Patient Protection and Affordable Care Act

Provisions

The ACA includes provisions to take effect between 2010 and 2020, although most took effect on January 1, 2014. The number and complexity of changes was unprecedented in the US health care system. Not all provisions took full effect. Some were made discretionary, some were deferred and others were discarded before implementation.

Individual insurance

Guaranteed issue prohibits insurers from denying coverage to individuals due to pre-existing conditions. States were required to ensure the availability of insurance for individual children who did not have coverage via their families.

States were required to expand Medicaid eligibility to include individuals and families with incomes up to 133% of the federal poverty level, including adults without disabilities or dependent children. The law provides a 5% "income disregard", making the effective income eligibility limit for Medicaid 138% of the poverty level.

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

Dependents were permitted to remain on their parents' insurance plan until their 26th birthday, including dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.

Among the groups who remained uninsured were:

Subsidies

Households with incomes between 100% and 400% of the federal poverty level were eligible to receive federal subsidies for policies purchased via an exchange. Subsidies are provided as an advanceable, refundable tax credit Additionally, small businesses are eligible for a tax credit provided that they enroll in the SHOP Marketplace. Under the law, workers whose employers offer affordable coverage will not be eligible for subsidies via the exchanges. To be eligible the cost of employer-based health insurance must exceed 9.5% of the worker's household income.

Premiums were the same for everyone of a given age, regardless of preexisting conditions. Premiums were allowed to vary by enrollee age, but those for the oldest enrollees (age 45-64 average expenses $5,542) could only be three times as large as those for adults (18-24 $1,836).

Individual

The individual mandate is the requirement to buy insurance or pay a penalty for everyone not covered by an employer sponsored health plan, Medicaid, Medicare or other public insurance programs (such as Tricare). Also exempt were those facing a financial hardship or who were members in a recognized religious sect exempted by the Internal Revenue Service.

The mandate and the limits on open enrollment were designed to avoid the insurance death spiral in which healthy people delay insuring themselves until they get sick. In such a situation, insurers would have to raise their premiums to cover the relatively sicker and thus more expensive policies, which could create a vicious cycle in which more and more people drop their coverage.

The purpose of the mandate was to prevent the healthcare system from succumbing to adverse selection, which would result in high premiums for the insured and little coverage (and thus more illness and medical bankruptcy) for the uninsured. Studies by the CBO, Gruber and Rand Health concluded that a mandate was required. The mandate increased the size and diversity of the insured population, including more young and healthy participants to broaden the risk pool, spreading costs. Experience in New Jersey and Massachusetts offered divergent outcomes.

Business

Businesses that employ 50 or more people but do not offer health insurance to their full-time employees 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. This provision was included to encourage employers to continue providing insurance once the exchanges began operating. Approximately 44% of the population was covered directly or indirectly through an employer.

Excise taxes

Excise taxes for the Affordable Care Act raised $16.3 billion in fiscal year 2015 (17% of all excise taxes collected by the Federal Government). $11.3 billion was an excise tax placed directly on health insurers based on their market share. The ACA was going to impose a 40% "Cadillac tax" on expensive employer sponsored health insurance but that was postponed until 2018. Annual excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well.

Essential health benefits

The National Academy of Medicine defined the law's "essential health benefits" as "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care" and others rated Level A or B by the U.S. Preventive Services Task Force. In determining what would qualify as an essential benefit, the law required that standard benefits should offer at least that of a "typical employer plan". States may require additional services.

Contraceptives

One provision in the law mandates that health insurance cover "additional preventive care and screenings" for women. The guidelines mandate "[a]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity". This mandate applies to all employers and educational institutions except for religious organizations. These regulations were included on the recommendations of the Institute of Medicine.

Risk management

ACA provided three ways to control risk for insurers in the individual and business markets: temporary reinsurance, temporary risk corridors, and permanent risk adjustment.

Risk corridor program

The risk-corridor program was a temporary risk management device defined under the PPACA section 1342 to encourage reluctant insurers into the "new and untested" ACA insurance market during the first three years that ACA was implemented (2014-2016). For those years the Department of Health and Human Services (HHS) "would cover some of the losses for insurers whose plans performed worse than they expected. Insurers that were especially profitable, for their part, would have to return to HHS some of the money they earned on the exchanges" According to an article in Forbes, risk corridors "had been a successful part of the Medicare prescription drug benefit, and the ACA's risk corridors were modeled after Medicare's Plan D." They operated on the principle that "more participation would mean more competition, which would drive down premiums and make health insurance more affordable" and "[w]hen insurers signed up to sell health plans on the exchanges, they did so with the expectation that the risk-corridor program would limit their downside losses." The risk corridors succeeded in attracting ACA insurers. The program did not pay for itself as planned with "accumulated losses" up to $8.3 billion for 2014 and 2015 alone. Authorization had to be given so that HHS could pay insurers from "general government revenues". Congressional Republicans "railed against" the program as a 'bailout' for insurers. Then-Rep. Jack Kingston (R-Ga.), on the Appropriations Committee that funds the Department of Health and Human Services and the Labor Department "[slipped] in a sentence" — Section 227 — in the "massive" appropriations Consolidated Appropriations Act, 2014 (H.R. 3547) that said that no funds in the discretionary spending bill "could be used for risk-corridor payments." This effectively "blocked the administration from obtaining the necessary funds from other programs" and placed Congress in a potential breach of contract with insurers who offered qualified health plans, under the Tucker Act as it did not pay the insurers. On February 10, 2017, in the Moda Health v the US Government, Moda, one of the insurers that struggled financially because of the elimination of the risk corridor program, won a "$214-million judgment against the federal government". Justice Thomas C. Wheeler stated, "the Government "made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, 'to say to [Moda], 'The joke is on you. You shouldn't have trusted us,' is hardly worthy of our great government."

Temporary reinsurance

Temporary reinsurance for insurance for insurers against unexpectedly high claims was a program that ran from 2014 through 2016. It was intended to limit insurer losses.

Risk adjustment

Of the three risk management programs, only risk adjustment was permanent. Risk adjustment attempts to spread risk among insurers to prevent purchasers with good knowledge of their medical needs from using insurance to cover their costs (adverse selection). Plans with low actuarial risk compensate plans with high actuarial risk.

Other provisions

The ACA has several other provisions:

Exchanges

Established the creation of health insurance exchanges in all fifty states. The exchanges are regulated, largely online marketplaces, administered by either federal or state government, where individuals and small business can purchase private insurance plans.

Setting up an exchange gives a state partial discretion on standards and prices of insurance. For example, states approve plans for sale, and influence (through limits on and negotiations with private insurers) the prices on offer. They can impose higher or state-specific coverage requirements—including whether plans offered in the state can cover abortion. States without an exchange do not have that discretion. The responsibility for operating their exchanges moves to the federal government.

State waivers

From 2017 onwards, states can apply for a "waiver for state innovation" that allows them to conduct experiments that meet certain criteria. To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as ACA, covers at least as many residents and does not increase the federal deficit. Such states can exempt states from some of ACA's central requirements, including the individual and employer mandates and the provision of an insurance exchange. The state would receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under ACA plan, if they cannot be paid out due to the structure of the state plan.

In May 2011, Vermont enacted Green Mountain Care, a state-based single-payer system for which they intended to pursue a waiver to implement. In December 2014, Vermont decided not to continue due to high expected costs.

Accountable Care Organizations

The Act allowed the creation of Accountable Care Organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated, high quality care to Medicare patients. ACOs were allowed to continue using a fee for service billing approach. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigating chronic disease. If they fail to do so, they are subject to penalties.

Unlike Health Maintenance Organizations, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality of care goals.

Others

Background

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. It was championed for a time by conservative economists and Republican senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of free rider problems. Specifically, because the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.

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

The 1993 Republican alternative, introduced by Senator John Chafee as the Health Equity and Access Reform Today Act, contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'. Advocates for the 1993 bill included prominent Republicans such as Senators Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond. Of 1993's 43 Republican Senators, 20 supported the HEART Act. Another Republican proposal, introduced in 1994 by Senator Don Nickles (R-OK), the Consumer Choice Health Security Act, contained an individual mandate with a penalty provision; however, Nickles subsequently removed the mandate from the bill, stating he had decided "that government should not compel people to buy health insurance". At the time of these proposals, Republicans did not raise constitutional issues with the mandate; Mark Pauly, who helped develop a proposal that included an individual mandate for George H. W. Bush, remarked, "I don't remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax."

In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Governor Mitt Romney vetoed the mandate, but after Democrats overrode his veto, he signed it into law. Romney's implementation of the 'Health Connector' exchange and individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 presidential campaign, Senator Jim DeMint praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured". Romney said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."

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

By 2008 many Democrats were considering this approach as the basis for healthcare reform. Experts said that the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill and that it was deliberately patterned after Romney's state healthcare plan.

Healthcare debate, 2008–10

Healthcare reform was a major topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, Hillary Clinton and the eventual nominee, Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a subsidy but rejected the use of an individual mandate.

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

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

Congressional Democrats and health policy experts like MIT economics professor Jonathan Gruber and David Cutler argued that guaranteed issue would require both community rating and an individual mandate to ensure that adverse selection and/or "free riding" would not result in an insurance "death spiral". This approach was taken because the president and congressional leaders had concluded that more progressive plans, such as the (single-payer) Medicare for All act, could not obtain filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas — the same basic outline was supported by former Senate majority leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill's drafters hoped to garner the votes necessary for passage.

However, following the adoption of an individual mandate, Republicans came to oppose the mandate and threatened to filibuster any bills that contained it. Senate minority leader Mitch McConnell, who led the Republican congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to prevent defections:

It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out.

Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". Journalist Ezra Klein wrote in The New Yorker that "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition." Reporter Michael Cooper of The New York Times wrote that: "the provision ... requiring all Americans to buy health insurance has its roots in conservative thinking."

The reform negotiations also attracted attention from lobbyists, including deals between certain lobby groups and the advocates of the law to win the support of groups that had opposed past reforms, as in 1993. The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both parties.

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

When Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations. 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." On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.

Senate

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

Negotiations were undertaken attempting to satisfy moderate Democrats and to bring Republican senators aboard; particular attention was given to Republicans Bennett, Enzi, Grassley and Snowe. On July 7 Franken was sworn into office, providing a potential 60th vote. On August 25 Ted Kennedy—a longtime healthcare reform advocate—died. Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.

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

The White House and Reid addressed Nelson's concerns during a 13-hour negotiation with two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges", which would require consumers to pay for the procedure out of pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska. The latter half of the compromise was derisively termed the "Cornhusker Kickback" and was repealed in the subsequent reconciliation amendment bill.

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

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters. His victory had become significant 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.

House

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".

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

House Democrats had expected to be able to negotiate changes in a House-Senate conference before passing a final bill. Since any bill that emerged from conference that differed from the Senate bill would have to pass the Senate over another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill. They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.

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 ACA in the first place; the bill had inherently non-budgetary regulations. Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."

The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their concerns, but they could not address abortion in the reconciliation bill as it would be non-budgetary. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. This won the support of Stupak and members of his group and assured the bill's passage. The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. The next day, Republicans introduced legislation to repeal the bill. Obama signed ACA into law on March 23, 2010. Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act over sixty times; no such attempt by Republicans has been successful. The amendment bill, The Health Care and Education Reconciliation Act, cleared the House on March 21; the Senate passed it by reconciliation on March 25, and Obama signed it on March 30.

Coverage

The law has caused a significant reduction in the number and percentage of people without health insurance. The CDC reported that the percentage of people without health insurance fell from 16.0% in 2010 to 8.9% during the January–June 2016 period. From Q4-2013 to Q1-2016, a Gallup survey found that the uninsured rate among adults declined from 17.1% to 11.0%, a decline of 6.1 percentage points. In a 2016 review, Obama presented data showing that the uninsured rate had declined by 43%, from 16.0% in 2010 to 9.1% in 2015, mostly in 2014. The uninsured rate dropped in every congressional district in the U.S. between 2013 and 2015.

In March 2016, the CBO reported that there were approximately 27 million people without insurance in 2016, a figure they expected would range from 26-28 million through 2026. CBO also estimated the percentage of insured among all U.S. residents would remain at 90% through that period, 92-93% excluding unauthorized immigrants.

Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64. As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not.

The Congressional Budget Office reported in March 2016 that there were approximately 12 million people covered by the exchanges (10 million of whom received subsidies to help pay for insurance) and 11 million made eligible for Medicaid by the law, a subtotal of 23 million people. An additional 1 million were covered by the ACA's "Basic Health Program," for a total of 24 million. CBO also estimated that the ACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling ACA coverage of 26 million, less 4 million for reductions in "employment-based coverage" and "non-group and other coverage." The Department of Health and Human Services (HHS) estimated that 20.0 million adults (aged 18–64) gained healthcare coverage via ACA as of February 2016, a 2.4 million increase over September 2015. HHS estimated that this 20.0 million included: a) 17.7 million from the start of open enrollment in 2013-2016; and b) 2.3 million young adults aged 19–25 who initially gained insurance from 2010-2013, as they were allowed to remain on their parent's plans until age 26. Of the 20.0 million, an estimated 6.1 million were aged 19–25.

By 2017, nearly 70% of those on the exchanges could purchase insurance for less than $75/month after subsidies, which rose to offset significant pre-subsidy price increases in the exchange markets. Healthcare premium cost increases in the employer market continued to moderate. For example, healthcare premiums for those covered by employers rose by 69% from 2000-2005, but only 27% from 2010 to 2015, with only a 3% increase from 2015 to 2016.

The ACA also helps reduce income inequality measured after taxes, due to higher taxes on the top 5% of income earners and both subsidies and Medicaid expansion for lower-income persons. CBO estimated that subsidies paid under the law in 2016 averaged $4,240 per person for 10 million individuals receiving them, roughly $42 billion. For scale, the subsidy for the employer market, in the form of exempting from taxation those health insurance premiums paid on behalf of employees by employers, was approximately $1,700 per person in 2016, or $266 billion total in the employer market. The employer market subsidy was not changed by the law.

Insurance exchanges

As of August 2016, 15 states operated their own exchanges. Other states either used the federal exchange, or operated in partnership with or supported by the federal government.

Medicaid expansion

As of December 2016 there were 32 states (including Washington DC) that had adopted the Medicaid extension, while 19 states had not. Those states that expanded Medicaid had a 7.3% uninsured rate on average in the first quarter of 2016, while those that did not expand Medicaid had a 14.1% uninsured rate, among adults aged 18 to 64. Following the Supreme Court ruling in 2012, which held that states would not lose Medicaid funding if they didn't expand Medicaid under the ACA, several states rejected expanded Medicaid coverage. Over half of the national uninsured population lived in those states. In a report to Congress, the Centers for Medicare and Medicaid Services (CMS) estimated that the cost of expansion was $6,366 per person for 2015, about 49 percent above previous estimates. An estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults. The Kaiser Family Foundation estimated in October 2015 that 3.1 million additional people were not covered because of states that rejected the Medicaid expansion.

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

Studies of the impact of state decisions to reject the Medicaid expansion calculated that up to 6.4 million people could fall into this status. The federal government initially paid for 100% of the expansion (through 2016). The subsidy tapered to 90% by 2020 and continued to shrink thereafter. Several states argued that they could not afford their 10% contribution. Studies suggested that rejecting the expansion would cost more than expanding Medicaid due to increased spending on uncompensated emergency care that otherwise would have been partially paid for by Medicaid coverage,

A 2016 study led by Harvard University health economics professor Benjamin Sommers found that residents of Kentucky and Arkansas, which both accepted the Medicaid expansion, were more likely to receive health care services and less likely to incur emergency room costs or have trouble paying their medical bills than before the expansion. Residents of Texas, which did not accept the Medicaid expansion, did not see a similar improvement during the same period. Kentucky opted for increased managed care, while Arkansas subsidized private insurance. The new Arkansas and Kentucky governors have proposed reducing or modifying their programs. Between 2013 and 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with 39% to 32% in Texas. Specific improvements included additional primary and preventive care, fewer emergency departments visits, reported higher quality care, improved health, improved drug affordability, reduced out-of-pocket spending and increased outpatient visits, increased diabetes screening, glucose testing among diabetes patients and regular care for chronic conditions.

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

Healthcare insurance costs

The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance, based on income levels. Higher income consumers receive lower subsidies. While pre-subsidy prices rose considerably from 2016 to 2017, so did the subsidies, to reduce the after-subsidy cost to the consumer. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas. However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reported that for the second-lowest cost "Silver plan" (a plan often selected and used as the benchmark for determining financial assistance), a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the subsidy/tax credit, despite large increases in the pre-subsidy price. This was consistent nationally. In other words, the subsidies increased along with the pre-subsidy price, fully offsetting the price increases.

Healthcare premium cost increases in the employer market continued to moderate after the implementation of the law. For example, healthcare premiums for those covered by employers rose by 69% from 2000-2005, but only 27% from 2010 to 2015, with only a 3% increase from 2015 to 2016. From 2008-2010 (prior to Obamacare) health insurance premiums rose by an average of 10% per year.

Several studies found that the financial crisis and accompanying recession could not account for the entirety of the slowdown and that structural changes likely share at least partial credit. A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation. Paul Krawzak claimed that even if cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly the growth of the population on Medicare.

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

Effect on deductibles and co-payments

While health insurance premium costs have moderated, some of this is because of insurance policies that have a higher deductible, co-payments and out-of-pocket maximums that shift costs from insurers to patients. In addition, many employees are choosing to combine a health savings account with higher deductible plans, making the impact of the ACA difficult to determine precisely.

For those who obtain their insurance through their employer ("group market"), a 2016 survey found that:

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

Health outcomes

Insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013. City University public health professors David Himmelstein and Steffie Woolhandler wrote in January 2017 that a rollback of the ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.

CBO estimates of revenue and impact on deficit

The CBO reported in several studies that the ACA would reduce the deficit, and that repealing it would increase the deficit. The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period: it calculated the law would result in $604 billion in total outlays offset by $813 billion in total receipts, resulting in a $210 billion net deficit reduction. The CBO separately predicted that while most of the spending provisions do not begin until 2014, revenue would exceed spending in those subsequent years. The CBO claimed 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"—ultimately extending the solvency of the Medicare trust fund by 8 years.

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

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

Major new sources of increased tax receipts include: higher Medicare taxes; annual fees on insurance providers; 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 40% excise tax on plans with annual insurance premiums in excess of $10,200 for an individual or $27,500 for a family; revenue from mandate penalty payments; a 10% federal sales tax on indoor tanning services. Predicted spending reductions included 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 excessively costly relative to government Medicare; and reductions in Medicare reimbursements to hospitals that failed standards of efficiency and care.

Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion. 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".

Opinions on CBO projections

The CBO cost estimates were criticized because they excluded the effects of potential legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019. However, the so-called "doc fix" is a separate issue that would have existed whether or not ACA became law - omitting its cost from ACA was no different from omitting the cost of other tax cuts.

Uwe Reinhardt, a Princeton health economist, wrote. "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003." Douglas Holtz-Eakin, CBO director during the George W. Bush administration, who later served as the chief economic policy adviser to U.S. Senator John McCain's 2008 presidential campaign, alleged that the bill would increase the deficit by $562 billion because, he argued, it front-loaded revenue and back-loaded benefits.

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

In 2010 David Walker, former U.S. Comptroller General then working for The Peter G. Peterson Foundation, stated that the CBO estimates are not likely to be accurate, because they were based on the assumption that the law would not change. The Center on Budget and Policy Priorities objected that Congress had a good record of implementing Medicare savings. According to their study, Congress followed through on the implementation of the vast majority of provisions enacted in the past 20 years to produce Medicare savings, although not the payment reductions addressed by the annual "doc fix".

Economic consequences

CBO estimated in June 2015 that repealing the ACA would:

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

The CBO estimated that the ACA would slightly reduce the size of the labor force and number of hours worked, as some would no longer be tethered to employers for their insurance. Cohn, citing CBO's projections, claimed that ACA's primary employment effect was to alleviate job lock: "People who are only working because they desperately need employer-sponsored health insurance will no longer do so." He concluded that 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.

Employer mandate and part-time work

The employer mandate requires employers meeting certain criteria to provide health insurance to their workers. The mandate applies to employers with more than 50 employees that do not offer health insurance to their full-time workers. Critics claimed that the mandate created a perverse incentive for business to keep their full-time headcount below 50 and to hire part-time workers instead. Between March 2010 and 2014 the number of part-time jobs declined by 230,000, while the number of full-time jobs increased by 2 million. In the public sector full-time jobs turned into part-time jobs much more than in the private sector. A 2016 study found only limited evidence that ACA had increased part-time employment.

Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees, to reflect the 30-hour-or-more definition for full-time worker. As of yet, however, only a small percent of companies have shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis). Trends in working hours and the effects of the Great Recession correlate with part-time working hour patterns. The impact of this provision may have been offset by other factors, including that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and the lower training and administration costs of a smaller full-time workforce over a larger part-time work force. Relatively few firms employ over 50 employees and more than 90% of them offered insurance. Workers without employer insurance could purchase insurance on the exchanges.

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

A 2013/4 survey by the National Association for Business Economics found that about 75 percent of those surveyed said ACA hadn’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.

Hospitals

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

Between January 2010 and 2015, a quarter of emergency room doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed that they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured patients.

Insurers claimed that because they have access to and collect patient data that allow evaluations of interventions, they are essential to ACO success. Large insurers formed their own ACOs. Many hospitals merged and purchased physician practices. The increased market share gave them more leverage in negotiations with insurers over costs and reduced patient care options.

Public opinion

Prior to the law's passage, polling indicated the public's views became increasingly negative in reaction to specific plans discussed during the legislative debate over 2009 and 2010. Polling statistics showed a general negative opinion of the law; with those in favor at approximately 40% and those against at 51%, as of October 2013. About 29% of whites approve of the law, compared with 61% of Hispanics and 91% of African Americans. Opinions were 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.

Specific elements were popular across the political spectrum, while others, such as the mandate to purchase insurance, were widely disliked. In a 2012 poll 44% supported the law, with 56% against. By party affiliation, 75% of Democrats, 27% of Independents and 14% of Republicans favored the law overall. 82% favored banning insurance companies from denying coverage to people with pre-existing conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate. Other polls showed additional provisions receiving majority support, including the 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.

In a 2010 poll, 62% of respondents said they thought ACA would "increase the amount of money they personally spend on health care", 56% said the bill "gives the government too much involvement in health care", and 19% said they thought they and their families would be better off with the legislation. Other polls found that people were concerned that the law would cost more than projected and would not do enough to control costs.

Some opponents believed that the reform did not go far enough: a 2012 poll indicated that 71% of Republican opponents rejected it overall, while 29% believed it did not go far enough; independent opponents were divided 67% to 33%; and among the much smaller group of Democratic opponents, 49% rejected it overall and 51% wanted more. In June 2013, a majority of the public (52–34%) indicated a desire for "Congress to implement or tinker with the law rather than repeal it". After the Supreme Court upheld the individual mandate, a 2012 poll held that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues".A 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA vs. 38.3% who had a favorable view (of more than 5,500 individuals).

A 2014 poll reported that 26% of Americans support ACA. Another held that 8% of respondents say that the Affordable Care Act "is working well the way it is". In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%, i.e., 65% wanted to leave ACA alone or improve upon it.

In 2015, a CBS News / New York Times poll reported that 47% of Americans approved the health care law. This was the first time that a major poll indicated that more respondents approved ACA than disapproved of it. The recurring Kaiser Health Tracking Poll from December 2016 reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.

Separate polls from Fox News and NBC/WSJ both taken during January 2017 indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who opposed it in the past (many prefer a "Medicare for All" approach) have shifted their positions since the ACA is under threat of repeal.

A January 2017 Morning Consult poll showed that 35% of respondents either believed that Obamacare and the Affordable Care Act were different or did not know. Approximately 45% were unsure whether the repeal of Obamacare also meant the repeal of the Affordable Care Act. 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the A.C.A. were repealed and no replacement enacted," with Democrats far more likely (79%) to know that fact than Republicans (47%).

A 2017 study found that personal experience with public health insurance programs leads to greater support for the Affordable Care Act, and the effects appear to be most pronounced among Republicans and low-information voters.

"Obamacare"

The term "Obamacare" was originally coined by opponents as a pejorative. The term emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott used 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". According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured. It first appeared 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."

By mid-2012, Obamacare had become the colloquial term used 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. Use of the term in a positive sense was suggested by Democrat John Conyers. Obama endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."

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...".

In October 2013 the Associated Press and NPR began cutting back on use of the term. 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".

"Death panels"

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

One was that under the law, seniors could be denied care due to their age and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an Independent Payment Advisory Board (IPAB). IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when the statutory levels set for Medicare were exceeded within any given 3-year period. In fact, the Board was prohibited from recommending changes that would reduce payments to certain providers before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.

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

In 2010, the Pew Research Center reported that 85% of Americans were familiar with the claim, and 30% believed it was true, backed by three contemporaneous polls. A poll in August 2012 found that 39% of Americans believed the claim. The allegation was named PolitiFact's "Lie of the Year", one of FactCheck.org's "whoppers" and the most outrageous term by the American Dialect Society. AARP described such rumors as "rife with gross—and even cruel—distortions".

Members of Congress

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

Illegal immigrants

ACA does not provide benefits to illegal immigrants. It explicitly denies insurance subsidies to "unauthorized (illegal) aliens".

Exchange "death spiral"

One argument against the ACA is that the insurers are leaving the marketplaces, as they cannot profitably cover the available pool of customers, which contains too many unhealthy participants relative to healthy participants. A scenario where prices rise, due to an unfavorable mix of customers from the insurer's perspective, resulting in fewer customers and fewer insurers in the marketplace, further raising prices, has been called a "Death Spiral." During 2017, the median number of insurers offering plans on the ACA exchanges in each state was 3.0, meaning half the states had more and half had fewer insurers. There were five states with one insurer in 2017; 13 states with two; 11 states with three; and the remainder had four insurers or more. Wisconsin had the most, with 15 insurers in the marketplace. The median number of insurers was 4.0 in 2016, 5.0 in 2015, and 4.0 in 2014.

Further, the CBO reported in January 2017 that it expected enrollment in the exchanges to rise from 10 million during 2017 to 13 million by 2027, assuming laws in place at the end of the Obama administration were continued. Following a 2015 CBO report that reached a similar conclusion, Paul Krugman wrote: "But the truth is that this report is much, much closer to what supporters of reform have said than it is to the scare stories of the critics--no death spirals, no job-killing, major gains in coverage at relatively low cost."

Opposition

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

As of 2013 unions that expressed concerns about ACA included the AFL-CIO, which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, whose leaders sent a letter to Reid and Pelosi arguing, " 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." In January 2014, Terry O'Sullivan, president of the Laborers' International Union of North America (LIUNA) and D. Taylor, president of Unite Here sent a letter to Reid and Pelosi stating, "ACA, as implemented, undermines fair marketplace competition in the health care industry."

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

National Federation of Independent Business v. Sebelius

Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds. In National Federation of Independent Business v. Sebelius, the Supreme Court ruled on a 5–4 vote that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.

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

Contraception mandate

In March 2012 the Roman Catholic Church, while supportive of ACA's objectives, voiced concern through the United States Conference of Catholic Bishops that aspects of the mandate covering contraception and sterilization and HHS's narrow definition of a religious organization violated the First Amendment right to free exercise of religion and conscience. Various lawsuits addressed these concerns.

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

House v. Burwell

In United States House of Representatives v. Burwell the House sued the administration alleging that the money for premium subsidy payments to insurers had not been appropriated, as required for any federal government spending. The Obamacare subsidy that helps customers pay premiums was not part of the suit. Without the cost-sharing subsidies, the government estimated that premiums would increase by 20 percent to 30 percent for silver plans.

Non-cooperation

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

Repeal efforts

ACA was the subject of unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives Steve King (R-IA) and Michele Bachmann (R-MN) introduced bills in the House to repeal ACA the day after it was signed, as did Senator Jim DeMint (R-SC) in the Senate. In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189. All Republicans and 3 Democrats voted for repeal. 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. In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down. President Obama had stated that he would have vetoed the bill even if it had passed both chambers of Congress.

Following the 2012 Supreme Court ruling upholding ACA as constitutional, Republicans held another vote to repeal the law on July 11; the House of Representatives voted with all 244 Republicans and 5 Democrats in favor of repeal, which marked the 33rd, partial or whole, repeal attempt. On February 3, 2015, the House of Representatives added its 67th repeal vote to the record (239 to 186). This attempt also failed.

2013 federal government shutdown

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

Republicans attempted to defund its implementation, and in October 2013, House Republicans refused to fund the federal government unless accompanied with a delay in ACA implementation, after the President unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay ACA, with the last version delaying enforcement of the individual mandate. The Democrat Senate leadership stated the Senate would only pass a "clean" funding bill without any restrictions on ACA. The government shutdown began on October 1. Senate Republicans threatened to block appointments to relevant agencies, such as the Independent Payment Advisory Board and Centers for Medicare and Medicaid Services.

2017 repeal effort

During a midnight congressional session starting January 11, 2017, the Senate of the 115th Congress of the United States voted to approve a "budget blueprint" which would allow Republicans to repeal parts of the law "without threat of a Democratic filibuster." The plan, which passed 51-48 is a budget blueprint named by Senate Republicans the "Obamacare 'repeal resolution.'" Democrats opposing the resolution staged a protest during the vote.

House Republicans announced their replacement for the ACA, the American Health Care Act, on March 6, 2017.

Implementation history

Once the law was signed, provisions began taking effect, in a process that continued for years. Some provisions never took effect, while others were deferred for various periods.

Existing individual health plans

Plans purchased after the date of enactment, March 23, 2010, or old plans that changed in specified ways would eventually have to be replaced by ACA-compliant plans.

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

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

In the fall of 2013, the Obama Administration announced a transitional relief program that would let states and carriers allow non-compliant individual and small group policies to renew at the end of 2013. In March 2014, HHS allowed renewals as late as October 1, 2016. In February 2016, these plans were allowed to renew up until October 1, 2017, but with a termination date no later than December 31, 2017.

2010

In June small business tax credits took effect. For certain small businesses, the credits reached up to 35% of premiums. At the same time uninsured people with pre-existing conditions could access the federal high-risk pool. Also, participating employment-based plans could obtain reimbursement for a portion of the cost of providing health insurance to early retirees.

In July the Pre-Existing Condition Insurance Plan (PCIP) took effect to offer insurance to those that had been denied coverage by private insurance companies because of a pre-existing condition. Despite estimates of up to 700,000 enrollees, at a cost of approximately $13,000/enrollee, only 56,257 enrolled at a $28,994 cost per enrollee.

2011

As of September 23, 2010, pre-existing conditions could no longer be denied coverage for children's policies. HHS interpreted this rule as a mandate for "guaranteed issue", requiring insurers to issue policies to such children. By 2011, insurers had stopped marketing child-only policies in 17 states, as they sought to escape this requirement.

The average beneficiary in the prior coverage gap would have spent $1,504 in 2011 on prescriptions. Such recipients saved an average $603. The 50 percent discount on brand name drugs provided $581 and the increased Medicare share of generic drug costs provided the balance. Beneficiaries numbered 2 million

2012

In National Federation of Independent Business v. Sebelius decided on June 28, 2012, the Supreme Court ruled that the individual mandate was constitutional when the associated penalties were construed as a tax. The decision allowed states to opt out of the Medicaid expansion. Several did so, although some later accepted the expansion.

2013

In January 2013 the Internal Revenue Service ruled that the cost of covering only the individual employee would be considered in determining whether the cost of coverage exceeded 9.5% of income. Family plans would not be considered even if the cost was above the 9.5% income threshold. This was estimated to leave 2–4 million Americans unable to afford family coverage under their employers’ plans and ineligible for subsidies.

A June 2013 study found that the MLR provision had saved individual insurance consumers $1.2 billion in 2011 and $2.1 billion in 2012, reducing their 2012 costs by 7.5%. The bulk of the savings were in reduced premiums, but some came from MLR rebates.

On July 2, 2013, the Obama Administration announced that it would delay the implementation of the employer mandate until 2015.

The Community Living Assistance Services and Supports Act (or CLASS Act) was enacted as Title VIII of Obamacare. It would have created a voluntary and public long-term care insurance option for employees. In October 2011 the administration announced it was unworkable and would be dropped. The CLASS Act was repealed January 1, 2013.

The launch for both the state and federal exchanges was troubled due to management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered endless problems. Operations stabilized in 2014, although not all planned features were complete.

CMS reported in 2013 that, while costs per capita continued to rise, the rate of increase in annual healthcare costs had fallen since 2002. Per capita cost increases averaged 5.4% annually between 2000 and 2013. Costs relative to GDP, which had been rising, had stagnated since 2009. Several studies attempted to explain the reductions. Reasons included:

2014

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

In Burwell v. Hobby Lobby the Supreme Court exempted closely held corporations with religious convictions from the contraception rule. In Wheaton College vs Burwell the Court issued an injunction allowing the evangelical college and other religiously affiliated nonprofit groups to completely ignore the contraceptive mandate.

A study found that average premiums for the second-cheapest silver plan were 10-21% less than average individual market premiums in 2013, while covering many more conditions. Credit for the reduced premiums was attributed to increased competition stimulated by the larger market, greater authority to review premium increases, the MLR and risk corridors.

Many of the initial plans featured narrow networks of doctors and hospitals.

A 2016 analysis found that health care spending by the middle class was 8.9% of household spending in 2014.

2015

By the beginning of the year, 11.7 million had signed up (ex-Medicaid). On December 31, 2015, about 8.8 million consumers had stayed in the program. Some 84 percent, or about 7.4 million, were subsidized.

Bronze plans were the second most popular in 2015, making up 22% of marketplace plan selections. Silver plans were the most popular, accounting for 67% of marketplace selections. Gold plans were 7%. Platinum plans accounted for 3%. On average across the four metal tiers, premiums were up 20% for HMOs and 18% for EPOs. Premiums for POS plans were up 15% from 2015 to 2016, while PPO premiums were up just 8%.

A 2015 study found 14% of privately insured consumers received a medical bill in the past two years from an out-of-network provider in the context of an overall in-network treatment event. Such out-of-network care is not subject to the lower negotiated rates of in-network care, increasing out-of-pocket costs. Another 2015 study found that the average out-of-network charges for the majority of 97 medical procedures examined "were 300% or higher compared to the corresponding Medicare fees" for those services.

Some 47% of the 2015 ACA plans sold on the Healthcare.gov exchange lacked standard out-of-network coverage. Enrollees in such plans, typically received no coverage for out-of-network costs (except for emergencies or with prior authorization). A 2016 study on Healthcare.gov health plans found a 24 percent increase in the percentage of ACA plans that lacked standard out-of-network coverage.

The December spending bill delayed the onset of the "Cadillac tax" on expensive insurance plans by two years, until 2020.

The average price of non-generic drugs rose 16.2% in 2015 and 98.2% since 2011.

2016

As of March 2016 11.1 million people had purchased exchange plans, while an estimated 9 million to 10 million people had gained Medicaid coverage, mostly low-income adults. 11.1 million were still covered, a decline of nearly 13 percent. 6.1 million uninsured 19-25 year olds gained coverage.

Employers

A survey of New York businesses found an increase of 8.5 percent in health care costs, less than the prior year's survey had expected. A 10 percent increase was expected for 2017. Factors included increased premiums, higher drug costs, ACA and aging workers. Some firms lowered costs by increasing cost-sharing (for higher employee contributions, deductibles and co-payments). 60% planned to further increase cost-sharing. Coverage and benefits were not expected to change. Approximately one fifth said ACA had pushed them to reduce their workforce. A larger number said they were raising prices.

Insurers

The five major national insurers expected to lose money on ACA policies in 2016. UnitedHealth withdrew from the Georgia and Arkansas exchanges for 2017, citing heavy losses. Humana exited other markets, leaving it operating in 156 counties in 11 states for 2017. 225 counties across the country had access to only a single ACA insurer. A study released in May estimated that 664 counties would have one insurer in 2017.

Aetna cancelled planned expansion of its offerings and following an expected $300 million loss in 2016 and then withdrew from 11 of its 15 states. In August 2016 Anthem said that its offerings were losing money, but also that it would expand its participation if a pending merger with Cigna was approved. Aetna and Humana's exit for 2017 left 8 rural Arizona counties with only Blue Cross/Blue Shield.

Blue Cross/Blue Shield Minnesota announced that it would exit individual and family markets in Minnesota in 2017, due to financial losses of $500 million over three years.

Another analysis found that 17 percent of eligibles may have a single insurer option in 2017. North Carolina, Oklahoma, Alaska, Alabama, South Carolina and Wyoming were expected to have a single insurer, while only 2 percent of 2016 eligibles had only one choice.

Aetna, Humana, UnitedHealth Group also exited various individual markets. Many local Blue Cross plans sharply narrowed their networks. In 2016 two thirds of individual plans were narrow-network HMO plans.

One of the causes of insurer losses is the lower income, older and sicker enrollee population. One 2016 analysis reported that while 81% of the population with incomes from 100-150% of the federal poverty level signed up, only 45% of those from 150-200% did so. The percentage continued to decline as income rose: 2% of those above 400% enrolled.

Costs

The law is designed to pay subsidies in the form of tax credits to the individuals or families purchasing the insurance, based on income levels. Higher income consumers receive lower subsidies. While pre-subsidy prices rose considerably from 2016 to 2017, so did the subsidies, to reduce the after-subsidy cost to the consumer. For example, a study published in 2016 found that the average requested 2017 premium increase among 40-year-old non-smokers was about 9 percent, according to an analysis of 17 cities, although Blue Cross Blue Shield proposed increases of 40 percent in Alabama and 60 percent in Texas. However, some or all of these costs are offset by subsidies, paid as tax credits. For example, the Kaiser Foundation reported that for the second-lowest cost "Silver plan" (a plan often selected and used as the benchmark for determining financial assistance), a 40-year old non-smoker making $30,000 per year would pay effectively the same amount in 2017 as they did in 2016 (about $208/month) after the subsidy/tax credit, despite large increases in the pre-subsidy price. This was consistent nationally. In other words, the subsidies increased along with the pre-subsidy price, fully offsetting the price increases.

Cooperatives

The number of ACA nonprofit insurance cooperatives for 2017 fell from 23 originally to 7 for 2017. The remaining 7 posted annual losses in 2015. A General Accountability Report found that co-ops’ 2015 premiums were generally below average. At the end of 2014, money co-ops and other ACA insurers had counted on risk corridor payments that didn't materialize. Maryland's Evergreen Health claims that ACA's risk-adjustment system does not adequately measure risk.

Medicaid

Newly elected Louisiana Governor John Bel Edwards issued an executive order to accept the expansion, becoming the 32nd state to do so. The program was expected to enroll an additional 300,000 Louisianans.

2017

More than 9.2 million people signed up for care on the national exchange (healthcare.gov) for 2017, down some 400,000 from 2016. This decline was due primarily to the election of President Trump, who pulled advertising encouraging people to signup for coverage, issued an executive order that attempts to eliminate the mandate, and has created significant uncertainty about the future of the ACA. Enrollments had been running ahead of 2016 prior to President Obama leaving office, with 9.8 million expected to sign-up, so President Trump's actions potentially cost about 600,000 national enrollments (i.e., 9.8 million expected - 9.2 million actual = 0.6 million impact). Of the 9.2 million, 3.0 million were new customers and 6.2 million were returning. The 9.2 million excludes the 11 states that run their own exchanges, which have signed up around 3 million additional people. These figures also exclude the additional coverage due to the Medicaid expansion, which covers another approximately 10 million persons, as described in the impact section above.

In February, Humana announced that it would withdraw from the individual insurance market in 2018, citing "further signs of an unbalanced risk pool." That month the IRS announced that it would not require that tax returns indicate that a person has health insurance, reducing the effectiveness of the individual mandate, in response to an executive order from President Donald Trump.

Aetna CEO Mark Bertolini stated that ACA was in a "death spiral" of escalating premiums and shrinking, skewed enrollment. However, a U.S. judge found that the Aetna CEO misrepresented why his company was leaving the exchanges; an important part of the reason was the Justice Department's opposition to the intended merger between Aetna and Humana. Aetna actually pulled out of states where it was making money on the exchanges, while remaining in some states where it was not. Further, the CBO reported in March 2017 that the healthcare exchanges were expected to be stable; i.e., they were not in a "death spiral."

Molina Healthcare, a major Medicaid provider, said that it was considering exiting some markets in 2018, citing "too many unknowns with the marketplace program." Molina lost $110 million in 2016 due to having to contribute $325 million more than expected to the ACA "risk transfer" fund that compensated insurers with unprofitable risk pools. These pools were establish to help prevent insurers from artificially selecting lower-risk pools.