Modern Money Operations

We discuss  modern monetary policy solutions most feared by the Plutocracy.

 

Provisions

The Act is divided into 10 titles[46] and contains provisions that became effective immediately, 90 days after enactment, and six months after enactment, as well as provisions phased in through to 2020.[47][48] Below are some of the key provisions of the Act. For simplicity, the amendments in the Health Care and Education Reconciliation Act of 2010 are integrated into this timeline.[49][50]

Effective at Enactment

The Food and Drug Administration is now authorized to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed.[51]

  • The Medicaid drug rebate for brand name drugs is increased to 23.1% (except the rebate for clotting factors and drugs approved exclusively for pediatric use increases to 17.1%), and the rebate is extended to Medicaid managed care plans; the Medicaid rebate for non-innovator, multiple source drugs is increased to 13% of average manufacturer price.[51]
  • A non-profit Patient-Centered Outcomes Research Institute is established, independent from government, to undertake comparative effectiveness research.[51] This is charged with examining the "relative health outcomes, clinical effectiveness, and appropriateness" of different medical treatments by evaluating existing studies and conducting its own. Its 19-member board is to include patients, doctors, hospitals, drug makers, device manufacturers, insurers, payers, government officials and health experts. It will not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment. Medicare may take the Institute's research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.[52] The bill forbids the Institute to develop or employ "a dollars per quality adjusted life year" (or similar measure that discounts the value of a life because of an individual's disability) as a threshold to establish what type of health care is cost effective or recommended. This makes it different from the UK's National Institute for Health and Clinical Excellence.
  • Creation of task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services.[51]
  • The Indian Health Care Improvement Act is reauthorized and amended.[51]
  • Chain restaurants and food vendors with 20 or more locations are required to display the caloric content of their foods on menus, drive-through menus, and vending machines. Additional information, such as saturated fat, carbohydrate, and sodium content, must also be made available upon request.[53] But first, the Food and Drug Administration has to come up with regulations, and as a result, calories disclosures may not appear until 2013 or 2014.[53]

Effective June 21, 2010

Adults with existing conditions became eligible to join a temporary high-risk pool, which will be superseded by the health care exchange in 2014.[48][54] To qualify for coverage, applicants must have a pre-existing health condition and have been uninsured for at least the past six months.[55] There is no age requirement.[55] The new program sets premiums as if for a standard population and not for a population with a higher health risk. Allows premiums to vary by age (4:1), geographic area, and family composition. Limit out-of-pocket spending to $5,950 for individuals and $11,900 for families, excluding premiums.[55][56][57]

Effective July 1, 2010

  • The President established, within the Department of Health and Human Services (HHS), a council to be known as the National Prevention, Health Promotion and Public Health Council to help begin to develop a National Prevention and Health Promotion Strategy. The Surgeon General shall serve as the Chairperson of the new Council.[58][59]
  • A 10% sales tax on indoor tanning took effect.[60]
Effective September 23, 2010
  • Insurers are prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays, in new policies issued.[61]
  • Dependents (children) will be permitted to remain on their parents' insurance plan until their 26th birthday,[62] and regulations implemented under the Act include dependents that no longer live with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.[63][64]
  • Insurers are prohibited from excluding pre-existing medical conditions (except in grandfathered individual health insurance plans) for children under the age of 19.[65][66]
  • Insurers are prohibited from charging co-payments, co-insurance, or deductibles for Level A or Level B preventive care and medical screenings on all new insurance plans.[67]
  • Individuals affected by the Medicare Part D coverage gap will receive a $250 rebate, and 50% of the gap will be eliminated in 2011.[68] The gap will be eliminated by 2020.
  • Insurers' abilities to enforce annual spending caps will be restricted, and completely prohibited by 2014.[48]
  • Insurers are prohibited from dropping policyholders when they get sick.[48]
  • Insurers are required to reveal details about administrative and executive expenditures.[48]
  • Insurers are required to implement an appeals process for coverage determination and claims on all new plans.[48]
  • Enhanced methods of fraud detection are implemented.[48]
  • Medicare is expanded to small, rural hospitals and facilities.[48]
  • Medicare patients with chronic illnesses must be monitored/evaluated on a 3 month basis for coverage of the medications for treatment of such illnesses.
  • Companies which provide early retiree benefits for individuals aged 55–64 are eligible to participate in a temporary program which reduces premium costs.[48]
  • A new website installed by the Secretary of Health and Human Services will provide consumer insurance information for individuals and small businesses in all states.[48]
  • A temporary credit program is established to encourage private investment in new therapies for disease treatment and prevention.[48]

Effective January 1, 2011

 

Effective January 1, 2012

Employers must disclose the value of the benefits they provided beginning in 2012 for each employee's health insurance coverage on the employees' annual Form W-2's.[74] This requirement was originally to be effective January 1, 2011, but was postponed by IRS Notice 2010–69 on October 23, 2010.[75]

  • New tax reporting changes were to come in effect to prevent tax evasion by corporations. However, in April 2011, Congress passed and President Obama signed the Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011 repealing this provision, because it was burdensome to small businesses.[76][77] Before PPACA businesses were required to notify the IRS on form 1099 of certain payments to individuals for certain services or property over a reporting threshold of $600.[78][79] Under the repealed law, reporting of payments to corporations would also be required.[80][81] Originally it was expected to raise $17 billion over 10 years.[82] The amendments made by Section 9006 of the Act were designed to apply to payments made by businesses after December 31, 2011, but will no longer apply because of the repeal of the section.[77][79]
Effective by August 1, 2012
  • All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay or coinsurance. Women's Preventive Services – including well-woman visits, support for breastfeeding equipment, contraception and domestic violence screening – will be covered without cost sharing.

Effective by January 1, 2013

Income from self-employment and wages of single individuals in excess of $200,000 annually will be subject to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to joint compensation of the two spouses), or $125,000 for a married person filing separately.[83] In addition, an additional Medicare tax of 3.8% will apply to unearned income, specifically the lesser of net investment income or the amount by which adjusted gross income exceeds $200,000 ($250,000 for a married couple filing jointly; $125,000 for a married person filing separately.Effective by January 1, 2014

Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal poverty level.[21] (Source: CRS)
  • Insurers are prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.[85]
  • Impose an annual penalty of $95, or up to 1% of income, whichever is greater, on individuals who are not covered by an acceptable insurance policy; this will rise to a minimum of $695 ($2,085 for families), or 2.5% of income, by 2016. [27][86] Exemptions to the mandatory coverage provision and penalty are permitted for religious reasons or for those for whom the least expensive policy would exceed 8% of their income.[87] On June 28, 2012, the Supreme Court ruled that this penalty "must be construed as imposing a tax on those who do not have health insurance." According to the Supreme Court, Congress does not have the power under the Commerce Clause to mandate insurance coverage, but it does have the power to levy the penalty as a tax.
  • Insurers are prohibited from establishing annual spending caps.[48]
  • Expand Medicaid eligibility; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[27][88]
  • Two years of tax credits will be offered to qualified small businesses. In order to receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee, excluding the owner of the business, of less than $25,000 and have fewer than 11 FTEs. The subsidy is reduced by 6.7% per additional employee and 4% per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.[89]
  • Impose a $2,000 per employee tax penalty on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).[90]
  • For employer sponsored plans, set a maximum of $2,000 annual deductible for a plan covering a single individual or $4,000 annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
  • The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped, although an Obama administration official later said the President does not support repealing this provision.[91][92][93][94]
  • Pay for new spending, in part, through spending and coverage cuts in Medicare Advantage, slowing the growth of Medicare provider payments (in part through the creation of a new Independent Payment Advisory Board), reducing Medicare and Medicaid drug reimbursement rate, cutting other Medicare and Medicaid spending.[50][95]
  • Revenue increases from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[96]
  • Establish health insurance exchanges, and subsidization of insurance premiums for individuals in households with income up to 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage.[97][88][98][99] Section 1401(36B) of PPACA explains that the subsidy will be provided as an advanceable, refundable tax credit[100] and gives a formula for its calculation.[101] Refundable tax credit is a way to provide government benefit to people even with no tax liability[102] (example: Earned Income Credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for family of four would be the following:
[[PASTING TABLES IS NOT SUPPORTED]]
a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four.[107][108] See Subsidy Calculator for specific dollar amount.[109]
b.^ DHHS and CBO estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the reform.[103]
  • The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.[110][106]
  • Members of Congress and their staff will only be offered health care plans through the exchange or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).[111]
  • A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5 billion in annual revenue.[86]
  • Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act to 2.3% from 2.6%)[112]
  • Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3 billion in annual revenue.[86]
  • The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of earned income.[113]
Effective by January 1, 2015
  • Physicians' payments from federally funded programs such as Medicare will be modified to be based on the quality of care, not the volume.
Effective by January 1, 2017
  • A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.[114]
  • A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.[115][116] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.[114]
  • In order to qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.[117]
  • A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.[115]
  • In April 2011 Vermont announced its intention to pursue a waiver in order to implement the single-payer system enacted in May 2011.[118][119][120][121] Oregon is also expected to request a waiver.[122]
Effective by 2018
  • All existing health insurance plans must cover approved preventive care and checkups without co-payment.[48]
  • A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill)[123] is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.[86][124]
Effective by 2020
  • The Medicare Part D coverage gap (a.k.a., "donut hole") would be completely phased out and hence closed.
Legislative history Background

Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement.

During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his four priorities if he won the presidency.[125] After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.[126] On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform and requested reform be enacted before the Congressional summer recess; but the reform was not passed by the requested date.[127] In July 2009, a series of bills were approved by committees within the House of Representatives.[128] Beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members met for a series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators Max Baucus (D-Montana), Chuck Grassley (R-Iowa), Kent Conrad (D-North Dakota), Olympia Snowe (R-Maine), Jeff Bingaman (D-New Mexico), and Mike Enzi (R-Wyoming), met for more than 60 hours, and the principles that they discussed became the foundation of the Senate's health care reform bill.[129] The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site[130] or at the Committee's own web site.[131] During the August 2009 congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. During the summer recess, the Tea Party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.[127][132]

Away from the televised meetings, the legislation became a "bonanza" for lobbyists,[133][134] including secret deals that were initially denied but subsequently confirmed.[135][136] The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.[137]

President Obama delivered a speech to a joint session of Congress supporting reform and again outlining his proposals.[138][139] 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.[127][140]

The Senate bill, the Patient Protection and Affordable Care Act, bore similarities to prior healthcare reform proposals introduced by Republicans. In 1993 Senator John Chafee introduced the Health Equity and Access Reform Today Act which contained a "Universal Coverage" requirement with a tax penalty for non-compliance.[141][142] In 1994 Senator Don Nickles introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision.[143] However, Nickles removed the mandate from the act shortly after introduction, stating that they had decided "that government should not compel people to buy health insurance."[144]

There were many threats made against members of Congress and many were assigned extra protection.[145][146][147][148][149][150][150][151][152][153][145][154][149][155][156][157][158][159][160][161]

Senate
Senate vote by state.
Two Democratic yeas
One Democratic yea, one Republican nay
One Republican nay, one Republican not voting
Two Republican nays
House vote by congressional district.
Democratic yea
Democratic nay
Republican nay
No representative seated

The Senate failed to take up debate on the House bill and instead took up H.R. 3590, a bill regarding housing tax breaks for service members.[162] As the United States Constitution requires all revenue-related bills to originate in the House,[163] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.[164] The bill as amended incorporated elements of earlier proposals that had been reported favorably by the Senate Health and Finance committees.

Passage in the Senate was temporarily blocked by a filibuster threat by Nebraska Senator Ben Nelson, who sided with the Republican minority. Nelson's support for the bill was won after it was amended to offer a higher rate of Medicaid reimbursement for Nebraska.[127] The compromise was derisively referred to as the "Cornhusker Kickback"[165] (and was later repealed by the reconciliation bill). On December 23, the Senate voted 60–39 to end debate on the bill, eliminating the possibility of a filibuster by opponents. The bill then passed by a party-line vote of 60–39 on December 24, 2009, with one senator (Jim Bunning) not voting.[166]

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate, having campaigned on giving the Republican minority the 41st vote needed to sustain a filibuster, even famously signing autographs as "Scott 41."[127][167][168]

House

Although White House Chief of Staff Rahm Emanuel argued for a less ambitious bill, House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care".[169][170] Obama's siding with 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 for reform.[169][170] Obama unveiled a health care reform plan of his own, drawing largely from the Senate bill. On February 22 he laid out a "Senate-leaning" proposal to consolidate the bills.[171] On February 25, he held a meeting with leaders of both parties urging passage of a reform bill.[127] The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.[170]

The most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and to instead pass the Senate's bill, and then pass amendments to it with a different bill allowing the Senate to pass the amendments via the reconciliation process.[169][172]

Initially, there were not enough supporters to pass the bill, thus requiring its proponents to negotiate with a group of pro-life Democrats, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion was substantive enough to cause their opposition to the bill. Instead of requesting inclusion of additional language specific to their abortion concerns in the bill, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. This concession won the support of Stupak and members of his group and assured passage of the bill.[173]

The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[174] The following day, Republicans introduced legislation to repeal the bill.[175] Obama signed the original bill into law on March 23, 2010.[176]

Impact Public policy impact Change in number of uninsured

CBO estimates the legislation will reduce the number of uninsured residents by 30 million, leaving 25 million uninsured residents in 2019 after the bill's provisions have all taken effect.[177][178][179][180] Among the people in this uninsured group will be:

  • Illegal immigrants, estimated at almost a third of the 25 million – they will be ineligible for insurance subsidies and Medicaid;[177][181][182] they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA).
  • Citizens not enrolled in Medicaid despite being eligible.[183]
  • Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.[183]
  • Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.[183]

Early experience under the Act was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.[184] On September 13, 2011, the Census Bureau released a report showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.[185]

Effects on insurance premiums

For the effect on health insurance premiums, the CBO referred[186]:15 to its November 2009 analysis[187] and stated that the effects would "probably be quite similar" to that earlier analysis. That analysis forecasted that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high premium plans reducing benefits in response to the tax.[187]

The Associated Press reported that, as a result of the Act's provisions concerning the Medicare Part D coverage gap, individuals falling in this "donut hole" would save about 40 percent.[188] Almost all of the savings came because, with regard to brand-name drugs, the Act secured a discount from pharmaceutical companies.[188] The change benefited more than two million people, most of them in the middle class.[188]

Federal expenditures and deficit impact Healthcare spending trends

In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:

Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."[189]

Expenditure estimates

In 2012, the Congressional Budget Office (CBO) projected the Act will require more than $1.7 trillion in gross federal spending over the period 2012–2022, some of which will be offset by penalties and tax increases related to coverage, resulting in net spending of more than $1.2 trillion.[190][180][191][179]

According to the Centers for Medicare and Medicaid Services, by 2019 the Act will increase expenditures on Medicaid and individual subsidies by $165 billion annually while reducing Medicare expenditures by $125 billion annually.[192]

CBO deficit reduction estimates
CBO – Deficit reduction under ACA

The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021.[193] CBO estimated in March 2011 that for the 2012–2021 period, the law would result in net receipts of $813 billion, offset by $604 billion in outlays, resulting in a $210 billion reduction in the deficit.[193]

As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143 billion[194] over the first decade, but half of that was due to expected premiums for the C.L.A.S.S. Act, which has since been abandoned.[195] Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the great degree of uncertainty involved in the data) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion.[186][196] 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".[197]

CBO also initially stated that the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs;"[186] A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019;[198][199][200][201][202] however, the "doc fix" remains a separate piece of legislation.[203] Subject to the same exclusion, the CBO initially estimated the federal government's share of the cost during the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the spending kicks in;[204][205] with revenue exceeding spending during these six years.[206]

Other financing-related debate and opinion

There was mixed opinion about the CBO estimates from others.

Uwe Reinhardt, a health economist at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003."[207]

Douglas Holtz-Eakin, a 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, opined that the bill would increase the deficit by $562 billion.[208]

Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700 billion in its first 10 years.[209][210]

Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false[211] and that repeal of the legislation would increase the deficit by $230 billion over the same period,[212] pointing to the CBO's 2011 analysis of the impact of repeal.[213]

The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (a noted health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;[214][215] "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."[215]

David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.[216] On the other hand, a Center on Budget and Policy Priorities analysis said that Congress has a good record of implementing Medicare savings. According to their study, Congress implemented the vast majority of the provisions enacted in the past 20 years to produce Medicare savings.[217][218]

Coverage for abortifacients, contraceptives, and sterilizations

With the exception of churches and houses of worship, the Act's contraceptive coverage mandate applies to all employers and educational institutions. The mandate applies to all new health insurance plans effective August 2012. It controversially includes Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds. Regulations[219] made under the act rely on the recommendations of the Institute of Medicine, which concluded that birth control is medically necessary "to ensure women's health and well-being."

Effect on national spending

The United States Department of Health and Human Services reported that the bill would increase "total national health expenditures" by more than $200 billion from 2010 to 2019.[11][220] The report also cautioned that the increases could be larger, because the Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back. The report projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors.[221][222]

Surgeon Atul Gawande has noted the bill contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.[223]

The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.[224]

After the bill was signed, AT&T, Caterpillar, Verizon, and John Deere issued financial reports showing large charges against earnings, up to US$1 billion in the case of AT&T, attributing the additional expenses to tax changes in the new health care law.[225] Under the new law, starting in 2013 companies can no longer deduct a subsidy for prescription drug benefits granted under Medicare Part D.[226]

Political impact Public opinion

Polls indicated that a majority of Americans did not support the overall law, although specific elements were very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. Democrats favored the law, while Republicans and Independents did not. For example, a Reuters-Ipsos poll during June 2012 indicated the following:

  • 56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% Independents, and 14% of Republicans favored the law overall.
  • 82% favored banning insurance companies from denying coverage to people with pre-existing conditions.
  • 61% favored allowing children to stay on their parents' insurance until age 26.
  • 72% supported requiring companies with more than 50 employees to provide insurance for their employees.
  • 61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.[227]
  • Other topics receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.[228][229]

Other specific ideas that showed majority support, such as purchasing drugs from Canada, limiting malpractice awards, and reducing the age to qualify for Medicare, were not enacted.[230]

Public opinion supported healthcare reform proposals in 2008, but turned negative when the plan changed in 2009, and remains opposed to the final version that was signed in 2010.[231][232] Though in 2008 then-Senators Barack Obama and Joseph Biden campaigned against requiring adults to buy insurance;[233] in 2009 President Obama reportedly changed his mind and agreed with insurance industry and Democratic Congressional proposals to include an individual mandate.[234][235] Public opinion of the legislation turned negative when the individual mandate proposal was announced, and remains opposed by a margin of 10 percentage points.[231][232][236]

In March 2010, pollsters probed the reasons for opposition. In a CNN poll, 62% of respondents said the Act would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they and their families would be better off with the legislation.[237] In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen wrote, "One of the more amazing aspects of the health-care debate is how steady public opinion has remained... 81% of voters say it's likely the plan will end up costing more than projected [and 59%] say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care. For these voters, the notion that you need to spend an additional trillion dollars doesn't make sense."[238] USA Today found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.[239]

A September 2010 Politico article reported that five House Democrats had run political ads highlighting their "no" votes on the bill, while there had not been any political ads highlighting a "yes" vote since April, when Harry Reid ran one. The article also reported a Kaiser Family Foundation poll "which showed 43 percent of the public supports the overhaul and 45 percent are opposed. Much of the disagreement falls along party lines."[240]

A June 2012 Reuters-Ipsos poll indicated that much of the opposition to the law was because Americans wanted more reform, not less. About one-third of Republicans and independents who oppose the law did so because it did not go far enough to fix healthcare. 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among Democratic opponents, 67% reject it overall, and 51% wanted the measure to go further.[227]

  Effective by January 1, 2014

Maximum Out-of-Pocket Premium Payments Under PPACA by Family Size and federal poverty level.[21] (Source: CRS)
  • Insurers are prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.[85]
  • Impose an annual penalty of $95, or up to 1% of income, whichever is greater, on individuals who are not covered by an acceptable insurance policy; this will rise to a minimum of $695 ($2,085 for families), or 2.5% of income, by 2016. [27][86] Exemptions to the mandatory coverage provision and penalty are permitted for religious reasons or for those for whom the least expensive policy would exceed 8% of their income.[87] On June 28, 2012, the Supreme Court ruled that this penalty "must be construed as imposing a tax on those who do not have health insurance." According to the Supreme Court, Congress does not have the power under the Commerce Clause to mandate insurance coverage, but it does have the power to levy the penalty as a tax.
  • Insurers are prohibited from establishing annual spending caps.[48]
  • Expand Medicaid eligibility; all individuals with income up to 133% of the poverty line qualify for coverage, including adults without dependent children.[27][88]
  • Two years of tax credits will be offered to qualified small businesses. In order to receive the full benefit of a 50% premium subsidy, the small business must have an average payroll per full-time equivalent ("FTE") employee, excluding the owner of the business, of less than $25,000 and have fewer than 11 FTEs. The subsidy is reduced by 6.7% per additional employee and 4% per additional $1,000 of average compensation. As an example, a 16 FTE firm with a $35,000 average salary would be entitled to a 10% premium subsidy.[89]
  • Impose a $2,000 per employee tax penalty on employers with more than 50 employees who do not offer health insurance to their full-time workers (as amended by the reconciliation bill).[90]
  • For employer sponsored plans, set a maximum of $2,000 annual deductible for a plan covering a single individual or $4,000 annual deductible for any other plan (see 111HR3590ENR, section 1302). These limits can be increased under rules set in section 1302.
  • The CLASS Act provision would have created a voluntary long-term care insurance program, but in October 2011 the Department of Health and Human Services announced that the provision was unworkable and would be dropped, although an Obama administration official later said the President does not support repealing this provision.[91][92][93][94]
  • Pay for new spending, in part, through spending and coverage cuts in Medicare Advantage, slowing the growth of Medicare provider payments (in part through the creation of a new Independent Payment Advisory Board), reducing Medicare and Medicaid drug reimbursement rate, cutting other Medicare and Medicaid spending.[50][95]
  • Revenue increases from a new $2,500 limit on tax-free contributions to flexible spending accounts (FSAs), which allow for payment of health costs.[96]
  • Establish health insurance exchanges, and subsidization of insurance premiums for individuals in households with income up to 400% of the poverty line. To qualify for the subsidy, the beneficiaries cannot be eligible for other acceptable coverage.[97][88][98][99] Section 1401(36B) of PPACA explains that the subsidy will be provided as an advanceable, refundable tax credit[100] and gives a formula for its calculation.[101] Refundable tax credit is a way to provide government benefit to people even with no tax liability[102] (example: Earned Income Credit). The formula was changed in the amendments (HR 4872) passed March 23, 2010, in section 1001. According to DHHS and CRS, in 2014 the income-based premium caps for a "silver" healthcare plan for family of four would be the following:
a.^ Note: In 2016, the FPL is projected to equal about $11,800 for a single person and about $24,000 for family of four.[107][108] See Subsidy Calculator for specific dollar amount.[109]
b.^ DHHS and CBO estimate the average annual premium cost in 2014 to be $11,328 for family of 4 without the reform.[103]
  • The U.S. Department of Health and Human Services (DHHS) and Internal Revenue Service (IRS) on May 23, 2012, issued joint final rules regarding implementation of new state-based health insurance exchanges to cover how the exchanges will determine eligibility for uninsured individuals and employees of small businesses seeking to buy insurance on the exchanges, as well as how the exchanges will handle eligibility determinations for low-income individuals applying for newly expanded Medicaid benefits.[110][106]
  • Members of Congress and their staff will only be offered health care plans through the exchange or plans otherwise established by the bill (instead of the Federal Employees Health Benefits Program that they currently use).[111]
  • A new excise tax goes into effect that is applicable to pharmaceutical companies and is based on the market share of the company; it is expected to create $2.5 billion in annual revenue.[86]
  • Most medical devices become subject to a 2.3% excise tax collected at the time of purchase. (Reduced by the reconciliation act to 2.3% from 2.6%)[112]
  • Health insurance companies become subject to a new excise tax based on their market share; the rate gradually rises between 2014 and 2018 and thereafter increases at the rate of inflation. The tax is expected to yield up to $14.3 billion in annual revenue.[86]
  • The qualifying medical expenses deduction for Schedule A tax filings increases from 7.5% to 10% of earned income.[113]
Effective by January 1, 2015
  • Physicians' payments from federally funded programs such as Medicare will be modified to be based on the quality of care, not the volume.
Effective by January 1, 2017
  • A state may apply to the Secretary of Health & Human Services for a "waiver for state innovation" provided that the state passes legislation implementing an alternative health care plan meeting certain criteria. The decision of whether to grant the waiver is up to the Secretary (who must annually report to Congress on the waiver process) after a public comment period.[114]
  • A state receiving the waiver would be exempt from some of the central requirements of the ACA, including the individual mandate, the creation by the state of an insurance exchange, and the penalty for certain employers not providing coverage.[115][116] The state would also receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under the ACA plan, but which cannot be paid out due to the structure of the state plan.[114]
  • In order to qualify for the waiver, the state plan must provide insurance at least as comprehensive and as affordable as that required by the ACA, must cover at least as many residents as the ACA plan would, and cannot increase the federal deficit. The coverage must continue to meet the consumer protection requirements of the ACA, such as the prohibition on increasing premiums because of pre-existing conditions.[117]
  • A bipartisan bill sponsored by Senators Ron Wyden and Scott Brown, and supported by President Obama, proposes making waivers available in 2014 rather than 2017, so that, for example, states that wish to implement an alternative plan need not set up an insurance exchange only to dismantle it a short time later.[115]
  • In April 2011 Vermont announced its intention to pursue a waiver in order to implement the single-payer system enacted in May 2011.[118][119][120][121] Oregon is also expected to request a waiver.[122]
Effective by 2018
  • All existing health insurance plans must cover approved preventive care and checkups without co-payment.[48]
  • A 40% excise tax on high cost ("Cadillac") insurance plans is introduced. The tax (as amended by the reconciliation bill)[123] is on insurance premiums in excess of $27,500 (family plans) and $10,200 (individual plans), and it is increased to $30,950 (family) and $11,850 (individual) for retirees and employees in high risk professions. The dollar thresholds are indexed with inflation; employers with higher costs on account of the age or gender demographics of their employees may value their coverage using the age and gender demographics of a national risk pool.[86][124]
Effective by 2020
  • The Medicare Part D coverage gap (a.k.a., "donut hole") would be completely phased out and hence closed.
Legislative history Background

Health care reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to be without health insurance at some point during each year. One point of difference between the plans was that Clinton's plan was to require all Americans to obtain coverage (in effect, an individual health insurance mandate), while Obama's was to provide a subsidy but not create a direct requirement.

During the general election campaign between Obama and the Republican nominee, Arizona Senator John McCain, Obama said that fixing health care would be one of his four priorities if he won the presidency.[125] After his inauguration, Obama announced to a joint session of Congress in February 2009 that he would begin working with Congress to construct a plan for health care reform.[126] On March 5, 2009, Obama formally began the reform process and held a conference with industry leaders to discuss reform and requested reform be enacted before the Congressional summer recess; but the reform was not passed by the requested date.[127] In July 2009, a series of bills were approved by committees within the House of Representatives.[128] Beginning June 17, 2009, and extending through September 14, 2009, three Democratic and three Republican Senate Finance Committee Members met for a series of 31 meetings to discuss the development of a health care reform bill. Over the course of the next three months, this group, Senators Max Baucus (D-Montana), Chuck Grassley (R-Iowa), Kent Conrad (D-North Dakota), Olympia Snowe (R-Maine), Jeff Bingaman (D-New Mexico), and Mike Enzi (R-Wyoming), met for more than 60 hours, and the principles that they discussed became the foundation of the Senate's health care reform bill.[129] The meetings were held in public and broadcast by C-SPAN and can be seen on the C-SPAN web site[130] or at the Committee's own web site.[131] During the August 2009 congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. During the summer recess, the Tea Party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.[127][132]

Away from the televised meetings, the legislation became a "bonanza" for lobbyists,[133][134] including secret deals that were initially denied but subsequently confirmed.[135][136] The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties.[137]

President Obama delivered a speech to a joint session of Congress supporting reform and again outlining his proposals.[138][139] 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.[127][140]

The Senate bill, the Patient Protection and Affordable Care Act, bore similarities to prior healthcare reform proposals introduced by Republicans. In 1993 Senator John Chafee introduced the Health Equity and Access Reform Today Act which contained a "Universal Coverage" requirement with a tax penalty for non-compliance.[141][142] In 1994 Senator Don Nickles introduced the Consumer Choice Health Security Act which also contained an individual mandate with a penalty provision.[143] However, Nickles removed the mandate from the act shortly after introduction, stating that they had decided "that government should not compel people to buy health insurance."[144]

There were many threats made against members of Congress and many were assigned extra protection.[145][146][147][148][149][150][150][151][152][153][145][154][149][155][156][157][158][159][160][161]

Senate
Senate vote by state.
Two Democratic yeas
One Democratic yea, one Republican nay
One Republican nay, one Republican not voting
Two Republican nays
House vote by congressional district.
Democratic yea
Democratic nay
Republican nay
No representative seated

The Senate failed to take up debate on the House bill and instead took up H.R. 3590, a bill regarding housing tax breaks for service members.[162] As the United States Constitution requires all revenue-related bills to originate in the House,[163] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their health care reform proposal, completely revising the content of the bill.[164] The bill as amended incorporated elements of earlier proposals that had been reported favorably by the Senate Health and Finance committees.

Passage in the Senate was temporarily blocked by a filibuster threat by Nebraska Senator Ben Nelson, who sided with the Republican minority. Nelson's support for the bill was won after it was amended to offer a higher rate of Medicaid reimbursement for Nebraska.[127] The compromise was derisively referred to as the "Cornhusker Kickback"[165] (and was later repealed by the reconciliation bill). On December 23, the Senate voted 60–39 to end debate on the bill, eliminating the possibility of a filibuster by opponents. The bill then passed by a party-line vote of 60–39 on December 24, 2009, with one senator (Jim Bunning) not voting.[166]

On January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate, having campaigned on giving the Republican minority the 41st vote needed to sustain a filibuster, even famously signing autographs as "Scott 41."[127][167][168]

House

Although White House Chief of Staff Rahm Emanuel argued for a less ambitious bill, House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care".[169][170] Obama's siding with 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 for reform.[169][170] Obama unveiled a health care reform plan of his own, drawing largely from the Senate bill. On February 22 he laid out a "Senate-leaning" proposal to consolidate the bills.[171] On February 25, he held a meeting with leaders of both parties urging passage of a reform bill.[127] The summit proved successful in shifting the political narrative away from the Massachusetts loss back to health care policy.[170]

The most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and to instead pass the Senate's bill, and then pass amendments to it with a different bill allowing the Senate to pass the amendments via the reconciliation process.[169][172]

Initially, there were not enough supporters to pass the bill, thus requiring its proponents to negotiate with a group of pro-life Democrats, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion was substantive enough to cause their opposition to the bill. Instead of requesting inclusion of additional language specific to their abortion concerns in the bill, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment. This concession won the support of Stupak and members of his group and assured passage of the bill.[173]

The House passed the bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[174] The following day, Republicans introduced legislation to repeal the bill.[175] Obama signed the original bill into law on March 23, 2010.[176]

Impact Public policy impact Change in number of uninsured

CBO estimates the legislation will reduce the number of uninsured residents by 30 million, leaving 25 million uninsured residents in 2019 after the bill's provisions have all taken effect.[177][178][179][180] Among the people in this uninsured group will be:

  • Illegal immigrants, estimated at almost a third of the 25 million – they will be ineligible for insurance subsidies and Medicaid;[177][181][182] they will also be exempt from the health insurance mandate and will remain eligible for emergency services under the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA).
  • Citizens not enrolled in Medicaid despite being eligible.[183]
  • Citizens not otherwise covered and opting to pay the annual penalty instead of purchasing insurance – mostly younger and single Americans.[183]
  • Citizens whose insurance coverage would cost more than 8% of household income and are exempt from paying the annual penalty.[183]

Early experience under the Act was that, as a result of the tax credit for small businesses, some businesses offered health insurance to their employees for the first time.[184] On September 13, 2011, the Census Bureau released a report showing that the number of uninsured 19- to 25-year-olds (now eligible to stay on their parents' policies) had declined by 393,000, or 1.6%.[185]

Effects on insurance premiums

For the effect on health insurance premiums, the CBO referred[186]:15 to its November 2009 analysis[187] and stated that the effects would "probably be quite similar" to that earlier analysis. That analysis forecasted that by 2016, for the non-group market comprising 17% of the market, premiums per person would increase by 10 to 13% but that over half of these insureds would receive subsidies that would decrease the premium paid to "well below" premiums charged under current law. For the small group market, 13% of the market, premiums would be impacted 1 to −3% and −8 to −11% for those receiving subsidies; for the large group market comprising 70% of the market, premiums would be impacted 0 to −3%, with insureds under high premium plans subject to excise taxes being charged −9 to −12%. The analysis was affected by various factors including increased benefits particularly for the nongroup markets, more healthy insureds due to the mandate, administrative efficiencies related to the health exchanges, and insureds under high premium plans reducing benefits in response to the tax.[187]

The Associated Press reported that, as a result of the Act's provisions concerning the Medicare Part D coverage gap, individuals falling in this "donut hole" would save about 40 percent.[188] Almost all of the savings came because, with regard to brand-name drugs, the Act secured a discount from pharmaceutical companies.[188] The change benefited more than two million people, most of them in the middle class.[188]

Federal expenditures and deficit impact Healthcare spending trends

In a May 2010 presentation on "Health Costs and the Federal Budget", CBO stated:

Rising health costs will put tremendous pressure on the federal budget during the next few decades and beyond. In CBO's judgment, the health legislation enacted earlier this year does not substantially diminish that pressure.

CBO further observed that "a substantial share of current spending on health care contributes little if anything to people's health" and concluded, "Putting the federal budget on a sustainable path would almost certainly require a significant reduction in the growth of federal health spending relative to current law (including this year's health legislation)."[189]

Expenditure estimates

In 2012, the Congressional Budget Office (CBO) projected the Act will require more than $1.7 trillion in gross federal spending over the period 2012–2022, some of which will be offset by penalties and tax increases related to coverage, resulting in net spending of more than $1.2 trillion.[190][180][191][179]

According to the Centers for Medicare and Medicaid Services, by 2019 the Act will increase expenditures on Medicaid and individual subsidies by $165 billion annually while reducing Medicare expenditures by $125 billion annually.[192]

CBO deficit reduction estimates
CBO – Deficit reduction under ACA

The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the period 2012–2021.[193] CBO estimated in March 2011 that for the 2012–2021 period, the law would result in net receipts of $813 billion, offset by $604 billion in outlays, resulting in a $210 billion reduction in the deficit.[193]

As of the bill's passage into law in 2010, CBO estimated the legislation would reduce the deficit by $143 billion[194] over the first decade, but half of that was due to expected premiums for the C.L.A.S.S. Act, which has since been abandoned.[195] Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period (because of the great degree of uncertainty involved in the data) it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2 trillion.[186][196] 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".[197]

CBO also initially stated that the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs;"[186] A commonly heard criticism of the CBO cost estimates is that CBO was required to exclude from its initial estimates the effects of likely "doc fix" legislation that would increase Medicare payments by more than $200 billion from 2010 to 2019;[198][199][200][201][202] however, the "doc fix" remains a separate piece of legislation.[203] Subject to the same exclusion, the CBO initially estimated the federal government's share of the cost during the first decade at $940 billion, $923 billion of which takes place during the final six years (2014–2019) when the spending kicks in;[204][205] with revenue exceeding spending during these six years.[206]

Other financing-related debate and opinion

There was mixed opinion about the CBO estimates from others.

Uwe Reinhardt, a health economist at Princeton, wrote that "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation", but went on to say "But even if the budget office errs significantly in its conclusion that the bill would actually help reduce the future federal deficit, I doubt that the financing of this bill will be anywhere near as fiscally irresponsible as was the financing of the Medicare Modernization Act of 2003."[207]

Douglas Holtz-Eakin, a 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, opined that the bill would increase the deficit by $562 billion.[208]

Republican House leadership and the Republican majority on the House Budget Committee estimate the law would increase the deficit by more than $700 billion in its first 10 years.[209][210]

Democratic House leadership and the Democratic minority on the House Budget Committee say the claims of budget gimmickry are false[211] and that repeal of the legislation would increase the deficit by $230 billion over the same period,[212] pointing to the CBO's 2011 analysis of the impact of repeal.[213]

The New Republic editors Noam Scheiber (an economist) and Jonathan Cohn (a noted health care policy analyst), countered critical assessments of the law's deficit impact, arguing that it is as likely, if not more so, for predictions to have underestimated deficit reduction than to have overestimated it. They noted that it is easier, for example, to account for the cost of definite levels of subsidies to specified numbers of people than account for savings from preventive health care, and that the CBO has a track record of consistently overestimating the costs of, and underestimating the savings of health legislation;[214][215] "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."[215]

David Walker, former U.S. Comptroller General now working for The Peter G. Peterson Foundation, has stated that the CBO estimates are not likely to be accurate, because it is based on the assumption that Congress is going to do everything they say they're going to do.[216] On the other hand, a Center on Budget and Policy Priorities analysis said that Congress has a good record of implementing Medicare savings. According to their study, Congress implemented the vast majority of the provisions enacted in the past 20 years to produce Medicare savings.[217][218]

Coverage for abortifacients, contraceptives, and sterilizations

With the exception of churches and houses of worship, the Act's contraceptive coverage mandate applies to all employers and educational institutions. The mandate applies to all new health insurance plans effective August 2012. It controversially includes Christian hospitals, Christian charities, Catholic universities, and other enterprises owned or controlled by religious organizations that oppose contraception on doctrinal grounds. Regulations[219] made under the act rely on the recommendations of the Institute of Medicine, which concluded that birth control is medically necessary "to ensure women's health and well-being."

Effect on national spending

The United States Department of Health and Human Services reported that the bill would increase "total national health expenditures" by more than $200 billion from 2010 to 2019.[11][220] The report also cautioned that the increases could be larger, because the Medicare cuts in the law may be unrealistic and unsustainable, forcing lawmakers to roll them back. The report projected that Medicare cuts could put nearly 15% of hospitals and other institutional providers into debt, "possibly jeopardizing access" to care for seniors.[221][222]

Surgeon Atul Gawande has noted the bill contains a variety of pilot programs that may have a significant impact on cost and quality over the long-run, although these have not been factored into CBO cost estimates. He stated these pilot programs cover nearly every idea healthcare experts advocate, except malpractice/tort reform. He argued that a trial and error strategy, combined with industry and government partnership, is how the U.S. overcame a similar challenge in the agriculture industry in the early 20th century.[223]

The Business Roundtable, an association of CEOs, commissioned a report from the consulting company Hewitt Associates that found that the legislation "could potentially reduce that trend line by more than $3,000 per employee, to $25,435" with respect to insurance premiums. It also stated that the legislation "could potentially reduce the rate of future health care cost increases by 15% to 20% when fully phased in by 2019". The group cautioned that this is all assuming that the cost-saving government pilot programs both succeed and then are wholly copied by the private market, which is uncertain.[224]

After the bill was signed, AT&T, Caterpillar, Verizon, and John Deere issued financial reports showing large charges against earnings, up to US$1 billion in the case of AT&T, attributing the additional expenses to tax changes in the new health care law.[225] Under the new law, starting in 2013 companies can no longer deduct a subsidy for prescription drug benefits granted under Medicare Part D.[226]

Political impact Public opinion

Polls indicated that a majority of Americans did not support the overall law, although specific elements were very popular across the political spectrum, with the notable exception of the mandate to purchase insurance. Democrats favored the law, while Republicans and Independents did not. For example, a Reuters-Ipsos poll during June 2012 indicated the following:

  • 56% of Americans overall were against the law, with 44% supporting it. By party affiliation, 75% of Democrats, 27% Independents, and 14% of Republicans favored the law overall.
  • 82% favored banning insurance companies from denying coverage to people with pre-existing conditions.
  • 61% favored allowing children to stay on their parents' insurance until age 26.
  • 72% supported requiring companies with more than 50 employees to provide insurance for their employees.
  • 61% opposed requiring all U.S. residents to own health insurance. By party affiliation, 19% of Republicans, 27% of Independents, and 41% of Democrats favored the mandate that all Americans buy health insurance.[227]
  • Other topics receiving majority support among all three affiliations included: creation of insurance pools so small businesses and the uninsured had access to insurance exchanges to take advantage of large group pricing benefits; and providing subsidies on a sliding scale to aid individuals and families who cannot afford health insurance.[228][229]

Other specific ideas that showed majority support, such as purchasing drugs from Canada, limiting malpractice awards, and reducing the age to qualify for Medicare, were not enacted.[230]

Public opinion supported healthcare reform proposals in 2008, but turned negative when the plan changed in 2009, and remains opposed to the final version that was signed in 2010.[231][232] Though in 2008 then-Senators Barack Obama and Joseph Biden campaigned against requiring adults to buy insurance;[233] in 2009 President Obama reportedly changed his mind and agreed with insurance industry and Democratic Congressional proposals to include an individual mandate.[234][235] Public opinion of the legislation turned negative when the individual mandate proposal was announced, and remains opposed by a margin of 10 percentage points.[231][232][236]

In March 2010, pollsters probed the reasons for opposition. In a CNN poll, 62% of respondents said the Act would "increase the amount of money they personally spend on health care," 56% said the bill "gives the government too much involvement in health care," and only 19% said they and their families would be better off with the legislation.[237] In The Wall Street Journal, pollsters Scott Rasmussen and Doug Schoen wrote, "One of the more amazing aspects of the health-care debate is how steady public opinion has remained... 81% of voters say it's likely the plan will end up costing more than projected [and 59%] say that the biggest problem with the health-care system is the cost: They want reform that will bring down the cost of care. For these voters, the notion that you need to spend an additional trillion dollars doesn't make sense."[238] USA Today found opinions were starkly divided by age, with a solid majority of seniors opposing the bill and a solid majority of those younger than 40 in favor.[239]

A September 2010 Politico article reported that five House Democrats had run political ads highlighting their "no" votes on the bill, while there had not been any political ads highlighting a "yes" vote since April, when Harry Reid ran one. The article also reported a Kaiser Family Foundation poll "which showed 43 percent of the public supports the overhaul and 45 percent are opposed. Much of the disagreement falls along party lines."[240]

A June 2012 Reuters-Ipsos poll indicated that much of the opposition to the law was because Americans wanted more reform, not less. About one-third of Republicans and independents who oppose the law did so because it did not go far enough to fix healthcare. 71% of Republican opponents reject it overall, while 29% believed it did not go far enough, while independent opponents are divided 67% to 33%. Among Democratic opponents, 67% reject it overall, and 51% wanted the measure to go further.[227]

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