</ref>{{rp|1}} It was intended to encourage reluctant insurers into ACA insurance market from 2014 to 2016. For those years the ] (DHHS) would cover some of the losses for insurers whose plans performed worse than they expected. Loss-making insurers would receive payments paid for in part by profit-making insurers.<ref>{{citation |title=Trouble on the Exchanges – Does the United States Owe Billions to Health Insurers? |author=Nicholas Bagley |journal=New England Journal of Medicine |date=November 24, 2016 |doi=10.1056/NEJMp1612486 |pmid=27959725 |volume=375 |issue=21 |pages=2017–2019}}</ref><ref>{{citation |url=https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/faq-risk-corridors-04-11-2014.pdf |date=April 11, 2014 |title=Risk Corridors and Budget Neutrality |publisher=] (CMS) |location=Washington, DC |access-date=February 11, 2017 |archive-date=March 13, 2021 |archive-url=https://web.archive.org/web/20210313153006/https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/faq-risk-corridors-04-11-2014.pdf |url-status=live }} ]</ref>{{attribution needed |date=July 2017}} Similar risk corridors had been established for the ].<ref>{{citation |title=Yes, Marco Rubio Led The Effort To End Obamacare's Health |date=December 15, 2015 |url=https://www.forbes.com/sites/theapothecary/2015/12/15/yes-marco-rubio-led-the-effort-to-end-obamacares-health-insurance-slush-fund/?sh=18f0f95b4688 |work=] |access-date=February 10, 2017}}{{cbignore|bot=medic}}</ref>
* Beginning January 1, 2013, the limit on pre-tax contributions to healthcare flexible spending accounts will be capped at $2,500 per year.<ref>{{cite web|url=http://www.foley.com/files/PPACASummary.pdf|title=PPACA Summary (Foley.com)}}</ref><ref>{{cite web|url=http://www.lifehealthpro.com/2012/09/12/8-things-you-might-not-know-about-ppaca?page=9|title=What You Might Not Know About PPACA}}</ref><ref>{{cite web|url=http://www.irs.gov/pub/irs-drop/n-12-40.pdf|title=IRS Notice 2012-40}}</ref>


While many insurers initially offered exchange plans, the program did not pay for itself as planned, losing up to $8.3 billion for 2014 and 2015. Authorization had to be given so DHHS could pay insurers from "general government revenues".{{attribution needed |date=July 2017}} However, the ] (H.R. 3547) stated that no funds "could be used for risk-corridor payments".<ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/news/fact-checker/wp/2015/12/23/rubios-inaccurate-claim-that-he-inserted-a-provision-restricting-obamacare-bailout-funds/ |title=Rubio's inaccurate claim that he 'inserted' a provision restricting Obamacare 'bailout' funds |newspaper=] |date=December 23, 2015 |first=Glenn |last=Kessler |access-date=July 27, 2017 |archive-date=March 6, 2021 |archive-url=https://web.archive.org/web/20210306054848/https://www.washingtonpost.com/news/fact-checker/wp/2015/12/23/rubios-inaccurate-claim-that-he-inserted-a-provision-restricting-obamacare-bailout-funds/ |url-status=live }}</ref>{{attribution needed |date=July 2017}} leaving the government in a potential breach of contract with insurers who offered qualified health plans.<ref name="latimes_GOP_ACA_corridor">{{cite news |author=Hiltzik, Michael |url=http://www.latimes.com/business/hiltzik/la-fi-hiltzik-risk-corridor-moda-20170210-story.html |title=With billions at stake, a federal judge just nullified the GOP's most cynical attack on Obamacare |work=] |date=February 10, 2017 |access-date=February 10, 2017 |archive-date=February 11, 2017 |archive-url=https://web.archive.org/web/20170211224404/http://www.latimes.com/business/hiltzik/la-fi-hiltzik-risk-corridor-moda-20170210-story.html}}</ref>
* Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act from 2.6% to 2.3%.)<ref>{{cite web|url=http://www.healthcare.gov/center/authorities/reconciliation_law.pdf|title=Health Care reform Reconciliation Act}}</ref> This tax will also apply to some medical devices, such as examination gloves and catheters, that are used in ].<ref name="Dotzenrod">{{cite news |title=IRS releases final rule on medical device tax |author=Constance Fore Dotzenrod |author2=Gregory C Sicilian |url=http://www.lexology.com/library/detail.aspx?g=9e5a8e7b-9383-4fe9-98c5-4961b16c1499 |newspaper=Lexology |date=December 10, 2012 |accessdate=December 13, 2012}}</ref>


Several insurers sued the government at the ] to recover the funds believed owed to them under the Risk Corridors program. While several were summarily closed, in the case of ''] v the United States'', Moda Health won a $214-million judgment in February 2017. Federal Claims judge ] stated, "the Government made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, to say to , 'The joke is on you. You shouldn't have trusted us,' is hardly worthy of our great government."<ref>{{citation |url=https://ecf.cofc.uscourts.gov/cgi-bin/show_public_doc?2016cv0649-23-0 |title=Moda Health Plan, Inc. v. The United States |publisher=US Courts |date=February 10, 2017 |access-date=February 10, 2017 |pages=40 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308105404/https://ecf.cofc.uscourts.gov/cgi-bin/show_public_doc?2016cv0649-23-0 |url-status=live }}</ref> Moda Health's case was appealed by the government to the ] along with the appeals of the other insurers; here, the Federal Circuit reversed the Moda Health ruling and ruled across all the cases in favor of the government, that the appropriations riders ceded the government from paying out remain money due to the insurers. The Supreme Court reversed this ruling in the consolidated case, '']'', reaffirming as with Judge Wheeler that the government had a responsibility to pay those funds under the ACA and the use of riders to de-obligate its from those payments was illegal.<ref name=":1">{{Cite web |title=Maine Community Health Options v. United States |url=https://www.scotusblog.com/case-files/cases/maine-community-health-options-v-united-states/ |website=SCOTUSblog |access-date=2020-05-02 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308145808/https://www.scotusblog.com/case-files/cases/maine-community-health-options-v-united-states/ |url-status=live }}</ref>
* Insurance companies are required to use simpler, more standardized paperwork, with the intention of helping consumers make apples-to-apples comparisons between the prices and benefits of different health plans.<ref>{{cite news|last=Doyle|first=Brion B.|title=Understanding the Impacts of the Patient Protection and Affordable Care Act|url=http://www.natlawreview.com/article/understanding-impacts-patient-protection-and-affordable-care-act|accessdate=17 April 2013|newspaper=The ]|date=March 5, 2013|author2=Varnum LLP}}</ref>


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


The temporary reinsurance program is meant to stabilize premiums by reducing the incentive for insurers to raise premiums due to concerns about higher-risk enrollees. Reinsurance was based on retrospective costs rather than prospective risk evaluations. Reinsurance was available from 2014 through 2016.<ref name=":4">{{Cite web |url=https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/ |title=Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors |last1=Semanskee |first1=Ashley |last2=Claxton |first2=Gary |date=August 17, 2016 |website=The Henry J. Kaiser Family Foundation |access-date=November 28, 2019 |archive-date=March 1, 2021 |archive-url=https://web.archive.org/web/20210301154915/https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/ |url-status=live }}</ref>
* Religious organizations that were given an extra year to implement the ] are no longer exempt. Certain non-exempt, non-grandfathered group health plans established and maintained by non-profit organizations with religious objections to covering contraceptive services may take advantage of a one-year enforcement safe harbor (i.e., until the first plan year beginning on or after August 1, 2013) by timely satisfying certain requirements set forth by the U.S. Department of Health & Human Services.<ref>{{cite web |title=Next Steps to Comply with Health Care Reform |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |publisher=Schiff Hardin LLP |work=The ]|date=2012-10-10|accessdate=2012-10-10}}</ref>


===Effective by October 1, 2013=== ====Risk adjustment====


Risk adjustment involves transferring funds from plans with lower-risk enrollees to plans with higher-risk enrollees. It was intended to encourage insurers to compete based on value and efficiency rather than by attracting healthier enrollees. Of the three risk management programs, only risk adjustment was permanent. Plans with low actuarial risk compensate plans with high actuarial risk.<ref name=":4" />
* Starting in October 2013, those looking to buy individual health insurance can enroll in subsidized plans offered through state-based exchanges (see below), with coverage beginning in January 2014.<ref>{{cite web|url=http://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html?hpt=hp_t5|title=Millions eligible for Obamacare subsidies, but most don't know it|author=]}}</ref><ref>{{cite web|url=http://www.kff.org/healthreform/upload/8213-2.pdf|title=ESTABLISHING HEALTH INSURANCE EXCHANGES: AN OVERVIEW OF STATE EFFORTS}}</ref><ref>{{cite web|url=http://www.healthcare.gov/marketplace/get-ready/index.html|title=Enrollment in the Marketplace starts in October 2013.}}</ref>


===Effective by January 1, 2014=== ===Medicaid expansion===


{{Main|Medicaid coverage gap}}
] and ].<ref name="private_pp" /> (Source: ])]]
ACA revised and expanded ] eligibility starting in 2014. All U.S. citizens and legal residents with income up to 133% of the ] would qualify for coverage in any state that participated in the Medicaid program. Previously, states could set various lower thresholds for certain groups and were not required to cover adults without dependent children. The federal government was to pay 100% of the increased cost in 2014, 2015 and 2016; 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and all subsequent years.<ref>{{cite news |author=HHS Press Office |date=March 29, 2013 |title=HHS finalizes rule guaranteeing 100 percent funding for new Medicaid beneficiaries |location=Washington, DC |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/news/press/2013pres/03/20130329a.html |access-date=April 23, 2013 |quote=effective January 1, 2014, the federal government will pay 100 percent of defined cost of certain newly eligible adult Medicaid beneficiaries. These payments will be in effect through 2016, phasing down to a permanent 90 percent matching rate by 2020. |archive-date=April 8, 2013 |archive-url=https://web.archive.org/web/20130408193512/http://www.hhs.gov/news/press/2013pres/03/20130329a.html |url-status=dead }}<br />{{cite journal |author=Centers for Medicare & Medicaid Services |date=April 2, 2013 |title=Medicaid program: Increased federal medical assistance percentage changes under the Affordable Care Act of 2010: Final rule |journal=Federal Register |volume=78 |issue=63 |pages=19917–19947 |quote=(A) 100 percent, for calendar quarters in calendar years (CYs) 2014 through 2016; (B) 95 percent, for calendar quarters in CY 2017; (C) 94 percent, for calendar quarters in CY 2018; (D) 93 percent, for calendar quarters in CY 2019; (E) 90 percent, for calendar quarters in CY 2020 and all subsequent calendar years.}}</ref><ref>{{cite web |title=HHS finalizes rule guaranteeing 100 percent funding for new medicaid beneficiaries |url=https://www.thelundreport.org/keywords/department-health-and-human-services |website=The Lund Report |access-date=23 June 2022 |archive-url=https://web.archive.org/web/20201030161511/https://www.thelundreport.org/content/hhs-finalizes-rule-guaranteeing-100-percent-funding-new-medicaid-beneficiaries |archive-date=30 October 2020 |location=Portland OR |date=29 March 2013 |agency=Department of Health and Human Services}}</ref><ref>{{Cite web|url=https://archive-it.org/collections/3926?fc=meta_Date:2013|title=Archive-It - News Releases|website=archive-it.org|access-date=August 23, 2022|archive-date=March 15, 2021|archive-url=https://web.archive.org/web/20210315031839/https://archive-it.org/collections/3926?fc=meta_Date:2013|url-status=live}}</ref><ref>{{Cite web |url=https://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-state-budgets |title=How Health Reform's Medicaid Expansion Will Impact State Budgets |date=July 11, 2012 |website=Center on Budget and Policy Priorities |access-date=July 24, 2019 |archive-date=November 30, 2020 |archive-url=https://web.archive.org/web/20201130021333/https://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-state-budgets |url-status=live }}</ref> A 5% "income disregard" made the effective income eligibility limit for Medicaid 138% of the poverty level.<ref name="138fpl" /> However, the ] ruled in '']'' that this provision of ACA was coercive, and that states could choose to continue at pre-ACA eligibility levels.


===Medicare savings===
* Insurers are prohibited from discriminating against or charging higher rates for any individual based on gender or pre-existing medical conditions.<ref>{{cite web|url=http://www.nh.gov/insurance/consumers/documents/naic_faq.pdf|title=I have been denied coverage because I have a pre-existing condition. What will this law do for me?|publisher=New Hampshire Insurance Department|work=Health Care Reform Frequently Asked Questions|accessdate=2012-06-28|page=2}}</ref>

* Insurers are prohibited from establishing annual spending caps.<ref name='Top 18' />
Medicare reimbursements were reduced to insurers and drug companies for private ] policies that the ] and ] found to be excessively costly relative to standard Medicare;<ref name="CMSMedicarePPACA" /><ref>{{cite web |title=Higher Spending Relative to Medicare Fee-for-Service May Not Ensure Lower Out-of-Pocket Costs for Beneficiaries |issue=GAO-08-522T |url=http://www.gao.gov/products/GAO-08-522T |website=Government Accountability Office |date=February 8, 2008 |access-date=October 7, 2013 |archive-date=February 25, 2021 |archive-url=https://web.archive.org/web/20210225111938/https://www.gao.gov/products/GAO-08-522T |url-status=live }}</ref> and to hospitals that failed standards of efficiency and care.<ref name="CMSMedicarePPACA" />
* Individuals who are not covered by an acceptable insurance policy will be charged an annual penalty of $95, or up to 1% of income over the filing minimum,<ref name=jct>"Generally, in 2010, the filing threshold is $9,350 for a single person or a married person filing separately and is $18,700 for married filing jointly." - Congress of the United States The Joint Committee on Taxation, "," March 21, 2010.</ref> whichever is greater; this will rise to a minimum of $695 ($2,085 for families),<ref>{{cite news|last=Doyle|first=Brion B.|title=Understanding the Impacts of the Patient Protection and Affordable Care Act|url=http://www.natlawreview.com/article/understanding-impacts-patient-protection-and-affordable-care-act|accessdate=17 April 2013|newspaper=The National Law Review|date=March 5, 2013|author2=Varnum LLP}}</ref> or 2.5% of income over the filing minimum,<ref name="jct" /> by 2016.<ref name="ksr_hlth" /><ref name = bglobetaximp>{{cite news|url=http://www.boston.com/business/personalfinance/managingyourmoney/archives/2010/03/tax_implication.html|title=Tax implications of health care reform legislation|author=Downey, Jamie|date=March 24, 2010|newspaper=]|accessdate=2010-03-25}}</ref> Exemptions to the ] and penalty are permitted for religious reasons, members of ], or for those for whom the least expensive policy would exceed 8% of their income.<ref>{{cite news|url=http://www.washingtonpost.com/blogs/ezra-klein/post/individual-mandate-101-what-it-is-why-it-matters/2011/08/25/gIQAhPzCeS_blog.html|title=Individual mandate 101: What it is, why it matters |publisher=Wonkblog at the Washington Post|coauthors=Sarah Kliff; Ezra Klein|date=March 27, 2012|accessdate=July 2, 2012}}</ref>

* In participating states, Medicaid eligibility is expanded; all individuals with income up to 133% of the ] qualify for coverage, including adults without dependent children.<ref name="ksr_hlth">{{cite news|url=http://www.kaiserhealthnews.org/Stories/2010/March/22/consumers-guide-health-reform.aspx|first=Phil |last=Galewitz|title=Consumers Guide To Health Reform|date=March 26, 2010|newspaper=Kaiser Health News}}</ref><ref name="cnn_ref1">{{cite news|url=http://www.cnn.com/2010/HEALTH/03/25/health.care.law.basics/index.html|title=5 key things to remember about health care reform|publisher=CNN|date=March 25, 2010 | accessdate=May 21, 2010}}</ref> As written, the ACA withheld ''all'' Medicaid funding from states declining to participate in the expansion. However, the Supreme Court ruled, in '']'', that this withdrawal of funding was unconstitutionally coercive, and that individual states had the right to opt out of the Medicaid expansion without losing ''pre-existing'' Medicaid funding from the federal government. As of April 25, 2013, fifteen states&mdash;], ], ], ], ], ], ], ], ], ], ], ], ], ], and ]&mdash;were not participating in the Medicaid expansion, with ten more&mdash;], ], ], ], ], ], ], ], ], and ]&mdash;leaning towards not participating.<ref>http://www.washingtonpost.com/blogs/wonkblog/wp/2013/04/25/the-outlook-for-medicaid-expansion-looks-bleak/</ref>
===Taxes===
*]s are established, and subsides for insurance premiums are given to individuals who buy a plan from an exchange and have a household income between 133% and 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage.<ref name="cnn_ref1" /><ref>{{cite web|title=Health Insurance Premium Credits Under PPACA (P.L. 111-148)|url=http://liberalarts.iupui.edu/economics/uploads/docs/jeanabrahamcrscredits.pdf|publisher=Congressional Research Service|author=Chris L. Peterson, Thomas Gibe|date=April 6, 2010}}</ref><ref name='Galewitz'>{{cite news | first=Phil | last=Galewitz | title=Health reform and you: A new guide | date=2010-03-22 | publisher=] | url =http://today.msnbc.msn.com/id/34609984/ns/health-health_care/ | accessdate = 2010-03-23 }}</ref><ref>{{cite web|url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance|title=Health Care Reform Bill 101|work=]}}</ref> Section 1401(36B) of PPACA explains that each subsidy will be provided as an advanceable, ]<ref name=sec1401>{{cite web|url=http://en.wikisource.org/Patient_Protection_and_Affordable_Care_Act/Title_I/Subtitle_E/Part_I/Subpart_A|title=Patient Protection and Affordable Care Act/Title I/Subtitle E/Part I/Subpart A}}</ref> and gives a formula for its calculation.<ref name=sec1401_p>]</ref> A ] is a way to provide government benefits to individuals who may have no tax liability<ref>{{cite web|url=http://hungerreport.org/2010/report/chapters/two/taxes/refundable-tax-credits|title=Refundable Tax Credit}}</ref> (such as the ]). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. The ] (DHHS) and ] (IRS) on May 23, 2012, issued joint final rules regarding implementation of the new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.<ref>{{cite web|url=http://www.gpo.gov/fdsys/pkg/FR-2012-05-23/pdf/2012-12421.pdf|title=Health Insurance Premium Tax Credit – from DHHS and IRS}}</ref><ref name="treasury_12">{{cite web|url=http://www.treasury.gov/press-center/Documents/36BFactSheet.PDF|title=Treasury Lays the Foundation to Deliver Tax Credits}}</ref> According to ] and ], in 2014 the income-based premium caps for a ] for a family of four will be the following:
====Medicare taxes====
{| class="wikitable" style="margin: 1em auto 1em auto"

|+ Health Insurance Premiums and Cost Sharing under PPACA for Average Family of 4<ref name="private_pp">{{cite web|url=http://bingaman.senate.gov/policy/crs_privhins.pdf|title=Private Health Insurance Provisions in PPACA (P.L. 111-148)|publisher=]|date=April 15, 2010}}</ref><ref name="treasury_12" /><ref name="hip-dhhs">http://www.healthcare.gov/law/resources/reports/premiums01282011a.pdf</ref><ref>{{cite web|author=by Administrator |url=http://www.samhsa.gov/Financing/post/Health-Insurance-Premiums-Past-High-Costs-Will-Become-the-Present-and-Future-Without-Health-Reform.aspx |title=Financing Center of Excellence &#124; SAMHSA &#124; Health Insurance Premiums: Past High Costs Will Become the Present and Future Without Health Reform |publisher=Samhsa.gov |date=2011-03-14 |accessdate=2012-06-29}}</ref><ref name="hipc">{{cite web|url=http://hrsa.dshs.wa.gov/MedicaidHealthCareReform/CRS/HealthInsurancePremiumCredits.pdf|title=Health Insurance Premium Credits Under PPACA|publisher=]|archiveurl=http://web.archive.org/web/20101027220254/http://hrsa.dshs.wa.gov/MedicaidHealthCareReform/CRS/HealthInsurancePremiumCredits.pdf|archivedate=October 27, 20120|date=April 28, 2010}}</ref>
Income from self-employment and wages of single individuals in excess of $200,000 annually are subjected to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to their total compensation), or $125,000 for a married person filing separately.<ref>{{Cite web |url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf |title=PPACA, section 9015 as modified by section 10906 |access-date=June 2, 2011 |archive-date=December 3, 2018 |archive-url=https://web.archive.org/web/20181203181442/https://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf |url-status=live }}</ref>

In ACA's companion legislation, the ], an additional tax of 3.8% was applied to unearned income, specifically the lesser of net investment income and the amount by which adjusted gross income exceeds the above income limits.<ref>{{Cite web|url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr4872enr/pdf/BILLS-111hr4872enr.pdf|title=HCERA section 1402|access-date=June 2, 2011|archive-date=December 3, 2018|archive-url=https://web.archive.org/web/20181203183414/https://www.gpo.gov/fdsys/pkg/BILLS-111hr4872enr/pdf/BILLS-111hr4872enr.pdf|url-status=live}}</ref>

====Excise taxes====

ACA included an excise tax of 40% ("]") on total employer premium spending in excess of specified dollar amounts (initially $10,200 for single coverage and $27,500 for family coverage<ref>{{cite journal |url=http://www.commonwealthfund.org/publications/issue-briefs/2015/dec/aca-cadillac-tax |title=Rethinking the Affordable Care Act's "Cadillac Tax": A More Equitable Way to Encourage "Chevy" Consumption |publisher=] |date=December 18, 2015 |first1=Sarah |last1=Nowak |first2=Christine |last2=Eibner |journal=Issue Brief (Commonwealth Fund) |volume=36 |pages=1–8 |pmid=26702468 |access-date=July 4, 2017 |archive-date=May 15, 2018 |archive-url=https://web.archive.org/web/20180515202525/http://www.commonwealthfund.org/publications/issue-briefs/2015/dec/aca-cadillac-tax |url-status=live }}</ref>) indexed to inflation. This tax was originally scheduled to take effect in 2018, but was delayed until 2020 by the ] and again to 2022. The excise tax on high-cost health plans was completely repealed as part of H.R.1865 - Further Consolidated Appropriations Act, 2020.

Excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well.<ref>{{cite book|url=http://www.taxpolicycenter.org/briefing-book/what-are-major-federal-excise-taxes-and-how-much-money-do-they-raise| archive-url = https://web.archive.org/web/20220526181331/https://www.taxpolicycenter.org/sites/default/files/briefing-book/tpc_briefing_book-may2022.pdf | archive-date = May 26, 2022 | title = A citizen's guide to the fascinating (though often complex) elements of the US tax system. | newspaper = Tax Policy Center |format =Briefing book|publisher=Urban-Brookings ]}}</ref> The tax was repealed in late 2019.<ref name="auto1">{{Cite news |last=Maurer |first=Mark |date=2019-12-23 |title=Finance Chiefs Relieved After Repeal of Cadillac Tax |work=] |publisher=News Corp |oclc=781541372 |archive-url=https://web.archive.org/web/20191225192330/https://www.wsj.com/articles/finance-chiefs-relieved-after-repeal-of-cadillac-tax-11577137387 |archive-date=2019-12-25 |url=https://www.wsj.com/articles/finance-chiefs-relieved-after-repeal-of-cadillac-tax-11577137387 |access-date=2022-05-20 |issn=0099-9660}}</ref>

===SCHIP===

The ] (CHIP) enrollment process was simplified.<ref>{{cite book |title=Children's Health Insurance Program Fact Sheets for Every State and Washington, DC |date=2019 |publisher=National Academy for State Health Policy |url=https://www.nashp.org/all-50-states-and-washington-d-c-chip-fact-sheets-for-all-years/ |access-date=1 July 2022 |archive-url=https://web.archive.org/web/20220121004745/https://www.nashp.org/wp-content/uploads/2019/12/AllStates_2019CHIPFactSheets.pdf |archive-date=21 January 2022 |format= pdf }}</ref><ref name="KFF1" />

===Dependents{{anchor|Dependent's Health Insurance}}===

Beginning September 23, 2010, dependents were permitted to remain on their parents' insurance plan until their 26th birthday, including dependents who no longer lived with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.<ref name="H.R.3590Enrolled" /><ref>{{cite web |url=https://obamawhitehouse.archives.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf |title=Young Adults and the Affordable Care Act |url-status=live |archive-url=https://web.archive.org/web/20170202210534/https://obamawhitehouse.archives.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf |via=] |work=] |archive-date=February 2, 2017 }}</ref>

===Employer mandate===

Businesses that employ fifty or more people but do not offer health insurance to their full-time employees are assessed additional tax if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the ].<ref name="kffpay" /><ref name="WSJ-mar25" /> This provision was included to encourage employers to continue providing insurance once the exchanges began operating.<ref name="http" />

===Delivery system reforms===

The act includes ] reforms intended to constrain costs and improve quality. These include Medicare payment changes to discourage ]s and ], ] initiatives, the ], the ], and ]s.

====Hospital quality====

Health care cost/quality initiatives included incentives to ], adopt ]s, and to coordinate care and prioritize quality over quantity.<ref name="NYMagChait2" />

====Bundled payments====

] switched from ] to ]s.<ref>{{cite web |last = Lowes | first = Robert | archive-url = https://web.archive.org/web/20111228062404/https://www.medscape.com/viewarticle/748502 | date = August 24, 2011 |archive-date = December 28, 2011 |url=http://www.medscape.com/viewarticle/748502 |title=Hospitals Pay Physicians in Medicare Bundled Payment Model|website=Medscape Medical News |publisher = WebMD|access-date=January 9, 2012}}{{Registration required}}</ref><ref>{{cite web |url=http://www.huronconsultinggroup.com/researchdetails.aspx?articleId=2577 |title=Key Healthcare Reform Initiatives: Medicare Bundled Payment Pilots |date=November 19, 2010 |publisher=Huron Consulting Group |access-date=January 9, 2012 |archive-date=April 12, 2012 |archive-url=https://web.archive.org/web/20120412101536/http://www.huronconsultinggroup.com/researchdetails.aspx?articleId=2577 |url-status=live }}</ref> A single payment was to be paid to a hospital and a physician group for a defined episode of care (such as a ]) rather than separate payments to individual service providers.<ref>{{cite web |url=http://www.medicare.gov/part-d/costs/coverage-gap/more-drug-savings-in-2020.html |title=More savings in the drug coverage gap coming through 2020 |publisher=Centers for Medicare & Medicaid Services |access-date=September 27, 2013 |archive-url=https://web.archive.org/web/20130923130511/https://www.medicare.gov/part-d/costs/coverage-gap/more-drug-savings-in-2020.html |archive-date=September 23, 2013 |url-status=dead }}</ref>

====Accountable care organizations====
{{main|Accountable care organization}}
The ] (MSSP) was established by section 3022 of the Affordable Care Act. It is the program by which an ] interacts with the federal government, and by which accountable care organizations can be created.<ref>{{Cite web |url=https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about |title=About the Program &#124; CMS |website=www.cms.gov |access-date=April 24, 2020 |archive-date=April 24, 2020 |archive-url=https://web.archive.org/web/20200424101635/https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about |url-status=live }}</ref> It is a ] model.

The Act allowed the creation of accountable care organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated care to Medicare patients. ACOs were allowed to continue using ] billing. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigation of ]. Missing cost or quality benchmarks subjected them to penalties.<ref name=":15">{{Cite web |url=http://khn.org/news/aco-accountable-care-organization-faq/ |first = Jenny | format = Video & explainer | archive-url = https://web.archive.org/web/20151219031845/https://khn.org/news/aco-accountable-care-organization-faq/| archive-date = December 19, 2015|department = Urgent care |last = Gold|title=Accountable Care Organizations, Explained |date=September 14, 2015 |publisher=Kaiser Health News |access-date=August 18, 2016}}</ref>

Unlike ]s, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality-of-care goals.<ref name=":15" />

===Medicare drug benefit (Part D)===

Medicare Part D participants received a 50% discount on brand name drugs purchased after exhausting their ].<ref>{{Cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/sf/brand-connect/wp/2014/03/17/what-the-affordable-care-act-means-for-prescription-coverage/ |title=What the Affordable Care Act means for prescription coverage |newspaper=] |access-date=August 7, 2016 |archive-date=July 13, 2020 |archive-url=https://web.archive.org/web/20200713030830/https://www.washingtonpost.com/sf/brand-connect/wp/2014/03/17/what-the-affordable-care-act-means-for-prescription-coverage/ |url-status=dead}}</ref> By 2020, the "doughnut hole" would be completely filled.<ref>{{cite web |title=Closing the Coverage Gap – Medicare Prescription Drugs Are Becoming More Affordable |date=January 2015 |publisher=CMS |url=http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130523191556/http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf |archive-date=May 23, 2013}}</ref>

===State waivers===

From 2017 onwards, states can apply for a "waiver for state innovation" which allows them to conduct experiments that meet certain criteria.<ref name="GPOStateWaiver" /> 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 ACA, covers at least as many residents and does not increase the federal deficit.<ref name="StateWaiverConditions" /> These states can escape some of ACA's central requirements, including the individual and employer mandates and the provision of an insurance exchange.<ref name="WaPoWaiverFlexibility" /> The state would 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 ACA, if they cannot be paid under the state plan.<ref name="GPOStateWaiver" />

===Other insurance provisions===

The ] (or CLASS Act) established a voluntary and public ] option for employees,<ref>{{cite news |last=Span |first=Paula |date=March 29, 2010 |url=https://www.nytimes.com/2010/03/30/health/30care.html |title=Options Expand for Affordable Long-Term Care |newspaper=] |issn=0362-4331 |oclc=1645522 |access-date=March 29, 2010 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308201600/https://www.nytimes.com/2010/03/30/health/30care.html |url-status=live }}</ref><ref name="multiple2" /><ref>{{cite news |url=https://www.sfexaminer.com/national-news/so-yeah-the-health-care-bill-was-really-an-awful-piece-of-legislation-that-sent-the-revolving-door-spinning-faster/ |newspaper=San Francisco Examiner |date=2011-02-28 |title=So, yeah, the health-care bill was really an awful piece of legislation that sent the revolving door spinning faster |access-date=2021-02-16 |archive-date=May 13, 2021 |archive-url=https://web.archive.org/web/20210513134925/https://www.sfexaminer.com/national-news/so-yeah-the-health-care-bill-was-really-an-awful-piece-of-legislation-that-sent-the-revolving-door-spinning-faster/ |url-status=live }}</ref> The program was abolished as impractical without ever having taken effect.<ref>{{cite web| publisher = ALM Media |location = Denver CO |first = Allison | last = Bell |url=http://www.lifehealthpro.com/2013/01/02/watchdogs-class-still-dead |title=Watchdogs: CLASS still dead |date=January 2, 2013 |website =LifeHealthPro |url-status=dead |archive-url=https://web.archive.org/web/20150812185238/http://www.lifehealthpro.com/2013/01/02/watchdogs-class-still-dead |archive-date=August 12, 2015 |access-date=January 2, 2013}}</ref>

Consumer Operated and Oriented Plans (CO-OP), member-governed non-profit insurers, could start providing health care coverage, based on a 5-year federal loan.<ref>{{Cite web |url=https://www.cms.gov/CCIIO/Programs-and-Initiatives/Insurance-Programs/Consumer-Operated-and-Oriented-Plan-Program.html |title=Consumer Operated and Oriented Plan Program |first1=Centers for |last1=Medicare |first2=Medicaid Services 7500 Security Boulevard |last2=Baltimore |first3=Md21244 |last3=Usa |date=May 8, 2013 |website=www.cms.gov |access-date=July 24, 2019 |archive-date=October 24, 2019 |archive-url=https://web.archive.org/web/20191024010226/https://www.cms.gov/CCIIO/Programs-and-Initiatives/Insurance-Programs/Consumer-Operated-and-Oriented-Plan-Program.html |url-status=live }}</ref> As of 2017, only four of the original 23 co-ops were still in operation.<ref>{{Cite web | last = Small | first = Leslie |archive-url = https://web.archive.org/web/20170818133103/https://www.fiercehealthcare.com/payer/one-just-four-co-ops-left-montana-insurer-returns-from-hiatus-high-hopes | archive-date = August 18, 2017 |url=https://www.fiercehealthcare.com/payer/one-just-four-co-ops-left-montana-insurer-returns-from-hiatus-high-hopes |title=Montana CO-OP, 1 of just 4 left, returns from hiatus with high hopes| publisher = Questex |location = Newton MA |website=FierceHealthcare |date=August 14, 2017 |access-date=December 1, 2019}}</ref>

===Nutrition labeling requirements===

] officially took effect in 2010, but implementation was delayed, and they actually took effect on May 7, 2018.<ref>{{Cite web |url=https://wreg.com/2018/05/07/affordable-care-acts-calorie-count-rules-go-into-effect/ |title=Affordable Care Act's calorie count rules go into effect| archive-url = https://web.archive.org/web/20200730071708/https://wreg.com/news/affordable-care-acts-calorie-count-rules-go-into-effect/ | archive-date = July 30, 2020 |location = Memphis TN | publisher = Tribune Media | website = WREG TV |agency = CNN Wire |quote = This is an archived article and the information in the article may be outdated|date=May 7, 2018}}</ref>

==Legislative history==

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

ACA followed a long series of unsuccessful attempts by one party or the other to pass major insurance reforms. Innovations were limited to ]s (2003), ] (1996) or ]s, which increased insurance options, but did not materially expand coverage. Health care was a major factor in multiple elections, but until 2009, neither party had the votes to overcome the other's opposition.

===Individual mandate===

The concept of an individual mandate goes back to at least 1989, when ], a ] think-tank, proposed an individual mandate as an alternative to ].<ref name="forbes1" /><ref>{{cite web |url=http://healthcarereform.procon.org/sourcefiles/1989_assuring_affordable_health_care_for_all_americans.pdf |first=Stuart M. |last=Butler |publisher=The Heritage Foundation |title=Assuring Affordable Healthcare for All Americans |year=1989 |access-date=August 3, 2017 |archive-date=October 6, 2016 |archive-url=https://web.archive.org/web/20161006185543/http://healthcarereform.procon.org/sourcefiles/1989_assuring_affordable_health_care_for_all_americans.pdf |url-status=dead }}</ref> It was championed for a time by conservative economists and ] senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of ]s. Specifically, because the 1986 ] (EMTALA) requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.<ref name="CommonSense" /><ref name="nyt-mandate" /><ref name="new-yorker-klein" />

President ] ] in 1993<ref name="nyt-mandate"/> that ultimately failed.<ref>{{cite news |last1=Cohn |first1=Bob |last2=Clift |first2=Eleanor |date=September 18, 1994 |url=http://www.newsweek.com/lost-chance-188330 |title=The Lost Chance |work=] |access-date=July 2, 2012 |archive-date=July 3, 2014 |archive-url=https://web.archive.org/web/20140703045920/http://www.newsweek.com/lost-chance-188330 |url-status=live }}</ref> Clinton negotiated a compromise with the ] to instead enact the ] in 1997.<ref>{{Cite journal|title=The Politics of EPSDT Policy in the 1990s: Policy Entrepreneurs, Political Streams, and Children's Health Benefits|first1=Alice|last1=Sardell|first2=Kay|last2=Johnson|date=June 19, 1998|journal=The Milbank Quarterly|volume=76|issue=2|pages=175–205|doi=10.1111/1468-0009.00086|pmid=9614420|pmc=2751076}}</ref> The failed Clinton plan 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.
]

The 1993 Republican ], contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'.<ref name="kaiserhealthnews1993" /> Advocates included prominent Republican senators such as ], ], ], ] and ].<ref>{{cite news |url=https://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |title=In 1993, Republicans Proposed A Mandate First |work = All things considered |archive-url = https://web.archive.org/web/20120401185114/https://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first | archive-date = 1 April 2012 |publisher=]|first1 = Guy | first2= Bob |last1= Raz | format = Radio interview and transcript |last2 = Bennett |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 |access-date=July 24, 2012 |archive-date=February 14, 2020 |archive-url=https://web.archive.org/web/20200214191918/https://healthcarereform.procon.org/view.resource.php?resourceID=004182 |url-status=live }}</ref> The 1994 Republican Consumer Choice Health Security Act, initially contained an individual mandate with a penalty provision;<ref>{{cite web |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |newspaper=Colorado Statesman |last =Carroll | first = Terrance D.| issn = 2577-2317 | oclc = 9542060 | format = Letter to the editor |url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |access-date=July 29, 2012 |url-status=dead |archive-date=April 18, 2010 |archive-url=https://web.archive.org/web/20100418180533/http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit}}</ref> however, author ] subsequently removed the mandate, stating, "government should not compel people to buy health insurance".<ref>{{cite news |url=https://www.nytimes.com/2012/02/27/opinion/gop-and-health-mandate.html |issn=0362-4331 |oclc=1645522 |work=] |title=G.O.P. and Health Mandate |date=February 26, 2012 |access-date=February 7, 2017 |archive-date=January 30, 2018 |archive-url=https://web.archive.org/web/20180130223905/http://www.nytimes.com/2012/02/27/opinion/gop-and-health-mandate.html |url-status=live }}</ref> At the time of these proposals, Republicans did not raise constitutional issues; 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" />
] went from 90% of its residents insured to 98%, the highest rate in the nation.<ref>{{cite news | first1 = Drew | last1 =Armstrong |first2 = Alex | last2 = Wayne |url=https://www.bloomberg.com/news/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law.html | archive-url = https://web.archive.org/web/20160313090332/https://www.bloomberg.com/news/articles/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law | archive-date = March 13, 2016 |website =Bloomberg |title=Romneycare's 98% Success Rate Defies Gripes on Obama Law |date=March 26, 2012}}</ref>]]

In 2006, ] was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an ]. Republican Governor ] used a line-item veto on some provisions, and the Democratic legislature overrode some of his changes (including the mandate).<ref name="governorromney" /> Romney's implementation of the ] and 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 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 Republican Senator ] and Democratic Senator ] introduced the ], which featured an individual mandate and state-based, ] called "State Health Help Agencies".<ref name="new-yorker-klein" /><ref name="new-yorker-lizza" /> The bill attracted bipartisan support, but died in committee. Many of its ] remained in Congress during the 2008 healthcare debate.<ref name="S.334summary" />

By 2008 many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill<ref name="kaiserhealthnews1993" /> and that it took ideas from the Massachusetts reforms.<ref>{{cite news |url=http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/06/28/romneycare_vs_obamacare |title=RomneyCare vs. ObamaCare |work=] |date=June 28, 2011 |first=Robert |last=Kuttner |access-date=September 23, 2013 |archive-date=December 17, 2015 |archive-url=https://web.archive.org/web/20151217080334/http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2011/06/28/romneycare_vs_obamacare/ |url-status=live }}</ref>

=== Academic foundation ===
A driving force behind Obama's healthcare reform was ], Director of the ].<ref>{{Cite news |last=Klein |first=Ezra |date=December 11, 2008 |title=The Number-Cruncher-in-Chief |work=THE AMERICAN PROSPECT}}</ref> Obama called Orszag his "healthcare czar" because of his knowledge of healthcare reform.<ref>{{Cite news |last=Kantor |first=Jodi |date=March 27, 2009 |title=Obama's Man on the Budget: Just 40 and Going Like 60 |issn=0362-4331 |oclc=1645522 |work=] |url=https://www.nytimes.com/2009/03/28/us/politics/28orszag.html |access-date=November 29, 2021 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701042641/https://www.nytimes.com/2009/03/28/us/politics/28orszag.html |url-status=live }}</ref> Orszag had previously been director of the ], and under his leadership the agency had focused on using cost analysis to create an affordable and effective approach to health care reform. Orszag claimed that healthcare reform became Obama's top agenda item because he wanted it to be his legacy.<ref>Suskind, Ron; ''Confidence Men, Wall Street, Washington, and the Education of a President.'' Harper Collins Publishing. pg. 140</ref> According to an article by Ryan Lizza in ''The New Yorker'', the core of "the Obama budget is Orszag's belief ...a government empowered with research on the most effective medical treatments". Obama bet "his presidency on Orszag's thesis of comparative effectiveness."<ref>{{Cite magazine |last=Lizza |first=Ryan |date=April 26, 2009 |title=Money Talk: Can Peter Orszag keep the President's political goals economically viable? |magazine=] |url=https://www.newyorker.com/magazine/2009/05/04/money-talks-4 |access-date=November 29, 2021 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701042643/https://www.newyorker.com/magazine/2009/05/04/money-talks-4 |url-status=live }}</ref> Orszag's policies were influenced by an article in ''The Annals of Internal Medicine''<ref>{{Cite journal |last1=Fisher |first1=Elliott S. |last2=Wennberg |first2=David E. |last3=Stukel |first3=Thrse A. |last4=Gottlieb |first4=Daniel J. |last5=Lucas |first5=F. L. |last6=Pinder |first6=Étoile L. |date=February 18, 2003 |title=The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care |journal=Annals of Internal Medicine |volume=138 |issue=4 |pages=273–287 |doi=10.7326/0003-4819-138-4-200302180-00006 |pmid=12585825 |s2cid=27581938}}</ref> co-authored by Elliott S. Fisher, David Wennberg and others. The article presented strong evidence based on the co-authors' research that numerous procedures, therapies and tests were being delivered with scant evidence of their medical value. If those procedures and tests could be eliminated, this evidence suggested, medical costs might provide the savings to give healthcare to the uninsured population.<ref>{{Cite news |date=November 25, 2007 |department=Editorial |title=The High Cost of Health Care |page=WK9(L) |issn=0362-4331 |oclc=1645522 |work=] |url=https://www.nytimes.com/2007/11/25/opinion/25sun1.html |url-access=subscription |access-date=June 22, 2022 |archive-date=June 22, 2022 |archive-url=https://web.archive.org/web/20220622233656/https://www.nytimes.com/2007/11/25/opinion/25sun1.html |url-status=live }}</ref> After reading a ''New Yorker'' article that used the "Dartmouth findings"<ref>{{Cite news |last=Gawande |first=Atul |date=May 25, 2009 |title=The Cost Conundrum: What a Texas town can teach us about health care |magazine=] |url=https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum |access-date=November 29, 2021 |archive-date=October 4, 2019 |archive-url=https://web.archive.org/web/20191004181959/https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum |url-status=live }}</ref> to compare two counties in Texas with enormous variations in Medicare costs using hard data, Obama directed that his entire staff read it.<ref>Suskind, Ron; ''Confidence Men, Wall Street, Washington, and the Education of a President.'' Harper Collins Publishing.&nbsp; pg. 324</ref> More than anything else, the Dartmouth data intrigued Obama<ref>{{Cite news |last=Leonhardt |first=David |date=April 28, 2009 |title=After the Great Recession |issn=0362-4331 |oclc=1645522 |format=Magazine |work=] |url=https://www.nytimes.com/2009/05/03/magazine/03Obama-t.html |access-date=November 29, 2021 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701042644/https://www.nytimes.com/2009/05/03/magazine/03Obama-t.html |url-status=live }}</ref> since it gave him an academic rationale for reshaping medicine.<ref>Suskind, Ron; Confidence Men, Wall Street, Washington, and the Education of a President. Harper Collins Publishing. pg. 321</ref>

The concept of comparing the effectiveness of healthcare options based on hard data ("comparative effectiveness" and "evidence-based medicine") was pioneered by John E. Wennberg, founder of ], co-founder of The Foundation for Informed Medical Decision Making and senior advisor to Health Dialog Inc., a venture that he and his researchers created to help insurers implement the Dartmouth findings.

===Healthcare debate, 2008–10===

{{See also|Health care reforms proposed during the Obama administration}}

Healthcare reform was a major topic during the ]. As the race narrowed, attention focused on the plans presented by the two leading candidates, ] and the eventual nominee, ]. Each candidate proposed a plan to cover the approximately 45&nbsp;million Americans estimated to not have health insurance at some point each year. Clinton's proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a ] without a mandate.<ref name="promise" /><ref>{{cite news |title=CNN Democratic presidential debate |url=http://www.cnn.com/2008/POLITICS/01/21/debate.transcript2/ |publisher=] |date=January 21, 2008 |access-date=September 26, 2013 |archive-date=October 29, 2013 |archive-url=https://web.archive.org/web/20131029221240/http://www.cnn.com/2008/POLITICS/01/21/debate.transcript2/ |url-status=live }}</ref>

During the ], Obama said fixing healthcare would be one of his top four priorities as president.<ref name="Sep2008FirstPresidentialDebate" /> Obama and his opponent, Senator ], both proposed health insurance reforms, though their plans differed. McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2{{nbsp}}million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost.<ref>{{Cite web |last1=Rustgi |first1=Sheila |last2=Collins |first2=Sara R. |last3=Davis |first3=Karen |last4=Nicholson |first4=Jennifer L. |title=The 2008 Presidential Candidates' Health Reform Proposals: Choices for America |website=The Commonwealth Fund |date=October 2008 |url=http://www.commonwealthfund.org/publications/fund-reports/2008/oct/the-2008-presidential-candidates-health-reform-proposals--choices-for-america |access-date=January 24, 2017 |archive-date=April 19, 2018 |archive-url=https://web.archive.org/web/20180419053058/http://www.commonwealthfund.org/publications/fund-reports/2008/oct/the-2008-presidential-candidates-health-reform-proposals--choices-for-america |url-status=live }}</ref>
], September 9, 2009]]

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" /><ref name="reuterstimeline" /> By July, a series of bills were approved by committees within the ].<ref name="EdLaborJul2009" /> On the Senate side, from June to September, the ] held a series of 31 meetings to develop a proposal. This group—in particular, Democrats ], ] and ], along with Republicans ], ] and ]—met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the foundation of a Senate bill.<ref>{{cite web |title=Health Care Reform from Conception to Final Passage |url=http://finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65 |access-date=November 23, 2010 |archive-date=July 16, 2015 |archive-url=https://web.archive.org/web/20150716154102/http://www.finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65 |url-status=live }}</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 |archive-url=https://archive.today/20120802043711/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 |url-status=dead |archive-date=August 2, 2012 |title=Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN |publisher=] |access-date=November 30, 2010 }}</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 |access-date=April 1, 2012 |url-status=dead |archive-url=https://web.archive.org/web/20130111185729/http://www.finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |archive-date=January 11, 2013}}</ref>

Congressional Democrats and health policy experts, such as ] economics professor ]<ref name="GruberBio2" /> and ], argued that ] would require both ] and an individual mandate to ensure that ] or ] would not result in an ].<ref name="HowTheyDidIt" /> They chose this approach after concluding that ] in the Senate was not present for more progressive plans such as ]. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate Majority Leaders ], ], ] and ]—the bill's drafters hoped to garner the necessary votes.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/health-care/party-is-such-sweet-sorrow |title=Party Is Such Sweet Sorrow |magazine=] |date=September 4, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922034246/http://www.newrepublic.com/article/health-care/party-is-such-sweet-sorrow |url-status=live }}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |title=Obama's Moderate Health Care Plan |magazine=] |date=April 22, 2010 |access-date=March 10, 2017 |archive-date=September 12, 2015 |archive-url=https://web.archive.org/web/20150912072533/http://www.newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |url-status=live }}<br />{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |magazine=] |date=December 19, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922012607/http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |url-status=live }}</ref>

However, following the incorporation of an individual mandate into the proposal, Republicans threatened to ] any bill that contained it.<ref name="forbes1" /> ] ], who led the Republican response, concluded Republicans should not support the bill.<ref name="ChaitLegislativeStrategy" />

Republican senators, including those who had supported earlier proposals with a similar mandate, began to describe the mandate as "unconstitutional". Journalist ] wrote in '']'', "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."<ref name="new-yorker-klein" />

The reform attracted attention from ],<ref>{{cite news |first1=Joe |last1=Eaton |first2=M. B. |last2=Pell |first3=Aaron |last3=Mehta |url=https://www.npr.org/templates/story/story.php?storyId=125170643 |title=Lobbying Giants Cash In On Health Overhaul |publisher=] |date=March 26, 2010 |access-date=April 9, 2012 |archive-date=February 7, 2021 |archive-url=https://web.archive.org/web/20210207141855/https://www.npr.org/templates/story/story.php?storyId=125170643 |url-status=live }}</ref> including deals between lobby groups and the advocates to win the support of groups who had opposed past proposals.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/politics/drug-deal |title=Drug Deal |magazine=] |date=August 25, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922004502/http://www.newrepublic.com/article/politics/drug-deal |url-status=live }}</ref><ref>{{cite news |url=http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html |work=] |first=Ryan |last=Grim |title=Internal Memo Confirms Big Giveaways In White House Deal With Big Pharma |date=August 13, 2009 |access-date=March 13, 2012 |archive-date=March 15, 2012 |archive-url=https://web.archive.org/web/20120315191425/http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html |url-status=live }}</ref><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 |access-date=April 1, 2012 |archive-url=https://web.archive.org/web/20120405053508/http://sunlightfoundation.com/projects/2009/healthcare_lobbyist_complex/ |archive-date=April 5, 2012 |url-status=dead }}</ref>
], September 12, 2009]]

During the August 2009 summer congressional recess, many members went back to their districts and held town hall meetings on the proposals. The nascent ] organized protests and many ] groups and individuals attended the meetings to oppose the proposed reforms.<ref name="reuterstimeline" /> Threats were made against members of Congress over the course of the debate.<ref name="WashPost-04092010" />

In September 2009 ] supporting the negotiations.<ref name="Sep2009JointAddress" /> 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. The ] requires all revenue-related bills to originate in the House.<ref name="Const-Revenue" /> To formally comply with this requirement, the Senate repurposed H.R. 3590, a bill regarding housing tax changes for service members.<ref name="ServicemembersHomeOwnershipTaxAct" /> It had been passed by the House as a revenue-related modification to the ]. The bill became the Senate's vehicle for its healthcare reform proposal, discarding the bill's original content.<ref>{{USBill|111|S.AMDT.|2786}}</ref> The bill ultimately incorporated elements of proposals that were reported favorably by the Senate ] and ] committees. With the Republican Senate minority vowing to ], 60 votes would be necessary to pass the Senate.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/why-reform-survived-august |title=Why Reform Survived August |magazine=] |date=September 7, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922032138/http://www.newrepublic.com/blog/the-treatment/why-reform-survived-august |url-status=live }}</ref> At the start of the ], Democrats had 58 votes. The ] was ultimately won by Democrat ], making 59. ] switched to the Democratic party in April 2009, giving them 60 seats, enough to end a filibuster.

Negotiations were undertaken attempting to satisfy moderate Democrats and to bring Republican senators aboard; particular attention was given to Republicans Bennett, Enzi, Grassley and Snowe.

After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. ] ] focused on satisfying centrists. The holdouts came down to ] of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat ]. Lieberman's demand that the bill not include a ]<ref name="HowTheyDidIt" /><ref name="HackerReform" /> was met,<ref name="PublicOption" /> although supporters won various concessions, including allowing state-based public options such as Vermont's failed ].<ref name="PublicOption" /><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/what-public-option-supporters-won |title=What Public Option Supporters Won |magazine=] |date=December 15, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922010420/http://www.newrepublic.com/blog/the-treatment/what-public-option-supporters-won |url-status=live }}</ref>
[[File:111th Congress 1st session Senate roll call 396.svg|thumb|upright=1.35|'''Senate vote by state'''
{{legend|#008|Democratic yes (58)}}
{{legend|#888|Independent yes (2)}}
{{legend|#800|Republican no (39)}}
{{legend|#F55|Republican not voting (1)}}]]

The White House and Reid addressed Nelson's concerns<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/ben-nelson-still-big-problem |title=Ben Nelson, Still a Big Problem (Updated) |magazine=] |date=December 17, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922021838/http://www.newrepublic.com/blog/the-treatment/ben-nelson-still-big-problem |url-status=live }}</ref> during a 13-hour negotiation with two concessions: a compromise on ], 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 |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/breaking-nelson-says-yes-makes-60 |title=Nelson Says Yes; That Makes 60 |magazine=] |date=December 19, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922005945/http://www.newrepublic.com/blog/the-treatment/breaking-nelson-says-yes-makes-60 |url-status=live }}</ref> The latter half of the compromise was derisively termed the "Cornhusker Kickback"<ref>{{cite news |title={{-'}}Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment |url=https://www.foxnews.com/politics/cornhusker-out-more-deals-in-health-care-bill-gives-special-treatment/ |date=March 19, 2010 |publisher=] |access-date=April 26, 2010 |archive-date=May 25, 2010 |archive-url=https://web.archive.org/web/20100525144812/http://www.foxnews.com/politics/2010/03/18/cornhusker-kickback-gets-boot-health/ |url-status=live }}</ref> and was later removed.

On December 23, the Senate voted 60–39 to end debate on the bill: a ] to end the ].<ref>{{cite web |url=https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00395 |title=Roll Call vote No. 395 – On the Cloture Motion (Motion to Invoke Cloture on H.R. 3590) |publisher=] |access-date=July 20, 2017 |archive-date=September 3, 2009 |archive-url=https://web.archive.org/web/20090903095012/https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00395 |url-status=live }}</ref> The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except ], who did not vote).<ref name="USS RC 2009-396" /> The bill was endorsed by the ] and ].<ref> {{Webarchive|url=https://web.archive.org/web/20160303203029/http://www.huffingtonpost.com/2010/03/19/aarp-ama-announce-support_n_506060.html |date=March 3, 2016 }}. ''The Huffington Post'', March 19, 2010.</ref>

On January 19, 2010, ] Republican ] was ] to replace the recently deceased ], having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.<ref name="reuterstimeline" /><ref>{{cite news |first=J. Scott |last=Applewhite |agency=] |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 |access-date=April 19, 2012 |archive-date=September 16, 2018 |archive-url=https://web.archive.org/web/20180916052413/https://www.cleveland.com/nation/index.ssf/2010/01/senator-elect_scott_brown_welc.html |url-status=live }}</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 |access-date=April 9, 2012 |archive-date=September 16, 2018 |archive-url=https://web.archive.org/web/20180916052308/https://votesmart.org/public-statement/477580/scott-brown-responds-to-martha-coakleys-misleading-health-care-distortions |url-status=live }}</ref> Additionally, the symbolic importance of losing Kennedy's ] made many Congressional Democrats concerned about the political cost of the bill.<ref>{{cite news |first=Nate |last=Silver |url=http://www.fivethirtyeight.com/2010/01/will-base-abandon-hope.html |title=Will the Base Abandon Hope? |work=] |date=January 21, 2010 |access-date=July 28, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921061425/http://www.fivethirtyeight.com/2010/01/will-base-abandon-hope.html |url-status=dead }}</ref><ref name="BillPassageOptions" />

====House====

[[File:111th Congress roll call 165.svg|thumb|upright=1.35|'''House vote by congressional district'''
{{legend|#000080|Democratic yes (219)}}
{{legend|#5050FF|Democratic no (34)}}
{{legend|#800000|Republican no (178)}}
{{legend|#C8C8C8|No representative seated (4)}}]]
[[File:United States 2024.svg|thumb|House vote by agreement.{{legend|#00ff00|Yes (219)}}
{{legend|#FF00FF|No (212)}}
{{legend|#c8c8c8|No representative seated (4)}}[[File:Obamacare 2010byparty.svg|thumb|House vote by party

{{legend|#000080|Democratic yes (219)}}
{{legend|#5050FF|Democratic no (34)}}
{{legend|#800000|Republican no (178)}}
{{legend|#C8C8C8|No representative seated (4)}}]]]]



With Democrats no longer able to get the 60 votes to break a filibuster in the Senate, ] ] argued that Democrats should scale back to a less ambitious bill, but ] ] pushed back, dismissing more moderate reform as "Kiddie Care".<ref name="nytimesjourney" /><ref name="PoliticoPelosi" />

Obama remained insistent on comprehensive reform. The news that ] in ] intended to raise premium rates for its patients by as much as 39% gave him new evidence of the need for reform.<ref name="nytimesjourney" /><ref name="PoliticoPelosi" /> On February 22, he laid out a "Senate-leaning" proposal to consolidate the bills.<ref>{{cite web |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=Kaiser Health News |date=February 22, 2010 |access-date=June 29, 2012 |archive-date=May 25, 2012 |archive-url=https://web.archive.org/web/20120525133004/http://www.kaiserhealthnews.org/Daily-Reports/2010/February/22/President-Obama-Health-Care-Reform-Plan.aspx |url-status=live }}</ref> He held a meeting with both parties' leaders on February 25. The Democrats decided the House would pass the Senate's bill, to avoid another Senate vote.

House Democrats had expected to be able to negotiate changes ] before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass 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 by the ].<ref name="nytimesjourney" /><ref name="Reconciliationprimer" /><ref name="538Paths218" />

Per the ], reconciliation cannot be subject to a ]. But reconciliation is ], which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations.<ref>{{cite news |first=Nate |last=Silver |url=http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |title=1. Reconciliation! 2. ??? 3. Profit! |work=] |date=January 21, 2010 |access-date=July 28, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921061506/http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |url-status=dead }}</ref><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |title=Reconciliation: Why Most Dems Don't Want to Go There |magazine=] |date=September 21, 2009 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922031717/http://www.newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |url-status=live }}</ref> Although the already-passed Senate bill could not have been passed by 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 ] Democrats led by ] who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their concerns, but they could not address abortion in the reconciliation bill as it would be non-budgetary. Instead, Obama issued ], reaffirming the principles in the ] to continue banning the use of federal funds for abortion.<ref name="EO13535" /><ref>{{Cite web |last1=Salganicoff |first1=Alina |last2=Sobel |first2=Laurie |last3=Gomez |first3=Ivette |last4=Published |first4=Amrutha Ramaswamy |date=2024-03-14 |title=The Hyde Amendment and Coverage for Abortion Services Under Medicaid in the Post-Roe Era |url=https://www.kff.org/womens-health-policy/issue-brief/the-hyde-amendment-and-coverage-for-abortion-services-under-medicaid-in-the-post-roe-era/ |access-date=2024-11-07 |website=KFF |language=en-US}}</ref> This won the support of Stupak and members of his group and assured the bill's passage.<ref name="538Paths218" /><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/stupak-makes-deal-reform-pass |title=Stupak Makes A Deal, Reform To Pass |magazine=] |date=March 21, 2010 |access-date=March 10, 2017 |archive-date=September 12, 2015 |archive-url=https://web.archive.org/web/20150912072349/http://www.newrepublic.com/blog/jonathan-chait/stupak-makes-deal-reform-pass |url-status=live }}</ref> The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.<ref name="USH RC 2010-165" /> It passed the ], by 220–211, the same day (with the Senate passing this bill via reconciliation by 56-43 a few days later). The day after the passage of ACA, March 22, Republicans introduced legislation to repeal it.<ref name="PelosiSawyer" /> Obama signed ACA into law on March 23, 2010.<ref name="24health"/>

===Post-enactment===

Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act more than sixty times.<ref>{{cite web |url=http://www.msnbc.com/rachel-maddow-show/groundhog-day-republicans-vote-repeal-obamacare |title=On Groundhog Day, Republicans vote to repeal Obamacare |author=Benen, Steve |date=February 2, 2016 |publisher=] |access-date=October 30, 2016 |archive-date=February 2, 2016 |archive-url=https://web.archive.org/web/20160202205114/http://www.msnbc.com/rachel-maddow-show/groundhog-day-republicans-vote-repeal-obamacare |url-status=live }}</ref>

The ] eliminated the fine for violating the individual mandate, starting in 2019. (The requirement itself is still in effect.)<ref name="auto" /> In 2019 Congress repealed the so-called "Cadillac" tax on health insurance benefits, an excise tax on medical devices, and the Health Insurance Tax.<ref name="auto1"/>

The ], enacted during the ], expanded subsidies for marketplace health plans. A continuation of these subsidies was introduced as part of the ].

==Impact==

]
]

===Coverage===

{{See also|Health insurance coverage in the United States}}

The law caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% from January to June 2016.<ref>{{Cite web |url=https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201611_01.pdf |title=National Health Interview Survey, January to June 2016 |website=CDC.gov |access-date=November 23, 2016 |archive-date=November 24, 2016 |archive-url=https://web.archive.org/web/20161124093831/https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201611_01.pdf |url-status=live }}</ref> The uninsured rate dropped in every congressional district in the U.S. from 2013 to 2015.<ref>{{cite news |last1=Barry-Jester |first1=Anna Maria |last2=Ben |first2=Casselman |title=Obamacare Has Increased Insurance Coverage Everywhere |url=http://fivethirtyeight.com/features/obamacare-has-increased-insurance-coverage-everywhere/ |access-date=October 12, 2016 |work=] |date=September 22, 2016 |archive-date=October 12, 2016 |archive-url=https://web.archive.org/web/20161012232043/http://fivethirtyeight.com/features/obamacare-has-increased-insurance-coverage-everywhere/ |url-status=live }}</ref> The ] reported in March 2016 that approximately 12 million people were covered by the exchanges (10 million of whom received subsidies) and 11 million added to Medicaid. Another million were covered by ACA's "Basic Health Program", for a total of 24 million.<ref name="CBO_Subsidy2016">{{Cite web |url=https://www.cbo.gov/publication/51385 |title=Federal Subsidies for Health Insurance Coverage for People Under Age 65:2016 to 2026 |website=United States. Congressional Budget Office |archive-url=https://web.archive.org/web/20161209084800/https://www.cbo.gov/publication/51385 |archive-date=December 9, 2016 |format=Report |date=March 24, 2016 |access-date=November 23, 2016}}</ref> CBO estimated that ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4{{nbsp}}million for reductions in "employment-based coverage" and "non-group and other coverage".<ref name="CBO_Subsidy2016" />

The ] (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016;<ref name="HHS_ASPE16" /> similarly, the ] found in 2016 that 19.2 million non-elderly Americans gained health insurance coverage from 2010 to 2015.<ref>{{cite web |url=http://www.urban.org/sites/default/files/publication/86761/2001041-who-gained-health-insurance-coverage-under-the-aca-and-where-do-they-live.pdf |title=Who Gained Health Insurance Coverage Under the ACA, and Where Do They Live? |work=Urban Institute |date=December 2016 |access-date=April 22, 2017 |author=Garrett, Bowen |pages=2 |archive-date=March 1, 2021 |archive-url=https://web.archive.org/web/20210301141240/https://www.urban.org/sites/default/files/publication/86761/2001041-who-gained-health-insurance-coverage-under-the-aca-and-where-do-they-live.pdf |url-status=live }}</ref> In 2016, CBO estimated the uninsured at approximately 27 million people, or around 10% of the population or 7–8% excluding unauthorized immigrants.<ref name="CBO_Subsidy2016" />

States that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not had a 14.1% uninsured rate, among adults aged 18–64.<ref name="Urban_Q12016">{{Cite web |url=http://hrms.urban.org/briefs/health-insurance-coverage-ACA-March-2016.html |title=Health Reform Monitoring Survey |access-date=December 5, 2016 |archive-date=November 21, 2016 |archive-url=https://web.archive.org/web/20161121020226/http://hrms.urban.org/briefs/health-insurance-coverage-ACA-March-2016.html |url-status=dead }}</ref> As of December 2016 32 states (including Washington DC) had adopted the Medicaid extension.<ref name=KFF-Medicaid/>

A 2017 study found that the ACA reduced socioeconomic disparities in health care access.<ref>{{Cite journal |last1=Griffith |first1=Kevin |last2=Evans |first2=Leigh |last3=Bor |first3=Jacob |date=August 1, 2017 |title=The Affordable Care Act Reduced Socioeconomic Disparities In Health Care Access |journal=Health Affairs |volume=36 |issue=8 |pages=1503–1510 |doi=10.1377/hlthaff.2017.0083 |pmid=28747321 |pmc=8087201 |publisher=Project HOPE |oclc=07760874 |issn=0278-2715}}</ref>

The Affordable Care Act reduced the percent of Americans between 18 and 64 who were uninsured from 22.3 percent in 2010 to 12.4 percent in 2016. About 21 million more people have coverage ten years after the enactment of the ACA.<ref>{{cite news |last1=Slavitt |first1=Andy |title=Affordable Care Act at 10: Amid coronavirus, never more popular, threatened or necessary |url=https://eu.usatoday.com/story/opinion/2020/03/23/obamacare-10th-anniversary-amid-coronavirus-column/2888511001/ |access-date=March 31, 2020 |work=]|date=March 23, 2020 |archive-url=https://web.archive.org/web/20200331233236/https://www.usatoday.com/story/opinion/2020/03/23/obamacare-10th-anniversary-amid-coronavirus-column/2888511001/ |archive-date=March 31, 2020}}</ref><ref name=NYT20200323GoodnoughAbelsonetAl>{{cite news |author=Goodnough, Abby |author2=Abelson, Reed |author3=Sanger-Katz, Margot |author4=Kliff, Sarah |title=Obamacare Turns 10. Here's a Look at What Works and Doesn't. |url=https://www.nytimes.com/2020/03/23/health/obamacare-aca-coverage-cost-history.html |access-date=March 31, 2020 |date=March 23, 2020 |archive-url=https://web.archive.org/web/20200330105840/https://www.nytimes.com/2020/03/23/health/obamacare-aca-coverage-cost-history.html |archive-date=March 30, 2020 |issn=0362-4331 |oclc=1645522 |newspaper=]}}</ref> Ten years after its enactment studies showed that the ACA also had a positive effect on health and caused a reduction in mortality.<ref name=NYT20200323GoodnoughAbelsonetAl />

===Taxes===
]

] from the Affordable Care Act raised $16.3 billion in ] 2015. $11.3 billion came from an excise tax placed directly on health insurers based on their market share. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs.

The ] tax was $695 per individual or $2,085 per family at a minimum, reaching as high as 2.5% of household income (whichever was higher). The tax was set to $0 beginning in 2019.<ref>{{Cite web |url=https://www.fool.com/taxes/2018/01/07/what-the-individual-mandate-repeal-means-for-the-a.aspx |title=What the Individual Mandate Repeal Means for the Average American - |last=Caplinger |first=Dan |date=January 7, 2018 |website=The Motley Fool |access-date=July 20, 2018 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308005204/https://www.fool.com/taxes/2018/01/07/what-the-individual-mandate-repeal-means-for-the-a.aspx |url-status=live }}</ref>

In the fiscal year 2018, the individual and employer mandates yielded $4 billion each. Excise taxes on insurers and drug makers added $18 billion. Income tax surcharges produced 437 billion.<ref>{{Cite web |url=https://www.taxpolicycenter.org/briefing-book/what-tax-changes-did-affordable-care-act-make |title=What tax changes did the Affordable Care Act make? |website=Tax Policy Center |access-date=July 20, 2018 |archive-date=February 23, 2021 |archive-url=https://web.archive.org/web/20210223220331/https://www.taxpolicycenter.org/briefing-book/what-tax-changes-did-affordable-care-act-make |url-status=live }}</ref>

ACA reduced income inequality measured after taxes, due to the income tax surcharges and subsidies.<ref>{{Cite web |url=https://obamawhitehouse.archives.gov/sites/default/files/page/files/20160923_record_inequality_cea.pdf |title=The Economic Record of the Obama Administration: Progress Reducing Inequality |url-status=live |archive-url=https://web.archive.org/web/20170120220838/https://obamawhitehouse.archives.gov/sites/default/files/page/files/20160923_record_inequality_cea.pdf |archive-date=January 20, 2017|via=] |work=] |access-date=December 6, 2016}}</ref> CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. The tax subsidy for the employer market, was approximately $1,700 per person in 2016, or $266 billion total.<ref name="CBO_Subsidy2016" />

===Insurance exchanges===

{{Main|Health insurance marketplace}}

As of August 2016, 15 states operated their own ]. Other states either used the federal exchange, or operated in partnership with or supported by the federal government.<ref name=":0" /> By 2019, 12 states and Washington DC operated their own exchanges.<ref>{{Cite web |url=https://www.healthcare.gov/marketplace-in-your-state/ |title=The Marketplace in your state |website=HealthCare.gov |access-date=November 29, 2019 |archive-date=March 20, 2021 |archive-url=https://web.archive.org/web/20210320032745/https://www.healthcare.gov/marketplace-in-your-state/ |url-status=live }}</ref>

===Medicaid expansion in practice===

] by state.<ref name=KFF-Medicaid>{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |date=December 2023 |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map |publisher=]. Map is updated as changes occur. Click on states for details. |access-date=July 26, 2023 |archive-date=June 24, 2022 |archive-url=https://web.archive.org/web/20220624102415/https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ |url-status=live }}</ref>
{{legend|#2b83ba|Not adopted}}
{{legend|#89CC7F|Adopted}}
{{legend|#FECDAC|Implemented}}]]

As of December 2019, 37 states (including Washington DC) had adopted the Medicaid extension.<ref name=KFF-Medicaid/> Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while the others had a 14.1% uninsured rate, among adults aged 18 to 64.<ref name="Urban_Q12016" /> Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they did not expand Medicaid under ACA, several states rejected the option. Over half the national uninsured population lived in those states.<ref name="NYT52413" />

The ] (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9{{nbsp}}to 10 million people had gained Medicaid coverage, mostly low-income adults.{{citation needed|date=September 2022}} The ] estimated in October 2015 that 3.1 million additional people were not covered because of states that rejected the Medicaid expansion.<ref>{{cite journal |last1=Artiga |first1=Samantha |last2=Hill |first2=Latoya |last3=Orgera |first3=Kendal |last4=Damico |first4=Anthony |title=Health Coverage by Race and Ethnicity, 2010-2019 |journal=] |date=16 July 2021 |url=https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/ |access-date=23 June 2022 |archive-date=20 August 2021 |archive-url=https://web.archive.org/web/20210820215024/https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/}}</ref><ref>{{Cite web |url=http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/ |title=The Impact of the Coverage Gap for Adults in States not Expanding Medicaid |date=October 26, 2015 |access-date=February 26, 2017 |archive-date=December 20, 2013 |archive-url=https://web.archive.org/web/20131220003457/http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/ |url-status=live }}</ref>

In many states income thresholds were significantly below 133% of the poverty line.<ref name="Kliff, Sarah" /> Many states did not make Medicaid available to childless adults at any income level.<ref name="HealthCare Reform Magazine" /> Because subsidies on exchange insurance plans were not available to those below the poverty line, such individuals had no new options.<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=] |date=July 17, 2013 |access-date=July 26, 2013 |archive-date=May 1, 2014 |archive-url=https://web.archive.org/web/20140501030742/http://kff.org/medicaid/issue-brief/analyzing-the-impact-of-state-medicaid-expansion-decisions/ |url-status=live }}</ref><ref name="Families USA" /> For example, in Kansas, where only non-disabled adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance. Absent children, non-disabled adults were not eligible for Medicaid there.<ref name="NYT52413" />

Studies of the impact of Medicaid expansion rejections calculated that up to 6.4 million people would have too much income for Medicaid but not qualify for exchange subsidies.<ref>{{cite news |title=We Don't Know Everything About Obamacare. But We Know Who's Trying to Sabotage It |first=Jonathan |last=Cohn |magazine=] |date=July 19, 2013 |url=https://newrepublic.com/article/113947/obamacare-implementation-and-role-state-officials |access-date=March 10, 2017 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308190151/https://newrepublic.com/article/113947/obamacare-implementation-and-role-state-officials |url-status=live }}</ref> Several states argued that they could not afford the 10% contribution in 2020.<ref>{{cite web |last1=Udow-Phillips |first1=Marianne |last2=Fangmeier |first2=Joshua |last3=Buchmueller |first3=Thomas |last4=Levy |first4=Helen |title=The ACA's Medicaid Expansion: Michigan Impact |date=October 2012 |url=http://www.chrt.org/assets/price-of-care/CHRT-Issue-Brief-October-2012.pdf |publisher=Center for Healthcare Research & Transformation |location=Ann Arbor, MI |access-date=June 21, 2022 |type=Issue Brief |archive-date=October 30, 2012 |archive-url=https://web.archive.org/web/20121030055038/http://www.chrt.org/assets/price-of-care/CHRT-Issue-Brief-October-2012.pdf}}</ref><ref name="CNNMedicaid"/><ref name="Medicaiddeal"/> Some studies suggested rejecting the expansion would cost more due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,<ref>{{cite journal |last2=Eibner |first2=Christine |last1=Price |first1=Carter C. |title=For states that opt out of Medicaid expansion: 3.6 million fewer insured and $8.4 billion less in federal payments |journal=Health Affairs |date=2013 |volume=32 |issue=6 |pages=1030–1036 |doi=10.1377/hlthaff.2012.1019 |archive-url=https://web.archive.org/web/20160624174634/http://www.healthpolicyproject.org/Publications_files/Medicaid/2013/13-06-HealthAffairs-MedicaidExpCosts.pdf |archive-date=June 24, 2016 |pmid=23733976 |url=http://www.healthpolicyproject.org/Publications_files/Medicaid/2013/13-06-HealthAffairs-MedicaidExpCosts.pdf |access-date=21 June 2022 |publisher=Project HOPE: The People-to-People Health Foundation |location=Bethesda, MD |s2cid=23502669 |issn=1544-5208 |oclc=07760874}}</ref><ref>{{cite news |website=Wonkblog |issn=0190-8286 |oclc=2269358 |title=The terrible deal for states rejecting Medicaid |url=https://www.washingtonpost.com/news/wonk/wp/2013/06/04/wonkbook-the-terrible-deal-for-states-rejecting-medicaid/?variant=116ae929826d1fd3&variant=116ae929826d1fd3 |date=June 4, 2013 |archive-url=https://web.archive.org/web/20171122114327/https://www.washingtonpost.com/news/wonk/wp/2013/06/04/wonkbook-the-terrible-deal-for-states-rejecting-medicaid/ |archive-date=November 22, 2017 |publisher=] |last1=Klein |first1=Ezra |first2=Evan |last2=Soltas}}</ref>

A 2016 study found that residents of Kentucky and Arkansas, which both expanded Medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period.<ref name="Sommers"/><ref>{{Cite magazine |last=Rutkin |first=Aviva |url=https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans|magazine=New Scientist |title=Obamacare has already improved health of low-income Americans |archive-url=https://web.archive.org/web/20160920082511/https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans |archive-date=September 20, 2016 |publisher=Reed Elsevier |location=London |access-date=June 21, 2022}}</ref> Kentucky opted for increased managed care, while Arkansas subsidized private insurance. Later Arkansas and Kentucky governors proposed reducing or modifying their programs. From 2013 to 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas.<ref name="Sommers">{{cite journal |last2=Blendon |last3=Orav |last4=Epstein |first2=Robert J. |first3=E. John |first4=Arnold M. |last1=Sommers |first1=Benjamin D. |title=Changes in utilization and health among low-income adults after medicaid expansion or expanded private insurance |journal=JAMA Internal Medicine |date=October 2016 |volume=176 |issue=10 |pages=1501–1509 |doi=10.1001/jamainternmed.2016.4419 |pmid=27532694 |url=https://jamanetwork.com/journals/intemed/articlepdf/2542420/ioi160066.pdf |archive-url=https://web.archive.org/web/20220621144827if_/https://jamanetwork.com/journals/intemed/articlepdf/2542420/ioi160066.pdf |archive-date=21 June 2022 |access-date=21 June 2022 |publisher=American Medical Association |s2cid=7874611 |issn=2168-6114}}</ref><ref>{{Cite web |url=https://www.hsph.harvard.edu/news/press-releases/medicaid-expansion-aca-lbetter-health-care-improved-health-low-income-adults/ |title=Medicaid expansion under ACA linked with better health care, improved health for low-income adults |publisher=Harvard T.H. Chan School of Public Health |website=www.hsph.harvard.edu |access-date=August 30, 2016 |date=August 8, 2016 |archive-date=February 23, 2021 |archive-url=https://web.archive.org/web/20210223181609/https://www.hsph.harvard.edu/news/press-releases/medicaid-expansion-aca-lbetter-health-care-improved-health-low-income-adults/ |url-status=live }}</ref>

A 2016 ] study found that states that expanded Medicaid had lower premiums on exchange policies, because they had fewer low-income enrollees, whose health on average is worse than that of those with higher income.<ref>{{Cite news |url=https://www.nytimes.com/2016/08/26/upshot/how-expanding-medicaid-may-lower-insurance-premiums.html |title=How Expanding Medicaid Can Lower Insurance Premiums for All |last=Sanger-Katz |first=Margot |date=August 25, 2016 |newspaper=] |issn=1553-8095 |oclc=1645522 |access-date=September 4, 2016 |archive-date=November 12, 2020 |archive-url=https://web.archive.org/web/20201112024254/https://www.nytimes.com/2016/08/26/upshot/how-expanding-medicaid-may-lower-insurance-premiums.html |url-status=live }}</ref>

In September 2019, the Census Bureau reported that states that expanded Medicaid under the ACA had considerably lower uninsured rates than states that did not. For example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid.<ref name="Census_2018">{{Cite web |url=https://www.census.gov/library/publications/2019/demo/p60-267.html |title=Health Insurance Coverage in the United States: 2018 |date=September 10, 2019 |access-date=September 13, 2019 |archive-date=March 21, 2021 |archive-url=https://web.archive.org/web/20210321163104/https://www.census.gov/library/publications/2019/demo/p60-267.html |url-status=live }}</ref> The drop in uninsured rates due to expanded Medicaid has broadened access to care among low-income adults, with post-ACA studies indicating an improvement in affordability, access to doctors, and usual sources of care.<ref name="ACA_low_income" />

A study using national data from the Health Reform Monitoring Survey determined that unmet need due to cost and inability to pay medical bills significantly decreased among low-income (up to 138% FPL) and moderate-income (139-199% FPL) adults, with unmet need due to cost decreasing by approximately 11 percentage points among low-income adults by the second enrollment period.<ref name="ACA_low_income" /> Importantly, issues with cost-related unmet medical needs, skipped medications, paying medical bills, and annual out-of-pocket spending have been significantly reduced among low-income adults in Medicaid expansion states compared to non-expansion states.<ref name="ACA_low_income" />

As well, expanded Medicaid has led to a 6.6% increase in physician visits by low-income adults, as well as increased usage of preventative care such as dental visits and cancer screenings among childless, low-income adults.<ref name="ACA_low_income" /> Improved health care coverage due to Medicaid expansion has been found in a variety of patient populations, such as adults with mental and substance use disorders, trauma patients, cancer patients, and people living with HIV.<ref name="trauma_medicaid" /><ref name="HIV_medicaid" /><ref name="ACC_surgery_cancer" /><ref name="ACA_mental_2017" /> Compared to 2011–13, in 2014 there was a 5.4 percentage point reduction in the uninsured rate of adults with mental disorders (from 21.3% to 15.9%) and a 5.1 percentage point reduction in the uninsured rate of adults with substance use disorders (from 25.9% to 20.8%); with increases in coverage occurring primarily through Medicaid.<ref name="ACA_mental_2017" /> Use of mental health treatment increased by 2.1 percentage points, from 43% to 45.1%.<ref name="ACA_mental_2017" />

Among trauma patients nationwide, the uninsured rate has decreased by approximately 50%.<ref name="trauma_medicaid" /> Adult trauma patients in expansion states experienced a 13.7 percentage point reduction in uninsured rates compared to adult trauma patients in non-expansion states, and an accompanying 7.4 percentage point increase in discharge to rehabilitation.<ref>{{cite journal |title=Association of Medicaid Expansion With Access to Rehabilitative Care in Adult Trauma Patients |year=2019 |doi=10.1001/jamasurg.2018.5177 |last1=Zogg |first1=Cheryl K. |last2=Scott |first2=John W. |last3=Metcalfe |first3=David |last4=Gluck |first4=Abbe R. |last5=Curfman |first5=Gregory D. |last6=Davis |first6=Kimberly A. |last7=Dimick |first7=Justin B. |last8=Haider |first8=Adil H. |journal=JAMA Surgery |volume=154 |issue=5 |pages=402–411 |issn=2168-6262 |publisher=American Medical Association |pmid=30601888 |pmc=6537775}}</ref> Following Medicaid expansion and dependent coverage expansion, young adults hospitalized for acute traumatic injury in Maryland experienced a 60% increase in rehabilitation, 25% reduction in mortality, and a 29.8% reduction in failure-to-rescue.<ref>{{cite journal |title=Implications of the Patient Protection and Affordable Care Act on Insurance Coverage and Rehabilitation Use Among Young Adult Trauma Patients |year=2016 |doi=10.1001/jamasurg.2016.3609 |last1=Zogg |first1=Cheryl K. |last2=Payró Chew |first2=Fernando |last3=Scott |first3=John W. |last4=Wolf |first4=Lindsey L. |last5=Tsai |first5=Thomas C. |last6=Najjar |first6=Peter |last7=Olufajo |first7=Olubode A. |last8=Schneider |first8=Eric B. |last9=Haut |first9=Elliott R. |last10=Haider |first10=Adil H. |last11=Canner |first11=Joseph K. |journal=JAMA Surgery |volume=151 |issue=12 |pages=e163609 |issn=2168-6262 |publisher=American Medical Association |pmid=27760245 |s2cid=43605163 |doi-access=free }}</ref> Medicaid expansion's swift impact on cancer patients was demonstrated in a study using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that evaluated more than 850,000 patients diagnosed with breast, lung, colorectal, prostate cancer, or thyroid cancer from 2010 to 2014. The study found that a cancer diagnosis in 2014 was associated with a 1.9 percentage-point absolute and 33.5% relative decrease in uninsured rates compared to a diagnosis made between 2010 and 2013.<ref name="ACC_surgery_cancer" /> Another study, using Surveillance, Epidemiology, and End Results (SEER) Program data from 2010 to 2014, found that Medicaid expansion was associated with a 6.4% net increase in early stage (in situ, local, or regional) diagnoses of all cancers combined.<ref name="ACA_cancer_10yr" />

Data from the Centers for Disease and Prevention's (CDC) Medical Monitoring Project demonstrated that between 2009 and 2012, approximately 18% of people living with HIV (PLWH) who were actively receiving HIV treatment were uninsured<ref name="ACA_HIV" /> and that at least 40% of HIV-infected adults receiving treatment were insured through Medicaid or Medicare, programs they qualified for only once their disease was advanced enough to be covered as a disability under Social Security.<ref name="ACA_HIV" /> Expanded Medicaid coverage of PLWH has been positively associated with health outcomes such as viral suppression, retention of care, hospitalization rates, and morbidity at the time of hospitalization.<ref name="HIV_medicaid" /> An analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data found a 2.8% annual increase in viral suppression rates among all PLWH from 2010 to 2015 due to Medicaid expansion.<ref name="ACA_HIV_90" /> In Nebraska, PLWH newly covered by Medicaid expansion in 2013-14 were four times more likely to be virally suppressed than PLWH who were eligible but remained uninsured.<ref name="ACA_HIV_90" /> As an early adopter of Medicaid expansion, Massachusetts found a 65% rate of viral suppression among all PLWH and an 85% rate among those retained in healthcare in 2014, both substantially higher than the national average.<ref name="ACA_HIV_90" />

An analysis of hospital discharge data from 2012 to 2014 in four Medicaid expansion states and two non-expansion states revealed hospitalizations of uninsured PLWH fell from 13.7% to 5.5% in the four expansion states and rose from 14.5% to 15.7% in the two non-expansion states.<ref name="ACA_ryan_HIV_2019" /> Importantly, uninsured PLWH were 40% more likely to die in the hospital than insured PLWH.<ref name="ACA_ryan_HIV_2019" /> Other notable health outcomes associated with Medicaid expansion include improved glucose monitoring rates for patients with diabetes, better hypertension control, and reduced rates of major post-operative morbidity.<ref name="Medicaid_Expan_Sys_Rev" />

A July 2019 study by the National Bureau of Economic Research (NBER) indicated that states enacting Medicaid expansion exhibited statistically significant reductions in mortality rates.<ref>{{Cite book |last1=Miller |first1=Sarah |last2=Altekruse |first2=Sean |last3=Johnson |first3=Norman |last4=Wherry |first4=Laura |date=July 2019 |title=Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data |location=Cambridge, MA |publisher=National Bureau of Economic Research |series=NBER Working Paper No. 26081 |doi=10.3386/w26081 |s2cid=164463149 |url=http://www.nber.org/papers/w26081.pdf |access-date=March 29, 2022 |archive-date=April 19, 2022 |archive-url=https://web.archive.org/web/20220419004435/https://www.nber.org/system/files/working_papers/w26081/w26081.pdf |url-status=live }}</ref> From that study, states that took Medicaid expansion "saved the lives of at least 19,200 adults aged 55 to 64 over the four-year period from 2014 to 2017."<ref name=CBPP>Broaddus, Matt, & Aron-Dine, Aviva. (November 6, 2019). . Center on Budget and Policy Priorities. Archived at the on December 17, 2019.</ref> Further, 15,600 older adults died prematurely in the states that did not enact Medicaid expansion in those years according to the NBER research. "The lifesaving impacts of Medicaid expansion are large: an estimated 39 to 64 percent reduction in annual mortality rates for older adults gaining coverage."<ref name=CBPP />

Due to many states' failure to expand, many Democrats co-sponsored the proposed 2021 Cover Now Act that would allow county and municipal governments to fund Medicaid expansion.<ref>{{cite news |last1=Cunningham |first1=Paige W. |title=The Health 202: Democrats devise a way to finally expand Medicaid in resistant states |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/politics/2021/06/17/health-202-democrats-devise-way-finally-expand-medicaid-resistant-states/ |archive-url=https://web.archive.org/web/20211002051813/https://www.washingtonpost.com/politics/2021/06/17/health-202-democrats-devise-way-finally-expand-medicaid-resistant-states/ |archive-date=2 October 2021 |access-date=21 June 2022 |url-access=subscription |newspaper=] |date=17 June 2021 |first2=Alexandra |last2=Ellerbeck}}</ref>

==== Gaps in expansion ====
Despite the significant increase in access to insurance coverage and healthcare services across the board, the ACA's Medicaid expansion has not fully addressed problems of economic equity. Critics argue that Medicaid expansion has not reduced ] by a significant margin, as the amount households paid out of pocket for healthcare over the past ten years (in the form of ], ], etc.) rose by 77%.<ref name=":02">{{Cite journal |last1=Gaffney |first1=Adam |last2=McCormick |first2=Danny |date=2017-04-08 |title=The Affordable Care Act: implications for health-care equity |url=https://linkinghub.elsevier.com/retrieve/pii/S0140673617307869 |journal=The Lancet |language=English |volume=389 |issue=10077 |pages=1442–1452 |doi=10.1016/S0140-6736(17)30786-9 |issn=0140-6736 |pmid=28402826}}</ref> Additionally, 30% of providers deny Medicaid patients, which affects the accessibility of quality care.<ref name=":12">{{Cite web |last=Pipes |first=Sally |title=Medicaid Expansion Would Only Expand Waste And Poor Care |url=https://www.forbes.com/sites/sallypipes/2022/04/25/medicaid-expansion-would-only-expand-waste-and-poor-care/ |access-date=2024-12-21 |website=Forbes |language=en}}</ref> This increase in denial may be in part because providers receive 62 cents from Medicaid for every dollar received from private insurers.<ref name=":12" /> Studies on insurance rates show that economic inequality still persists: a significantly higher proportion of those with income greater than 100% but less than 200% of the ] were uninsured from 2010 to 2015 than of those with income greater than 200% of the federal poverty level.<ref name=":02" /> This is exacerbated by the 2012 Supreme Court decision allowing states to opt out of Medicaid, since many of the states that have opted out have more vulnerable populations, with large numbers of minorities or low-income people.<ref name=":02" />

Medicaid patients have also reported receiving "second-class" treatment compared to privately insured patients, with longer wait times and lower quality of care.<ref name=":02" />

==== Medicaid expansion by state ====
{| class="wikitable sortable"
|+
!State or territory
!Status of expansion
!Date of expansion
!Health insurance marketplace
!Notes
|- |-
|{{Flag|Alabama}}
! Income % of ]
|No expansion
! Premium Cap as a Share of Income
|N/A
! Income $ (family of 4){{ref|fedpovlevel|a}}
|]
! Max Annual Out-of-Pocket Premium
|
! Premium Savings{{ref|fedpovlevelb|b}}
! Additional Cost-Sharing Subsidy
|- |-
|{{Flag|Alaska}}
| 133%
|In effect
| 3% of income
|September 1, 2015
| $31,900
|]
| $992
|
| $10,345
| $5,040
|- |-
|{{Flag|Arizona}}
| 150%
|In effect
| 4% of income
|January 1, 2014
| $33,075
|]
| $1,323
|
| $9,918
| $5,040
|- |-
|{{Flag|Arkansas}}
| 200%
|In effect
| 6.3% of income
|January 1, 2014
| $44,100
|], ]
| $2,778
|State implemented expansion through a "private option" under a Section 1115 waiver through the Arkansas Health Care Independence Program (HCIP). Work requirement added in 2018 through Arkansas Works. Work requirement removed in 2021. Currently only state using "private option" as of 2022.
| $8,366
| $4,000
|- |-
|{{Flag|California}}
| 250%
|In effect
| 8.05% of income
|January 1, 2014
| $55,125
|], ]
| $4,438
|
| $6,597
| $1,930
|- |-
|{{Flag|Colorado}}
| 300%
|In effect
| 9.5% of income
|January 1, 2014
| $66,150
|], ]
| $6,284
|
| $4,628
| $1,480
|- |-
|{{Flag|Connecticut}}
| 350%
|In effect
| 9.5% of income
|January 1, 2014
| $77,175
|], ]
| $7,332
|
| $3,512
| $1,480
|- |-
|{{Flag|Delaware}}
| 400%
|In effect
| 9.5% of income
|January 1, 2014
| $88,200
|]
| $8,379
|
| $2,395
|-
| $1,480
|{{Flag|Florida}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Georgia (U.S. state)|name=Georgia}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Hawaii}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Idaho}}
|In effect
|January 1, 2020
|], ]
|Enacted through ].
|-
|{{Flag|Illinois}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Indiana}}
|In effect
|February 1, 2015
|]
|
|-
|{{Flag|Iowa}}
|In effect
|January 1, 2014
|]
|
|-
|{{Flag|Kansas}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Kentucky}}
|In effect
|January 1, 2014
|], ]
|Enacted through gubernatorial executive order
|-
|{{Flag|Louisiana}}
|In effect
|July 1, 2016
|]
|Enacted through gubernatorial executive order
|-
|{{Flag|Maine}}
|In effect
|January 10, 2019
|]
|Enacted through ], but implementation was delayed due to gubernatorial opposition. coverage retroactive to 7/2/2018.
|-
|{{Flag|Maryland}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Massachusetts}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Michigan}}
|In effect
|April 1, 2014
|]
|
|-
|{{Flag|Minnesota}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Mississippi}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Missouri}}
|In effect
|October 1, 2021
|]
|Enacted through ], but applications were denied until October 1, 2021, due to legislative opposition to the amendment. coverage retroactive to 7/1/2021.
|-
|{{Flag|Montana}}
|In effect
|January 1, 2016
|]
|Legislature enacted expansion with a work requirement; work requirement was due to take effect in January 2020 but never received federal approval. Current expansion is extended to June 2025.
|-
|{{Flag|Nebraska}}
|In effect
|October 1, 2020
|]
|enacted through ].
|-
|{{Flag|Nevada}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|New Hampshire}}
|In effect
|August 15, 2014
|]
|
|-
|{{Flag|New Jersey}}
|In effect
|January 1, 2014
|]
|
|-
|{{Flag|New Mexico}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|New York}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|North Dakota}}
|In effect
|January 1, 2014
|]
|
|-
|{{Flag|North Carolina}}
|Expansion pending
|June 2023 (expected)
|]
|Legislature expanded Medicaid. Signed into law by Governor ]. Expansion expected to go into effect when the state adopts a budget in June 2023.<ref>{{Cite news |last=Stolberg |first=Sheryl Gay |date=2023-03-27 |title=North Carolina Expands Medicaid After Republicans Abandon Their Opposition |language=en-US |work=] |url=https://www.nytimes.com/2023/03/27/us/politics/north-carolina-medicaid-expansion.html |access-date=2023-03-31 |issn=0362-4331 |archive-date=March 30, 2023 |archive-url=https://web.archive.org/web/20230330224459/https://www.nytimes.com/2023/03/27/us/politics/north-carolina-medicaid-expansion.html |url-status=live }}</ref>
|-
|{{Flag|Ohio}}
|In effect
|January 1, 2014
|]
|
|-
|{{Flag|Oklahoma}}
|In effect
|July 1, 2021
|]
|Enacted through ].
|-
|{{Flag|Oregon}}
|In effect
|January 1, 2014
|] (2012–2015), ]
|
|-
|{{Flag|Pennsylvania}}
|In effect
|January 1, 2015
|], ]
|
|-
|{{Flag|Rhode Island}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|South Carolina}}
|No expansion
|N/A
|]
|
|-
|{{Flag|South Dakota}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Tennessee}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Texas}}
|No expansion
|N/A
|]
|
|-
|{{Flag|Utah}}
|In effect
|January 1, 2020
|]
|Enacted through ], but subsequently scaled back through legislative action to enforce a Section 1115 waiver for eligibility.
|-
|{{Flag|Vermont}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Virginia}}
|In effect
|January 1, 2019
|]
|
|-
|{{Flag|Washington}}
|In effect
|January 1, 2014
|], ]
|
|-
|{{Flag|Washington, D.C.}}
|In effect
|
|], ]
|
|-
|{{Flag|West Virginia}}
|In effect
|January 1, 2014
|]
|
|-
|{{Flag|Wisconsin}}
|No expansion
|N/A
|]
|
|- |-
|{{Flag|Wyoming}}
| colspan="6" style="text-align:left; background:white; border-top:1px solid black; padding:0 1em;"|
|No expansion
<small>a.{{note|fedpovlevel}}Note: In 2016, the ] is projected to equal about $11,800 for a single person and about $24,000 for family of four.<ref name="cbo_est">{{cite web|url=http://www.cbo.gov/doc.cfm?index=10781|title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Care Act}}</ref><ref name=whitehouse>{{cite web|url=http://www.whitehouse.gov/health-care-meeting/proposal/whatsnew/affordability|title=Policies to Improve Affordability and Accountability|publisher=The White House}}</ref> See Subsidy Calculator for specific dollar amount.<ref name="kaiser_c">{{cite web|url=http://healthreform.kff.org/SubsidyCalculator.aspx|title=Kaiser Family Foundation:Health Reform Subsidy Calculator – Premium Assistance for Coverage in Exchanges/Gateways}}</ref>
|N/A
b.{{note|fedpovlevelb}}] and ] estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the reform.<ref name="hip-dhhs" /></small>
|]
|
|} |}
* Section 2708 to the Public Health Service Act becomes effective, which prohibits patient eligibility waiting periods in excess of 90 days for group health plan coverage. The 90-day rule applies to all grandfathered and non-grandfathered group health plans and group health insurance issuers, including multiemployer health plans and single-employer group health plans pursuant to collective bargaining arrangements.<ref>{{cite journal|last=Gordon|first=Amy|coauthors=Megan Mardy, Jamie A. Weyeneth|title=Patient Protection and Affordable Care Act (ACA) Guidance on 90-Day Waiting Periods and Certificates of Creditable Coverage|journal=The National Law Review|date=April 12, 2013|url=http://www.natlawreview.com/article/patient-protection-and-affordable-care-act-aca-guidance-90-day-waiting-periods-and-c|accessdate=17 April 2013|publisher=McDermott Will & Emery}}</ref> Plans will still be allowed to impose eligibility requirements based on factors other than the lapse of time; for example, a health plan can restrict eligibility to employees who work at a particular location or who are in an eligible job classification. The waiting period limitation means that coverage must be effective no later than the 91st day after the employee satisfies the substantive eligibility requirements.<ref>{{cite journal|last=Davis II|first=Hugh W.|coauthors=Poyner Spruill LLP|title=Health Reform - New Guidance On Eligibility Waiting Periods (or, when is 90 days not 90 days?)|journal=The National Law Review|date=April 16, 2013|url=http://www.natlawreview.com/article/health-reform-new-guidance-eligibility-waiting-periods-or-when-90-days-not-90-days|accessdate=20 April 2013}}</ref>
* Two years of tax credits will be offered to qualified small businesses. To receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee of no more than $50,000 and have no more than 25 FTEs. For the purposes of the calculation of FTEs, seasonal employees, and owners and their relations, are not considered. The subsidy is reduced by 3.35 percentage points per additional employee and 2 percentage points per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.<ref>{{Cite book|title=Summary of Small Business Health Insurance Tax Credit Under PPACA (P.L. 111-148)|url=http://healthreform.kff.org/~/media/Files/KHS/docfinder/crssmallbusinesscredit.pdf|date=April 20, 2010|first=Chris L.|last=Peterson|publisher=]|page=3 (Table 2)|first2=Hinda|last2=Chaikind|separator=,|lastauthoramp=yes|postscript=|accessdate=February 23, 2011|archiveurl=http://web.archive.org/web/20101008065416/http://healthreform.kff.org/~/media/Files/KHS/docfinder/crssmallbusinesscredit.pdf|archivedate=October 8, 2010}}</ref>
* A $2,000 per employee penalty will be imposed on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).<ref name="WSJ-mar25"/> "Full-time" is defined as, with respect to any month, an employee who is employed on average at least 30 hours of service per week.<ref>http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleD-chap43-sec4980H.pdf</ref>
* For employer-sponsored plans, a $2,000 maximum annual deductible is established for any plan covering a single individual or a $4,000 maximum annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
* To finance part of the new spending, spending and coverage cuts are made to Medicare Advantage, the growth of Medicare provider payments are slowed (in part through the creation of a new ]), Medicare and Medicaid drug reimbursement rates are decreased, and other Medicare and Medicaid spending is cut.<ref name="CRFB" /><ref>{{cite news|url=http://online.wsj.com/public/resources/documents/st_healthcareproposals_20090912.html|title=Health Reform, Point by Point – Bills Compared|date=March 22, 2010|newspaper=]|accessdate=2010-04-07}}</ref>
* Revenue is increased from a new $2,500 limit on tax-free contributions to ]s (FSAs), which allow for payment of health costs.<ref>{{cite web |work=] |url=http://newsok.com/medical-expense-accounts-could-be-limited-to-2500/article/3415512 |title=Medical Expense Accounts Could be Limited to $2,500 |date=November 8, 2009 |first=Paula |last=Burkes}}</ref>
* Members of Congress and their staff are only offered health care plans through the exchange or plans otherwise established by the bill (instead of the ] that they currently use).<ref>, section 1312: "... the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."</ref>
* A new ] goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5&nbsp;billion in annual revenue.<ref name = bglobetaximp/>
* Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3&nbsp;billion in annual revenue.<ref name = bglobetaximp/>
* The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of adjusted gross income (AGI).<ref>{{cite news| url=http://www.usatoday.com/money/perfi/taxes/2010-03-24-investtax24_ST_N.htm|title=Highlights of the Tax Provisions in Health Care Reform|publisher=Accuracy in Media | first=Matt | last=Krantz | date=March 24, 2010 | accessdate=May 21, 2010}}</ref>
* Consumer Operated and Oriented Plans (CO-OP), which are member-governed non-profit insurers, entitled to a 5-year federal loan, are permitted to start providing health care coverage.<ref>{{cite web|url=http://www.healthcare.gov/law/features/choices/co-op/index.html|title=Consumer Operated and Oriented Plans (CO-OPs)}}</ref>
* The ] provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped.<ref>{{cite news| url=http://www.boston.com/news/nation/washington/articles/2011/10/17/ruling_could_speed_repeal_of_long_term_care_plan/ | work=The Boston Globe | first=Ricardo | last=Alonso-Zaldivar | title=White House waffling on long-term care plan? | date=October 17, 2011}}</ref> The CLASS Act was repealed January 1, 2013.<ref>{{cite web|url=http://www.forbes.com/sites/howardgleckman/2013/01/01/fiscal-cliff-deal-repeals-class-act-creates-long-term-care-commission/|title=Fiscal Cliff Deal Repeals CLASS Act -- Creates Long Term Care Commission|publisher=Forbes|date=January 1, 2013}}</ref>
<!-- The provision of the ACA regarding free choice vouchers was repealed by Section 1858 of the Department of Defense and Full-Year Continuing Appropriations Act, 2011. See http://thomas.gov/cgi-bin/bdquery/z?d112:HR01473:@@@D&summ2=m& and http://www.gpo.gov/fdsys/pkg/PLAW-112publ10/pdf/PLAW-112publ10.pdf * Employed individuals who pay more than 9.5% of their income on health insurance premiums will be permitted to purchase subsidized private insurance through the exchanges.<ref>{{Cite news|title=How the Health Care Overhaul Could Affect You|url=http://www.nytimes.com/interactive/2010/03/21/us/health-care-reform.html|date=March 21, 2010|first=Farhana|last=Hosssain|work=The New York Times|first2=Kevin|last2=Quealy|separator=,|lastauthoramp=yes|postscript=|accessdate=March 22, 2011}}</ref> If the employer provides an employer sponsored plan but the individual earns less than 400% of the Federal Poverty level and could qualify for a government subsidy, the employee is entitled to obtain a "free choice voucher" from the employer of equivalent value to the employer's offering, which can be spent in the exchange to buy a subsidized policy of his own choosing.<ref>Section 10108 FREE CHOICE VOUCHERS</ref> --->


===Effective by October 1, 2014=== ===Insurance costs===


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


National health care expenditures rose faster than national income both before (2009–2013: 3.73%) and after (2014–2018: 4.82%) ACA's major provisions took effect.<ref>{{cite web |last1=Kurani |first1=Nisha |last2=Ortaliza |first2=Jared |last3=Wager |first3=Emma |last4=Fox |first4=Lucas |last5=Amin |first5=Krutika |title=How has U.S. spending on healthcare changed over time? |url=https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/#Contribution%20to%20change%20in%20total%20national%20health%20expenditures,%20from%202019-2020,%20by%20spending%20category |department = Health Spending |website=Peterson-KFF Health System Tracker |access-date=2 July 2022 |archive-url=https://web.archive.org/web/20220412164359/https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/ |archive-date=12 April 2022 |format=Chart collection |date=25 February 2022}}</ref><ref name="cms-cost" /> Premium prices rose considerably before and after. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9{{nbsp}}percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas.<ref>{{Cite web |url=https://thehill.com/policy/healthcare/291056-next-president-faces-possible-obamacare-meltdown/ |title=Next president faces possible ObamaCare meltdown |last=Ferris |issn=1521-1568 |oclc=31153202 |first=Sarah |date=August 11, 2016 |work=] |archive-date=August 14, 2016 |url-status=live |archive-url=https://web.archive.org/web/20160814182544/http://thehill.com/policy/healthcare/291056-next-president-faces-possible-obamacare-meltdown |access-date=August 15, 2016}}</ref> However, some or all these costs were offset by tax credits. For example, the ] reported that for the second-lowest cost "Silver plan", a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the tax credit, despite a large increase in the list price. This was consistent nationally. In other words, the subsidies increased along with the premium price, fully offsetting the increases for subsidy-eligible enrollees.<ref>{{Cite web |title=2017 Premium Changes and Insurer Participation in the Affordable Care Act's Health Insurance Marketplaces |url=http://kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/ |website=] |location=San Francisco |last1=Cox |first1=Cynthia |first5=Gary |last5=Claxton |first6=Larry |last6=Levitt |first2=Michelle |last2=Long |first4=Rabah |last4=Kamal |first3=Ashley |last3=Semanskee |archive-url=https://web.archive.org/web/20161115210643/https://www.kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/ |archive-date=15 November 2016 |access-date=18 June 2022 |date=November 2016}}</ref>
===Effective by January 1, 2015===


Premium cost increases in the employer market moderated after 2009. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015,<ref name="Kaiser15" /> with only a 3% increase from 2015 to 2016.<ref>{{Cite web |url=http://kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016-more-workers-enroll-in-high-deductible-plans-with-savings-option-over-past-two-years/ |title=Average Annual Workplace Family Health Premiums Rise Modest 3% |date=September 14, 2016 |website=] |access-date=November 23, 2016 |archive-date=January 19, 2022 |archive-url=https://web.archive.org/web/20220119221200/https://www.kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016-more-workers-enroll-in-high-deductible-plans-with-savings-option-over-past-two-years/ |url-status=live }}</ref> From 2008 to 2010 (before passage of ACA) health insurance premiums rose by an average of 10% per year.<ref>{{Cite web |url=http://www.commonwealthfund.org/publications/press-releases/2014/jun/new-analysis-of-health-insurance-premium-trends |title=New Analysis of Health Insurance Premium Trends in the Individual Market Finds Average Yearly Increases of 10 Percent or More Prior to the Affordable Care Act |website=Commonwealth Fund |date=June 5, 2014 |access-date=February 2, 2017 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023011623/http://www.commonwealthfund.org/publications/press-releases/2014/jun/new-analysis-of-health-insurance-premium-trends |url-status=live }}</ref>
* CMS begins using the Medicare fee schedule to give larger payments to physicians who provide high-quality care compared with cost.<ref>{{cite web|url=http://www.healthcare.gov/law/timeline/ |title= Implementation Timeline}}</ref>


Several studies found that the ] and accompanying recession could not account for the entirety of the slowdown and that structural changes likely shared at least partial credit.<ref name="NYTLowrey1" /><ref name="paulryan" /><ref>{{cite web |first=Jonathan |last=Chait |title=Someone Tell Ted Cruz the Obamacare War Is Over |url=http://nymag.com/daily/intelligencer/2013/09/someone-tell-ted-cruz-the-obamacare-war-is-over.html |date=September 26, 2013 |work=] |access-date=September 30, 2013 |archive-date=November 2, 2017 |archive-url=https://web.archive.org/web/20171102065413/http://nymag.com/daily/intelligencer/2013/09/someone-tell-ted-cruz-the-obamacare-war-is-over.html |url-status=live }}</ref><ref>{{cite news |title=Health Cost Growth Slows Further Even as Economy Rebounds |publisher=] |first=Alex |last=Wayne |date=June 18, 2013 |url=https://www.bloomberg.com/news/print/2013-06-18/health-cost-growth-slows-further-even-as-economy-rebounds.html |access-date=March 10, 2017 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023011642/https://www.bloomberg.com/news/print/2013-06-18/health-cost-growth-slows-further-even-as-economy-rebounds.html |url-status=live }}</ref> A 2013 study estimated that changes to the health system had been 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 |access-date=July 26, 2013 |archive-date=March 18, 2021 |archive-url=https://web.archive.org/web/20210318090743/https://www.kff.org/health-costs/issue-brief/assessing-the-effects-of-the-economy-on-the-recent-slowdown-in-health-spending-2/ |url-status=live }}</ref>{{Clarify|reason=Appears to get the relationship backwards. The article says that 77% of the reduction in health care increases comes from inflation and GDP, not the other way around. |date=November 2019}} Paul Krawzak claimed that even if 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 |work=Roll Call |first=Paul |last=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 |access-date=July 28, 2013 |archive-date=July 10, 2020 |archive-url=https://web.archive.org/web/20200710115947/https://www.rollcall.com/2013/06/14/in-spending-debate-baby-boomer-issue-remains-a-headache-for-legislators/ |url-status=dead }}</ref>
===Effective by October 1, 2015===


In a 2016 review, Barack Obama claimed that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.<ref>{{cite journal |author=Obama B |year=2016 |title=United States Health Care Reform – Progress to Date and Next Steps |journal=JAMA |volume=316 |issue=5 |pages=525–32 |doi=10.1001/jama.2016.9797 |pmid=27400401 |pmc=5069435 }}</ref>
* States are allowed to shift children eligible for care under the Children's Health Insurance Program to health care plans sold on their exchanges, as long as HHS approves.<ref name="commonwealthfund.org"/>


===Effective by January 1, 2016=== ====Deductibles and co-payments====


A contributing factor to premium cost moderation was that the insured faced higher ]s, ]s and out-of-pocket maximums. In addition, many employees chose to combine a ] with higher deductible plans, making the net impact of ACA difficult to determine precisely.
* States are permitted to form health care choice compacts and allows insurers to sell policies in any state participating in the compact.<ref name="commonwealthfund.org"/>
* The threshold for itemizing medical expenses increases from 7.5% of income to 10% for seniors.<ref>{{cite web|url=http://www.onclive.com/media/pdf/654be33e20de6bf0d83f2bdfeb25284f.pdf |title= How will health care reform affect you?}}</ref>


For the group market (employer insurance), a 2016 survey found that:
===Effective by January 1, 2017===
* Deductibles grew 63% from 2011 to 2016, while premiums increased 19% and worker earnings grew by 11%.
* In 2016, 4 in 5 workers had an insurance deductible, which averaged $1,478. For firms with less than 200 employees, the deductible averaged $2,069.
* The percentage of workers with a deductible of at least $1,000 grew from 10% in 2006 to 51% in 2016. The 2016 figure dropped to 38% after taking employer contributions into account.<ref>{{Cite news |url=https://www.washingtonpost.com/news/wonk/wp/2016/09/14/the-quiet-change-to-insurance-plans-thats-making-health-care-more-expensive-for-patients/ |title=How companies are quietly changing your health plan to make you pay more |issn=0190-8286 |oclc=2269358 |last=Johnson |first=Carolyn Y. |date=September 14, 2016 |newspaper=] |access-date=September 14, 2016 |archive-date=November 3, 2020 |archive-url=https://web.archive.org/web/20201103072824/https://www.washingtonpost.com/news/wonk/wp/2016/09/14/the-quiet-change-to-insurance-plans-thats-making-health-care-more-expensive-for-patients/ |url-status=live }}</ref>


For the non-group market, of which two-thirds are covered by ACA exchanges, a survey of 2015 data found that:
* A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.<ref name=autogenerated4>{{cite web|url=http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm |title=Public Law 111 – 148, section 1332 |publisher=Gpo.gov |date= |accessdate=2012-06-29}}</ref> A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.<ref name=autogenerated1>{{cite news| url=http://www.washingtonpost.com/wp-dyn/content/article/2011/02/28/AR2011022806535.html | work=The Washington Post | first1=Amy | last1=Goldstein | first2=Dan | last2=Balz | title=Obama offers states more flexibility in health-care law | date=March 1, 2011}}</ref><ref name="WydenHuffingtonPostinterview">{{cite news
* 49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
| url = http://www.huffingtonpost.com/2010/03/24/wyden-health-care-lawsuit_n_511748.html
* Many exchange enrollees qualify for cost-sharing subsidies that reduce their net deductible.
| title = Wyden: Health Care Lawsuits Moot, States Can Opt Out Of Mandate
* While about 75% of enrollees were "very satisfied" or "somewhat satisfied" with their choice of doctors and hospitals, only 50% had such satisfaction with their annual deductible.
| date = March 24, 2010
* While 52% of those covered by ACA exchanges felt "well protected" by their insurance, in the group market 63% felt that way.<ref>{{Cite web |url=http://kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/ |title=Survey of Non-Group Health Insurance Enrollees, Wave 3 |date=May 20, 2016 |website=kff.org |publisher=] |access-date=September 14, 2016 |archive-date=February 4, 2021 |archive-url=https://web.archive.org/web/20210204144902/https://www.kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/ |url-status=live }}</ref>
| work= The Huffington Post
| accessdate = March 27, 2010
| first=Sam
| last=Stein
}}</ref> The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.<ref name=autogenerated4 /> To qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.<ref>{{cite web|url=http://www.healthcare.gov/news/factsheets/stateinnovation03102011a.html |title=Preparing for Innovation: Proposed Process for States to Adopt Innovative Strategies to Meet the Goals of the Affordable Care Act |publisher=U.S. Department of Health & Human Services |date=November 16, 2011 |accessdate=April 1, 2012}}</ref> A bipartisan bill sponsored by Senators ] and ], and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.<ref name=autogenerated1 /> In April 2011 ] announced its intention to pursue a waiver to implement the ] enacted in May 2011.<ref>{{cite web|url=http://governor.vermont.gov/http%3A/%252Fgovernor.vermont.gov/node/add/media-federal-rules |title=Gov. Shumlin issued the following statement on health care rules |publisher=Governor.vermont.gov |date=March 14, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite web|url=http://www.bipartisanpolicy.org/blog/2011/03/health-reform-flexibility-and-wyden-brown-waiver-state-innovation |title=Health Reform Flexibility and the Wyden-Brown Waiver for State Innovation |publisher=Bipartisan Policy Center |date=March 4, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Estes |first=Adam Clark |url=http://www.theatlanticwire.com/national/2011/05/vermont-becomes-first-state-pass-single-payer-health-care/38207/ |title=Vermont Becomes First State to Enact Single-Payer Health Care |work=The Atlantic |date=May 26, 2011 |accessdate=April 1, 2012}}</ref><ref>{{cite news| url=http://www.huffingtonpost.com/2011/05/26/vermont-health-care-reform-law-single-payer_n_867573.html | work=The Huffington Post | first=Nicholas | last=Wing | title=Vermont Single-Payer Health Care Law Signed By Governor | date=May 26, 2011}}</ref> In September 2011 ] announced it would also be seeking a waiver to set up its own single payer healthcare system.<ref>{{cite web|url=http://www.dailykos.com/story/2011/09/30/1021603/-Gov-Schweitzer-pushing-single-payer-in-Montana-ahead-of-Affordable-Care-Act | title= Single payer in Montana}}</ref>
* States may allow large employers and multi-employer health plans to purchase coverage in the Exchange.
* Two federally regulated 'multi-state plan' (MSP) insurers, with one being non-profit and the other being forbidden from providing coverage for abortion services, will be available to all states. They will have to abide by the same federal regulations as required by individual state's qualified health plans available on the exchanges and must provide the same identical cover privileges and premiums in all states. MSPs will be phased in nationally, being available in 60% of all states in 2014, 70% in 2015, 85% in 2016 with full national coverage in 2017.<ref>{{cite web|url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf | title= Multi-State Plans Under the Affordable Care Act}}</ref>


===Effective by January 1, 2018=== ===Health outcomes===


According to a 2014 study, ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.<ref>{{Cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/news/fact-checker/wp/2015/04/01/obamas-claim-the-affordable-care-act-was-a-major-reason-in-preventing-50000-patient-deaths/ |title=Obama's claim the Affordable Care Act was a 'major reason' in preventing 50,000 patient deaths |newspaper=]|first = Glenn| last = Kessler | date = April 1, 2015 |format = Fact checker |archive-url = https://web.archive.org/web/20161105140151/https://www.washingtonpost.com/news/fact-checker/wp/2015/04/01/obamas-claim-the-affordable-care-act-was-a-major-reason-in-preventing-50000-patient-deaths/ |archive-date = November 5, 2016 |access-date=November 10, 2016}}</ref> Himmelstein and Woolhandler wrote in January 2017 that a rollback of ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.<ref>{{Cite news |issn=0190-8286 |oclc=2269358 |first1=David |first2=Steffi |last1=Himmelstein |last2=Woolhandler |date=January 23, 2017 |title=Repealing the Affordable Care Act will kill more than 43,000 people annually |newspaper=] |url=https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-kill-more-than-43000-people-annually/ |access-date=June 15, 2022 |archive-url=https://web.archive.org/web/20220305021836/https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-kill-more-than-43000-people-annually/ |archive-date=March 5, 2022}}</ref>
* All ''existing'' health insurance plans must cover approved preventive care and checkups without co-payment.<ref name='Top 18' />
* A 40% ] on high cost ] is introduced. The tax (as amended by the reconciliation bill)<ref name=Gold>{{cite web
|url=http://www.kaiserhealthnews.org/Stories/2010/March/18/Cadillac-Tax-Explainer-Update.aspx
|title='Cadillac' Insurance Plans Explained
|first=Jenny
|last=Gold
|publisher=]
|date=2010-01-15}}</ref> is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.<ref name = bglobetaximp/><ref>{{cite web|url=http://docs.house.gov/energycommerce/TIMELINE.pdf|title=H.R. 4872, The Health Care & Education Affordability Reconciliation Act of 2010 Implementation Timeline|date=March 18, 2010|publisher=U.S. House Committees on Ways & Means, Energy & Commerce, and Education & Labor|page=7|accessdate=March 24, 2010}}</ref>
<!-- * Various new taxes are introduced -- commented out until concrete citations are provided -->


According to the Kaiser Foundation, expanding Medicaid in the remaining states would cover up to 4.5 million persons.<ref>{{Cite web |url=https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ |last1=Garfield |last2=Damico |first1=Rachel |first2=Anthony |title=The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid |publisher=] |website=kff.org |access-date=June 15, 2022 |archive-date=December 9, 2017 |archive-url=https://web.archive.org/web/20171209183440/https://www.kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ |date=March 21, 2019}}</ref> A 2021 study found a significant decline in mortality rates in the states that opted in to the Medicaid expansion program compared with those states that did not do so. The study reported that states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017.<ref>{{Cite journal |last1=Miller |first1=Sarah |last2=Johnson |first2=Norman |last3=Wherry |first3=Laura R. |date=2021-01-30 |title=Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data* |url=https://doi.org/10.1093/qje/qjab004 |journal=The Quarterly Journal of Economics |volume=136 |issue=3 |pages=1783–1829 |doi=10.1093/qje/qjab004 |issn=0033-5533 |access-date=February 4, 2021 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701042645/https://academic.oup.com/qje/article-abstract/136/3/1783/6124639?redirectedFrom=fulltext |url-status=live }}</ref><ref>Truthout, July 25, 2019 {{Webarchive|url=https://web.archive.org/web/20201107235328/https://truthout.org/articles/republicans-refusal-to-expand-medicaid-resulted-in-over-15000-deaths/ |date=November 7, 2020 }}</ref>
===Effective by January 1, 2019===


Dependent Coverage Expansion (DCE) under the ACA has had a demonstrable effect on various health metrics of young adults, a group with a historically low level of insurance coverage and utilization of care.<ref name="ACA_DCE_2017" /> Numerous studies have shown the target age group gained private health insurance relative to an older group after the policy was implemented, with an accompanying improvement in having a usual source of care, reduction in out-of-pocket costs of high-end medical expenditures, reduction in frequency of Emergency Department visits, 3.5% increase in hospitalizations and 9% increase in hospitalizations with a psychiatric diagnosis, 5.3% increase in utilizing specialty mental health care by those with a probable mental illness, 4% increase in reporting excellent mental health, and a 1.5-6.2% increase in reporting excellent physical health.<ref name="ACA_DCE_2017" /> Studies have also found that DCE was associated with improvements in cancer prevention, detection, and treatment among young adult patients.<ref name="ACA_cancer_10yr" /><ref name="ACA_cancer_YA" /> A study of 10,010 women aged 18–26 identified through the 2008-12 National Health Interview Survey found that the likelihood of HPV vaccination initiation and completion increased by 7.7 and 5.8 percentage points respectively when comparing before and after October 1, 2010.<ref name="ACA_cancer_YA" /> Another study using National Cancer Database (NCDB) data from 2007 to 2012 found a 5.5 percentage point decrease in late-stage (stages III/IV) cervical cancer diagnosis for women aged 21–25 after DCE, and an overall decrease of 7.3 percentage points in late-stage diagnosis compared to those aged 26–34.<ref name="ACA_cancer_10yr" /> A study using SEER Program data from 2007 to 2012 found a 2.7 percentage point increase in diagnosis at stage I disease for patients aged 19–25 compared with those aged 26–34 for all cancers combined.<ref name="ACA_cancer_10yr" /> Studies focusing on cancer treatment after DCE found a 12.8 percentage point increase in the receipt of fertility-sparing treatment among cervical cancer patients aged 21–25 and an overall increase of 13.4 percentage points compared to those aged 26–34, as well as an increased likelihood that patients aged 19–25 with stage IIB-IIIC colorectal cancer receive timely adjuvant chemotherapy compared to those aged 27–34.<ref name="ACA_cancer_10yr" />
* Medicaid extends coverage to former foster care youths who were in foster care for at least six months and are under 25 years old.<ref name="thenationalcampaign.org"/>


Two 2018 '']'' studies found the Hospital Readmissions Reduction Program (HRRP) was associated with increased post-discharge mortality for patients hospitalized for heart failure and pneumonia.<ref>{{Cite journal |last1=Fonarow |first1=Gregg C. |last2=Yancy |first2=Clyde W. |last3=Matsouaka |first3=Roland A. |last4=Peterson |first4=Eric D. |last5=Hernandez |first5=Adrian F. |last6=Heidenreich |first6=Paul A. |last7=DeVore |first7=Adam D. |last8=Cox |first8=Margueritte |last9=Bhatt |first9=Deepak L. |date=January 1, 2018 |title=Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure |journal=JAMA Cardiology |volume=3 |issue=1 |pages=44–53 |doi=10.1001/jamacardio.2017.4265 |pmid=29128869 |pmc=5833526 |issn=2380-6583}}</ref><ref>{{Cite journal |last1=Yeh |first1=Robert W. |last2=Shen |first2=Changyu |last3=Haneuse |first3=Sebastien |last4=Wasfy |first4=Jason H. |last5=Maddox |first5=Karen E. Joynt |last6=Wadhera |first6=Rishi K. |date=December 25, 2018 |title=Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia |journal=JAMA |volume=320 |issue=24 |pages=2542–2552 |doi=10.1001/jama.2018.19232 |pmid=30575880 |pmc=6583517 |issn=0098-7484}}</ref><ref>{{Cite web |url=https://reason.com/2018/12/27/it-sure-looks-like-this-obamacare-progra/ |title=It Sure Looks Like This Obamacare Program Has Led to More People Dying |date=December 27, 2018 |website=Reason.com |access-date=June 6, 2019 |archive-date=December 11, 2020 |archive-url=https://web.archive.org/web/20201211015615/https://reason.com/2018/12/27/it-sure-looks-like-this-obamacare-progra/ |url-status=live }}</ref> A 2019 ''JAMA'' study found that ACA decreased emergency department and hospital use by uninsured individuals.<ref>{{Cite journal |last1=Pines |first1=Jesse M. |last2=Thode |first2=Henry C. |last3=Singer |first3=Adam J. |date=April 5, 2019 |title=US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act |journal=JAMA Network Open |volume=2 |issue=4 |pages=e192662 |doi=10.1001/jamanetworkopen.2019.2662 |pmid=31002327 |pmc=6481443}}</ref> Several studies have indicated that increased 30-day, 90-day, and 1-year post-discharge mortality of heart failure patients can be attributed to "gaming the system" through inappropriate triage systems in emergency departments, use of observation stays when admissions are warranted, and delay of readmission beyond the 30th day post-discharge, strategies that can reduce readmission rates at the expense of quality of care and patient survival.<ref>{{cite journal |title=The Hospital Readmissions Reduction Program – Learning from Failure of a Healthcare Policy |year=2018 |doi=10.1002/ejhf.1212 |last1=Gupta |first1=Ankur |last2=Fonarow |first2=Gregg C. |journal=European Journal of Heart Failure |volume=20 |issue=8 |pages=1169–1174 |pmid=29791084 |pmc=6105419}}</ref> The HRRP was also shown to disproportionately penalize safety-net hospitals that predominately serve low-income patients.<ref>{{cite journal |title=Inequality and the health-care system in the USA |year=2017 |doi=10.1016/S0140-6736(17)30398-7 |last1=Dickman |first1=Samuel L. |last2=Himmelstein |first2=David U. |last3=Woolhandler |first3=Steffie |journal=The Lancet |volume=389 |issue=10077 |pages=1431–1441 |pmid=28402825 |s2cid=13654086}}</ref> A 2020 study by Treasury Department economists in the '']'' using a ] (the IRS sent letters to some taxpayers noting that they had paid a fine for not signing up for health insurance but not to other taxpayers) found that over two years, obtaining health insurance reduced mortality by 12 percent.<ref name=":6">{{Cite news |url=https://www.nytimes.com/2019/12/10/upshot/irs-letter-health-insurance-fine-study.html |title=The I.R.S. Sent a Letter to 3.9 Million People. It Saved Some of Their Lives. |last=Kliff |first=Sarah |date=December 10, 2019 |work=] |access-date=December 20, 2019 |issn=1553-8095 |oclc=1645522 |archive-date=February 17, 2021 |archive-url=https://web.archive.org/web/20210217220347/https://www.nytimes.com/2019/12/10/upshot/irs-letter-health-insurance-fine-study.html |url-status=live }}</ref><ref>{{Cite journal |last1=Goldin |first1=Jacob |last2=Lurie |first2=Ithai Z. |last3=McCubbin |first3=Janet |title=Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach |journal=The Quarterly Journal of Economics |year=2020 |volume=136 |pages=1–49 |doi=10.1093/qje/qjaa029|doi-access=free }}</ref> The study concluded that the letters, sent to 3.9 million people, may have saved 700 lives.<ref name=":6" />
===Effective by January 1, 2020===


A 2020 ''JAMA'' study found that Medicare expansion under the ACA was associated with reduced incidence of advanced-stage breast cancer, indicating that Medicaid accessibility led to early detection of breast cancer and higher survival rates.<ref>{{Cite journal |last1=Blanc |first1=Justin M. Le |last2=Heller |first2=Danielle R. |last3=Friedrich |first3=Ann |last4=Lannin |first4=Donald R. |last5=Park |first5=Tristen S. |date=2020-07-01 |title=Association of Medicaid Expansion Under the Affordable Care Act With Breast Cancer Stage at Diagnosis |journal=JAMA Surgery |volume=155 |issue=8 |pages=752–758 |doi=10.1001/jamasurg.2020.1495 |pmid=32609338 |issn=2168-6262 |publisher=American Medical Association |pmc=7330827}}</ref> Recent studies have also attributed to Medicaid expansion an increase in use of smoking cessation medications, cervical cancer screening, and colonoscopy, as well as an increase in the percentage of early-stage diagnosis of all cancers and the rate of cancer surgery for low-income patients.<ref name="medicaid_cancer_continu" /><ref>{{cite journal |title=Impact of the Affordable Care Act on Colorectal Cancer Outcomes: A Systematic Review |year=2020 |doi=10.1016/j.amepre.2019.11.018 |last1=Xu |first1=Michelle R. |last2=Kelly |first2=Amanda M.B. |last3=Kushi |first3=Lawrence H. |last4=Reed |first4=Mary E. |last5=Koh |first5=Howard K. |last6=Spiegelman |first6=Donna |journal=American Journal of Preventive Medicine |volume=58 |issue=4 |pages=596–603 |pmid=32008799 |pmc=7175922}}</ref> These studies include a 2.1% increase in the probability of smoking cessation in Medicaid expansion states compared to non-expansion states, a 24% increase in smoking cessation medication use due to increased Medicaid-financed smoking cessation prescriptions, a 27.7% increase in the rate of colorectal cancer screening in Kentucky following Medicaid expansion with an accompanying improvement in colorectal cancer survival, and a 3.4% increase in cancer incidence following Medicaid expansion that was attributed to an increase in early-stage diagnoses.<ref name="medicaid_cancer_continu" />
* The Medicare Part D coverage gap (a.k.a., "donut hole") will be completely phased out and hence closed.


Transition-of-care interventions and Alternative Payment Models under the ACA have also shown promise in improving health outcomes.<ref name="ACA_TOC_2017" /><ref name="ACA_APM_Ortho" /> Post-discharge provider appointment and telephone follow-up interventions have been shown to reduce 30-day readmission rates among general medical-surgical inpatients.<ref name="ACA_TOC_2017" /> Reductions in 60, 90, and 180 post-discharge day readmission rates due to transition-of-care interventions have also been demonstrated, and a reduction in 30-day mortality has been suggested.<ref name="ACA_TOC_2017" /> Total joint arthroplasty bundles as part of the Bundled Payments for Care Improvement initiative have been shown to reduce discharge to inpatient rehabilitation facilities and post-acute care facilities, decrease hospital length of stay by 18% without sacrificing quality of care, and reduce the rate of total joint arthroplasty readmissions, half of which were due to surgical complications.<ref name="ACA_APM_Ortho" /> The Hospital Value-Based Purchasing Program in Medicaid has also shown the potential to improve health outcomes, with early studies reporting positive and significant effects on total patient experience score, 30-day readmission rates, incidences of pneumonia and pressure ulcers, and 30-day mortality rates for pneumonia.<ref name="ACA_HVBP_2020" /> The patient-centered medical home (PCMH) payment and care model, a team-based approach to population health management that risk-stratifies patients and provides focused care management and outreach to high-risk patients, has been shown to improve diabetes outcomes.<ref name="APM_diabetes" /> A widespread PCMH demonstration program focusing on diabetes, known as the Chronic Care Initiative in the Commonwealth of Pennsylvania, found statistically significant improvements in A1C testing, LDL-C testing, nephropathy screening and monitoring, and eye examinations, with an accompanying reduction in all-cause emergency department visits, ambulatory care-sensitive emergency department visits, ambulatory visits to specialists, and a higher rate of ambulatory visits to primary care providers.<ref name="APM_diabetes" /> The ACA overall has improved coverage and care of diabetes, with a significant portion of the 3.5 million uninsured US adults aged 18–64 with diabetes in 2009-10 likely gaining coverage and benefits such as closure of the Medicaid Part D coverage gap for insulin.<ref name="ACA_diabetes" /> 2.3 million of the approximately 4.6 million people aged 18–64 with undiagnosed diabetes in 2009–2010 may also have gained access to zero-cost preventative care due to section 2713 of the ACA, which prohibits cost sharing for United States Preventive Services Taskforce grade A or B recommended services, such as diabetes screenings.<ref name="ACA_diabetes" />
==Legislative history==


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


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


In March 2018, the CBO reported that ACA had reduced income inequality in 2014, saying the law led the lowest and second quintiles (the bottom 40%) to receive an average of an additional $690 and $560 respectively while causing households in the top 1% to pay an additional $21,000 due mostly to the net investment income tax and the additional Medicare tax. The law placed relatively little burden on households in the top quintile (top 20%) outside of the top 1%.<ref name="CBO_Dist14">{{Cite web |url=https://www.cbo.gov/publication/53597 |title=The Distribution of Household Income, 2014 &#124; Congressional Budget Office |website=United States. Congressional Budget Office |format=Report |archive-url=https://web.archive.org/web/20180412233412/https://www.cbo.gov/publication/53597 |archive-date=April 12, 2018 |date=March 19, 2018}}</ref>
When, in 1993, President ] ] which included a mandate for employers to provide health insurance to all employees through a regulated marketplace of ]s, Republican Senators proposed a bill that would have required individuals, and not employers, to buy insurance, as an alternative to Clinton's plan.<ref name="nyt-mandate"/> Ultimately the Clinton plan failed amid concerns that it was overly complex or unrealistic, and in the face of an unprecedented barrage of negative advertising funded by politically conservative groups and the health-insurance industry.<ref name="newsweek-clinton">{{cite news | work = ] | title = The Lost Chance | first = Bob | last= Cohn | coauthors = Eleanor Clift | date = September 18, 1994 | accessdate= July 2, 2012 | url =http://www.thedailybeast.com/newsweek/1994/09/18/the-lost-chance.print.html}}</ref> (After failing to obtain a comprehensive reform of the health care system, Clinton did however negotiate a compromise with the ] to instead enact the ] in 1997).


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


{{See also|United States public debt|Provisions of the Patient Protection and Affordable Care Act}}
] with Ted Kennedy and a bipartisan group of state legislators, April 12, 2006.]]


The CBO reported in multiple studies that ACA would reduce the deficit, and repealing it would increase the deficit, primarily because of the elimination of Medicare reimbursement cuts.<ref name="CBO50252" /><ref name="CBO22077" /> The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:<ref name="CBO22077" /><ref name="CBO43104" /> it calculated the law would result in $604 billion in ] offset by $813 billion in ], resulting in a $210 billion net deficit reduction.<ref name="CBO22077" /> The CBO separately predicted that while most of the spending provisions do not begin until 2014,<ref name="CBO-Pelosi" /><ref name="RollCallCBO" /> revenue would exceed spending in those subsequent years.<ref name="CBO-Pelosi2" />{{Dead link|date=February 2023}} The CBO claimed 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" />—ultimately extending the solvency of the ] by eight 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 |access-date=September 3, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921054048/http://www.cbpp.org/cms/?fa=view&id=3746 |url-status=live }}</ref>
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"/>


This estimate was made prior to the ] that enabled states to ], thereby forgoing the related 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" /><ref name="CBO43472" /><ref>{{cite news |last=Sahadi |first=Jeanne |url=https://money.cnn.com/2012/03/13/news/economy/health-reform-costs |title=Health reform coverage cost falls slightly |publisher=] |date=March 13, 2012 |access-date=June 29, 2012 |archive-date=May 15, 2012 |archive-url=https://web.archive.org/web/20120515143358/http://money.cnn.com/2012/03/13/news/economy/health-reform-costs/ |url-status=live }}</ref>
The following year (2007), Senators ] and ] introduced the
], a bill that also featured an individual mandate, and which attracted bipartisan support.<ref name="new-yorker-klein">{{cite news | work = ] | first = Ezra | last = Klein | authorlink = Ezra Klein | title = Unpopular Mandate | accessdate = June 19, 2012 | date = June 25, 2012 | url = http://www.newyorker.com/reporting/2012/06/25/120625fa_fact_klein}}</ref><ref name="new-yorker-lizza">{{cite news | work = ] | title= Romney's dilemma | url = http://www.newyorker.com/reporting/2011/06/06/110606fa_fact_lizza | first = Ryan | last = Lizza | authorlink = Ryan Lizza | accessdate = June 19, 2012 | date = June 6, 2011}}</ref> Among the Republican co-sponsors still in Congress during the health care debate: Senators ], ], ], ], ], ], and ].<ref> from the ] ] website</ref><ref>, from Senator Wyden's website</ref>


The CBO in June 2015 forecast that repeal of ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic ] effects. The CBO also forecast that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2025, mainly by boosting the supply of labor.<ref name="CBO50252" />
Given the history of bipartisan support for the idea, and its track record in Massachusetts; by 2008 Democrats were considering it as a basis for comprehensive, national health care reform: Experts have pointed out that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill;<ref name="kaiserhealthnews1993"/> and that it was deliberately patterned after former Republican Governor of Massachusetts Mitt Romney's ] (which contains an individual mandate).<ref></ref> ], a key architect of the Massachusetts reform, advised the Clinton and Obama Presidential campaigns on their health care proposals, served as a technical consultant to the Obama Administration, and helped Congress draft the ACA.


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&nbsp;trillion.<ref name="CBO-Reid-Dec2009" /><ref name="CNN-Mar18" /> 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 |work=] |access-date=April 7, 2010 |archive-date=September 16, 2018 |archive-url=https://web.archive.org/web/20180916052342/https://www.politifact.com/truth-o-meter/statements/2010/mar/18/nancy-pelosi/pelosi-cbo-says-health-reform-bill-would-cut-defic/ |url-status=live }}</ref>
===Health care debate, 2008–2010===
{{Main|Health care reforms proposed during the Obama administration}}


In 2017 CBO estimated that repealing the individual mandate alone would reduce the 10-year deficit by $338 billion.<ref>{{Cite web |url=http://politi.co/2hdAFBI |title=CBO: Obamacare mandate repeal would cut deficit by $338 billion |last=Haberkorn |first=Jennifer |website=]|date=November 8, 2017 |access-date=November 29, 2019}}</ref>
Health care reform was a major topic of discussion during the ]. As the race narrowed, attention focused on the plans presented by the two leading candidates, ] Senator ] and the eventual nominee, ] Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45&nbsp;million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual ]), while Obama's was to provide a ] but not create a direct requirement. During the ] campaign between Obama and the Republican nominee, ] Senator ], Obama said that fixing health care would be one of his top four priorities if he won the presidency.<ref name="Sep2008FirstPresidentialDebate">{{Cite news | url = http://elections.nytimes.com/2008/president/debates/transcripts/first-presidential-debate.html | title = The First Presidential Debate | date = September 26, 2008 | work = The New York Times }}</ref>


====Opinions on CBO projections====
], September 9, 2009.]]


The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200&nbsp;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 |access-date=April 1, 2012 |url-status=dead |archive-url=https://archive.today/20120717095633/http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |archive-date=July 17, 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{{'-}} |work=National Review |author=James Capretta |access-date=December 2, 2010 |archive-date=December 23, 2010 |archive-url=https://web.archive.org/web/20101223073630/http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta |url-status=live }}</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 |access-date=April 1, 2012 |archive-url=https://web.archive.org/web/20110126045757/http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |archive-date=January 26, 2011 |url-status=dead }}</ref> However, the so-called "]" is a separate issue that would have existed with or without ACA.<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 |access-date=April 1, 2012 |archive-date=February 20, 2012 |archive-url=https://web.archive.org/web/20120220015958/http://cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |url-status=live }}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |title=The Doc Fix Myth And The Right's Misinformation Feedback Loop |magazine=] |date=March 24, 2010 |access-date=March 10, 2017 |archive-date=September 12, 2015 |archive-url=https://web.archive.org/web/20150912112258/http://www.newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |url-status=live }}</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 |date=January 7, 2011 |access-date=March 12, 2012 |archive-date=March 12, 2012 |archive-url=https://web.archive.org/web/20120312164824/http://www.cbpp.org/cms/index.cfm?fa=view&id=3366 |url-status=live }}</ref> The ] objected that Congress had a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20&nbsp;years to produce Medicare savings, although not the doc fix.<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 |access-date=March 28, 2010 |date=December 4, 2009 |archive-date=March 24, 2010 |archive-url=https://web.archive.org/web/20100324181543/http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |url-status=live }}</ref><ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |newspaper=] |access-date=March 28, 2010 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308083159/http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |url-status=dead }}</ref> The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.<ref>Klein, Ezra. (June 26, 2010). "" ''Wonkbook'', The Washington Post. Archived (Blog) at the on October 9, 2012. {{ISSN|0190-8286}} {{OCLC|2269358}}. Accessed July 27, 2011.</ref>
After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.<ref name="Feb2009JointSessionAddress">{{Cite news | url = http://www.whitehouse.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress | title = Remarks of President Barack Obama – Address to Joint Session of Congress | date = February 24, 2009 | publisher = The White House | accessdate = March 24, 2010 }}</ref> On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform.<ref name="reuterstimeline">{{cite news | url = http://www.reuters.com/article/idUSTRE62L0JA20100322 | publisher = Reuters | title = Timeline: Milestones in Obama's quest for healthcare reform | accessdate = March 22, 2010 | date=March 22, 2010 }}</ref> By July, a series of bills were approved by committees within the ].<ref name="EdLaborJul2009">{{Cite news | url = http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml | title = Affordable Health Care for America Act | last = Kruger | first = Mike | date = October 29, 2009 | publisher = ] | accessdate = March 24, 2010 |archiveurl=http://web.archive.org/web/20100106013943/http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml |archivedate= January 6, 2010 }}</ref> On the Senate side, beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican ] Members met for a series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators ], ], ], ], ], and ], met for more than 60 hours, and the principles that they discussed (in conjunction with the other Committees) became the foundation of the Senate's health care reform bill.<ref>{{cite web|title=Health Care Reform from Conception to Final Passage|accessdate=2010-11-23|url=http://finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65}}</ref> The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site<ref> Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN</ref> or at the Committee's own web site.<ref>{{cite web|url=http://finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |title=Senate Finance Committee hearings for 111th Congress |publisher=Finance.senate.gov |date= |accessdate=April 1, 2012}}</ref>


] ], wrote, "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."<ref>{{cite news |title=Wrapping Your Head Around the Health Bill |author=Reinhardt, Uwe |newspaper=] |date=March 24, 2010 |issn=1553-8095 |oclc=1645522 |url=https://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill |access-date=October 9, 2010 |author-link=Uwe Reinhardt |archive-date=March 9, 2021 |archive-url=https://web.archive.org/web/20210309084408/https://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill |url-status=live }}</ref> ] alleged that the bill would increase the deficit by $562&nbsp;billion because, he argued, it front-loaded revenue and back-loaded benefits.<ref>{{cite news |url=https://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html |work=] |issn=0362-4331 |oclc=1645522 |title=The Real Arithmetic of Health Care Reform |first=Douglas |last=Holtz-Eakin |date=March 21, 2010 |access-date=February 7, 2017 |archive-date=March 14, 2021 |archive-url=https://web.archive.org/web/20210314191334/http://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html |url-status=live }}</ref>
With ] as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like ] and ] argued that ] would require both a (partial) ] and an ] to prevent either ] and/or ] from creating an ].<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/75077/how-they-did-it |title=How They Did It |publisher=The New Republic |date=2010-05-21 }}</ref> They convinced Obama that this was necessary, which persuaded the Administration to accept Congressional proposals that included a mandate.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/the-top-ten-things-worth-fighting |title=The Top Ten Things Worth Fighting For |publisher=The New Republic |date=2009-10-13 }}</ref> This approach was preferred because the President and Congressional leaders concluded that more liberal plans (such as ]) could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas - the same basic outline was supported by former Senate Majority Leaders ], ], ] and ] - the bill's drafters hoped to increase the chances of getting the necessary votes for passage.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/article/health-care/party-is-such-sweet-sorrow |title=Party Is Such Sweet Sorrow |publisher=The New Republic |date=2009-09-04 }}</ref><ref>{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |title=Obama's Moderate Health Care Plan |publisher=The New Republic |date=2010-04-22 }}</ref><ref name="newrepublic1">{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |publisher=The New Republic |date=2009-12-19 }}</ref>


Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from ], and that the CBO had a track record of overestimating costs and underestimating savings of health legislation;<ref name="CBOMethodology" /><ref name="CBOTrackRecord" /> stating, "innovations in the delivery of medical care, like greater use of ]s<ref>{{Cite web |url=https://www.medicalrecords.com/emr-buyers-guide/electronic-medical-records-deadline |title=Electronic Medical Records Deadline |website=MedicalRecords.com |access-date=July 24, 2019 |archive-date=March 9, 2021 |archive-url=https://web.archive.org/web/20210309013837/https://www.medicalrecords.com/emr-buyers-guide/electronic-medical-records-deadline |url-status=live }}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses{{nbsp}}... 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" />
However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to filibuster any bills that contained it.<ref name="forbes1"/> Senate Minority Leader ], who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections:<ref name="newrepublic1"/>
:"It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out."<ref>{{cite news|author=Carl Hulse and Adam Nagourney |url=http://www.nytimes.com/2010/03/17/us/politics/17mcconnell.html?pagewanted=1&hp |title=Senate G.O.P. Leader Finds Weapon in Unity |publisher=The New York Times |date=2010-03-16 }}</ref>
Republican Senators (including those who had supported previous bills with a similar mandate) began to describe the mandate as "unconstitutional". Writing in '']'', Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."<ref name="new-yorker-klein"/> The '']'' subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's health care law requiring all Americans to buy health insurance has its roots in conservative thinking."<ref name="nyt-mandate"/><ref name="politifact1993"/>


In 2010 ] said the CBO estimates were not likely to be accurate, because they were based on the assumption that the law would not change.<ref name="deficit_david_walker_cbo_innacurate" />
], September 12, 2009.]]


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


{{Further|topic=health insurance mandates|Health insurance mandate}}
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>


The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers.<ref name="GPO" /> Critics claimed it created a ] to hire part-timers instead.<ref name="ChaitNotWreck" /><ref name="KliffPartTime" /> However, between March 2010 and 2014, the number of part-time jobs declined by 230,000 while the number of full-time jobs increased by two million.<ref name="FORBES" /><ref name="BUREAU OF LABOR AND STATISTICS" /> In the public sector full-time jobs turned into part-time jobs much more than in the private sector.<ref name="FORBES" /><ref>{{cite news |last=Conover |first=Chris |title=Who Can Deny It? Obamacare Is Accelerating U.S. Towards A Part-Time Nation |url=https://www.forbes.com/sites/theapothecary/2013/07/31/who-can-deny-it-obamacare-is-accelerating-u-s-towards-a-part-time-nation/ |work=] |access-date=November 11, 2014 |archive-date=March 9, 2021 |archive-url=https://web.archive.org/web/20210309061155/https://www.forbes.com/sites/theapothecary/2013/07/31/who-can-deny-it-obamacare-is-accelerating-u-s-towards-a-part-time-nation/ |url-status=live }}</ref> A 2016 study found only limited evidence that ACA had increased part-time employment.<ref>{{cite journal |last1=Moriya |first1=A. S. |last2=Selden |first2=T. M. |last3=Simon |first3=K. I. |title=Little Change Seen In Part-Time Employment As A Result Of The Affordable Care Act |journal=Health Affairs |date=January 5, 2016 |volume=35 |issue=1 |pages=119–123 |doi=10.1377/hlthaff.2015.0949 |pmid=26733709}}</ref>
To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 ] supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.<ref name="Sep2009JointAddress">{{cite web | url = http://www.whitehouse.gov/the-press-office/remarks-president-a-joint-session-congress-health-care | title = Remarks by the President to a Joint Session of Congress on Health Care | date = September 10, 2009 | publisher = The White House | accessdate = March 24, 2010}}</ref> In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."<ref>{{cite web |last=Kennedy |first=Edward M. |authorlink=Ted Kennedy |title=Text of letter to the President from Senator Edward M. Kennedy |url=http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/ |date=2009-05-12 |work= |publisher=] |accessdate=2009-09-10| archiveurl= http://web.archive.org/web/20090910065606/http://www.whitehouse.gov/the_press_office/Text-of-letter-to-the-President-from-Senator-Edward-M-Kennedy/| archivedate= 10 September 2009 <!--DASHBot-->| deadurl= no}}</ref> On November 7, the House of Representatives passed the ] on a 220–215 vote and forwarded it to the Senate for passage.<ref name="reuterstimeline"/>


Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees,<ref>{{cite news |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 |work=The Virginian-Pilot |date=February 8, 2013 |access-date=February 13, 2013 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023012524/http://hamptonroads.com/2013/02/state-workers-parttime-hours-capped-due-health-law |url-status=dead }}<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 |website=ThinkProgress |date=February 11, 2013 |access-date=February 13, 2013 |archive-date=June 6, 2016 |archive-url=https://web.archive.org/web/20160606152622/http://thinkprogress.org/health/2013/02/11/1568291/virginia-employees-obamacare/ |url-status=live }}</ref>{{Unreliable source? |date=October 2013}}<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=] |date=January 14, 2013 |access-date=February 13, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921053946/http://tv.msnbc.com/2013/01/14/colleges-roll-back-faculty-hours-in-response-to-obamacare/ |url-status=live }}<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 |website=ThinkProgress |date=January 14, 2013 |access-date=February 13, 2013 |archive-date=March 14, 2016 |archive-url=https://web.archive.org/web/20160314222513/http://thinkprogress.org/health/2013/01/14/1445301/four-public-colleges-obamacare/ |url-status=live }}</ref>{{Unreliable source? |date=October 2013}} to reflect the 30-hour-or-more definition for full-time worker.<ref name="GPO" /> As of 2013, few companies had shifted their workforce towards more part-time hours (4% in a survey from the ]).<ref name="KliffPartTime" /> Trends in working hours<ref name="NPRPartTime" /> and the recovery from the ] correlate with the shift from part-time to full-time work.<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 |url-status=dead |archive-url=https://web.archive.org/web/20140715044934/http://wonkwire.rollcall.com/2013/09/04/stop-blaming-obamacare-part-time-workers/ |archive-date=July 15, 2014}}</ref><ref>{{cite magazine |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 |magazine=Slate |date=July 15, 2013 |access-date=July 22, 2013 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023013506/http://www.slate.com/blogs/moneybox/2013/07/15/obamacare_part_time_work.html |url-status=live }}</ref> Other confounding impacts include that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and lowers corresponding training and administration costs from a smaller, more stable workforce.<ref name="KliffPartTime" /><ref name="NPRPartTime" /><ref>{{cite journal |author=Jost, Timothy |title=Implementing Health Reform: A One-Year Employer Mandate Delay |url=https://www.healthaffairs.org/do/10.1377/forefront.20130703.032734 |journal=Health Affairs |publisher=Project HOPE |location=Washington, DC |issn=1544-5208 |oclc=07760874 |date=July 2, 2013 |doi=10.1377/forefront.20130703.032734 |access-date=March 29, 2022 |archive-date=March 29, 2022 |archive-url=https://web.archive.org/web/20220329211402/https://www.healthaffairs.org/do/10.1377/forefront.20130703.032734 |url-status=live }}</ref> Relatively few firms employ over 50 employees<ref name="KliffPartTime" /> and more than 90% of them already offered insurance.<ref name="CohnDelay" />
===Senate===


Most policy analysts (both right and left) were critical of the employer mandate provision.<ref name="ChaitNotWreck" /><ref name="CohnDelay" /> They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful;<ref name="CBPPEmpMand." /><ref name="MandateRepeal" /> that the raised ] of the 50th worker for businesses could limit companies' growth;<ref>{{cite magazine |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 |magazine=Slate |date=July 3, 2013 |access-date=July 22, 2013 |archive-date=July 29, 2018 |archive-url=https://web.archive.org/web/20180729013901/http://www.slate.com/blogs/moneybox/2013/07/03/obamacare_delayed_a_good_idea_covering_up_a_big_problem.html |url-status=live }}</ref> that the costs of reporting and administration were not worth the costs of maintaining employer plans;<ref name="CBPPEmpMand." /><ref name="MandateRepeal" /> and noted that the employer mandate was not essential to maintain adequate risk pools.<ref>{{cite web |first=Jonathan |last=Chait |title=Obamacare Haters Struggling to Understand What 'Nonessential' Means |date=July 3, 2013 |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-haters-struggle-to-get-nonessential.html |work=] |access-date=July 22, 2013 |archive-date=July 14, 2013 |archive-url=https://web.archive.org/web/20130714042149/http://nymag.com/daily/intelligencer/2013/07/obamacare-haters-struggle-to-get-nonessential.html |url-status=live }}<br />{{cite web |first=Jonathan |last=Chait |title=Obamacare Still Not Collapsing |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |work=] |date=July 3, 2013 |access-date=July 22, 2013 |archive-date=July 4, 2013 |archive-url=https://web.archive.org/web/20130704100820/http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |url-status=live }}</ref><ref name="Mandate3" /> The provision generated vocal opposition from business interests and some unions who were not granted exemptions.<ref name="MandateRepeal" /><ref name="WSJ"/>
The Senate began work on its on proposals while the House was still working on ]; it instead took up H.R. 3590, a bill regarding housing tax breaks for service members.<ref name="ServicemembersHomeOwnershipTaxAct">{{Cite news | title = House OKs tax breaks for military homeowners | first = Rick | last = Maze | url = http://www.airforcetimes.com/news/2009/10/military_homeownerhelp_taxfree_100809w/ | newspaper = ] | date = October 8, 2009 | accessdate = March 24, 2010 }}</ref> As the ] requires all revenue-related bills to originate in the House,<ref name="Const-Revenue">] art. I, § 7, cl. 1.</ref> the Senate took up this bill since it was first passed by the House as a revenue-related modification to the ]. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.<ref>{{USBill|111|S.AMDT.|2786}}</ref> The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate ] and ] committees.


===Hospitals===
With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.<ref>{{cite 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=2009-09-07 }}</ref> At the start of the ], Democrats had only 58 votes (the Senate seat in Minnesota that would be won by ] was still undergoing a recount, and Arlen Specter was still a Republican). To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican Senators (particular attention was given to Bob Bennett, Chuck Grassley, Mike Enzi, and Olympia Snowe). Negotiations continued even after July 7 – when Al Franken was sworn into office and by which time Arlen Specter had switched parties – because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy – a long-time advocate for health care reform – died, depriving Democrats of their 60th vote. Whilst ] was appointed as Senator Kennedy's temporary replacement on September 24 (regaining the Democrats' 60th vote); 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="Jonathan Cohn">{{cite news|author=Jonathan Cohn |url=http://www.newrepublic.com/article/75077/how-they-did-it |title=How They Did It |work=The New Republic|date=2010-05-21 |publisher=The New Republic }}</ref>


From the start of 2010 to November 2014, 43 hospitals in ] closed. Critics claimed the new law had caused these closures. Many rural hospitals were built using funds from the 1946 ]. Some of these hospitals reopened as other medical facilities, but only a small number operated ] (ER) or ] centers.<ref>{{cite news |last1=O'Donnell |first1=Jayne |last2=Ungar |first2=Laura |last3=Hoyer |first3=Meghan |date=November 12, 2014 |title=Rural hospitals in critical condition |url=https://www.usatoday.com/longform/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/ |newspaper=] |access-date=January 28, 2015 |archive-date=September 16, 2015 |archive-url=https://web.archive.org/web/20150916011235/http://www.usatoday.com/longform/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/ |url-status=live }}<br />{{cite news |last=Hamada |first=Omar L. |date=November 18, 2014 |title=Obamacare has detrimental effect on rural hospitals |url=http://www.tennessean.com/story/opinion/contributors/2014/11/19/obamacare-detrimental-effect-rural-hospitals/19087985/ |newspaper=The Tennessean |access-date=January 28, 2015 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701042654/https://www.tennessean.com/story/opinion/contributors/2014/11/19/obamacare-detrimental-effect-rural-hospitals/19087985/ |url-status=live }}</ref>
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="Jonathan Cohn"/> even though it had majority support in Congress.<ref name="newrepublic2">{{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=2010-03-12 }}</ref> There was debate among supporters of the bill about the importance of the public option,<ref>{{cite news|url=http://www.huffingtonpost.com/marcia-angell-md/is-the-house-health-care_b_350190.html |title=Is the House Healthcare Bill Better Than Nothing? |work=The Huffington Post |accessdate=January 12, 2012 |date=November 9, 2009}}</ref> although the vast majority of supporters concluded that the it was a minor part of the reform overall,<ref>{{cite 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=2009-12-20 }}</ref> and that Congressional Democrats' fight for it won various concessions (including conditional wavers allowing states to set up state-based public options,<ref name="newrepublic2"/> for example Vermont's ]).<ref>{{cite 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=2009-12-15 }}</ref>


Between January 2010 and 2015, a quarter of ER doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured.<ref>{{cite news |url=http://www.washingtontimes.com/news/2015/may/4/er-visits-under-obamacare-doctors-say/#ixzz3ZH4xpm5H |title=ER visits up under Obamacare despite promises, doctors' poll finds |first=Tom Jr. |last=Howell |work=The Washington Times |date=May 4, 2015 |access-date=May 6, 2015 |archive-date=March 3, 2021 |archive-url=https://web.archive.org/web/20210303221345/https://www.washingtontimes.com/news/2015/may/4/er-visits-under-obamacare-doctors-say/#ixzz3ZH4xpm5H |url-status=live }}</ref> Michael Lee Jr. and ] at Boston Children's Hospital analyzed national emergency department visits among children aged 0 to 17 from 2009 to 2016 using the American Community Survey (ACS) and Nationwide Emergency Department Sample (NEDS). They found no immediate change in pediatric emergency department visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends, almost 10%.<ref>{{cite journal |last1=Lee |first1=Michael |last2=Monuteaux |first2=Michael C. |title=Trends in pediatric emergency department use after the Affordable Care Act |journal=Pediatrics |date=2019 |volume=143 |issue=6 |doi=10.1542/peds.2018-3542 |pmid=31118219 |publisher=American Academy of Pediatrics |location=Itasca, IL |s2cid=162182158 |issn=1098-4275 |quote=ED visit rates increased by 1.1% per year pre-2014 and 9.8% from 2014 to 2016 (incidence rate ratio 1.09, 95% confidence interval 1.03-1.15, P = .005)|doi-access=free }}</ref>
[[File:111th Congress 1st session Senate roll call 396.svg|thumb|300px|Senate vote by state.
{{legend|#000080|Two Democratic yeas}}
{{legend|#800080|One Democratic yea, one Republican nay}}
{{legend|#FF5050|One Republican nay, one Republican not voting}}
{{legend|#800000|Two Republican nays}}]]


Several large insurers formed ACOs. Many hospitals merged and purchased physician practices, amounting to a significant consolidation of the provider industry. The increased market share gave them more leverage with insurers and reduced patient care options.<ref name=":15" />
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=2009-12-17 }}</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=2010-01-20 }}</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 name="newrepublic1"/><ref>{{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=2010-01-19 }}</ref><ref>{{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=2010-03-16}}</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=2012-02-28 }}</ref> After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges" (requiring consumers to pay for the procedure out-of-pocket, if the state decided it); and an amendment to offer a higher rate of ] reimbursement for Nebraska.<ref name="reuterstimeline"/><ref>{{cite 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=2009-12-19 }}</ref> The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"<ref>{{cite news|title={{-'}}Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment|url=http://www.foxnews.com/politics/2010/03/18/cornhusker-kickback-gets-boot-health/|date=March 19, 2010|publisher=]|accessdate=April 26, 2010}}</ref> (and was later repealed by the subsequent reconciliation amendment bill).


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


]
On January 19, 2010, ] Republican ] was elected to the Senate in a special election to replace Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41".<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=2012-04-09}}</ref><ref>{{cite press release|url=http://www.votesmart.org/public-statement/477580/scott-brown-responds-to-martha-coakleys-misleading-health-care-distortions |title=Public Statements – Project Vote Smart |publisher=Votesmart.org |date=2010-01-13 |accessdate=2012-04-09}}</ref>


CBO estimated in June 2015 that repealing ACA would:
===House===
* Decrease GDP in the short-term, as government spending (on subsidies) was only partially replaced by spending by recipients.
[[File:111th Congress roll call 165.svg|thumb|300px|House vote by congressional district.
* Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021–2025 period. CBO cited ACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing ACA would remove those disincentives, encouraging workers to supply more labor, increasing the total number of hours worked by about 1.5% over the 2021–2025 period.
{{legend|#000080|Democratic yea}}
* Remove the higher tax rates on capital income, thereby encouraging investment, raising the capital stock and output in the long-run.<ref name="CBO50252" />
{{legend|#5050FF|Democratic nay}}
{{legend|#800000|Republican nay}}
{{legend|#C8C8C8|No representative seated}}]]
]
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. ] ] argued the Democrats should scale-back for a less ambitious bill; ] ] pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care".<ref name="nytimesjourney">{{Cite news
| title = Health Vote Caps a Journey Back From the Brink
| first = Sheryl
| last = Stolberg
| author2 = Jeff Zeleny
| author3 = Carl Hulse
| url = http://www.nytimes.com/2010/03/21/health/policy/21reconstruct.html
| newspaper = ]
| date = March 20, 2010
| accessdate = March 23, 2010
}}</ref><ref name="PoliticoPelosi">{{Cite news
| title = Pelosi steeled W.H. for health push
| first = Carrie
| last = Brown
| author2 = Glenn Thrush
| url = http://www.politico.com/news/stories/0310/34753.html
| newspaper = ]
| date = March 20, 2010
| accessdate = March 23, 2010
}}</ref> Obama remained insistent on comprehensive reform and the news that ] in ] intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.<ref name="nytimesjourney"/><ref name="PoliticoPelosi"/> On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.<ref>{{cite web|author= |url=http://www.kaiserhealthnews.org/Daily-Reports/2010/February/22/President-Obama-Health-Care-Reform-Plan.aspx |title=White House Unveils Revamped Reform Plan, GOP And Industry React |publisher=Kaiserhealthnews.org |date=2010-02-22 |accessdate=2012-06-29}}</ref> He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.<ref name="reuterstimeline"/> The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.<ref name="PoliticoPelosi"/>


In 2015 the progressive ] found no evidence that companies were reducing worker hours to avoid ACA requirements<ref>{{Cite web |url=https://www.randstadusa.com/workforce360/workforce-insights/the-affordable-care-act-and-employers/91/ |title=The Affordable Care Act and Employers|date = 2014 |last = Loi | first = Eric |website = Randstad USA | publisher = Ernst & Young LLP |access-date=August 11, 2016 |archive-date=July 25, 2020 |archive-url=https://web.archive.org/web/20200725005448/https://www.randstadusa.com/workforce360/workforce-insights/the-affordable-care-act-and-employers/91/ |url-status=dead}}</ref> for employees working more than 30 hours per week.<ref>{{cite web |url=http://www.cepr.net/blogs/cepr-blog/is-the-affordable-care-act-a-hidden-jobs-killer |last1 = Jorgensen |last2 = Baker | date = July 24, 2013| agency = Roosevelt Institute's Econobytes | first1 = Helene |first2 = Dean |title=Is the Affordable Care Act a Hidden Jobs Killer? |publisher =Center for Economic and Policy Research |website =CEPR Blog|access-date=August 26, 2015 |archive-date=October 24, 2019 |archive-url=https://web.archive.org/web/20191024045839/http://cepr.net/blogs/cepr-blog/is-the-affordable-care-act-a-hidden-jobs-killer |url-status=dead}}</ref>
With Democrats having ], but having already passed the Senate bill with 60 votes on December 23; the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the ], and pass the Senate's bill (The Patient Protection and Affordable Care Act) instead. Various health policy experts encouraged the House to pass the Senate version of the bill.<ref>{{cite web|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 in a (House-Senate) Conference before passing a final bill. With that option off the table (as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster); the House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill (ultimately the ]), which could be passed via the ] process.<ref name="nytimesjourney"/><ref name="Reconciliationprimer">{{cite web|author=Jonathan Chait |url=http://www.newrepublic.com/blog/jonathan-chait/brief-reconciliation-primer |title=A Brief Reconciliation Primer |publisher=The New Republic |date=2010-02-20 }}</ref> Unlike the regular order, reconciliation is not subject to a ] (which requires 60 votes to break), but the process is ], which is why it was never able to be used to pass a comprehensive reform bill (with its inherently non-budgetary regulations as in the ACA) in the first place.<ref>{{cite web|author=Jonathan Cohn |url=http://www.newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |title=Reconciliation: Why Most Dems Don't Want to Go There |publisher=The New Republic |date=2009-09-21 }}</ref> Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes -- higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal -- mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."<ref name="Reconciliationprimer"/>


CBO estimated that ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Jonathan Cohn claimed that ACA's primary employment effect was to alleviate ]<ref name="CBOjobs" /> and the reform's only significant employment impact was the retirement of those who were working only to stay insured.<ref name="ACAEconomyCohn" />
The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman ]. The group found the possibility of federal funding for ] would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued ], reaffirming the principles in the ]. This concession won the support of Stupak and members of his group and assured passage of the bill.<ref name="EO13535">] of March 24, 2010 – ''Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act'', Vol.&nbsp;75, No.&nbsp;59,&nbsp;{{USFedReg|75|15599}}, March 29, 2010.</ref> The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.<ref name="USH RC 2010-165">{{cite web|url=http://clerk.house.gov/evs/2010/roll165.xml |title=Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act) |publisher=Office of the Clerk: House of Representatives |date=2010-03-21 |accessdate=2012-04-09}}</ref> The following day, Republicans introduced legislation to repeal the bill.<ref name="PelosiSawyer">{{Cite news
| title = Pelosi Defends Health Care Fight Tactics
| first = Margaret
| last = Aro
| author2 = Mark Mooney
| url = http://abcnews.go.com/WN/Politics/house-speaker-nancy-pelosis-exclusive-interview-diane-sawyer/story?id=10172685
| newspaper = ]
| date = March 22, 2010
| accessdate = March 23, 2010
}}</ref> Obama signed the original bill (the 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 opinion==


]
===Public policy===


Public views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Approval varied by party, race and age. Some elements were more widely favored (preexisting conditions) or opposed (individual mandate).
====Change in number of uninsured====
CBO originally estimated the legislation will reduce the number of uninsured residents by 32&nbsp;million, leaving 23&nbsp;million uninsured residents in 2019 after the bill's provisions have all taken effect.<ref name="cbouninsured">{{cite web|url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf|title=Cost Estimate for Pending Health Care Legislation|date=March 20, 2010|publisher=]|accessdate=March 28, 2010}}</ref><ref name="CBO43090">{{cite web|url=http://www.cbo.gov/publication/43090 |title=The Effects of the Affordable Care Act on Employment-Based Health Insurance |publisher=Congressional Budget Office |date=March 15, 2012 |accessdate= |quote=''Highlights and Key Findings'' , March 23, 2012 }}</ref><ref name=fewer/><ref name="CBO43076">{{cite web |url=http://www.cbo.gov/publication/43076 |title=Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 13, 2012 |accessdate=April 6, 2012}}</ref> A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the ] to PPACA's expansion of Medicaid.<ref name=cbooptout>{{cite web| url= http://www.cbo.gov/publication/43472 | title= Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision|date=July 24, 2012 | publisher= CBO | accessdate= 2012-02-23}}</ref><ref name=optout>{{cite web| url= http://money.cnn.com/2012/07/23/news/economy/health-reform/ | title= 6 million will lose out on Medicaid expansion| first=Emily Jane|last= Fox |work=CNNMoney |date=July 24, 2012 | publisher= CNN | accessdate= 2012-07-25}}</ref>


In a 2010 ], 62% of respondents said they thought 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 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 |date=March 22, 2010 |publisher=] |access-date=December 28, 2010 |archive-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210216230530/http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf |url-status=live }}</ref> Other polls found that people were concerned the law would cost more than projected and would not do enough to control costs.<ref>{{cite news |title=Why Obama Can't Move the Health-Care Numbers |last1=Rasmussen |first1=Scott |date=March 9, 2010 |work=] |last2=Schoen |first2=Doug |publisher=News Corp |oclc=781541372 |issn=0099-9660 |archive-url=https://web.archive.org/web/20150402002455/https://www.wsj.com/articles/SB10001424052748704784904575111993559174212 |archive-date=April 2, 2015 |url=https://www.wsj.com/articles/SB10001424052748704784904575111993559174212}}</ref>
Among the people in this uninsured group will be:
* ], estimated to be around eight million <!--almost a third of the 25&nbsp;million --> – they will be ineligible for insurance ] and Medicaid;<ref name="cbouninsured"/><ref>{{Cite journal|title=Treatment of Noncitizens Under the Patient Protection and Affordable Care Act|url=http://www.ciab.com/WorkArea/DownloadAsset.aspx?id=2189|date=March 22, 2011|first=Alison|last=Siskin|publisher=]|accessdate=October 14, 2011|id=R41714}}</ref><ref>{{Cite journal|title=PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges|url=http://www.nationalaglawcenter.org/assets/crs/R41664.pdf|date=March 2, 2011|first=Hinda|last=Chaikind|publisher=]|first2=Curtis W.|last2=Copeland|first3=C. Stephen| last3=Redhead| first4=Jennifer| last4=Staman| accessdate=October 14, 2011|id=R41664}}</ref> they will also be exempt from the ] and will remain eligible for emergency services under the 1986 ] (EMTALA).
*Citizens not enrolled in Medicaid despite being eligible.<ref name="notcovered">{{cite news| url= http://www.csmonitor.com/USA/2010/0323/Obama-signs-health-care-bill-Who-won-t-be-covered| title= Obama signs health care bill: Who won't be covered?|last=Trumbull|first=Mark|date=March 23, 2010|work=]|accessdate=March 24, 2010}}</ref>
*Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.<ref name="notcovered"/>
*Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.<ref name="notcovered"/>
*Citizens who live in states that opt out of the Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage through the states' new insurance exchanges.<ref name=optout/>


In a 2012 poll 44% supported the law, with 56% against. By 75% of Democrats, 27% of Independents and 14% of Republicans favored the law. 82% favored banning insurance companies from denying coverage to people with preexisting 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, and 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" /> Other polls showed additional provisions receiving majority support, including the exchanges, pooling small businesses and the uninsured with other consumers and providing subsidies.<ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does |title=Republicans hate 'Obamacare', but like most of what it does |website=Wonkblog |publisher=] |author=Klein, Ezra |date=June 26, 2012 |access-date=June 28, 2012 |archive-url=https://web.archive.org/web/20120629112038/http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does/ |archive-date=June 29, 2012 |url-status=dead}}</ref><ref>{{cite web |author=Sargent, Greg |issn=0190-8286 |oclc=2269358 |url=https://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 |work=The Plum Line |publisher=]|date=June 25, 2012 |archive-url=https://web.archive.org/web/20120707184007/https://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 |archive-date=July 7, 2012 |access-date=June 28, 2012}}</ref>
Early experience under PPACA was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.<ref>{{Cite news | last = Levey| first = Noam N.| title = More small businesses are offering health benefits to workers| newspaper = ]| date = December 27, 2010 | url = http://www.latimes.com/health/healthcare/la-fi-health-coverage-20101227,0,5024491.story}}</ref> On September 13, 2011, the Census Bureau released a report showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.<ref>{{Cite journal|title=Income, Poverty, and Health Insurance Coverage in the United States: 2010|url=http://www.census.gov/prod/2011pubs/p60-239.pdf| month=September|year=2011|publisher=]| first= Carmen| last= DeNavas-Walt|last2=et al.|pages=26–27|accessdate=October 15, 2011}}</ref> A later report from the Government Accountability Office in 2012 found that of the 4 million small businesses that were offered the tax credit only 170,300 businesses claimed it.<ref>Ellmers, R. (2012, May 31). Small business subcommittee on healthcare & technology chairwoman Renee Ellmers: Need a job: support small businesses. Congressional Documents and Publications. Retrieved online from http://www.dowjones.com/factiva</ref><ref>Lawrimore, E. (2012, June 27). Barraso’s 2nd opinion: Obamacare small business tax credit is a bust. Congressional Documents and Publications. Retrieved from http://www.dowjones.com/factiva</ref> Due to the effect of the U.S. Supreme court ruling, states can opt-in or out of the expansion of Medicaid. Arkansas, California, Connecticut, Delaware, District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, Vermont, and Washington are implementing the expansion; Florida, Louisiana, Mississippi, Georgia, South Carolina, and Texas are not.<ref>{{cite news |title=How States are using their flexibility |author=U-T San Diego Editorial Board |url=http://www.utsandiego.com/news/2012/aug/12/tp-how-states-are-using-their-flexibility/ |newspaper=] |date=12 August 2012 |accessdate=27 August 2012}}
</ref><ref>{{cite news |title=States opting out of Medicaid expansion could leave many uninsured |author=Stephanie Condon |url=http://www.cbsnews.com/8301-503544_162-57465110-503544/states-opting-out-of-medicaid-expansion-could-leave-many-uninsured/ |newspaper=CBS News |date=2 August 2012 |accessdate=27 August 2012}}</ref><ref>{{cite news |title=The backlash begins: States start opting out of Medicaid expansion |author=Sarah Kliff |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/02/the-backlash-begins-states-start-opting-out-of-medicaid-expansion/ |newspaper=Washington Post |date=2 July 2012 |accessdate=27 August 2012}}</ref><ref>{{cite news |title=Fifteen governors reject or leaning against expanded Medicaid program |author=Elise Viebeck |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/236033-fifteen-governors-reject-or-leaning-against-expanded-medicaid-program |newspaper=The Hill |date=3 July 2012 |accessdate=27 August 2012}}</ref>


Some opponents believed the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.<ref name="most" />
Also, in part due to the new regulations of guaranteed issue and ensuring children could remain included on their parents plans until age 26; in September 2010 some insurance companies announced that in response to the law, they would end the issuance of new child-only policies.<ref>, CBS News, September 22, 2010</ref><ref>, ''Los Angeles Times'', September 21, 2010</ref> Kentucky Insurance Commissioner Sharon Clark said the decision by insurers to stop offering such policies was a violation of state law and ordered insurers to offer an open enrollment period in January 2011 for Kentuckians under 19.<ref>{{cite web|last=Truman |first=Cheryl |url=http://www.kentucky.com/2010/11/19/1530685/state-orders-health-insurers-to.html |title=State orders health insurers to offer child-only policies|publisher=Kentucky.com |date=2010-11-19 |accessdate=2012-06-28}}</ref> An August 2011 Congressional report found that passage of the health care law prompted health insurance carriers to stop selling new child-only health plans in many states. Of the 50&nbsp;states, 17 reported that there were currently no carriers selling child only health plans to new enrollees. Thirty-nine states indicated at least one insurance carrier exited the child-only market following enactment of the health care laws.<ref>{{Cite press release|url=http://help.senate.gov/newsroom/press/release/?id=141b967c-935c-43d7-8565-147d7a64c70e&groups=Ranking|title=Report: Access to Child-Only Health Plans Declines Under New Health Care Law|date=August 2, 2011|publisher=]}}</ref>


In June 2013, a majority of the public (52–34%) indicated a desire for "Congress to implement or tinker with the law rather than repeal it".<ref>{{cite news |first=Jonathan |last=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=] |access-date=June 14, 2013 |archive-date=November 2, 2017 |archive-url=https://web.archive.org/web/20171102015339/http://nymag.com/daily/intelligencer/2013/06/obamacare-and-conservative-self-delusion.html |url-status=live }}</ref> After the Supreme Court upheld the individual mandate, a 2012 poll held 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. {{Webarchive|url=https://web.archive.org/web/20201112025430/http://content.usatoday.com/communities/theoval/post/2012/07/poll-most-oppose-blocking-obama-health-care-law/1 |date=November 12, 2020 }}. ''USA Today''. Retrieved July 8, 2012.</ref><!-- remmed out ] & ] comments - seems consistent with ] American filmmaker, author, ] and political activist ] criticized the ACA by saying it is a "pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go".<ref name="NYT-20131231"/><ref name="TNR-20140105"/>
====Effects on insurance premiums====


In February 2014, American ]-winning syndicated columnist, political commentator and physician ] described the buyer's remorse Americans are having over the ACA, saying it is having a "wide, broad effect". Because so many people are being negatively impacted by the law, he said, "the bleeding is happening among Independents and also among Democrats".<ref>{{cite news |url=http://www.foxnews.com/on-air/on-the-record/2014/02/28/krauthammer-buyers-remorse-obama-comes-obamacare-having-wide-broad-effect-bleeding-happen |title=Krauthammer: Buyer's remorse on Obama comes from ObamaCare having 'this wide, broad effect ... the bleeding is happening among Independents and Democrats' |publisher=] |date=February 27, 2014}}</ref> -->
For the effect on health insurance premiums, the CBO referred<ref name="CBO-Reid-Dec2009"/>{{Rp|15}} to its November 2009 analysis<ref name=CBOPremiumEffect>{{cite web|url=http://www.cbo.gov/doc.cfm?index=10781&type=1 |title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act |publisher=Cbo.gov |date=2009-11-30 |accessdate=2012-06-29}}</ref> and stated that the effects would "probably be quite similar" to that earlier analysis. The analysis forecasts that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors, including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high-premium plans reducing benefits in response to the tax.<ref name=CBOPremiumEffect/>


As of October 2013, approximately 40% were in favor while 51% were against.<ref>{{cite web |url=http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls |title=Obama and Democrats' Health Care Plan |website=RealClearPolitics |date=October 13, 2013 |access-date=March 26, 2014 |archive-date=March 16, 2021 |archive-url=https://web.archive.org/web/20210316053944/http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls |url-status=live }}</ref><ref>{{cite news |last=Swanson |first=Emily |date=July 30, 2009 |url=http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html |title=Health Care Plan: Favor/Oppose |work=Pollster.com |access-date=July 14, 2011 |archive-date=October 1, 2018 |archive-url=https://web.archive.org/web/20181001170205/http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html |url-status=live }}</ref> About 29% of ] approved of the law, compared with 61% of ] and 91% of ]s.<ref>{{cite web |url=http://www.people-press.org/files/legacy-pdf/9-16-13%20Health%20Care%20Release.pdf |title=As Health Care Law Proceeds, Opposition and Uncertainty Persist |date=September 16, 2013 |publisher=Pew Research Center |access-date=December 18, 2013 |archive-date=April 24, 2018 |archive-url=https://web.archive.org/web/20180424151816/http://www.people-press.org/files/legacy-pdf/9-16-13%20Health%20Care%20Release.pdf |url-status=live }}</ref> A solid majority of seniors opposed the idea and a solid majority of those under forty were in favor.<ref>{{cite news |url=https://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=] |access-date=March 24, 2010 |archive-date=June 20, 2012 |archive-url=https://web.archive.org/web/20120620184320/http://www.usatoday.com/news/washington/2010-03-23-health-poll-favorable_N.htm |url-status=live }}</ref>
The ] reported that, as a result of PPACA's provisions concerning the ] (between the ''initial coverage limit'' and the ''catastrophic coverage threshold'' in the ] ] program), individuals falling in this "donut hole" would save about 40 percent.<ref name="shrinks">{{cite web| last = Alonso-Zaldivar | first = Ricardo| title = AP Newsbreak: Medicare's drug coverage gap shrinks| publisher = ]| date = November 27, 2011| url = http://www.businessweek.com/ap/financialnews/D9R93OMO3.htm| accessdate = October 25, 2012}}</ref> Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies.<ref name="shrinks"/> The change benefited more than two million people, most of them in the middle class.<ref name="shrinks"/>


A 2014 poll reported that 26% of Americans support ACA.<ref>{{cite news |url=http://bigstory.ap.org/article/poll-obama-health-law-fails-gain-support |title=AP-GfK Poll: Obama's health care fails to gain support |date=March 28, 2014 |access-date=March 30, 2014 |publisher=] |archive-date=April 1, 2014 |archive-url=https://web.archive.org/web/20140401024529/http://bigstory.ap.org/article/poll-obama-health-law-fails-gain-support |url-status=dead}}</ref> A later 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA versus 38.3% who had a favorable view (of more than 5,500 individuals).<ref>{{cite web |url=https://www.rand.org/health/projects/health-reform-opinion.html |title=RAND Health Reform Opinion Study |date=May 1, 2014 |publisher=RAND Health |access-date=May 10, 2014 |archive-date=November 29, 2018 |archive-url=https://web.archive.org/web/20181129194516/https://www.rand.org/health/projects/health-reform-opinion.html |url-status=live }}</ref> Another held that 8% of respondents agreed the Affordable Care Act "is working well the way it is".<ref>{{cite web |archive-url=https://web.archive.org/web/20140503034720/https://online.wsj.com/news/articles/SB10001424052702303678404579533362696579096 |archive-date=May 3, 2014 |url=https://online.wsj.com/news/articles/SB10001424052702303678404579533362696579096 |title=The ObamaCare 8% |newspaper=] |publisher=News Corp |oclc=781541372 |issn= 1042-9840 |date=April 30, 2014 |access-date=May 1, 2014}}</ref> In late 2014, a ] poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.<ref>], " {{Webarchive |url=https://web.archive.org/web/20171023012206/http://www.alan.com/2014/12/01/poll-voters-no-longer-want-to-repeal-obamacare/ |date=October 23, 2017 }}", ''Liberaland'', December 1, 2014.</ref>
The non-partisan ] estimates that "about 4 million" (3.9 million or 1.2% of the ]) will pay the penalty in 2016.<ref>Congressional Budget Office, "," Congress of the United States, December 2010, pp 71,73.</ref> In September 2012, the CBO estimated that nearly six million will pay a $1,200&nbsp;penalty in 2016. Also, nearly 80&nbsp;percent of those who will face the penalty would be making up to or less than five times the federal poverty level. This would work out to $55,850&nbsp;or less &nbsp;for an individual and $115,250&nbsp;or less for a family of four.<ref>{{cite news|last=Alonso-Zaldivar|first=Ricardo|title=Tax penalty to hit nearly 6M uninsured people|agency=Associated Press|date=2012-09-19|url=http://www.google.com/hostednews/ap/article/ALeqM5jmIII4FgDvIW-bij_fdHF4v0Whbw?docId=48328c71af0241c39aef95fda77612f7|archiveurl=http://www.webcitation.org/6ApAsoQ8h|archivedate=2012-09-20|deadurl=no }}</ref>


In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved.<ref>{{cite web |url=http://www.cbsnews.com/news/poll-obamacare-and-the-supreme-court/ |title=Poll: Obamacare and the Supreme Court |work=] |date=June 22, 2015 |access-date=June 23, 2015 |archive-date=December 1, 2020 |archive-url=https://web.archive.org/web/20201201040030/https://www.cbsnews.com/news/poll-obamacare-and-the-supreme-court/ |url-status=live }}</ref> A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.<ref>{{cite web |url=http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/ |title=After the Election, the Public Remains Sharply Divided on Future of the Affordable Care Act |publisher=] |date=December 3, 2016 |access-date=December 3, 2016 |archive-date=February 25, 2021 |archive-url=https://web.archive.org/web/20210225032025/https://www.kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/ |url-status=live }}</ref>
In January 2013, the ] ruled that only the cost of covering the individual employee but not their family can be used for determining whether the cost of employer-based health coverage exceeds 9.5 percent of the worker’s household income, which is necessary to obtain taxpayer-subsidized coverage on the new health insurance exchanges starting in 2014. ''The New York Times'' said this could leave millions of Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies to buy coverage elsewhere.<ref> ''New York Times'', February 2, 2013</ref>


Separate polls from Fox News and NBC/''WSJ'', both taken during January 2017, indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who had once opposed it (many still prefer "Medicare for all") shifted their positions because ACA was under threat of repeal.<ref>{{cite web |url=https://www.nytimes.com/interactive/2017/02/01/us/politics/100000004904286.mobile.html |title=Obamacare More Popular Than Ever, Now That It May Be Repealed |work=] |date=February 1, 2017 |access-date=February 3, 2017 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023012422/https://www.nytimes.com/interactive/2017/02/01/us/politics/100000004904286.mobile.html |url-status=live }}</ref> Another January 2017 poll reported that 35% of respondents believed "Obamacare" and the "Affordable Care Act" were different or did not know. (About 45% were unsure whether "repeal of Obamacare" also meant "repeal of the Affordable Care Act".) 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the ACA were repealed and no replacement enacted", with Democrats far more likely (79%) to know that fact than Republicans (47%).<ref>{{Cite news |url=https://www.nytimes.com/2017/02/07/upshot/one-third-dont-know-obamacare-and-affordable-care-act-are-the-same.html |title=One-Third Don't Know Obamacare and Affordable Care Act Are the Same |last1=Dropp |first1=Kyle |date=February 7, 2017 |newspaper=] |access-date=February 8, 2017 |last2=Nyhan |first2=Brendan |issn=1553-8095 |oclc=1645522 |archive-date=March 9, 2021 |archive-url=https://web.archive.org/web/20210309045108/https://www.nytimes.com/2017/02/07/upshot/one-third-dont-know-obamacare-and-affordable-care-act-are-the-same.html// |url-status=live }}</ref> A 2017 study found that personal experience with public health insurance programs led to greater support for the ACA, most prominently among Republicans and low-information voters.<ref>{{Cite journal |last1=Lerman |first1=Amy E. |last2=McCabe |first2=Katherine T. |date=January 24, 2017 |title=Personal Experience and Public Opinion: A Theory and Test of Conditional Policy Feedback |journal=The Journal of Politics |volume=79 |issue=2 |pages=624–641 |doi=10.1086/689286 |s2cid=157429497 |issn=0022-3816}}</ref>
In March 2013, a report by The Lewin Group subsidiary of ], sponsored and published by the ], predicted that insurers' claims costs in the individual health insurance market could rise an average of 32&nbsp;percent nationally by 2017. Insurers in some states could see claims costs in the individual health insurance market go up higher than that with increases estimated at 80&nbsp;percent in Ohio and Wisconsin, and 60&nbsp;percent in California, Idaho, Maryland and Indiana. States such as New York, Vermont, and Massachusetts could see decreases of 13–14&nbsp;percent in insurers' claims costs in the individual health insurance market, however. The effect on insurance premiums was outside the scope of the study and was not addressed in the report. Larry Levitt, a health policy analyst from the ], cautioned that the Lewin Group study did not factor in efforts in the reform to control costs, and assumes huge increases in the individual market (which compromises just 6% of those under 65 currently); in contrast, Levitt said "I don't think anyone expects significant increases in the employer market," where the majority of Americans get their health insurance. Secretary of Health and Human Services Kathleen Sebelius also indicated that some cost increase in the individual market was expected because the standard of insurance allowed in the health care exchanges (run by the states or the federal government) would be higher quality than that generally available currently (and thus more expensive), and that the government subsidies provided to make insurance affordable weren't included in the Lewin Group estimates.<ref name="Haught 2013">{{cite web|author=Haught, Randy (]); Aherns, John (])|date=March 26, 2013|title=Cost of the future newly insured under the Affordable Care Act (ACA)|location=Schaumburg|publisher=]|url=http://cdn-files.soa.org/web/research-cost-aca-report.pdf|accessdate=April 12, 2013}}<br/>{{cite news|last=Aigner-Treworgy|first=Adam|date=March 27, 2013|title=Health care law will raise insurers' costs, actuaries say|work=CNN politicalticker... blog|publisher=]|url=http://politicalticker.blogs.cnn.com/2013/03/27/health-care-law-will-raise-insurers-costs-actuaries-say/|accessdate=April 12, 2013}}<br/>{{cite web|last=Robertson|first=Lori|date=April 5, 2013|title=Health insurance premium spin|location=Philadelphia|publisher=]|url=http://www.factcheck.org/2013/04/insurance-premium-spin/|accessdate=April 12, 2013}}</ref>


By the end of 2023, a Morning Consult poll of registered voters found that 57% approved of the Affordable Care Act, while 30% disapproved of it. 85% of Democrats, 56% of independents, and 28% of Republicans supported the law.<ref>{{cite news |url=https://pro.morningconsult.com/analysis/obamacare-polling-popularity |title=Obamacare Has Become Even More Popular Over Biden's Presidency |date=December 6, 2023 |publisher=] |access-date=January 11, 2024 |archive-date=January 11, 2024 |archive-url=https://web.archive.org/web/20240111192353/https://pro.morningconsult.com/analysis/obamacare-polling-popularity |url-status=live }}</ref>
====Coverage for contraceptives====
{{main|Contraceptive mandate (United States)}}
The ACA includes a ] coverage mandate that, with the exception of churches and houses of worship, applies to all employers and educational institutions. These regulations<ref name="Final Rule">{{cite web|title=Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules|url=http://www.gpo.gov/fdsys/granule/FR-2012-02-15/2012-3547/content-detail.html|publisher=Federal Register, GPO|accessdate=February 15, 2012|author=Dept. Health and Human Services|format=77 FR 8725|date=February 10, 2012|quote=Summary: ''These regulations finalize, without change, interim final regulations authorizing the exemption of group health plans and group health insurance coverage sponsored by certain religious employers from having to cover certain preventive health services under provisions of the Patient Protection and Affordable Care Act''.}}</ref> made under PPACA rely on the recommendations of the ], which concluded that access to contraception is medically necessary "to ensure women's health and well-being."<ref>{{cite news | publisher = CNN | title = Birth control should be fully covered under health plans, report says | first = Madison | last = Park | url = http://www.cnn.com/2011/HEALTH/07/19/birth.control.iom/index.html | date = July 19, 2011 | accessdate = August 27, 2012}}</ref>


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


The term "Obamacare" was originally coined by opponents as a ]. According to research by ], the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured.<ref name="NYT20120803" /> The term officially emerged in March 2007 when healthcare ] Jeanne Schulte Scott wrote, "We will soon see a ']-care' and 'Obama-care' to go along with ']-care', ']-care', and a totally revamped and remodeled ']' from the 1990s".<ref name="CNN20120625Obamacare" /><ref name="NYT20120325" />
===Federal deficit and health care costs===
{{See also|United States public debt}}


In May 2007, ] introduced it to political discourse, saying, "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" />
====CBO deficit reduction estimates====
]
The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021.<ref name="CBO22077">{{cite web|url=http://www.cbo.gov/publication/22077 |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |publisher=Congressional Budget Office |date=March 30, 2011 |accessdate=April 6, 2012}}</ref><ref name="CBO43104">{{cite web |url=http://www.cbo.gov/publication/43104 |title=Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act |publisher=Congressional Budget Office |date=March 16, 2012 |accessdate=April 6, 2012}}</ref> CBO estimated in March 2011 that for the 2012–2021 period, the law would result in net receipts of $813 billion, offset by $604 billion in outlays, resulting in a $210 billion reduction in the deficit.<ref name="CBO22077"/>


By mid-2012, Obamacare had become the ] term used both by supporters and opponents.<ref name="NYT20120803" /> Obama eventually endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."<ref>{{cite news |first=Lucy |last=Madison |url=http://www.cbsnews.com/news/on-bus-tour-obama-embraces-obamacare-says-i-do-care/ |title=On bus tour, Obama embraces 'Obamacare', says 'I do care{{'-}} |work=] |date=August 15, 2011 |access-date=April 28, 2012 |archive-date=February 25, 2021 |archive-url=https://web.archive.org/web/20210225044208/https://www.cbsnews.com/news/on-bus-tour-obama-embraces-obamacare-says-i-do-care/ |url-status=live }}</ref>
In 2012, the CBO updated its cost estimates for a portion of the bill, but did not update its estimate of the net deficit impact of the whole bill (which was still estimated to reduce budget deficits overall).<ref name="CBO43080"/> The ACA's provisions related to insurance coverage were projected earlier in 2012 to have a net cost of $1,252 billion over the 2012–2022 period; that amount represented a gross cost to the federal government of $1,762 billion, offset in part by $510 billion in receipts and other budgetary effects (primarily revenues from penalties and other sources). The addition of 2022 to the projection period had the effect of increasing the costs of the coverage provisions of the ACA relative to those projected in March 2011 for the 2012-2021 period because that change added a year in which the expansion of eligibility for Medicaid and the subsidies for health insurance purchased through the exchanges would have been in effect. This estimate was made prior to the Supreme Court's ruling regarding the expansion of Medicaid program to the individual states however.<ref name="CBO43076" /> CBO and JCT now estimate that the insurance coverage provisions of the ACA will have a net cost of $1,168 billion over the 2012–2022 period—compared with $1,252 billion projected in March 2012 for that 11-year period—for a net reduction of $84 billion. (Those figures do not include the budgetary impact of other provisions of the ACA, which in the aggregate reduce budget deficits.)<ref name="CBO43472">{{cite web|url=http://www.cbo.gov/publication/43472 |title=CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=August 6, 2012}}</ref>


The use of "Obamacare" became increasingly rare, and at the ], Obama said, "I noticed, by the way, since it became popular, they don't call it 'Obamacare' no more."<ref>{{Cite web|url=https://apnews.com/live/updates-democratic-national-convention-harris-walz|title=Highlights from Election 2024: RFK Jr. says he is suspending, not ending his campaign. His campaign says he 'has not endorsed Trump'|website=AP News}}</ref>
As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143&nbsp;billion<ref name="CBO21351">{{cite web |url=http://www.cbo.gov/publication/21351 |title=Cost Estimates for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation) |publisher=Congressional Budget Office |date=March 20, 2010 |accessdate=April 6, 2012}}</ref> over the first decade, but half of that was due to expected premiums for the ], which has since been abandoned.<ref>{{cite news| url=http://www.bloomberg.com/news/2011-10-14/u-s-won-t-start-class-long-term-care-insurance-sebelius-says.html | publisher=Bloomberg | first1=Alex | last1=Wayne | first2=Drew | last2=Armstrong | title=U.S. Won't Start Long-Term Care Insurance | date=October 14, 2011}}</ref> Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the great degree of uncertainty involved in the data) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2&nbsp;trillion.<ref name="CBO-Reid-Dec2009"/><ref name="CNN-Mar18">{{Cite news
| url = http://www.cnn.com/2010/POLITICS/03/18/health.care.latest/index.html
| publisher = CNN
| title = Where does health care reform stand?
| date = March 18, 2010
| accessdate = May 12, 2010
}}</ref>
CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".<ref>{{cite news|url=http://www.politifact.com/truth-o-meter/statements/2010/mar/18/nancy-pelosi/pelosi-cbo-says-health-reform-bill-would-cut-defic/|title=Pelosi: CBO says health reform bill would cut deficits by $1.2 trillion in second decade|last=Farley|first=Robert|date=March 18, 2010|publisher=]|accessdate=2010-04-07}}</ref>


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


<!-- Please read WP:UNDUE and WP:FRINGE. Please. -->
====Opinions on CBO projections====
There was mixed opinion about the CBO estimates.


===="Death panels"====
], 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>


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


On August 7, 2009, ] created the term "]s" to describe groups who would decide whether sick patients were "worthy" of medical care.<ref name="Not so" /> "Death panel" referred to two claims about early drafts.
'']'' editors ] (an economist) and ] (a noted health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from ], and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;<ref>{{cite news |title=Is the CBO Biased Against Health Care Reform? |author=Noam Scheiber |publisher=The New Republic |date=September 17, 2009 |url=http://www.tnr.com/blog/the-stash/the-cbo-biased-against-health-care-reform }}</ref><ref name=autogenerated3>{{cite news |title=The GOP's Trick Play |author=Jonathan Cohn |publisher=The New Republic |date=January 21, 2011 |url=http://www.tnr.com/blog/jonathan-cohn/81941/trick-play }}</ref> "innovations in the delivery of medical care, like greater use of ]s<ref>{{cite web|url=http://www.medicalrecords.com/physicians/electronic-medical-records-deadline |title=Electronic Medical Records (Health Information Technology)}}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another – and that meant there wasn't much hard data to prove the savings would materialize."<ref name=autogenerated3 />


One was that under the law, seniors could be denied care due to their age<ref>{{cite web |url=http://snopes.com/politics/medical/over75.asp |title=Seniors Beware |website=Snopes |date=August 23, 2012 |access-date=July 17, 2013 |archive-date=July 1, 2024 |archive-url=https://web.archive.org/web/20240701043153/https://www.snopes.com/fact-check/seniors-beware/ |url-status=live }}</ref> and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an ] (IPAB).<ref name="salon08132013" /> IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when statutory expenditure levels were exceeded within any given three-year period. In fact, the Board was prohibited from recommending changes that would reduce payments before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.<ref>{{cite web |first1=Jack |last1=Ebeler |first2=Tricia |last2=Neuman |first3=Juliette |last3=Cubanski |title=The Independent Payment Advisory Board: A New Approach to Controlling Medicare Spending |url=http://kff.org/health-reform/issue-brief/the-independent-payment-advisory-board-a-new/ |publisher=] |date=April 13, 2011 |page=3 |access-date=November 27, 2013 |archive-date=March 1, 2021 |archive-url=https://web.archive.org/web/20210301060545/https://www.kff.org/health-reform/issue-brief/the-independent-payment-advisory-board-a-new/ |url-status=live }}</ref><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/jonathan-cohn/87102/ipab-medicare-commission-repeal-ryan-schwartz |title=Here We Go Again, With the Death Panels |magazine=] |date=April 20, 2011 |access-date=March 10, 2017 |archive-date=September 22, 2015 |archive-url=https://web.archive.org/web/20150922221033/http://www.newrepublic.com/blog/jonathan-cohn/87102/ipab-medicare-commission-repeal-ryan-schwartz |url-status=live }}</ref>
], former ] now working for ], has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.<ref name="deficit_david_walker_cbo_innacurate">{{cite news|url=http://www.npr.org/blogs/thetwo-way/2010/03/health_overhaul_another_promis.html|title=Health Overhaul Another Promise U.S. Can't Afford: Expert|last=James|first=Frank|date=March 19, 2010|publisher=]|accessdate=2010-04-07}}</ref> The ] objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20&nbsp;years to produce Medicare savings.<ref>{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |title=Congress Has Good Record of Implementing Medicare Savings |publisher=CBPP |accessdate=2010-03-28 }}</ref><ref>{{cite news |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |work=The Washington Post |accessdate=2010-03-28 }}</ref>


The other related issue concerned ] consultation: ] would have reimbursed physicians for providing patient-requested consultations for Medicare recipients on end-of-life health planning (which is covered by many private plans), enabling patients to specify, on request, the kind of care they wished to receive.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/mandatory-death-counseling-exposed |title=Mandatory Death Counseling – exposed! |magazine=] |date=August 13, 2009 |access-date=March 10, 2017 |archive-date=September 21, 2015 |archive-url=https://web.archive.org/web/20150921235058/http://www.newrepublic.com/blog/the-treatment/mandatory-death-counseling-exposed |url-status=live }}</ref> The provision was not included in ACA.<ref>{{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 |first1=Christi |last1=Parsons |first2=Andrew |last2=Zajac |newspaper=] |date=August 14, 2009 |url=https://www.latimes.com/archives/la-xpm-2009-aug-14-na-health-end-of-life14-story.html |access-date=July 20, 2013 |archive-date=November 26, 2010 |archive-url=https://web.archive.org/web/20101126193741/http://articles.latimes.com/2009/aug/14/nation/na-health-end-of-life14 |url-status=live }}</ref>
Republican ] leadership and the Republican majority on the ] estimate the law would increase the deficit by more than $700&nbsp;billion in its first 10&nbsp;years.<ref>{{cite web|last=Ryan |first=Paul |url=http://budget.house.gov/healthcare/ |title=The Budgetary Consequences of the President's Health Care Overhaul |publisher=House of Representatives Committee on the Budget |accessdate=April 1, 2012}}</ref><ref>{{cite web|last=Seymour |first=Don |url=http://www.speaker.gov/Blog/?postid=219211 |title=Repealing Job-Killing Health Care Law "First Step Toward Fiscal Sanity" |publisher=Speaker of the House John Boehner |date=January 6, 2011 |accessdate=April 1, 2012}}</ref>


In 2010, the ] reported that 85% of Americans were familiar with the claim, and 30% believed it was true, backed by three contemporaneous polls.<ref>{{Cite journal |first=Brendan |last=Nyhan |title=Why the "Death Panel" Myth Wouldn't Die: Misinformation in the Health Care Reform Debate |journal=The Forum |volume=8 |issue=1 |year=2010 |doi=10.2202/1540-8884.1354 |url=http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf |citeseerx=10.1.1.692.9614 |s2cid=144075499 |access-date=July 1, 2013 |archive-date=June 4, 2019 |archive-url=https://web.archive.org/web/20190604135225/http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf |url-status=dead }}</ref> The allegation was named ]'s 2009 "Lie of the Year",<ref name="Not so" /><ref>{{Cite news |title=PolitiFact's Lie of the Year: 'Death panels' |publisher=] |date=December 19, 2009 |url=http://politifact.com/truth-o-meter/article/2009/dec/18/politifact-lie-year-death-panels |first=Angie |last=Drobnic Holan |access-date=November 19, 2010 |archive-date=January 13, 2020 |archive-url=https://web.archive.org/web/20200113082025/https://www.politifact.com/truth-o-meter/article/2009/dec/18/politifact-lie-year-death-panels/ |url-status=live }}</ref> one of ]'s "whoppers"<ref>{{Cite news |title=False Euthanasia Claims |first1=Jess |last1=Henig |first2=Lori |last2=Robertson |publisher=] |date=July 29, 2010 |url=http://www.factcheck.org/2009/07/false-euthanasia-claims |access-date=July 20, 2013 |archive-date=February 24, 2021 |archive-url=https://web.archive.org/web/20210224220630/https://www.factcheck.org/2009/07/false-euthanasia-claims/ |url-status=live }}</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=Robertson, Lori |url=http://www.factcheck.org/2009/12/whoppers-of-2009 |publisher=] |access-date=April 28, 2011 |archive-date=March 10, 2021 |archive-url=https://web.archive.org/web/20210310232257/https://www.factcheck.org/2009/12/whoppers-of-2009/ |url-status=live }}</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=] |access-date=October 8, 2010 |archive-date=April 12, 2019 |archive-url=https://web.archive.org/web/20190412061753/http://www.americandialect.org/2009-Word-of-the-Year-PRESS-RELEASE.pdf |url-status=live }}</ref> ] described such rumors as "rife with gross—and even cruel—distortions".<ref name="snopes1" />
Democratic ] leadership and the Democratic minority on the ] say the claims of budget gimmickry are false<ref>{{cite web|url=http://democrats.budget.house.gov/press-release/mythbuster-cms-actuary-debunks-gop-talking-point-health-reform-and-deficit |title=MYTHBUSTER – CMS Actuary Debunks GOP Talking Point on Health Reform and the Deficit |publisher=Committee on the Budget &#124; United States House of Representatives |date=January 26, 2011 |accessdate=April 1, 2012}}</ref> and that repeal of the legislation would increase the deficit by $230&nbsp;billion over the same period,<ref> Committee on the Budget | United States House of Representatives</ref> pointing to the CBO's 2011 analysis of the impact of repeal.<ref name=autogenerated2>Heavey, Susan (February 18, 2011), , Reuters, retrieved March 13, 2011</ref>


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


ACA requires members of Congress and their staffs to obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the insurance offered to federal employees (the ]).<ref> {{Webarchive|url=https://web.archive.org/web/20181211230603/http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm |date=December 11, 2018 }}, section 1312: "...{{nbsp}}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><ref>{{Cite news |title=Congress Exempt from Health Bill? |first=Lori |last=Robertson |publisher=] |date=January 20, 2010 |url=http://www.factcheck.org/2010/01/congress-exempt-from-health-bill |access-date=August 18, 2013 |archive-date=March 5, 2021 |archive-url=https://web.archive.org/web/20210305200603/https://www.factcheck.org/2010/01/congress-exempt-from-health-bill/ |url-status=live }}</ref>
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>


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


ACA explicitly denies insurance subsidies to "unauthorized (illegal) ]".<ref name="cbouninsured" /><ref name="Chaikind2011" /><ref>{{Cite news |title=The Democrats' health care bills would provide 'free health care for illegal immigrants' |publisher=] |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 |first=Robert |last=Farley |access-date=August 19, 2013 |archive-date=September 16, 2018 |archive-url=https://web.archive.org/web/20180916052045/https://www.politifact.com/truth-o-meter/statements/2010/jan/21/chain-email/chain-e-mail-claims-health-care-bills-congress-wou/ |url-status=live }}</ref>
The law created the ] and requires numerous pilots and demonstrations to be conducted which may have an impact on the cost of healthcare in the long-run.<ref>Kuraitis V. (2010). . e-CareManagement.com.</ref> Although these cost reductions have not been factored into CBO cost estimates, the experiments cover nearly every idea healthcare experts advocate, except malpractice/].<ref name="NewYorker-Gawande">{{Cite journal | author = ] | month = December | year = 2009 | url = http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all| title = Testing, Testing | journal = ]| accessdate = March 22, 2010}}</ref>


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


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


Opponents claimed that combining immediate coverage with no provision for preexisting conditions would lead people to wait to get insured until they got sick. The individual mandate was designed to push people to get insured without waiting. This has been called a "death spiral".<ref>{{cite web |url=https://www.bloomberg.com/view/articles/2017-01-18/the-once-and-future-obamacare-death-spiral |title=The Once and Future Obamacare Death Spiral |date=January 18, 2017 |publisher=] |access-date=January 30, 2017 |archive-date=January 19, 2017 |archive-url=https://web.archive.org/web/20170119031220/https://www.bloomberg.com/view/articles/2017-01-18/the-once-and-future-obamacare-death-spiral |url-status=live }}</ref> In the years after 2013, many insurers did leave specific marketplaces, claiming the risk pools were too small.
According to the ], by 2019 PPACA will increase expenditures on Medicaid and individual subsidies by $165&nbsp;billion annually while reducing Medicare expenditures by $125&nbsp;billion annually.<ref>http://heartland.org/sites/all/modules/custom/heartland_migration/files/pdfs/27696.pdf</ref> The ] reported that the bill would increase "total national health expenditures" by more than $200&nbsp;billion from 2010 to 2019.<ref name="autogenerated5">{{cite web|url=https://www.cms.gov/ActuarialStudies/Downloads/S_PPACA_2009-12-10.pdf |title=Estimated Financial Effects of the Patient Protection and Affordable Care Act of 2009 |publisher=Centers for Medicare and Medicaid Services |date=December 10, 2009 |accessdate=April 1, 2012}}</ref><ref>http://www.politico.com/static/PPM110_091211_financial_impact.html</ref> The report also cautioned that the increases could be larger, because the Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back: They projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors.<ref>{{dead link|date=March 2012}} ], April 23, 2010</ref> The Medicare Actuary report still concluded that "Additional Federal revenues would further offset the coverage costs; however, the Office of the Actuary does not have the expertise necessary to estimate all such impacts. The Congressional Budget Office and the Joint Committee on Taxation have estimated an overall reduction in the Federal Budget deficit through 2019 under the ACA."<ref>Richard S. Foster, , ], April 22, 2010</ref>


The ] number of insurers per state was 4.0 in 2014, 5.0 in 2015, 4.0 in 2016 and 3.0 in 2017. Five states had one insurer in 2017, 13 had two, 11 had three; the remainder had four or more.<ref>{{cite web |url=http://kff.org/other/state-indicator/number-of-issuers-participating-in-the-individual-health-insurance-marketplace/?currentTimeframe=0 |title=Number of Insurers Participating in the Individual Health Insurance Marketplaces |publisher=] |date=January 30, 2017 |access-date=January 30, 2017 |archive-date=January 27, 2017 |archive-url=https://web.archive.org/web/20170127051523/http://kff.org/other/state-indicator/number-of-issuers-participating-in-the-individual-health-insurance-marketplace/?currentTimeframe=0 |url-status=live }}</ref>
===Political===


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


At various times during and after ACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan."<ref>{{cite web |url=https://obamawhitehouse.archives.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay |work=] |title=A Town Hall, and a Health Care Model, in Green Bay |date=June 11, 2009 |via=] |access-date=November 9, 2013 |archive-date=May 4, 2021 |archive-url=https://web.archive.org/web/20210504003513/https://obamawhitehouse.archives.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay |url-status=live }}</ref><ref name="ObamaPromise" /> However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,<ref>{{cite news |url=http://www.cnn.com/2013/11/08/politics/obama-obamacare-apology |title=After the big Obamacare apology: where things stand |date=November 8, 2013 |access-date=November 9, 2013 |publisher=] |archive-date=November 9, 2013 |archive-url=https://web.archive.org/web/20131109074558/http://www.cnn.com/2013/11/08/politics/obama-obamacare-apology/ |url-status=live }}</ref> and several million more risked seeing their current plans canceled.<ref>{{cite web |url=http://www.cnn.com/2013/11/07/politics/obama-obamacare-apology |title=Obama apologizes for insurance cancellations due to Obamacare |date=November 7, 2013 |publisher=] |access-date=July 29, 2014 |archive-date=November 8, 2013 |archive-url=https://web.archive.org/web/20131108072839/http://www.cnn.com/2013/11/07/politics/obama-obamacare-apology |url-status=live }}</ref><ref>{{cite news |url=http://www.bizjournals.com/denver/news/2013/11/08/health-insurers-canceling-plans-say.html |title=Health insurers say they're canceling plans because of federal law |last=Sealover |first=Ed |date=November 8, 2013 |work=Denver Business Journal |access-date=November 9, 2013 |archive-date=November 9, 2013 |archive-url=https://web.archive.org/web/20131109210039/http://www.bizjournals.com/denver/news/2013/11/08/health-insurers-canceling-plans-say.html |url-status=live }}</ref>
Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. '']'', describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."<ref>{{cite news|author=Micah Cohen |url=http://fivethirtyeight.blogs.nytimes.com/2013/05/01/uncertainty-still-clouds-health-care-law/ |title=Uncertainty Still Clouds Health Care Law |date=May 1, 2013|work=FiveThirtyEight}}</ref> For example, a Reuters-Ipsos poll during June 2012 indicated the following:
*56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall.
*82% favored banning insurance companies from denying coverage to people with pre-existing conditions.
*61% favored allowing children to stay on their parents' insurance until age 26.
*72% supported requiring companies with more than 50 employees to provide insurance for their employees.
*61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.<ref name=most>{{cite news|last=Zengerle |first=Patricia |url=http://www.reuters.com/article/2012/06/24/us-usa-campaign-healthcare-idUSBRE85N01M20120624 |title=Reuters-Most Americans Oppose Health Law But Like the Provisions|publisher=Reuters.com |date= June 24, 2012 |accessdate=2012-06-28}}</ref>
*Other polls showed additional provisions receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.<ref>{{cite news|url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does/ |title=Washington Post-Republicans hate ‘Obamacare,’ but like most of what it does|publisher=Washingtonpost.com |date= June 26, 2012|accessdate=2012-06-28}}</ref><ref>{{cite news|last=Sargent |first=Greg |url=http://www.washingtonpost.com/blogs/plum-line/post/republicans-support-obamas-health-reforms--as-long-as-his-name-isnt-on-them/2012/06/25/gJQAq7E51V_blog.html |title=Washington Post-Greg Sargent-The Plum Line|publisher=Washingtonpost.com |date=June 25, 2012 |accessdate=2012-06-28}}</ref>
*Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),<ref>{{cite news|author=Uwe E. Reinhardt |url=http://economix.blogs.nytimes.com/2009/12/18/reimporting-american-drugs-from-canada/ |title=Reimporting American Drugs From Canada |date=December 18, 2009|work=Economix}}</ref> ], reducing the age to qualify for Medicare, and the ].<ref name=NEJMPublicOpinion>{{cite journal |author=Blendon RJ, Benson JM |title=Public opinion at the time of the vote on health care reform |journal=N. Engl. J. Med. |volume=362 |issue=16 |pages=e55 |year=2010 |month=April |pmid=20375397 |doi=10.1056/NEJMp1003844 |url=}}</ref>


Obama's previous unambiguous assurance that consumers could keep their own plans became a focal point for critics, who challenged his truthfulness.<ref>{{cite magazine |last=Weigel |first=David |date=November 8, 2013 |title=The White House's Website Still Says If You Like Your Plan You Can Keep It |url=http://www.slate.com/blogs/weigel/2013/11/08/the_white_house_s_web_site_still_says_if_you_like_your_plan_you_can_keep.html |magazine=Slate |access-date=November 9, 2013 |archive-date=November 8, 2013 |archive-url=https://web.archive.org/web/20131108232659/http://www.slate.com/blogs/weigel/2013/11/08/the_white_house_s_web_site_still_says_if_you_like_your_plan_you_can_keep.html |url-status=live }}</ref><ref>{{cite news |url=https://www.economist.com/news/united-states/21588951-congress-hears-tales-baffling-ineptitude-debacle |title=Obamacare: The debacle |date=November 2, 2013 |newspaper=] |access-date=November 8, 2013 |archive-date=November 7, 2013 |archive-url=https://web.archive.org/web/20131107185749/http://www.economist.com/news/united-states/21588951-congress-hears-tales-baffling-ineptitude-debacle |url-status=live }}</ref> Various bills were introduced in Congress to allow people to keep their plans.<ref>{{cite news |url=http://www.mcclatchydc.com/2013/11/08/207999/congress-weighing-laws-to-let.html |title=Congress weighing laws to let people keep health insurance |last=Schoof |first=Renee |date=November 8, 2013 |access-date=November 14, 2013 |publisher=McClatchyDC |archive-date=November 13, 2013 |archive-url=https://web.archive.org/web/20131113010850/http://www.mcclatchydc.com/2013/11/08/207999/congress-weighing-laws-to-let.html |url-status=live }}</ref>
Pollsters probed the reasons for opposition.<ref>{{cite news| url=http://facts.kff.org/chart.aspx?ch=1683 | work=Kaiser Family Foundation | title=Negative Views Driven By Many Factors}}</ref> In a ] ], 62% of respondents said they thought the 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>http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf</ref> In '']'', pollsters ] and ] wrote, "81% of voters say it's likely the plan will end up costing more than projected say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care. For these voters, the notion that you need to spend an additional trillion dollars doesn't make sense."<ref>{{cite news| url=http://online.wsj.com/article/SB10001424052748704784904575111993559174212.html | work=The Wall Street Journal | first1=Scott | last1=Rasmussen | first2=Doug | last2=Schoen | title=Why Obama Can't Move the Health-Care Numbers | date=March 9, 2010}}</ref> However, a June 2012 Reuters-Ipsos poll indicated that part of the opposition to the law was because some Americans did not believe the reform went far enough and wanted more done, not less. Among those opposed to the bill, 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among (the relative much smaller group of) Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.<ref name=most/>


] initially cited various estimates that only about 2% of the total insured population (4{{nbsp}}million out of 262 million) received such notices,<ref>{{cite news |url=http://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |title=Lie of the Year: "If you like your health care plan, you can keep it |date=December 12, 2014 |access-date=April 5, 2018 |publisher=] |archive-date=December 13, 2013 |archive-url=https://web.archive.org/web/20131213061554/http://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |url-status=live }}</ref> but readers later voted Obama's claims as the 2013 "Lie of the Year".<ref>{{Cite web |url=https://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |title=Lie of the Year: 'If you like your health care plan, you can keep it' |last=Drobnic Holan |first=Angie |date=December 12, 2013 |website=] |access-date=December 1, 2019 |archive-date=December 13, 2013 |archive-url=https://web.archive.org/web/20131213061554/https://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |url-status=live }}</ref>
Following ], a poll released in July 2012 showed that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues."<ref>Jackson, David. ''USA Today.'' Retrieved: 8 July 2012.</ref>


==Criticism and opposition==
====Term "Obamacare"====
Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions,<ref name="WSJ" /><ref name="wapo" /> ] advocacy groups,<ref name="NYT-20131018" /><ref name="NYT-20140126" /> Republicans, 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=https://www.nytimes.com/2013/07/07/us/politics/conservatives-aggressive-ad-campaign-seeks-to-cast-doubt-on-health-law.html |work=] |issn=0362-4331 |oclc=1645522 |date=January 20, 2011 |access-date=February 7, 2017 |archive-date=November 12, 2020 |archive-url=https://web.archive.org/web/20201112040804/http://www.nytimes.com/2013/07/07/us/politics/conservatives-aggressive-ad-campaign-seeks-to-cast-doubt-on-health-law.html |url-status=live }}</ref> These groups claimed the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit.<ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/article/113994/obamacare-implementation-conservatives-brace-it-working |title=Conservatives Brace for the Possibility Obamacare Won't Totally Suck |magazine=] |date=July 23, 2013 |access-date=March 10, 2017 |archive-date=December 12, 2020 |archive-url=https://web.archive.org/web/20201212155407/https://newrepublic.com/article/113994/obamacare-implementation-conservatives-brace-it-working |url-status=live }}</ref> Some opposed the idea of ], viewing insurance as similar to other unsubsidized goods.<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 |access-date=August 5, 2013 |archive-date=December 25, 2020 |archive-url=https://web.archive.org/web/20201225215008/https://www.cato.org/blog/anti-universal-coverage-club-manifesto |url-status=live }}</ref><ref>{{cite news |first=Jonathan |last=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 |work=] |date=June 25, 2012 |access-date=August 5, 2013 |archive-date=July 5, 2018 |archive-url=https://web.archive.org/web/20180705062650/http://nymag.com/daily/intelligencer/2012/06/health-care-as-privilege-what-gop-wont-admit.html |url-status=live }}</ref> President ] repeatedly promised to "repeal and replace" it.<ref>{{Cite web |url=https://www.cnbc.com/2016/11/09/trumps-first-100-day-agenda-may-be-stymied-by-his-own-party.html |title=Here's what's coming from the Trump administration |last=Schoen |first=John W. |date=November 9, 2016 |website=] |access-date=November 16, 2016 |archive-date=October 10, 2018 |archive-url=https://web.archive.org/web/20181010125138/https://www.cnbc.com/2016/11/09/trumps-first-100-day-agenda-may-be-stymied-by-his-own-party.html |url-status=live }}</ref><ref>{{cite news |last1=Haberman |first1=Maggie |last2=Pear |first2=Robert |title=Trump Tells Congress to Repeal and Replace Health Care Law 'Very Quickly' |url=https://www.nytimes.com/2017/01/10/us/repeal-affordable-care-act-donald-trump.html |access-date=January 25, 2017 |issn=0362-4331 |oclc=1645522 |work=] |date=January 10, 2017 |archive-date=March 7, 2017 |archive-url=https://web.archive.org/web/20170307124935/https://www.nytimes.com/2017/01/10/us/repeal-affordable-care-act-donald-trump.html |url-status=live }}</ref>


{{As of|2013}} unions that expressed concerns included the ],<ref name="AFLCIO" /> which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the ], ], and ], whose leaders sent a letter to Reid and Pelosi arguing, "PPACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class."<ref name="WSJ" /> In January 2014, Terry O'Sullivan, president of the ] (LIUNA) and ], president of ] sent a letter to Reid and Pelosi stating, "ACA, as implemented, undermines fair marketplace competition in the health care industry."<ref name="wapo" />
The term "Obamacare" was originally coined by opponents, notably Mitt Romney in 2007, as a pejorative term. According to '']'', the term was first put in print in March 2007, when health care lobbyist Jeanne Schulte Scott penned it in a health industry journal. "We will soon see a ']-care' and 'Obama-care' to go along with ']-care,' ']-care,' and a totally revamped and remodeled ']-care' ]", Schulte Scott wrote.<ref name="CNN20120625Obamacare" /><ref name="NYT20120325">{{cite news|title=Fighting to Control the Meaning of ‘Obamacare’|url=http://www.nytimes.com/interactive/2012/03/25/us/politics/fighting-to-control-the-meaning-of-obamacare.html|accessdate=June 29, 2012|newspaper=The New York Times|date=March 25, 2012|author=Amanda Cox, Alicia Desantis and Jeremy White}}</ref> The expression Obamacare first was used in early 2007 generally by writers describing the candidate’s proposal for expanding coverage for the uninsured according to research by Elspeth Reeve at ] magazine.<ref name="NYT20120803" /> The word was first uttered in a political campaign by ] in May 2007 in ], ]. Romney said: "] We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over health care'. And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."<ref name="CNN20120625Obamacare" />


In October 2016, ], the governor of Minnesota and a member of the ], said ACA had "many good features" but it was "no longer affordable for increasing numbers of people"; he called on the state legislature to provide emergency relief to policyholders.<ref>{{cite news |url=http://www.politico.com/story/2016/10/minnesota-mark-dayton-obamacare-not-affordable-229690 |title=Democratic governor: Obamacare 'no longer affordable' for many |publisher=] |date=October 12, 2016 |first=Rachana |last=Pradhan |access-date=January 30, 2017 |archive-date=February 4, 2021 |archive-url=https://web.archive.org/web/20210204142034/https://www.politico.com/story/2016/10/minnesota-mark-dayton-obamacare-not-affordable-229690 |url-status=live }}</ref> Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.<ref>{{cite news |url=http://www.politico.com/story/2016/10/mark-dayton-obamacare-comments-affordable-230156 |title=Democratic governor expresses regret over Obamacare comments, requests emergency relief for rate hikes |publisher=] |date=October 21, 2016 |first=Paul |last=Demko |access-date=January 30, 2017 |archive-date=November 8, 2020 |archive-url=https://web.archive.org/web/20201108092226/https://www.politico.com/story/2016/10/mark-dayton-obamacare-comments-affordable-230156 |url-status=live }}</ref>
By mid-2012 it was the common term used by both sides.<ref name="NYT20120803">{{cite news|last=Baker|first=Peter|title=Democrats Embrace Once Pejorative ‘Obamacare’ Tag|url=http://www.nytimes.com/2012/08/04/health/policy/democrats-embrace-once-pejorative-obamacare-tag.html?_r=1|accessdate=6 August 2012|newspaper=The New York Times|date=3 August 2012}}</ref> Use of the term in a positive sense was suggested by Democratic politicians such as ] (D-MI).<ref>{{cite web|last=Nelson |first=Steven |url=http://dailycaller.com/2011/06/08/democratic-leader-wants-to-reclaim-obamacare-make-it-a-compliment/ |title=Democratic Rep. John Conyers wants to reclaim 'ObamaCare', make it a compliment |work=The Daily Caller |date=June 8, 2011 |accessdate=April 1, 2012}}</ref> President Obama said subsequently, "I have no problem with people saying Obama cares. I do care."<ref>{{cite news| url=http://www.cbsnews.com/8301-503544_162-20092578-503544.html | publisher=CBS News | title=On bus tour, Obama embraces 'Obamacare', says 'I do care{{'-}}}}</ref> Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased ] ], triggered by the term, to direct people to the official HHS site.<ref name=smith20101217>{{cite news|url=http://www.politico.com/blogs/bensmith/1210/HHS_buys_ObamaCare.html|work=Politico|title=HHS Buys 'ObamaCare{{'-}}|first=Ben|last=Smith|date=December 17, 2010|accessdate=February 9, 2011}}</ref> In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post ] messages that begin, "I like #Obamacare because...".<ref name=thehill>{{cite web | last = Strauss | first = Daniel | title = Obama camp's pitch to supporters: 'Hell yeah, I'm for Obamacare{{'-}} | work = ] | date = March 23, 2012 | url = http://thehill.com/blogs/blog-briefing-room/news/217893-obama-reelection-campaign-urges-supporters-to-say-im-for-obamacare | accessdate = March 27, 2012}}</ref> According to an analysis by the ], the term "Obamacare" has been used nearly 3,000 times in Congressional speeches since its debut as a phrase on ] in July 2009.<ref name="CNN20120625Obamacare">{{cite news|last=Wallace|first=Gregory|title={{-'}}Obamacare': The word that defined the health care debate|url=http://articles.cnn.com/2012-06-25/politics/politics_obamacare-word-debate_1_health-reform-law-health-care-affordable-care-act?_s=PM:POLITICS|publisher=CNN|accessdate=September 4, 2012|date=June 25, 2012}}</ref>


===Legal challenges===
===Working hours for part-time employees===
{{Main|Constitutional challenges to the Patient Protection and Affordable Care Act}}
In 2013, the State of Virginia limited all part-time employees, from janitors to adjunct professors, to working no more than 29 hours per week so that they would not qualify for mandatory health insurance coverage under the law.<ref> ''The Virginian-Pilot'', February 8, 2013</ref> Florida’s ], Pennsylvania’s ], Ohio’s ], and New Jersey’s ] have instituted similar rules,<ref></ref> as have restaurants such as ], ], ],<ref> ''ThinkProgress'', February 11, 2013</ref> ], ], and some ] and ] franchises.<ref></ref>
{{See also|National Federation of Independent Business v. Sebelius|King v. Burwell|Efforts to repeal the Patient Protection and Affordable Care Act}}


====''National Federation of Independent Business v. Sebelius''====
==Opposition and resistance==
{{Main|National Federation of Independent Business v. Sebelius}}
As with all complex legislation the act contains errors and provisions which need to be improved by tweaks or ]s in order to make the legislation work well in practice and avoid ]. Strong opposition in Congress by Republicans opposed to the act resulted in ] which prevented these routine adjustments and placed the program in danger.<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>
===Refusal to expand Medicaid coverage===
A number of conservative and Southern "red" states have opted to reject the expanded Medicaid coverage provided for by the act. Over half of the uninsured live in those states. They include ]<ref name=NTY52413 />, ],<ref name=NTY52413 /> ],<ref name=NTY52413 /> ],<ref name=NTY52413 /> ],<ref name=NTY52413 /> ],<ref name=NTY52413 /> and ].<ref name=NTY52413 /> As of May 24, 2013 a number of states had not made final decisions, and lists of states which have opted out or were considering opting out varied,<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=AvalereHealth50213>{{cite web|title=© Avalere Health LLC To Date, 20 States & DC Plan to Expand Medicaid Eligibility, 14 Will Not Expand, and the Remainder Are Undecided|url=http://www.avalerehealth.net/news/spotlight/20130502_Medicaid_Expansion.pdf|publisher=AvalereHealth.Net|accessdate=May 24, 2013|date=Updated May 2, 2013|quote=© Avalere Health LLC To Date, 20 States & DC Plan to Expand Medicaid Eligibility, 14 Will Not Expand, and the Remainder Are Undecided}}</ref> but ],<ref name=AvalereHealth50213 />],<ref name="State stands" /> ],<ref name="State stands" /> ],<ref name=WP5513 /> ],<ref name=WP5513 /> ],<ref name="State stands" /> ],<ref name=WP5513 /> ],<ref name="State stands" /> ],<ref name="State stands" /> ],<ref name="State stands" /> ],<ref name="State stands" /> and ]<ref name="State stands" /> seemed to have decided to reject expanded coverage.<ref name="State stands">{{cite web|title=Where each state stands on ACA's Medicaid expansion: A roundup of what each state's leadership has said about their Medicaid plans|url=http://www.advisory.com/Daily-Briefing/2012/11/09/MedicaidMap#lightbox/1/|publisher=The Advisory Board Company|date=May 24, 2013|accessdate=May 24, 2013}}</ref>


Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds.<ref>{{cite web |last=Cauchi |first=Richard |title=State Legislation and Actions Challenging Certain Health Reforms |url=http://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx |publisher=National Conference of State Legislatures |date=November 15, 2013 |access-date=November 28, 2013 |archive-date=November 6, 2013 |archive-url=https://web.archive.org/web/20131106074036/http://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx |url-status=live }}</ref><ref>{{cite web |title=Health Care Lawsuit Case Challenges |url=http://www.healthcarelawsuits.org/cases.php |publisher=Independent Women's Forum |date=November 26, 2013 |access-date=November 28, 2013 |archive-date=October 10, 2010 |archive-url=https://web.archive.org/web/20101010040456/http://www.healthcarelawsuits.org/cases.php |url-status=live }}</ref>{{failed verification|reason=Probably want one of the subsidiary pages to this page |date=May 2016}} The Supreme Court ruled, 5–4, that the individual mandate was constitutional when viewed as a tax, although ] under the ].
Low-income individuals and families above 100% and up to 400% of the ] will receive ]<ref>{{cite web|url=http://www.kff.org/healthreform/upload/7962-02.pdf |title=Explaining Health Care Reform: Questions About Health Insurance Subsidies |publisher=Kaiser Family |month=April|year=2010 |accessdate=April 1, 2012}}</ref> on a ] if they choose to purchase insurance via an exchange (those from 133% to 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of income);<ref>{{cite web|author=Peter Grier |url=http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-reform-bill-101-Who-gets-subsidized-insurance |title=Health care reform bill 101: Who gets subsidized insurance? |work=]|date=March 20, 2010|accessdate=January 9, 2012}}</ref> while Medicaid eligibility is expanded to include all individuals and families with incomes up to 133% of ], effectively 138%, and simplifies the ] enrollment process. In '']'', the Supreme Court effectively allowed states to opt out of the Medicaid expansion, and some states have stated their intention to do so. States that choose to reject the Medicaid expansion can set their own Medicaid eligibility thresholds, which in many states are significantly below 133% of the poverty line; in addition, many states do not make Medicaid available to childless adults at any income level. Because subsidies on insurance plans purchased through exchanges are not available to those below 100% of the poverty line, this will create a coverage gap in those states.<ref>{{cite web |url=http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/07/05/what-happens-if-a-state-opts-out-of-medicaid-in-one-chart/ |title=What Happens if a State Opts Out of Medicaid, in One Chart |author=Kliff, Sarah |date=July 5, 2012 |publisher=The Washington Post |accessdate=July 15, 2012}}</ref><ref>{{cite web|url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and Medicaid Expansion|publisher=HealthCare Reform Magazine|date=July 13, 2010 |accessdate=January 9, 2012}}</ref><ref>{{cite web|url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf|title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |date= |accessdate=April 1, 2012}}</ref> 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>


The Court further determined that states could not be forced to expand Medicaid. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.<ref name="NatLawReview2012">{{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 |access-date=July 2, 2012 |archive-date=July 2, 2012 |archive-url=https://web.archive.org/web/20120702224304/http://www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules |url-status=live }}</ref>
===Legal challenges===
{{main|Constitutional challenges to the Patient Protection and Affordable Care Act}}
Opponents of the Patient Protection and Affordable Care Act have turned to the federal courts to challenge the constitutionality of the legislation.<ref>{{cite web|last=Cauchi|first=Richard|title=State Legislation and Actions Challenging Certain Health Reforms, 2011–2012|url=http://www.ncsl.org/issues-research/health/state-laws-and-actions-challenging-aca.aspx|publisher=National Conference of State Legislatures|accessdate=June 30, 2012|date=June 28, 2012}}</ref><ref>{{cite web|title=Legal Challenges to the Affordable Care Act|url=http://www.hfma.org/Templates/Print.aspx?id=24263|work=Healthcare Financial Management Association|publisher=Healthcare Financial Management Association|accessdate=June 30, 2012}}</ref> The Supreme Court upheld the individual mandate (5-4) on the basis that it is a tax rather than protection under the Commerce Clause, but determined that States could not be forced to participate in the expansion of Medicaid. All provisions of PPACA will continue in effect or will take effect as scheduled subject to States determination on Medicaid expansion.<ref>{{cite web |title=Analysis: U.S. Supreme Court Upholds the Affordable Care Act: Roberts Rules? |url=http://www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules |publisher=von Briesen & Roper, S.C. |work=The National Law Review|date=2012-06-29|accessdate=2012-07-02}}</ref>


===Repeal efforts=== ====Contraception mandate====
{{Main|Burwell v. Hobby Lobby Stores, Inc.|Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania}}
Efforts to oppose and repeal the legislation drew broad support from prominent ] advocacy groups, certain small business organizations, and the ].<ref></ref> It was also the subject of repeal efforts by ] in the 111th and 112th Congresses:


In March 2012, the ], while supportive of ACA's objectives, voiced concern through the ] that aspects of the mandate covering contraception and sterilization and ]'s narrow definition of a religious organization violated the ] right to ] and conscience. Various lawsuits addressed these concerns,<ref>{{cite web |url=http://www.usccb.org/issues-and-action/religious-liberty/march-14-statement-on-religious-freedom-and-hhs-mandate.cfm |title=March 14, 2012 Statement on Religious Freedom and HHS Mandate |date=March 14, 2012 |publisher=United States Conference of Catholic Bishops |access-date=April 28, 2012 |archive-date=May 11, 2012 |archive-url=https://web.archive.org/web/20120511200449/http://www.usccb.org/issues-and-action/religious-liberty/march-14-statement-on-religious-freedom-and-hhs-mandate.cfm |url-status=live }}</ref><ref>{{cite news |last=Goodstein |first=Laurie |title=Catholics File Suits on Contraceptive Coverage |url=https://www.nytimes.com/2012/05/22/us/catholic-groups-file-suits-on-contraceptive-coverage.html |issn=0362-4331 |oclc=1645522 |newspaper=] |date=May 21, 2012 |access-date=February 7, 2017 |archive-date=February 23, 2021 |archive-url=https://web.archive.org/web/20210223071041/https://www.nytimes.com/2012/05/22/us/catholic-groups-file-suits-on-contraceptive-coverage.html |url-status=live }}</ref> including '']'', which looked at private corporations and their duties under the ACA.
====111th Congress====
Reps. ] of ] and ] of ], both Republicans, introduced bills in the House to repeal PPACA shortly after it was passed, as did Sen. ] in the Senate.<ref>{{cite web|last=O'Brien |first=Michael |url=http://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |title=GOP quick to release 'repeal' bills |work=The Hill |date=March 22, 2010 |accessdate=April 1, 2012}}</ref> None of the three bills were considered by either body.


In '']'', the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice ] said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the , that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice ] filed a concurring opinion in the judgment, in which ] joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."<ref>{{cite web |title=Supreme Court allows Trump to exempt employers from Obamacare birth control mandate |url=https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |archive-date=July 25, 2020 |archive-url=https://web.archive.org/web/20200725005137/https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |work=] |publisher=Walt Disney |access-date=June 18, 2022 |last1=Dwyer |first1=Devin}}</ref>
====112th Congress====
In 2011, the Republican-controlled House of Representatives voted 245–189 to approve a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R.2),<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002:|title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=] |date=2011-01-19}}</ref> which, if enacted, would repeal the Patient Protection and Affordable Care Act and the health care-related text of the Health Care and Education Reconciliation Act of 2010. All Republicans and 3 Democrats voted for repeal.<ref>{{cite web |url=http://clerk.house.gov/evs/2011/roll014.xml |title=Final Vote Results for passage of Repealing the Job-Killing Health Care Law Act (H.R. 2) |publisher=] |date=2011-01-19}}</ref> In the Senate, the bill was offered as an amendment to an unrelated bill, and was subsequently voted down.<ref>{{cite web|url=http://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=112&session=1&vote=00009 |title=Motion to Waive All Applicable Budgetary Discipline Re: McConnell Amdt. No. 13 |publisher=U.S. Senate |date=February 2, 2011 |accessdate=April 1, 2012}}</ref> Before votes in both houses of the Congress took place, President Obama stated that he would ] the bill should it pass both chambers.<ref>{{cite web |url=http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994/ |title=House Passes Health Care Repeal 245–189 |publisher=] |date=2011-01-19}}</ref> Democrats in the House proposed that repeal not take effect until a majority of the Senators and Representatives had opted out of the ]. The Republicans voted down this measure.<ref>{{cite web| last = Beutler| first = Brian | title = Dems Press GOPers To Repeal Their Own Benefits Along With Health Care Law| work = ]| date = January 19, 2011| url = http://tpmdc.talkingpointsmemo.com/2011/01/dems-press-gopers-to-repeal-their-own-benefits-along-with-health-care-law.php?ref=dcblt | accessdate = 2011-01-21}}</ref>


In a later lawsuit brought by private health insurance buyers and businesses, Judge ] of the Federal District Court for the Northern District of Texas ruled in March 2023 that the ACA's provision of contraceptives, HIV testing, and screenings for cancer, diabetes, and mental health violated the plaintiffs' freedom of religious exercise, and placed an injunction on that portion of the ACA. The Biden administration planned to seek a hold on O'Connor's decision.<ref>{{cite web | url=https://apnews.com/article/obamacare-insurance-preventative-care-texas-aa57fa6fd782e2170bc80210fd00065b | title=Judge's ruling undercuts US health law's preventive care | website=] | date=March 30, 2023 | access-date=March 30, 2023 | archive-date=March 30, 2023 | archive-url=https://web.archive.org/web/20230330194018/https://apnews.com/article/obamacare-insurance-preventative-care-texas-aa57fa6fd782e2170bc80210fd00065b | url-status=live }}</ref>
On June 28, 2012, following the law being ruled as constitutional by the Supreme Court, House Majority Leader ] stated that the House would again vote to repeal the law in July when Congress returns from recess.<ref>{{cite news |url=http://www.usatoday.com/news/washington/story/2012-06-28/health-care-romney-obama/55893858/1?csp=34news |title=Romney, GOP leaders pledge to repeal health care law |newspaper=USA Today |last=Kucinich |first=Jackie |date=June 28, 2012 |accessdate=June 29, 2012}}</ref><ref>{{cite news |url=http://online.wsj.com/article/SB10001424052702303561504577494682627914026.html |title=Romney, GOP Pledge to Repeal Health Law |last=Boles |first=Corey |newspaper=The Wall Street Journal |date=June 28, 2012 |accessdate=June 29, 2012}}</ref><ref>{{cite web |url=http://www.politico.com/news/stories/0612/77939.html |title=Health care decision: House GOP to renew repeal effort |last1=Sherman |first1=Jake |last2=Raju |first2=Manu |last3=Kim |first3=Seung Min |work=Politico |date=June 28, 2012 |accessdate=June 29, 2012}}</ref> On July 11, 2012, the House of Representatives voted to repeal the law with 5 Democrats and all 239 Republicans voting in favor of the repeal.<ref name="H.R.6079">{{cite news| url=http://www.foxnews.com/politics/2012/07/11/house-approves-obamacare-repeal-in-first-vote-since-court-ruling/ | publisher=FoxNews | title=House approves ObamaCare repeal in first vote since Supreme Court ruling| date=July 11, 2012}}</ref><ref name="thirtythree">{{cite news| url=http://abcnews.go.com/blogs/politics/2012/07/house-obamacare-repeal-thirty-third-times-the-charm/ | publisher=ABC News | title=House Obamacare Repeal: Thirty-Third Time’s the Charm? | date=July 11, 2012}}</ref> This was the 31st effort by the House of Representatives to repeal the bill in the 112th Congress.<ref name="thirtyone">{{cite web |url=http://articles.baltimoresun.com/2012-07-11/health/bal-republicans-repeal-health-reform_1_house-votes-repeal-care-reform-bill |title=House of representatives votes to repeal health reform for the 31st time |last1=Walker |first1=Andrea K. |work=Baltimore Sun |date=July 11, 2012 |accessdate=July 12, 2012}}</ref> With President Obama's reelection and the Democrats expanding their majority in the Senate following the ], Republicans conceded that repeal almost certainly will not occur.<ref>http://thehill.com/blogs/healthwatch/health-reform-implementation/266689-conservatives-are-begin-to-admit-defeat-in-their-three-year-war-against-obamacare</ref>


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


On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.<ref>{{cite news |url=https://abcnews.go.com/Politics/supreme-court-upholds-obama-health-care-subsidies/story?id=31931412 |title=Supreme Court Upholds Obamacare Subsidies, President Says ACA 'Is Here to Stay' |last1=Taylor |first1=Audrey |last2=Seanz |first2=Arlette |last3=Levine |first3=Mike |publisher=] |date=June 25, 2015 |access-date=June 25, 2015 |archive-date=June 26, 2015 |archive-url=https://web.archive.org/web/20150626063336/http://abcnews.go.com/Politics/supreme-court-upholds-obama-health-care-subsidies/story?id=31931412 |url-status=live }}</ref>
], citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate job-lock: "people who are only working because they desperately need employer-sponsored health insurance will no longer do so."<ref>{{cite web|last=Cohn|first=Jonathan|title=Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs.|url=http://www.newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs |publisher=The New Republic}}</ref> He concluded that "reform’s only significant employment impact was a reduction in the labor force, primarily because people holding onto jobs just to keep insurance could finally retire"<ref>{{cite web|last=Cohn|first=Jonathan|title=Obamacare, Good for the Economy.|url=http://www.newrepublic.com/blog/plank/104035/obamacare-romney-economy-benefit-job-regulation-noam |publisher=The New Republic}}</ref> once they have health insurance outside of their jobs.


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


House Republicans sued the Obama administration in 2014, alleging that cost-sharing reduction subsidy payments to insurers were unlawful because Congress had not appropriated funds to pay for them. The argument classified the CSR subsidy as discretionary spending subject to annual appropriation. In May 2016, a federal judge ruled for the plaintiffs, but the Obama administration appealed.<ref>{{cite web |author=explainer |url=https://www.commonwealthfund.org/publications/explainer/2017/apr/essential-facts-about-health-reform-alternatives-eliminating-cost |title=Eliminating Cost-Sharing Reductions in ACA |date=April 28, 2017 |doi=10.26099/19sf-a521 |access-date=December 1, 2019 |publisher=Commonwealth Fund |archive-date=July 13, 2020 |archive-url=https://web.archive.org/web/20200713220629/https://www.commonwealthfund.org/publications/explainer/2017/apr/essential-facts-about-health-reform-alternatives-eliminating-cost |url-status=live }}</ref> Later, President Trump ended the payments. This led to further litigation.<ref name=":3">{{Cite journal |last1=Keith |first1=Katie |url=https://www.healthaffairs.org/do/10.1377/forefront.20190217.755658/full/ |title=More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments |date=February 27, 2019 |journal=Health Affairs Forefront |doi=10.1377/forefront.20190217.755658 |access-date=March 29, 2022 |archive-date=March 29, 2022 |archive-url=https://web.archive.org/web/20220329210411/https://www.healthaffairs.org/do/10.1377/forefront.20190217.755658/full/ |url-status=live }}</ref>
Revised CBO accounting, based on the latest repeal effort passed in the House of Representatives (H.R.&nbsp;6079) on July 11, 2012 and taking into account the Supreme Court's ruling concerning the expansion of Medicaid by the States, that, on balance, the direct spending and revenue effects of enacting the ''Repeal of Obamacare Act'' legislation would cause a net increase in federal budget deficits of $109&nbsp;billion over the 2013–2022 period. Specifically, CBO estimates that H.R.&nbsp;6079 would reduce direct spending by $890&nbsp;billion and reduce revenues by $1&nbsp;trillion between 2013 and 2022, thus adding $109&nbsp;billion to federal budget deficits over that period.<ref name="H.R.6079" /><ref name="CBO43471">{{cite web |url=http://cbo.gov/publication/43471 |title=Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=July 27, 2012}}</ref>


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


The House sued the administration, alleging that the money for CSRs to insurers had not been appropriated, as required for any federal government spending. The ACA subsidy that helps customers pay premiums was not part of the suit.
Among those receiving waivers were employers, large insurers, such as ] and ], and union plans covering about one million employees. ], one of the employers that received a waiver, has 30,000 hourly employees whose plans have annual caps of $10,000. The waivers are issued for one year and can be reapplied for.<ref name="nytimes.com">{{cite news| url=http://www.nytimes.com/2010/10/07/business/07insure.html | work=The New York Times | first=Reed | last=Abelson | title=U.S. Waivers After Threats of Lost Health Coverage | date=October 6, 2010}}</ref><ref>{{cite news| url=http://www.suntimes.com/business/2782232,Waivers-on-healthreform.article | work=] | title=30 Companies Get One-Year Waiver From Health Reform Rule | date=October 7, 2010}}</ref> Referring to the adjustments as "a balancing act", ], director of the Office of Health Reform at the White House, said, "The president wants to have a smooth glide path to 2014."<ref name="nytimes.com"/> On January 26, 2011, HHS said it had to date granted a total of 733 waivers for 2011, covering 2.1&nbsp;million people, or about 1% of the privately insured population.<ref>"", HHS-CMS-CCIIO, see section "Applications for Waiver of the Annual Limits Requirements"</ref> In June 2011, the Obama Administration announced that all applications for new waivers and renewals of existing ones have to be filed by September 22 of that year, and no new waivers would be approved after this date.<ref>{{cite news|url=http://www.msnbc.msn.com/id/43445375/ns/politics/ |title=Obama administration to end health care waivers |agency=Associated Press |publisher=msnbc.com |date=June 17, 2011 |accessdate=April 1, 2012}}</ref>

Without the CSRs, the government estimated that premiums would increase by 20% to 30% for silver plans.<ref>{{Cite web |url=http://www.politico.com/story/2016/05/house-gop-wins-obamacare-lawsuit-223121 |title=House GOP wins Obamacare lawsuit |last=Haberkorn |first=Jennifer |date=May 12, 2016 |work=] |access-date=August 21, 2016 |archive-date=August 14, 2016 |archive-url=https://web.archive.org/web/20160814133653/http://www.politico.com/story/2016/05/house-gop-wins-obamacare-lawsuit-223121 |url-status=live }}</ref> In 2017, the uncertainty about whether the payments would continue caused Blue Cross Blue Shield of North Carolina to try to raise premiums by 22.9% the next year, as opposed to an increase of 8.8% that it would have sought if the payments were assured.<ref>{{Citation |last=Sargent |first=Greg |title=Trump's latest tantrum will hurt hundreds of thousands of people. Here's how. |newspaper=] |date=May 26, 2017 |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/blogs/plum-line/wp/2017/05/26/trumps-latest-tantrum-will-hurt-hundreds-of-thousands-of-people-heres-how/?tid=hybrid_collaborative_1_na |access-date=May 29, 2017 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023012817/https://www.washingtonpost.com/blogs/plum-line/wp/2017/05/26/trumps-latest-tantrum-will-hurt-hundreds-of-thousands-of-people-heres-how/?tid=hybrid_collaborative_1_na |url-status=live }}</ref>

U.S. District Judge ] ruled that the cost-sharing program was unconstitutional for spending money that has not been specifically provided by an act of Congress, but concluded that Congress had in fact authorized that program to be created. The judge also found that Congress had provided authority to cover the spending for the tax credits to consumers who use them to help afford health coverage.<ref name="Denniston">{{cite web |url=http://www.scotusblog.com/2016/05/judge-billions-spent-illegally-on-aca-benefits/ |title=Judge: Billions spent illegally on ACA benefits |last=Denniston |first=Lyle |date=2016-05-12 |website=SCOTUSblog |access-date=2017-02-10 |archive-date=February 11, 2017 |archive-url=https://web.archive.org/web/20170211083011/http://www.scotusblog.com/2016/05/judge-billions-spent-illegally-on-aca-benefits/ |url-status=live }}</ref> Collyer enjoined further cost-sharing payments, but stayed the order pending appeal to the ]. The case ended in a settlement before the Circuit Court.

====''California v. Texas''====
{{main|California v. Texas}}

Texas and 19 other states filed a civil suit in the ] in February 2018, arguing that with the passage of the ], which eliminated the tax for not having health insurance, the individual mandate no longer had a constitutional basis and thus the entire ACA was no longer constitutional.<ref>{{cite web |title=Complaint for Declaratory and Injunctive Relief |id=Case 4:18-cv-00167-O |date=2018-02-26 |url=https://www.courtlistener.com/recap/gov.uscourts.txnd.299449/gov.uscourts.txnd.299449.1.0.pdf |access-date=December 15, 2018 |archive-date=July 26, 2020 |archive-url=https://web.archive.org/web/20200726051600/https://www.courtlistener.com/recap/gov.uscourts.txnd.299449/gov.uscourts.txnd.299449.1.0.pdf |url-status=live }}</ref> The ] said it would no longer defend the ACA in court, but 17 states led by California stepped in to do so.<ref name="cnn 20181214" />

District Judge ] of Texas ruled for the plaintiffs on December 14, 2018, writing that the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional." He then further reasoned that the individual mandate is an essential part of the entire law, and thus was not severable, making the entire law unconstitutional.<ref>{{Cite web |last=Sullivan |first=Peter |date=December 14, 2018 |url=https://thehill.com/policy/healthcare/421511-federal-judge-in-texas-strikes-down-obamacare/ |title=Federal judge in Texas strikes down ObamaCare |website=] |issn=1521-1568 |oclc=31153202 |access-date=December 15, 2018 |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215013835/https://thehill.com/policy/healthcare/421511-federal-judge-in-texas-strikes-down-obamacare |url-status=live }}</ref><ref>{{Cite web |url=https://www.wsj.com/articles/federal-judge-rules-affordable-care-act-is-unconstitutional-11544838743 |title=Federal Judge Rules Affordable Care Act Is Unconstitutional Without Insurance-Coverage Penalty |last=Armour |first=Stephanie |date=December 14, 2018 |publisher=News Corp |oclc=781541372 |issn=0099-9660 |website=] |access-date=December 15, 2018 |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215043107/https://www.wsj.com/articles/federal-judge-rules-affordable-care-act-is-unconstitutional-11544838743 |url-status=live }}</ref> O'Connor's decision regarding severability turned on several passages from the Congressional debate that focused on the importance of the mandate.<ref>{{Cite web |url=https://lawshelf.com/blog/post/federal-judge-in-texas-strikes-down-obamacare |title=Federal Judge in Texas Strikes Down "Obamacare" |website=lawshelf.com |access-date=May 14, 2019 |archive-date=May 14, 2019 |archive-url=https://web.archive.org/web/20190514121812/https://lawshelf.com/blog/post/federal-judge-in-texas-strikes-down-obamacare |url-status=live }}</ref> While he ruled the law unconstitutional, he did not overturn the law.<ref name="cnn 20181214">{{cite web |url=https://www.cnn.com/2018/12/14/politics/texas-aca-lawsuit/index.html |title=Federal judge in Texas strikes down Affordable Care Act |first1=Ariane |last1=de Vogue |first2=Tami |last2=Luhby |date=December 14, 2018 |access-date=December 14, 2018 |publisher=] |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215021340/https://www.cnn.com/2018/12/14/politics/texas-aca-lawsuit/index.html |url-status=live }}</ref>

The intervening states appealed the decision to the ]. These states argued that Congress's change in the tax was only reducing the amount of the tax, and that Congress had the power to write a stronger law to this end.<ref>{{cite web |url=https://www.cnn.com/2019/07/08/politics/affordable-care-act-court/index.html |title=Affordable Care Act gears up for momentous test in court |last=Biskupic |first=Joan |author-link=Joan Biskupic |date=July 8, 2019 |publisher=] |access-date=July 8, 2019 |archive-date=July 8, 2019 |archive-url=https://web.archive.org/web/20190708130932/https://www.cnn.com/2019/07/08/politics/affordable-care-act-court/index.html |url-status=live }}</ref><ref name="wapost 20181214">{{cite news |url=https://www.washingtonpost.com/national/health-science/federal-judge-in-texas-rules-obama-health-care-law-unconstitutional/2018/12/14/9e8bb5a2-fd63-11e8-862a-b6a6f3ce8199_story.html |title=Federal judge in Texas rules entire Obama health-care law is unconstitutional |first=Amy |last=Goldstein |date=December 14, 2018 |access-date=December 14, 2018 |issn=0190-8286 |oclc=2269358 |newspaper=] |archive-date=December 15, 2018 |archive-url=https://web.archive.org/web/20181215021631/https://www.washingtonpost.com/national/health-science/federal-judge-in-texas-rules-obama-health-care-law-unconstitutional/2018/12/14/9e8bb5a2-fd63-11e8-862a-b6a6f3ce8199_story.html |url-status=live }}</ref> O'Connor stayed his decision pending the appeal.<ref>{{cite web |url=https://www.cnn.com/2018/12/30/politics/judge-affordable-care-act-remain-in-effect-appeal/index.html |title=Judge says Affordable Care Act will remain in effect during appeal |first1=Kate |last1=Sullivan |first2=Tami |last2=Luhby |date=December 30, 2018 |access-date=December 31, 2018 |publisher=] |archive-date=December 31, 2018 |archive-url=https://web.archive.org/web/20181231012052/https://www.cnn.com/2018/12/30/politics/judge-affordable-care-act-remain-in-effect-appeal/index.html |url-status=live }}</ref> The Fifth Circuit heard the appeal on July 9, 2019; in the interim, the U.S. Department of Justice joined with Republican states to argue that the ACA was unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. An additional question was addressed, as the Republican plaintiffs challenged the Democratic states' ] to defend the ACA.<ref>{{cite web |url=https://www.nytimes.com/2019/07/09/health/obamacare-appeals-court.html |title=Appeals Court Seems Skeptical About Constitutionality of Obamacare Mandate |first=Abby |last=Goodnough |date=July 9, 2019 |access-date=July 9, 2019 |archive-date=July 10, 2019 |archive-url=https://web.archive.org/web/20190710222740/https://www.nytimes.com/2019/07/09/health/obamacare-appeals-court.html |issn=0362-4331 |oclc=1645522 |work=]}}</ref>

In December 2019, the Fifth Circuit agreed the individual mandate was unconstitutional, but did not agree that the entire law should be voided. Instead, it remanded the case to the District Court for reconsideration of that question.<ref>{{cite news |last=Demko |first=Paul |title=Court voids Obamacare mandate—but not the whole law |newspaper=] |date=December 18, 2019 |url=https://www.politico.com/news/2019/12/18/court-finds-obamacare-mandate-unconstitutional-sends-case-back-to-lower-court-087389 |access-date=February 6, 2020 |archive-date=January 9, 2021 |archive-url=https://web.archive.org/web/20210109011307/https://www.politico.com/news/2019/12/18/court-finds-obamacare-mandate-unconstitutional-sends-case-back-to-lower-court-087389 |url-status=live }}</ref> The Supreme Court accepted the case in March 2020, to be heard in the 2020–2021 term,<ref>{{cite web |url=https://www.nytimes.com/2020/03/02/us/supreme-court-obamacare-appeal.html |title=Supreme Court to Hear Obamacare Appeal |first=Adam |last=Liptak |date=March 2, 2020 |access-date=March 2, 2020 |issn=0362-4331 |oclc=1645522 |work=] |archive-date=March 2, 2020 |archive-url=https://web.archive.org/web/20200302151009/https://www.nytimes.com/2020/03/02/us/supreme-court-obamacare-appeal.html |url-status=live }}</ref> with the ruling likely falling after the 2020 elections.<ref name="ollstein">{{Citation |last1=Ollstein |first1=Alice Miranda |last2=Arkin |first2=James |title=Democrats seize on anti-Obamacare ruling to steamroll GOP in 2020 |newspaper=] |date=December 26, 2019 |url=https://www.politico.com/news/2019/12/26/democrats-anti-obamacare-2020-elections-089765 |access-date=February 6, 2020 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013002/https://www.politico.com/news/2019/12/26/democrats-anti-obamacare-2020-elections-089765 |url-status=live }}</ref>

Democrats pointed out that the effect of invalidating the entire law would be to remove popular provisions such as the protection for preexisting conditions, and that the Republicans had still not offered any replacement plan—important issues in the 2020 elections.<ref name="ollstein" />

On June 17, 2021, the Court rejected the challenge in a 7–2 decision, ruling that Texas and the other plaintiff states did not have standing to challenge the provision, leaving the full ACA intact.<ref>{{Cite web |url=https://apnews.com/article/supreme-court-dismisses-obamacare-challenge-67cc2e9604a70b1b329c5f3b4177a688 |title=Supreme Court dismisses challenge to Obama health law |first=Mark |last=Sherman |date=June 17, 2021 |access-date=June 17, 2021 |publisher=] |archive-date=October 15, 2021 |archive-url=https://web.archive.org/web/20211015225822/https://apnews.com/article/supreme-court-dismisses-obamacare-challenge-67cc2e9604a70b1b329c5f3b4177a688 |url-status=live }}</ref><ref>{{cite web |url=https://www.msnbc.com/rachel-maddow-show/affordable-care-act-survives-supreme-court-challenge-again-n1271151 |title=Affordable Care Act survives Supreme Court challenge (again) |first=Steve |last=Benen |author-link=Steve Benen |date=June 17, 2021 |access-date=June 17, 2021 |publisher=] |archive-date=November 6, 2021 |archive-url=https://web.archive.org/web/20211106212447/https://www.msnbc.com/rachel-maddow-show/affordable-care-act-survives-supreme-court-challenge-again-n1271151 |url-status=live }}</ref><ref>{{Cite web |author=Ariane de Vogue and Chandelis Duster |title=Supreme Court dismisses challenge to Affordable Care Act, leaving it in place |date=June 17, 2021 |url=https://www.cnn.com/2021/06/17/politics/supreme-court-affordable-care-act-obamacare/index.html |access-date=2021-06-18 |publisher=] |archive-date=June 18, 2021 |archive-url=https://web.archive.org/web/20210618193127/https://www.cnn.com/2021/06/17/politics/supreme-court-affordable-care-act-obamacare/index.html |url-status=live }}</ref>

====Risk corridors====
{{further|Maine Community Health Options v. United States}}
The Supreme Court ruled that promised risk corridor payments must be made even in the absence of specific appropriation of money by Congress.<ref name=":1" />

====Non-cooperation====
Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements over which they had discretion.<ref>{{cite news |first=Sandhya |last=Somashekhar |title=States find new ways to resist health law |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/national/health-science/states-find-new-ways-to-resist-health-law/2013/08/28/c63f8498-0a93-11e3-8974-f97ab3b3c677_story.html |newspaper=] |date=August 29, 2013 |access-date=September 7, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013011/https://www.washingtonpost.com/national/health-science/states-find-new-ways-to-resist-health-law/2013/08/28/c63f8498-0a93-11e3-8974-f97ab3b3c677_story.html |url-status=live }}</ref><ref name="Ornstein" /> For example, Missouri declined to expand Medicaid or ] engaging in active ], enacting a statute forbidding any state or local official to render any aid not specifically required by federal law.<ref name="NYT80213" /> Other Republicans discouraged efforts to advertise the law's benefits. Some conservative political groups launched ad campaigns to discourage enrollment.<ref>{{cite news |title=The Right's Latest Scheme to Sabotage Obamacare |first=Jonathan |last=Cohn |magazine=] |date=July 25, 2013 |url=https://newrepublic.com/article/114028/obamacare-sabotage-watch-conservative-campaign-gets-real |access-date=March 10, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013005/https://newrepublic.com/article/114028/obamacare-sabotage-watch-conservative-campaign-gets-real |url-status=live }}</ref><ref>{{cite news |title=Inside the Obamacare Resistance |first=Sarah |last=Kliff |issn=0190-8286 |oclc=2269358 |newspaper=] |date=August 1, 2013 |url=https://www.washingtonpost.com/news/wonk/wp/2013/08/01/inside-the-obamacare-resistance/?variant=116ae929826d1fd3&variant=116ae929826d1fd3 |access-date=June 25, 2021 |archive-date=March 8, 2023 |archive-url=https://web.archive.org/web/20230308204320/https://www.washingtonpost.com/news/wonk/wp/2013/08/01/inside-the-obamacare-resistance/?variant=116ae929826d1fd3&variant=116ae929826d1fd3 |url-status=live }}</ref>

===Repeal and modification efforts===
{{Main|Efforts to repeal the Patient Protection and Affordable Care Act}}

ACA was the subject of many unsuccessful 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=https://thehill.com/blogs/blog-briefing-room/news/64853-gop-quick-to-release-repeal-bills/ |title=GOP quick to release 'repeal' bills |work=] |date=March 22, 2010 |access-date=April 1, 2012 |archive-date=January 29, 2022 |issn=1521-1568 |oclc=31153202 |archive-url=https://web.archive.org/web/20220129173857/https://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |url-status=live }}</ref> In 2011, after Republicans gained control of the House, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189.<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002: |archive-url=https://web.archive.org/web/20140922023012/http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002: |url-status=dead |archive-date=September 22, 2014 |title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=] |date=January 19, 2011 }}</ref> All Republicans and three 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 |access-date=February 12, 2012 |archive-date=November 25, 2013 |archive-url=https://web.archive.org/web/20131125231822/http://clerk.house.gov/evs/2011/roll014.xml |url-status=live }}</ref> In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down.<ref>{{cite web |url=https://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 |access-date=April 1, 2012 |archive-date=August 13, 2021 |archive-url=https://web.archive.org/web/20210813085926/https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=112&session=1&vote=00009 |url-status=live }}</ref> President Obama said he would ] the bill had it passed.<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 |access-date=January 21, 2011 |archive-url=https://web.archive.org/web/20110708110210/http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994/ |archive-date=July 8, 2011 |url-status=dead}}</ref>
]

On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.<ref>{{cite news |title=House votes -again-to repeal Obamacare |url=http://www.cnn.com/2015/02/03/politics/obamacare-repeal-vote-house/index.html |agency=] |date=February 3, 2015 |author=Deirdre Walsh |access-date=February 4, 2015 |archive-date=January 25, 2021 |archive-url=https://web.archive.org/web/20210125112222/https://www.cnn.com/2015/02/03/politics/obamacare-repeal-vote-house/index.html |url-status=live }}</ref>

====2013 federal government shutdown====
Strong partisan disagreement in Congress prevented adjustments to the Act's provisions.<ref name="NYT52613" /> But at least one change, a proposed repeal of a tax on medical devices, received bipartisan support.<ref>{{cite news |last=Lipton |first=Eric |title=In Shift, Lobbyists Look for Bipartisan Support to Repeal a Tax |url=https://www.nytimes.com/2013/03/20/us/politics/lobbyists-look-for-bipartisan-support-to-repeal-a-tax.html |issn=0362-4331 |oclc=1645522 |newspaper=] |date=March 19, 2013 |access-date=February 7, 2017 |archive-date=September 2, 2017 |archive-url=https://web.archive.org/web/20170902030942/http://www.nytimes.com/2013/03/20/us/politics/lobbyists-look-for-bipartisan-support-to-repeal-a-tax.html |url-status=live }}</ref> Some Congressional Republicans argued against improvements to the law on the grounds that they would weaken the arguments for repeal.<ref name="MandateRepeal" /><ref name="ChaitNotCollapsing" />

Republicans attempted to defund the ACA's implementation,<ref name="Ornstein" /><ref>{{cite news |first=Jonathan |last=Cohn |title=What Defunding Health Reform Would Do |url=https://newrepublic.com/blog/jonathan-cohn/80411/what-defunding-health-reform-would-do |magazine=] |date=December 23, 2010 |access-date=March 10, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013001/https://newrepublic.com/article/80411/what-defunding-health-reform-would-do |url-status=live }}</ref> and in October 2013 House Republicans refused to fund the federal government unless it came with an implementation delay, after Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay the ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership said the Senate would pass only a bill without any restrictions on ACA. ] lasted from October 1 to October 17.<ref>{{cite news |issn=0190-8286 |oclc=2269358 |archive-date=October 1, 2013 |archive-url=https://web.archive.org/web/20131001122124/https://www.washingtonpost.com/politics/washington-braces-for-the-first-shutdown-of-the-national-government-in-17-years/2013/09/30/977ebca2-29bd-11e3-97a3-ff2758228523_story.html |url=https://www.washingtonpost.com/politics/washington-braces-for-the-first-shutdown-of-the-national-government-in-17-years/2013/09/30/977ebca2-29bd-11e3-97a3-ff2758228523_story.html |title=Shutdown begins: Stalemate forces first U.S. government closure in 17 years |newspaper=] |date=October 1, 2013 |access-date=June 21, 2022 |author1=Montgomery, Lori |author2=Kane, Paul }}<br />{{cite news |url=https://www.washingtonpost.com/blogs/post-politics/wp/2013/09/19/mccain-efforts-to-repeal-and-defund-obamacare-not-rational |title=McCain: Efforts to repeal and defund Obamacare 'not rational{{'-}} |newspaper=] |date=September 19, 2013 |issn=0190-8286 |oclc=2269358 |author=Blake, Aaron |access-date=September 24, 2013 |archive-date=March 12, 2016 |archive-url=https://web.archive.org/web/20160312235114/https://www.washingtonpost.com/blogs/post-politics/wp/2013/09/19/mccain-efforts-to-repeal-and-defund-obamacare-not-rational |url-status=live }}</ref><ref name="Beutler" /><ref>{{cite news |first=Jonathan |last=Cohn |title=Tea Party to Republicans: Shut Down the Government, or You're a Sellout |url=https://newrepublic.com/article/114229/tea-party-wants-government-shutdown-over-obamacare |magazine=] |date=August 7, 2013 |access-date=March 10, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013007/https://newrepublic.com/article/114229/tea-party-wants-government-shutdown-over-obamacare |url-status=live }}</ref>

====2017 repeal effort====
{{Main|2017 Patient Protection and Affordable Care Act replacement proposals}}
]
During a midnight congressional session starting January 11, the Senate of the ] voted to approve a "budget blueprint" that would allow ] to repeal parts of the law "without threat of a ] ]".<ref>{{Cite news |url=https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html |title=Senate Takes Major Step Toward Repealing Health Care Law |last1=Kaplan |first1=Thomas |date=January 12, 2017 |work=] |issn=0362-4331 |oclc=1645522 |last2=Pear |first2=Robert |access-date=January 12, 2017 |archive-date=January 12, 2017 |archive-url=https://web.archive.org/web/20170112113923/https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html |url-status=live }}</ref><ref>{{Cite news |url=https://www.foxnews.com/politics/gop-senate-to-move-forward-on-obamacare-repeal |title=GOP Senate to Move Forward on ObamaCare Repeal |date=January 11, 2017 |publisher=] Politics |access-date=January 12, 2017}}</ref> The plan, which passed 51–48, was named by Senate Republicans the "Obamacare 'repeal resolution.{{' "}}<ref>{{Cite news |url=http://www.cnn.com/2017/01/11/politics/senate-obamacare-repeal/ |title=Senate Opens Obamacare Repeal Drive with Overnight Marathon |last1=Lee |first1=MJ |date=January 12, 2017 |publisher=]|last2=Barrett |first2=Ted |last3=LoBianco |first3=Tom |access-date=January 12, 2017}}</ref> Democrats opposing the resolution staged a protest during the vote.<ref>{{Cite news |url=http://www.nbcnews.com/politics/congress/senate-vote-obamacare-repeal-measure-late-night-session-n705816 |title=Senate Approves First Step Toward Repealing Obamacare in Late-Night Session |last=Caldwell |first=Leigh Ann |date=January 12, 2017 |publisher=] |access-date=January 12, 2017}}</ref>

] announced their replacement, the ], on March 6.<ref>{{cite news |last1=Golstein |first1=Amy |last2=DeBonis |first2=Mike |last3=Snell |first3=Kelsey |title=House Republicans release long-awaited plan to repeal and replace Obamacare |url=https://www.washingtonpost.com/powerpost/new-details-emerge-on-gop-plans-to-repeal-and-replace-obamacare/2017/03/06/04751e3e-028f-11e7-ad5b-d22680e18d10_story.html |access-date=March 7, 2017 |issn=0190-8286 |oclc=2269358 |newspaper=]}}</ref> On March 24, the AHCA failed amid a revolt among Republican representatives.<ref>{{cite news |last1=Pear |first1=Robert |title=Push to Repeal Health Law Fails |url=https://www.nytimes.com/2017/03/24/us/politics/health-care-affordable-care-act.html |access-date=March 24, 2017 |issn=0362-4331 |oclc=1645522 |newspaper=] |date=March 24, 2017}}</ref>

On May 4 the House voted to pass the AHCA by a margin of 217 to 213.<ref>{{cite news |url=http://edition.cnn.com/2017/05/04/politics/health-care-vote/ |title=House Republicans pass bill to repeal and replace Obamacare |publisher=] |date=May 4, 2017 |access-date=May 4, 2017}}</ref> The Senate Republican leadership announced that Senate Republicans would write their own version of the bill instead of voting on the House version.<ref>{{Cite web |url=https://www.businessinsider.com/senate-plan-for-healthcare-bill-ahca-2017-5 |title=Senate Republicans signal they plan to scrap bill the House just passed and write their own |first=Bob |last=Bryan |website=] |date=May 4, 2017}}</ref>

] McConnell named a group of 13 Republicans to draft the substitute version in private, raising bipartisan concerns about lack of transparency.<ref>{{cite news |work=] |title=Secrecy Surrounding Senate Health Bill Raises Alarms in Both Parties |url=https://www.nytimes.com/2017/06/15/us/politics/secrecy-surrounding-senate-health-bill-raises-alarms-in-both-parties.html |issn=0362-4331 |oclc=1645522 |first1=Thomas |last1=Kaplan |first2=Robert |last2=Pear |date=June 15, 2017 |url-status=live |archive-url=https://web.archive.org/web/20170618182849/https://www.nytimes.com/2017/06/15/us/politics/secrecy-surrounding-senate-health-bill-raises-alarms-in-both-parties.html |archive-date=June 18, 2017}}</ref><ref>{{cite news |newspaper=] |title=The remarkable steps Republicans are taking to obscure what's in their health-care bill |first=Philip |last=Bump |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/news/politics/wp/2017/06/13/the-remarkable-steps-republicans-are-taking-to-obscure-whats-in-their-health-care-bill/ |date=June 13, 2017 |url-status=live |archive-url=https://web.archive.org/web/20170620082523/https://www.washingtonpost.com/news/politics/wp/2017/06/13/the-remarkable-steps-republicans-are-taking-to-obscure-whats-in-their-health-care-bill/ |archive-date=June 20, 2017}}</ref><ref>{{cite news |publisher=] |title=The Senate's Health Care Bill Remains Shrouded in Secrecy |first1=Benjy |last1=Sarlin |first2=Leigh Ann |last2=Caldwell |url=http://www.nbcnews.com/politics/congress/senate-s-health-care-bill-remains-shrouded-secrecy-n772456 |date=June 15, 2017 |url-status=live |archive-url=https://web.archive.org/web/20170619162148/http://www.nbcnews.com/politics/congress/senate-s-health-care-bill-remains-shrouded-secrecy-n772456 |archive-date=June 19, 2017}}</ref> On June 22, Republicans released the first discussion draft, which renamed it the "Better Care Reconciliation Act of 2017" (BCRA).<ref>{{cite web |url=https://www.budget.senate.gov/imo/media/doc/SENATEHEALTHCARE.pdf |title=H.R. 1628, Better Care Reconciliation Act of 2017, discussion draft ERN17282 |publisher=Senate Budget Committee |date=June 22, 2017}}</ref> On July 25, although no amendment proposal had garnered majority support, Republicans voted to advance the bill to the floor and begin formal consideration of amendments. Senators ] and ] were the only two dissenting Republicans, making the vote a 50–50 tie. Vice President ] then cast the tie-breaking vote in the affirmative.<ref>{{cite web |url=http://www.cnn.com/2017/07/25/politics/senate-health-care-vote/index.html |title=McCain returns as Senate advances health bill |author1=Lauren Fox |author2=MJ Lee |author3=Phil Mattingly |author4=Ted Barrett |publisher=]|date=July 25, 2017 |url-status=live |archive-url=https://web.archive.org/web/20170725204952/http://www.cnn.com/2017/07/25/politics/senate-health-care-vote/index.html |archive-date=July 25, 2017}}</ref>

The revised BCRA failed, 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but that too failed, 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to ACA, failed by 49–51, with Collins, Murkowski, and McCain joining all Democrats and independents in voting against it.<ref>{{Citation |last=Klein |first=Ezra |author-link=Ezra Klein |title=The GOP's massive health care failures, explained |publisher=] |date=July 28, 2017 |url=https://www.vox.com/health-care/2017/7/28/16055284/gop-massive-health-care-failures-explained |archive-url=https://web.archive.org/web/20170728212507/https://www.vox.com/health-care/2017/7/28/16055284/gop-massive-health-care-failures-explained |archive-date=July 28, 2017 |access-date=August 3, 2017}}</ref>

====Proposed changes in 2024====
Donald Trump, who has historically opposed the ACA,<ref>{{Cite journal|title=Why Trumpcare failed|first=Roger|last=Collier|date=May 1, 2017|journal=Canadian Medical Association Journal|volume=189|issue=17|pages=E645–E646|doi=10.1503/cmaj.1095414|pmid=28461382|pmc=5415398}}</ref><ref>{{Cite web|url=https://apnews.com/article/trump-obamacare-health-care-biden-c2b1f5776310870deed2fb997b07fc2c|title=Trump says he will renew efforts to replace 'Obamacare' if he wins a second term|date=November 27, 2023|website=AP News}}</ref><ref>{{Cite web|url=https://www.nbcnews.com/politics/congress/trump-doubles-saying-obamacare-sucks-must-replaced-rcna126978|title=Trump doubles down, saying 'Obamacare Sucks' and must be replaced|date=November 29, 2023|website=NBC News}}</ref> has said during the ] that he plans to modify or scrap sections it, saying he has "proposals." ] has said that Trump intends to allow insurance companies to discriminate against people with preexisting conditions or ], with ] replaced with private insurance.<ref>{{Cite web|url=https://nymag.com/intelligencer/article/trump-health-plan-charge-more-preexisting-conditions-concept-plan-j-d-vance.html|title=Trump's Health-Care Plan Lets Insurers Charge More for Preexisting Conditions|first=Jonathan|last=Chait|date=September 17, 2024|website=Intelligencer}}</ref><ref>{{Cite web|url=https://www.nbcnews.com/politics/2024-election/donald-trump-misrepresents-repeal-affordable-care-act-obamacare-rcna171293|title=Donald Trump misrepresents his push to repeal the Affordable Care Act|date=September 16, 2024|website=NBC News}}</ref><ref>{{Cite web|url=https://www.semafor.com/article/09/17/2024/jd-vance-cracks-open-the-pre-existing-condition-debates|title=JD Vance reopens the pre-existing condition debates &#124; Semafor}}</ref> Kamala Harris said she would "maintain and grow" the ACA.<ref>{{Cite web|url=https://www.ajmc.com/view/harris-defends-aca-while-trump-calls-for-much-better-healthc-plan-during-debate|title=Harris Defends ACA While Trump Calls for "Much Better" Health Plan During Debate|date=September 11, 2024|website=AJMC}}</ref><ref>{{Cite web|url=https://www.mddionline.com/medical-device-regulations/healthcare-showdown-trump-and-harris-spar-over-legacy-of-obamacare-|title=Trump and Harris Clash Over Healthcare Policy|website=www.mddionline.com}}</ref>

===Actions to hinder implementation===
]}}</ref>]]

Under both the ACA (current law) and the AHCA, the CBO reported that the health exchange marketplaces would remain stable.<ref name="CBO_Score1" /> But Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums.<ref>{{Cite news |url=https://www.nytimes.com/2017/07/27/opinion/health-care-obamacare.html |title=Opinion &#124; Killing Obamacare Softly |first=Thomas B. |last=Edsall |newspaper=] |issn=0362-4331 |oclc=1645522 |date=July 27, 2017}}</ref> Concern about the exchanges became another argument for reforms. Past and ongoing Republican attempts to weaken the law have included:
* Lawsuits such as '']'' and '']''.
* President Trump ended the payment of ] subsidies to insurers on October 12, 2017. CBO estimated in September 2017 that discontinuing the payments would add an average of 15–20 percentage points to health insurance costs on the exchanges in 2018 while increasing the budget deficit nearly $200 billion over a decade.<ref name="VoxCBO1">{{Cite web |url=https://www.vox.com/policy-and-politics/2017/9/14/16308502/cbo-trump-obamacare-premiums |title=CBO: Trump is making Obamacare premiums more expensive |first=Sarah |last=Kliff |date=September 14, 2017 |website=]}}</ref> In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019.<ref name=":3" /> Several insurers and actuarial groups estimated this resulted in a 20 percentage point or more increase in premiums for the 2018 plan year. In other words, premium increases expected to be 10% or less in 2018 became 28–40% instead.<ref>Scott, Dylan (October 18, 2017). . Vox.</ref><ref>Kliff, Sarah. (October 18, 2017). . ''Vox''. Archived at on November 8, 2017.</ref> The insurers would need to make up the $7 billion they had previously received in cost-sharing reductions (CSRs) by raising premiums. Since most premiums are subsidized, the federal government would cover most of the increases. CBO also estimated that initially up to one million fewer people would have health insurance coverage, although rising subsidies might eventually offset this. The 85% of enrollees who received subsidies would be unaffected. CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level.<ref>Congressional Budget Office. (August 15, 2017). . Archived at on October 16, 2017.</ref> Several insurance companies who sued the United States for failure to pay CSRs won cases in 2018 and 2019. The judiciary decided the insurance companies are entitled to unpaid CSRs.<ref name=":3"/><ref>{{cite journal |last1=Keith |first1=Katie |title=Insurer Wins First CSR Payment Decision; Updates On BHP And Risk Corridors Litigation |url=https://www.healthaffairs.org/do/10.1377/forefront.20180906.295628/full/ |journal=Health Affairs |date=September 6, 2018 |doi=10.1377/forefront.20180906.295628}}</ref>
* The 2015 appropriations bill had a rider that ended the payment of risk corridor funds. This was repeated in later years. This resulted in the bankruptcy of many co-ops. This action was attributed to Senator ].<ref>{{Cite news |url=https://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html |title=Marco Rubio Quietly Undermines Affordable Care Act |first=Robert |last=Pear |newspaper=] |issn=0362-4331 |oclc=1645522 |date=December 9, 2015}}</ref> The cutoff generated some 50 lawsuits. The Supreme Court granted ] in 2019 in the case '']''.<ref>{{Cite journal |url=https://www.commonwealthfund.org/blog/2019/supreme-court-hear-case-affordable-care-acts-risk-corridors |title=Supreme Court to Hear Case on Affordable Care Act's Risk Corridors |publisher=Commonwealth Fund |journal=To the Point |access-date=December 1, 2019 |author=Jost, Timothy S. |date=October 25, 2019 |doi=10.26099/pwc0-k005 |archive-date=February 16, 2020 |archive-url=https://web.archive.org/web/20200216164912/https://www.commonwealthfund.org/blog/2019/supreme-court-hear-case-affordable-care-acts-risk-corridors}}</ref><ref>{{cite news |last1=Galewitz |first1=Phil |date=December 9, 2010 |title=ACA Insurers In The Supreme Court: Why Consumers Should Pay Attention |url=https://www.npr.org/sections/health-shots/2019/12/09/786315240/aca-insurers-in-the-supreme-court-why-consumers-should-pay-attention?t=1585694181108 |access-date=March 31, 2020 |publisher=National Public Radio |archive-url=https://web.archive.org/web/20200331224050/https://www.npr.org/sections/health-shots/2019/12/09/786315240/aca-insurers-in-the-supreme-court-why-consumers-should-pay-attention?t=1585694181108 |archive-date=March 31, 2020}}</ref><ref>{{cite news |location=Washington DC |first1=Ian |last1=Millhiser |title=Obamacare had an unusually good day at the Supreme Court |url=https://www.vox.com/2019/12/10/21004821/obamacare-supreme-court-risk-corridors-maine-community |access-date=March 31, 2020 |publisher=] |date=December 10, 2019 |archive-url=https://web.archive.org/web/20191230061526/https://www.vox.com/2019/12/10/21004821/obamacare-supreme-court-risk-corridors-maine-community |archive-date=December 30, 2019}}</ref>
* Trump weakened the individual mandate with his first executive order, which limited enforcement of the tax. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding Obama's instructions to reject them.<ref>{{Cite web |url=https://www.politico.com/story/2017/05/03/trump-obamacare-mandate-enforcement-237937 |title=Trump still enforcing Obamacare mandate |first1=Brianna |last1=Ehley |first2=Aaron |last2=Lorenzo |website=]|date=May 3, 2017 }}</ref>
* Trump reduced funding for advertising for exchange enrollment by up to 90%, with other reductions to support resources used to answer questions and help people sign-up for coverage.<ref>{{Cite web |url=https://www.vox.com/2017/8/31/16236280/trump-obamacare-outreach-ads |title=Trump is slashing Obamacare's advertising budget by 90% |first=Sarah |last=Kliff |date=August 31, 2017 |website=]}}</ref> The CBO said the reductions would reduce ACA enrollment.<ref name="VoxCBO1" />
* Trump reduced the enrollment period for 2018 by half, to 45 days.<ref>{{Cite news |date=November 4, 2017 |url=https://www.nytimes.com/2017/11/04/opinion/obamacare-vs-the-saboteurs.html |title=Opinion &#124; Obamacare vs. the Saboteurs |issn=0362-4331 |oclc=1645522 |author=The Editorial Board |newspaper=]}}</ref>
* Trump made public statements that the exchanges were unstable or in a ].<ref>{{Cite web |url=https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |first1=Louise |last1=Norris |access-date= |archive-date=November 18, 2017 |archive-url=https://web.archive.org/web/20171118012524/https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |title=10 ways the GOP sabotaged Obamacare |date=May 17, 2017 |website=healthinsurance.org}}</ref>

===Socialism debate===
Many economically conservative opponents called the ACA "]" or "]", pointing to the government redistribution of wealth via subsidies for low-income purchasers, expansion of the government-run Medicaid insurance, government requirements as to what products can be sold on the exchanges, and the individual mandate, which reduces freedom of consumer choice to be uninsured.<ref>{{Cite web |url=https://www.foxnews.com/transcript/bill-oreilly-obamacare-and-socialism |title=Bill O'Reilly: ObamaCare and socialism |date=March 24, 2015 |website=]}}</ref><ref>{{Cite web |url=https://www.huffpost.com/entry/obamacare-socialism-louie-gohmert-steve-king_n_1383973 |title=Lawmakers Renew Socialism, 'Let People Die' Charges |first1=Michael |last1=McAuliff |first2=Sara |last2=Kenigsberg |date=March 27, 2012 |website=]}}</ref><ref>{{Cite web |url=https://www.foxnews.com/health/october-1-private-health-care-ends-socialism-begins |title=October 1: Private health care ends, socialism begins |first=Manny |last=Alvarez |date=March 25, 2015 |website=]}}</ref>

Other observers considered the law a relatively capitalist or "regulated free-market" means of paying for near-universal health care, because it creates new marketplaces with choices for consumers, largely relies on private employers and private health insurance companies, maintains private ownership of hospitals and doctor's offices, and was originally advocated for by economic conservatives as a capitalist alternative to ].<ref>{{Cite web |url=https://www.huffpost.com/entry/what-do-socialists-think_b_4054666 |title=What Do Socialists Think of Obamacare? |first1=Michael |last1=Smerconish |date=October 6, 2013 |website=]}}</ref><ref name="no_sense">{{Cite web |title=Why Calling Obamacare 'Socialism' Makes No Sense |url=https://abcnews.go.com/ABC_Univision/Politics/calling-obamacare-socialism-makes-sense-analysis/story?id=20435162 |website=] |archive-date=October 8, 2013 |archive-url=https://web.archive.org/web/20131008120048/https://abcnews.go.com/ABC_Univision/Politics/calling-obamacare-socialism-makes-sense-analysis/story?id=20435162 |publisher=Walt Disney |access-date=June 18, 2022 |last1=Rivero |first1=Daniel}}</ref><ref name="obamacarefacts">{{Cite web |url=https://obamacarefacts.com/2015/03/30/why-obamacare-is-not-socialism/ |title=Why ObamaCare is Not Socialism |date=March 30, 2015 |website=Obamacare Facts}}</ref> Some pointed out that the previous system also had socialist aspects. Even for-profit private health insurance companies socialize risk and redistribute wealth from people who have it (all premium payers) to those who need it (by paying for medically necessary healthcare).<ref name="obamacarefacts" /> The requirement to provide emergency care also forced redistribution from people who pay insurance premiums to those who choose to be uninsured, when they visit the emergency room.<ref name="no_sense" />

Some Obamacare supporters accused conservatives of using the term "socialism" as a scare tactic for Obamacare as it was for Medicare and Medicaid,<ref name="obamacarefacts" /> and some embraced the label "socialism" as desirable, distinguishing ] as most desirable for education and health care,<ref>{{Cite web |url=https://www.businessinsider.com/republicans-socialism-democratic-obamacare-bernie-sanders-aoc-socialist-2019-8 |title=Republicans have themselves to thank for socialism |first=Emmanuel |last=Ocbazghi |website=]}}</ref> and ] as undesirable.<ref name="obamacarefacts" /> Milos Forman opined that critics "falsely equate Western European-style socialism, and its government provision of social insurance and health care, with Marxist–Leninist totalitarianism".<ref>{{Cite web |url=https://healthcarereform.procon.org/questions/is-obamacare-a-socialist-law-debated/ |title=Is Obamacare a Socialist Law? - DEBATED - Obamacare |date=November 25, 2024 |publisher=ProCon.org}}</ref>

==Implementation==

{{Main|Implementation history of the Patient Protection and Affordable Care Act}}

In 2010 small business tax credits took effect.<ref name="hist">{{cite web |url=https://resources.ehealthinsurance.com/affordable-care-act/history-timeline-affordable-care-act-aca |title=History of the Affordable Care Act (ACA) |date=October 22, 2014}}</ref> Then ] (PCIP) took effect to offer insurance to those who had been denied coverage by private insurance companies because of a preexisting condition.<ref name="hist" /> By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement.<ref>{{Cite web |url=http://www.help.senate.gov/imo/media/doc/Child-Only%20Health%20Insurance%20Report%20Aug%202,%202011.pdf |title=Health Care Reforrm Law's Impact on Child-Only Health Insurance Policies |last=Enzi |first=Michael B. |date=August 2, 2011 |website=United States Senate |access-date=August 10, 2016}}</ref> In '']'' the Supreme Court allowed states to opt out of the Medicaid expansion.<ref>{{cite web |last=Liptak |first=Adam |date=September 30, 2012 |location=Pittsburgh |url=http://www.post-gazette.com/stories/news/us/supreme-court-justices-face-important-rulings-in-upcoming-term-655566/ |title=Supreme Court justices face important rulings in upcoming term September |website=post-gazette.com |agency=] |access-date=September 30, 2012}}</ref><ref>{{Cite web |url=http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/ |title=Status of State Action on the Medicaid Expansion Decision |publisher=] |access-date=August 12, 2016}}</ref><ref>{{cite web |last1=Walton |first1=Alice G. |title=How To Explain The Obamacare Ruling To A Five-Year-Old |url=https://www.forbes.com/sites/alicegwalton/2012/07/02/how-to-explain-the-obamacare-ruling-to-a-five-year-old/#23e103e723e1 |website=]|access-date=May 5, 2017}}</ref>

In 2013, the ] ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold.<ref>{{cite news |author=The Editorial Board |date=February 2, 2013 |title=A Cruel Blow to American Families |url=https://www.nytimes.com/2013/02/03/opinion/sunday/a-cruel-blow-to-american-families.html |archive-url=https://web.archive.org/web/20130207214914/https://www.nytimes.com/2013/02/03/opinion/sunday/a-cruel-blow-to-american-families.html |archive-date=February 7, 2013 |issn=0362-4331 |oclc=1645522 |work=]}}</ref><ref>{{cite news |url=https://newrepublic.com/article/112327/obamacare-not-universal-you-thought |title=Not-So-Universal Health Care |last=Cohn |first=Jonathan |date=February 5, 2013 |magazine=]}}</ref> On July{{nbsp}}2 Obama delayed the employer mandate until 2015.<ref name="CohnDelay" /><ref name="treasurystatement" /><ref name="REG-138006-12" /> The launch for both the state and federal exchanges was beset by management and technical failings. ], the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered many problems.<ref>{{cite news |last=Kennedy |first=Kelly |date=December 1, 2013 |newspaper=] |url=https://www.usatoday.com/story/news/politics/2013/12/01/federalexchangmeetsgoal/3795523/ |title=White House claims success on HealthCare.gov repairs |access-date=December 1, 2013}}</ref> Operations stabilized in 2014, although not all planned features were complete.<ref>{{cite news |url=http://www.cnn.com/2013/10/22/politics/obamacare-website-four-reasons |title=Rough Obamacare rollout: 4 reasons why |last=Cohen |first=Tom |date=October 23, 2013 |publisher=]|access-date=November 5, 2013}}</ref><ref>{{cite news |url=http://www.csmonitor.com/USA/Latest-News-Wires/2013/1106/Senate-Democrats-frustrated-with-botched-rollout-of-Obamacare |title=Senate Democrats frustrated with botched rollout of Obamacare |last1=Holland |first1=Steve |date=November 6, 2013 |newspaper=The Christian Science Monitor |last2=Rampton |first2=Roberta |agency=] |access-date=November 19, 2013}}</ref>

The ] released a non-partisan study in 2014 that concluded the administration had not provided "effective planning or oversight practices" in developing the exchanges.<ref name="AP-20140731" /> In '']'' the Supreme Court exempted closely held corporations with religious convictions from the contraception rule.<ref name=":2" /> At the beginning of the 2015, 11.7 million had signed up (ex-Medicaid).<ref>{{Cite news |url=https://www.bloomberg.com/news/articles/2015-06-02/obamacare-dropouts-lead-to-enrollment-decline-of-1-5-million |title=Obamacare Sign-Ups Decline to 10.2 Million as Some Don't Pay |last=Tracer |first=Zachary |website=Bloomberg.com |date=June 2, 2015 |access-date=August 21, 2016}}</ref> By the end of the year about 8.8 million consumers had stayed in the program.<ref>{{Cite web |url=https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-11.html |title=December 31, 2015 Effectuated Enrollment Snapshot |date=March 11, 2016 |access-date=June 18, 2022 |archive-date=April 11, 2016 |archive-url=https://web.archive.org/web/20160411120015/https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-03-11.html |location=Baltimore, MD |publisher=Health and Human Services |website=cms.gov}}</ref> Congress repeatedly delayed the onset of the "]" on expensive insurance plans first until 2020<ref>{{Cite web |url=http://www.politico.com/story/2015/12/white-house-obamacare-cadillac-tax-216881 |title=How the White House lost on the Cadillac Tax |last=COOK |first=NANCY |date=December 16, 2015 |publisher=]|access-date=August 21, 2016}}</ref> and later until 2022 and repealed it in late 2019.<ref name="auto1"/>

An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults. The five major national insurers expected to lose money on ACA policies in 2016,<ref>{{Cite news |url=https://www.wsj.com/articles/aetna-to-drop-some-affordable-care-act-markets-1471311737 |title=Aetna to Drop Some Affordable Care Act Markets |last=Mathews |first=Anna Wilde |date=August 16, 2016 |newspaper=]|publisher=News Corp |oclc=781541372 |issn=0099-9660 |access-date=August 16, 2016}}</ref> in part because the enrollees were lower income, older and sicker than expected.<ref>{{Cite news |url=https://www.wsj.com/articles/the-unstable-economics-in-obamas-health-law-1471452938 |title=The Unstable Economics in Obama's Health Law |last=Ip |first=Greg |date=August 17, 2016 |newspaper=] |issn=0099-9660 |access-date=August 23, 2016}}</ref>

More than 9.2 million people (3.0 million new customers and 6.2 million returning) enrolled on the national exchange in 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump.<ref name="ACA_NYT2017" /> The eleven states that run their own exchanges signed up about 3{{nbsp}}million more.<ref name="ACA_NYT2017">{{Cite web |url=https://www.nytimes.com/2017/02/03/us/politics/affordable-care-act-obama-care-sign-up.html |title=Affordable Care Act signups dip amid uncertainty and Trump attacks |website=] |last1=Pear |first1=Robert |access-date=June 18, 2022 |archive-date=February 5, 2017 |issn=0362-4331 |oclc=1645522 |archive-url=https://web.archive.org/web/20170205110857/https://www.nytimes.com/2017/02/03/us/politics/affordable-care-act-obama-care-sign-up.html |date=February 3, 2017}}</ref> The IRS announced that it would not require that tax returns indicate a person has health insurance, reducing the effectiveness of the individual mandate, in response to Trump's executive order.<ref>{{Cite news |url=http://www.washingtontimes.com/news/2017/feb/14/irs-weakens-enforcement-obamacare-individual-manda/ |title=IRS weakens enforcement of Obamacare individual mandate: Report |last=Morton |first=Victor |date=February 14, 2017 |newspaper=The Washington Times |access-date=February 16, 2017}}</ref> The CBO reported in March that the healthcare exchanges were expected to be stable.<ref name="CBO_Score1">{{Cite web |url=https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestimate/americanhealthcareact_0.pdf |title=American Healthcare Act Cost Estimate |website=United States. Congressional Budget Office |date=March 13, 2017 |access-date=March 24, 2017 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215012927/https://www.cbo.gov/ |url-status=dead }}</ref> In May the House voted to repeal the ACA using the American Health Care Act (AHCA), but the AHCA was defeated in the Senate.<ref>{{cite news |title=House Passes Bill to Repeal Obamacare: Live Updates |publisher=News Corp |oclc=781541372 |issn=1042-9840|url=https://www.wsj.com/livecoverage/house-gop-obamacare-repeal-bill-vote |access-date=May 5, 2017 |work=]}}</ref><ref>{{cite news |last1=Epstein |first1=Reid J. |title=Analyst Sees Danger for House Republicans After Health Bill Vote |url=https://blogs.wsj.com/washwire/2017/05/05/analyst-sees-danger-for-house-republicans-after-health-bill-vote/ |publisher=News Corp |oclc=781541372 |issn=1042-9840 |access-date=May 5, 2017 |work=]|date=May 5, 2017}}</ref> The Tax Cuts and Jobs Act set the individual mandate penalty at $0 starting in 2019.<ref name="hatchsays" /> The CBO estimated that the change would cause 13 million fewer people to have health insurance in 2027.<ref>{{cite web |last=O'Brien |first=Elizabeth |date=December 2, 2017 |title=The Senate's Tax Bill Eliminates the Individual Mandate for Health Insurance. Here's What You Need to Know |url=https://money.com/gop-tax-reform-bill-individual-mandate/ |url-status=live |website=Money |issn=0149-4953 |location=New York City |archive-url=https://web.archive.org/web/20200302102755/https://money.com/gop-tax-reform-bill-individual-mandate/ |archive-date=March 2, 2020}}</ref>

The 2017 Individual Market Stabilization Bill was proposed to fund cost cost-sharing reductions,<ref>{{Cite news |url=https://www.nytimes.com/2017/10/17/us/politics/alexander-murray-deal-obamacare-subsidies.html |title=2 Senators Strike Deal on Health Subsidies That Trump Cut Off |first1=Thomas |last1=Kaplan |first2=Robert |last2=Pear |date=October 17, 2017 |issn=0362-4331 |oclc=1645522 |work=] |archive-url=https://web.archive.org/web/20171018072702/https://www.nytimes.com/2017/10/17/us/politics/alexander-murray-deal-obamacare-subsidies.html?_r=0 |archive-date=October 18, 2017 |access-date=June 18, 2022}}</ref> provide more flexibility for state waivers, allow a new "Copper Plan" offering only catastrophic coverage, allow interstate insurance compacts, and redirect consumer fees to states for outreach. The bill failed.

By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicaid or via an alternative program.<ref>{{Cite web |archive-date=November 20, 2013 |archive-url=https://web.archive.org/web/20131120111501/https://www.advisory.com/daily-briefing/resources/primers/medicaidmap |url=https://www.advisory.com/daily-briefing/resources/primers/medicaidmap |work=Daily Briefing |title=Where the states stand on Medicaid expansion |publisher=The Advisory Board |access-date=June 18, 2022 |date=February 6, 2019}}</ref>

==In popular culture==
'']'' presented a sketch in October 2009 about the legislation's gridlock, with ] playing an angry President Obama confronting three senators opposing the plan.<ref>{{Cite web |url=https://www.youtube.com/watch?v=h8UObIn9gKw |archive-url=https://ghostarchive.org/varchive/youtube/20211220/h8UObIn9gKw |archive-date=2021-12-20 |url-status=live |title=The Rock Obama: Health Care Gridlock - Saturday Night Live|date=October 25, 2013 |via=www.youtube.com}}{{cbignore}}</ref>

The show aired another sketch in September 2013 with ] as President Obama rolling out the plan to the public, and ] and other cast members playing ordinary Americans helping him in advocating for the legislation.<ref>{{Cite web |url=https://www.youtube.com/watch?v=sRwvdXeriDg |archive-url=https://ghostarchive.org/varchive/youtube/20211220/sRwvdXeriDg |archive-date=2021-12-20 |url-status=live |title=Obamacare Explained - SNL|date=September 29, 2013 |via=www.youtube.com}}{{cbignore}}</ref>


==See also== ==See also==
{{Portal|United States|Politics|Law|Medicine}}
*]
* ]
*] ("RomneyCare")
* ]
*]
* ]
*]
* ] (sometimes called "Romneycare")
*]
* ]
*U.S. ] with 8 other countries in tabular form
* ] (Reform to the American Health Care system signed into law by President Obama)
* ]
* ]
* ]
* U.S. ] with eight other countries (tabular form)


==References== ==References==

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<ref name="Const-Revenue">] art. I, § 7, cl. 1.</ref>

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<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>

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<ref name="FederalRegister">{{cite web |url=http://www.gpo.gov/fdsys/granule/FR-2011-12-07/2011-31289/content-detail.html |title=Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act |date=December 7, 2011 |publisher=Federal Register |page=76573 |volume=76 |issue=235 |access-date=April 1, 2012}}</ref>

<ref name="FinalRule">{{cite web |url=http://www.gpo.gov/fdsys/granule/FR-2012-02-15/2012-3547/content-detail.html |title=Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules |date=February 10, 2012 |publisher=Federal Register |format=77 FR 8725 |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''. |author=Dept. Health and Human Services |access-date=February 15, 2012}}</ref>

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<ref name="FORBES">{{cite web |last=Ungar |first=Rick |title=The Real Numbers On 'The Obamacare Effect' Are In-Now Let The Crow Eating Begin |url=https://www.forbes.com/sites/rickungar/2014/03/10/the-real-numbers-on-the-obamacare-effect-are-in-now-let-the-crow-eating-begin/ |work=]|access-date=November 11, 2014}}</ref>

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<ref name="governorromney">{{cite web |first=Molly |last=Ball |title=Was Mitt Romney a Good Governor? |url=https://www.theatlantic.com/politics/archive/2012/05/was-mitt-romney-a-good-governor/257942 |work=] |date=May 31, 2012 |access-date=October 28, 2013}}</ref>
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<ref name="GruberBio2">{{cite web |url=http://economics.mit.edu/faculty/gruberj |title=Jonathan Gruber (economist) |publisher=MIT Department of Economics |access-date=September 2, 2013}}{{cite web |url=http://economics.mit.edu/files/7840 |title=Jonathan Gruber: short biography |publisher=MIT Department of Economics |access-date=September 2, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130928032016/http://economics.mit.edu/files/7840 |archive-date=September 28, 2013 }}</ref>

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<ref name="HealthCare Reform Magazine">{{cite web |last1=Hislop |first1=Reginald M. |url=http://www.healthcarereformmagazine.com/article/health-reform-and-medicaid-expansion.html |title=Health Reform and Medicaid Expansion |location=Royal Palm Beach, FL |work=HealthCare Reform Magazine |date=July 13, 2010 |access-date=January 9, 2012}}</ref>

<ref name="HealthCareGov">{{cite web |url=https://www.healthcare.gov/marketplace/individual/ |title=Welcome to the Marketplace |website=HealthCare.Gov |publisher=the ]}}<br /> {{cite web |url=https://www.healthcare.gov/what-is-the-health-insurance-marketplace |title=What is the Health Insurance Marketplace? |website=HealthCare.Gov |publisher=The ]}}</ref>

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<ref name="hip-dhhs">{{cite web |url=http://kff.org/health-reform/issue-brief/explaining-health-care-reform-questions-about-health/ |title=Explaining Health Care Reform |date=October 30, 2020 |publisher=]}}</ref>

<ref name="H.R.3590Enrolled">, section 1001 (adding section 2714 to the ]): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26&nbsp;years of age."</ref>

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<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=Kaiser Health News |date=February 23, 2010 |access-date=July 29, 2012}}<br />{{cite web |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=Kaiser Health News |date=February 23, 2010 |access-date=July 29, 2012}}</ref>

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<ref name="NYT52613">{{cite news |title=Partisan Gridlock Thwarts Effort to Alter Health Law |url=https://www.nytimes.com/2013/05/27/us/politics/polarized-congress-thwarts-changes-to-health-care-law.html |newspaper=]|date=May 26, 2013 |author=Weisman, Jonathan |author2=Pear, Robert |access-date=May 27, 2013 |issn=0362-4331 |oclc=1645522 |quote=we cannot use any of the normal tools to resolve ambiguities or fix problems}}</ref>

<ref name="NYT52413">{{cite news |title=States' Policies on Health Care Exclude Some of the Poorest |url=https://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html |newspaper=] |date=May 24, 2013 |first=Robert |last=Pear |issn=0362-4331 |oclc=1645522 |access-date=May 25, 2013 |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>

<ref name="NYT80213">{{cite news |title=Missouri Citizens Face Obstacles to Coverage |url=https://www.nytimes.com/2013/08/03/us/missouri-citizens-face-obstacles-to-coverage.html |newspaper=]|date=August 2, 2013 |issn=0362-4331 |oclc=1645522 |first=Robert |last=Pear |access-date=August 3, 2013}}</ref>

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<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 |url=https://www.nytimes.com/2012/02/15/health/policy/health-care-mandate-was-first-backed-by-conservatives.html |issn=0362-4331 |oclc=1645522 |access-date=July 2, 2012}}</ref>

<ref name="NYTLowrey1">{{Cite journal |first=Annie |last=Lowrey |date=May 7, 2013 |url=https://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 |issn=0362-4331 |oclc=1645522 |journal=] |access-date=June 10, 2013}}</ref>

<ref name="ObamaPromise">{{cite web |first=Louis |last=Jacobson |title=Barack Obama says that what he'd said was you could keep your plan 'if it hasn't changed since the law passed{{'-}} |url=http://www.politifact.com/truth-o-meter/statements/2013/nov/06/barack-obama/barack-obama-says-what-hed-said-was-you-could-keep/ |publisher=]|access-date=November 9, 2013}}</ref>

<ref name="optout">{{cite news |url=https://money.cnn.com/2012/07/23/news/economy/health-reform |title=6 million will lose out on Medicaid expansion |first=Emily Jane |last=Fox |publisher=] |date=July 24, 2012 |access-date=July 25, 2012}}</ref>

<ref name="Ornstein">{{cite news |first=Norm |last=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 |work=National Journal |date=July 24, 2013}}</ref>

<ref name="paulryan">{{cite news |title=The Facts Are In and Paul Ryan Is Wrong |first=Jonathan |last=Chait |work=] |date=May 10, 2013 |url=http://nymag.com/daily/intelligencer/2013/05/facts-are-in-and-paul-ryan-is-wrong.html}}</ref>

<ref name="PelosiSawyer">{{Cite news |title=Pelosi Defends Health Care Fight Tactics |first1=Margaret |last1=Aro |first2=Mark |last2=Mooney |url=https://abcnews.go.com/WN/Politics/house-speaker-nancy-pelosis-exclusive-interview-diane-sawyer/story?id=10172685 |newspaper=] |date=March 22, 2010 |access-date=March 23, 2010}}</ref>

<ref name="PoliticoPelosi">{{Cite news |title=Pelosi steeled W.H. for health push |first1=Carrie |last1=Brown |first2=Glenn |last2=Thrush |url=http://www.politico.com/news/stories/0310/34753.html |newspaper=] |date=March 20, 2010 |access-date=March 23, 2010}}</ref>

<ref name="promise">{{cite web |first=Andrew |last=Cline |title=How Obama Broke His Promise on Individual Mandates |url=https://www.theatlantic.com/politics/archive/2012/06/how-obama-broke-his-promise-on-individual-mandates/259183/ |work=] |date=June 29, 2012 |access-date=September 26, 2013}}</ref>

<ref name="PublicOption">{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/the-public-option-still-dead |title=The Public Option, Still Dead |magazine=] |date=March 12, 2010}}</ref>

<ref name="Reconciliationprimer">{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/brief-reconciliation-primer |title=A Brief Reconciliation Primer |magazine=] |date=February 20, 2010}}</ref>

<ref name="ReferenceB">{{cite web |url=http://www.shrm.org/publications/hrnews/pages/coverpreventivecare.aspx |title=Login |access-date=February 18, 2015 }}{{Dead link|date=September 2023 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>

<ref name="REG-138006-12">{{cite journal |last=Madara |first=Matthew R. |date=February 11, 2014 |title=ACA Employer Shared Responsibility Delay Included in Final Regs |journal=Tax Notes Today |volume=28 |issue=1}}</ref>

<ref name="reuterstimeline">{{cite news |url=https://www.reuters.com/article/idUSTRE62L0JA20100322 |work=]|title=Timeline: Milestones in Obama's quest for healthcare reform |date=March 22, 2010 |access-date=March 22, 2010}}</ref>

<ref name="RollCallCBO">{{Cite news |title=CBO: Health Care Overhaul Would Cost $940&nbsp;Billion |first=Steven |last=Dennis |url=http://www.rollcall.com/news/44347-1.html |newspaper=] |date=March 18, 2010 |access-date=March 22, 2010}}</ref>

<ref name="salon08132013">{{cite news |first=Brian |last=Beutler |title=A new kind of birther and death panel insanity explodes |url=http://www.salon.com/2013/08/13/republicans_still_pander_to_birthers_and_death_panelists/ |work=]|date=August 13, 2013 |access-date=December 3, 2013}}</ref>

<ref name="sec1401">{{Cite web |author=United States Congress |url=https://en.wikisource.org/Patient_Protection_and_Affordable_Care_Act/Title_I/Subtitle_E/Part_I/Subpart_A |title=Patient Protection and Affordable Care Act |via=Wikisource}}</ref>

<ref name="sec1401_p">]</ref>

<ref name="S.334summary">{{cite web |title=Bill Summary & Status – S.334 |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d110:SN00334:@@@S |publisher=] ] |access-date=September 24, 2013 |archive-date=October 25, 2015 |archive-url=https://web.archive.org/web/20151025092928/http://thomas.loc.gov/cgi-bin/bdquery/z?d110:SN00334:@@@S |url-status=dead }}</ref>

<ref name="SchiffHardinLLP">{{cite web |url=http://www.natlawreview.com/article/next-steps-to-comply-health-care-reform |title=Next Steps to Comply with Health Care Reform |date=October 10, 2012 |work=The National Law Review |access-date=October 10, 2012}}</ref>

<ref name="Sep2008FirstPresidentialDebate">{{Cite news |title=The First Presidential Debate |date=September 26, 2008 |issn=1553-8095 |oclc=1645522 |work=] |url=http://elections.nytimes.com/2008/president/debates/transcripts/first-presidential-debate.html}}</ref>

<ref name="Sep2009JointAddress">{{cite web |url=https://obamawhitehouse.archives.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 |access-date=March 24, 2010 |url-status=live |archive-url=https://web.archive.org/web/20170126012951/https://obamawhitehouse.archives.gov/the-press-office/remarks-president-a-joint-session-congress-health-care |via=] |work=] |archive-date=January 26, 2017}}</ref>

<ref name="ServicemembersHomeOwnershipTaxAct">{{Cite news |url=https://www.congress.gov/bill/111th-congress/house-bill/3590/summary/81 |title=Summary: H.R.3590—111th Congress (2009–2010) |publisher=Library of Congress |date=July 30, 2017}}</ref>

<ref name="SHNS">{{cite news |url=http://public.shns.com/node/52359 |title=Health reform bill will cause several near-term changes |last=Bowman |first=Lee |date=March 22, 2010 |agency=Scripps Howard News Service |access-date=March 23, 2010 |url-status=dead |archive-url=https://web.archive.org/web/20101227022643/http://public.shns.com/node/52359 |archive-date=December 27, 2010 }}</ref>

<ref name="snopes1">{{cite web |url=http://snopes.com/politics/medical/euthanasia.asp |title=Euthanasia Counseling |website=]|date=August 13, 2009}}</ref>

<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 |date=November 16, 2011 |publisher=U.S. Department of Health & Human Services |access-date=April 1, 2012}}</ref>

<ref name="TamiLuhby">{{cite news |url=https://money.cnn.com/2013/04/23/news/economy/obamacare-subsidies/index.html |title=Millions eligible for Obamacare subsidies, but most don't know it |last=Luhby |first=Tami |date=April 23, 2013 |publisher=] |access-date=June 22, 2013}}</ref>

<ref name="Top 18">{{cite news |url=http://www.huffingtonpost.com/2010/03/22/the-top-18-immediate-effe_n_508315.html#s75147 |title=The Top 18 Immediate Effects Of The Health Care Bill |last1=Binckes |first1=Jeremy |date=March 22, 2010 |work=] |last2=Wing |first2=Nick |access-date=March 22, 2010 |archive-url=https://web.archive.org/web/20210215023627/https://www.huffpost.com/entry/health-reform-bill-summary_n_508315 |archive-date=February 15, 2021}}</ref>

<ref name="treasurystatement">{{cite web |url=http://www.treasury.gov/connect/blog/Pages/Continuing-to-Implement-the-ACA-in-a-Careful-Thoughtful-Manner-.aspx |title=Continuing to Implement the ACA in a Careful, Thoughtful Manner |last=Mazur |first=Mark |publisher=United States Department of the Treasury |access-date=July 16, 2013}}</ref>

<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 |access-date=April 9, 2012}}</ref>

<ref name="USS RC 2009-396">{{cite web |url=https://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=] |access-date=January 9, 2012}}</ref>

<ref name="wapo">{{cite news |issn=0190-8286 |oclc=2269358 |url=https://apps.washingtonpost.com/g/page/politics/labor-leaders-letter-to-harry-reid-and-nancy-pelosi/785/ |title=Labor leaders' letter to Harry Reid and Nancy Pelosi |newspaper=] |date=January 27, 2014 |access-date=February 13, 2014 |archive-date=February 15, 2021 |archive-url=https://web.archive.org/web/20210215013105/https://apps.washingtonpost.com/g/page/politics/labor-leaders-letter-to-harry-reid-and-nancy-pelosi/785/ |url-status=dead }}</ref>

<ref name="WaPoWaiverFlexibility">{{cite news |url=https://www.washingtonpost.com/wp-dyn/content/article/2011/02/28/AR2011022806535.html |title=Obama offers states more flexibility in health-care law |last1=Goldstein |first1=Amy |issn=0190-8286 |oclc=2269358 |date=March 1, 2011 |newspaper=] |last2=Balz |first2=Dan}}</ref>

<ref name="WashPost-04092010">{{cite news |title=Anger over health-care reform spurs rise in threats against Congress members |issn=0190-8286 |oclc=2269358 |first1=Sari |last1=Horwitz |first2=Ben |last2=Pershing |date=April 9, 2010 |newspaper=] |url=https://www.washingtonpost.com/wp-dyn/content/article/2010/04/08/AR2010040805476.html?nav=hcmodule |access-date=April 9, 2010}}</ref>

<ref name="WSJ">{{cite news |title=Union Letter: Obamacare Will 'Destroy The Very Health and Wellbeing' of Workers |publisher=News Corp |oclc=781541372 |issn=1042-9840 |newspaper=] |date=July 12, 2013 |url=https://blogs.wsj.com/corporate-intelligence/2013/07/12/union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ |access-date=October 7, 2013 |archive-url=https://web.archive.org/web/20131207095718/https://blogs.wsj.com/corporate-intelligence/2013/07/12/union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ |archive-date=December 7, 2013}}</ref>

<ref name="WSJ-mar25">{{cite news |title=What Health Overhaul Means for Small Businesses |last=McNamara |first=Kristen |date=March 25, 2010 |publisher=News Corp |oclc=781541372 |issn=0099-9660 |newspaper=] |url=https://www.wsj.com/articles/SB10001424052748703312504575141533342803608 |archive-url=https://web.archive.org/web/20150421054808/https://www.wsj.com/articles/SB10001424052748703312504575141533342803608 |archive-date=April 21, 2015}}</ref>

<ref name="trauma_medicaid">{{cite journal |title=Impact of the Affordable Care Act on trauma and emergency general surgery: An Eastern Association for the Surgery of Trauma systematic review and meta-analysis |year=2019 |doi=10.1097/TA.0000000000002368 |pmid=31095067 |last1=Zerhouni |first1=Y. A. |last2=Scott |first2=J. W. |last3=Ta |first3=C. |last4=Hsu |first4=P. C. |last5=Crandall |first5=M. |last6=Gale |first6=S. C. |last7=Schoenfeld |first7=A. J. |last8=Bottiggi |first8=A. J. |last9=Cornwell Ee |first9=3rd |last10=Eastman |first10=A. |last11=Davis |first11=J. K. |last12=Joseph |first12=B. |author13=Robinson BRH |last14=Shafi |first14=S. |last15=White |first15=C. Q. |last16=Williams |first16=B. H. |last17=Haut |first17=E. R. |last18=Haider |first18=A. H. |journal=The Journal of Trauma and Acute Care Surgery |volume=87 |issue=2 |pages=491–501 |s2cid=155102212}}</ref>

<ref name="HIV_medicaid">{{cite journal |title=Early Impact of the Patient Protection and Affordable Care Act on People Living With HIV: A Systematic Review |year=2019 |doi=10.1097/JNC.0000000000000079 |pmid=31021962 |last1=Ginossar |first1=T. |last2=Van Meter |first2=L. |last3=Ali Shah |first3=S. F. |last4=Bentley |first4=J. M. |last5=Weiss |first5=D. |last6=Oetzel |first6=J. G. |journal=The Journal of the Association of Nurses in AIDS Care |volume=30 |issue=3 |pages=259–269 |s2cid=133608874}}</ref>

<ref name="Medicaid_Expan_Sys_Rev">{{cite journal |title=The Effects Of Medicaid Expansion Under The ACA: A Systematic Review |publisher=Project HOPE |issn=0278-2715 |oclc=07760874 |year=2018 |doi=10.1377/hlthaff.2017.1491 |last1=Mazurenko |first1=Olena |last2=Balio |first2=Casey P. |last3=Agarwal |first3=Rajender |last4=Carroll |first4=Aaron E. |last5=Menachemi |first5=Nir |journal=Health Affairs |volume=37 |issue=6 |pages=944–950 |pmid=29863941 |s2cid=46937241}}</ref>

<ref name="ACC_surgery_cancer">{{cite journal |title=Implications of the Affordable Care Act on Surgery and Cancer Care |year=2018 |doi=10.1016/j.soc.2018.05.001 |last1=Loehrer |first1=Andrew P. |last2=Chang |first2=George J. |journal=Surgical Oncology Clinics of North America |issn=1055-3207 |volume=27 |issue=4 |pages=603–614 |pmid=30213405 |s2cid=52269681}}</ref>

<ref name="medicaid_cancer_continu">{{cite journal |title=The Affordable Care Act's Medicaid Expansion and Impact Along the Cancer-Care Continuum: A Systematic Review |year=2020 |doi=10.1093/jnci/djaa043 |last1=Moss |first1=Haley A. |last2=Wu |first2=Jenny |last3=Kaplan |first3=Samantha J. |last4=Zafar |first4=S Yousuf |journal=JNCI: Journal of the National Cancer Institute |volume=112 |issue=8 |pages=779–791 |pmid=32277814 |pmc=7825479}}</ref>

<ref name="ACA_DCE_2017">{{cite journal |title=Impact of the Affordable Care Act's Dependent Coverage Expansion on the Health Care and Health Status of Young Adults: What Do We Know So Far? |year=2018 |doi=10.1177/1077558716682171 |last1=Breslau |first1=Joshua |last2=Stein |first2=Bradley D. |last3=Han |first3=Bing |last4=Shelton |first4=Shoshanna |last5=Yu |first5=Hao |journal=Medical Care Research and Review |volume=75 |issue=2 |pages=131–152 |pmid=29148321 |pmc=5696114}}</ref>

<ref name="ACA_low_income">{{cite journal |title=The Affordable Care Act's Impacts on Access to Insurance and Health Care for Low-Income Populations |year=2017 |doi=10.1146/annurev-publhealth-031816-044555 |last1=Kominski |first1=Gerald F. |last2=Nonzee |first2=Narissa J. |last3=Sorensen |first3=Andrea |journal=Annual Review of Public Health |volume=38 |pages=489–505 |pmid=27992730 |pmc=5886019}}</ref>

<ref name="ACA_APM_Ortho">{{cite journal |title=Alternative Payment Models in Total Joint Arthroplasty Under the Affordable Care Act |year=2019 |doi=10.2106/JBJS.RVW.18.00061 |last1=Cizmic |first1=Zlatan |last2=Novikov |first2=David |last3=Feng |first3=James |last4=Iorio |first4=Richard |last5=Meftah |first5=Morteza |journal=JBJS Reviews |volume=7 |issue=3 |pages=e4 |pmid=30870316 |s2cid=78092576}}</ref>

<ref name="ACA_TOC_2017">{{cite journal |title=The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review |year=2017 |last1=Kamermayer |first1=A. K. |last2=Leasure |first2=A. R. |last3=Anderson |first3=L. |journal=Dimensions of Critical Care Nursing |volume=36 |issue=6 |pages=311–316 |doi=10.1097/DCC.0000000000000266 |pmid=28976480 |s2cid=23862010}}</ref>

<ref name="APM_diabetes">{{cite journal |title=The Impact of New Payment Models on Quality of Diabetes Care and Outcomes |year=2016 |doi=10.1007/s11892-016-0743-5 |last1=McGinley |first1=Erin L. |last2=Gabbay |first2=Robert A. |journal=Current Diabetes Reports |volume=16 |issue=6 |page=51 |pmid=27091445 |s2cid=25295047}}</ref>

<ref name="ACA_HIV">{{cite journal |title=Current and (Potential) Future Effects of the Affordable Care Act on HIV Prevention |year=2016 |doi=10.1007/s11904-016-0306-z |last1=Viall |first1=Abigail H. |last2=McCray |first2=Eugene |last3=Mermin |first3=Jonathan |last4=Wortley |first4=Pascale |journal=Current HIV/AIDS Reports |issn=1548-3576 |lccn=2004212063 |publisher=Springer Science+Business Media |oclc=54104357 |volume=13 |issue=2 |pages=95–106 |pmid=26894486 |s2cid=40527966}}</ref>

<ref name="ACA_diabetes">{{cite journal |title=The Affordable Care Act and Diabetes Diagnosis and Care: Exploring the Potential Impacts |year=2016 |doi=10.1007/s11892-016-0712-z |last1=Myerson |first1=Rebecca |last2=Laiteerapong |first2=Neda |journal=Current Diabetes Reports |volume=16 |issue=4 |page=27 |pmid=26892908 |pmc=4807352}}</ref>

<ref name="ACA_HVBP_2020">{{cite journal |title=Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review |year=2020 |doi=10.1097/MLR.0000000000001354 |pmid=32692140 |last1=Hong |first1=Y. R. |last2=Nguyen |first2=O. |last3=Yadav |first3=S. |last4=Etzold |first4=E. |last5=Song |first5=J. |last6=Duncan |first6=R. P. |last7=Turner |first7=K. |journal=Medical Care |volume=58 |issue=8 |pages=734–743 |s2cid=220672544}}</ref>

<ref name="ACA_cancer_10yr">{{cite journal |title=The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years |year=2020 |doi=10.3322/caac.21604 |last1=Zhao |first1=Jingxuan |last2=Mao |first2=Ziling |last3=Fedewa |first3=Stacey A. |last4=Nogueira |first4=Leticia |last5=Yabroff |first5=K. Robin |last6=Jemal |first6=Ahmedin |last7=Han |first7=Xuesong |journal=CA: A Cancer Journal for Clinicians |volume=70 |issue=3 |pages=165–181 |issn=1542-4863 |lccn=55030061 |oclc=1044790 |pmid=32202312 |s2cid=214616995}}</ref>

<ref name="ACA_ryan_HIV_2019">{{cite journal |title=The Ryan White HIV/AIDS Program after the Patient Protection and Affordable Care Act full implementation: a critical review of predictions, evidence, and future directions |year=2019 |pmid=31634860 |last1=Ginossar |first1=T. |last2=Oetzel |first2=J. |last3=Van Meter |first3=L. |last4=Gans |first4=A. A. |last5=Gallant |first5=J. E. |journal=Topics in Antiviral Medicine |publisher=International Antiviral Society-USA |volume=27 |issue=3 |issn=2161-5853 |lccn=2011243333 |location=San Francisco |pages=91–100 |pmc=6892620}}</ref>

<ref name="ACA_HIV_90">{{cite journal |title=The Impact of ACA and Medicaid Expansion on Progress Toward UNAIDS 90-90-90 Goals |year=2019 |doi=10.1007/s11904-019-00429-6 |last1=Adamson |first1=Blythe |last2=Lipira |first2=Lauren |last3=Katz |first3=Aaron B. |journal=Current HIV/AIDS Reports |issn=1548-3576 |lccn=2004212063 | publisher = Springer Science+Business Media |oclc=54104357 |volume=16 |issue=1 |pages=105–112 |pmid=30762215 |s2cid=73454313}}</ref>

<ref name="ACA_mental_2017">{{cite journal |title=Insurance Coverage and Treatment Use Under the Affordable Care Act Among Adults With Mental and Substance Use Disorders |year=2017 |doi=10.1176/appi.ps.201600182 |last1=Saloner |first1=Brendan |last2=Bandara |first2=Sachini |last3=Bachhuber |first3=Marcus |last4=Barry |first4=Colleen L. |issn=1557-9700 |publisher=American Psychiatric Association |journal=Psychiatric Services |volume=68 |issue=6 |pages=542–548 |pmid=28093059|doi-access=free }}</ref>

<ref name="ACA_cancer_YA">{{cite journal |title=The Affordable Care Act and Cancer Care for Young Adults |year=2017 |doi=10.1097/PPO.0000000000000265 |last1=Han |first1=Xuesong |last2=Jemal |first2=Ahmedin |journal=The Cancer Journal |volume=23 |issue=3 |pages=194–198 |pmid=28537966}}</ref>

}}


==Further reading== ==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 |last=Barr |first=Donald A. |title=Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America |url={{google books |plainurl=y |id=yZLJrmNoEzkC}} |year=2011 |publisher=JHU Press |isbn=978-1-4214-0218-5}}
* {{cite journal |publisher=University of Chicago Press |last1=Bossaler |first1=Jenny S. |title=Access to affordable care through public libraries |journal=The Library Quarterly |date=April 2016 |volume=86 |issue=2 |pages=193–212 |issn=0024-2519| jstor=26561661 |oclc=01755858 |doi=10.1086/685400|s2cid=147627006 }}
* {{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 |title=CCH's Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact |location=Chicago, IL |publisher=Wolters Kluwer Law & Business |url={{google books |plainurl=y |id=tCTt0sq2vaEC}} |year=2010 |isbn=978-0-8080-2287-9}} Two volumes: This book contains an editorially enhanced version of the Patient Protection and Affordable Care Act that integrates in place changes made to it by the Reconciliation Act of 2010. ... A website, www.mediregs.com/cchhealthreform, has been created to expand access to key legislative materials.
* {{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 journal |last1=Fang |first1=Hanming |last2=Krueger |first2=Dirk |date=2022 |title=The Affordable Care Act After a Decade: Its Impact on the Labor Market and the Macro Economy |doi=10.3386/w29240 |journal=Annual Review of Economics |issn=1941-1391 |lccn=2008214322 |publisher=National Bureau of Economic Research | location = Cambridge MA |oclc=190859329 |volume=14 |issue=1|doi-access=free }}
* {{cite book | author = John E. McDonough | title = Inside National Health Reform | publisher = University of California Press | year = 2011 | month = September | isbn = 9780520270190 }}
* {{cite book |last=Feldman |first=Arthur M. |title=Understanding Health Care Reform: Bridging the Gap Between Myth and Reality |url={{google books |plainurl=y |id=dSszUQPKSZIC}} | archive-url = https://archive.org/details/understandinghea0000feld | archive-date = 2022-06-16 |orig-date=2011 |publisher=CRC Press |year =2012 |isbn=978-1-4398-7948-1}}
*
* {{cite book |last1=Jacobs |first1=Lawrence R. |first2=Theda |last2=Skocpol |title=Health Care Reform and American Politics |url={{google books |plainurl=y |id=VcsmJybD32wC}} |year=2010 |publisher=Oxford University Press |isbn=978-0-19-978142-3}}
;Preliminary CBO documents
* {{cite book |first=John E. |last=McDonough |title=Inside National Health Reform |url={{google books |plainurl=y |id=e1Z6D-K9Rx8C}} |publisher=University of California Press |date=August 2, 2011 |isbn=978-0-520-27019-0}}
* − December 19, 2009
* {{cite book |last=Brill |first=Steven |author-link=Steven Brill (journalist) |title=America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System |url={{google books |plainurl=y |id=hnAOBAAAQBAJ}} |publisher=Random House |date=January 5, 2015 |isbn=978-0-8129-9695-1}}
* {{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 |website=United States. Congressional Budget Office |date=July 24, 2012 |archive-url=https://web.archive.org/web/20120727001632/http://cbo.gov/publication/43471 |format=Cost estimate |archive-date=July 27, 2012 |access-date=July 27, 2012}}
* {{cite web |first=Douglas W. |last=Elmendorf |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 |website=United States. Congressional Budget Office |archive-url=https://web.archive.org/web/20091205173644/http://www.cbo.gov/ftpdocs/107xx/doc10781/11-30-Premiums.pdf |archive-date=December 5, 2009 |date=November 30, 2009 |access-date=June 29, 2012}}
* {{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 |website=United States. Congressional Budget Office |archive-url=https://web.archive.org/web/20120303101517/http://cbo.gov/publication/41472 |archive-date=March 3, 2012 |date=May 26, 2011 |access-date=April 1, 2012}}
* {{cite journal |url=http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2013/dec/1718_glied_how_states_stand_gain_lose_medicaid_expansion_ib_v2.pdf |title=How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion |date=December 2013 |publisher=The Commonwealth Fund |author1=Glied, Sherry |author2=Ma, Stephanie |journal=Issue Brief |volume=32 |pages=1–12 |pmid=24344468 |author-link1=Sherry Glied |access-date=February 20, 2016}}
* {{cite journal |title=Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act |journal=] |author=Jost, Timothy |date=February 24, 2014 |publisher=Project HOPE |location=Washington, DC |issn=1544-5208 |oclc=07760874 |doi=10.1377/forefront.20140224.037390}}
* {{cite web |title=Multi-state plans under the Affordable Care Act |author1=Riley, Trish |author2=Thorpe, Jane Hyatt |date=2012 |location=The George Washington University |publisher=School of Public Health and Health Services |work=Department of Health Policy |url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130626114302/http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |archive-date=June 26, 2013 }}
* {{cite web |title=Following The Affordable Care Act |website=Health Affairs |oclc=07760874 |issn=1544-5208 |url=https://www.healthaffairs.org/topic/bms010 |access-date=August 10, 2019}}
* {{cite web |title=Pre-Affordable Care Act (2011 Archived) Health Insurance Consumer Guides for the Fifty States From Georgetown University Health Policy Institute (Can be used to explore the pre-ACA health insurance system) |url=http://www.healthinsuranceinfo.net/guides_map.htm#altList |archive-url=https://web.archive.org/web/20110429193146/http://www.healthinsuranceinfo.net/guides_map.htm#altList |archive-date=April 29, 2011 |access-date=Apr 29, 2011}}
* {{cite book |last=Mettler |first=Suzanne |year= 2011 |title=The Submerged State: How Invisible Government Policies Undermine American Democracy |publisher=University of Chicago Press |isbn=9780226521664 |oclc=928901062}}
* {{cite web |last1=Mettler |first1=Suzanne |others = Society Pages |date=April 17, 2012|title=The Submerged State |website = Office Hours podcast | url = https://archive.org/details/podcast_office-hours_suzanne-mettler-on-the-submerg_1000365943260 | quote = Identifier 1000365943260}}
* {{cite journal |last1=Jacobs |first1=Lawrence R. |last2=Mettler |first2=Suzanne |date=2020 |title=What Health Reform Tells Us about American Politics |journal=Journal of Health Politics, Policy and Law |volume=45 |issue=4 |pages=581–593 |issn=0361-6878 |lccn=76646971 |oclc=2115780 |pmid=32186336 |doi=10.1215/03616878-8255505|s2cid=212752729 }}

===Preliminary CBO documents===

* . United States. Congressional Budget Office December 19, 2009. (Cost estimate)
** 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) ** 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) ** 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> * , United States. Congressional Budget Office. November 18, 2009. (Cost estimate)<br /><small>(The additional and related CBO reporting that follows can be accessed from the above link)</small>
** Estimated Distribution Of Individual Mandate Penalties (November 20, 2009) ** 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 Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009)
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** Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009) ** Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009)


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


* . April 22, 2010.
;] (CMS) Estimates of the impact of H.R. 3590
*. December 10, 2009. * . April 22, 2010.

*. December 10, 2009.
===CMS Estimates of the impact of H.R. 3590===

* . December 10, 2009.
* . December 10, 2009.

===Senate Finance Committee meetings===

; also available from


==External links== ==External links==
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* – 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
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Latest revision as of 06:04, 31 December 2024

U.S. federal statute also known as Obamacare "Obamacare" redirects here. For the song, see Obamacare (song).

Affordable Care Act
Great Seal of the United States
Long titleAn Act Entitled The Patient Protection and Affordable Care Act
Acronyms (colloquial)ACA, PPACA
NicknamesObamacare, Affordable Care Act, Health Insurance Reform, Healthcare Reform
Enacted bythe 111th United States Congress
EffectiveMarch 23, 2010; 14 years ago (2010-03-23)
Most major provisions phased in by January 2014; remaining provisions phased in by 2020; penalty enforcing individual mandate set at $0 starting 2019
Citations
Public law111–148
Statutes at Large124 Stat. 119 through 124 Stat. 1025 (906 pages)
Codification
Acts amendedPublic Health Service Act
Legislative history
  • Introduced in the House as the "Service Members Home Ownership Tax Act of 2009" (H.R. 3590) by Charles Rangel (D–NY) on September 17, 2009
  • Committee consideration by Ways and Means
  • Passed the House on November 7, 2009 (220–215)
  • Passed the Senate as the "Patient Protection and Affordable Care Act" on December 24, 2009 (60–39) with amendment
  • House agreed to Senate amendment on March 21, 2010 (219–212)
  • Signed into law by President Barack Obama on March 23, 2010
Major amendments
Health Care and Education Reconciliation Act of 2010
Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011
Tax Cuts and Jobs Act of 2017
United States Supreme Court cases

The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act (PPACA) and informally as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965. Most of the act's provisions are still in effect.

The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.

The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to changes to individual insurance markets. Both received new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office (CBO) reports said that overall these provisions reduced the budget deficit, that repealing ACA would increase the deficit, and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.

The act largely retained the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled. Insurers were made to accept all applicants without charging based on preexisting conditions or demographic status (except age). To combat the resultant adverse selection, the act mandated that individuals buy insurance (or pay a monetary penalty) and that insurers cover a list of "essential health benefits".

Before and after enactment the ACA faced strong political opposition, calls for repeal and legal challenges. In National Federation of Independent Business v. Sebelius, the Supreme Court ruled that states could choose not to participate in the law's Medicaid expansion, but upheld the law as a whole. The federal health insurance exchange, HealthCare.gov, faced major technical problems at the beginning of its rollout in 2013. Polls initially found that a plurality of Americans opposed the act, although its individual provisions were generally more popular. By 2017, the law had majority support. The Tax Cuts and Jobs Act of 2017 set the individual mandate penalty at $0 starting in 2019 due to its overall unpopularity and to reduce the federal budget deficit.

Provisions

See also: Provisions of the Patient Protection and Affordable Care Act
The President and White House staff react to the House of Representatives passing the bill on March 21, 2010.
Jim Clyburn and Nancy Pelosi celebrate after the House passes the amended bill on March 21.

ACA amended the Public Health Service Act of 1944 and inserted new provisions on affordable care into Title 42 of the United States Code. The individual insurance market was radically overhauled, and many of the law's regulations applied specifically to this market, while the structure of Medicare, Medicaid, and the employer market were largely retained. Some regulations applied to the employer market, and the law also made delivery system changes that affected most of the health care system.

Further information: Commission on Key National Indicators

Insurance regulations: individual policies

All new individual major medical health insurance policies sold to individuals and families faced new requirements. The requirements took effect on January 1, 2014. They include:

  • Guaranteed issue prohibits insurers from denying coverage to individuals because of preexisting conditions.
  • States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
  • A partial community rating allows premiums to vary only by age and location, regardless of preexisting conditions. Premiums for older applicants can be no more than three times those for the youngest.
  • Essential health benefits must be provided. The National Academy of Medicine defines the law's "essential health benefits" as "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" and others rated Level A or B by the U.S. Preventive Services Task Force. In determining essential benefits, the law required that standard benefits should offer at least that of a "typical employer plan". States may require additional services.
  • Preventive care and screenings for women. "ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity". This mandate applies to all employers and educational institutions except for religious organizations. These regulations were included on the recommendations of the Institute of Medicine.
In 2012 Senator Sheldon Whitehouse created this summary to explain his view on the act.
  • Annual and lifetime coverage caps on essential benefits were banned.
  • Insurers are forbidden from dropping policyholders when they become ill.
  • All policies must provide an annual maximum out-of-pocket (MOOP) payment cap for an individual's or family's medical expenses (excluding premiums). After the MOOP payment is reached, all remaining costs must be paid by the insurer.
  • Preventive care, vaccinations and medical screenings cannot be subject to co-payments, co-insurance or deductibles. Specific examples of covered services include: mammograms and colonoscopies, wellness visits, gestational diabetes screening, HPV testing, STI counseling, HIV screening and counseling, contraceptive methods, breastfeeding support/supplies and domestic violence screening and counseling.
  • The law established four tiers of coverage: bronze, silver, gold and platinum. All categories offer essential health benefits. The categories vary in their division of premiums and out-of-pocket costs: bronze plans have the lowest monthly premiums and highest out-of-pocket costs, while platinum plans are the reverse. The percentages of health care costs 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).
  • Insurers are required to implement an appeals process for coverage determination and claims on all new plans.
  • Insurers must spend at least 80–85% of premium dollars on health costs; rebates must be issued if this is violated.

Individual mandate

The individual mandate required everyone to have insurance or pay a penalty. The mandate and limits on open enrollment were designed to avoid the insurance death spiral, minimize the free rider problem and prevent the healthcare system from succumbing to adverse selection.

The mandate was intended to increase the size and diversity of the insured population, including more young and healthy participants to broaden the risk pool, spreading costs.

Among the groups who were not subject to the individual mandate are:

  • Illegal immigrants. Estimated at 8 million, roughly a third of the 23 million projection, they are ineligible for insurance subsidies and Medicaid. They remain eligible for emergency services.
  • Medicaid-eligible citizens not enrolled in Medicaid.
  • Citizens whose insurance coverage would cost more than 8% of household income.
  • Citizens who live in states that opt-out of Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage.

The Tax Cuts and Jobs Act of 2017, set to $0 the penalty for not complying with the individual mandate, starting in 2019.

Exchanges

Main article: Health insurance marketplace

ACA mandated that health insurance exchanges be provided for each state. The exchanges are regulated, largely online marketplaces, administered by either federal or state governments, where individuals, families and small businesses can purchase private insurance plans. Exchanges first offered insurance for 2014. Some exchanges also provide access to Medicaid.

States that set up their own exchanges have some discretion on standards and prices. For example, states approve plans for sale, and thereby influence (through negotiations) prices. They can impose additional coverage requirements—such as abortion. Alternatively, states can make the federal government responsible for operating their exchanges.

Premium subsidies

Individuals whose household incomes are between 100% and 400% of the federal poverty level (FPL) are eligible to receive federal subsidies for premiums for policies purchased on an ACA exchange, provided they are not eligible for Medicare, Medicaid, the Children's Health Insurance Program, or other forms of public assistance health coverage, and do not have access to affordable coverage (no more than 9.86% of income for the employee's coverage) through their own or a family member's employer. Households below the federal poverty level are not eligible to receive these subsidies. Lawful Residents and some other legally present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for subsidies if they meet all other eligibility requirements. Married people must file taxes jointly to receive subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.

The subsidies for an ACA plan purchased on an exchange stop at 400% of the federal poverty level (FPL). According to the Kaiser Foundation, this results in a sharp "discontinuity of treatment" at 400% FPL, which is sometimes called the "subsidy cliff". After-subsidy premiums for the second lowest cost silver plan (SCLSP) just below the cliff are 9.86% of income in 2019.

Subsidies are provided as an advanceable, refundable tax credit.

The amount of subsidy is sufficient to reduce the premium for the second-lowest-cost silver plan (SCLSP) on an exchange to a sliding-scale percentage of income. The percentage is based on the percent of federal poverty level (FPL) for the household, and varies slightly from year to year. In 2019, it ranged from 2.08% of income (100%-133% FPL) to 9.86% of income (300%-400% FPL). The subsidy can be used for any plan available on the exchange, but not catastrophic plans. The subsidy may not exceed the premium for the purchased plan.

(In this section, the term "income" refers to modified adjusted gross income.)

Small businesses are eligible for a tax credit provided they enroll in the SHOP Marketplace.

Maximum net premium after subsidies (2019) for family of four
Income % of federal poverty level Premium cap as a share of income Income Maximum annual net premium after subsidy
(second-lowest-cost silver plan) 		Maximum out-of-pocket
133% 3.11% of income $33,383 $1,038 $5,200
150% 4.15% of income $37,650 $1,562 $5,200
200% 6.54% of income $50,200 $3,283 $5,200
250% 8.36% of income $62,750 $5,246 $12,600
300% 9.86% of income $75,300 $7,425 $15,800
400% 9.86% of income $100,400 $9,899 $15,800

a. In 2019, the federal poverty level was $25,100 for family of four (outside of Alaska and Hawaii).

b. If the premium for the second lowest cost silver plan (SLCSP) is greater than the amount in this column, the amount of the premium subsidy will be such that it brings the net cost of the SCLSP down to the amount in this column. Otherwise, there will be no subsidy, and the SLCSP premium will (of course) be no more than (usually less than) the amount in this column.

Note: The numbers in the table do not apply for Alaska and Hawaii.

Cost-sharing reduction subsidies

Main article: Cost sharing reductions subsidy

As written, ACA mandated that insurers reduce copayments and deductibles for ACA exchange enrollees earning less than 250% of the FPL. Medicaid recipients were not eligible for the reductions.

So-called cost-sharing reduction (CSR) subsidies were to be paid to insurance companies to fund the reductions. During 2017, approximately $7 billion in CSR subsidies were to be paid, versus $34 billion for premium tax credits.

The latter was defined as mandatory spending that does not require an annual Congressional appropriation. CSR payments were not explicitly defined as mandatory. This led to litigation and disruption later.

Risk management

ACA implemented multiple approaches to helping mitigate the disruptions to insurers that came with its many changes.

Risk corridors

The risk-corridor program was a temporary risk management device. It was intended to encourage reluctant insurers into ACA insurance market from 2014 to 2016. For those years the Department of Health and Human Services (DHHS) would cover some of the losses for insurers whose plans performed worse than they expected. Loss-making insurers would receive payments paid for in part by profit-making insurers. Similar risk corridors had been established for the Medicare prescription drug benefit.

While many insurers initially offered exchange plans, the program did not pay for itself as planned, losing up to $8.3 billion for 2014 and 2015. Authorization had to be given so DHHS could pay insurers from "general government revenues". However, the Consolidated Appropriations Act, 2014 (H.R. 3547) stated that no funds "could be used for risk-corridor payments". leaving the government in a potential breach of contract with insurers who offered qualified health plans.

Several insurers sued the government at the United States Court of Federal Claims to recover the funds believed owed to them under the Risk Corridors program. While several were summarily closed, in the case of Moda Health v the United States, Moda Health won a $214-million judgment in February 2017. Federal Claims judge Thomas C. Wheeler stated, "the Government made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, to say to , 'The joke is on you. You shouldn't have trusted us,' is hardly worthy of our great government." Moda Health's case was appealed by the government to the United States Court of Appeals for the Federal Circuit along with the appeals of the other insurers; here, the Federal Circuit reversed the Moda Health ruling and ruled across all the cases in favor of the government, that the appropriations riders ceded the government from paying out remain money due to the insurers. The Supreme Court reversed this ruling in the consolidated case, Maine Community Health Options v. United States, reaffirming as with Judge Wheeler that the government had a responsibility to pay those funds under the ACA and the use of riders to de-obligate its from those payments was illegal.

Reinsurance

The temporary reinsurance program is meant to stabilize premiums by reducing the incentive for insurers to raise premiums due to concerns about higher-risk enrollees. Reinsurance was based on retrospective costs rather than prospective risk evaluations. Reinsurance was available from 2014 through 2016.

Risk adjustment

Risk adjustment involves transferring funds from plans with lower-risk enrollees to plans with higher-risk enrollees. It was intended to encourage insurers to compete based on value and efficiency rather than by attracting healthier enrollees. Of the three risk management programs, only risk adjustment was permanent. Plans with low actuarial risk compensate plans with high actuarial risk.

Medicaid expansion

Main article: Medicaid coverage gap

ACA revised and expanded Medicaid eligibility starting in 2014. All U.S. citizens and legal residents with income up to 133% of the poverty line would qualify for coverage in any state that participated in the Medicaid program. Previously, states could set various lower thresholds for certain groups and were not required to cover adults without dependent children. The federal government was to pay 100% of the increased cost in 2014, 2015 and 2016; 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and all subsequent years. A 5% "income disregard" made the effective income eligibility limit for Medicaid 138% of the poverty level. However, the Supreme Court ruled in NFIB v. Sebelius that this provision of ACA was coercive, and that states could choose to continue at pre-ACA eligibility levels.

Medicare savings

Medicare reimbursements were reduced to insurers and drug companies for private Medicare Advantage policies that the Government Accountability Office and Medicare Payment Advisory Commission found to be excessively costly relative to standard Medicare; and to hospitals that failed standards of efficiency and care.

Taxes

Medicare taxes

Income from self-employment and wages of single individuals in excess of $200,000 annually are subjected to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to their total compensation), or $125,000 for a married person filing separately.

In ACA's companion legislation, the Health Care and Education Reconciliation Act of 2010, an additional tax of 3.8% was applied to unearned income, specifically the lesser of net investment income and the amount by which adjusted gross income exceeds the above income limits.

Excise taxes

ACA included an excise tax of 40% ("Cadillac tax") on total employer premium spending in excess of specified dollar amounts (initially $10,200 for single coverage and $27,500 for family coverage) indexed to inflation. This tax was originally scheduled to take effect in 2018, but was delayed until 2020 by the Consolidated Appropriations Act, 2016 and again to 2022. The excise tax on high-cost health plans was completely repealed as part of H.R.1865 - Further Consolidated Appropriations Act, 2020.

Excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well. The tax was repealed in late 2019.

SCHIP

The State Children's Health Insurance Program (CHIP) enrollment process was simplified.

Dependents

Beginning September 23, 2010, dependents were permitted to remain on their parents' insurance plan until their 26th birthday, including dependents who no longer lived with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.

Employer mandate

Businesses that employ fifty or more people but do not offer health insurance to their full-time employees are assessed additional tax if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the employer mandate. This provision was included to encourage employers to continue providing insurance once the exchanges began operating.

Delivery system reforms

The act includes delivery system reforms intended to constrain costs and improve quality. These include Medicare payment changes to discourage hospital-acquired conditions and readmissions, bundled payment initiatives, the Center for Medicare and Medicaid Innovation, the Independent Payment Advisory Board, and accountable care organizations.

Hospital quality

Health care cost/quality initiatives included incentives to reduce hospital infections, adopt electronic medical records, and to coordinate care and prioritize quality over quantity.

Bundled payments

Medicare switched from fee-for-service to bundled payments. A single payment was to be paid to a hospital and a physician group for a defined episode of care (such as a hip replacement) rather than separate payments to individual service providers.

Accountable care organizations

Main article: Accountable care organization

The Medicare Shared Savings Program (MSSP) was established by section 3022 of the Affordable Care Act. It is the program by which an accountable care organization interacts with the federal government, and by which accountable care organizations can be created. It is a fee-for-service model.

The Act allowed the creation of accountable care organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated care to Medicare patients. ACOs were allowed to continue using fee-for-service billing. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigation of chronic disease. Missing cost or quality benchmarks subjected them to penalties.

Unlike health maintenance organizations, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality-of-care goals.

Medicare drug benefit (Part D)

Medicare Part D participants received a 50% discount on brand name drugs purchased after exhausting their initial coverage and before reaching the catastrophic-coverage threshold. By 2020, the "doughnut hole" would be completely filled.

State waivers

From 2017 onwards, states can apply for a "waiver for state innovation" which allows them to conduct experiments that meet certain criteria. To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as ACA, covers at least as many residents and does not increase the federal deficit. These states can escape some of ACA's central requirements, including the individual and employer mandates and the provision of an insurance exchange. The state would 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 ACA, if they cannot be paid under the state plan.

Other insurance provisions

The Community Living Assistance Services and Supports Act (or CLASS Act) established a voluntary and public long-term care insurance option for employees, The program was abolished as impractical without ever having taken effect.

Consumer Operated and Oriented Plans (CO-OP), member-governed non-profit insurers, could start providing health care coverage, based on a 5-year federal loan. As of 2017, only four of the original 23 co-ops were still in operation.

Nutrition labeling requirements

Nutrition labeling requirements officially took effect in 2010, but implementation was delayed, and they actually took effect on May 7, 2018.

Legislative history

Main articles: Health care reform in the United States and Health care reform debate in the United States
President Obama signs the Patient Protection and Affordable Care Act on March 23, 2010.

ACA followed a long series of unsuccessful attempts by one party or the other to pass major insurance reforms. Innovations were limited to health savings accounts (2003), medical savings accounts (1996) or flexible spending accounts, which increased insurance options, but did not materially expand coverage. Health care was a major factor in multiple elections, but until 2009, neither party had the votes to overcome the other's opposition.

Individual mandate

The concept of an individual mandate goes back to at least 1989, when The Heritage Foundation, a conservative think-tank, proposed an individual mandate as an alternative to single-payer health care. It was championed for a time by conservative economists and Republican senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of free rider problems. Specifically, because the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.

President Bill Clinton proposed a major healthcare reform bill in 1993 that ultimately failed. Clinton negotiated a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997. The failed Clinton plan included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations. Republican senators proposed an alternative that would have required individuals, but not employers, to buy insurance.

John Chafee

The 1993 Republican Health Equity and Access Reform Today (HEART) Act, contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'. Advocates included prominent Republican senators such as John Chafee, Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond. The 1994 Republican Consumer Choice Health Security Act, initially contained an individual mandate with a penalty provision; however, author Don Nickles subsequently removed the mandate, stating, "government should not compel people to buy health insurance". At the time of these proposals, Republicans did not raise constitutional issues; Mark Pauly, who helped develop a proposal that included an individual mandate for George H. W. Bush, remarked, "I don't remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax."

Mitt Romney's Massachusetts went from 90% of its residents insured to 98%, the highest rate in the nation.

In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Governor Mitt Romney used a line-item veto on some provisions, and the Democratic legislature overrode some of his changes (including the mandate). Romney's implementation of the 'Health Connector' exchange and individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 presidential campaign, Senator Jim DeMint 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 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."

In 2007 Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which featured an individual mandate and state-based, regulated insurance markets called "State Health Help Agencies". The bill attracted bipartisan support, but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate.

By 2008 many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill and that it took ideas from the Massachusetts reforms.

Academic foundation

A driving force behind Obama's healthcare reform was Peter Orszag, Director of the Office of Management and Budget. Obama called Orszag his "healthcare czar" because of his knowledge of healthcare reform. Orszag had previously been director of the Congressional Budget Office, and under his leadership the agency had focused on using cost analysis to create an affordable and effective approach to health care reform. Orszag claimed that healthcare reform became Obama's top agenda item because he wanted it to be his legacy. According to an article by Ryan Lizza in The New Yorker, the core of "the Obama budget is Orszag's belief ...a government empowered with research on the most effective medical treatments". Obama bet "his presidency on Orszag's thesis of comparative effectiveness." Orszag's policies were influenced by an article in The Annals of Internal Medicine co-authored by Elliott S. Fisher, David Wennberg and others. The article presented strong evidence based on the co-authors' research that numerous procedures, therapies and tests were being delivered with scant evidence of their medical value. If those procedures and tests could be eliminated, this evidence suggested, medical costs might provide the savings to give healthcare to the uninsured population. After reading a New Yorker article that used the "Dartmouth findings" to compare two counties in Texas with enormous variations in Medicare costs using hard data, Obama directed that his entire staff read it. More than anything else, the Dartmouth data intrigued Obama since it gave him an academic rationale for reshaping medicine.

The concept of comparing the effectiveness of healthcare options based on hard data ("comparative effectiveness" and "evidence-based medicine") was pioneered by John E. Wennberg, founder of The Dartmouth Institute, co-founder of The Foundation for Informed Medical Decision Making and senior advisor to Health Dialog Inc., a venture that he and his researchers created to help insurers implement the Dartmouth findings.

Healthcare debate, 2008–10

See also: Health care reforms proposed during the Obama administration

Healthcare reform was a major topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, Hillary Clinton and the eventual nominee, 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 proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a subsidy without a mandate.

During the general election, Obama said fixing healthcare would be one of his top four priorities as president. Obama and his opponent, Senator John McCain, both proposed health insurance reforms, though their plans differed. McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2 million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost.

President Obama addressing Congress regarding healthcare reform, September 9, 2009

Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform. By July, a series of bills were approved by committees within the House of Representatives. On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a proposal. This group—in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe—met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the foundation of a Senate bill.

Congressional Democrats and health policy experts, such as MIT economics professor Jonathan Gruber and David Cutler, argued that guaranteed issue would require both community rating and an individual mandate to ensure that adverse selection or "free riding" would not result in an insurance "death spiral". They chose this approach after concluding that filibuster-proof support in the Senate was not present for more progressive plans such as single-payer. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate Majority Leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill's drafters hoped to garner the necessary votes.

However, following the incorporation of an individual mandate into the proposal, Republicans threatened to filibuster any bill that contained it. Senate Minority Leader Mitch McConnell, who led the Republican response, concluded Republicans should not support the bill.

Republican senators, including those who had supported earlier proposals with a similar mandate, began to describe the mandate as "unconstitutional". Journalist Ezra Klein wrote in The New Yorker, "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."

The reform attracted attention from lobbyists, including deals between lobby groups and the advocates to win the support of groups who had opposed past proposals.

Tea Party protesters at the Taxpayer March on Washington, September 12, 2009

During the August 2009 summer congressional recess, many members went back to their districts and held town hall meetings on the proposals. The nascent Tea Party movement organized protests and many conservative groups and individuals attended the meetings to oppose the proposed reforms. Threats were made against members of Congress over the course of the debate.

In September 2009 Obama delivered another speech to a joint session of Congress supporting the negotiations. On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.

Senate

The Senate began work on its own proposals while the House was still working. The United States Constitution requires all revenue-related bills to originate in the House. To formally comply with this requirement, the Senate repurposed H.R. 3590, a bill regarding housing tax changes for service members. It had been passed by the House as a revenue-related modification to the Internal Revenue Code. The bill became the Senate's vehicle for its healthcare reform proposal, discarding the bill's original content. The bill ultimately incorporated elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican Senate minority vowing to filibuster, 60 votes would be necessary to pass the Senate. At the start of the 111th Congress, Democrats had 58 votes. The Minnesota Senate election was ultimately won by Democrat Al Franken, making 59. Arlen Specter switched to the Democratic party in April 2009, giving them 60 seats, enough to end a filibuster.

Negotiations were undertaken attempting to satisfy moderate Democrats and to bring Republican senators aboard; particular attention was given to Republicans Bennett, Enzi, Grassley and Snowe.

After the Finance Committee vote on October 15, negotiations turned to moderate Democrats. Senate Majority Leader Harry Reid focused on satisfying centrists. The holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat Ben Nelson. Lieberman's demand that the bill not include a public option was met, although supporters won various concessions, including allowing state-based public options such as Vermont's failed Green Mountain Care.

Senate vote by state   Democratic yes (58)   Independent yes (2)   Republican no (39)   Republican not voting (1)

The White House and Reid addressed Nelson's concerns during a 13-hour negotiation with 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 Medicaid reimbursement for Nebraska. The latter half of the compromise was derisively termed the "Cornhusker Kickback" and was later removed.

On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster. The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except Jim Bunning, who did not vote). The bill was endorsed by the American Medical Association and AARP.

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the recently deceased Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters. Additionally, the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of the bill.

House

House vote by congressional district   Democratic yes (219)   Democratic no (34)   Republican no (178)   No representative seated (4)
House vote by agreement.  Yes (219)   No (212)   No representative seated (4)
House vote by party   Democratic yes (219)   Democratic no (34)   Republican no (178)   No representative seated (4)


With Democrats no longer able to get the 60 votes to break a filibuster in the Senate, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill, but House Speaker Nancy Pelosi pushed back, dismissing more moderate reform as "Kiddie Care".

Obama remained insistent on comprehensive reform. The news that Anthem in California intended to raise premium rates for its patients by as much as 39% gave him new evidence of the need for reform. On February 22, he laid out a "Senate-leaning" proposal to consolidate the bills. He held a meeting with both parties' leaders on February 25. The Democrats decided the House would pass the Senate's bill, to avoid another Senate vote.

House Democrats had expected to be able to negotiate changes in a House–Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass 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. They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.

Per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass ACA in the first place; the bill had inherently non-budgetary regulations. Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."

The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their concerns, but they could not address abortion in the reconciliation bill as it would be non-budgetary. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment to continue banning the use of federal funds for abortion. This won the support of Stupak and members of his group and assured the bill's passage. The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. It passed the second bill, by 220–211, the same day (with the Senate passing this bill via reconciliation by 56-43 a few days later). The day after the passage of ACA, March 22, Republicans introduced legislation to repeal it. Obama signed ACA into law on March 23, 2010.

Post-enactment

Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act more than sixty times.

The Tax Cuts and Jobs Act of 2017 eliminated the fine for violating the individual mandate, starting in 2019. (The requirement itself is still in effect.) In 2019 Congress repealed the so-called "Cadillac" tax on health insurance benefits, an excise tax on medical devices, and the Health Insurance Tax.

The American Rescue Plan Act of 2021, enacted during the COVID-19 pandemic in the United States, expanded subsidies for marketplace health plans. A continuation of these subsidies was introduced as part of the Inflation Reduction Act of 2022.

Impact

U.S. health insurance coverage by source in 2016. CBO estimated ACA/Obamacare was responsible for 23 million persons covered via exchanges and Medicaid expansion.
This chart illustrates several aspects of the Affordable Care Act, including number of persons covered, cost before and after subsidies, and public opinion.

Coverage

See also: Health insurance coverage in the United States

The law caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% from January to June 2016. The uninsured rate dropped in every congressional district in the U.S. from 2013 to 2015. The Congressional Budget Office reported in March 2016 that approximately 12 million people were covered by the exchanges (10 million of whom received subsidies) and 11 million added to Medicaid. Another million were covered by ACA's "Basic Health Program", for a total of 24 million. CBO estimated that ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4 million for reductions in "employment-based coverage" and "non-group and other coverage".

The U.S. Department of Health and Human Services (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016; similarly, the Urban Institute found in 2016 that 19.2 million non-elderly Americans gained health insurance coverage from 2010 to 2015. In 2016, CBO estimated the uninsured at approximately 27 million people, or around 10% of the population or 7–8% excluding unauthorized immigrants.

States that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not had a 14.1% uninsured rate, among adults aged 18–64. As of December 2016 32 states (including Washington DC) had adopted the Medicaid extension.

A 2017 study found that the ACA reduced socioeconomic disparities in health care access.

The Affordable Care Act reduced the percent of Americans between 18 and 64 who were uninsured from 22.3 percent in 2010 to 12.4 percent in 2016. About 21 million more people have coverage ten years after the enactment of the ACA. Ten years after its enactment studies showed that the ACA also had a positive effect on health and caused a reduction in mortality.

Taxes

Excise taxes percentage 2015

Excise taxes from the Affordable Care Act raised $16.3 billion in fiscal year 2015. $11.3 billion came from an excise tax placed directly on health insurers based on their market share. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs.

The Individual mandate tax was $695 per individual or $2,085 per family at a minimum, reaching as high as 2.5% of household income (whichever was higher). The tax was set to $0 beginning in 2019.

In the fiscal year 2018, the individual and employer mandates yielded $4 billion each. Excise taxes on insurers and drug makers added $18 billion. Income tax surcharges produced 437 billion.

ACA reduced income inequality measured after taxes, due to the income tax surcharges and subsidies. CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. The tax subsidy for the employer market, was approximately $1,700 per person in 2016, or $266 billion total.

Insurance exchanges

Main article: Health insurance marketplace

As of August 2016, 15 states operated their own health insurance marketplace. Other states either used the federal exchange, or operated in partnership with or supported by the federal government. By 2019, 12 states and Washington DC operated their own exchanges.

Medicaid expansion in practice

ACA Medicaid expansion by state.   Not adopted   Adopted   Implemented

As of December 2019, 37 states (including Washington DC) had adopted the Medicaid extension. Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while the others had a 14.1% uninsured rate, among adults aged 18 to 64. Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they did not expand Medicaid under ACA, several states rejected the option. Over half the national uninsured population lived in those states.

The Centers for Medicare and Medicaid Services (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 to 10 million people had gained Medicaid coverage, mostly low-income adults. The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered because of states that rejected the Medicaid expansion.

In many states income thresholds were significantly below 133% of the poverty line. Many states did not make Medicaid available to childless adults at any income level. Because subsidies on exchange insurance plans were not available to those below the poverty line, such individuals had no new options. For example, in Kansas, where only non-disabled adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance. Absent children, non-disabled adults were not eligible for Medicaid there.

Studies of the impact of Medicaid expansion rejections calculated that up to 6.4 million people would have too much income for Medicaid but not qualify for exchange subsidies. Several states argued that they could not afford the 10% contribution in 2020. Some studies suggested rejecting the expansion would cost more due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,

A 2016 study found that residents of Kentucky and Arkansas, which both expanded Medicaid, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period. Kentucky opted for increased managed care, while Arkansas subsidized private insurance. Later Arkansas and Kentucky governors proposed reducing or modifying their programs. From 2013 to 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas.

A 2016 DHHS study found that states that expanded Medicaid had lower premiums on exchange policies, because they had fewer low-income enrollees, whose health on average is worse than that of those with higher income.

In September 2019, the Census Bureau reported that states that expanded Medicaid under the ACA had considerably lower uninsured rates than states that did not. For example, for adults between 100% and 399% of poverty level, the uninsured rate in 2018 was 12.7% in expansion states and 21.2% in non-expansion states. Of the 14 states with uninsured rates of 10% or greater, 11 had not expanded Medicaid. The drop in uninsured rates due to expanded Medicaid has broadened access to care among low-income adults, with post-ACA studies indicating an improvement in affordability, access to doctors, and usual sources of care.

A study using national data from the Health Reform Monitoring Survey determined that unmet need due to cost and inability to pay medical bills significantly decreased among low-income (up to 138% FPL) and moderate-income (139-199% FPL) adults, with unmet need due to cost decreasing by approximately 11 percentage points among low-income adults by the second enrollment period. Importantly, issues with cost-related unmet medical needs, skipped medications, paying medical bills, and annual out-of-pocket spending have been significantly reduced among low-income adults in Medicaid expansion states compared to non-expansion states.

As well, expanded Medicaid has led to a 6.6% increase in physician visits by low-income adults, as well as increased usage of preventative care such as dental visits and cancer screenings among childless, low-income adults. Improved health care coverage due to Medicaid expansion has been found in a variety of patient populations, such as adults with mental and substance use disorders, trauma patients, cancer patients, and people living with HIV. Compared to 2011–13, in 2014 there was a 5.4 percentage point reduction in the uninsured rate of adults with mental disorders (from 21.3% to 15.9%) and a 5.1 percentage point reduction in the uninsured rate of adults with substance use disorders (from 25.9% to 20.8%); with increases in coverage occurring primarily through Medicaid. Use of mental health treatment increased by 2.1 percentage points, from 43% to 45.1%.

Among trauma patients nationwide, the uninsured rate has decreased by approximately 50%. Adult trauma patients in expansion states experienced a 13.7 percentage point reduction in uninsured rates compared to adult trauma patients in non-expansion states, and an accompanying 7.4 percentage point increase in discharge to rehabilitation. Following Medicaid expansion and dependent coverage expansion, young adults hospitalized for acute traumatic injury in Maryland experienced a 60% increase in rehabilitation, 25% reduction in mortality, and a 29.8% reduction in failure-to-rescue. Medicaid expansion's swift impact on cancer patients was demonstrated in a study using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that evaluated more than 850,000 patients diagnosed with breast, lung, colorectal, prostate cancer, or thyroid cancer from 2010 to 2014. The study found that a cancer diagnosis in 2014 was associated with a 1.9 percentage-point absolute and 33.5% relative decrease in uninsured rates compared to a diagnosis made between 2010 and 2013. Another study, using Surveillance, Epidemiology, and End Results (SEER) Program data from 2010 to 2014, found that Medicaid expansion was associated with a 6.4% net increase in early stage (in situ, local, or regional) diagnoses of all cancers combined.

Data from the Centers for Disease and Prevention's (CDC) Medical Monitoring Project demonstrated that between 2009 and 2012, approximately 18% of people living with HIV (PLWH) who were actively receiving HIV treatment were uninsured and that at least 40% of HIV-infected adults receiving treatment were insured through Medicaid or Medicare, programs they qualified for only once their disease was advanced enough to be covered as a disability under Social Security. Expanded Medicaid coverage of PLWH has been positively associated with health outcomes such as viral suppression, retention of care, hospitalization rates, and morbidity at the time of hospitalization. An analysis of Behavioral Risk Factor Surveillance System (BRFSS) survey data found a 2.8% annual increase in viral suppression rates among all PLWH from 2010 to 2015 due to Medicaid expansion. In Nebraska, PLWH newly covered by Medicaid expansion in 2013-14 were four times more likely to be virally suppressed than PLWH who were eligible but remained uninsured. As an early adopter of Medicaid expansion, Massachusetts found a 65% rate of viral suppression among all PLWH and an 85% rate among those retained in healthcare in 2014, both substantially higher than the national average.

An analysis of hospital discharge data from 2012 to 2014 in four Medicaid expansion states and two non-expansion states revealed hospitalizations of uninsured PLWH fell from 13.7% to 5.5% in the four expansion states and rose from 14.5% to 15.7% in the two non-expansion states. Importantly, uninsured PLWH were 40% more likely to die in the hospital than insured PLWH. Other notable health outcomes associated with Medicaid expansion include improved glucose monitoring rates for patients with diabetes, better hypertension control, and reduced rates of major post-operative morbidity.

A July 2019 study by the National Bureau of Economic Research (NBER) indicated that states enacting Medicaid expansion exhibited statistically significant reductions in mortality rates. From that study, states that took Medicaid expansion "saved the lives of at least 19,200 adults aged 55 to 64 over the four-year period from 2014 to 2017." Further, 15,600 older adults died prematurely in the states that did not enact Medicaid expansion in those years according to the NBER research. "The lifesaving impacts of Medicaid expansion are large: an estimated 39 to 64 percent reduction in annual mortality rates for older adults gaining coverage."

Due to many states' failure to expand, many Democrats co-sponsored the proposed 2021 Cover Now Act that would allow county and municipal governments to fund Medicaid expansion.

Gaps in expansion

Despite the significant increase in access to insurance coverage and healthcare services across the board, the ACA's Medicaid expansion has not fully addressed problems of economic equity. Critics argue that Medicaid expansion has not reduced cost-sharing by a significant margin, as the amount households paid out of pocket for healthcare over the past ten years (in the form of deductibles, co-payments, etc.) rose by 77%. Additionally, 30% of providers deny Medicaid patients, which affects the accessibility of quality care. This increase in denial may be in part because providers receive 62 cents from Medicaid for every dollar received from private insurers. Studies on insurance rates show that economic inequality still persists: a significantly higher proportion of those with income greater than 100% but less than 200% of the federal poverty level were uninsured from 2010 to 2015 than of those with income greater than 200% of the federal poverty level. This is exacerbated by the 2012 Supreme Court decision allowing states to opt out of Medicaid, since many of the states that have opted out have more vulnerable populations, with large numbers of minorities or low-income people.

Medicaid patients have also reported receiving "second-class" treatment compared to privately insured patients, with longer wait times and lower quality of care.

Medicaid expansion by state

State or territory Status of expansion Date of expansion Health insurance marketplace Notes
 Alabama No expansion N/A HealthCare.gov
 Alaska In effect September 1, 2015 HealthCare.gov
 Arizona In effect January 1, 2014 HealthCare.gov
 Arkansas In effect January 1, 2014 Arkansas Health Connector, HealthCare.gov State implemented expansion through a "private option" under a Section 1115 waiver through the Arkansas Health Care Independence Program (HCIP). Work requirement added in 2018 through Arkansas Works. Work requirement removed in 2021. Currently only state using "private option" as of 2022.
 California In effect January 1, 2014 Covered California, HealthCare.gov
 Colorado In effect January 1, 2014 Connect for Health Colorado, HealthCare.gov
 Connecticut In effect January 1, 2014 Access Health CT, HealthCare.gov
 Delaware In effect January 1, 2014 HealthCare.gov
 Florida No expansion N/A HealthCare.gov
 Georgia No expansion N/A HealthCare.gov
 Hawaii In effect January 1, 2014 Hawaii Health Connector, HealthCare.gov
 Idaho In effect January 1, 2020 Your Health Idaho, HealthCare.gov Enacted through 2018 Idaho Proposition 2.
 Illinois In effect January 1, 2014 Illinois Health Benefits Exchange, HealthCare.gov
 Indiana In effect February 1, 2015 HealthCare.gov
 Iowa In effect January 1, 2014 HealthCare.gov
 Kansas No expansion N/A HealthCare.gov
 Kentucky In effect January 1, 2014 Kynect, HealthCare.gov Enacted through gubernatorial executive order
 Louisiana In effect July 1, 2016 HealthCare.gov Enacted through gubernatorial executive order
 Maine In effect January 10, 2019 HealthCare.gov Enacted through 2017 Maine Question 2, but implementation was delayed due to gubernatorial opposition. coverage retroactive to 7/2/2018.
 Maryland In effect January 1, 2014 Maryland Health Connection, HealthCare.gov
 Massachusetts In effect January 1, 2014 Massachusetts Health Insurance Connector, HealthCare.gov
 Michigan In effect April 1, 2014 HealthCare.gov
 Minnesota In effect January 1, 2014 MNsure, HealthCare.gov
 Mississippi No expansion N/A HealthCare.gov
 Missouri In effect October 1, 2021 HealthCare.gov Enacted through 2020 Missouri Amendment 2, but applications were denied until October 1, 2021, due to legislative opposition to the amendment. coverage retroactive to 7/1/2021.
 Montana In effect January 1, 2016 HealthCare.gov Legislature enacted expansion with a work requirement; work requirement was due to take effect in January 2020 but never received federal approval. Current expansion is extended to June 2025.
 Nebraska In effect October 1, 2020 HealthCare.gov enacted through 2018 Nebraska Initiative 427.
 Nevada In effect January 1, 2014 Nevada Health Link, HealthCare.gov
 New Hampshire In effect August 15, 2014 HealthCare.gov
 New Jersey In effect January 1, 2014 HealthCare.gov
 New Mexico In effect January 1, 2014 New Mexico Health Insurance Exchange, HealthCare.gov
 New York In effect January 1, 2014 NY State of Health, HealthCare.gov
 North Dakota In effect January 1, 2014 HealthCare.gov
 North Carolina Expansion pending June 2023 (expected) HealthCare.gov Legislature expanded Medicaid. Signed into law by Governor Roy Cooper. Expansion expected to go into effect when the state adopts a budget in June 2023.
 Ohio In effect January 1, 2014 HealthCare.gov
 Oklahoma In effect July 1, 2021 HealthCare.gov Enacted through 2020 Oklahoma State Question 802.
 Oregon In effect January 1, 2014 Cover Oregon (2012–2015), HealthCare.gov
 Pennsylvania In effect January 1, 2015 Pennie, HealthCare.gov
 Rhode Island In effect January 1, 2014 HealthSource RI, HealthCare.gov
 South Carolina No expansion N/A HealthCare.gov
 South Dakota No expansion N/A HealthCare.gov
 Tennessee No expansion N/A HealthCare.gov
 Texas No expansion N/A HealthCare.gov
 Utah In effect January 1, 2020 HealthCare.gov Enacted through 2018 Utah Proposition 3, but subsequently scaled back through legislative action to enforce a Section 1115 waiver for eligibility.
 Vermont In effect January 1, 2014 Vermont Health Connect, HealthCare.gov
 Virginia In effect January 1, 2019 HealthCare.gov
 Washington In effect January 1, 2014 Washington Healthplanfinder, HealthCare.gov
 Washington, D.C. In effect DC Health Link, HealthCare.gov
 West Virginia In effect January 1, 2014 HealthCare.gov
 Wisconsin No expansion N/A HealthCare.gov
 Wyoming No expansion N/A HealthCare.gov

Insurance costs

See also: Health insurance costs in the United States and Health care prices in the United States

National health care expenditures rose faster than national income both before (2009–2013: 3.73%) and after (2014–2018: 4.82%) ACA's major provisions took effect. Premium prices rose considerably before and after. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas. However, some or all these costs were offset by tax credits. For example, the Kaiser Family Foundation reported that for the second-lowest cost "Silver plan", a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the tax credit, despite a large increase in the list price. This was consistent nationally. In other words, the subsidies increased along with the premium price, fully offsetting the increases for subsidy-eligible enrollees.

Premium cost increases in the employer market moderated after 2009. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015, with only a 3% increase from 2015 to 2016. From 2008 to 2010 (before passage of ACA) health insurance premiums rose by an average of 10% per year.

Several studies found that the financial crisis and accompanying recession could not account for the entirety of the slowdown and that structural changes likely shared at least partial credit. A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation. Paul Krawzak claimed that even if 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 the growth of the population on Medicare.

In a 2016 review, Barack Obama claimed that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.

Deductibles and co-payments

A contributing factor to premium cost moderation was that the insured faced higher deductibles, copayments and out-of-pocket maximums. In addition, many employees chose to combine a health savings account with higher deductible plans, making the net impact of ACA difficult to determine precisely.

For the group market (employer insurance), a 2016 survey found that:

  • Deductibles grew 63% from 2011 to 2016, while premiums increased 19% and worker earnings grew by 11%.
  • In 2016, 4 in 5 workers had an insurance deductible, which averaged $1,478. For firms with less than 200 employees, the deductible averaged $2,069.
  • The percentage of workers with a deductible of at least $1,000 grew from 10% in 2006 to 51% in 2016. The 2016 figure dropped to 38% after taking employer contributions into account.

For the non-group market, of which two-thirds are covered by ACA exchanges, a survey of 2015 data found that:

  • 49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
  • Many exchange enrollees qualify for cost-sharing subsidies that reduce their net deductible.
  • While about 75% of enrollees were "very satisfied" or "somewhat satisfied" with their choice of doctors and hospitals, only 50% had such satisfaction with their annual deductible.
  • While 52% of those covered by ACA exchanges felt "well protected" by their insurance, in the group market 63% felt that way.

Health outcomes

According to a 2014 study, ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013. Himmelstein and Woolhandler wrote in January 2017 that a rollback of ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.

According to the Kaiser Foundation, expanding Medicaid in the remaining states would cover up to 4.5 million persons. A 2021 study found a significant decline in mortality rates in the states that opted in to the Medicaid expansion program compared with those states that did not do so. The study reported that states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017.

Dependent Coverage Expansion (DCE) under the ACA has had a demonstrable effect on various health metrics of young adults, a group with a historically low level of insurance coverage and utilization of care. Numerous studies have shown the target age group gained private health insurance relative to an older group after the policy was implemented, with an accompanying improvement in having a usual source of care, reduction in out-of-pocket costs of high-end medical expenditures, reduction in frequency of Emergency Department visits, 3.5% increase in hospitalizations and 9% increase in hospitalizations with a psychiatric diagnosis, 5.3% increase in utilizing specialty mental health care by those with a probable mental illness, 4% increase in reporting excellent mental health, and a 1.5-6.2% increase in reporting excellent physical health. Studies have also found that DCE was associated with improvements in cancer prevention, detection, and treatment among young adult patients. A study of 10,010 women aged 18–26 identified through the 2008-12 National Health Interview Survey found that the likelihood of HPV vaccination initiation and completion increased by 7.7 and 5.8 percentage points respectively when comparing before and after October 1, 2010. Another study using National Cancer Database (NCDB) data from 2007 to 2012 found a 5.5 percentage point decrease in late-stage (stages III/IV) cervical cancer diagnosis for women aged 21–25 after DCE, and an overall decrease of 7.3 percentage points in late-stage diagnosis compared to those aged 26–34. A study using SEER Program data from 2007 to 2012 found a 2.7 percentage point increase in diagnosis at stage I disease for patients aged 19–25 compared with those aged 26–34 for all cancers combined. Studies focusing on cancer treatment after DCE found a 12.8 percentage point increase in the receipt of fertility-sparing treatment among cervical cancer patients aged 21–25 and an overall increase of 13.4 percentage points compared to those aged 26–34, as well as an increased likelihood that patients aged 19–25 with stage IIB-IIIC colorectal cancer receive timely adjuvant chemotherapy compared to those aged 27–34.

Two 2018 JAMA studies found the Hospital Readmissions Reduction Program (HRRP) was associated with increased post-discharge mortality for patients hospitalized for heart failure and pneumonia. A 2019 JAMA study found that ACA decreased emergency department and hospital use by uninsured individuals. Several studies have indicated that increased 30-day, 90-day, and 1-year post-discharge mortality of heart failure patients can be attributed to "gaming the system" through inappropriate triage systems in emergency departments, use of observation stays when admissions are warranted, and delay of readmission beyond the 30th day post-discharge, strategies that can reduce readmission rates at the expense of quality of care and patient survival. The HRRP was also shown to disproportionately penalize safety-net hospitals that predominately serve low-income patients. A 2020 study by Treasury Department economists in the Quarterly Journal of Economics using a randomized controlled trial (the IRS sent letters to some taxpayers noting that they had paid a fine for not signing up for health insurance but not to other taxpayers) found that over two years, obtaining health insurance reduced mortality by 12 percent. The study concluded that the letters, sent to 3.9 million people, may have saved 700 lives.

A 2020 JAMA study found that Medicare expansion under the ACA was associated with reduced incidence of advanced-stage breast cancer, indicating that Medicaid accessibility led to early detection of breast cancer and higher survival rates. Recent studies have also attributed to Medicaid expansion an increase in use of smoking cessation medications, cervical cancer screening, and colonoscopy, as well as an increase in the percentage of early-stage diagnosis of all cancers and the rate of cancer surgery for low-income patients. These studies include a 2.1% increase in the probability of smoking cessation in Medicaid expansion states compared to non-expansion states, a 24% increase in smoking cessation medication use due to increased Medicaid-financed smoking cessation prescriptions, a 27.7% increase in the rate of colorectal cancer screening in Kentucky following Medicaid expansion with an accompanying improvement in colorectal cancer survival, and a 3.4% increase in cancer incidence following Medicaid expansion that was attributed to an increase in early-stage diagnoses.

Transition-of-care interventions and Alternative Payment Models under the ACA have also shown promise in improving health outcomes. Post-discharge provider appointment and telephone follow-up interventions have been shown to reduce 30-day readmission rates among general medical-surgical inpatients. Reductions in 60, 90, and 180 post-discharge day readmission rates due to transition-of-care interventions have also been demonstrated, and a reduction in 30-day mortality has been suggested. Total joint arthroplasty bundles as part of the Bundled Payments for Care Improvement initiative have been shown to reduce discharge to inpatient rehabilitation facilities and post-acute care facilities, decrease hospital length of stay by 18% without sacrificing quality of care, and reduce the rate of total joint arthroplasty readmissions, half of which were due to surgical complications. The Hospital Value-Based Purchasing Program in Medicaid has also shown the potential to improve health outcomes, with early studies reporting positive and significant effects on total patient experience score, 30-day readmission rates, incidences of pneumonia and pressure ulcers, and 30-day mortality rates for pneumonia. The patient-centered medical home (PCMH) payment and care model, a team-based approach to population health management that risk-stratifies patients and provides focused care management and outreach to high-risk patients, has been shown to improve diabetes outcomes. A widespread PCMH demonstration program focusing on diabetes, known as the Chronic Care Initiative in the Commonwealth of Pennsylvania, found statistically significant improvements in A1C testing, LDL-C testing, nephropathy screening and monitoring, and eye examinations, with an accompanying reduction in all-cause emergency department visits, ambulatory care-sensitive emergency department visits, ambulatory visits to specialists, and a higher rate of ambulatory visits to primary care providers. The ACA overall has improved coverage and care of diabetes, with a significant portion of the 3.5 million uninsured US adults aged 18–64 with diabetes in 2009-10 likely gaining coverage and benefits such as closure of the Medicaid Part D coverage gap for insulin. 2.3 million of the approximately 4.6 million people aged 18–64 with undiagnosed diabetes in 2009–2010 may also have gained access to zero-cost preventative care due to section 2713 of the ACA, which prohibits cost sharing for United States Preventive Services Taskforce grade A or B recommended services, such as diabetes screenings.

Distributional impact

The distributional impact of the Affordable Care Act (ACA or Obamacare) during 2014. ACA raised taxes mainly on the top 1% to fund approximately $600 in benefits on average for the bottom 40% of families.

In March 2018, the CBO reported that ACA had reduced income inequality in 2014, saying the law led the lowest and second quintiles (the bottom 40%) to receive an average of an additional $690 and $560 respectively while causing households in the top 1% to pay an additional $21,000 due mostly to the net investment income tax and the additional Medicare tax. The law placed relatively little burden on households in the top quintile (top 20%) outside of the top 1%.

Federal deficit

CBO estimates of revenue and impact on deficit

See also: United States public debt and Provisions of the Patient Protection and Affordable Care Act

The CBO reported in multiple studies that ACA would reduce the deficit, and repealing it would increase the deficit, primarily because of the elimination of Medicare reimbursement cuts. The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period: it calculated the law would result in $604 billion in total outlays offset by $813 billion in total receipts, resulting in a $210 billion net deficit reduction. The CBO separately predicted that while most of the spending provisions do not begin until 2014, revenue would exceed spending in those subsequent years. The CBO claimed 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"—ultimately extending the solvency of the Medicare trust fund by eight years.

This estimate was made prior to the Supreme Court's ruling that enabled states to opt out of the Medicaid expansion, thereby forgoing the related federal funding. The CBO and JCT subsequently updated the budget projection, estimating the impact of the ruling would reduce the cost estimate of the insurance coverage provisions by $84 billion.

The CBO in June 2015 forecast that repeal of ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic feedback effects. The CBO also forecast that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2025, mainly by boosting the supply of labor.

Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion. CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".

In 2017 CBO estimated that repealing the individual mandate alone would reduce the 10-year deficit by $338 billion.

Opinions on CBO projections

The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019. However, the so-called "doc fix" is a separate issue that would have existed with or without ACA. The Center on Budget and Policy Priorities objected that Congress had 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, although not the doc fix. The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.

Health economist Uwe Reinhardt, wrote, "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." Douglas Holtz-Eakin alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.

Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from preventive healthcare, and that the CBO had a track record of overestimating costs and underestimating savings of health legislation; stating, "innovations in the delivery of medical care, like greater use of electronic medical records and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses ... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another—and that meant there wasn't much hard data to prove the savings would materialize."

In 2010 David Walker said the CBO estimates were not likely to be accurate, because they were based on the assumption that the law would not change.

Employer mandate and part-time work

Further information on health insurance mandates: Health insurance mandate

The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers. Critics claimed it created a perverse incentive to hire part-timers instead. However, between March 2010 and 2014, the number of part-time jobs declined by 230,000 while the number of full-time jobs increased by two million. In the public sector full-time jobs turned into part-time jobs much more than in the private sector. A 2016 study found only limited evidence that ACA had increased part-time employment.

Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees, to reflect the 30-hour-or-more definition for full-time worker. As of 2013, few companies had shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis). Trends in working hours and the recovery from the Great Recession correlate with the shift from part-time to full-time work. Other confounding impacts include that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and lowers corresponding training and administration costs from a smaller, more stable workforce. Relatively few firms employ over 50 employees and more than 90% of them already offered insurance.

Most policy analysts (both right and left) were critical of the employer mandate provision. They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful; that the raised marginal cost of the 50th worker for businesses could limit companies' growth; that the costs of reporting and administration were not worth the costs of maintaining employer plans; and noted that the employer mandate was not essential to maintain adequate risk pools. The provision generated vocal opposition from business interests and some unions who were not granted exemptions.

Hospitals

From the start of 2010 to November 2014, 43 hospitals in rural areas closed. Critics claimed the new law had caused these closures. Many rural hospitals were built using funds from the 1946 Hill–Burton Act. Some of these hospitals reopened as other medical facilities, but only a small number operated emergency rooms (ER) or urgent care centers.

Between January 2010 and 2015, a quarter of ER doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured. Michael Lee Jr. and Michael C. Monuteaux at Boston Children's Hospital analyzed national emergency department visits among children aged 0 to 17 from 2009 to 2016 using the American Community Survey (ACS) and Nationwide Emergency Department Sample (NEDS). They found no immediate change in pediatric emergency department visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends, almost 10%.

Several large insurers formed ACOs. Many hospitals merged and purchased physician practices, amounting to a significant consolidation of the provider industry. The increased market share gave them more leverage with insurers and reduced patient care options.

Economic consequences

Coverage rate, employer market cost trends, budgetary impact, and income inequality aspects of the Affordable Care Act

CBO estimated in June 2015 that repealing ACA would:

  • Decrease GDP in the short-term, as government spending (on subsidies) was only partially replaced by spending by recipients.
  • Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021–2025 period. CBO cited ACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing ACA would remove those disincentives, encouraging workers to supply more labor, increasing the total number of hours worked by about 1.5% over the 2021–2025 period.
  • Remove the higher tax rates on capital income, thereby encouraging investment, raising the capital stock and output in the long-run.

In 2015 the progressive Center for Economic and Policy Research found no evidence that companies were reducing worker hours to avoid ACA requirements for employees working more than 30 hours per week.

CBO estimated that ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Jonathan Cohn claimed that ACA's primary employment effect was to alleviate job lock and the reform's only significant employment impact was the retirement of those who were working only to stay insured.

Public opinion

Congressional Democrats celebrating the 6th anniversary of the Affordable Care Act in March 2016 on the steps of the U.S. Capitol.
Congressional Democrats celebrate the 6th anniversary of the Affordable Care Act on the steps of the Capitol.

Public views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Approval varied by party, race and age. Some elements were more widely favored (preexisting conditions) or opposed (individual mandate).

In a 2010 poll, 62% of respondents said they thought 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 19% said they thought they and their families would be better off with the legislation. Other polls found that people were concerned the law would cost more than projected and would not do enough to control costs.

In a 2012 poll 44% supported the law, with 56% against. By 75% of Democrats, 27% of Independents and 14% of Republicans favored the law. 82% favored banning insurance companies from denying coverage to people with preexisting 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, and 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. Other polls showed additional provisions receiving majority support, including the exchanges, pooling small businesses and the uninsured with other consumers and providing subsidies.

Some opponents believed the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more.

In June 2013, a majority of the public (52–34%) indicated a desire for "Congress to implement or tinker with the law rather than repeal it". After the Supreme Court upheld the individual mandate, a 2012 poll held 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".

As of October 2013, approximately 40% were in favor while 51% were against. About 29% of whites approved of the law, compared with 61% of Hispanics and 91% of African Americans. A solid majority of seniors opposed the idea and a solid majority of those under forty were in favor.

A 2014 poll reported that 26% of Americans support ACA. A later 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA versus 38.3% who had a favorable view (of more than 5,500 individuals). Another held that 8% of respondents agreed the Affordable Care Act "is working well the way it is". In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.

In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved. A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.

Separate polls from Fox News and NBC/WSJ, both taken during January 2017, indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who had once opposed it (many still prefer "Medicare for all") shifted their positions because ACA was under threat of repeal. Another January 2017 poll reported that 35% of respondents believed "Obamacare" and the "Affordable Care Act" were different or did not know. (About 45% were unsure whether "repeal of Obamacare" also meant "repeal of the Affordable Care Act".) 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the ACA were repealed and no replacement enacted", with Democrats far more likely (79%) to know that fact than Republicans (47%). A 2017 study found that personal experience with public health insurance programs led to greater support for the ACA, most prominently among Republicans and low-information voters.

By the end of 2023, a Morning Consult poll of registered voters found that 57% approved of the Affordable Care Act, while 30% disapproved of it. 85% of Democrats, 56% of independents, and 28% of Republicans supported the law.

Political aspects

"Obamacare"

The term "Obamacare" was originally coined by opponents as a pejorative. According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured. The term officially emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott wrote, "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care', 'Edwards-care', and a totally revamped and remodeled 'Hillary-care' from the 1990s".

In May 2007, Mitt Romney introduced it to political discourse, saying, "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."

By mid-2012, Obamacare had become the colloquial term used both by supporters and opponents. Obama eventually endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."

The use of "Obamacare" became increasingly rare, and at the 2024 Democratic National Convention, Obama said, "I noticed, by the way, since it became popular, they don't call it 'Obamacare' no more."

Common misconceptions

"Death panels"

Main article: Death panel

On August 7, 2009, Sarah Palin created the term "death panels" to describe groups who would decide whether sick patients were "worthy" of medical care. "Death panel" referred to two claims about early drafts.

One was that under the law, seniors could be denied care due to their age and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an Independent Payment Advisory Board (IPAB). IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when statutory expenditure levels were exceeded within any given three-year period. In fact, the Board was prohibited from recommending changes that would reduce payments before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.

The other related issue concerned advance-care planning consultation: a section of the House reform proposal would have reimbursed physicians for providing patient-requested consultations for Medicare recipients on end-of-life health planning (which is covered by many private plans), enabling patients to specify, on request, the kind of care they wished to receive. The provision was not included in ACA.

In 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and 30% believed it was true, backed by three contemporaneous polls. The allegation was named PolitiFact's 2009 "Lie of the Year", one of FactCheck.org's "whoppers" and the most outrageous term by the American Dialect Society. AARP described such rumors as "rife with gross—and even cruel—distortions".

Members of Congress

ACA requires members of Congress and their staffs to obtain health insurance either through an exchange or some other program approved by the law (such as Medicare), instead of using the insurance offered to federal employees (the Federal Employees Health Benefits Program).

Illegal immigrants

ACA explicitly denies insurance subsidies to "unauthorized (illegal) aliens".

Exchange "death spiral"

Opponents claimed that combining immediate coverage with no provision for preexisting conditions would lead people to wait to get insured until they got sick. The individual mandate was designed to push people to get insured without waiting. This has been called a "death spiral". In the years after 2013, many insurers did leave specific marketplaces, claiming the risk pools were too small.

The median number of insurers per state was 4.0 in 2014, 5.0 in 2015, 4.0 in 2016 and 3.0 in 2017. Five states had one insurer in 2017, 13 had two, 11 had three; the remainder had four or more.

"If you like your plan"

At various times during and after ACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan." However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated, and several million more risked seeing their current plans canceled.

Obama's previous unambiguous assurance that consumers could keep their own plans became a focal point for critics, who challenged his truthfulness. Various bills were introduced in Congress to allow people to keep their plans.

PolitiFact initially cited various estimates that only about 2% of the total insured population (4 million out of 262 million) received such notices, but readers later voted Obama's claims as the 2013 "Lie of the Year".

Criticism and opposition

Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions, conservative advocacy groups, Republicans, small business organizations and the Tea Party movement. These groups claimed the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit. Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods. President Donald Trump repeatedly promised to "repeal and replace" it.

As of 2013 unions that expressed concerns included the AFL–CIO, which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, whose leaders sent a letter to Reid and Pelosi arguing, "PPACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class." In January 2014, Terry O'Sullivan, president of the Laborers' International Union of North America (LIUNA) and D. Taylor, president of Unite Here sent a letter to Reid and Pelosi stating, "ACA, as implemented, undermines fair marketplace competition in the health care industry."

In October 2016, Mark Dayton, the governor of Minnesota and a member of the Minnesota Democratic–Farmer–Labor Party, said ACA had "many good features" but it was "no longer affordable for increasing numbers of people"; he called on the state legislature to provide emergency relief to policyholders. Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.

Legal challenges

Main article: Constitutional challenges to the Patient Protection and Affordable Care Act See also: National Federation of Independent Business v. Sebelius, King v. Burwell, and Efforts to repeal the Patient Protection and Affordable Care Act

National Federation of Independent Business v. Sebelius

Main article: National Federation of Independent Business v. Sebelius

Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds. The Supreme Court ruled, 5–4, that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.

The Court further determined that states could not be forced to expand Medicaid. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.

Contraception mandate

Main articles: Burwell v. Hobby Lobby Stores, Inc. and Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania

In March 2012, the Roman Catholic Church, while supportive of ACA's objectives, voiced concern through the United States Conference of Catholic Bishops that aspects of the mandate covering contraception and sterilization and HHS's narrow definition of a religious organization violated the First Amendment right to free exercise of religion and conscience. Various lawsuits addressed these concerns, including Burwell v. Hobby Lobby Stores, Inc., which looked at private corporations and their duties under the ACA.

In Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania, the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice Clarence Thomas said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the , that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice Elena Kagan filed a concurring opinion in the judgment, in which Stephen Breyer joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."

In a later lawsuit brought by private health insurance buyers and businesses, Judge Reed O'Connor of the Federal District Court for the Northern District of Texas ruled in March 2023 that the ACA's provision of contraceptives, HIV testing, and screenings for cancer, diabetes, and mental health violated the plaintiffs' freedom of religious exercise, and placed an injunction on that portion of the ACA. The Biden administration planned to seek a hold on O'Connor's decision.

King v Burwell

Main article: King v. Burwell

On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.

House v. Price

Main article: House v. Price

House Republicans sued the Obama administration in 2014, alleging that cost-sharing reduction subsidy payments to insurers were unlawful because Congress had not appropriated funds to pay for them. The argument classified the CSR subsidy as discretionary spending subject to annual appropriation. In May 2016, a federal judge ruled for the plaintiffs, but the Obama administration appealed. Later, President Trump ended the payments. This led to further litigation.

United States House of Representatives v. Azar

Main article: United States House of Representatives v. Azar

The House sued the administration, alleging that the money for CSRs to insurers had not been appropriated, as required for any federal government spending. The ACA subsidy that helps customers pay premiums was not part of the suit.

Without the CSRs, the government estimated that premiums would increase by 20% to 30% for silver plans. In 2017, the uncertainty about whether the payments would continue caused Blue Cross Blue Shield of North Carolina to try to raise premiums by 22.9% the next year, as opposed to an increase of 8.8% that it would have sought if the payments were assured.

U.S. District Judge Rosemary M. Collyer ruled that the cost-sharing program was unconstitutional for spending money that has not been specifically provided by an act of Congress, but concluded that Congress had in fact authorized that program to be created. The judge also found that Congress had provided authority to cover the spending for the tax credits to consumers who use them to help afford health coverage. Collyer enjoined further cost-sharing payments, but stayed the order pending appeal to the United States Court of Appeals for the District of Columbia Circuit. The case ended in a settlement before the Circuit Court.

California v. Texas

Main article: California v. Texas

Texas and 19 other states filed a civil suit in the United States District Court for the Northern District of Texas in February 2018, arguing that with the passage of the Tax Cuts and Jobs Act of 2017, which eliminated the tax for not having health insurance, the individual mandate no longer had a constitutional basis and thus the entire ACA was no longer constitutional. The Department of Justice said it would no longer defend the ACA in court, but 17 states led by California stepped in to do so.

District Judge Reed O'Connor of Texas ruled for the plaintiffs on December 14, 2018, writing that the "Individual Mandate can no longer be fairly read as an exercise of Congress's Tax Power and is still impermissible under the Interstate Commerce Clause—meaning the Individual Mandate is unconstitutional." He then further reasoned that the individual mandate is an essential part of the entire law, and thus was not severable, making the entire law unconstitutional. O'Connor's decision regarding severability turned on several passages from the Congressional debate that focused on the importance of the mandate. While he ruled the law unconstitutional, he did not overturn the law.

The intervening states appealed the decision to the Fifth Circuit. These states argued that Congress's change in the tax was only reducing the amount of the tax, and that Congress had the power to write a stronger law to this end. O'Connor stayed his decision pending the appeal. The Fifth Circuit heard the appeal on July 9, 2019; in the interim, the U.S. Department of Justice joined with Republican states to argue that the ACA was unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. An additional question was addressed, as the Republican plaintiffs challenged the Democratic states' standing to defend the ACA.

In December 2019, the Fifth Circuit agreed the individual mandate was unconstitutional, but did not agree that the entire law should be voided. Instead, it remanded the case to the District Court for reconsideration of that question. The Supreme Court accepted the case in March 2020, to be heard in the 2020–2021 term, with the ruling likely falling after the 2020 elections.

Democrats pointed out that the effect of invalidating the entire law would be to remove popular provisions such as the protection for preexisting conditions, and that the Republicans had still not offered any replacement plan—important issues in the 2020 elections.

On June 17, 2021, the Court rejected the challenge in a 7–2 decision, ruling that Texas and the other plaintiff states did not have standing to challenge the provision, leaving the full ACA intact.

Risk corridors

Further information: Maine Community Health Options v. United States

The Supreme Court ruled that promised risk corridor payments must be made even in the absence of specific appropriation of money by Congress.

Non-cooperation

Officials in Texas, Florida, Alabama, Wyoming, Arizona, Oklahoma and Missouri opposed those elements over which they had discretion. For example, Missouri declined to expand Medicaid or establish a health insurance marketplace engaging in active non-cooperation, enacting a statute forbidding any state or local official to render any aid not specifically required by federal law. Other Republicans discouraged efforts to advertise the law's benefits. Some conservative political groups launched ad campaigns to discourage enrollment.

Repeal and modification efforts

Main article: Efforts to repeal the Patient Protection and Affordable Care Act

ACA was the subject of many unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives Steve King and Michele Bachmann introduced bills in the House to repeal the ACA the day after it was signed, as did Senator Jim DeMint in the Senate. In 2011, after Republicans gained control of the House, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189. All Republicans and three Democrats voted for repeal. In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down. President Obama said he would veto the bill had it passed.

2017 House Budget

On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.

2013 federal government shutdown

Strong partisan disagreement in Congress prevented adjustments to the Act's provisions. But at least one change, a proposed repeal of a tax on medical devices, received bipartisan support. Some Congressional Republicans argued against improvements to the law on the grounds that they would weaken the arguments for repeal.

Republicans attempted to defund the ACA's implementation, and in October 2013 House Republicans refused to fund the federal government unless it came with an implementation delay, after Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay the ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership said the Senate would pass only a bill without any restrictions on ACA. The government shutdown lasted from October 1 to October 17.

2017 repeal effort

Main article: 2017 Patient Protection and Affordable Care Act replacement proposals
McCain votes no on repealing the Affordable Care Act by giving a thumbs down.

During a midnight congressional session starting January 11, the Senate of the 115th Congress of the United States voted to approve a "budget blueprint" that would allow Republicans to repeal parts of the law "without threat of a Democratic filibuster". The plan, which passed 51–48, was named by Senate Republicans the "Obamacare 'repeal resolution.'" Democrats opposing the resolution staged a protest during the vote.

House Republicans announced their replacement, the American Health Care Act, on March 6. On March 24, the AHCA failed amid a revolt among Republican representatives.

On May 4 the House voted to pass the AHCA by a margin of 217 to 213. The Senate Republican leadership announced that Senate Republicans would write their own version of the bill instead of voting on the House version.

Leader McConnell named a group of 13 Republicans to draft the substitute version in private, raising bipartisan concerns about lack of transparency. On June 22, Republicans released the first discussion draft, which renamed it the "Better Care Reconciliation Act of 2017" (BCRA). On July 25, although no amendment proposal had garnered majority support, Republicans voted to advance the bill to the floor and begin formal consideration of amendments. Senators Susan Collins and Lisa Murkowski were the only two dissenting Republicans, making the vote a 50–50 tie. Vice President Mike Pence then cast the tie-breaking vote in the affirmative.

The revised BCRA failed, 43–57. A subsequent "Obamacare Repeal and Reconciliation Act" abandoned the "repeal and replace" approach in favor of a straight repeal, but that too failed, 45–55. Finally, the "Health Care Freedom Act", nicknamed "skinny repeal" because it would have made the least change to ACA, failed by 49–51, with Collins, Murkowski, and McCain joining all Democrats and independents in voting against it.

Proposed changes in 2024

Donald Trump, who has historically opposed the ACA, has said during the 2024 United States presidential debates that he plans to modify or scrap sections it, saying he has "proposals." JD Vance has said that Trump intends to allow insurance companies to discriminate against people with preexisting conditions or disability, with subsidized insurance replaced with private insurance. Kamala Harris said she would "maintain and grow" the ACA.

Actions to hinder implementation

Tax Cuts and Jobs Act—number of additional persons uninsured

Under both the ACA (current law) and the AHCA, the CBO reported that the health exchange marketplaces would remain stable. But Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums. Concern about the exchanges became another argument for reforms. Past and ongoing Republican attempts to weaken the law have included:

  • Lawsuits such as King v. Burwell and House v. Price.
  • President Trump ended the payment of cost-sharing reduction subsidies to insurers on October 12, 2017. CBO estimated in September 2017 that discontinuing the payments would add an average of 15–20 percentage points to health insurance costs on the exchanges in 2018 while increasing the budget deficit nearly $200 billion over a decade. In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019. Several insurers and actuarial groups estimated this resulted in a 20 percentage point or more increase in premiums for the 2018 plan year. In other words, premium increases expected to be 10% or less in 2018 became 28–40% instead. The insurers would need to make up the $7 billion they had previously received in cost-sharing reductions (CSRs) by raising premiums. Since most premiums are subsidized, the federal government would cover most of the increases. CBO also estimated that initially up to one million fewer people would have health insurance coverage, although rising subsidies might eventually offset this. The 85% of enrollees who received subsidies would be unaffected. CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level. Several insurance companies who sued the United States for failure to pay CSRs won cases in 2018 and 2019. The judiciary decided the insurance companies are entitled to unpaid CSRs.
  • The 2015 appropriations bill had a rider that ended the payment of risk corridor funds. This was repeated in later years. This resulted in the bankruptcy of many co-ops. This action was attributed to Senator Marco Rubio. The cutoff generated some 50 lawsuits. The Supreme Court granted certiorari in 2019 in the case Maine Community Health Options v. United States.
  • Trump weakened the individual mandate with his first executive order, which limited enforcement of the tax. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding Obama's instructions to reject them.
  • Trump reduced funding for advertising for exchange enrollment by up to 90%, with other reductions to support resources used to answer questions and help people sign-up for coverage. The CBO said the reductions would reduce ACA enrollment.
  • Trump reduced the enrollment period for 2018 by half, to 45 days.
  • Trump made public statements that the exchanges were unstable or in a death spiral.

Socialism debate

Many economically conservative opponents called the ACA "socialist" or "socialized medicine", pointing to the government redistribution of wealth via subsidies for low-income purchasers, expansion of the government-run Medicaid insurance, government requirements as to what products can be sold on the exchanges, and the individual mandate, which reduces freedom of consumer choice to be uninsured.

Other observers considered the law a relatively capitalist or "regulated free-market" means of paying for near-universal health care, because it creates new marketplaces with choices for consumers, largely relies on private employers and private health insurance companies, maintains private ownership of hospitals and doctor's offices, and was originally advocated for by economic conservatives as a capitalist alternative to single-payer health care. Some pointed out that the previous system also had socialist aspects. Even for-profit private health insurance companies socialize risk and redistribute wealth from people who have it (all premium payers) to those who need it (by paying for medically necessary healthcare). The requirement to provide emergency care also forced redistribution from people who pay insurance premiums to those who choose to be uninsured, when they visit the emergency room.

Some Obamacare supporters accused conservatives of using the term "socialism" as a scare tactic for Obamacare as it was for Medicare and Medicaid, and some embraced the label "socialism" as desirable, distinguishing democratic socialism as most desirable for education and health care, and communism as undesirable. Milos Forman opined that critics "falsely equate Western European-style socialism, and its government provision of social insurance and health care, with Marxist–Leninist totalitarianism".

Implementation

Main article: Implementation history of the Patient Protection and Affordable Care Act

In 2010 small business tax credits took effect. Then Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those who had been denied coverage by private insurance companies because of a preexisting condition. By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement. In National Federation of Independent Business v. Sebelius the Supreme Court allowed states to opt out of the Medicaid expansion.

In 2013, the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold. On July 2 Obama delayed the employer mandate until 2015. The launch for both the state and federal exchanges was beset by management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered many problems. Operations stabilized in 2014, although not all planned features were complete.

The Government Accountability Office released a non-partisan study in 2014 that concluded the administration had not provided "effective planning or oversight practices" in developing the exchanges. In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule. At the beginning of the 2015, 11.7 million had signed up (ex-Medicaid). By the end of the year about 8.8 million consumers had stayed in the program. Congress repeatedly delayed the onset of the "Cadillac tax" on expensive insurance plans first until 2020 and later until 2022 and repealed it in late 2019.

An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults. The five major national insurers expected to lose money on ACA policies in 2016, in part because the enrollees were lower income, older and sicker than expected.

More than 9.2 million people (3.0 million new customers and 6.2 million returning) enrolled on the national exchange in 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump. The eleven states that run their own exchanges signed up about 3 million more. The IRS announced that it would not require that tax returns indicate a person has health insurance, reducing the effectiveness of the individual mandate, in response to Trump's executive order. The CBO reported in March that the healthcare exchanges were expected to be stable. In May the House voted to repeal the ACA using the American Health Care Act (AHCA), but the AHCA was defeated in the Senate. The Tax Cuts and Jobs Act set the individual mandate penalty at $0 starting in 2019. The CBO estimated that the change would cause 13 million fewer people to have health insurance in 2027.

The 2017 Individual Market Stabilization Bill was proposed to fund cost cost-sharing reductions, provide more flexibility for state waivers, allow a new "Copper Plan" offering only catastrophic coverage, allow interstate insurance compacts, and redirect consumer fees to states for outreach. The bill failed.

By 2019, 35 states and the District of Columbia had either expanded coverage via traditional Medicaid or via an alternative program.

In popular culture

SNL presented a sketch in October 2009 about the legislation's gridlock, with Dwayne Johnson playing an angry President Obama confronting three senators opposing the plan.

The show aired another sketch in September 2013 with Jay Pharoah as President Obama rolling out the plan to the public, and Aaron Paul and other cast members playing ordinary Americans helping him in advocating for the legislation.

See also

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Further reading

Preliminary CBO documents

  • Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment. United States. Congressional Budget Office December 19, 2009. (Cost estimate)
    • Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
    • Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
  • Base Analysis—H.R. 3590, Patient Protection and Affordable Care Act, United States. Congressional Budget Office. November 18, 2009. (Cost estimate)
    (The additional and related CBO reporting that follows can be accessed from the above link)
    • Estimated Distribution Of Individual Mandate Penalties (November 20, 2009)
    • Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009)
    • Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009)
    • Estimated Average Premiums Under Current Law (December 5, 2009)
    • Additional Information About Employment-Based Coverage (December 7, 2009)
    • Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009)

CMS Estimates of the impact of P.L. 111-148

CMS Estimates of the impact of H.R. 3590

Senate Finance Committee meetings

Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN; also available from Finance.Senate.Gov (accessed April 1, 2012).

External links

ACA text

Affordable Care Act
Key articles
Provisions
Constitutional challenges
Health insurance marketplaces
Federal insurance exchangeHealthCare.gov
Other reform proposals
from the 111th Congress
See also
Categories:
Affordable Care Act: Difference between revisions Add topic