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Patient Protection and Affordable Care Act

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Title: Patient Protection and Affordable Care Act  
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Subject: Health insurance marketplace, 2010 in the United States, In the news/Candidates/March 2010, List of bills in the 113th United States Congress, 2011 in the United States
Collection: 111Th United States Congress, 2009 in American Law, 2009 in American Politics, 2009 in Law, 2010 in American Law, 2010 in American Politics, 2010 in Law, Controversies in the United States, Excise Taxes, Healthcare Reform Legislation in the United States, Internal Revenue Code, Internal Revenue Service, Life Sciences Industry, Patient Protection and Affordable Care Act, Presidency of Barack Obama, United States Federal Health Legislation, United States Supreme Court Cases of the Roberts Court
Publisher: World Heritage Encyclopedia

Patient Protection and Affordable Care Act

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

The Patient Protection and Affordable Care Act (PPACA),[1][2] commonly called the Affordable Care Act (ACA) or "Obamacare",[3] is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act,[4] it represents the most significant regulatory overhaul of the U.S. healthcare system since the passage of Medicare and Medicaid in 1965.[5]

The ACA was enacted with the goals of increasing the quality and affordability of health insurance, lowering the uninsured rate by expanding public and private insurance coverage, and reducing the costs of healthcare for individuals and the government. It introduced a number of mechanisms—including mandates, subsidies, and insurance exchanges—meant to increase coverage and affordability.[6][7] The law also requires insurance companies to cover all applicants within new minimum standards and offer the same rates regardless of pre-existing conditions or sex.[8] Additional reforms aimed to reduce costs and improve healthcare outcomes by shifting the system towards quality over quantity through increased competition, regulation, and incentives to streamline the delivery of healthcare. In 2011 the Congressional Budget Office projected that the ACA would lower both future deficits[9] and Medicare spending.[10]

On June 28, 2012, the United States Supreme Court upheld the constitutionality of the ACA's individual mandate as an exercise of Congress's taxing power[11] in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the ACA's Medicaid expansion under penalty of losing their current Medicaid funding.[12][13][14] Since the ruling, the law and its implementation have continued to face challenges in Congress and federal courts, and from some state governments, conservative advocacy groups, labor unions, and small business organizations.

As of May 2014, approximately 20 million Americans had gained health insurance coverage under the ACA, and the percentage of uninsured Americans dropped from 18% in 2013 to 13.4% in May 2014.[15]


  • Overview of provisions 1
  • Legislative history 2
    • Background 2.1
    • Healthcare debate, 2008–10 2.2
      • Senate 2.2.1
      • House 2.2.2
  • Impact 3
    • Public policy 3.1
      • Change in number of uninsured 3.1.1
      • Insurance exchanges and the individual mandate 3.1.2
        • Implementation
      • Change in insurance standards 3.1.3
        • Coverage for contraceptives
      • Effects on insurance premiums 3.1.4
      • Healthcare cost inflation 3.1.5
      • Federal deficit 3.1.6
        • CBO estimates of revenue and impact on deficit
        • Opinions on CBO projections
      • Employer mandate and part-time working hours 3.1.7
      • Changes in existing individual insurance plans 3.1.8
      • Clawback controversy 3.1.9
      • Public opinion 3.1.10
    • Political 3.2
      • Term "Obamacare" 3.2.1
      • Common misconceptions 3.2.2
        • "Death panels"
        • Exemptions for Congressmen
        • Benefits for illegal immigrants
  • Opposition and resistance 4
    • Legal challenges 4.1
    • State rejections of Medicaid expansion 4.2
    • Non-cooperation 4.3
    • Repeal efforts 4.4
      • 2013 federal government shutdown 4.4.1
      • Economic consequences 4.4.2
      • Impact of repeal on federal budget projections 4.4.3
  • See also 5
  • References 6
  • Further reading 7
  • External links 8

Overview of provisions

The President and White House Staff react to the House of Representatives passing the bill on March 21, 2010.

The ACA includes numerous provisions that take effect between 2010 and 2020. Policies issued before 2010 are exempted by a grandfather clause from many of the changes to insurance standards, but they are affected by other provisions.[16][17] Significant reforms, most of which took effect on January 1, 2014, include:

  • [20]
  • Minimum standards for health insurance policies are established.[21][22][23][24][25]
  • An individual mandate[26][27] requires all individuals not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs (such as Tricare) to secure an approved private-insurance policy or pay a penalty, unless the applicable individual has a financial hardship or is a member of a recognized religious sect exempted by the Internal Revenue Service.[28] The law includes subsidies to help people with low incomes comply with the mandate.[29]
  • Health insurance exchanges operate as a new avenue by which individuals and small businesses in every state can compare policies and buy insurance (with a government subsidy if eligible).[30] In the first year of operation, open enrollment on the exchanges ran from October 1, 2013 to March 31, 2014. The original purchase deadline date to be covered for January 1, 2014 was December 15, 2013, but the deadline was pushed back, first to December 23, 2013 and later to December 24, 2013.[31][32][33][34] For plans starting in 2015, the proposed enrollment period is November 15, 2014–February 15, 2015.[35]
  • Low-income individuals and families whose incomes are between 100% and 400% of the federal poverty level will receive federal subsidies on a sliding scale if they purchase insurance via an exchange.[36] Those from 133% to 150% of the poverty level will be subsidized such that their premium costs will be 3% to 4% of income.[37] In 2013, the subsidy would apply for incomes up to $45,960 for an individual or $94,200 for a family of four; consumers can choose to receive their tax credits in advance, and the exchange will send the money directly to the insurer every month.[38] Small businesses will be eligible for subsidies.[39]
  • Medicaid eligibility expanded to include individuals and families with incomes up to 133% of the federal poverty level, including adults without disabilities and without dependent children.[40] The law also provides for a 5% "income disregard", making the effective income eligibility limit for Medicaid 138% of the poverty level.[41] Furthermore, the State Children's Health Insurance Program (CHIP) enrollment process is simplified.[40] However, in National Federation of Independent Business v. Sebelius, the Supreme Court ruled that states may opt out of the Medicaid expansion, and several have done so.
  • Reforms to the Medicare payment system are meant to promote greater efficiency in the healthcare delivery system by restructuring Medicare reimbursements from fee-for-service to bundled payments.[42][43] Under the new payment system, a single payment is paid to a hospital and a physician group for a defined episode of care (such as a hip replacement) rather than individual payments to individual service providers. In addition, the Medicare Part D coverage gap (commonly called the "donut hole") will shrink incrementally, closing completely by January 1, 2020.[44]
  • Businesses which employ 50 or more people but do not offer health insurance to their full-time employees will pay a tax penalty 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.[45][46] In July 2013, the Internal Revenue Service delayed enforcement of this provision for one year.[47]

Legislative history


The Patient Protection and Affordable Care Act consists of a combination of measures to control healthcare costs, and an expansion of coverage through public and private insurance: broader Medicaid eligibility and Medicare coverage, and subsidized, regulated private insurance. An individual mandate coupled with subsidies for private insurance as a means for universal healthcare was considered the best way to win the support of the Senate because it had been included in prior bipartisan reform proposals. The concept goes back to at least 1989, when the conservative Heritage Foundation proposed an individual mandate as an alternative to single-payer health care.[48] 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 (which nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.[49][50][51]

When President

  • Video: Obama signs Healthcare Bill
  • Supreme Court Ruling on the ACA-June 28, 2012
  • Remarks by the President on Supreme Court Ruling on the Affordable Care Act-June 28, 2012
  • – Department of Health and Human Services website on the law
  • Affordable Care Act collected news and commentary at The New York Times
  • Health Reform collected news and commentary at The Wall Street Journal
  • Basics: Health care reform issues as provided by Emily Smith from CNN June 25, 2012
  • Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act Congressional Research Service
  • Timeline of the health care law as provided by CNN June 17, 2012
  • Kaiser Family Foundation: Health Reform Subsidy Calculator – Premium Assistance for Coverage in Exchanges/Gateways
  • Three Days of Argument: Obamacare On Trial Audiobook – Complete coverage of the arguments to the Supreme Court regarding Obamacare
  • Obamacare coverage by CBSnews
  • Supreme Court ruling caps a century of American debate over how to get medical care for all An Associated Press timeline published in various national newspapers on June 28, 2012, briefly listing 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.
  • "Lines Crossed: Separation of Church and State. Has the Obama Administration Trampled on Freedom of Religion and Freedom of Conscience?" Hearing before the Congressional Committee on Oversight and Government Reform February 16, 2012
    • '"Where Are the Women?": Lawmakers Walk Out on Contraception Rule Hearing After Female Witness Barred' Democracy Now! February 17, 2012
Other links
  • PDF of the Patient Protection and Affordable Care Act ("PPACA"; Public Law 111–148) after consolidating the amendments made by Title X of PPACA itself and by the Health Care and Education Reconciliation Act of 2010 ("HCERA"; Public Law 111–152) into one revision.
  • Plain Text or PDF formats of H. R. 3590 (Public Law 111-148), as engrossed or passed by the Senate and printed via FDsys.
  • The Patient Protection and Affordable Care Act, full text, summary, background, provisions and more, via Democratic Policy Committee (
  • Summary of H.R. 3590 (March 23, 2010) via THOMAS.
  • Patient Protection and Affordable Care Act (2010; 111th Congress H.R. 3590) entry at GovTrack
  • The law as published by the U.S. Government Printing Office
Copies of the Act hosted online or readily downloadable

External links

  • Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN; also available from Finance.Senate.Gov (accessed April 1, 2012).
Senate Finance Committee Meetings
  • Estimated Financial Effects of the "Patient Protection and Affordable Care Act of 2009," as Proposed by the Senate Majority Leader on November 18, 2009. December 10, 2009.
  • Estimated Effects of the "Patient Protection and Affordable Care Act" on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts. December 10, 2009.
Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of H.R. 3590
  • Estimated Financial Effects of the "Patient Protection and Affordable Care Act," as Amended. April 22, 2010.
  • Estimated Effects of the "Patient Protection and Affordable Care Act," as Amended, on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts. April 22, 2010.
Centers for Medicare and Medicaid Services (CMS) Estimates of the impact of P.L. 111-148
  • Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment − December 19, 2009
    • Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
    • Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
  • Base Analysis – H.R. 3590, Patient Protection and Affordable Care Act, − November 18, 2009.
    (The Additional and/or Related CBO reporting that follows can be accessed from the above link)
    • Estimated Distribution Of Individual Mandate Penalties (November 20, 2009)
    • Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009)
    • Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009)
    • Estimated Average Premiums Under Current Law (December 5, 2009)
    • Additional Information About Employment-Based Coverage (December 7, 2009)
    • Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009)
Preliminary CBO documents
  • Barr, Donald A. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. JHU Press.  
  • CCH (2010). Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact. CCH Incorporated.   1183pp
  • Feldman, Arthur M. (2011). Understanding Health Care Reform: Bridging the Gap Between Myth and Reality. CRC Press.  
  • Jacobs, Lawrence R.; Theda Skocpol (2010). Health Care Reform and American Politics. Oxford U.P.  
  • John E. McDonough (August 2, 2011). Inside National Health Reform. University of California Press.  

Further reading

  1. ^ Pub.L. 111–148, 124 Stat. 119, codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C.
  2. ^ "Public Law 111–148".  
  3. ^ a b c d Wallace, Gregory (June 25, 2012). Obamacare': The word that defined the health care debate"'". CNN. Retrieved September 4, 2012. 
  4. ^ Pub.L. 111–152, 124 Stat. 1029, codified as amended at scattered sections of the Internal Revenue Code and in 42 U.S.C., 19 U.S.C., and 20 U.S.C.
  5. ^ Vicini, James; Stempel, Jonathan (June 28, 2012). "US top court upholds healthcare law in Obama triumph". Reuters. 
  6. ^ Pear, Robert (July 7, 2012). "Health Law Critics Prepare to Battle Over Insurance Exchange Subsidies".  
  7. ^ Krugman, Paul (January 31, 2010). "Krugman calls Senate health care bill similar to law in Massachusetts". Tampa Bay Times. Retrieved August 29, 2012. 
  8. ^ "ObamaCare Survives the Supreme Court: 5 Takeaways". The Week. June 28, 2012. Retrieved June 30, 2012. 
  9. ^ Elmendorf, Douglas W. (March 30, 2011). "CBO's Analysis of the Major Health Care Legislation Enacted in March 2010" (PDF).  
  10. ^ Elmendorf, Douglas W. (June 21, 2011). "CBO's 2011 Long-Term Budget Outlook" (PDF).  
  11. ^ ABA Health eSource (July 12, 2012). "Supreme Court Upholds PPACA". Retrieved November 20, 2013. 
  12. ^ Pg 55–58, slip opinion, National Federation of Independent Business v. Sebelius, U.S. Supreme Court (June 28, 2012)
  13. ^ Barrett, Paul M. (June 28, 2012). "Supreme Court Supports Obamacare, Bolsters Obama". BloombergBusinessweek. Retrieved June 30, 2012. 
  14. ^ National Post Wire Services (June 28, 2012). "Obamacare upheld by the U.S. Supreme Court". National Post. Retrieved June 30, 2012. 
  15. ^ Blumenthal D, Collins SR (2014). "Health care coverage under the Affordable Care Act--a progress report.". N Engl J Med 371 (3): 275–81.  
  16. ^ "What if I have a grandfathered health insurance plan?". 
  17. ^ Fernandez, Bernadette (April 27, 2010). "Grandfathered Health Plans Under the Patient Protection and Affordable Care Act (PPACA)". Congressional Research Service. 
  18. ^ a b U.S. Department of Health and Human Services (June 28, 2010). "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".  
  19. ^ a b Pool, Gentrie (October 7, 2010). "After PPACA: The Future of the Health Insurance Underwriter". Retrieved April 9, 2012. 
  20. ^ "Selected Patient Protection and Affordable Care Act (PPACA) implementation dates of interest to RNs as caregivers, RNs as patients, and RNs as employees". Retrieved April 9, 2012. 
  21. ^ a b Cohn, Jonathan (June 12, 2013). "You Call This Insurance?". The New Republic. 
  22. ^ a b "Essential Health Benefits – Glossary". September 23, 2010. Retrieved January 9, 2012. 
  23. ^ "HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress" (Press release). July 11, 2011. Retrieved April 9, 2012. 
  24. ^ "Patient Protection and Affordable Care Act of 2009: Health Insurance Exchanges". National Association of Insurance Commissioners. April 20, 2010. Retrieved April 9, 2012. 
  25. ^ "The Patients' Bill of Rights: Ending annual and lifetime limits" (Press release). FamiliesUSA. September 23, 2010. Retrieved April 9, 2012. 
  26. ^ a b c "Minimum Coverage Provision ("individual mandate")". American Public Health Association (APHA). 
  27. ^ "Perkins Accounting Firm Newsroom Bulletin Health Insurance Legislation Mandates" (Press release). April 9, 2012. Archived from the original on September 9, 2012. Retrieved March 4, 2013. 
  28. ^ Galewitz, Phil (March 26, 2010). "Consumers Guide To Health Reform". Kaiser Health News. 
  29. ^ a b Luhby, Tami (April 23, 2013). "Millions eligible for Obamacare subsidies, but most don't know it".  
  30. ^ a b c "Welcome to the Marketplace". HealthCare.Gov, managed by the  
    "What is the Health Insurance Marketplace?". HealthCare.Gov, managed by the  
  31. ^  
  32. ^ "Establishing Health Insurance Exchanges: An Overview of State Efforts". 
  33. ^ "Health Insurance Marketplace Opens, Offers Millions of Americans Quality, Affordable Health Care Coverage" (Press release). October 1, 2013. Retrieved October 4, 2013. 
  34. ^ Morgan, David; Begley, Sharon (September 30, 2013). "Obamacare push accelerates as government shutdown nears". Reuters. Retrieved October 1, 2013. Sebelius said on Monday that "the key date really is the 15th of December," the deadline for buying coverage that starts on January 1. 
  35. ^ "Glossary: Open Enrollment Period". Retrieved October 4, 2013. 
  36. ^ a b c d e "Explaining Health Care Reform: Questions About Health Insurance Subsidies". Kaiser Family Foundation. July 1, 2012. Retrieved July 1, 2012. 
  37. ^ a b Grier, Peter (March 20, 2010). "Health care reform bill 101: Who gets subsidized insurance?".  
  38. ^ Andrews, Michelle (August 27, 2013). "Health Insurance Exchanges Prompt Consumers' Questions".  
  39. ^ a b "Small Business Health Care Tax Credit for Small Employers". Internal Revenue Service. December 13, 2011. Retrieved January 9, 2012. 
  40. ^ a b "Where are States Today? Medicaid and CHIP Eligibility Levels for Children and Non-Disabled Adults". Kaiser Family Foundation. March 28, 2013. 
  41. ^ a b c "Medicaid Expansion". American Public Health Association (APHA). Is Medicaid eligibility expanding to 133 or 138 percent FPL, and what is MAGI?. Retrieved July 24, 2013. 
  42. ^ "Access". Medscape. Retrieved January 9, 2012. 
  43. ^ "Key Healthcare Reform Initiatives: Medicare Bundled Payment Pilots". Huron Consulting Group. November 19, 2010. Retrieved January 9, 2012. 
  44. ^ "More savings in the drug coverage gap coming through 2020". Centers for Medicare & Medicaid Services. Retrieved September 27, 2013. 
  45. ^ "Explaining Health Care Reform: What is Employer "Pay-or-Play" Requirement?".  
  46. ^ McNamara, Kristen (March 25, 2010). "What Health Overhaul Means for Small Businesses". The Wall Street Journal. 
  47. ^ Dorning, Mike; Wayne, Alex (July 3, 2013). "Health-Law Employer Mandate Delayed by U.S. Until 2015".  
  48. ^ a b c d Roy, Avik (February 7, 2012). "The Tortuous History of Conservatives and the Individual Mandate". Forbes Magazine. 
  49. ^ Cohn, Jonathan (April 9, 2010). "Common Sense". The New Republic. 
  50. ^ a b c Cooper, Michael (February 14, 2012). "Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later".  
  51. ^ a b c  
  52. ^ Cohn, Bob; Clift, Eleanor (September 18, 1994). "The Lost Chance".  
  53. ^ Fouhy, Beth (October 5, 2007). "Hillary Claims Credit for Child Program".  
  54. ^ a b "Chart: Comparing Health Reform Bills: Democrats and Republicans 2009, Republicans 1993". February 23, 2010. Retrieved July 29, 2012. 
    "Summary Of A 1993 Republican Health Reform Plan". February 23, 2010. Retrieved July 29, 2012. 
  55. ^ "In 1993, Republicans Proposed A Mandate First". NPR. March 31, 2012. 
  56. ^ "History of the Individual Health Insurance Mandate, 1989-2010 Republican Origins of Democratic Health Care Provision". February 9, 2012. 
  57. ^ a b "Facebook post says Republicans embraced individual mandate in 1993". PolitiFact. April 19, 2012. 
  58. ^ "AG Suthers couldn't be more wrong in his decision to file lawsuit". Retrieved July 29, 2012. 
  59. ^ "G.O.P. and Health Mandate". The New York Times. February 26, 2012. 
  60. ^ "Romneycare’s 98% Success Rate Defies Gripes on Obama Law". Bloomberg. March 26, 2012. 
  61. ^ Ball, Molly (May 31, 2012). "Was Mitt Romney a Good Governor?". The Atlantic. Retrieved October 28, 2013. 
  62. ^ a b  
  63. ^ "Bill Summary & Status - S.334".  
  64. ^ Kuttner, Robert (June 28, 2011). "RomneyCare vs. ObamaCare". The Boston Globe. Retrieved September 23, 2013. 
  65. ^ a b "Jonathan Gruber". MIT Department of Economics. Retrieved September 2, 2013. 
    "Jonathan Gruber: short biography". MIT Department of Economics. Retrieved September 2, 2013. 
  66. ^ Cline, Andrew. "How Obama Broke His Promise on Individual Mandates". The Atlantic. Retrieved September 26, 2013. 
  67. ^ "CNN Democratic presidential debate". CNN. January 21, 2008. Retrieved September 26, 2013. 
  68. ^ "The First Presidential Debate". The New York Times. September 26, 2008. 
  69. ^ "Remarks of President Barack Obama – Address to Joint Session of Congress". The White House. February 24, 2009. Retrieved March 24, 2010. 
  70. ^ a b c d e "Timeline: Milestones in Obama's quest for healthcare reform". Reuters. March 22, 2010. Retrieved March 22, 2010. 
  71. ^ Kruger, Mike (October 29, 2009). "Affordable Health Care for America Act".  
  72. ^ "Health Care Reform from Conception to Final Passage". Retrieved November 23, 2010. 
  73. ^ "Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN". C-SPAN. 
  74. ^ "Senate Finance Committee hearings for 111th Congress". Finance.Senate.Gov. Retrieved April 1, 2012. 
  75. ^ a b c Cohn, Jonathan (May 21, 2010). "How They Did It". The New Republic. 
  76. ^ Cohn, Jonathan (October 13, 2009). "The Top Ten Things Worth Fighting For". The New Republic. 
  77. ^ Cohn, Jonathan (September 4, 2009). "Party Is Such Sweet Sorrow". The New Republic. 
  78. ^ Chait, Jonathan (April 22, 2010). "Obama's Moderate Health Care Plan". The New Republic. 
    Chait, Jonathan (December 19, 2009). "The Republican Health Care Blunder". The New Republic. 
  79. ^ Chait, Jonathan (December 19, 2009). "The Republican Health Care Blunder". The New Republic. 
  80. ^ Hulse, Carl; Nagourney, Adam (March 16, 2010). "Senate G.O.P. Leader Finds Weapon in Unity". The New York Times. 
  81. ^ Eaton, Joe; Pell, M. B.; Mehta, Aaron (March 26, 2010). "Lobbying Giants Cash In On Health Overhaul". NPR. Retrieved April 9, 2012. 
  82. ^ Cohn, Jonathan (August 25, 2009). "Drug Deal". The New Republic. 
  83. ^ Grim, Ryan (August 13, 2009). "Internal Memo Confirms Big Giveaways In White House Deal With Big Pharma". Huffington Post. 
  84. ^ "Visualizing The Health Care Lobbyist Complex". Sunlight Foundation. July 22, 2009. Retrieved April 1, 2012. 
  85. ^ Horwitz, Sari; Pershing, Ben (April 9, 2010). "Anger over health-care reform spurs rise in threats against Congress members".  
  86. ^ Kellman, Laurie; Abrams, Jim (March 26, 2010). "Threats against lawmakers spread after health vote". Associated Press. 
  87. ^ "Remarks by the President to a Joint Session of Congress on Health Care". The White House. September 10, 2009. Retrieved March 24, 2010. 
  88. ^  
  89. ^ Maze, Rick (October 8, 2009). "House OKs tax breaks for military homeowners".  
  90. ^ U.S. Const. art. I, § 7, cl. 1.
  91. ^ S.Amdt. 2786
  92. ^ Cohn, Jonathan (September 7, 2009). "Why Reform Survived August". The New Republic. 
  93. ^ a b c Hacker, Jacob S. (December 20, 2009). "Why I Still Believe in This Bill". The New Republic. 
  94. ^ a b Cohn, Jonathan (March 12, 2010). "The Public Option, Still Dead". The New Republic. 
  95. ^ Angell, Marcia (November 9, 2009). "Is the House Healthcare Bill Better Than Nothing?". The Huffington Post. Retrieved January 12, 2012. 
  96. ^ Cohn, Jonathan (December 15, 2009). "What Public Option Supporters Won". The New Republic. 
  97. ^ Cohn, Jonathan (December 17, 2009). "Ben Nelson, Still a Big Problem (Updated)". The New Republic. 
  98. ^ Raju, Manu (January 20, 2010). "Olympia Snowe puzzled by Harry Reid comments". Politico. 
  99. ^ Chait, Jonathan (December 19, 2009). "The Republican Health Care Blunder". The New Republic. 
    Chait, Jonathan (January 19, 2010). "Revisiting Snowe's Lay Down". The New Republic. 
    Chait, Jonathan (March 16, 2010). "(Non)sense of Snowe". The New Republic. 
  100. ^ Cohn, Jonathan (December 19, 2009). "BREAKING: Nelson Says Yes; That Makes 60". The New Republic. 
  101. ^ Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment"'".  
  102. ^ "Roll Call vote No. 396 – On Passage of the Bill (H.R. 3590 as Amended)". U.S. Senate. Retrieved January 9, 2012. 
  103. ^ "AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation". The Huffington Post, March 19, 2010.
  104. ^ Applewhite, J. Scott. "Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts". McClatchy-Tribune News Service. Associated Press. Retrieved April 19, 2012. 
  105. ^ "Public Statements – Project Vote Smart" (Press release). January 13, 2010. Retrieved April 9, 2012. 
  106. ^ Silver, Nate (January 21, 2010). "Will the Base Abandon Hope?".  
  107. ^ a b c d Cohn, Jonathan (January 17, 2010). "How to Pass the Bill--Whatever Happens Tuesday". The New Republic. 
  108. ^ a b c Stolberg, Sheryl; Zeleny, Jeff; Hulse, Carl (March 20, 2010). "Health Vote Caps a Journey Back From the Brink".  
  109. ^ a b Brown, Carrie; Thrush, Glenn (March 20, 2010). "Pelosi steeled W.H. for health push".  
  110. ^ "White House Unveils Revamped Reform Plan, GOP And Industry React". February 22, 2010. Retrieved June 29, 2012. 
  111. ^ Pollack, Harold. "'"47 (Now 51) Health Policy Experts (Including Me) Say 'Sign the Senate bill.. The New Republic. Retrieved January 12, 2012. 
  112. ^ a b Chait, Jonathan (February 20, 2010). "A Brief Reconciliation Primer". The New Republic. 
  113. ^ a b Silver, Nate (December 26, 2009). "For Pelosi, Many Paths to 218".  
  114. ^ Silver, Nate (January 21, 2010). "1. Reconciliation! 2. ??? 3. Profit!".  
  115. ^ Cohn, Jonathan (September 21, 2009). "Reconciliation: Why Most Dems Don't Want to Go There". The New Republic. 
  116. ^ Executive Order 13535 of March 24, 2010 — Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act, Vol. 75, No. 59 75 F.R. 15599, March 29, 2010.
  117. ^ Chait, Jonathan (March 21, 2010). "Stupak Makes A Deal, Reform To Pass". The New Republic. 
  118. ^ "Roll Call vote No. 165: On Motion to Concur in Senate Amendments (Patient Protection and Affordable Care Act)". Office of the Clerk: House of Representatives. March 21, 2010. Retrieved April 9, 2012. 
  119. ^ Aro, Margaret; Mooney, Mark (March 22, 2010). "Pelosi Defends Health Care Fight Tactics".  
  120. ^ Stolberg, Sheryl; Pear, Robert (March 23, 2010). "Obama Signs Health Care Overhaul Bill, With a Flourish". The New York Times. Retrieved March 24, 2010. 
  121. ^ "Is the Affordable Care Act Helping or Hurting?".  
  122. ^ a b c d "Cost Estimate for Pending Health Care Legislation".  
  123. ^ "Updated Estimates for the Insurance Coverage Provisions of the Affordable Care Act". Congressional Budget Office. March 13, 2012. Retrieved April 6, 2012. 
  124. ^ a b Pecquet, Julian (March 13, 2012). "CBO: Obama's health law to cost less, cover fewer people than first thought". The Hill. Retrieved June 29, 2012. 
  125. ^ "Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision". CBO. July 24, 2012. Retrieved February 23, 2012. 
  126. ^ a b Fox, Emily Jane (July 24, 2012). "6 million will lose out on Medicaid expansion". CNNMoney (CNN). Retrieved July 25, 2012. 
  127. ^ a b Chaikind, Hinda; Copeland, Curtis W.; Redhead, C. Stephen; Staman, Jennifer (March 2, 2011). "PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges".  
  128. ^ a b c Trumbull, Mark (March 23, 2010). "Obama signs health care bill: Who won't be covered?".  
  129. ^ "Medical Debt Huge Bankruptcy Culprit - Study: It's Behind Six-In-Ten Personal Filings".  
  130. ^ Cohn, Jonathan (January 19, 2011). "Why Today's Vote Matters". The New Republic. 
    Cohn, Jonathan (June 13, 2012). "Obamacare, Good for the Economy". The New Republic. 
    Cohn, Jonathan (February 11, 2011). "Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs". The New Republic. 
  131. ^ a b Cohn, Jonathan (March 7, 2010). "What, You Have a Better Idea for Cost Control?". The New Republic. 
  132. ^ "Insurers to Bail on Child-Only Policies as Health Care Law Looms". CBS News. September 22, 2010. 
  133. ^ Helfand, Duke (September 21, 2010). "Big health insurers to stop selling new child-only policies". Los Angeles Times. 
  134. ^ "Report: Access to Child-Only Health Plans Declines Under New Health Care Law" (Press release).  
  135. ^ DeNavas-Walt, Carmen; et al. (September 8, 2011). "Income, Poverty, and Health Insurance Coverage in the United States: 2010".  
  136. ^ "Public- and Private-Sector Initiatives Are Reducing Health Disparities Among Children: A Conversation With Kathryn Santoro, MA, Director of Policy and Development for the National Institute for Health Care Management Foundation". Agency for Healthcare Research and Quality. 2013-04-24. Retrieved 2013-09-26. 
  137. ^ "A Cruel Blow to American Families". The New York Times. February 2, 2013. 
  138. ^ Cohn, Jonathan (February 5, 2013). "Not-So-Universal Health Care". The New Republic. 
  139. ^ "Commonwealth Fund-New Survey-July 10, 2014". Retrieved 2014-07-29. 
  140. ^ "In U.S., Uninsured Rate Sinks to 13.4% in Second Quarter-July 10, 2014". Retrieved 2014-07-29. 
  141. ^ "Rand Corporation-Changes in Health Insurance Enrollment Since 2013-2014". Retrieved 2014-07-29. 
  142. ^ Young, Jeffrey (September 14, 2014). "Almost All Obamacare Enrollees Are Paying For Coverage".  
  143. ^ "Insurance Exchanges". American Public Health Association (APHA). 
  144. ^ a b Cohn, Jonathan (April 29, 2013). "Obamacare Sticker Shock: Not Very Shocking". The New Republic. 
  145. ^ Cohn, Jonathan (April 30, 2013). "'"Obamacare's New Paperwork Is Simpler than Private Insurers. The New Republic. 
    Cohn, Jonathan (April 29, 2013). "Why Obamacare Is Not a 'Train Wreck' (Again)". The New Republic. 
  146. ^ Young, Jeffery (September 25, 2013). "Obamacare Benefits Enrollment Will Start Slowly, White House Predicts". The Huffington Post. Retrieved October 2, 2013. 
  147. ^ a b Cohn, Jonathan (August 5, 2013). "Burn Your Obamacare Card, Burn Yourself". The New Republic. 
  148. ^ a b Public Law 111 – 148, 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)."
  149. ^ "ACA Basics and Background". American Public Health Association (APHA). 3. Why do we need the ACA?. Retrieved July 25, 2013. 
  150. ^ Cohn, Jonathan (January 18, 2011). "More Government in Health Care? Yes. You Got a Problem With That?". The New Republic. 
    Cohn, Jonathan (April 15, 2011). "When Republicans Oppose Competition". The New Republic. 
  151. ^ "Summary of Benefits and Coverage". HealthCare.Gov, managed by the  
  152. ^ Kliff, Sarah (May 30, 2013). "Are Obamacare's Exchanges Competitive? Here's What The Experts Say". The Washington Post. 
  153. ^ Cohn, Jonathan (May 31, 2013). "Another Obamacare Train Wreck Not Happening". The New Republic. 
  154. ^ Trish Riley; Jane Hyatt Thorpe. "Multi-State Plans Under the Affordable Care Act". George Washington University Medical Center, Department of Health Policy. 
  155. ^ Abelson, Reed (June 16, 2013). "Choice of Health Plans to Vary Sharply From State to State".  
  156. ^ a b Cox, Cynthia; Claxton, Gary; Levitt, Larry (June 6, 2013). "Beyond Rebates: How Much Are Consumers Saving from the ACA's Medical Loss Ratio Provision?".  
  157. ^ a b c Cohn, Jonathan (March 21, 2012). "Reform With No Mandate? Ask New Jersey About That". The New Republic. 
  158. ^ Cohn, Jonathan (January 18, 2011). "More Government in Health Care? Yes. You Got a Problem With That?". The New Republic. 
    Cohn, Jonathan (July 15, 2013). "Obamacare's Individual Mandate Can't Wait". The New Republic. 
  159. ^ McClanahan, Carolyn (August 4, 2013). "Reader's Questions About Obamacare – Misinformation Abounds". Forbes. Retrieved 15 August 2013. 
  160. ^ a b Pippenger, Nathan (March 28, 2012). "Health Care Reform Without The Mandate?". The New Republic. 
  161. ^ Cohn, Jonathan (April 9, 2010). "Common Sense". The New Republic. 
    Cohn, Jonathan (April 2, 2012). "What If the Mandate Goes?". The New Republic. 
  162. ^ Cohn, Jonathan (July 15, 2013). "Obamacare's Individual Mandate Can't Wait". The New Republic. 
    Cohn, Jonathan (April 2, 2012). "What If the Mandate Goes?". The New Republic. 
  163. ^ Cohn, Jonathan (June 8, 2012). "Just in Case: How Reform Might Survive Without the Mandate". The New Republic. 
  164. ^ Cohn, Jonathan (April 2, 2012). "What If the Mandate Goes?". The New Republic. 
    Cohn, Jonathan (June 8, 2012). "Just in Case: How Reform Might Survive Without the Mandate". The New Republic. 
  165. ^ Krugman, Paul (January 8, 2010). "One Health Reform, Indivisible". The New York Times. 
  166. ^ Banthin, Jessica (March 20, 2012). "Effects of Eliminating the Individual Mandate to Obtain Health Insurance". CBO. 
  167. ^ a b Jonathan Gruber (February 2011). "Health Care Reform without the Individual Mandate". Center for American Progress. 
  168. ^ Eibner, Christine; Price, Carter (2012). "The Effect of the Affordable Care Act on Enrollment and Premiums, With and Without the Individual Mandate". Rand Health. 
  169. ^ Cohn, Jonathan (April 9, 2010). "Common Sense". The New Republic. 
    Cohn, Jonathan (April 2, 2012). "What If the Mandate Goes?". The New Republic. 
    Cohn, Jonathan (December 26, 2011). "Was the Mandate a Mistake?". The New Republic. 
  170. ^ Cohn, Jonathan (December 26, 2011). "Was the Mandate a Mistake?". The New Republic. 
  171. ^ Alonso-Zaldivar, Ricardo (September 19, 2012). "Tax penalty to hit nearly 6M uninsured people". Associated Press. Archived from the original on September 20, 2012. 
  172. ^ Cohn, Jonathan (August 1, 2013). "Six Reasons Hipsters Will Bite on Obamacare". The New Republic. 
  173. ^ a b "State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Table". Kaiser Family Foundation. May 28, 2013. 
    "State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Map". Kaiser Family Foundation. May 28, 2013. 
  174. ^ a b "State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 - Notes". Kaiser Family Foundation. May 28, 2013. 
  175. ^ "State Health Insurance Exchange Laws: The First Generation". The CommonWealth Fund. July 25, 2012. 
  176. ^ Adams, Rebecca (July 22, 2013). "The Question of Abortion Coverage in Health Exchanges".  
  177. ^ "Obamacare: Separating Myth From Fact". Taylor Benefits. December 18, 2013. Retrieved December 18, 2013. 
  178. ^ a b "Public Law 111 – 148, section 1332". Retrieved June 29, 2012. 
  179. ^ "Preparing for Innovation: Proposed Process for States to Adopt Innovative Strategies to Meet the Goals of the Affordable Care Act". U.S. Department of Health & Human Services. November 16, 2011. Retrieved April 1, 2012. 
  180. ^ Goldstein, Amy; Balz, Dan (March 1, 2011). "Obama offers states more flexibility in health-care law". The Washington Post. 
  181. ^ "Gov. Shumlin issued the following statement on health care rules". March 14, 2011. Retrieved April 1, 2012. 
  182. ^ Estes, Adam Clark (May 26, 2011). "Vermont Becomes First State to Enact Single-Payer Health Care". The Atlantic. Retrieved April 1, 2012. 
  183. ^ Wing, Nicholas (May 26, 2011). "Vermont Single-Payer Health Care Law Signed By Governor". The Huffington Post. 
  184. ^ Cohen, Tom (October 23, 2013). "Rough Obamacare rollout: 4 reasons why". CNN. Retrieved November 5, 2013. 
  185. ^ Editorial Board (November 4, 2013). "Obamacare's critics justified: Our view". USA Today. 
  186. ^ Holland, Steve; Rampton, Roberta (November 6, 2013). "Senate Democrats frustrated with botched rollout of Obamacare". Reuters (Christian Science Monitor). Retrieved November 19, 2013. 
  187. ^ Kennedy, Kelly (December 1, 2013). "White House claims success on repairs". USA Today. Retrieved December 1, 2013. 
  188. ^ Dwyer, Devin (November 6, 2013). Obamacare' Memos Reveal Chaos, Confusion of October Rollout"'". ABC News. Retrieved November 19, 2013. 
  189. ^ Haberkorn, Jennifer; Allen, Jonathan (October 24, 2013). "Hill Democrats frustrated by Obamacare rollout". Retrieved November 19, 2013. 
  190. ^ Jones, Willie (November 4, 2013). "The Obamacare Rollout: What Really Happened?". IEEE Spectrum. Retrieved November 19, 2013. 
  191. ^ Cornwell, Susan (November 1, 2013). "Factbox: U.S. officials mired in controversy over Obamacare rollout". Reuters (Yahoo! News). Retrieved November 20, 2013. 
  192. ^ Blackstone, John (November 8, 2013). "S.F. programmers build alternative to". CBS News. Retrieved November 19, 2013. 
  193. ^ Simpson, Connor (November 2, 2013). "Three Guys Built a Better". The Atlantic. Retrieved November 19, 2013. 
  194. ^ Miller, S. A. (November 20, 2013). "Obama wants to rebrand, remarket ObamaCare". New York Post. Retrieved November 20, 2013. 
  195. ^ Gross, Grant (November 5, 2013). "Senators question security at". NetworkWorld. Retrieved December 1, 2013. 
  196. ^ Clayton, Mark (November 19, 2013). "Is secure? In Congress, cyber-experts vouch for Obamacare site". The Christian Science Monitor. Retrieved December 1, 2013. 
  197. ^ Finkle, Jim; Selyukh, Alina (November 19, 2013). "Some cyber security experts recommend shutting Obamacare site". Reuters. Retrieved December 1, 2013. 
  198. ^ "Promoting the Affordable Care Act to Indigenous Peoples". Indian Country Today Media Network. 2014-03-23. Retrieved 2014-03-28. 
  199. ^ "Committee Learns Who's Paid for Obamacare: As of April 15, Only 67 Percent of Enrollees in Federal Marketplace Had Paid First Month's Premium". House Energy and Commerce Committee. April 30, 2014. 
  200. ^ "Ranking Member Waxman Releases Memo on Misleading Republican Report on ACA Enrollment". Energy and Commerce Committee Democrats. April 30, 2014. 
  201. ^ Werner, Erica (May 7, 2014). "Health insurers: Payment rates above 80 percent". Associated Press. Retrieved May 7, 2014. 
  202. ^ Alonso-Zaldivar, Ricardo (July 31, 2014). "Probe exposes flaws behind rollout".  
  203. ^ a b c Binckes, Jeremy; Wing, Nick (March 22, 2010). "The Top 18 Immediate Effects Of The Health Care Bill". The Huffington Post. Retrieved March 22, 2010. 
  204. ^ "I have been denied coverage because I have a pre-existing condition. What will this law do for me?". Health Care Reform Frequently Asked Questions. New Hampshire Insurance Department. p. 2. Retrieved June 28, 2012. 
  205. ^ H.R. 3590 Enrolled, section 1001 (adding section 2714 to the Public Health Service Act): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age."
  206. ^ Pear, Robert (May 10, 2010). "Rules Let Youths Stay on Parents' Insurance". The New York Times. 
  207. ^ "Key Features of the Affordable Care Act By Year". June 7, 2013. Retrieved June 7, 2013. 
  208. ^ a b c Levitt, Larry; Claxton, Gary; Pollitz, Karen (October 18, 2011). "Questions About Essential Health Benefits". Kaiser Family. 
  209. ^ "Essential Health Benefits"., managed by the  
    "What does Marketplace health insurance cover?". HealthCare.Gov, managed by the  
  210. ^ "Quick Take: Essential Health Benefits: What Have States Decided for Their Benchmark?". Kaiser Family. December 7, 2012. 
  211. ^ a b "Summary of the Affordable Care Act". Kaiser Family Foundation. April 23, 2013. 
  212. ^ "Health Insurance Market Reforms: Prevention". Centers for Medicare and Medicaid Services. December 21, 2010. Retrieved September 8, 2013. 
  213. ^ "Next Steps to Comply with Health Care Reform". The National Law Review. October 10, 2012. Retrieved October 10, 2012. 
  214. ^ "How do I choose Marketplace insurance?". HealthCare.Gov, managed by the  
  215. ^ "Health Plan Categories". HealthCare.Gov, managed by the  
  216. ^ "Medical Loss Ratio". Centers for Medicaid and Medicare Services. Retrieved October 2, 2013. 
  217. ^ "Medical Loss Ratio Requirements Under the Patient Protection and Affordable Care Act". Federal Register 76 (235). December 7, 2011. p. 76573. Retrieved April 1, 2012. 
  218. ^ PPACA, 2713,(a)(4)
  219. ^ Women's Preventive Services Guidelines HRSA, US Department of Health and Human Services
  220. ^ "Women's Preventive Services Coverage and Non-Profit Religious Organizations". Centers for Medicare and Medicaid Services. Retrieved September 8, 2013. 
  221. ^ Kliff, Sarah (August 1, 2012). "Five facts about the health law's contraceptive mandate". The Washington Post. Retrieved November 29, 2012. 
  222. ^ Dept. Health and Human Services (February 10, 2012). "Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules" (77 FR 8725). Federal Register. Retrieved February 15, 2012. 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. 
  223. ^ Park, Madison (July 19, 2011). "Birth control should be fully covered under health plans, report says". CNN. Retrieved August 27, 2012. 
  224. ^ Cohn, Jonathan (February 8, 2012). "Religious Institutions Matter. So Do Their Employees". The New Republic. 
  225. ^ Cohn, Jonathan (February 10, 2012). "Obama's Deal on Birth Control Coverage". The New Republic. 
  226. ^ Mears, Bill (March 23, 2014). "Justices to hear 'Hobby Lobby' case on Obamacare birth control rule". CNN. Retrieved March 28, 2014. 
  227. ^ Burwell v. Hobby Lobby, 573 U.S. (United States Supreme Court 2014).
  228. ^ "Wheaton College v. Burwell (573 U. S. ____ (2014)): 2014-07-03 injunction pending appeal order". U.S. Supreme Court. 3 July 2014. Retrieved 9 July 2014. 
  229. ^ Liptak, Adam (3 July 2014). "Birth Control Order Deepens Divide Among Justices". The New York Times. Retrieved 9 July 2014. 
  230. ^ Adler, Jonathan A. (3 July 2014). "Supreme Court grants Wheaton College an injunction against contraception mandate accommodation". The Washington Post. Retrieved 9 July 2014. 
  231. ^ Dockterman, Eliana (9 July 2014). "Supreme Court Rules on Religious College’s Birth Control Plea". Time Magazine. Retrieved 9 July 2014. 
  232. ^ Jaschik, Scott (7 July 2014). "Religious College Exemption". Retrieved 9 July 2014. 
  233. ^ Liptak, Adam; Pear, Robert (4 July 2014). "Obama Weighs Steps to Cover Contraception". Retrieved 9 July 2014. 
  234. ^ Cohn, Jonathan (April 29, 2013). "Obamacare Sticker Shock: Not Very Shocking". The New Republic. 
    Cohn, Jonathan (June 5, 2013). "Un-rigging the Rate-Shock Debate". The New Republic. 
  235. ^ Chait, Jonathan (June 5, 2013). "Is Obamacare a War on Bros?". New York. 
  236. ^ a b Hensley, Scott (September 26, 2013). How Much Will Obamacare Cost Me?' Try Our Calculator"'".  
  237. ^ Cohn, Jonathan (August 14, 2013). "The Big Savings Obamacare Critics Miss". The New Republic. 
  238. ^ a b c "Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act" (PDF). Congressional Budget Office. December 19, 2009. Retrieved March 22, 2010. 
  239. ^ a b "An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act". November 30, 2009. Retrieved June 29, 2012. 
  240. ^ Cohn, Jonathan (July 18, 2013). "The Obamacare Train Still Hasn't Wrecked". The New Republic. 
  241. ^ Chait, Jonathan (September 26, 2013). "Someone Tell Ted Cruz the Obamacare War Is Over". New York. 
  242. ^ Goddard, Teagan (September 5, 2013). "(Kaiser Family Foundation) Study Finds 'Lower Than Expected' Obamacare Premiums". Teagan Goddard's Wonkwire. 
  243. ^ Mukherjee, Sy (September 5, 2013). "Major New Study On Obamacare Premiums Should End The 'Rate Shock' Hysteria Once And For All".  
  244. ^ Aigner-Treworgy, Adam (March 27, 2013). "Health care law will raise insurers' costs, actuaries say". PoliticalTicker... blog (CNN). Retrieved April 12, 2013. 
    Robertson, Lori (April 5, 2013). "Health Insurance Premium Spin". Philadelphia:  
  245. ^ a b c Alonso-Zaldivar, Ricardo (November 27, 2011). "AP Newsbreak: Medicare's drug coverage gap shrinks".  
  246. ^ a b c "Health Costs and the Federal Budget". Congressional Budget Office. May 28, 2010. Retrieved April 1, 2012. 
  247. ^ Cohn, Jonathan (December 11, 2009). "New Cost Estimate on Senate Bill". The New Republic. 
  248. ^ a b c Cohn, Jonathan (January 21, 2011). "The GOP's Trick Play". The New Republic. 
  249. ^ a b Scheiber, Noam (September 17, 2009). "Is the CBO Biased Against Health Care Reform?". The New Republic. 
  250. ^ Gruber, Jonathan (2011). Health Care Reform: What It Is, Why It's Necessary, How It Works. United States: Hill and Wang. p. 101.  
  251. ^  , revised published in: National Tax Journal, Vol. 64, 2011, p. 893-908
  252. ^ Kuraitis V. (2010). Pilots, Demonstrations & Innovation in the ACA Healthcare Reform Legislation.
  253. ^ Gawande, Atul (December 14, 2009). "Testing, Testing".  
  254. ^ Farley, Robert (March 19, 2010). "Obama says health reform legislation could reduce costs in employer plans by up to $3,000". Retrieved April 7, 2010. 
  255. ^ "Centers for Medicare and Medicaid Services-Statistics, Trends and Reports". Retrieved September 23, 2013. 
  256. ^ Cohn, Jonathan (April 12, 2011). "More Skin in the Game – for Seniors?". The New Republic. 
  257. ^ a b c Lowrey, Annie (May 7, 2013). "Slowdown in Rise of Healthcare Costs May Persist".  
  258. ^ Levin, Yuval (May 24, 2013). "Healthcare Costs and Budget".  
  259. ^ a b Chait, Jonathan (May 29, 2013). "Yuval Levin Dissembles Madly". New York. 
  260. ^ a b Chait, Jonathan (May 10, 2013). "The Facts Are In and Paul Ryan Is Wrong". New York. 
  261. ^ Chait, Jonathan (September 26, 2013). "Someone Tell Ted Cruz the Obamacare War Is Over". New York. 
  262. ^ Wayne, Alex (June 18, 2013). "Health Cost Growth Slows Further Even as Economy Rebounds". Bloomberg L.P. 
  263. ^ "Assessing the Effects of the Economy on the Recent Slowdown in Health Spending".  
  264. ^ Krawzak, Paul (June 14, 2013). "In Spending Debate, Baby Boomer Issue Remains a Headache for Legislators". Roll Call. 
  265. ^ "Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act". Congressional Budget Office. March 16, 2012. Retrieved October 7, 2013. 
  266. ^ a b "CBO's Analysis of the Major Health Care Legislation Enacted in March 2010". Congressional Budget Office. March 30, 2011. Retrieved April 6, 2012. 
  267. ^ "Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act". Congressional Budget Office. March 16, 2012. Retrieved April 6, 2012. 
  268. ^ "H.R. 4872, Reconciliation Act of 2010" (PDF). Congressional Budget Office. March 18, 2010. Retrieved March 22, 2010. 
  269. ^ Dennis, Steven (March 18, 2010). "CBO: Health Care Overhaul Would Cost $940 Billion".  
  270. ^ Klein, Ezra (March 22, 2010). "What does the health-care bill do in its first year?".  
  271. ^ Judith Solomon; Paul N. Van de Water (April 18, 2012). "Letter: Improving the Strength and Solvency of Medicare". The Center on Budget and Policy Priorities. 
  272. ^ "CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision". Congressional Budget Office. July 24, 2012. Retrieved August 6, 2012. 
  273. ^ Sahadi, Jeanne (March 13, 2012). "Health reform coverage cost falls slightly". CNN. Retrieved June 29, 2012. 
  274. ^ a b "Affordable Care Act Update: Implementing Medicare Cost Savings". Centers for Medicare and Medicaid Services. August 2, 2010. Retrieved October 7, 2013. 
  275. ^ "Higher Spending Relative to Medicare Fee-for-Service May Not Ensure Lower Out-of-Pocket Costs for Beneficiaries". Government Accountability Office. February 8, 2008. Retrieved October 7, 2013. 
  276. ^ "Where does health care reform stand?". CNN. March 18, 2010. Retrieved May 12, 2010. 
  277. ^ Farley, Robert (March 18, 2010). "Pelosi: CBO says health reform bill would cut deficits by $1.2 trillion in second decade".  
  278. ^ "Sen. Tom Coburn: Obamacare PR campaign anchored in spin, not reality". The Washington Examiner. July 8, 2006. Retrieved April 1, 2012. 
  279. ^ James Capretta. "'"Obamacare's Cooked Books and the 'Doc Fix. National Review. 
  280. ^ Hogberg, David (November 22, 2010). "'"GOP Might Target ObamaCare As Part Of A Medicare 'Doc Fix. Investor's Business Daily. Retrieved April 1, 2012. 
  281. ^ "Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010". Congressional Budget Office. March 19, 2010. Retrieved April 1, 2012. 
  282. ^ Chait, Jonathan (March 24, 2010). "The Doc Fix Myth And The Right's Misinformation Feedback Loop". The New Republic. 
  283. ^ Van de Water, Peter. "Debunking False Claims About Health Reform, Jobs, and the Deficit". Center for Budget and Policy Priorities. 
  284. ^  
  285. ^ Holtz-Eakin, Douglas (March 21, 2010). "The Real Arithmetic of Health Care Reform". The New York Times. 
  286. ^ "Electronic Medical Records (Health Information Technology)". 
  287. ^ James, Frank (March 19, 2010). "Health Overhaul Another Promise U.S. Can't Afford: Expert".  
  288. ^ "Congress Has Good Record of Implementing Medicare Savings". CBPP. Retrieved March 28, 2010. 
  289. ^ "Can Congress cut Medicare costs?". The Washington Post. Retrieved March 28, 2010. 
  290. ^ a b Chait, Jonathan (July 3, 2013). "Obamacare Still Not Collapsing". New York. 
  291. ^ a b Cohn, Jonathan (July 15, 2013). "Obamacare's Individual Mandate Can't Wait". The New Republic. 
  292. ^ a b Government Printing Office. "Title 26 - Internal Revenue Code". 
  293. ^ a b c Cohn, Jonathan (May 21, 2013). "Weaseling Out of Obamacare". The New Republic. 
  294. ^ a b "Data Note: Americans' Satisfaction with Insurance Coverage". Kaiser Family Foundation. August 31, 2009. 
    "Data Note: Americans' Satisfaction with Insurance Coverage, Poll PDF". Kaiser Family Foundation. September 2009. 
  295. ^ "Health Coverage & Uninsured". Kaiser Family Foundation. June 20, 2013. 
    "Health Insurance Coverage of the Total Population". Kaiser Family Foundation. June 20, 2013. 
  296. ^ "'"Pg 14 of 'Kaiser Health Tracking Poll: June 2013. Kaiser Family Foundation. June 2013. 
  297. ^ a b c d Chait, Jonathan (July 3, 2013). "Obama Employer Mandate Delay Train Wreck! Or Not". New York. 
  298. ^ a b c Sarah Kliff (May 6, 2013). "Will Obamacare lead to millions more part-time workers? Companies are still deciding". Washington Post. 
  299. ^ Kincaid, David. "Obamacare Side Effect: Rise of the Part-Time Economy". Free Enterprise. Retrieved 11 November 2014. 
  300. ^ Hiltzik, Mike. "This Boehner/McConnell Obamacare 'fix' could hurt millions of Americans". LA Times. Retrieved 11 November 2014. 
  301. ^ a b c Ungar, Rick. "The Real Numbers On 'The Obamacare Effect' Are In-Now Let The Crow Eating Begin". Forbes. Retrieved 11 November 2014. 
  302. ^ "Employment Situation Summary". Bureau of Labor & Statistics. Retrieved 11 November 2014. 
  303. ^ Conover, Chris. "Who Can Deny It? Obamacare Is Accelerating U.S. Towards A Part-Time Nation". Forbes. Retrieved 11 November 2014. 
  304. ^ Bill Sizemore (February 8, 2013). "Va. workers' part-time hours capped due to health law". The Virginian-Pilot. 
    Annie-Rose Strasser (February 11, 2013). "Virginia Cuts State Employees' Hours To Avoid Providing Obamacare Coverage". ThinkProgress. 
  305. ^ Ned Resnikoff (January 14, 2013). "Colleges roll back faculty hours in response to Obamacare". MSNBC. 
    Sy Mukherjee (January 14, 2013). "Four Public Colleges Will Cut Adjunct Faculty Hours To Avoid Providing Health Coverage Under Obamacare". ThinkProgress. 
  306. ^ a b "As Health Law Changes Loom, A Shift To Part-Time Workers". NPR. April 29, 2013. 
  307. ^ Jared Bernstein (September 4, 2013). "Stop Blaming Obamacare for Part-Time Workers". Teagan Goddard's Wonkwire. 
  308. ^ Matthew Yglesias (July 15, 2013). "Obamacare's Not To Blame For Increasing Part-time Work". Slate. 
  309. ^ Timothy Jost (July 2, 2013). "Implementing Health Reform: A One-Year Employer Mandate Delay". Health Affairs. 
  310. ^ a b c Cohn, Jonathan (July 2, 2013). "Some Bad News About Obamacare That Isn't Bogus". The New Republic. 
  311. ^ "Am I eligible for coverage in the Marketplace?". HealthCare.Gov, managed by the  
  312. ^ a b c Robert Greenstein and Judith Solomon (July 3, 2013). "Finance Committee Makes Flawed Employer Requirement in Health Reform Bill Still More Problematic".  
  313. ^ a b c d e Ezra Klein (July 2, 2013). "Will Obamacare lead to millions more part-time workers? Companies are still deciding". Washington Post. 
  314. ^ Matthew Yglesias (July 3, 2013). "Delaying Employer Responsibility Fines Is a Good Idea—the Real Problem Comes Later". Slate. 
  315. ^ Chait, Jonathan (July 3, 2013). "Obamacare Haters Struggling to Understand What 'Nonessential' Means". New York. 
    Chait, Jonathan (July 3, 2013). "Obamacare Still Not Collapsing". New York. 
  316. ^ Cohn, Jonathan (July 8, 2013). "An Obamacare Debate We Should Be Having". The New Republic. 
  317. ^ "Union Letter: Obamacare Will 'Destroy The Very Health and Wellbeing' of Workers", The Wall Street Journal, July 12, 2013
  318. ^ a b c Madara, Matthew R. (February 11, 2014). "ACA Employer Shared Responsibility Delay Included in Final Regs". Tax Notes Today. 2014 TNT 28-1. 
  319. ^ Mazur, Mark. "Continuing to Implement the ACA in a Careful, Thoughtful Manner". United States Department of the Treasury. Retrieved July 16, 2013. 
  320. ^ Torres, Carlos (January 27, 2014). "Economists See Little Effect on Hiring From U.S. Health-Care Law". Bloomberg L.P. Retrieved January 27, 2014. 
  321. ^ "A Town Hall, and a Health Care Model, in Green Bay". The White House Blog. The White House. Retrieved November 9, 2013. 
  322. ^ a b c Jacobson, Louis. "'"Barack Obama says that what he'd said was you could keep your plan 'if it hasn't changed since the law passed. PolitiFact. Times Publishing Company. Retrieved November 9, 2013. 
  323. ^ "After the big Obamacare apology: where things stand". CNN. November 8, 2013. Retrieved November 9, 2013. 
  324. ^ "Obama apologizes for insurance cancellations due to Obamacare". Retrieved 2014-07-29. 
  325. ^ Obama blames 'bad apple' insurers for canceled coverage,, October 30, 2013
  326. ^ Sealover, Ed (November 8, 2013). "Health insurers say they're canceling plans because of federal law". Denver Business Journal ( Retrieved November 9, 2013. 
  327. ^ "Obama apologizes to Americans who lost health plans". Fox News. November 8, 2013. Retrieved November 9, 2013. 
  328. ^ Schoof, Renee (November 8, 2013). "Congress weighing laws to let people keep health insurance". McClatchyDC. Retrieved November 14, 2013. 
  329. ^ Weigel, David (November 8, 2013). "The White House's Website Still Says If You Like Your Plan You Can Keep It". Retrieved November 9, 2013. 
  330. ^ "Obamacare: The debacle".  
  331. ^ With elections looming, Obamacare rattling Democratic nerves, CNN, November 8, 2013
  332. ^ """Krauthammer: Obamacare Turned A Landslide In Virginia Into A "Cliffhanger. Real Clear Politics. November 6, 2013. Retrieved November 10, 2013. 
  333. ^ Goldberg, Jonah (November 5, 2013). "Jonah Goldberg: Obama health lie freaks Dems". USA Today. 
  334. ^ Wemple, Erik (November 6, 2013). "'"Jon Stewart of 'The Daily Show' calls Obama 'somewhat dishonest', accuses opponents of 'lying. Washington Post. 
  335. ^ "Some Illinois Medicaid patients' assets at risk". 2014-02-05. Retrieved 2014-08-04. 
  336. ^ a b "Obama and Democrats' Health Care Plan". RealClearPolitics. October 13, 2013. Retrieved March 26, 2014. 
  337. ^ Swanson, Emily (July 30, 2009). "Health Care Plan: Favor/Oppose". 
  338. ^ "As Health Care Law Proceeds, Opposition and Uncertainty Persist". Pew Research Center. September 16, 2013. 
  339. ^ Page, Susan (March 24, 2010). "Poll: Health care plan gains favor". USA Today. Retrieved March 24, 2010. 
  340. ^ a b Micah Cohen (May 1, 2013). "Uncertainty Still Clouds Health Care Law". FiveThirtyEight. 
  341. ^ a b Nate Silver (January 23, 2010). "Health Care Polls: Opinion Gap or Information Gap?".  
  342. ^ a b Zengerle, Patricia (June 24, 2012). "Reuters-Most Americans Oppose Health Law But Like the Provisions". Reuters. Retrieved June 28, 2012. 
  343. ^ Ezra Klein (June 26, 2012). "Republicans hate 'Obamacare', but like most of what it does". The Washington Post. Retrieved June 28, 2012. 
  344. ^ Greg Sargent (June 25, 2012). "Republicans Support Obama's Health Reforms - As Long As His Name Isn't On Them". The Washington Post. Retrieved June 28, 2012. 
  345. ^ Uwe E. Reinhardt (December 18, 2009). "Reimporting American Drugs From Canada". Economix. 
  346. ^ Blendon RJ, Benson JM (April 22, 2010). "Public opinion at the time of the vote on health care reform". N. Engl. J. Med. 362 (16): e55.  
  347. ^ "Negative Views Driven By Many Factors". Kaiser Family Foundation. 
  348. ^ "CNN Opinion Research Poll". CNN. March 22, 2010. 
  349. ^ Rasmussen, Scott; Schoen, Doug (March 9, 2010). "Why Obama Can't Move the Health-Care Numbers". The Wall Street Journal. 
  350. ^ "Public Wants Changes in Entitlements, Not Changes in Benefits". Pew Research Center. July 7, 2011. 
  351. ^ Cohn, Jonathan (March 23, 2012). "Obamacare's (Somewhat) Happy Birthday". The New Republic. 
  352. ^ Chait, Jonathan (June 13, 2013). "Obamacare, Public Opinion, and Conservative Self-Delusion". New York Magazine. 
  353. ^ Jackson, David. "Poll: Most oppose blocking Obama health care law". USA Today. Retrieved July 8, 2012.
  354. ^ "RAND Health Reform Opinion Study". RAND Health. May 1, 2014. Retrieved May 10, 2014. 
  355. ^ "AP-GfK Poll: Obama's health care fails to gain support". Associated Press. March 28, 2014. Retrieved March 30, 2014. 
  356. ^ "The ObamaCare 8%". The Wall Street Journal. April 30, 2014. Retrieved May 1, 2014. 
  357. ^ Amanda Cox, Alicia Desantis and Jeremy White (March 25, 2012). "'"Fighting to Control the Meaning of 'Obamacare. The New York Times. Retrieved June 29, 2012. 
  358. ^ a b Baker, Peter (August 3, 2012). "Democrats Embrace Once Pejorative 'Obamacare' Tag". The New York Times. Retrieved August 6, 2012. 
  359. ^ Nelson, Steven (June 8, 2011). "Democratic Rep. John Conyers wants to reclaim 'ObamaCare', make it a compliment". The Daily Caller. Retrieved April 1, 2012. 
  360. ^ Madison, Lucy (August 15, 2011). "'"On bus tour, Obama embraces 'Obamacare', says 'I do care. CBS News. Retrieved April 28, 2012. 
  361. ^ Smith, Ben (December 17, 2010). "'"HHS Buys 'ObamaCare. Politico. Retrieved February 9, 2011. 
  362. ^ Strauss, Daniel (March 23, 2012). "'"Obama camp's pitch to supporters: 'Hell yeah, I'm for Obamacare.  
  363. ^ Prince, Richard (October 2, 2013). "AP, NPR Curb Use of "Obamacare" Term". Robert C. Maynard Institute for Journalism Education. Retrieved October 5, 2013. 
  364. ^ Gold, Hadas (October 4, 2013). "'"AP, NPR to cut back on 'Obamacare. Politico. Retrieved October 19, 2013. 
  365. ^ a b """Sarah Palin falsely claims Barack Obama runs a "death panel.  
  366. ^ Drobnic Holan, Angie (December 19, 2009). "'"PolitiFact's Lie of the Year: 'Death panels. PolitiFact. Retrieved November 19, 2010. 
  367. ^ Henig, Jess; Robertson, Lori (July 29, 2010). "False Euthanasia Claims". FactCheck. 
  368. ^ FactCheck staff (December 24, 2009). "Whoppers of 2009—We review the choicest falsehoods from a year that kept us busy". FactCheck. University of Pennsylvania: Annenberg Public Policy Center. Retrieved April 28, 2011. 
  369. ^ Tweet' 2009 Word of the Year, 'Google' Word of the Decade, as voted by American Dialect Society"'".  
  370. ^ a b "Euthanasia Counseling". August 13, 2009. 
  371. ^ Nyhan, Brendan (2010). "Why the "Death Panel" Myth Wouldn't Die: Misinformation in the Health Care Reform Debate" (PDF). The Forum (Berkeley Electronic Press) 8 (1).  
  372. ^ Viebeck, Elise (September 26, 2012). "'"Poll: Four in 10 believe in Obama healthcare law 'death panels. The Hill. 
  373. ^ "Seniors Beware". August 23, 2012. 
  374. ^ a b Beutler, Brian (August 13, 2013). "A new kind of birther and death panel insanity explodes". Retrieved December 3, 2013. 
  375. ^ Ebeler, Jack; Neuman, Tricia; Cubanski, Juliette (April 13, 2011). "The Independent Payment Advisory Board: A New Approach to Controlling Medicare Spending". Kaiser Family Foundation. p. 3 of 24. Retrieved November 27, 2013. 
  376. ^ Cohn, Jonathan (April 20, 2011). "Here We Go Again, With the Death Panels". The New Republic. 
  377. ^ Cohn, Jonathan (August 13, 2009). "Mandatory Death Counseling – exposed!". The New Republic. 
  378. ^ Parsons, Christi; Zajac, Andrew (August 14, 2009). "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". Los Angeles Times. 
  379. ^ Chait, Jonathan (August 6, 2013). "Congress Exempts Itself From Obamacare! Or Something!". New York. 
  380. ^ Cohn, Jonathan (August 13, 2013). "The Latest Obamacare Lie That Just Won't Die". The New Republic. 
  381. ^ Bowers, Becky (August 14, 2013). "Sen. Ted Cruz says Obama 'just granted all of Congress an exception' to Obamacare". PolitiFact. Retrieved August 19, 2013. 
  382. ^ Robertson, Lori (January 20, 2010). "Congress Exempt from Health Bill?".  
  383. ^ Viebeck, Elise (27 February 2013). "Poll: Four in 10 think illegals are covered by Obama healthcare law". The Hill. Retrieved 7 December 2013. 
  384. ^ Farley, Robert (January 21, 2010). "'"The Democrats' health care bills would provide 'free health care for illegal immigrants. PolitiFact. Retrieved August 19, 2013. 
  385. ^ Stolberg, Sheryl Gay (October 18, 2013). "States Are Focus of Effort to Foil Health Care Law".  
  386. ^ The Editorial Board (January 25, 2014). "The Koch Party".  
  387. ^ Peters, Jeremy (January 20, 2011). "Conservatives' Aggressive Ad Campaign Seeks to Cast Doubt on Health Law". The New York Times. 
  388. ^ Chait, Jonathan (July 23, 2013). "Conservatives Brace for the Possibility Obamacare Won't Totally Suck". The New Republic. 
  389. ^ Michael Cannon (July 6, 2007). "The Anti-Universal Coverage Club Manifesto". Cato Institute. 
  390. ^ Chait, Jonathan (June 25, 2012). "Health Care As a Privilege: What the GOP Won't Admit". New York. 
  391. ^ "Resolution 54: AFL-CIO Convention Resolution on the Affordable Care Act". AFL-CIO. September 11, 2013. Retrieved October 7, 2013. 
  392. ^ "Union Letter: Obamacare Will ‘Destroy The Very Health and Wellbeing’ of Workers". Wall Street Journal. July 12, 2013. Retrieved October 7, 2013. 
  393. ^ "Labor leaders' letter to Harry Reid and Nancy Pelosi". The Washington Post. January 27, 2014. Retrieved February 13, 2014. 
  394. ^ Cauchi, Richard (November 15, 2013). "State Legislation and Actions Challenging Certain Health Reforms". National Conference of State Legislatures. Retrieved November 28, 2013. 
  395. ^ "Health Care Lawsuit Case Challenges". Health Care Lawsuits. Independent Women's Forum. November 26, 2013. Retrieved November 28, 2013. 
  396. ^ "Analysis: U.S. Supreme Court Upholds the Affordable Care Act: Roberts Rules?". The National Law Review. von Briesen & Roper, S.C. June 29, 2012. Retrieved July 2, 2012. 
  397. ^ "March 14, 2012 Statement on Religious Freedom and HHS Mandate". United States Conference of Catholic Bishops. March 14, 2012. Retrieved April 28, 2012. 
  398. ^ Goodstein, Laurie (May 21, 2012). "Catholics File Suits on Contraceptive Coverage". New York Times. 
  399. ^ a b "Status of State Action on the Medicaid Expansion Decision, as of October 22, 2013". Kaiser Family Foundation. October 22, 2013. 
  400. ^ a b Robert Pear (May 24, 2013). "States' Policies on Health Care Exclude Some of the Poorest". The New York Times. Retrieved May 25, 2013. In most cases, [Sandy Praeger, Insurance Commissioner of Kansas], 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." 
  401. ^ Sarah Kliff (May 5, 2013). "Florida rejects Medicaid expansion, leaves 1 million uninsured". The Washington Post. Retrieved May 24, 2013. 
  402. ^ "Beyond the pledges: Where the states stand on Medicaid". The Advisory Board Company. July 26, 2013. Retrieved August 27, 2013. 
  403. ^ a b c Tami Luhby (July 1, 2013). "States forgo billions by opting out of Medicaid expansion". CNN. 
  404. ^ Kliff, Sarah (July 5, 2012). "What Happens if a State Opts Out of Medicaid, in One Chart". The Washington Post. Retrieved July 15, 2012. 
  405. ^ "Health Reform and MedicaidExpansion". HealthCare Reform Magazine. July 13, 2010. Retrieved January 9, 2012. 
  406. ^ "Analyzing the Impact of State Medicaid Expansion Decisions". Kaiser Family Foundation. July 17, 2013. 
  407. ^ "Enrollment Policy Provisions in the Patient Protection and Affordable Care Act". Families USA. Retrieved April 1, 2012. 
  408. ^ Cohn, Jonathan (July 19, 2013). "We Don't Know Everything About Obamacare. But We Know Who's Trying to Sabotage It". The New Republic. 
  409. ^ "Is Medicaid Expansion Good for the States?". U.S. News & World Report. 
  410. ^ Evan Soltas (June 4, 2013). "Wonkbook: The terrible deal for states rejecting Medicaid". The Washington Post. 
  411. ^ Sandhya Somashekhar (August 29, 2013). "States find new ways to resist health law". The Washington Post. 
  412. ^ a b Norm Ornstein (July 24, 2013). "The Unprecedented and Contemptible Attempts to Sabotage Obamacare". National Journal. 
  413. ^ Robert Pear (August 2, 2013). "Missouri Citizens Face Obstacles to Coverage". The New York Times. Retrieved August 3, 2013. 
  414. ^ Cohn, Jonathan (July 25, 2013). "The Right's Latest Scheme to Sabotage Obamacare". The New Republic. 
  415. ^ Sarah Kliff (August 1, 2013). "Inside the Obamacare Resistance". The Washington Post. 
  416. ^ O'Brien, Michael (March 22, 2010). "GOP quick to release 'repeal' bills". The Hill. Retrieved April 1, 2012. 
  417. ^ "Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2".  
  418. ^ "Final Vote Results for passage of Repealing the Job-Killing Health Care Law Act (H.R. 2)".  
  419. ^ Beutler, Brian (January 19, 2011). "Dems Press GOPers To Repeal Their Own Benefits Along With Health Care Law".  
  420. ^ "Motion to Waive All Applicable Budgetary Discipline Re: McConnell Amdt. No. 13". U.S. Senate. February 2, 2011. Retrieved April 1, 2012. 
  421. ^ "House Passes Health Care Repeal 245–189".  
  422. ^ Boles, Corey (June 28, 2012). "Romney, GOP Pledge to Repeal Health Law". The Wall Street Journal. Retrieved June 29, 2012. 
  423. ^ "House Obamacare Repeal: Thirty-Third Time's the Charm?". ABC News. July 11, 2012. 
  424. ^ Walker, Andrea K. (July 11, 2012). "House of representatives votes to repeal health reform for the 31st time". Baltimore Sun. Retrieved July 12, 2012. 
  425. ^ Baker, Sam. (November 7, 2012) "'"Conservatives begin to admit defeat in their 3-year war against 'ObamaCare. The Hill. Retrieved July 17, 2013.
  426. ^ Jonathan Weisman; Robert Pear (May 26, 2013). "Partisan Gridlock Thwarts Effort to Alter Health Law". The New York Times. Retrieved May 27, 2013. we cannot use any of the normal tools to resolve ambiguities or fix problems 
  427. ^ Lipton, Eric (March 19, 2013). "In Shift, Lobbyists Look for Bipartisan Support to Repeal a Tax". New York Times. 
  428. ^ Cohn, Jonathan (December 23, 2010). "What Defunding Health Reform Would Do". The New Republic. 
  429. ^ Lori Montgomery and Paul Kane (October 1, 2013). "Shutdown begins: Stalemate forces first U.S. government closure in 17 years".  
    Blake, Aaron (September 19, 2013). "'"McCain: Efforts to repeal and defund Obamacare 'not rational.  
  430. ^ Beutler, Brian (September 19, 2013). "New test could expose GOP's pack of charlatans".  
  431. ^ Cohn, Jonathan (August 7, 2013). "Tea Party to Republicans: Shut Down the Government, or You're a Sellout". The New Republic. 
  432. ^ Moody, Chris (October 9, 2013). "Meet one of the conservative advocacy groups behind the GOP's government shutdown strategy". Yahoo! News. 
  433. ^ Joseph, Cameron (October 9, 2013). "Heritage Action leader: Paul Ryan's shutdown offer off-target".  
  434. ^ Miller, Zeke J. (September 30, 2013). "Hidden Hand: How Heritage Action Drove DC To Shut Down".  
  435. ^ Goddard, Teagan (May 17, 2013). "Blocking the Medicare Reform Board Won't Stop Reform". 
  436. ^ Cohn, Jonathan (May 24, 2010). "Save Donald". The New Republic. 
    Cohn, Jonathan (July 6, 2010). "Meet The Don". The New Republic. 
  437. ^ Cohn, Jonathan (July 19, 2011). "The New Nullification: GOP v. Obama Nominees". The New Republic. 
  438. ^ a b c Jackson, Brooks; Robertson, Lori (January 7, 2011). "A 'Job-Killing' Law?".  
  439. ^ Farley, Robert; Holan, Angie Drobnic (January 20, 2011). "The health care law a 'job killer'? The evidence falls short".  
  440. ^ Cohn, Jonathan (February 11, 2011). "Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs". The New Republic. 
  441. ^ Cohn, Jonathan (June 13, 2012). "Obamacare, Good for the Economy". The New Republic. 
  442. ^ Heavey, Susan (February 18, 2011), "Repealing healthcare law would cost $210 bln: CBO", Reuters, retrieved March 13, 2011
  443. ^ "Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010". Congressional Budget Office. May 26, 2011. Retrieved April 1, 2012. 
  444. ^ "Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act". Congressional Budget Office. July 24, 2012. Retrieved July 27, 2012. 


See also

In May 2011, the nonpartisan Congressional Budget Office (CBO) analyzed proposals to repeal the law. Mirroring its analysis of the law itself, the CBO estimated that repealing the entire law (both its taxing and spending provisions) would increase the net 2011–2021 federal deficit by $210 billion.[442][443] Revised CBO accounting, following the July 11, 2012, House repeal vote (H.R. 6079), and taking into account the impact of Supreme Court ruling, was consistent with its previous estimate: that repeal would cause a net increase in federal budget deficits of $109 billion over the 2013–2022 period.[444]

Impact of repeal on federal budget projections

Jonathan Cohn, citing the projections of the CBO, summarized that the primary employment effect of the ACA is to alleviate job lock: "People who are only working because they desperately need employer-sponsored health insurance will no longer do so."[440] He concluded that the "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" because they have health insurance outside of their jobs.[441]

The House Republican leadership put forth the argument in favor of repeal that "this is a job-killing law, period."[438] They contended that the ACA would lead to a loss of 650,000 jobs, attributing the figure to a report by the Congressional Budget Office.[438] However, FactCheck noted that the 650,000 figure was not included in the CBO report referred to, saying that the Republican statement "badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect [on employment] 'will probably be small.'"[438] PolitiFact also rated the Republican statement as "False".[439]

Economic consequences

Republicans attempted to defund its implementation,[412][428] and in October 2013, House Republicans, supported by Senators Rand Paul, Ted Cruz, Mike Lee, and Marco Rubio, refused to fund the federal government unless accompanied with a delay in implementation of the ACA, after the President unilaterally pushed back the employer mandate by one year, which critics claim he had no legal right to do. The Republican-held House of Representatives passed three versions of a bill funding all elements of the government while submitting various versions which would repeal or delay the ACA, with the last version delaying enforcement of the “individual mandate”. These bills were unable to muster enough votes in the Democrat-held Senate, with Democratic leadership stating the Senate would only pass a "clean" funding bill without any restrictions on the ACA. After Congress failed to pass a continuing funding resolution by midnight on October 1, a government shutdown ensued.[429][430][431] Conservative groups such as Heritage Action provided lobbying support for the linkage between the ACA and the government shutdown.[432][433][434] Senate Republicans threatened to block appointments to relevant agencies, such as the Independent Payment Advisory Board[435] and Centers for Medicare and Medicaid Services.[436][437]

Strong partisan disagreement in Congress has prevented adjustments to the Act's provisions.[426] However, at least one change, a proposed repeal of a tax on medical devices, has received bipartisan support.[427] Some Congressional Republicans argue against improvements to the law on the grounds they would weaken the arguments for repeal.[290][313]

2013 federal government shutdown

Following the 2012 Supreme Court ruling upholding the ACA as constitutional, Republicans held another vote to repeal the law on July 11;[422] the House of Representatives voted with all 244 Republicans and 5 Democrats in favor of repeal—it marked the 33rd, partial or whole, repeal attempt.[423][424] With President Obama's reelection and the Democrats expanding their majority in the Senate following the 2012 elections, many Republicans conceded that repeal almost certainly will not occur.[425]

The ACA has been the subject of unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: U.S. House Reps Steve King (R-IA) and Michele Bachmann (R-MN) introduced bills in the House to repeal the ACA the day after it was signed, as did Senator Jim DeMint (R-SC) in the U.S. Senate.[416] In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill entitled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed on a 245–189 vote.[417] All Republicans and 3 Democrats voted for repeal.[418] House Democrats proposed an amendment that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program; Republicans voted down the measure.[419] In the Senate, the bill was offered as an amendment to an unrelated bill but was voted down.[420] President Obama had stated that he would have vetoed the bill even if it had passed both chambers of Congress.[421]

Repeal efforts

Officials in several states have decided to oppose those elements of the ACA over which they have discretion.[411][412] For example, Missouri declined to expand Medicaid or establish a health insurance marketplace but is also engaged in an active program of non-cooperation, having enacted a statute forbidding any state or local official to render any aid not specifically required by federal law to the functioning of the Affordable Care Act.[413] Other Republican politicians have tried to discourage efforts to advertise the benefits of the law, and some conservative political groups have launched ad campaigns to discourage enrollment.[414][415]


For states that do expand Medicaid, the law provides that the federal government will pay for 100% of the expansion for the first three years and then gradually reduce its subsidy to 90% by 2020.[403] Several opposing states argue that the 10% of the funding of the expansion that they will be responsible for will be too much for their states' budgets.[403][409] However, studies suggest that rejecting the expansion will cost states more than expanding Medicaid due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage.[410]

However, the Supreme Court ruling created the potential for a coverage gap. States that choose to reject the Medicaid expansion can maintain the pre-existing Medicaid eligibility thresholds they have set, which in many states are significantly below 133% of the poverty line for most individuals.[404] Furthermore, many states do not make Medicaid available to childless adults at any income level.[405] Because subsidies on insurance plans purchased through exchanges are not available to those below the poverty line, this will create a coverage gap in those states between the state Medicaid threshold and the subsidy eligibility threshold.[406][407] For example, in Kansas, where only those able-bodied adults with children and with an income below 32% of the poverty line are eligible for Medicaid, those with incomes from 32% to 100% 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.[400] Studies of the impact of state decisions to reject the Medicaid expansion, as of July 2013, calculate that up to 6.4 million Americans could fall into this coverage gap.[408]

The drafters of the ACA had intended for Medicaid to cover individuals and families with incomes up to 133% (138% under effective definitions of income[41]) of the federal poverty level by expanding Medicaid eligibility and simplifying the CHIP enrollment process. Low-income individuals and families above 100% and up to 400% of the federal poverty level will receive federal subsidies[36] on a sliding scale if they choose to purchase insurance via an exchange. For example, individuals with incomes between 133% and 150% of the poverty level would be subsidized such that their premium cost would be 3% to 4% of their income.[37]

Following the Supreme Court ruling in NFIB v. Sebelius, several states with legislatures or governorships controlled by Republicans opted to reject the expanded Medicaid coverage provided for by the Act. Over half of the national uninsured population lives in those states.[400] As of September 2014, with the addition of Pennsylvania], 27 states and the District of Columbia have adopted the Medicaid expansion; a few states remain undecided.[399][401][402] States that declined to expand Medicaid before 2014 may still choose to opt in at any time.[403]

Medicaid expansion by state.[399]
  Expanding Medicaid
  Considering Medicaid expansion
  Not expanding Medicaid

State rejections of Medicaid expansion

The First Amendment right to free exercise of religion and conscience. Numerous lawsuits are pending addressing these concerns.[397][398]

Opponents of the Patient Protection and Affordable Care Act turned to the federal courts to challenge the constitutionality of the legislation.[394][395] In National Federation of Independent Business v. Sebelius, decided on June 28, 2012, the Supreme Court ruled on a 5–4 vote that the individual mandate is constitutional under Congress's taxation powers, although the law could not have been upheld under Congress's regulatory power under the Commerce Clause. The Court also determined that states could not be forced to participate in the Medicaid expansion, effectively allowing states to opt out of this provision. As written, the ACA withheld all Medicaid funding from states declining to participate in the expansion. The Supreme Court ruled that this withdrawal of funding was unconstitutionally coercive and that individual states had the right to opt out of the Medicaid expansion without losing preexisting Medicaid funding from the federal government. All provisions of ACA will continue in effect or will take effect as scheduled subject to the states' determination on Medicaid expansion.[396]

Legal challenges

Some unions have expressed concerns about the negative impact the ACA will have on their members' health care benefits, including the AFL-CIO,[391] which called the ACA "highly disruptive" to union health care plans and said it would drive up costs of union-sponsored plans; and International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, leaders of which sent a letter to Harry Reid (D-NV) and Nancy Pelosi (D-CA) stating that "the ACA 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."[392] More recently, Terry O’Sullivan, president of the Laborers’ International Union of North America (LIUNA) and D. Taylor, president of Unite Here sent a letter to Harry Reid (D-NV) and Nancy Pelosi (D-CA) stating that, "The ACA, as implemented, undermines fair marketplace competition in the health care industry."[393]

Efforts to oppose and repeal the legislation have drawn support from prominent Tea Party movement.[387] These groups believe the law will lead to disruption of existing health plans, increased costs from new insurance standards, and that it will increase the deficit.[388] Some are also against the idea of universal healthcare, viewing insurance as similar to other commodities to which people are not entitled.[389][390]

Opposition and resistance

Another common misconception is that the ACA provides benefits to illegal immigrants.[383] In fact, the ACA explicitly denies insurance subsidies to "unauthorized (illegal) aliens".[122][127][384]

Benefits for illegal immigrants

A separate common misconception about the ACA is that members of Congress are exempt from the Act's reforms. In fact, the 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). The federal government will continue to maintain its contributions to the new health insurance plans of federal employees.[148][379][380][381][382]

Exemptions for Congressmen

The "death panel" misconception distorts separate issues initially related to two proposed provisions found in the early drafts of the ACA. One was a claim that under the law, seniors can be denied care due to their age[373] and the other that the government will advise them to end their own lives instead of receiving due care[374] — the former eventually morphing into alluding to the Independent Payment Advisory Board (IPAB), which was established with the passage of the ACA, instead.[374] The IPAB has the authority to determine then recommend additional cost-saving changes to the Medicare program by facilitating the adoption of additional cost-effective treatments and similar cost-recovering measures when the statutory levels set for the administration of the Medicare program are exceeded within any given 3-year cycle scheduled. In fact, the Board is prohibited from recommending changes that would reduce payments to certain providers before 2020, and is also prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.[375][376] The other related issue concerns advance-care planning consultation: a section of the House reform proposal would have reimbursed physicians for providing voluntary consultations of Medicare recipients on end-of-life health planning (which is also covered by many private plans), enabling patients to specify, on request, the kind of care they wish to receive in their old age.[377] As described by the site, "This provision would allow patients to prepare for the day when they might be seriously ill and unable to make medical decisions for themselves by engaging in consultations with doctors to discuss the full range of end-of-life care options available to them, and to have the cost of such consultations covered by Medicare ... [including] directives to accept or refuse extreme life-saving measures, selection of hospice care programs, appointment of relatives" to act on the patient's behalf, etc.[370] The provision was not included in the final draft of the 2009 bill that was enacted into law.[378]

On August 7, 2009, Sarah Palin claimed the proposed legislation would create "death panels" that would decide if sick and elderly Americans were "worthy" of medical care.[365] The allegation was named PolitiFact's "Lie of the Year",[365][366] one of FactCheck's "whoppers",[367][368] and the most outrageous term by the American Dialect Society.[369] The AARP described such rumors as "rife with gross—and even cruel—distortions."[370] In 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and 30% believed it was true, with three contemporaneous polls finding similar results.[371] A poll in August 2012 found that 39% of Americans still believed the "death panels" claim.[372]

"Death panels"

Common misconceptions

In October 2013 the Associated Press and NPR began cutting back on use of the term.[363] Stuart Seidel, NPR's managing editor, said that the term "seems to be straddling somewhere between being a politically-charged term and an accepted part of the vernacular".[364]

By mid-2012, Obamacare had become the most common colloquial term used to refer to the law by both supporters and opponents. In contrast, the use of "Patient Protection and Affordable Care Act" or "Affordable Care Act" became limited to more formal and official use.[358] Use of the term in a positive sense was suggested by Democrat John Conyers.[359] President Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."[360] Because of the number of "Obamacare" search engine queries, the Department of Health and Human Services purchased Google advertisements, triggered by the term, to direct people to the official HHS site.[361] In March 2012, the Obama reelection campaign embraced the term "Obamacare", urging Obama's supporters to post Twitter messages that begin, "I like #Obamacare because...".[362] After its debut as a phrase on Capitol Hill, according to an analysis by the Sunlight Foundation, from July 2009 to June 2012 the term "Obamacare" was used nearly 3,000 times in congressional speeches.[3]

The term "Obamacare" was originally coined by opponents of the Affordable Care Act as a pejorative term for the law. The term was first put in print in March 2007 when healthcare lobbyist Jeanne Schulte Scott penned it in a health industry journal, writing "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".[3][357] According to research by Elspeth Reeve at The Atlantic magazine, the expression Obamacare first was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured.[358] The word was first uttered in a political campaign by Mitt Romney in May 2007 in Des Moines, Iowa. Romney said, "In my state, I worked on healthcare for some time. We had half a million people without insurance, and I said, 'How can we get those people insured without raising taxes and without having government take over 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."[3]

Term "Obamacare"


A Wall Street Journal/NBC poll released April 30, 2014, indicated that 8% of respondents say that the Affordable Care Act "is working well the way it is."[356]

An Associated Press-GfK poll released March 28, 2014 showed that 26% of Americans support the ACA.[355]

Polling averages from RealClearPolitics showed public approval of the ACA as 52.1% against and 38.6% for (poll averages from February 27 to March 25, 2014).[336]

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".[352] Following the Supreme Court upholding the constitutionality of the individual mandate in National Federation of Independent Business v. Sebelius, 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."[353] The RAND Health Reform Opinion Study for May 1, 2014, showed that 48.9% of respondents had an unfavorable view of the ACA vs. 38.3% who had a favorable view (of more than 5,500 individuals).[354]

Many Democrats believe that the ACA will grow more popular over time, like Medicare did after its implementation,[350] as the benefits of the law take effect and close the information gap about the contents of the bill.[340][341][351]

However, part of the opposition to the law is because some Americans believe the reform did not go far enough: A Reuters-Ipsos poll indicated that, for those opposed to the bill, 71% of Republican opponents reject it overall while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the relatively much smaller group of Democratic opponents, 49% reject it overall, and 51% wanted the measure to go further.[342]

Pollsters probed the reasons for opposition.[347] In a CNN poll, 62% of respondents said they thought the ACA would "increase the amount of money they personally spend on health care", 56% said the bill "gives the government too much involvement in health care", and 19% said they thought they and their families would be better off with the legislation.[348] Other polls found that people were concerned that the law would cost more than projected, and would not do enough to control the cost of health care affecting their families.[349]

Specific elements are very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. FiveThirtyEight, describing public opinion of the law, said, "while surveys have consistently found that a plurality of Americans have an overall negative view of the Affordable Care Act, they have just as consistently shown that large majorities of Americans favor individual elements of the law."[340][341] For example, a Reuters-Ipsos poll during June 2012 indicated that 44% of Americans supported the law, with 56% against. By party affiliation, 75% of Democrats, 27% of Independents, and 14% of Republicans favored the law overall. Individual provisions of the law received varying levels of support: 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, 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.[342] Other polls showed additional provisions receiving majority support include the creation of insurance exchanges, pooling small businesses and the uninsured with other consumers so that more people can take advantage of large group pricing benefits, and providing subsidies to individuals and families to make health insurance more affordable.[343][344] Other specific ideas that were not enacted but which showed majority support included importing prescription drugs from Canada (with its lower, government-controlled prices),[345] limiting malpractice awards, reducing the age to qualify for Medicare, and the Public health insurance option.[346]

Public opinion polls indicate that the United States public generally supports healthcare reform, but the public's views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Polling statistics for the general population show a general negative opinion of the law in the first years; with those in favor at approximately 40% and those against at 51%, as of October 2013.[336][337] About 29% of whites approve of the law, compared with 61% of Hispanics and 91% of African Americans, according a Pew Research Center and USA Today survey conducted on 4–8 September 2013.[338] USA Today found opinions were strongly divided by age of the person at the law's inception, with a solid majority of seniors opposing the bill and a solid majority of those younger than forty years old in favor.[339]

Public opinion

The asset-recovery provision of Medicaid, nicknamed the "clawback" provision, was enacted in 1993 by Congress in response to rising Medicaid administrative costs. States were compelled to try to recover costs from the estates of the deceased who used the program for long-term care, either via liens placed on an individual's home or claims on their assets. There was also an option for states to recover other routine medical care expenses. The expansion of Medicaid under the Affordable Care Act made more residents eligible for Medicaid. The state and federal government as of February 2014 have not clarified clawback guidelines, triggering complaints from consumers and advocacy groups from the uncertainty.[335]

Clawback controversy

On November 7, 2013, President Obama stated: "I am sorry that [people losing their plans] are finding themselves in this situation based on assurances they got from me", and he promised to work to help the affected Americans.[327] Various acts have been introduced in Congress to allow people to keep their existing individual insurance plans.[328] President Obama's previous unambiguous assurance that consumers' could keep their own plans has become a focal point for critics of the ACA[329][330] and a political liability for the law's proponents.[331][332] Whether or not President Obama knew that his statements were incorrect at the time he made them has also become the focus of discussion.[322][333][334]

At various times during and after the debate surrounding the ACA, Obama stated that "if you like your health care plan, you'll be able to keep your health care plan".[321][322] However, the law grandfathers only those insurance plans that were in effect before the law was enacted and have not been significantly changed since then.[322] Plans that do not satisfy these criteria must be cancelled if they do not comply with the law's new requirements for insurance standards. Furthermore, the law does not prohibit insurers from cancelling older plans for other reasons, such as a determination that a plan is too expensive to maintain. For these reasons, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were being terminated,[323] and several million more are in danger of seeing their current plans cancelled.[324][325][326]

Changes in existing individual insurance plans

On 10 February 2014, the Treasury Department issued Treasury Decision 9655, which are final regulation, that it would delay the employer mandate until 2015.[318] The Treasury Decision 9655 modifies Proposed Regulations REG-138006-12.[318]

A 2013/4 survey by the National Association for Business Economics found that about 75 percent of those surveyed said the ACA hasn’t influenced their planning or expectations for 2014, and 85 percent said the law wouldn’t prompt a change in their hiring practices. Some 21 percent of 64 businesses surveyed said that the act would have a harmful effect and 5 percent said it would be beneficial.[320]

On July 2, 2013, the Obama Administration announced on the Treasury Department's Proposed Regulations REG-138006-12[318] would delay the implementation of the employer mandate for one year, until 2015.[310][319]

Regardless of the rationale for maintaining existing insurance arrangements for those happy with them, most policy analysts (on both the right and left) are critical of the employer mandate provision on the policy merits.[297][310] They argue that the perverse incentives regarding part-time hours, even if they do not change many existing insurance plans, are real and harmful;[312][313] that the raised marginal cost of the 50th worker for businesses could limit companies’ growth;[314] that the costs of reporting and administration—the paperwork for businesses and the state enforcement—are not worth the trade-off of incentivizing the maintenance of current employer plans;[312][313] and note that the employer mandate, unlike the individual mandate, is a non-essential part of the law.[315][291] Some analysts have suggested that an alternate 'pay or play' version of the employer mandate would partially avoid these problems, by instead taxing business that do not offer insurance by a percentage of their payroll rather than using the 50-employee and 30-hour cut-offs.[297][312][313] Furthermore, many healthcare policy analysts think it would be better to transition away from the employer-based system to systems (whether state- or market-based) where insurance is more portable and stable, and hence think that it is a bad idea to even try to maintain existing employer insurance systems.[316] The effects of the provision have also generated vocal opposition from business interests and some unions not granted exemptions.[313][317]

Several businesses and the State of Virginia have clarified the contracts of their part-time employees by adding a 29-hour a week cap,[304][305] to reflect the 30-hour threshold for full-time hours, as defined by the law.[292] Some labor market experts claim such shifts are not clearly attributable to the implementation of the ACA: pre-existing, long-term trends in working hours,[306] and the effects of the Great Recession correlate with part-time working hour patterns.[307][308] The impact of this provision on employers' decision-making is partially offset by other factors: offering healthcare helps attract and retain employees, while increasing productivity and reducing absenteeism; and to trade a smaller full-time workforce for a larger part-time work force carries costs of training and administration for a business.[298][306][309] The amount of employers with over 50 employees is relatively small,[298] and more than 90% of these already offer insurance,[310] so changes in employer plans from this provision are expected to be small.[297] Workers who do not receive insurance from an employer plan would be able to purchase insurance on the exchanges.[311]

Despite concerns over a massive spike in part-time workers driven by cost-cutting efforts on the part of large employers, the number of part-time jobs in the United States had, in fact, declined by 230,000, while the number of full-time jobs has increased by 2 million during the period leading up to the start-date of Obamacare as of early 2014.[301] [302] Where full-time jobs have turned into part-time jobs seems to be in the public-sector, as an effort to reduce state and federal deficits, rather than as an effort to maintain or increase corporate profits in the private sectors (the original fear of individuals who coined the term 'Obamacare Effect').[301][303]

As no company with fewer than 50 full-time employees will face this penalty, many are concerned that the employer mandate creates a perverse incentive for business to employ people part-time instead of full-time.[297][298] This hypothetical phenomena has sometimes been referred to by commentators on both sides of the political spectrum as "The Obamacare Effect."[299] [300][301]

The employer mandate is a penalty that will be incurred by employers with more than 50 employees that do not offer health insurance to their full-time workers.[292] This provision was included as a disincentive for employers considering dropping their current insurance plans once the insurance exchanges began operating as an alternative source of insurance.[293] Proponents of the reform law wanted to address the parts of the healthcare system they believed to not be working well, while causing minimal disruption to those happy with the coverage they have.[294][293] Lawmakers recognized that approximately 80% of Americans already have insurance, of whom 54% (44% of the total population) are covered directly or indirectly through an employer, and 29% (23% of the total population) are covered by the government—mainly though Medicare and Medicaid.[295][296] While 73% of the total population reported themselves satisfied with their insurance situation, significant minorities, even among those that reported favorably, had medically-related financial troubles and/or dissatisfaction with aspects of their insurance coverage, especially among the poor and sick.[294] The intent of the employer mandate (along with a grandfather clause in the ACA) is to help ensure that existing employer-sponsored insurance plans that people like will stay in place.[293]

Not to be confused with the individual mandate[290][291]

Employer mandate and part-time working hours

David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because they are based on the assumption that Congress is going to do everything they say they're going to do.[287] The Center on Budget and Policy Priorities objected: in its analysis, Congress has a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings.[288][289]

The New Republic editors Noam Scheiber and Jonathan Cohn, countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive healthcare, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;[248][249] "innovations in the delivery of medical care, like greater use of electronic medical records[286] 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."[248]

[285] There was mixed opinion about the CBO estimates.

Opinions on CBO projections

A commonly heard complaint regarding the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019.[278][279][280] However, the "doc fix" is a separate issue that would have existed whether or not the ACA became law - omitting its cost from the ACA is no different from omitting the cost of the Bush tax cuts.[281][282][283]

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.[238][276] 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".[277]

Major sources of deficit reduction include:[211] higher Medicare taxes on the wealthy; new annual fees on health insurance providers; similar fees on the healthcare industry such as manufacturers and importers of brand-name pharmaceutical drugs and certain medical devices; limits on tax deductions of medical expenses and flexible spending accounts; a new 40% excise tax on "Cadillac" insurance policies - plans with annual insurance premiums in excess of $10,200 for an individual or $27,500 for a family; revenue from mandate penalty payments; a 10% federal sales tax on indoor tanning services; and spending offsets such as a reduction in Medicare reimbursements to insurers and drug companies for private Medicare Advantage policies that the Government Accountability Office and Medicare Payment Advisory Commission found to be overpaid (relative to government Medicare);[274][275] and reductions in Medicare reimbursements to hospitals that do not meet standards of efficiency and care.[274]

However, this estimate was made prior to the Supreme Court's ruling that enabled states to opt out of the Medicaid expansion, thereby forgoing the 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.[124][272][273]

The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:[266][267] 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 reduction in the deficit.[266] The CBO separately noted that while most of the spending provisions do not begin until 2014,[268][269] revenue will still exceed spending in those subsequent years.[270] The CBO averred 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"[238]—ultimately extending the solvency of the Medicare trust fund by 8 years.[271]

CBO: Deficit reduction under the ACA; the "bump" is from the coverage expansion starting 2014[265]
CBO estimates of revenue and impact on deficit

Federal deficit

One study estimated that the changes to the health system are responsible for about a quarter of the recent reduction in inflation.[263] Paul Krawzak posits 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.[264]

Uncertainty exists about the extent to which each factor is responsible for the recent reduction in health inflation, and about the durability of the overall trend, including the accompanying reduction in long-term deficit projections due to reduced healthcare costs. However, several studies found that the temporary effects of the recession cannot account for the entirety of the slowdown and that structural changes likely share at least partial credit.[257][260][261][262]

  • Higher unemployment due to the 2008-2010 recession, which has limited the ability of consumers to purchase healthcare;
  • Out-of-pocket payments, and deductibles, which constitute the amount an individual pays for their health costs before insurance begins to cover claims, have risen. These rising costs generally cause less consumption of healthcare services.[256] The proportion of workers with employer-sponsored health insurance requiring a deductible climbed to about three-quarters in 2012 from about half in 2006.[257][258]
  • Structural changes[257] in the healthcare system made by the ACA that aim to shift the healthcare system from paying-for-quantity to paying-for-quality. Examples include incentives to bundled payments to coordinate care and prioritize quality over quantity.[259] Some of these changes have occurred due to healthcare providers acting in anticipation of future implementation of reforms.[259][260]

The Centers for Medicare and Medicaid Services reported in 2013 that, while costs per capita continue to rise, the rate of increase in annual healthcare costs has fallen since 2002. Per capita cost increases have averaged 5.4% annually since 2000. Costs relative to GDP, which had been rising, have stagnated since 2009.[255] Several studies have attempted to explain the reduction in the rate of annual increase. Reasons include, among others:

The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates which 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 all of this would be dependent upon the success of the cost-saving government pilot programs which must then be wholly copied in the private market.[254]

[253] These cost reductions were not factored into CBO cost estimates.[252] and requires numerous pilot programs and demonstrations that may affect healthcare costs.Center for Medicare and Medicaid InnovationThe law created the
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.[251]
[250] to significantly "bend the curve" of rising healthcare costs:guaranteed has acknowledged that the ACA is not [65], a consultant who helped develop both the Massachusetts healthcare reform under Mitt Romney and the ACA,Jonathan Gruber

He and fellow The New Republic editor Noam Scheiber claimed the CBO did not include in its estimate various cost-saving provisions intended to reduce health inflation,[248] also positing that the CBO has a history of consistently underestimating the impact of health legislation.[249]

CBO doesn't produce estimates of how reform will affect overall health care spending — that is, the amount of money our society, as a whole, will devote to health care. But the official actuary for Medicare does. The actuary determined that ... the long-term trend is towards less spending: Inflation after ten years would be lower than it is now. And it's the long-term trend that matters most ... [The Affordable Care Act] will reduce the cost of care—not by a lot and not by as much as possible in theory, but as much as is possible in this political universe.[131][247]
, a health policy analyst, commented: Jonathan Cohn
... there is considerable agreement that a substantial share of current spending on health care contributes little if anything to people's health, and providers and health analysts are making significant efforts to make the health system more efficient... [though] it is not clear what specific policies the federal government can adopt to generate fundamental changes in the health system; that is, it is not clear what specific policies would translate the potential for significant cost savings into reality.[246]
and concluded, [246]The CBO further observed that "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)."

In a May 2010 presentation on "Health Costs and the Federal Budget", the CBO stated that "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."[246]

U.S. Healthcare Costs as a Percentage of GDP, 2000-2011
U.S. healthcare costs as a percentage of GDP from 2000 to 2011.

U.S. Healthcare Cost Inflation, 2000-2011
U.S. healthcare cost inflation from 2000 to 2011.

Healthcare cost inflation

In June 2013, a study by the Kaiser Family Foundation focused on actual experience under the Act as it affected individual market consumers (those buying insurance on their own). The study found that the Medical Loss Ratio provision of the Act had saved this group of consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%.[156] The bulk of the savings were in reduced premiums for individual insurance, but some came from premium rebates paid to consumers by insurance companies that had failed to meet the requirements of the Act. The Associated Press reported that, as a result of ACA's provisions closing the Medicare Part D coverage gap (between the "initial coverage limit" and the "catastrophic coverage threshold" in the prescription drug program), individuals formerly falling in this "donut hole" would save about 40 percent.[245] Almost all of the savings came reportedly because, with regard to brand-name drugs, ACA secured a discount from pharmaceutical companies.[245] The change benefited more than two million people, most of them in the middle class.[245]

Larry Levitt, a health policy analyst from the Kaiser Family Foundation, noted that the individual market compromises a relatively small share of those under 65, and said, in contrast, "I don't think anyone expects significant [cost] 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 insurance exchanges would be higher quality than that generally available currently (and thus more expensive), and that the government subsidies provided to make insurance affordable are intended to more than offset this effect.[244]

For the effect on health insurance premiums, the CBO forecast that by 2016 the individual market would comprise 17% of the market, and that premiums per person would increase by 10% to 13% but that over half of these individuals would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law.[238][239] It also forecast that 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 those under high premium plans subject to excise taxes being charged −9% to −12% less. Factors taken into account by this analysis included: increased benefits particularly for the individual market, more healthy policyholders due to the mandate, administrative efficiencies related to the health exchanges, and high-premium insurance plans reducing some benefits in response to the tax.[239] As of September 2013, the final projections of the average monthly premium scheduled to be offered in the exchanges came in below CBO expectations, reducing expected costs not only for consumers but also for the government by reducing the overall cost of the subsidies.[240][241][242][243]

Several studies on insurance premiums expect that with the subsidies offered under the ACA, more people will pay less (than they did prior to the reforms) than those who will pay more, and that those premiums will be more stable (even in changing health circumstances) and transparent, due to the regulations on insurance.[234][235][236] The Kaiser Family Foundation has calculated that about half the people who currently buy insurance on their own today will be eligible for subsidies. Among those receiving subsidies (which excludes those with incomes above four times the poverty line — about $46,000 for individuals or $94,000 for a family of four), the subsidies are projected to be worth an average of $5,548 per household, which would effectively discount the projected price of insurance by two-thirds, on average.[237] For individuals, NPR and the Kaiser Family Foundation collaborated to produce a quick online calculator for people to estimate their premiums and subsidy amount, based on where they live, income, and family size.[236]

Effects on insurance premiums

The contraception rule has also been challenged by corporations as a burden against their religious expression. The first challenge to reach the Supreme Court was Burwell v. Hobby Lobby.[226] The Court ruled that closely held corporations, such as Hobby Lobby, would be exempt from the contraception rule under the Religious Freedom Restoration Act, which applies to regulations that govern the activities of closely held for-profit corporations.[227] In a follow up case to Burwell v. Hobby Lobby the U.S. Supreme Court issued an injunction pending appeal under which an evangelical college in Illinois and other religiously affiliated nonprofit groups will not have to fill out a form offered to religious nonprofits that would effectively transfer the cost of its employees’ contraceptives to insurers. Wheaton College argued that filling out the form would “trigger” emergency contraceptive coverage and is therefore still against the institution’s religious beliefs.[228][229][230][231][232][233]

The initial regulations proved controversial among certain religious groups, most notably evangelicals and Lutherans, and especially the Roman Catholic hierarchy, whose hospitals, charities and educational institutions of higher learning, as well as other enterprises, oppose contraception on doctrinal grounds.[224] To accommodate those concerns while 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."[225]

[223][222], which concluded that access to contraception is medically necessary "to ensure women's health and well-being."Institute of Medicine These regulations were included on the recommendations of the [221][220] One provision in the law mandates that health insurance cover "additional preventive care and screenings" for women, as specified in regulations to be issued by the

Coverage for contraceptives

Insurers are also required to implement an appeals process for coverage determination and claims on all new plans.[203] They are also required to spend at least 80–85% of premium dollars on health costs and claims instead of administrative costs and profits; rebates must be issued to policyholders if this is violated.[216][217]

In addition, the law established four tiers of coverage: bronze, silver, gold, and platinum. All categories offer the same set of essential health benefits. What the categories specify is the division of premiums and out-of-pocket costs: bronze plans will have the lowest monthly premiums and highest out-of-pocket costs, and vice versa for platinum plans.[208][214] 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).[215]

Among the essential health benefits, preventive care, childhood immunizations and adult vaccinations, and medical screenings are covered by an insurance plan's premiums, and cannot be subject to any co-payments, co-insurance, or deductibles.[211][212] Specific examples of such services covered include: mammograms and colonoscopies, wellness visits, gestational diabetes screening, HPV testing, STI counseling, HIV screening and counseling, FDA-approved contraceptive methods, breastfeeding support and supplies, and domestic violence screening and counseling.[213]

Under the law's authorization, Secretary of Health Kathleen Sebelius issued a set of defined "essential health benefits"[22] that all new insurance plans have to include. Insurers are prohibited from imposing annual or lifetime coverage caps on these essential benefits.[203][207] These cover: "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care."[208][209] In determining what would qualify as an essential benefit, the law requires that the scope of standard benefits should equal that of a "typical employer plan."[208] States have some discretion in determining what should be considered the benchmark plan within the requirements of the law, and may include services beyond those set out by the Secretary.[210]

The ACA includes regulations that set standards for insurance,[21] some specified in the law, others subsequently established by the Secretary of Health and Human Services. Among these new standards are a ban on the ability to drop policyholders if they become sick,[203] a ban on price discrimination on the basis of pre-existing conditions or sex through a partial community rating,[204] and allowing children and dependents to remain on their parents' insurance plan until their 26th birthday.[205][206]

Change in insurance standards

On July 30, 2014, the Government Accountability Office released a non-partisan study that concluded the administration did not provide "effective planning or oversight practices" in developing the website.[202]

The House Energy and Commerce Committee reported on April 30, 2014, that 67% of individuals and families who had selected a health plan in the Federally Facilitated Marketplace had paid their first month’s premium; and that 25% of paid enrollees are ages 18 to 34.[199] On the same day, Committee ranking member Henry A. Waxman issued a statement saying the reporting was "... inaccurate, irresponsible, and out-of-date" accompanied by a memorandum detailing the basis behind his statement.[200] A week later, representatives for top health insurance companies told members of Congress that more than 80 percent of people who've signed up under the new health care law have gone on to pay their premiums.[201]

As of March 2013, "radio ads providing information on the Affordable Care Act" have been broadcast in Ojibwe, Yupik, Inupiat, Lakota and Navajo, according to Indian Country Today Media Network.[198]

Various committees in both chambers of Congress have conducted hearings where cyber security concerns related to have been discussed. Experts disagree over the extent is vulnerable to cyber attacks.[194][195][196][197]

Early implementation efforts for the healthcare exchanges, especially the exchanges operated by the federal government, have received nearly universally negative reactions in the media and from politicians.[184][185][186], the website that allows people to apply for insurance through the exchanges operated by the federal government, crashed on opening and suffered from a rash of problems throughout the first month.[187] Many users have also found the available plans to be unattractive.[188][189][190][191] Ongoing problems with the website have prompted the development of HealthSherpa, an independently produced alternative to, that contains consumer information.[192][193]

Kathleen Sebelius and Todd Park, the White House's chief technology officer

As of November 19, 2013, only Vermont, a state in which Republicans are but a small minority, in May 2011, has enacted an alternative plan — a state-based single-payer system for which they intend to pursue a waiver to implement.[181][182][183]

The law is also designed to be flexible by allowing states, from 2017 onwards, to apply for a "waiver for state innovation" from the federal government that allows them to experiment with their own state-based system, on condition that it meets certain criteria.[178] To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as that the ACA would, covers at least as many residents, and does not increase the federal deficit.[179] Provided a state meets these conditions, receiving a waiver can exempt states from some of the central requirements of the ACA, including the individual mandate, the provision of an insurance exchange, and the employer mandate.[180] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, if they cannot be paid out due to the structure of the state plan.[178]

Under the law, setting up an exchange gives a state partial discretion on standards and prices of insurance, aside from those specifics set-out in the ACA.[174][175] For example, those administering the exchange will be able to determine which plans are sold on or excluded from the exchanges, and adjust (through limits on and negotiations with private insurers) the prices on offer. They will also be able to impose higher or state-specific coverage requirements—including whether plans offered in the state are prohibited from covering abortion (making the procedure an out-of-pocket expense) or mandated to cover abortions that a physician determines is medically necessary; in either case, federal subsidies are prohibited from being used to fund the procedure.[176][177] If a state does not set up an exchange itself, they lose that discretion, and the responsibility to set up exchanges for such states defaults to the federal government, whereby the Department of Health and Human Services assumes the authority and legal obligation to operate all functions in these federally facilitated exchanges.[174] As of May 2013, 23 states and the District of Columbia plan to operate state-based exchanges themselves, seven of which will do so in partnership with the federal government—an arrangement where they retain discretionary management but the federal government executes various functions. The remaining 27 states default to federally facilitated exchanges.[173]

Health insurance exchanges by state.[173]
  Creating state-operated exchanges
  Establishing state-federal partnership exchanges
  Defaulting to federal exchange

These regulations are enabled to function due to the individual mandate[26] — the requirement to buy insurance or pay a penalty—and the limits on open enrollment,[147][159] without which healthy people might put-off insuring themselves until they got sick. In such a situation, insurers would have to raise their premiums to afford the remaining (relatively sicker and thus more expensive) population,[26][160][161] which could create a vicious cycle in which more and more people drop their coverage – a result known as an insurance death spiral.[162] Alternatively, the process could settle at a stable equilibrium relying on relatively high premiums for the insured and less coverage (and thus more illness and medical bankruptcy) for the uninsured.[157][160][163] The absence of the Mandate would have likely caused the exchanges as a whole to malfunction, and ultimately perform similarly to the current private insurance market, according to its supporters,[164][165] based on studies by the CBO, Jonathan Gruber, and Rand Health have concluded.[166][167][168] Conversely, the inclusion of the mandate increases the size and diversity of the insured population, broadening the risk pool to spread the cost of insurance in a sustainable manner.[169] Policy experience in New Jersey on the one hand and Massachusetts on the other offers evidence of such divergent outcomes.[157][167][170] In September 2012, the Congressional Budget Office estimated that nearly six million will pay the penalty in 2016.[171][172]

The insurance exchanges are a method designed to create a market for private insurance in a way that addresses market failures, such as the high number of uninsured, medical bankruptcies, coverage limits, unaffordability, and inflation[149] through regulation:[150][93] Only approved plans that meet certain standards will be allowed to be sold on the exchanges, and insurers will be prohibited from denying insurance to consumers on the basis of pre-existing conditions.[18][19] Several methods will be employed to make these plans affordable: Subsidies will be provided to those eligible.[36][39] Regulations intended to reduce prices through competition will make plans and prices more transparent and price comparisons more accessible for consumers with online information;[151][152][153] and federally approved, multi-state plans will be phased-into state exchanges[154] to help guarantee enough options.[155] And price regulations will be implemented, including a minimum medical loss ratio,[156] and partial community rating that prevents price discrimination from pricing individuals out of the market through unaffordable plans or premium increases on the insured[144][157]namely poor and sick individuals who are more expensive to cover for insurers motivated either by profit maximization and/or the economics of insurance; specifically, the risk of an insurance pool not providing enough net-premiums to offset net-pay-outs.[158]

The exchanges will take the form of websites where the private plans allowed on sale within them will be regulated and comparable: Consumers will be able to visit these websites or ring a call center, compare the plans on offer, fill out a form to the government that will be used to determine their eligibility for subsidies, and then purchase the insurance of their choice from the options available during limited open enrollment periods.[145] The first open enrollment period will last from October 1, 2013 to March 31, 2014, after which time uninsured individuals generally may not purchase insurance through an exchange until the following open enrollment period. In subsequent years, the open enrollment period will start on October 15 and end on December 7.[146][147] Despite some controversy, Members of Congress and their staff will participate in this system: they are required to obtain health insurance through the exchanges or plans otherwise approved by the bill (such as Medicare) instead of the Federal Employees Health Benefits Program that they currently use.[148]

The Act establishes state-based health insurance exchanges. The exchanges are regulated, online marketplaces, administered by either federal or state government, where individuals and small business can purchase private insurance plans starting October 1, 2013, with coverage beginning January 1, 2014.[30][143][144] Individuals with incomes between 100% and 400% of the federal poverty level who purchase insurance plans via an exchange will be eligible to receive federal subsidies to help pay premium costs.[29][36]

Insurance exchanges and the individual mandate

Multiple 2014 studies and surveys indicated that the number of uninsured had fallen due to expanded Medicaid eligibility and health insurance exchanges established due to PPACA. These changes took effect January 1, 2014. The Commonwealth Fund reported in July 2014 that an additional 9.5 million people aged 19-64 had obtained health insurance, roughly 5% of the working-aged population.[139] Gallup reported in July 2014 that the uninsured rate among adults 18 and over fell from 18.0% in Q3 2013 to 13.4% by Q2 2014.[140] The Rand Corporation reported that by March 2014: "Enrollment in employer-sponsored insurance plans increased by 8.2 million and Medicaid enrollment increased by 5.9 million, although some individuals did lose coverage during this period. The authors also found that 3.9 million people are now covered through the state and federal marketplaces — the so called insurance exchanges — and less than 1 million people who previously had individual-market insurance became uninsured during the period in question. While the survey cannot tell if this latter group lost their insurance due to cancellation or because they simply felt the cost was too high, the overall number is very small, representing less than 1 percent of people between the ages of 18 and 64."[141] Thereafter, data from August 2014 showed that 7.3 million people had enrolled through the marketplace and paid their premiums.[142]

Under the law, those workers whose employers offer "affordable coverage" will not be eligible for subsidies in the exchanges. To be eligible, per the law's definition, the cost of employer-based health insurance must exceed 9.5% of the worker’s household income. In January 2013 the Internal Revenue Service ruled that only the cost of covering the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. However, the cost of a family plan is often higher, but the ruling means that those higher costs will not be considered even if the extra premiums push the cost of coverage above the 9.5% income threshold. The New York Times said this could leave 2–4 million Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies to buy coverage elsewhere.[137][138]

Due to the new regulations of guaranteed issue, and allowing children to be included on their parents' plans until age 26, several insurance companies announced that they would stop issuing new child-only policies.[132][133][134] However, because children would now be covered by their parents' plans, the Census Bureau found that the number of uninsured 19- to 25-year-olds had declined by 1.6% or 393,000 people by 2011.[135] Starting January 1, 2014, state health insurance exchanges will be required to offer a child-only coverage option, and Medicaid eligibility will be made available to 16 million individuals with incomes below 133% of the federal poverty level.[136]

ACA drafters believed that increasing insurance coverage would not only improve quality of life but also help reduce medical bankruptcies (currently the leading cause of bankruptcy in America[129]) and job lock.[130] In addition, many believed that expanding coverage would help ensure that the cost controls successfully function; healthcare providers could more easily adapt to payment system reforms that incentivize value over quantity if their costs were partially offset—for example, hospitals having to do less charity care or insurers having larger and more stable risk pools to distribute costs over.[131]

  • Illegal immigrants, estimated at around 8 million—or roughly a third of the 23 million projection—will be ineligible for insurance subsidies and Medicaid.[122][127] They will also be exempt from the health insurance mandate but will remain eligible for emergency services under provisions in the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA).
  • Citizens not enrolled in Medicaid despite being eligible.[128]
  • Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance, mostly younger and single Americans.[128]
  • Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.[128]
  • 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.[126]

Among the people who will remain uninsured:

The ACA has two primary mechanisms for increasing insurance coverage: expanding Medicaid eligibility to include individuals within 138% of the federal poverty level,[41] and creating state-based insurance exchanges where individuals and small business can buy health insurance plans—those individuals with incomes between 100% and 400% of the federal poverty level will be eligible for subsidies to do so.[30][36] The Congressional Budget Office (CBO) originally estimated that the legislation will reduce the number of uninsured residents by 32 million, leaving 23 million uninsured residents in 2019 after the bill's provisions have all taken effect.[122][123][124] With the elderly covered by Medicare, the CBO estimate projected that the law would raise the proportion of insured non-elderly citizens from 83% to 94%.[122] A July 2012 CBO estimate raised the expected number of uninsured by 3 million, reflecting the successful legal challenge to the ACA's expansion of Medicaid.[125][126]

Change in number of uninsured

The New York Times summarized the overall impact of the Affordable Care Act on a variety of dimensions during October 2014. The number of uninsured persons has been reduced significantly. About 7.3 million people remain enrolled in private coverage through the online marketplaces; 85% of those qualified for federal subsidies to help pay premiums. For those who qualified for subsidies through the federal exchange, the subsidies lowered the cost by 76% on average. Middle-income persons who don't qualify for subsidies are more likely to have challenges with premium costs. It is too early to tell whether the Act has affected health outcomes. While healthcare cost increases have slowed in recent years, the effect of ACA on this trend is unclear. The healthcare industry has generally been helped by the law, due to the additional customers the law created for it.[121]

Public policy


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 abortion concerns, but they could not include additional such language in the reconciliation bill as it would be non-budgetary and thus outside the process's domain. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[116] This won the support of Stupak and members of his group and assured the bill's passage.[113][117] 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.[118] The next day, Republicans introduced legislation to repeal the bill.[119] Obama signed the ACA into law on March 23, 2010.[120] The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21; the Senate passed it by reconciliation on March 25, and Obama signed it on March 30.

Unlike rules under regular order, as 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 the ACA in the first place; the bill had inherently non-budgetary regulations.[114][115] Still, 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."[112]

Various health policy experts encouraged the House to pass the Senate version,[111] but House Democrats were not happy with it and had expected to be able to negotiate changes in a House-Senate conference before passing a final bill.[107] With that option off the table, since any bill that emerged from conference that differed from the Senate bill would have to be passed in the Senate despite another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[107] They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.[108][112][113]

Brown's election meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[108][109] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[108][109] On February 22, President Obama laid out a "Senate-leaning" proposal to consolidate the bills.[110] He held a meeting with both parties' leaders on February 25. With Democrats having lost a filibuster-proof supermajority in the Senate but having already passed the Senate bill with 60 votes on December 24, comprehensive reform proponents' most workable option was for the House to abandon its bill, the Affordable Health Care for America Act, and pass the Senate's bill, the Patient Protection and Affordable Care Act, instead.

President Obama signing the Patient Protection and Affordable Care Act on March 23, 2010.
House vote by congressional district.
  Democratic yea (219)
  Democratic nay (34)
  Republican nay (178)
  No representative seated (4)


Several weeks later, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.[70][104][105] The special election had become significant to the reform debate because of its effects on the legislative process. The first was psychological: the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of passing a bill.[106][107] The second effect was more practical: the loss of the Democratic supermajority complicated reform proponents' legislative strategy.[107]

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).[102] The bill was endorsed by the AMA and AARP.[103]

With every other Democrat now in favor and every Republican now opposed, the White House and Reid moved on to addressing Nelson's concerns in order to win filibuster-proof support for the bill;[97] they had by this point concluded "it was a waste of time dealing with [Snowe]"[98] because, after her vote for the draft bill in the Finance Committee, she had come under intense pressure from the Republican Senate leadership.[99] After a final 13-hour negotiation, Nelson's support for the bill was won 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.[70][100] The latter half of the compromise was derisively called the "Cornhusker Kickback"[101] and was repealed in the subsequent reconciliation amendment bill.

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

After the Finance Committee vote, negotiations turned to the demands of moderate Democrats, whose votes would be necessary to break the anticipated Republican filibuster. Majority leader Harry Reid focused on satisfying the Democratic caucus's centrist members until the holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and Ben Nelson, a conservative Democrat, representing Nebraska. Lieberman, despite intense negotiations with Reid in search of a compromise, refused to support a public option, agreeing to vote for the bill only if the provision were not included,[75][93] although it had majority support in Congress. His demand was met.[94] There was debate among the bill's supporters over the importance of the public option,[95] although the vast majority of supporters concluded it was a minor part of the reform overall,[93] and Congressional Democrats' fight for it won various concessions, including conditional waivers allowing states to set up state-based public options such as Vermont's Green Mountain Care.[94][96]

To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring several Republican senators aboard; particular attention was given to Bob Bennett, Mike Enzi, Chuck Grassley, and Olympia Snowe. Negotiations continued even after July 7 — when Franken was sworn into office, and by which time Specter had switched parties — due to disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. Then, on August 25, before the bill could come up for a vote, Ted Kennedy—a longtime healthcare reform advocate—died, depriving Democrats of their 60th vote. Before Kennedy's seat was filled, attention was drawn to Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, but she explicitly stated that this did not mean she would support the final bill.[75] Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.

The Senate began work on its own proposals while the House was still working on the Affordable Health Care for America Act. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.[89] As the United States Constitution requires all revenue-related bills to originate in the House,[90] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.[91] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[92] At the start of the 111th Congress, Democrats had only 58 votes; the Senate seat in Minnesota ultimately won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican.


To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.[87] He acknowledged the polarization of the debate, and quoted a letter from the late Senator Edward "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."[88] 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.[70]

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 conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.[70] There were also many threats made against members of Congress over the course of the Congressional debate.[85][86]

The reform negotiations also attracted a great deal of attention from lobbyists,[81] including deals between certain lobby groups and the advocates of the law to win the support of groups which had opposed past reforms, as in 1993.[82][83] The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.[84]

Tea Party protesters at the Taxpayer March on Washington, September 12, 2009.
[57][50] wrote that: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's healthcare law requiring all Americans to buy health insurance has its roots in conservative thinking."The New York Times Reporter Michael Cooper of [51] that "the end result was ... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."The New Yorker wrote in Ezra KleinRepublican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional." Journalist
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.[80]
[79], who led 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:Mitch McConnell Senate minority leader [48] any bills that contained it.filibusterHowever, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threatened to

[78][77] With

After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.[69][70] By July, a series of bills were approved by committees within the House of Representatives.[71] On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a healthcare reform bill. This group — in particular, Democrats Max Baucus, Jeff Bingaman, and Kent Conrad, and Republicans Mike Enzi, Chuck Grassley, and Olympia Snowe — met for more than 60 hours, and the principles that they discussed, in conjunction with the other committees, became the foundation of the Senate's healthcare reform bill.[72][73][74]

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

Healthcare reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, 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 plan would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's provided a subsidy but rejected the use of an individual mandate.[66][67] During the general election, Obama said that fixing healthcare would be one of his top four priorities if he won the presidency.[68]

Healthcare debate, 2008–10

By 2008 many Democrats were considering using this approach as the basis for healthcare reform. Experts have said that the legislation that eventually emerged from Congress in 2009 and 2010 bears many similarities to the 2007 bill[54] and that it was deliberately patterned after Romney's state healthcare plan.[64] Jonathan Gruber, a professor of economics at MIT and an architect of Massachusetts' health care reform who advised the Clinton and Obama presidential campaigns on healthcare issues, served as a technical consultant to the Obama administration, and helped draft the ACA.[65]

In 2007, a year after the Massachusetts reform, Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which also featured an individual mandate and state-based regulated insurance markets called "State Health Help Agencies".[51][62] The bill initially attracted bipartisan support but died in committee. Many of the sponsors and co-sponsors remained in Congress during the 2008 healthcare debate.[63]

In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contained both an individual health insurance mandate and an insurance exchange. Republican Governor Mitt Romney vetoed the mandate, but after Democrats overrode his veto, he signed it into law.[61] 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."[62]

Mitt Romney's Massachusetts went from 90% of its residents insured to 98%, the highest rate in the nation.[60]

The 1993 Republican alternative, introduced by Senator [48]

John Chafee

[53] in 1997.State Children's Health Insurance Program (SCHIP) to instead enact the 105th Congress After failing to obtain a comprehensive reform of the healthcare system, Clinton negotiated a compromise with the [52] Ultimately the Clinton plan failed amid an unprecedented barrage of negative advertising funded by politically conservative groups and the health insurance industry and due to concerns that it was overly complex.[50]

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