View source for Finance:Affordable Care Act

{{short description|U.S. federal statute also known as Obamacare}}
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{{Infobox U.S. legislation
| enacted by = 111th
| effective date = {{start date and age|2010|3|23}}<br />Most major provisions phased in by January 2014; remaining provisions phased in by 2020; penalty enforcing individual mandate set at $0 starting 2019
| cite public law = 111–148
| cite statutes at large = {{USStat|124|119}} ''through'' {{USStat|124|1025}} (906 pages)
| public law url = https://www.govinfo.gov/app/details/PLAW-111publ148/PLAW-111publ148
| leghisturl = https://www.congress.gov/bill/111th-congress/house-bill/3590/all-actions
| introducedin = House
| introducedbill = '''the''' "Service Members Home Ownership Tax Act of 2009" ({{USBill|111|H.R.|3590}})
| introducedby = Charles Rangel (D–NY)
| introduceddate = September 17, 2009
| committees = Ways and Means
| passedbody1 = House
| passeddate1 = November 7, 2009
| passedvote1 = [http://clerk.house.gov/evs/2009/roll887.xml 220–215]
| passedbody2 = Senate
| passedas2 = "Patient Protection and Affordable Care Act"
| passeddate2 = December 24, 2009
| passedvote2 = [https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00396 60–39]
| agreedbody3 = House
| agreeddate3 = March 21, 2010
| agreedvote3 = [http://clerk.house.gov/evs/2010/roll165.xml 219–212]
| signedpresident = [[Biography:Barack Obama|Barack Obama]]
| signeddate = March 23, 2010
| amendments = Health Care and Education Reconciliation Act of 2010<br />Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011<br />Tax Cuts and Jobs Act of 2017
| name = Affordable Care Act
| fullname = An Act Entitled The Patient Protection and Affordable Care Act
| acronym = ACA, PPACA
| nickname = Obamacare, Affordable Care Act, Health Insurance Reform, Healthcare Reform
| acts amended = Public Health Service Act
| title amended = 
| sections created = 
| sections amended =
| SCOTUS cases = {{ubl|''National Federation of Independent Business v. Sebelius'', {{ussc|567|519|2012}}|''Burwell v. Hobby Lobby Stores, Inc.'', {{ussc|573|682|2014}}|''King v. Burwell'', {{ussc|docket=14-114|volume=576|year=2015}}|''Zubik v. Burwell'', {{ussc|docket=14-1418|volume=578|year=2016}}|''Maine Community Health Options v. United States'', {{ussc|docket=18-1023|volume=590|year=2020}}|''Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania'', {{ussc|docket=19-431|volume=591|year=2020}}|''California v. Texas'', {{ussc|docket=19-840|volume=593|year=2021}}|''Cummings v. Premier Rehab Keller, P.L.L.C.'', {{ussc|docket=20-219|volume=596|year=2022}}}}
}}

The '''Affordable Care Act''' ('''ACA'''), formally known as the '''Patient Protection and Affordable Care Act''' ('''PPACA''') and colloquially known as '''Obamacare''', is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President [[Biography:Barack Obama|Barack Obama]] on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965.<ref name="Oberlander2010" /><ref name="Blumenthal2015" /><ref name="CohenEtAl" /><ref name="ReutersSCOTUS" />

The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered.<ref name="CBO_Subsidy2016" /><ref name="HHS_ASPE16">{{Cite web |url=https://aspe.hhs.gov/pdf-report/health-insurance-coverage-and-affordable-care-act-2010-2016 |first1  =  Namrata|  first2 = Kenneth |first3 =Emily | last1= Uberoi |last2 =Finegold| last3=Gee |title=Health Insurance Coverage and the Affordable Care Act, 2010–2016|publisher =  U.S. Department of Health and Human Services  |department= Assistant Secretary for Planning and Evaluation |access-date=December 7, 2016 | archive-url = https://web.archive.org/web/20211205091604/https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//142146/ACA2010-2016.pdf  | archive-date = December 5, 2021|date=March 2, 2016}}</ref> The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.<ref name="Kaiser15">{{Cite web |url=http://files.kff.org/attachment/summary-of-findings-2015-employer-health-benefits-survey |title=Employer Health Benefits 2015 |website=Kaiser Family Foundation |access-date=November 19, 2016}}</ref>

The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to changes to individual insurance markets. Both received new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several [[Organization:Congressional Budget Office|Congressional Budget Office]] (CBO) reports said that overall these provisions reduced the budget deficit, that repealing ACA would increase the deficit,<ref name="CBO50252" /><ref name="CBO22077" /> and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.<ref name="CBO_Dist14"/>

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

Before and after enactment the ACA faced strong political opposition, calls for repeal and legal challenges. In ''National Federation of Independent Business v. Sebelius'', the Supreme Court ruled that states could choose not to participate in the law's Medicaid expansion, but upheld the law as a whole.<ref name="NatLawReview2012"/> The federal health insurance exchange, HealthCare.gov, faced major technical problems at the beginning of its rollout in 2013. Polls initially found that a plurality of Americans opposed the act, although its individual provisions were generally more popular.<ref>{{cite web |last1=Kirzinger |first1=Ashley |last2=Sugarman |first2=Elise |last3=Brodie |first3=Mollyann |title=Kaiser Health Tracking Poll: November 2016 |url=http://www.kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-november-2016/ |publisher=Kaiser Family Foundation |access-date=July 23, 2017 |date=December 1, 2016}}</ref> By 2017, the law had majority support.<ref>{{cite news |title=Gallup: ObamaCare has majority support for first time |url=http://thehill.com/policy/healthcare/327267-poll-obamacare-has-majority-support-for-first-time |access-date=November 18, 2017 |work=The Hill}}</ref> The Tax Cuts and Jobs Act of 2017 set the individual mandate penalty at $0 starting in 2019.<ref name="auto">{{cite journal |url=https://www.commonwealthfund.org/publications/fund-reports/2018/jul/eliminating-individual-mandate-penalty-behavioral-factors |title=The Effect of Eliminating the Individual Mandate Penalty and the Role of Behavioral Factors &#124; Commonwealth Fund |website=www.commonwealthfund.org |year=2018 |doi=10.26099/SWQZ-5G92 |last1=Eibner |first1=Christine |last2=Nowak |first2=Sarah}}</ref> This raised questions about whether the ACA was still constitutional.<ref>Pear, Robert. (December 18, 2017). [https://www.nytimes.com/2017/12/18/us/politics/tax-cut-obamacare-individual-mandate-repeal.html "Without the Insurance Mandate, Health Care's Future May Be in Doubt"]. ''{{wipe|The New York Times}}'' {{ISSN|0362-4331}} {{OCLC|1645522}}.</ref><ref>Sullivan, Peter. (December 2, 2017). [http://thehill.com/policy/healthcare/362838-senate-gop-repeals-obamacare-mandate "Senate GOP repeals ObamaCare mandate"] ''The Hill''.</ref><ref>{{cite journal |last1=Jost |first1=Timothy |title=The Tax Bill And The Individual Mandate: What Happened, And What Does It Mean? |journal=Health Affairs |date=20 December 2017 |doi=10.1377/forefront.20171220.323429 |publisher=Project HOPE |location=Washington, DC |issn=0278-2715 |oclc=07760874}}</ref> In June 2021, the Supreme Court upheld the ACA for the third time in ''California v. Texas''.<ref>{{cite news |last1=Totenberg |first1=Nina |title=Obamacare Wins For The 3rd Time At The Supreme Court |url=https://www.npr.org/2021/06/17/988837265/obamacare-wins-for-the-3rd-time-at-the-supreme-court |publisher=National Public Radio |date=June 17, 2021}}</ref>

==Provisions==
[[File:Barack Obama reacts to the passing of Healthcare bill.jpg|thumb|The President and White House staff react to the House of Representatives passing the bill on March 21, 2010.]]
[[File:View From the Speaker's Office Tonight (4452690853).jpg|thumb|right|Jim Clyburn and Nancy Pelosi celebrate after the House passes the amended bill on March 21.]]

ACA amended the Public Health Service Act of 1944 and inserted new provisions on affordable care into Title 42 of the United States Code.<ref name="Oberlander2010">{{cite journal |last1=Oberlander |first1=Jonathan |title=Long Time Coming: Why Health Reform Finally Passed |journal=Health Affairs |publisher=Project HOPE |oclc=07760874 |date=June 1, 2010 |volume=29 |issue=6 |pages=1112–1116 |doi=10.1377/hlthaff.2010.0447 |pmid=20530339 |issn=0278-2715|doi-access=free }}</ref><ref name="Blumenthal2015">{{cite journal |last1=Blumenthal |first1=David |last2=Abrams |first2=Melinda |last3=Nuzum |first3=Rachel |title=The Affordable Care Act at 5 Years |journal=New England Journal of Medicine |date=June 18, 2015 |volume=372 |issue=25 |pages=2451–2458 |doi=10.1056/NEJMhpr1503614 |pmid=25946142 |s2cid=28486139 |issn=0028-4793 |doi-access=free }}</ref><ref name="CohenEtAl">{{cite book |last1=Cohen |first1=Alan B. |last2=Colby |first2=David C. |last3=Wailoo |first3=Keith A. |last4=Zelizer |first4=Julian E. |title=Medicare and Medicaid at 50: America's Entitlement Programs in the Age of Affordable Care |date=June 1, 2015 |publisher=Oxford University Press |isbn=978-0-19-023156-9 |url=https://books.google.com/books?id=H9DGBwAAQBAJ}}</ref><ref name="24health">{{cite news |last1=Stolberg |first1=Sheryl Gay |last2=Pear |first2=Robert |title=Obama Signs Health Care Overhaul Bill, With a Flourish |url=https://www.nytimes.com/2010/03/24/health/policy/24health.html |work={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |access-date=June 22, 2022 |archive-date=March 25, 2010 |archive-url=https://web.archive.org/web/20100325200505/https://www.nytimes.com/2010/03/24/health/policy/24health.html |page=A19 |date=March 23, 2010}}</ref><ref name="ReutersSCOTUS">{{cite news |last1=Vicini |first1=James |last2=Stempel |first2=Jonathan |last3=Biskupic |first3=Joan |title=Top court upholds healthcare law in Obama triumph |url=https://www.reuters.com/article/us-usa-healthcare-court-idUSBRE85R06420120628 |work={{wipe|Reuters}}|date=June 28, 2017}}</ref> The individual insurance market was radically overhauled, and many of the law's regulations applied specifically to this market,<ref name="Oberlander2010" /> while the structure of Medicare, Medicaid, and the employer market were largely retained.<ref name="Blumenthal2015" /> Some regulations applied to the employer market, and the law also made delivery system changes that affected most of the health care system.<ref name="Blumenthal2015" />

===Insurance regulations: individual policies===
All new individual major medical health insurance policies sold to individuals and families faced new requirements.<ref>{{Cite web |url=https://www.healthcare.gov/fees/plans-that-count-as-coverage/ |title=Health insurance that counts as coverage |website=HealthCare.gov |access-date=October 2, 2019}}</ref> The requirements took effect on January 1, 2014. They include:
* Guaranteed issue prohibits insurers from denying coverage to individuals due to preexisting conditions.<ref>{{cite web |title=Health benefits & coverage for pre-existing conditions |url=https://www.healthcare.gov/coverage/pre-existing-conditions/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210211230724/https://www.healthcare.gov/coverage/pre-existing-conditions/ |archive-date=February 11, 2021}}</ref> 
* States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
* A partial community rating allows premiums to vary only by age and location, regardless of preexisting conditions. Premiums for older applicants can be no more than three times those for the youngest.<ref>{{cite web |url=http://www.naifa.org/practice-resources/prp/age-band-rating-(aca) |title=Age Band Rating (ACA) |publisher=[[Organization:National Association of Personal Financial Advisors|National Association of Personal Financial Advisors]] |access-date=September 24, 2016 |archive-date=September 24, 2016 |archive-url=https://web.archive.org/web/20160924202123/http://www.naifa.org/practice-resources/prp/age-band-rating-(aca) |url-status=dead}}</ref>
* Essential health benefits must be provided. The National Academy of Medicine defines the law's "essential health benefits" as "ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care"<ref name="Hhs.gov" /><ref name="essential" /> and others<ref>{{Cite web |url=https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/ratereview.html |title=ratereview |first1=Centers for |last1=Medicare |first2=Medicaid Services 7500 Security Boulevard |last2=Baltimore |first3=Md21244 |last3=US |date=December 19, 2014 |website=www.cms.gov}}</ref> rated Level A or B<ref>{{Cite web |url=http://www.ahrq.gov/prevention/guidelines/index.html |title=Clinical Guidelines and Recommendations |website=www.ahrq.gov |access-date=November 28, 2019}}</ref> by the U.S. Preventive Services Task Force.<ref name="ReferenceB" /> In determining essential benefits, the law required that standard benefits should offer at least that of a "typical employer plan".<ref name="KaiserEHB" /> States may require additional services.<ref>{{cite web |url=http://kff.org/health-reform/fact-sheet/quick-take-essential-health-benefits-what-have-states-decided-for-their-benchmark |title=Quick Take: Essential Health Benefits: What Have States Decided for Their Benchmark? |date=December 7, 2012 |publisher=Kaiser Family}}</ref>
* Preventive care and screenings for women.<ref>[https://www.govtrack.us/congress/bills/111/hr3590/text PPACA], 2713,(a)(4)</ref> "[A]ll Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity".<ref>[http://www.hrsa.gov/womensguidelines/ Women's Preventive Services Guidelines] HRSA, U.S. Department of Health and Human Services</ref> This mandate applies to all employers and educational institutions except for religious organizations.<ref name="faqs" /><ref name="Kliff" /> These regulations were included on the recommendations of the Institute of Medicine.<ref name="FinalRule" /><ref name="cnncontra" />

[[File:Health Care Delivery System Reform and The Patient Protection & Affordable Care Act.pdf|thumb|In 2012 Senator Sheldon Whitehouse created this summary to explain his view on the act.]]
* Annual and lifetime coverage caps on essential benefits were banned.<ref name="healthcare" /><ref name="hhs" /><ref>{{cite web |title=Health insurance rights & protections: Ending lifetime & yearly limits |url=https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210127070050/https://www.healthcare.gov/health-care-law-protections/lifetime-and-yearly-limits/ |archive-date=January 27, 2021}}</ref>
* Insurers are forbidden from dropping policyholders when they become ill.<ref name="Top 18" /><ref>{{cite web |title=Health insurance rights & protections |url=https://www.healthcare.gov/health-care-law-protections/rights-and-protections/ |website=HealthCare.gov |access-date=February 16, 2021 |archive-url=https://web.archive.org/web/20210129062759/https://www.healthcare.gov/health-care-law-protections/rights-and-protections/ |archive-date=January 29, 2021}}</ref>
* All policies must provide an annual maximum out-of-pocket (MOOP) payment cap for an individual's or family's medical expenses (excluding premiums). After the MOOP payment is reached, all remaining costs must be paid by the insurer.<ref>{{cite web |title=How do out-of-pocket maximums work? |publisher=Blue Cross Blue Shield of Michigan |url=http://www.bcbsm.com/index/health-insurance-help/faqs/topics/how-health-insurance-works/out-of-pocket-maximums.html}}</ref>
* Preventive care, vaccinations and medical screenings cannot be subject to co-payments, [[Finance:Co-insurance#In health insurance|co-insurance]] or [[Finance:Deductible#Health and travel insurance|deductibles]].<ref name="SHNS" /><ref name="KaiserSummary" /><ref name="cmsprev" /> Specific examples of covered services include: mammograms and colonoscopies, wellness visits, [[Medicine:Gestational diabetes|gestational diabetes]] screening, HPV testing, [[Medicine:Sexually transmitted infection|STI]] counseling, HIV screening and counseling, contraceptive methods, breastfeeding support/supplies and [[Medicine:Domestic violence|domestic violence]] screening and counseling.<ref name="SchiffHardinLLP" />{{anchor|Platinum plan}}
* The law established four tiers of coverage: bronze, silver, gold and platinum. All categories offer essential health benefits. The categories vary in their division of premiums and out-of-pocket costs: bronze plans have the lowest monthly premiums and highest out-of-pocket costs, while platinum plans are the reverse.<ref name="KaiserEHB" /><ref name="choose" /> The percentages of health care costs that plans are expected to cover through premiums (as opposed to out-of-pocket costs) are, on average: 60% (bronze), 70% (silver), 80% (gold), and 90% (platinum).<ref>{{cite web |url=https://www.healthcare.gov/glossary/health-plan-categories/ |title=Health Plan Categories |website=HealthCare.Gov |publisher=the Centers for Medicare and Medicaid Services}}</ref>
* Insurers are required to implement an [[Social:Appeal|appeal]]s process for coverage determination and claims on all new plans.<ref name="Top 18" />
* Insurers must [[Finance:Loss ratio#Medical loss ratio|spend at least 80–85% of premium dollars]] on health costs; rebates must be issued if this is violated.<ref name="cmsprog" /><ref name="FederalRegister" />

===Individual mandate===
The [[Medicine:Health insurance mandate#Affordable Care Act|individual mandate]]<ref name="AHPAMandate" /> required everyone to have insurance or pay a penalty. The mandate and limits on open enrollment<ref name="CohnOE" /><ref name="LimitedOEForbes" /> were designed to avoid the [[Finance:Death spiral (insurance)|insurance death spiral]], minimize the free rider problem and prevent the healthcare system from succumbing to [[Finance:Adverse selection|adverse selection]].

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

Among the groups who were not subject to the individual mandate are:
* Illegal immigrants, estimated at 8{{nbsp}}million—or roughly a third of the 23 million projection—are ineligible for insurance subsidies and Medicaid.<ref name="cbouninsured" /><ref name="Chaikind2011" /> They remain eligible for emergency services.
* Medicaid-eligible citizens not enrolled in Medicaid.<ref name="notcovered" />
* Citizens whose insurance coverage would cost more than 8% of household income.<ref name="notcovered" />
* Citizens who live in states that opt-out of Medicaid expansion and who qualify for neither existing Medicaid coverage nor subsidized coverage.<ref name="optout" />

The Tax Cuts and Jobs Act of 2017,<ref name="hatchsays">{{cite news |url=http://www.foxnews.com/opinion/2017/12/20/sen-orrin-hatch-repealing-individual-mandate-tax-is-beginning-end-obamacare-era.html |title=Sen. Orrin Hatch: Repealing the individual mandate tax is the beginning of the end of the ObamaCare era |last=Hatch |first=Orrin |date=December 20, 2017 |access-date=December 21, 2017 |publisher=Fox News}}</ref> set to $0 the penalty for not complying with the individual mandate, starting in 2019.<ref name="auto" />

===Exchanges===
ACA mandated that health insurance exchanges be provided for each state. The exchanges are regulated, largely online marketplaces, administered by either federal or state governments, where individuals, families and small businesses can purchase private insurance plans.<ref name="HealthCareGov" /><ref name="aphabasics" /><ref name="CohnExchanges" /> Exchanges first offered insurance for 2014. Some exchanges also provide access to Medicaid.<ref>{{Cite web |url=https://www.mass.gov/files/documents/2019/06/28/aca-3-english.pdf |title=Paper MA ACA application (for the MA Health Connector, the state exchange) |date=August 10, 2019 |access-date=August 10, 2019 |archive-date=July 26, 2019 |archive-url=https://web.archive.org/web/20190726160950/https://www.mass.gov/files/documents/2019/06/28/aca-3-english.pdf |url-status=dead}}</ref><ref>{{cite web |url=https://edocs.dhs.state.mn.us/lfserver/Public/DHS-6696-ENG |title=MN ACA application (MNSURE, their state exchange) |date=August 10, 2019}}</ref>

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

===Premium subsidies===
Individuals whose household incomes are between 100% and 400% of the federal poverty level (FPL) are eligible to receive [[Finance:Subsidy|federal subsidies]] for premiums for policies purchased on an ACA exchange, provided they are not eligible for Medicare, Medicaid, the Children's Health Insurance Program, or other forms of public assistance health coverage, and do not have access to affordable coverage (no more than 9.86% of income for the employee's coverage) through their own or a family member's employer.<ref name="KaiserFamily" /><ref name="TamiLuhby" /><ref name="hip-dhhs" /> Households below the federal poverty level are not eligible to receive these subsidies. Lawful Residents and some other legally present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for subsidies if they meet all other eligibility requirements.<ref>{{Cite web |url=https://www.healthcare.gov/immigrants/immigration-status/ |title=Find out what immigration statuses qualify for coverage in the Health Insurance Marketplace®. |website=HealthCare.gov}}</ref><ref name="KaiserFamily" /> Married people must file taxes jointly to receive subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.

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

Subsidies are provided as an advanceable, [[Finance:Tax credit#State tax credits|refundable tax credit]].<ref name="sec1401" /><ref name="sec1401_p" />

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

(In this section, the term "income" refers to modified [[Finance:Adjusted gross income|adjusted gross income]].<ref name="KaiserFamily" /><ref>{{Cite web |url=http://laborcenter.berkeley.edu/modified-adjusted-gross-income-under-the-affordable-care-act/ |title=Modified Adjusted Gross Income under the Affordable Care Act |last1=Research |first1=UC Berkeley Center for Labor |last2=Education |date=July 1, 2014 |website=Center for Labor Research and Education |access-date=October 2, 2019}}</ref>)

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

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

<small>Note: The numbers in the table do not apply for Alaska and Hawaii.</small>
|}

===Cost-sharing reduction subsidies===


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

So-called cost-sharing reduction (CSR) subsidies were to be paid to insurance companies to fund the reductions. During 2017, approximately $7 billion in CSR subsidies were to be paid, versus $34 billion for premium tax credits.<ref>[https://www.cbo.gov/publication/53091 "Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2017 to 2027"]. United States. Congressional Budget Office. September 14, 2017. (Report).</ref>

The latter was defined as [[Finance:Mandatory spending|mandatory spending]] that does not require an annual Congressional appropriation. CSR payments were not explicitly defined as mandatory. This led to litigation and disruption later.{{explain|date=July 2022}}

===Risk management===

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

====Risk corridors====

The risk-corridor program was a temporary risk management device.<ref>{{citation |url=http://www.rubio.senate.gov/public/_cache/files/1dc92ef8-c340-4cfd-95c0-67369a557f1e/2AA5EF8F125279800BFABC8B8BA37072.05.24.2016-crs-rubio-memo-risk-corridors-1-5-16-1-redacted.pdf |title=Lawsuits to Recover Payments under the Risk Corridors Program of the Affordable Care Act |date=January 5, 2016 |access-date=February 11, 2017 |author=Legislative Attorneys, American Law Division |publisher=[[Social:Congressional Research Service|Congressional Research Service]] |page=6}}</ref>{{rp|1}} It was intended to encourage reluctant insurers into ACA insurance market from 2014 to 2016. For those years the Department of Health and Human Services (DHHS) would cover some of the losses for insurers whose plans performed worse than they expected. Loss-making insurers would receive payments paid for in part by profit-making insurers.<ref>{{citation |title=Trouble on the Exchanges – Does the United States Owe Billions to Health Insurers? |author=Nicholas Bagley |journal=New England Journal of Medicine |date=November 24, 2016 |doi=10.1056/NEJMp1612486 |pmid=27959725 |volume=375 |issue=21 |pages=2017–2019}}</ref><ref>{{citation |url=https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/faq-risk-corridors-04-11-2014.pdf |date=April 11, 2014 |title=Risk Corridors and Budget Neutrality |publisher=Centers for Medicare & Medicaid Services (CMS) |location=Washington, DC}} Department of Health and Human Services</ref>{{attribution needed |date=July 2017}} Similar risk corridors had been established for the [[Medicine:Medicare Part D|Medicare prescription drug benefit]].<ref>{{citation |title=Yes, Marco Rubio Led The Effort To End Obamacare's Health |date=December 15, 2015 |url=https://www.forbes.com/sites/theapothecary/2015/12/15/yes-marco-rubio-led-the-effort-to-end-obamacares-health-insurance-slush-fund/?sh=18f0f95b4688 |work={{wipe|Forbes}} |access-date=February 10, 2017}}{{cbignore|bot=medic}}</ref>

While many insurers initially offered exchange plans, the program did not pay for itself as planned, losing up to $8.3 billion for 2014 and 2015. Authorization had to be given so DHHS could pay insurers from "general government revenues".{{attribution needed |date=July 2017}} However, the Consolidated Appropriations Act, 2014 (H.R. 3547) stated that no funds "could be used for risk-corridor payments".<ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/news/fact-checker/wp/2015/12/23/rubios-inaccurate-claim-that-he-inserted-a-provision-restricting-obamacare-bailout-funds/ |title=Rubio's inaccurate claim that he 'inserted' a provision restricting Obamacare 'bailout' funds |newspaper={{wipe|The Washington Post}} |date=December 23, 2015 |first=Glenn |last=Kessler}}</ref>{{attribution needed |date=July 2017}} leaving the government in a potential breach of contract with insurers who offered qualified health plans.<ref name="latimes_GOP_ACA_corridor">{{cite news |author=Hiltzik, Michael |url=http://www.latimes.com/business/hiltzik/la-fi-hiltzik-risk-corridor-moda-20170210-story.html |title=With billions at stake, a federal judge just nullified the GOP's most cynical attack on Obamacare |work={{wipe|Los Angeles Times}} |date=February 10, 2017 |access-date=February 10, 2017 |archive-date=February 11, 2017 |archive-url=https://web.archive.org/web/20170211224404/http://www.latimes.com/business/hiltzik/la-fi-hiltzik-risk-corridor-moda-20170210-story.html}}</ref>

Several insurers sued the government at the United States Court of Federal Claims to recover the funds believed owed to them under the Risk Corridors program. While several were summarily closed, in the case of ''Moda Health v the United States'', Moda Health won a $214-million judgment in February 2017. Federal Claims judge Thomas C. Wheeler stated, "the Government made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, to say to [Moda], 'The joke is on you. You shouldn't have trusted us,' is hardly worthy of our great government."<ref>{{citation |url=https://ecf.cofc.uscourts.gov/cgi-bin/show_public_doc?2016cv0649-23-0 |title=Moda Health Plan, Inc. v. The United States |publisher=US Courts |date=February 10, 2017 |access-date=February 10, 2017 |pages=40}}</ref> Moda Health's case was appealed by the government to the United States Court of Appeals for the Federal Circuit along with the appeals of the other insurers; here, the Federal Circuit reversed the Moda Health ruling and ruled across all the cases in favor of the government, that the appropriations riders ceded the government from paying out remain money due to the insurers. The Supreme Court reversed this ruling in the consolidated case, ''Maine Community Health Options v. United States'', reaffirming as with Judge Wheeler that the government had a responsibility to pay those funds under the ACA and the use of riders to de-obligate its from those payments was illegal.<ref name=":1">{{Cite web |title=Maine Community Health Options v. United States |url=https://www.scotusblog.com/case-files/cases/maine-community-health-options-v-united-states/ |website=SCOTUSblog |access-date=2020-05-02}}</ref>

====Reinsurance====

The temporary reinsurance program is meant to stabilize premiums by reducing the incentive for insurers to raise premiums due to concerns about higher-risk enrollees. Reinsurance was based on retrospective costs rather than prospective risk evaluations. Reinsurance was available from 2014 through 2016.<ref name=":4">{{Cite web |url=https://www.kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/ |title=Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors |last1=Semanskee |first1=Ashley |last2=Claxton |first2=Gary |date=August 17, 2016 |website=The Henry J. Kaiser Family Foundation |access-date=November 28, 2019}}</ref>

====Risk adjustment====

Risk adjustment involves transferring funds from plans with lower-risk enrollees to plans with higher-risk enrollees. It was intended to encourage insurers to compete based on value and efficiency rather than by attracting healthier enrollees. Of the three risk management programs, only risk adjustment was permanent. Plans with low actuarial risk compensate plans with high actuarial risk.<ref name=":4" />

===Medicaid expansion===

ACA revised and expanded Medicaid eligibility starting in 2014. All U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. The federal government was to pay 100% of the increased cost in 2014, 2015 and 2016; 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and all subsequent years.<ref>{{cite news |author=HHS Press Office |date=March 29, 2013 |title=HHS finalizes rule guaranteeing 100 percent funding for new Medicaid beneficiaries |location=Washington, DC |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/news/press/2013pres/03/20130329a.html |access-date=April 23, 2013 |quote=effective January 1, 2014, the federal government will pay 100 percent of defined cost of certain newly eligible adult Medicaid beneficiaries. These payments will be in effect through 2016, phasing down to a permanent 90 percent matching rate by 2020. |archive-date=April 8, 2013 |archive-url=https://web.archive.org/web/20130408193512/http://www.hhs.gov/news/press/2013pres/03/20130329a.html |url-status=dead }}<br />{{cite journal |author=Centers for Medicare & Medicaid Services |date=April 2, 2013 |title=Medicaid program: Increased federal medical assistance percentage changes under the Affordable Care Act of 2010: Final rule |journal=Federal Register |volume=78 |issue=63 |pages=19917–19947 |quote=(A) 100 percent, for calendar quarters in calendar years (CYs) 2014 through 2016; (B) 95 percent, for calendar quarters in CY 2017; (C) 94 percent, for calendar quarters in CY 2018; (D) 93 percent, for calendar quarters in CY 2019; (E) 90 percent, for calendar quarters in CY 2020 and all subsequent calendar years.}}</ref><ref>{{cite web |title=HHS finalizes rule guaranteeing 100 percent funding for new medicaid beneficiaries |url=https://www.thelundreport.org/keywords/department-health-and-human-services |website=The Lund Report |access-date=23 June 2022 |archive-url=https://web.archive.org/web/20201030161511/https://www.thelundreport.org/content/hhs-finalizes-rule-guaranteeing-100-percent-funding-new-medicaid-beneficiaries |archive-date=30 October 2020 |location=Portland OR |date=29 March 2013 |agency=Department of Health and Human Services}}</ref><ref>{{Cite web|url=https://archive-it.org/collections/3926?fc=meta_Date:2013|title=Archive-It - News Releases|website=archive-it.org}}</ref><ref>{{Cite web |url=https://www.cbpp.org/research/how-health-reforms-medicaid-expansion-will-impact-state-budgets |title=How Health Reform's Medicaid Expansion Will Impact State Budgets |date=July 11, 2012 |website=Center on Budget and Policy Priorities}}</ref> A 5% "income disregard" made the effective income eligibility limit for Medicaid 138% of the poverty level.<ref name="138fpl" /> However, the Supreme Court ruled in ''NFIB v. Sebelius'' that this provision of ACA was coercive, and that states could choose to continue at pre-ACA eligibility levels.

===Medicare savings===

Medicare reimbursements were reduced to insurers and drug companies for private Medicare Advantage policies that the [[Engineering:Government Accountability Office|Government Accountability Office]] and Medicare Payment Advisory Commission found to be excessively costly relative to standard Medicare;<ref name="CMSMedicarePPACA" /><ref>{{cite web |title=Higher Spending Relative to Medicare Fee-for-Service May Not Ensure Lower Out-of-Pocket Costs for Beneficiaries |issue=GAO-08-522T |url=http://www.gao.gov/products/GAO-08-522T |website=Government Accountability Office |date=February 8, 2008 |access-date=October 7, 2013}}</ref> and to hospitals that failed standards of efficiency and care.<ref name="CMSMedicarePPACA" />

===Taxes===
====Medicare taxes====

Income from self-employment and wages of single individuals in excess of $200,000 annually are subjected to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to their total compensation), or $125,000 for a married person filing separately.<ref>{{Cite web |url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf |title=PPACA, section 9015 as modified by section 10906}}</ref>

In ACA's companion legislation, the Health Care and Education Reconciliation Act of 2010, an additional tax of 3.8% was applied to unearned income, specifically the lesser of net investment income and the amount by which adjusted gross income exceeds the above income limits.<ref>{{Cite web|url=http://www.gpo.gov/fdsys/pkg/BILLS-111hr4872enr/pdf/BILLS-111hr4872enr.pdf|title=HCERA section 1402}}</ref>

====Excise taxes====

ACA included an excise tax of 40% ("Cadillac tax") on total employer premium spending in excess of specified dollar amounts (initially $10,200 for single coverage and $27,500 for family coverage<ref>{{cite journal |url=http://www.commonwealthfund.org/publications/issue-briefs/2015/dec/aca-cadillac-tax |title=Rethinking the Affordable Care Act's "Cadillac Tax": A More Equitable Way to Encourage "Chevy" Consumption |publisher=Commonwealth Fund |date=December 18, 2015 |first1=Sarah |last1=Nowak |first2=Christine |last2=Eibner |journal=Issue Brief (Commonwealth Fund) |volume=36 |pages=1–8 |pmid=26702468 }}</ref>) indexed to inflation. This tax was originally scheduled to take effect in 2018, but was delayed until 2020 by the Consolidated Appropriations Act, 2016 and again to 2022. Excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well.<ref>{{cite book|url=http://www.taxpolicycenter.org/briefing-book/what-are-major-federal-excise-taxes-and-how-much-money-do-they-raise| archive-url = https://web.archive.org/web/20220526181331/https://www.taxpolicycenter.org/sites/default/files/briefing-book/tpc_briefing_book-may2022.pdf  |  archive-date = May 26, 2022 | title = A citizen's guide to the fascinating (though often complex) elements of the US tax system.  |format =Briefing book|publisher=Urban-Brookings Tax Policy Center}}</ref> The tax was repealed in late 2019.<ref name="auto1">{{Cite news |last=Maurer |first=Mark |date=2019-12-23 |title=Finance Chiefs Relieved After Repeal of Cadillac Tax |work={{wipe|The Wall Street Journal}} |publisher=News Corp |oclc=781541372 |archive-url=https://web.archive.org/web/20191225192330/https://www.wsj.com/articles/finance-chiefs-relieved-after-repeal-of-cadillac-tax-11577137387 |archive-date=2019-12-25 |url=https://www.wsj.com/articles/finance-chiefs-relieved-after-repeal-of-cadillac-tax-11577137387 |access-date=2022-05-20 |issn=0099-9660}}</ref>

===SCHIP===

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

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

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

===Employer mandate===

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

===Delivery system reforms===

The act includes delivery system reforms intended to constrain costs and improve quality. These include Medicare payment changes to discourage [[Medicine:Hospital-acquired condition|hospital-acquired condition]]s and [[Medicine:Hospital readmission|readmissions]], bundled payment initiatives, the Center for Medicare and Medicaid Innovation, the Independent Payment Advisory Board, and accountable care organizations.

====Hospital quality====

Health care cost/quality initiatives included incentives to [[Medicine:Hospital-acquired infection|reduce hospital infections]], adopt electronic medical records, and to coordinate care and prioritize quality over quantity.<ref name="NYMagChait2" />

====Bundled payments====

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

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

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

Unlike 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.<ref name=":15" />

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

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

===State waivers===

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

===Other insurance provisions===

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

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

===Nutrition labeling requirements===

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

==Legislative history==

[[File:Obama signs health care-20100323.jpg|thumb|upright=1.35|President Obama signs the Patient Protection and Affordable Care Act on March 23, 2010.]]

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

===Individual mandate===

The concept of an individual mandate goes back to at least 1989, when [[Organization:The Heritage Foundation|The Heritage Foundation]], a conservative think-tank, proposed an individual mandate as an alternative to single-payer health care.<ref name="forbes1" /><ref>{{cite web |url=http://healthcarereform.procon.org/sourcefiles/1989_assuring_affordable_health_care_for_all_americans.pdf |first=Stuart M. |last=Butler |publisher=The Heritage Foundation |title=Assuring Affordable Healthcare for All Americans |year=1989 |access-date=August 3, 2017 |archive-date=October 6, 2016 |archive-url=https://web.archive.org/web/20161006185543/http://healthcarereform.procon.org/sourcefiles/1989_assuring_affordable_health_care_for_all_americans.pdf |url-status=dead }}</ref> It was championed for a time by conservative economists and 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.<ref name="CommonSense" /><ref name="nyt-mandate" /><ref name="new-yorker-klein" />

President Bill Clinton proposed a major healthcare reform bill in 1993<ref name="nyt-mandate"/> that ultimately failed.<ref>{{cite news |last1=Cohn |first1=Bob |last2=Clift |first2=Eleanor |date=September 18, 1994 |url=http://www.newsweek.com/lost-chance-188330 |title=The Lost Chance |work=Newsweek |access-date=July 2, 2012}}</ref> Clinton negotiated a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997.{{citation needed |date=April 2021}} The failed Clinton plan included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations. Republican senators proposed an alternative that would have required individuals, but not employers, to buy insurance.
[[File:U.S. Senator John Chafee.jpg|thumb|John Chafee]]

The 1993 Republican Health Equity and Access Reform Today (HEART) Act, contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'.<ref name="kaiserhealthnews1993" /> Advocates included prominent Republican senators such as John Chafee, Orrin Hatch, [[Biography:Chuck Grassley|Chuck Grassley]], Bob Bennett and Kit Bond.<ref>{{cite news |url=https://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |title=In 1993, Republicans Proposed A Mandate First |work = All things considered |archive-url = https://web.archive.org/web/20120401185114/https://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |  archive-date = 1 April 2012 |publisher=NPR|first1 = Guy | first2=  Bob |last1=  Raz | format = Radio interview and transcript |last2 = Bennett |date=March 31, 2012}}</ref><ref>{{cite web |url=http://healthcarereform.procon.org/view.resource.php?resourceID=004182 |title=History of the Individual Health Insurance Mandate, 1989–2010 Republican Origins of Democratic Health Care Provision |publisher=ProCon.org |date=February 9, 2012}}</ref> The 1994 Republican Consumer Choice Health Security Act, initially contained an individual mandate with a penalty provision;<ref>{{cite web |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |newspaper=Colorado Statesman |last =Carroll | first =  Terrance D.|	issn = 2577-2317 | oclc = 9542060 | format = Letter to the editor |url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |access-date=July 29, 2012 |url-status=dead |archive-date=April 18, 2010 |archive-url=https://web.archive.org/web/20100418180533/http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit}}</ref> however, author Don Nickles subsequently removed the mandate, stating, "government should not compel people to buy health insurance".<ref>{{cite news |url=https://www.nytimes.com/2012/02/27/opinion/gop-and-health-mandate.html |issn=0362-4331 |oclc=1645522 |work={{wipe|The New York Times}}|title=G.O.P. and Health Mandate |date=February 26, 2012}}</ref> At the time of these proposals, Republicans did not raise constitutional issues; 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."<ref name="forbes1" />
[[File:P112912PS-0444 - President Barack Obama and Mitt Romney in the Oval Office - crop.jpg|thumb|Mitt Romney's {{wipe|Massachusetts}} went from 90% of its residents insured to 98%, the highest rate in the nation.<ref>{{cite news | first1 =  Drew  | last1 =Armstrong  |first2 = Alex |     last2 =   Wayne  |url=https://www.bloomberg.com/news/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law.html | archive-url = https://web.archive.org/web/20160313090332/https://www.bloomberg.com/news/articles/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law  | archive-date  = March 13, 2016  |website =Bloomberg |title=Romneycare's 98% Success Rate Defies Gripes on Obama Law |date=March 26, 2012}}</ref>]]

In 2006, 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.<ref name="governorromney" /> 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."<ref name="new-yorker-lizza" />

In 2007 Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which featured an individual mandate and state-based, regulated insurance markets called "State Health Help Agencies".<ref name="new-yorker-klein" /><ref name="new-yorker-lizza" /> The bill attracted bipartisan support, but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate.<ref name="S.334summary" />

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

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

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

===Healthcare debate, 2008–10===


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, [[Biography:Barack Obama|Barack Obama]]. Each candidate proposed a plan to cover the approximately 45&nbsp;million Americans estimated to not have health insurance at some point each year. Clinton's proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a [[Finance:Subsidy|subsidy]] without a mandate.<ref name="promise" /><ref>{{cite news |title=CNN Democratic presidential debate |url=http://www.cnn.com/2008/POLITICS/01/21/debate.transcript2/ |publisher=CNN|date=January 21, 2008 |access-date=September 26, 2013}}</ref>

During the general election, Obama said fixing healthcare would be one of his top four priorities as president.<ref name="Sep2008FirstPresidentialDebate" /> Obama and his opponent, Senator John McCain, both proposed health insurance reforms, though their plans differed. McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2{{nbsp}}million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost.<ref>{{Cite web |last1=Rustgi |first1=Sheila |last2=Collins |first2=Sara R. |last3=Davis |first3=Karen |last4=Nicholson |first4=Jennifer L. |title=The 2008 Presidential Candidates' Health Reform Proposals: Choices for America |website=The Commonwealth Fund |date=October 2008 |url=http://www.commonwealthfund.org/publications/fund-reports/2008/oct/the-2008-presidential-candidates-health-reform-proposals--choices-for-america}}</ref>
[[File:Joint blog close PS-0774.jpg|thumb|left|President Obama addressing Congress regarding healthcare reform, September 9, 2009]]

Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.<ref name="Feb2009JointSessionAddress" /><ref name="reuterstimeline" /> By July, a series of bills were approved by committees within the House of Representatives.<ref name="EdLaborJul2009" /> On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a proposal. This group—in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, [[Biography:Chuck Grassley|Chuck Grassley]] and Olympia Snowe—met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the foundation of a Senate bill.<ref>{{cite web |title=Health Care Reform from Conception to Final Passage |url=http://finance.senate.gov/issue/?id=32be19bd-491e-4192-812f-f65215c1ba65 |access-date=November 23, 2010}}</ref><ref>{{cite web |url=http://www.c-spanvideo.org/videoLibrary/search-results.php?organization=%22Finance%22&organization=%22Senate+Committee%22&date-from=01%2F06%2F2009&date-to=01%2F02%2F2011 |archive-url=https://archive.today/20120802043711/http://www.c-spanvideo.org/videoLibrary/search-results.php?organization=%22Finance%22&organization=%22Senate+Committee%22&date-from=01%2F06%2F2009&date-to=01%2F02%2F2011 |url-status=dead |archive-date=August 2, 2012 |title=Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN |publisher={{wipe|C-SPAN}} |access-date=November 30, 2010 }}</ref><ref>{{cite web |url=http://finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |title=Senate Finance Committee hearings for 111th Congress |publisher=Finance.Senate.Gov |access-date=April 1, 2012 |url-status=dead |archive-url=https://web.archive.org/web/20130111185729/http://www.finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |archive-date=January 11, 2013}}</ref>

Congressional Democrats and health policy experts, such as MIT economics professor Jonathan Gruber<ref name="GruberBio2" /> and David Cutler, argued that guaranteed issue would require both community rating and an individual mandate to ensure that [[Finance:Adverse selection|adverse selection]] and/or "free riding" would not result in an [[Finance:Death spiral (insurance)|insurance "death spiral"]].<ref name="HowTheyDidIt" /> They chose this approach after concluding that [[Social:Supermajority#United States|filibuster-proof support]] in the Senate was not present for more progressive plans such as single-payer. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate Majority Leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill's drafters hoped to garner the necessary votes.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/health-care/party-is-such-sweet-sorrow |title=Party Is Such Sweet Sorrow |magazine=The New Republic |date=September 4, 2009}}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/obamas-moderate-health-care-plan |title=Obama's Moderate Health Care Plan |magazine=The New Republic |date=April 22, 2010}}<br />{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |magazine=The New Republic |date=December 19, 2009}}</ref>

However, following the incorporation of an individual mandate into the proposal, Republicans threatened to filibuster any bill that contained it.<ref name="forbes1" /> Senate Minority Leader [[Biography:Mitch McConnell|Mitch McConnell]], who led the Republican response, concluded Republicans should not support the bill.<ref name="ChaitLegislativeStrategy" />

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

The reform attracted attention from [[Social:Lobbying|lobbyists]],<ref>{{cite news |first1=Joe |last1=Eaton |first2=M. B. |last2=Pell |first3=Aaron |last3=Mehta |url=https://www.npr.org/templates/story/story.php?storyId=125170643 |title=Lobbying Giants Cash In On Health Overhaul |publisher=NPR|date=March 26, 2010 |access-date=April 9, 2012}}</ref> including deals between lobby groups and the advocates to win the support of groups who had opposed past proposals.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/politics/drug-deal |title=Drug Deal |magazine=The New Republic |date=August 25, 2009}}</ref><ref>{{cite news |url=http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html |work=HuffPost |first=Ryan |last=Grim |title=Internal Memo Confirms Big Giveaways In White House Deal With Big Pharma |date=August 13, 2009}}</ref><ref>{{cite web |url=http://sunlightfoundation.com/projects/2009/healthcare_lobbyist_complex |title=Visualizing The Health Care Lobbyist Complex |publisher=Sunlight Foundation |date=July 22, 2009 |access-date=April 1, 2012 |archive-url=https://web.archive.org/web/20120405053508/http://sunlightfoundation.com/projects/2009/healthcare_lobbyist_complex/ |archive-date=April 5, 2012 |url-status=dead }}</ref>
[[File:9.12 tea party in DC.jpg|thumb|Tea Party protesters at the Taxpayer March on Washington, September 12, 2009]]

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

In September 2009 Obama delivered another speech to a joint session of Congress supporting the negotiations.<ref name="Sep2009JointAddress" /> 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.<ref name="reuterstimeline" />

====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.<ref name="Const-Revenue" /> To formally comply with this requirement, the Senate repurposed H.R. 3590, a bill regarding housing tax changes for service members.<ref name="ServicemembersHomeOwnershipTaxAct" /> It had been passed by the House as a revenue-related modification to the Internal Revenue Code. The bill became the Senate's vehicle for its healthcare reform proposal, discarding the bill's original content.<ref>{{USBill|111|S.AMDT.|2786}}</ref> The bill ultimately incorporated elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican Senate minority vowing to filibuster, 60 votes would be necessary to pass the Senate.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/why-reform-survived-august |title=Why Reform Survived August |magazine=The New Republic |date=September 7, 2009}}</ref> At the start of the 111th Congress, Democrats had 58 votes. The Minnesota Senate election was ultimately won by Democrat Al Franken, making 59. Arlen Specter switched to the Democratic party in April 2009, giving them 60 seats, enough to end a filibuster.

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

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

The White House and Reid addressed Nelson's concerns<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/ben-nelson-still-big-problem |title=Ben Nelson, Still a Big Problem (Updated) |magazine=The New Republic |date=December 17, 2009}}</ref> 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.<ref name="reuterstimeline" /><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/breaking-nelson-says-yes-makes-60 |title=Nelson Says Yes; That Makes 60 |magazine=The New Republic |date=December 19, 2009}}</ref> The latter half of the compromise was derisively termed the "Cornhusker Kickback"<ref>{{cite news |title={{-'}}Cornhusker' Out, More Deals In: Health Care Bill Gives Special Treatment |url=http://www.foxnews.com/politics/2010/03/18/cornhusker-kickback-gets-boot-health |date=March 19, 2010 |publisher=Fox News |access-date=April 26, 2010}}</ref> and was later removed.

On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster.<ref>{{cite web |url=https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=111&session=1&vote=00395 |title=Roll Call vote No. 395 – On the Cloture Motion (Motion to Invoke Cloture on H.R. 3590) |publisher=U.S. Senate |access-date=July 20, 2017}}</ref> The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except Jim Bunning, who did not vote).<ref name="USS RC 2009-396" /> The bill was endorsed by the American Medical Association and AARP.<ref>[http://www.huffingtonpost.com/2010/03/19/aarp-ama-announce-support_n_506060.html "AARP, AMA Announce Support For Health Care Bill: Largest Doctors And Retiree Groups Backing Legislation"]. ''The Huffington Post'', March 19, 2010.</ref>

On January 19, 2010, {{wipe|Massachusetts}} Republican Scott Brown was elected to the Senate in a special election to replace the recently deceased Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.<ref name="reuterstimeline" /><ref>{{cite news |first=J. Scott |last=Applewhite |agency=Associated Press |url=http://www.cleveland.com/nation/index.ssf/2010/01/senator-elect_scott_brown_welc.html |title=Senator-elect Scott Brown welcomed as Republican hero after upset victory in Massachusetts |publisher=McClatchy-Tribune News Service |access-date=April 19, 2012}}</ref><ref>{{cite press release |url=http://www.votesmart.org/public-statement/477580/scott-brown-responds-to-martha-coakleys-misleading-health-care-distortions |title=Public Statements – Project Vote Smart |publisher=Votesmart.org |date=January 13, 2010 |access-date=April 9, 2012}}</ref> Additionally, the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of the bill.<ref>{{cite news |first=Nate |last=Silver |url=http://www.fivethirtyeight.com/2010/01/will-base-abandon-hope.html |title=Will the Base Abandon Hope? |work=FiveThirtyEight |date=January 21, 2010 |access-date=July 28, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921061425/http://www.fivethirtyeight.com/2010/01/will-base-abandon-hope.html |url-status=dead }}</ref><ref name="BillPassageOptions" />

====House====

[[File:111th Congress roll call 165.svg|thumb|upright=1.35|'''House vote by congressional district'''
{{legend|#000080|Democratic yes (219)}}
{{legend|#5050FF|Democratic no (34)}}
{{legend|#800000|Republican no (178)}}
{{legend|#C8C8C8|No representative seated (4)}}]]

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

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

House Democrats had expected to be able to negotiate changes 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.<ref name="BillPassageOptions" /> They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.<ref name="nytimesjourney" /><ref name="Reconciliationprimer" /><ref name="538Paths218" />

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.<ref>{{cite news |first=Nate |last=Silver |url=http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |title=1. Reconciliation! 2. ??? 3. Profit! |work=FiveThirtyEight |date=January 21, 2010 |access-date=July 28, 2013 |archive-date=September 21, 2013 |archive-url=https://web.archive.org/web/20130921061506/http://www.fivethirtyeight.com/2010/01/1-reconciliation-2-3-profit.html |url-status=dead }}</ref><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/reconciliation-why-most-dems-dont-want-go-there |title=Reconciliation: Why Most Dems Don't Want to Go There |magazine=The New Republic |date=September 21, 2009}}</ref> Although the already-passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."<ref name="Reconciliationprimer" />

The remaining obstacle was a pivotal group of [[Social:Anti-abortion movements|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.<ref name="EO13535" /> This won the support of Stupak and members of his group and assured the bill's passage.<ref name="538Paths218" /><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/stupak-makes-deal-reform-pass |title=Stupak Makes A Deal, Reform To Pass |magazine=The New Republic |date=March 21, 2010}}</ref> The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.<ref name="USH RC 2010-165" /> It passed the second bill, by 220–211, the same day (with the Senate passing this bill via reconciliation by 56-43 a few days later). The day after the passage of ACA, March 22, Republicans introduced legislation to repeal it.<ref name="PelosiSawyer" /> Obama signed ACA into law on March 23, 2010.<ref name="24health"/>

===Post-enactment===

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

The Tax Cuts and Jobs Act of 2017 eliminated the fine for violating the individual mandate, starting in 2019. (The requirement itself is still in effect.)<ref name="auto" /> In 2019 Congress repealed the so-called "Cadillac" tax on health insurance benefits, an excise tax on medical devices, and the Health Insurance Tax.<ref name="auto1"/>

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

==Impact==

[[File:Health Insurance Coverage in the U.S. 2016 - v1.png|thumb|right|upright=2|U.S. health insurance coverage by source in 2016. CBO estimated ACA/Obamacare was responsible for 23 million persons covered via exchanges and Medicaid expansion.<ref name="CBO_Subsidy2016" />]]
[[File:ACA Panel Chart v1.png|thumb|upright=2|right|This chart illustrates several aspects of the Affordable Care Act, including number of persons covered, cost before and after subsidies, and public opinion.]]

===Coverage===


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

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

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

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

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

===Taxes===
[[File:Excise taxes.jpg|thumb|right|upright=1.35|Excise taxes percentage 2015]]

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

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

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

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

===Insurance exchanges===


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

===Medicaid expansion in practice===

[[File:Medicaid expansion map of US. Affordable Care Act.svg|thumb|upright=1.35|[[Medicaid coverage gap#Medicaid expansion|ACA Medicaid expansion]] by state.<ref name=KFF-Medicaid>{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |date=December 2023 |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map |publisher=KFF. Map is updated as changes occur. Click on states for details.}}</ref>
{{legend|#2b83ba|Not adopted}}
{{legend|#89CC7F|Adopted}}
{{legend|#FECDAC|Implemented}}]]

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

The 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{{nbsp}}to 10 million people had gained Medicaid coverage, mostly low-income adults.{{citation needed|date=September 2022}} 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.<ref>{{cite journal |last1=Artiga |first1=Samantha |last2=Hill |first2=Latoya |last3=Orgera |first3=Kendal |last4=Damico |first4=Anthony |title=Health Coverage by Race and Ethnicity, 2010-2019 |journal=Kaiser Family Foundation |date=16 July 2021 |url=https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/ |access-date=23 June 2022 |archive-date=20 August 2021 |archive-url=https://web.archive.org/web/20210820215024/https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/}}</ref><ref>{{Cite web |url=http://kff.org/disparities-policy/issue-brief/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity/ |title=The Impact of the Coverage Gap for Adults in States not Expanding Medicaid |date=October 26, 2015}}</ref>

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

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

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

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

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

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

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

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

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

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

A July 2019 study by the National Bureau of Economic Research (NBER) indicated that states enacting Medicaid expansion exhibited statistically significant reductions in mortality rates.<ref>{{Cite book |last1=Miller |first1=Sarah |last2=Altekruse |first2=Sean |last3=Johnson |first3=Norman |last4=Wherry |first4=Laura |date=July 2019 |title=Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data |location=Cambridge, MA |publisher=National Bureau of Economic Research |series=NBER Working Paper No. 26081 |doi=10.3386/w26081 |s2cid=164463149 |url=http://www.nber.org/papers/w26081.pdf}}</ref> From that study, states that took Medicaid expansion "saved the lives of at least 19,200 adults aged 55 to 64 over the four-year period from 2014 to 2017."<ref name=CBPP>Broaddus, Matt, & Aron-Dine, Aviva. (November 6, 2019). [https://www.cbpp.org/research/health/medicaid-expansion-has-saved-at-least-19000-lives-new-research-finds#_ftn1 ''Medicaid Expansion Has Saved at Least 19,000 Lives, New Research Finds. State Decisions Not to Expand Have Led to 15,000 Premature Deaths'']. Center on Budget and Policy Priorities. Archived at the [https://web.archive.org/web/20191217202443/https://www.cbpp.org/research/health/medicaid-expansion-has-saved-at-least-19000-lives-new-research-finds Wayback machine] on December 17, 2019.</ref> Further, 15,600 older adults died prematurely in the states that did not enact Medicaid expansion in those years according to the NBER research. "The lifesaving impacts of Medicaid expansion are large: an estimated 39 to 64 percent reduction in annual mortality rates for older adults gaining coverage."<ref name=CBPP />

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

==== Medicaid expansion by state ====
{| class="wikitable sortable"
|+
!State or territory
!Status of expansion
!Date of expansion
!Health insurance marketplace
!Notes
|-
|{{Flag|Alabama}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Alaska}}
|In effect
|September 1, 2015
|HealthCare.gov
|
|-
|{{Flag|Arizona}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Arkansas}}
|In effect
|January 1, 2014
|Arkansas Health Connector, HealthCare.gov
|State implemented expansion through a "private option" under a Section 1115 waiver through the Arkansas Health Care Independence Program (HCIP). Work requirement added in 2018 through Arkansas Works. Work requirement removed in 2021. Currently only state using "private option" as of 2022. 
|-
|{{Flag|California}}
|In effect
|January 1, 2014
|Covered California, HealthCare.gov
|
|-
|{{Flag|Colorado}}
|In effect
|January 1, 2014
|Connect for Health Colorado, HealthCare.gov
|
|-
|{{Flag|Connecticut}}
|In effect
|January 1, 2014
|Access Health CT, HealthCare.gov
|
|-
|{{Flag|Delaware}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Florida}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Georgia (U.S. state)|name=Georgia}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Hawaii}}
|In effect
|January 1, 2014
|Hawaii Health Connector, HealthCare.gov
|
|-
|{{Flag|Idaho}}
|In effect
|January 1, 2020
|Your Health Idaho, HealthCare.gov
|Enacted through 2018 Idaho Proposition 2.
|-
|{{Flag|Illinois}}
|In effect
|January 1, 2014
|Illinois Health Benefits Exchange, HealthCare.gov
|
|-
|{{Flag|Indiana}}
|In effect
|February 1, 2015
|HealthCare.gov
|
|-
|{{Flag|Iowa}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Kansas}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Kentucky}}
|In effect
|January 1, 2014
|Kynect, HealthCare.gov
|Enacted through gubernatorial executive order
|-
|{{Flag|Louisiana}}
|In effect
|July 1, 2016
|HealthCare.gov
|Enacted through gubernatorial executive order
|-
|{{Flag|Maine}}
|In effect
|January 10, 2019
|HealthCare.gov
|Enacted through 2017 Maine Question 2, but implementation was delayed due to gubernatorial opposition. coverage retroactive to 7/2/2018.
|-
|{{Flag|Maryland}}
|In effect
|January 1, 2014
|Maryland Health Connection, HealthCare.gov
|
|-
|{{Flag|Massachusetts}}
|In effect
|January 1, 2014
|Massachusetts Health Insurance Connector, HealthCare.gov
|
|-
|{{Flag|Michigan}}
|In effect
|April 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Minnesota}}
|In effect
|January 1, 2014
|MNsure, HealthCare.gov
|
|-
|{{Flag|Mississippi}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Missouri}}
|In effect
|October 1, 2021
|HealthCare.gov
|Enacted through 2020 Missouri Amendment 2, but applications were denied until October 1, 2021, due to legislative opposition to the amendment. coverage retroactive to 7/1/2021. 
|-
|{{Flag|Montana}}
|In effect
|January 1, 2016
|HealthCare.gov
|Legislature enacted expansion with a work requirement; work requirement was due to take effect in January 2020 but never received federal approval. Current expansion is extended to June 2025. 
|-
|{{Flag|Nebraska}}
|In effect
|October 1, 2020
|HealthCare.gov
|enacted through 2018 Nebraska Initiative 427.
|-
|{{Flag|Nevada}}
|In effect
|January 1, 2014
|Nevada Health Link, HealthCare.gov
|
|-
|{{Flag|New Hampshire}}
|In effect
|August 15, 2014
|HealthCare.gov
|
|-
|{{Flag|New Jersey}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|New Mexico}}
|In effect
|January 1, 2014
|New Mexico Health Insurance Exchange, HealthCare.gov
|
|-
|{{Flag|New York}}
|In effect
|January 1, 2014
|NY State of Health, HealthCare.gov
|
|-
|{{Flag|North Dakota}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|North Carolina}}
|Expansion pending
|June 2023 (expected)
|HealthCare.gov
|Legislature expanded Medicaid. Signed into law by Governor Roy Cooper. Expansion expected to go into effect when the state adopts a budget in June 2023.<ref>{{Cite news |last=Stolberg |first=Sheryl Gay |date=2023-03-27 |title=North Carolina Expands Medicaid After Republicans Abandon Their Opposition |language=en-US |work={{wipe|The New York Times}} |url=https://www.nytimes.com/2023/03/27/us/politics/north-carolina-medicaid-expansion.html |access-date=2023-03-31 |issn=0362-4331}}</ref>
|-
|{{Flag|Ohio}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Oklahoma}}
|In effect
|July 1, 2021
|HealthCare.gov
|Enacted through 2020 Oklahoma State Question 802.
|-
|{{Flag|Oregon}}
|In effect
|January 1, 2014
|Cover Oregon (2012-2015), HealthCare.gov
|
|-
|{{Flag|Pennsylvania}}
|In effect
|January 1, 2015
|Pennie, HealthCare.gov
|
|-
|{{Flag|Rhode Island}}
|In effect
|January 1, 2014
|HealthSource RI, HealthCare.gov
|
|-
|{{Flag|South Carolina}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|South Dakota}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Tennessee}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Texas}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Utah}}
|In effect
|January 1, 2020
|HealthCare.gov
|Enacted through 2018 Utah Proposition 3, but subsequently scaled back through legislative action to enforce a Section 1115 waiver for eligibility. 
|-
|{{Flag|Vermont}}
|In effect
|January 1, 2014
|Vermont Health Connect, HealthCare.gov
|
|-
|{{Flag|Virginia}}
|In effect
|January 1, 2019
|HealthCare.gov
|
|-
|{{Flag|Washington}}
|In effect
|January 1, 2014
|Washington Healthplanfinder, HealthCare.gov
|
|-
|{{Flag|Washington, D.C.}}
|In effect
|
|DC Health Link, HealthCare.gov
|
|-
|{{Flag|West Virginia}}
|In effect
|January 1, 2014
|HealthCare.gov
|
|-
|{{Flag|Wisconsin}}
|No expansion
|N/A
|HealthCare.gov
|
|-
|{{Flag|Wyoming}}
|No expansion
|N/A
|HealthCare.gov
|
|}

===Insurance costs===

[[File:US healthcare cost panel v1.png|thumb|upright=2|right| <ref name="cms-cost">{{cite web |url=https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsProjected.html |title=NationalHealthAccountsProjected |date=February 15, 2017}}</ref>]]

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

Premium cost increases in the employer market moderated after 2009. For example, healthcare premiums for those covered by employers rose by 69% from 2000 to 2005, but only 27% from 2010 to 2015,<ref name="Kaiser15" /> with only a 3% increase from 2015 to 2016.<ref>{{Cite web |url=http://kff.org/health-costs/press-release/average-annual-workplace-family-health-premiums-rise-modest-3-to-18142-in-2016-more-workers-enroll-in-high-deductible-plans-with-savings-option-over-past-two-years/ |title=Average Annual Workplace Family Health Premiums Rise Modest 3% |date=September 14, 2016 |website=Kaiser Family Foundation |access-date=November 23, 2016}}</ref> From 2008 to 2010 (before passage of ACA) health insurance premiums rose by an average of 10% per year.<ref>{{Cite web |url=http://www.commonwealthfund.org/publications/press-releases/2014/jun/new-analysis-of-health-insurance-premium-trends |title=New Analysis of Health Insurance Premium Trends in the Individual Market Finds Average Yearly Increases of 10 Percent or More Prior to the Affordable Care Act |website=Commonwealth Fund |date=June 5, 2014}}</ref>

Several studies found that the [[Finance:Financial crisis of 2007–08|financial crisis]] and accompanying recession could not account for the entirety of the slowdown and that structural changes likely shared at least partial credit.<ref name="NYTLowrey1" /><ref name="paulryan" /><ref>{{cite web |first=Jonathan |last=Chait |title=Someone Tell Ted Cruz the Obamacare War Is Over |url=http://nymag.com/daily/intelligencer/2013/09/someone-tell-ted-cruz-the-obamacare-war-is-over.html |date=September 26, 2013 |work=New York Intelligencer}}</ref><ref>{{cite news |title=Health Cost Growth Slows Further Even as Economy Rebounds |publisher={{wipe|Bloomberg News}} |first=Alex |last=Wayne |date=June 18, 2013 |url=https://www.bloomberg.com/news/print/2013-06-18/health-cost-growth-slows-further-even-as-economy-rebounds.html}}</ref> A 2013 study estimated that changes to the health system had been responsible for about a quarter of the recent reduction in inflation.<ref>{{cite web |title=Assessing the Effects of the Economy on the Recent Slowdown in Health Spending |publisher=Kaiser Family Foundation |date=April 22, 2013 |url=http://kff.org/health-costs/issue-brief/assessing-the-effects-of-the-economy-on-the-recent-slowdown-in-health-spending-2}}</ref>{{Clarify|reason=Appears to get the relationship backwards. The article says that 77% of the reduction in health care increases comes from inflation and GDP, not the other way around. |date=November 2019}} Paul Krawzak claimed that even if cost controls succeed in reducing the amount spent on healthcare, such efforts on their own may be insufficient to outweigh the long-term burden placed by demographic changes, particularly the growth of the population on Medicare.<ref>{{cite web |title=In Spending Debate, Baby Boomer Issue Remains a Headache for Legislators |work=Roll Call |first=Paul |last=Krawzak |date=June 14, 2013 |url=http://www.rollcall.com/news/in_spending_debate_baby_boomer_issue_remains_a_headache_for_legislators-225650-1.html}}</ref>

In a 2016 review, Barack Obama claimed that from 2010 through 2014 mean annual growth in real per-enrollee Medicare spending was negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010; similarly, mean real per-enrollee growth in private insurance spending was 1.1% per year over the period, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010.<ref>{{cite journal |author=Obama B |year=2016 |title=United States Health Care Reform – Progress to Date and Next Steps |journal=JAMA |volume=316 |issue=5 |pages=525–32 |doi=10.1001/jama.2016.9797 |pmid=27400401 |pmc=5069435 }}</ref>

====Deductibles and co-payments====

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

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

For the non-group market, of which two-thirds are covered by ACA exchanges, a survey of 2015 data found that:
* 49% had individual deductibles of at least $1,500 ($3,000 for family), up from 36% in 2014.
* Many exchange enrollees qualify for cost-sharing subsidies that reduce their net deductible.
* While about 75% of enrollees were "very satisfied" or "somewhat satisfied" with their choice of doctors and hospitals, only 50% had such satisfaction with their annual deductible.
* While 52% of those covered by ACA exchanges felt "well protected" by their insurance, in the group market 63% felt that way.<ref>{{Cite web |url=http://kff.org/health-reform/poll-finding/survey-of-non-group-health-insurance-enrollees-wave-3/ |title=Survey of Non-Group Health Insurance Enrollees, Wave 3 |date=May 20, 2016 |website=kff.org |publisher=Kaiser Family Foundation |access-date=September 14, 2016}}</ref>

===Health outcomes===

According to a 2014 study, ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.<ref>{{Cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/news/fact-checker/wp/2015/04/01/obamas-claim-the-affordable-care-act-was-a-major-reason-in-preventing-50000-patient-deaths/ |title=Obama's claim the Affordable Care Act was a 'major reason' in preventing 50,000 patient deaths |newspaper={{wipe|The Washington Post}}|first  = Glenn| last = Kessler | date = April 1, 2015  |format = Fact checker  |archive-url = https://web.archive.org/web/20161105140151/https://www.washingtonpost.com/news/fact-checker/wp/2015/04/01/obamas-claim-the-affordable-care-act-was-a-major-reason-in-preventing-50000-patient-deaths/  |archive-date    =  November 5, 2016 |access-date=November 10, 2016}}</ref> Himmelstein and Woolhandler wrote in January 2017 that a rollback of ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.<ref>{{Cite news |issn=0190-8286 |oclc=2269358 |first1=David |first2=Steffi |last1=Himmelstein |last2=Woolhandler |date=January 23, 2017 |title=Repealing the Affordable Care Act will kill more than 43,000 people annually |newspaper={{wipe|The Washington Post}} |url=https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-kill-more-than-43000-people-annually/ |access-date=June 15, 2022 |archive-url=https://web.archive.org/web/20220305021836/https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-kill-more-than-43000-people-annually/ |archive-date=March 5, 2022}}</ref>

According to the Kaiser Foundation, expanding Medicaid in the remaining states would cover up to 4.5 million persons.<ref>{{Cite web |url=https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ |last1=Garfield |last2=Damico |first1=Rachel |first2=Anthony |title=The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid |publisher=Kaiser Family Foundation |website=kff.org |access-date=June 15, 2022 |archive-date=December 9, 2017 |archive-url=https://web.archive.org/web/20171209183440/https://www.kff.org/uninsured/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/ |date=March 21, 2019}}</ref> A 2021 study found a significant decline in mortality rates in the states that opted in to the Medicaid expansion program compared with those states that did not do so. The study reported that states decisions' not to expand Medicaid resulted in approximately 15,600 excess deaths from 2014 through 2017.<ref>{{Cite journal |last1=Miller |first1=Sarah |last2=Johnson |first2=Norman |last3=Wherry |first3=Laura R. |date=2021-01-30 |title=Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data* |url=https://doi.org/10.1093/qje/qjab004 |journal=The Quarterly Journal of Economics |volume=136 |issue=3 |pages=1783–1829 |doi=10.1093/qje/qjab004 |issn=0033-5533}}</ref><ref>Truthout, July 25, 2019 [https://truthout.org/articles/republicans-refusal-to-expand-medicaid-resulted-in-over-15000-deaths/ Republicans' Refusal to Expand Medicaid Resulted in Over 15,000 Deaths]</ref>

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

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

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

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

===Distributional impact===

[[File:1b-ACA Distribution in 2014.png|thumb|right|upright=2|The distributional impact of the Affordable Care Act (ACA or Obamacare) during 2014. ACA raised taxes mainly on the top 1% to fund approximately $600 in benefits on average for the bottom 40% of families.]]

In March 2018, the CBO reported that ACA had reduced income inequality in 2014, saying the law led the lowest and second quintiles (the bottom 40%) to receive an average of an additional $690 and $560 respectively while causing households in the top 1% to pay an additional $21,000 due mostly to the net investment income tax and the additional Medicare tax. The law placed relatively little burden on households in the top quintile (top 20%) outside of the top 1%.<ref name="CBO_Dist14">{{Cite web |url=https://www.cbo.gov/publication/53597 |title=The Distribution of Household Income, 2014 &#124; Congressional Budget Office |website=United States. Congressional Budget Office |format=Report |archive-url=https://web.archive.org/web/20180412233412/https://www.cbo.gov/publication/53597 |archive-date=April 12, 2018 |date=March 19, 2018}}</ref>

===Federal deficit===
====CBO estimates of revenue and impact on deficit====


The CBO reported in multiple studies that ACA would reduce the deficit, and repealing it would increase the deficit, primarily because of the elimination of Medicare reimbursement cuts.<ref name="CBO50252" /><ref name="CBO22077" /> The 2011 comprehensive CBO estimate projected a net deficit reduction of more than $200 billion during the 2012–2021 period:<ref name="CBO22077" /><ref name="CBO43104" /> it calculated the law would result in $604 billion in [[Finance:Government spending|total outlays]] offset by $813 billion in [[Finance:Government revenue|total receipts]], resulting in a $210 billion net deficit reduction.<ref name="CBO22077" /> The CBO separately predicted that while most of the spending provisions do not begin until 2014,<ref name="CBO-Pelosi" /><ref name="RollCallCBO" /> revenue would exceed spending in those subsequent years.<ref name="CBO-Pelosi2" />{{Dead link|date=February 2023}} The CBO claimed the bill would "substantially reduce the growth of Medicare's payment rates for most services; impose an excise tax on insurance plans with relatively high premiums; and make various other changes to the federal tax code, Medicare, Medicaid, and other programs"<ref name="CBO-Reid-Dec2009" />—ultimately extending the solvency of the Medicare trust fund by eight years.<ref>{{cite news |author1=Judith Solomon |author2=Paul N. Van de Water |url=http://www.cbpp.org/cms/?fa=view&id=3746 |title=Letter: Improving the Strength and Solvency of Medicare |publisher=The Center on Budget and Policy Priorities |date=April 18, 2012}}</ref>

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 [[Organization:Congressional Budget Office|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.<ref name="fewer" /><ref name="CBO43472" /><ref>{{cite news |last=Sahadi |first=Jeanne |url=https://money.cnn.com/2012/03/13/news/economy/health-reform-costs |title=Health reform coverage cost falls slightly |publisher=CNN|date=March 13, 2012 |access-date=June 29, 2012}}</ref>

The CBO in June 2015 forecast that repeal of ACA would increase the deficit between $137 billion and $353 billion over the 2016–2025 period, depending on the impact of macroeconomic [[Finance:Dynamic scoring|feedback]] effects. The CBO also forecast that repeal of ACA would likely cause an increase in GDP by an average of 0.7% in the period from 2021 to 2025, mainly by boosting the supply of labor.<ref name="CBO50252" />

Although the CBO generally does not provide cost estimates beyond the 10-year budget projection period because of the degree of uncertainty involved in the projection, it decided to do so in this case at the request of lawmakers, and estimated a second decade deficit reduction of $1.2&nbsp;trillion.<ref name="CBO-Reid-Dec2009" /><ref name="CNN-Mar18" /> CBO predicted deficit reduction around a broad range of one-half percent of GDP over the 2020s while cautioning that "a wide range of changes could occur".<ref>{{cite news |url=http://www.politifact.com/truth-o-meter/statements/2010/mar/18/nancy-pelosi/pelosi-cbo-says-health-reform-bill-would-cut-defic |title=Pelosi: CBO says health reform bill would cut deficits by $1.2 trillion in second decade |last=Farley |first=Robert |date=March 18, 2010 |work=PolitiFact.com |access-date=April 7, 2010}}</ref>

In 2017 CBO estimated that repealing the individual mandate alone would reduce the 10-year deficit by $338 billion.<ref>{{Cite web |url=http://politi.co/2hdAFBI |title=CBO: Obamacare mandate repeal would cut deficit by $338 billion |last=Haberkorn |first=Jennifer |website=Politico|date=November 8, 2017 |access-date=November 29, 2019}}</ref>

====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&nbsp;billion from 2010 to 2019.<ref>{{cite web |url=http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |title=Sen. Tom Coburn: Obamacare PR campaign anchored in spin, not reality |work=The Washington Examiner |date=July 8, 2006 |access-date=April 1, 2012 |url-status=dead |archive-url=https://archive.today/20120717095633/http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |archive-date=July 17, 2012 }}</ref><ref>{{cite news |url=http://www.nationalreview.com/critical-condition/55996/obamacare-s-cooked-books-and-doc-fix/james-c-capretta |title=Obamacare's Cooked Books and the 'Doc Fix{{'-}} |work=National Review |author=James Capretta}}</ref><ref>{{cite web |last=Hogberg |first=David |url=http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |title=GOP Might Target ObamaCare As Part Of A Medicare 'Doc Fix' |work=Investor's Business Daily |date=November 22, 2010 |access-date=April 1, 2012 |archive-url=https://web.archive.org/web/20110126045757/http://www.investors.com/NewsAndAnalysis/Article/554579/201011221909/GOP-Might-Target-ObamaCare-As-Part-Of-A-Medicare-Doc-Fix.aspx |archive-date=January 26, 2011 |url-status=dead }}</ref> However, the so-called "doc fix" is a separate issue that would have existed with or without ACA.<ref>{{cite web |url=http://www.cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |title=Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010 |publisher=Congressional Budget Office |date=March 19, 2010 |access-date=April 1, 2012}}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/jonathan-chait/the-doc-fix-myth |title=The Doc Fix Myth And The Right's Misinformation Feedback Loop |magazine=The New Republic |date=March 24, 2010}}</ref><ref>{{cite web |last=Van de Water |first=Peter |title=Debunking False Claims About Health Reform, Jobs, and the Deficit |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3366 |publisher=Center for Budget and Policy Priorities |date=January 7, 2011 }}</ref> 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&nbsp;years to produce Medicare savings, although not the doc fix.<ref>{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=3021 |title=Congress Has Good Record of Implementing Medicare Savings |publisher=CBPP |access-date=March 28, 2010 |date=December 4, 2009}}</ref><ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |title=Can Congress cut Medicare costs? |newspaper={{wipe|The Washington Post}} |access-date=March 28, 2010 |archive-date=March 8, 2021 |archive-url=https://web.archive.org/web/20210308083159/http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html |url-status=dead }}</ref> The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.<ref>Klein, Ezra. (June 26, 2010). "[http://voices.washingtonpost.com/ezra-klein/2010/06/what_to_do_about_the_doc_fix.html What to do about the doc fix?]" ''Wonkbook'', The Washington Post. Archived (Blog) at the [https://web.archive.org/web/20121009120836/http://voices.washingtonpost.com/ezra-klein/2010/06/what_to_do_about_the_doc_fix.html Wayback Machine] on October 9, 2012. {{ISSN|0190-8286}} {{OCLC|2269358}}. Accessed July 27, 2011.</ref>

Health economist Uwe Reinhardt, wrote, "The rigid, artificial rules under which the Congressional Budget Office must score proposed legislation unfortunately cannot produce the best unbiased forecasts of the likely fiscal impact of any legislation."<ref>{{cite news |title=Wrapping Your Head Around the Health Bill |author=Reinhardt, Uwe |newspaper={{wipe|The New York Times}} |date=March 24, 2010 |issn=1553-8095 |oclc=1645522 |url=https://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill |access-date=October 9, 2010 |author-link=Uwe Reinhardt}}</ref> Douglas Holtz-Eakin alleged that the bill would increase the deficit by $562&nbsp;billion because, he argued, it front-loaded revenue and back-loaded benefits.<ref>{{cite news |url=https://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html |work={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |title=The Real Arithmetic of Health Care Reform |first=Douglas |last=Holtz-Eakin |date=March 21, 2010}}</ref>

Scheiber and Cohn rejected critical assessments of the law's deficit impact, arguing that predictions were biased towards underestimating deficit reduction. They noted, for example, it is easier to account for the cost of definite levels of subsidies to specified numbers of people than to account for savings from preventive healthcare, and that the CBO had a track record of overestimating costs and underestimating savings of health legislation;<ref name="CBOMethodology" /><ref name="CBOTrackRecord" /> stating, "innovations in the delivery of medical care, like greater use of electronic medical records<ref>{{Cite web |url=https://www.medicalrecords.com/emr-buyers-guide/electronic-medical-records-deadline |title=Electronic Medical Records Deadline |website=MedicalRecords.com}}</ref> and financial incentives for more coordination of care among doctors, would produce substantial savings while also slowing the relentless climb of medical expenses{{nbsp}}... But the CBO would not consider such savings in its calculations, because the innovations hadn't really been tried on such large scale or in concert with one another—and that meant there wasn't much hard data to prove the savings would materialize."<ref name="CBOMethodology" />

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

===Employer mandate and part-time work===


The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers.<ref name="GPO" /> Critics claimed it created a [[Social:Perverse incentive|perverse incentive]] to hire part-timers instead.<ref name="ChaitNotWreck" /><ref name="KliffPartTime" /> However, between March 2010 and 2014, the number of part-time jobs declined by 230,000 while the number of full-time jobs increased by two million.<ref name="FORBES" /><ref name="BUREAU OF LABOR AND STATISTICS" /> In the public sector full-time jobs turned into part-time jobs much more than in the private sector.<ref name="FORBES" /><ref>{{cite news |last=Conover |first=Chris |title=Who Can Deny It? Obamacare Is Accelerating U.S. Towards A Part-Time Nation |url=https://www.forbes.com/sites/theapothecary/2013/07/31/who-can-deny-it-obamacare-is-accelerating-u-s-towards-a-part-time-nation/ |work={{wipe|Forbes}}|access-date=November 11, 2014}}</ref> A 2016 study found only limited evidence that ACA had increased part-time employment.<ref>{{cite journal |last1=Moriya |first1=A. S. |last2=Selden |first2=T. M. |last3=Simon |first3=K. I. |title=Little Change Seen In Part-Time Employment As A Result Of The Affordable Care Act |journal=Health Affairs |date=January 5, 2016 |volume=35 |issue=1 |pages=119–123 |doi=10.1377/hlthaff.2015.0949 |pmid=26733709}}</ref>

Several businesses and the state of Virginia added a 29-hour-a-week cap for their part-time employees,<ref>{{cite news |url=http://hamptonroads.com/2013/02/state-workers-parttime-hours-capped-due-health-law |title=Va. workers' part-time hours capped due to health law |author=Bill Sizemore |work=The Virginian-Pilot |date=February 8, 2013 |access-date=February 13, 2013 |archive-date=October 23, 2017 |archive-url=https://web.archive.org/web/20171023012524/http://hamptonroads.com/2013/02/state-workers-parttime-hours-capped-due-health-law |url-status=dead }}<br />{{cite web |url=http://thinkprogress.org/health/2013/02/11/1568291/virginia-employees-obamacare |title=Virginia Cuts State Employees' Hours To Avoid Providing Obamacare Coverage |author=Annie-Rose Strasser |website=ThinkProgress |date=February 11, 2013 }}</ref>{{Unreliable source? |date=October 2013}}<ref>{{cite web |url=http://tv.msnbc.com/2013/01/14/colleges-roll-back-faculty-hours-in-response-to-obamacare |title=Colleges roll back faculty hours in response to Obamacare |author=Ned Resnikoff |publisher=MSNBC|date=January 14, 2013}}<br />{{cite web |url=http://thinkprogress.org/health/2013/01/14/1445301/four-public-colleges-obamacare |title=Four Public Colleges Will Cut Adjunct Faculty Hours To Avoid Providing Health Coverage Under Obamacare |author=Sy Mukherjee |website=ThinkProgress |date=January 14, 2013}}</ref>{{Unreliable source? |date=October 2013}} to reflect the 30-hour-or-more definition for full-time worker.<ref name="GPO" /> As of 2013, few companies had shifted their workforce towards more part-time hours (4% in a survey from the Federal Reserve Bank of Minneapolis).<ref name="KliffPartTime" /> Trends in working hours<ref name="NPRPartTime" /> and the recovery from the Great Recession correlate with the shift from part-time to full-time work.<ref>{{cite news |author=Jared Bernstein |title=Stop Blaming Obamacare for Part-Time Workers |url=http://wonkwire.rollcall.com/2013/09/04/stop-blaming-obamacare-part-time-workers |publisher=Teagan Goddard's Wonkwire |date=September 4, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20140715044934/http://wonkwire.rollcall.com/2013/09/04/stop-blaming-obamacare-part-time-workers/ |archive-date=July 15, 2014}}</ref><ref>{{cite magazine |author=Matthew Yglesias |title=Obamacare's Not To Blame For Increasing Part-time Work |url=http://www.slate.com/blogs/moneybox/2013/07/15/obamacare_part_time_work.html |magazine=Slate |date=July 15, 2013}}</ref> Other confounding impacts include that health insurance helps attract and retain employees, increases productivity and reduces absenteeism; and lowers corresponding training and administration costs from a smaller, more stable workforce.<ref name="KliffPartTime" /><ref name="NPRPartTime" /><ref>{{cite journal |author=Jost, Timothy |title=Implementing Health Reform: A One-Year Employer Mandate Delay |url=https://www.healthaffairs.org/do/10.1377/forefront.20130703.032734 |journal=Health Affairs |publisher=Project HOPE |location=Washington, DC |issn=1544-5208 |oclc=07760874 |date=July 2, 2013 |doi=10.1377/forefront.20130703.032734 }}</ref> Relatively few firms employ over 50 employees<ref name="KliffPartTime" /> and more than 90% of them already offered insurance.<ref name="CohnDelay" />

Most policy analysts (both right and left) were critical of the employer mandate provision.<ref name="ChaitNotWreck" /><ref name="CohnDelay" /> They argued that the perverse incentives regarding part-time hours, even if they did not change existing plans, were real and harmful;<ref name="CBPPEmpMand." /><ref name="MandateRepeal" /> that the raised [[Finance:Marginal cost|marginal cost]] of the 50th worker for businesses could limit companies' growth;<ref>{{cite magazine |author=Matthew Yglesias |title=Delaying Employer Responsibility Fines Is a Good Idea—the Real Problem Comes Later |url= http://www.slate.com/blogs/moneybox/2013/07/03/obamacare_delayed_a_good_idea_covering_up_a_big_problem.html |magazine=Slate |date=July 3, 2013}}</ref> that the costs of reporting and administration were not worth the costs of maintaining employer plans;<ref name="CBPPEmpMand." /><ref name="MandateRepeal" /> and noted that the employer mandate was not essential to maintain adequate risk pools.<ref>{{cite web |first=Jonathan |last=Chait |title=Obamacare Haters Struggling to Understand What 'Nonessential' Means |date=July 3, 2013 |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-haters-struggle-to-get-nonessential.html |work=New York Intelligencer}}<br />{{cite web |first=Jonathan |last=Chait |title=Obamacare Still Not Collapsing |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |work=New York Intelligencer |date=July 3, 2013}}</ref><ref name="Mandate3" /> The provision generated vocal opposition from business interests and some unions who were not granted exemptions.<ref name="MandateRepeal" /><ref name="WSJ"/>

===Hospitals===

From the start of 2010 to November 2014, 43 hospitals in [[Earth:Rural area#United States|rural areas]] closed. Critics claimed the new law had caused these closures. Many rural hospitals were built using funds from the 1946 Hill–Burton Act. Some of these hospitals reopened as other medical facilities, but only a small number operated [[Medicine:Emergency department|emergency rooms]] (ER) or urgent care centers.<ref>{{cite news |last1=O'Donnell |first1=Jayne |last2=Ungar |first2=Laura |last3=Hoyer |first3=Meghan |date=November 12, 2014 |title=Rural hospitals in critical condition |url=https://www.usatoday.com/longform/news/nation/2014/11/12/rural-hospital-closings-federal-reimbursement-medicaid-aca/18532471/ |newspaper=[[Software:USA Today|USA Today]] |access-date=January 28, 2015}}<br />{{cite news |last=Hamada |first=Omar L. |date=November 18, 2014 |title=Obamacare has detrimental effect on rural hospitals |url=http://www.tennessean.com/story/opinion/contributors/2014/11/19/obamacare-detrimental-effect-rural-hospitals/19087985/ |newspaper=The Tennessean |access-date=January 28, 2015}}</ref>

Between January 2010 and 2015, a quarter of ER doctors said they had seen a major surge in patients, while nearly half had seen a smaller increase. Seven in ten ER doctors claimed they lacked the resources to deal with large increases in the number of patients. The biggest factor in the increased number of ER patients was insufficient primary care providers to handle the larger number of insured.<ref>{{cite news |url=http://www.washingtontimes.com/news/2015/may/4/er-visits-under-obamacare-doctors-say/#ixzz3ZH4xpm5H |title=ER visits up under Obamacare despite promises, doctors' poll finds |first=Tom Jr. |last=Howell |work=The Washington Times |date=May 4, 2015 |access-date=May 6, 2015}}</ref> Michael Lee Jr. and Michael C. Monuteaux at Boston Children's Hospital analyzed national emergency department visits among children aged 0 to 17 from 2009 to 2016 using the American Community Survey (ACS) and Nationwide Emergency Department Sample (NEDS). They found no immediate change in pediatric emergency department visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends, almost 10%.<ref>{{cite journal |last1=Lee |first1=Michael |last2=Monuteaux |first2=Michael C. |title=Trends in pediatric emergency department use after the Affordable Care Act |journal=Pediatrics |date=2019 |volume=143 |issue=6 |doi=10.1542/peds.2018-3542 |pmid=31118219 |publisher=American Academy of Pediatrics |location=Itasca, IL |s2cid=162182158 |issn=1098-4275 |quote=ED visit rates increased by 1.1% per year pre-2014 and 9.8% from 2014 to 2016 (incidence rate ratio 1.09, 95% confidence interval 1.03-1.15, P = .005)|doi-access=free }}</ref>

Several large insurers formed ACOs. Many hospitals merged and purchased physician practices, amounting to a significant consolidation of the provider industry. The increased market share gave them more leverage with insurers and reduced patient care options.<ref name=":15" />

===Economic consequences===

[[File:Obamacare Panel 2.png|thumb|upright=2|right|Coverage rate, employer market cost trends, budgetary impact, and income inequality aspects of the Affordable Care Act]]

CBO estimated in June 2015 that repealing ACA would:
* Decrease GDP in the short-term, as government spending (on subsidies) was only partially replaced by spending by recipients.
* Increase the supply of labor and aggregate compensation by about 0.8 and 0.9 percent over the 2021–2025 period. CBO cited ACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing ACA would remove those disincentives, encouraging workers to supply more labor, increasing the total number of hours worked by about 1.5% over the 2021–2025 period.
* Remove the higher tax rates on capital income, thereby encouraging investment, raising the capital stock and output in the long-run.<ref name="CBO50252" />

In 2015 the progressive Center for Economic and Policy Research found no evidence that companies were reducing worker hours to avoid ACA requirements<ref>{{Cite web |url=https://www.randstadusa.com/workforce360/workforce-insights/the-affordable-care-act-and-employers/91/ |title=The Affordable Care Act and Employers|date = 2014 |last = Loi  |  first  = Eric |website = Randstad USA | publisher = Ernst & Young LLP |access-date=August 11, 2016 |archive-date=July 25, 2020 |archive-url=https://web.archive.org/web/20200725005448/https://www.randstadusa.com/workforce360/workforce-insights/the-affordable-care-act-and-employers/91/ |url-status=dead}}</ref> for employees working more than 30 hours per week.<ref>{{cite web |url=http://www.cepr.net/blogs/cepr-blog/is-the-affordable-care-act-a-hidden-jobs-killer |last1 =  Jorgensen |last2 = Baker  | date = July 24, 2013| agency =  Roosevelt Institute's Econobytes |  first1 = Helene |first2  = Dean |title=Is the Affordable Care Act a Hidden Jobs Killer? |publisher =Center for Economic and Policy Research |website =CEPR Blog|access-date=August 26, 2015 |archive-date=October 24, 2019 |archive-url=https://web.archive.org/web/20191024045839/http://cepr.net/blogs/cepr-blog/is-the-affordable-care-act-a-hidden-jobs-killer |url-status=dead}}</ref>

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

==Public opinion==

[[File:6th anniversary of the Affordable Care Act.jpg|thumb|left|alt=Congressional Democrats celebrating the 6th anniversary of the Affordable Care Act in March 2016 on the steps of the U.S. Capitol.|Congressional Democrats celebrate the 6th anniversary of the Affordable Care Act on the steps of the Capitol.]]

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

In a 2010 [[Opinion poll|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.<ref>{{cite news |url=http://i2.cdn.turner.com/cnn/2010/images/03/22/rel5a.pdf |title=CNN Opinion Research Poll |date=March 22, 2010 |publisher=CNN}}</ref> Other polls found that people were concerned the law would cost more than projected and would not do enough to control costs.<ref>{{cite news |title=Why Obama Can't Move the Health-Care Numbers |last1=Rasmussen |first1=Scott |date=March 9, 2010 |work={{wipe|The Wall Street Journal}} |last2=Schoen |first2=Doug |publisher=News Corp |oclc=781541372 |issn=0099-9660 |archive-url=https://web.archive.org/web/20150402002455/https://www.wsj.com/articles/SB10001424052748704784904575111993559174212 |archive-date=April 2, 2015 |url=https://www.wsj.com/articles/SB10001424052748704784904575111993559174212}}</ref>

In a 2012 poll 44% supported the law, with 56% against. By 75% of Democrats, 27% of Independents and 14% of Republicans favored the law. 82% favored banning insurance companies from denying coverage to people with preexisting conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.<ref name="most" /> Other polls showed additional provisions receiving majority support, including the exchanges, pooling small businesses and the uninsured with other consumers and providing subsidies.<ref>{{cite news |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does |title=Republicans hate 'Obamacare', but like most of what it does |website=Wonkblog |publisher={{wipe|The Washington Post}} |author=Klein, Ezra |date=June 26, 2012 |access-date=June 28, 2012 |archive-url=https://web.archive.org/web/20120629112038/http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/26/poll-republicans-hate-obamacare-but-like-most-of-what-it-does/ |archive-date=June 29, 2012 |url-status=dead}}</ref><ref>{{cite web |author=Sargent, Greg |issn=0190-8286 |oclc=2269358 |url=https://www.washingtonpost.com/blogs/plum-line/post/republicans-support-obamas-health-reforms--as-long-as-his-name-isnt-on-them/2012/06/25/gJQAq7E51V_blog.html |title=Republicans Support Obama's Health Reforms – As Long As His Name Isn't On Them |work=The Plum Line |publisher={{wipe|The Washington Post}}|date=June 25, 2012 |archive-url=https://web.archive.org/web/20120707184007/https://www.washingtonpost.com/blogs/plum-line/post/republicans-support-obamas-health-reforms--as-long-as-his-name-isnt-on-them/2012/06/25/gJQAq7E51V_blog.html |archive-date=July 7, 2012 |access-date=June 28, 2012}}</ref>

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

In June 2013, a majority of the public (52–34%) indicated a desire for "Congress to implement or tinker with the law rather than repeal it".<ref>{{cite news |first=Jonathan |last=Chait |url=http://nymag.com/daily/intelligencer/2013/06/obamacare-and-conservative-self-delusion.html |title=Obamacare, Public Opinion, and Conservative Self-Delusion |date=June 13, 2013 |work=New York Intelligencer}}</ref> After the Supreme Court upheld the individual mandate, a 2012 poll held that "most Americans (56%) want to see critics of President Obama's health care law drop efforts to block it and move on to other national issues".<ref>Jackson, David. [http://content.usatoday.com/communities/theoval/post/2012/07/poll-most-oppose-blocking-obama-health-care-law/1 "Poll: Most oppose blocking Obama health care law"]. ''USA Today''. Retrieved July 8, 2012.</ref><!-- remmed out [[Biography:Michael Moore|Michael Moore]] & Charles Krauthammer comments - seems consistent with talk American filmmaker, author, social critic and political activist [[Biography:Michael Moore|Michael Moore]] criticized the ACA by saying it is a "pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go".<ref name="NYT-20131231"/><ref name="TNR-20140105"/>

In February 2014, American Pulitzer Prize-winning syndicated columnist, political commentator and physician Charles Krauthammer described the buyer's remorse Americans are having over the ACA, saying it is having a "wide, broad effect". Because so many people are being negatively impacted by the law, he said, "the bleeding is happening among Independents and also among Democrats".<ref>{{cite news |url=http://www.foxnews.com/on-air/on-the-record/2014/02/28/krauthammer-buyers-remorse-obama-comes-obamacare-having-wide-broad-effect-bleeding-happen |title=Krauthammer: Buyer's remorse on Obama comes from ObamaCare having 'this wide, broad effect ... the bleeding is happening among Independents and Democrats' |publisher=Fox News |date=February 27, 2014}}</ref> -->

As of October 2013, approximately 40% were in favor while 51% were against.<ref>{{cite web |url=http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls |title=Obama and Democrats' Health Care Plan |website=RealClearPolitics |date=October 13, 2013 |access-date=March 26, 2014}}</ref><ref>{{cite news |last=Swanson |first=Emily |date=July 30, 2009 |url=http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html |title=Health Care Plan: Favor/Oppose |work=Pollster.com}}</ref> About 29% of [[Social:Non-Hispanic whites|whites]] approved of the law, compared with 61% of Hispanics and 91% of African Americans.<ref>{{cite web |url=http://www.people-press.org/files/legacy-pdf/9-16-13%20Health%20Care%20Release.pdf |title=As Health Care Law Proceeds, Opposition and Uncertainty Persist |date=September 16, 2013 |publisher=Pew Research Center}}</ref> A solid majority of seniors opposed the idea and a solid majority of those under forty were in favor.<ref>{{cite news |url=https://www.usatoday.com/news/washington/2010-03-23-health-poll-favorable_N.htm |title=Poll: Health care plan gains favor |last=Page |first=Susan |date=March 24, 2010 |work=[[Software:USA Today|USA Today]] |access-date=March 24, 2010}}</ref>

A 2014 poll reported that 26% of Americans support ACA.<ref>{{cite news |url=http://bigstory.ap.org/article/poll-obama-health-law-fails-gain-support |title=AP-GfK Poll: Obama's health care fails to gain support |date=March 28, 2014 |access-date=March 30, 2014 |publisher=Associated Press |archive-date=April 1, 2014 |archive-url=https://web.archive.org/web/20140401024529/http://bigstory.ap.org/article/poll-obama-health-law-fails-gain-support |url-status=dead}}</ref> A later 2014 poll reported that 48.9% of respondents had an unfavorable view of ACA versus 38.3% who had a favorable view (of more than 5,500 individuals).<ref>{{cite web |url=https://www.rand.org/health/projects/health-reform-opinion.html |title=RAND Health Reform Opinion Study |date=May 1, 2014 |publisher=RAND Health |access-date=May 10, 2014}}</ref> Another held that 8% of respondents agreed the Affordable Care Act "is working well the way it is".<ref>{{cite web |archive-url=https://web.archive.org/web/20140503034720/https://online.wsj.com/news/articles/SB10001424052702303678404579533362696579096 |archive-date=May 3, 2014 |url=https://online.wsj.com/news/articles/SB10001424052702303678404579533362696579096 |title=The ObamaCare 8% |newspaper={{wipe|The Wall Street Journal}} |publisher=News Corp |oclc=781541372 |issn= 1042-9840 |date=April 30, 2014 |access-date=May 1, 2014}}</ref> In late 2014, a Rasmussen poll reported Repeal: 30%, Leave as is: 13%, Improve: 52%.<ref>Alan Colmes, "[http://www.alan.com/2014/12/01/poll-voters-no-longer-want-to-repeal-obamacare/ Poll: Voters No Longer Want To Repeal Obamacare] {{Webarchive |url=https://web.archive.org/web/20171023012206/http://www.alan.com/2014/12/01/poll-voters-no-longer-want-to-repeal-obamacare/ |date=October 23, 2017 }}", ''Liberaland'', December 1, 2014.</ref>

In 2015, a poll reported that 47% of Americans approved the health care law. This was the first time a major poll indicated that more respondents approved than disapproved.<ref>{{cite web |url=http://www.cbsnews.com/news/poll-obamacare-and-the-supreme-court/ |title=Poll: Obamacare and the Supreme Court |work=CBS News |date=June 22, 2015 |access-date=June 23, 2015}}</ref> A December 2016 poll reported that: a) 30% wanted to expand what the law does; b) 26% wanted to repeal the entire law; c) 19% wanted to move forward with implementing the law as it is; and d) 17% wanted to scale back what the law does, with the remainder undecided.<ref>{{cite web |url=http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/ |title=After the Election, the Public Remains Sharply Divided on Future of the Affordable Care Act |publisher=Kaiser Family Foundation|date=December 3, 2016}}</ref>

Separate polls from Fox News and NBC/''WSJ'', both taken during January 2017, indicated more people viewed the law favorably than did not for the first time. One of the reasons for the improving popularity of the law is that Democrats who had once opposed it (many still prefer "Medicare for all") shifted their positions because ACA was under threat of repeal.<ref>{{cite web |url=https://www.nytimes.com/interactive/2017/02/01/us/politics/100000004904286.mobile.html |title=Obamacare More Popular Than Ever, Now That It May Be Repealed |work={{wipe|The New York Times}} |date=February 1, 2017}}</ref> Another January 2017 poll reported that 35% of respondents believed "Obamacare" and the "Affordable Care Act" were different or did not know. (About 45% were unsure whether "repeal of Obamacare" also meant "repeal of the Affordable Care Act".) 39% did not know that "many people would lose coverage through Medicaid or subsidies for private health insurance if the ACA were repealed and no replacement enacted", with Democrats far more likely (79%) to know that fact than Republicans (47%).<ref>{{Cite news |url=https://www.nytimes.com/2017/02/07/upshot/one-third-dont-know-obamacare-and-affordable-care-act-are-the-same.html |title=One-Third Don't Know Obamacare and Affordable Care Act Are the Same |last1=Dropp |first1=Kyle |date=February 7, 2017 |newspaper={{wipe|The New York Times}} |access-date=February 8, 2017 |last2=Nyhan |first2=Brendan |issn=1553-8095 |oclc=1645522}}</ref> A 2017 study found that personal experience with public health insurance programs led to greater support for the ACA, most prominently among Republicans and low-information voters.<ref>{{Cite journal |last1=Lerman |first1=Amy E. |last2=McCabe |first2=Katherine T. |date=January 24, 2017 |title=Personal Experience and Public Opinion: A Theory and Test of Conditional Policy Feedback |journal=The Journal of Politics |volume=79 |issue=2 |pages=624–641 |doi=10.1086/689286 |s2cid=157429497 |issn=0022-3816}}</ref>

By the end of 2023, a Morning Consult poll of registered voters found that 57% approved of the Affordable Care Act, while 30% disapproved of it. 85% of Democrats, 56% of independents, and 28% of Republicans supported the law.<ref>{{cite news |url=https://pro.morningconsult.com/analysis/obamacare-polling-popularity |title=Obamacare Has Become Even More Popular Over Biden's Presidency |date=December 6, 2023 |publisher=Morning Consult}}</ref>

==Political aspects==
==="Obamacare"===

The term "Obamacare" was originally coined by opponents as a pejorative. According to research by Elspeth Reeve, the expression was used in early 2007, generally by writers describing the candidate's proposal for expanding coverage for the uninsured.<ref name="NYT20120803" /> The term officially emerged in March 2007 when healthcare lobbyist Jeanne Schulte Scott wrote, "We will soon see a 'Giuliani-care' and 'Obama-care' to go along with 'McCain-care', 'Edwards-care', and a totally revamped and remodeled '[[Social:Hillarycare|Hillary-care]]' from the 1990s".<ref name="CNN20120625Obamacare" /><ref name="NYT20120325" />

In May 2007, Mitt Romney introduced it to political discourse, saying, "How can we get those people insured without raising taxes and without having government take over healthcare?' And let me tell you, if we don't do it, the Democrats will. If the Democrats do it, it will be socialized medicine; it'll be government-managed care. It'll be what's known as Hillarycare or Barack Obamacare, or whatever you want to call it."<ref name="CNN20120625Obamacare" />

By mid-2012, Obamacare had become the colloquial term used both by supporters and opponents.<ref name="NYT20120803" /> Obama eventually endorsed the nickname, saying, "I have no problem with people saying Obama cares. I do care."<ref>{{cite news |first=Lucy |last=Madison |url=http://www.cbsnews.com/news/on-bus-tour-obama-embraces-obamacare-says-i-do-care/ |title=On bus tour, Obama embraces 'Obamacare', says 'I do care{{'-}} |work=CBS News|date=August 15, 2011 |access-date=April 28, 2012}}</ref>

===Common misconceptions===

<!-- Please read WP:UNDUE and WP:FRINGE. Please. -->

===="Death panels"====


On August 7, 2009, Sarah Palin created the term "death panels" to describe groups who would decide whether sick patients were "worthy" of medical care.<ref name="Not so" /> "Death panel" referred to two claims about early drafts.

One was that under the law, seniors could be denied care due to their age<ref>{{cite web |url=http://snopes.com/politics/medical/over75.asp |title=Seniors Beware |website=Snopes |date=August 23, 2012}}</ref> and the other that the government would advise seniors to end their lives instead of receiving care. The ostensible basis of these claims was the provision for an Independent Payment Advisory Board (IPAB).<ref name="salon08132013" /> IPAB was given the authority to recommend cost-saving changes to Medicare by facilitating the adoption of cost-effective treatments and cost-recovering measures when statutory expenditure levels were exceeded within any given three-year period. In fact, the Board was prohibited from recommending changes that would reduce payments before 2020, and was prohibited from recommending changes in premiums, benefits, eligibility and taxes, or other changes that would result in rationing.<ref>{{cite web |first1=Jack |last1=Ebeler |first2=Tricia |last2=Neuman |first3=Juliette |last3=Cubanski |title=The Independent Payment Advisory Board: A New Approach to Controlling Medicare Spending |url=http://kff.org/health-reform/issue-brief/the-independent-payment-advisory-board-a-new/ |publisher=Kaiser Family Foundation |date=April 13, 2011 |page=3 |access-date=November 27, 2013}}</ref><ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/jonathan-cohn/87102/ipab-medicare-commission-repeal-ryan-schwartz |title=Here We Go Again, With the Death Panels |magazine=The New Republic |date=April 20, 2011}}</ref>

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.<ref>{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/mandatory-death-counseling-exposed |title=Mandatory Death Counseling – exposed! |magazine=The New Republic|date=August 13, 2009}}</ref> The provision was not included in ACA.<ref>{{cite news |title=Senate committee scraps healthcare provision that gave rise to 'death panel' claims; Though the claims are widely discredited, the Senate Finance Committee is withdrawing from its bill the inclusion of advance-care planning consultations, calling them too confusing |first1=Christi |last1=Parsons |first2=Andrew |last2=Zajac |newspaper={{wipe|Los Angeles Times}} |date=August 14, 2009 |url=http://articles.latimes.com/2009/aug/14/nation/na-health-end-of-life14}}</ref>

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.<ref>{{Cite journal |first=Brendan |last=Nyhan |title=Why the "Death Panel" Myth Wouldn't Die: Misinformation in the Health Care Reform Debate |journal=The Forum |volume=8 |issue=1 |year=2010 |doi=10.2202/1540-8884.1354 |url=http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf |citeseerx=10.1.1.692.9614 |s2cid=144075499 |access-date=July 1, 2013 |archive-date=June 4, 2019 |archive-url=https://web.archive.org/web/20190604135225/http://www.dartmouth.edu/~nyhan/health-care-misinformation.pdf |url-status=dead }}</ref> The allegation was named PolitiFact's 2009 "Lie of the Year",<ref name="Not so" /><ref>{{Cite news |title=PolitiFact's Lie of the Year: 'Death panels' |publisher=PolitiFact|date=December 19, 2009 |url=http://politifact.com/truth-o-meter/article/2009/dec/18/politifact-lie-year-death-panels |first=Angie |last=Drobnic Holan |access-date=November 19, 2010}}</ref> one of FactCheck.org's "whoppers"<ref>{{Cite news |title=False Euthanasia Claims |first1=Jess |last1=Henig |first2=Lori |last2=Robertson |publisher=FactCheck.org |date=July 29, 2010 |url=http://www.factcheck.org/2009/07/false-euthanasia-claims}}</ref><ref>{{cite web |title=Whoppers of 2009—We review the choicest falsehoods from a year that kept us busy |date=December 24, 2009 |author=Robertson, Lori |url=http://www.factcheck.org/2009/12/whoppers-of-2009 |publisher=FactCheck.org |access-date=April 28, 2011}}</ref> and the most outrageous term by the American Dialect Society.<ref>{{cite web |url=http://www.americandialect.org/2009-Word-of-the-Year-PRESS-RELEASE.pdf |title={{-'}}Tweet' 2009 Word of the Year, 'Google' Word of the Decade, as voted by American Dialect Society |date=January 8, 2010 |publisher=American Dialect Society |access-date=October 8, 2010}}</ref> AARP described such rumors as "rife with gross—and even cruel—distortions".<ref name="snopes1" />

====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).<ref>[http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm Public Law 111 – 148], section 1312: "...{{nbsp}}the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."</ref><ref>{{Cite news |title=Congress Exempt from Health Bill? |first=Lori |last=Robertson |publisher=FactCheck.org |date=January 20, 2010 |url=http://www.factcheck.org/2010/01/congress-exempt-from-health-bill}}</ref>

====Illegal immigrants====

ACA explicitly denies insurance subsidies to "unauthorized (illegal) aliens".<ref name="cbouninsured" /><ref name="Chaikind2011" /><ref>{{Cite news |title=The Democrats' health care bills would provide 'free health care for illegal immigrants' |publisher=PolitiFact|date=January 21, 2010 |url=http://www.politifact.com/truth-o-meter/statements/2010/jan/21/chain-email/chain-e-mail-claims-health-care-bills-congress-wou |first=Robert |last=Farley |access-date=August 19, 2013}}</ref>

====Exchange "death spiral"====

[[File:County By County Projected Insurer Participation in Health Insurance Exchanges.png|frameless|right|upright=1.35]]

Opponents claimed that combining immediate coverage with no provision for preexisting conditions would lead people to wait to get insured until they got sick. The individual mandate was designed to push people to get insured without waiting. This has been called a "death spiral".<ref>{{cite web |url=https://www.bloomberg.com/view/articles/2017-01-18/the-once-and-future-obamacare-death-spiral |title=The Once and Future Obamacare Death Spiral |date=January 18, 2017 |publisher={{wipe|Bloomberg News}}}}</ref> In the years after 2013, many insurers did leave specific marketplaces, claiming the risk pools were too small.

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

===="If you like your plan"====

At various times during and after ACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan."<ref>{{cite web |url=https://obamawhitehouse.archives.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay |work=whitehouse.gov |title=A Town Hall, and a Health Care Model, in Green Bay |date=June 11, 2009|via=National Archives |access-date=November 9, 2013}}</ref><ref name="ObamaPromise" /> However, in fall 2013 millions of Americans with individual policies received notices that their insurance plans were terminated,<ref>{{cite news |url=http://www.cnn.com/2013/11/08/politics/obama-obamacare-apology |title=After the big Obamacare apology: where things stand |date=November 8, 2013 |access-date=November 9, 2013 |publisher=CNN}}</ref> and several million more risked seeing their current plans canceled.<ref>{{cite web |url=http://www.cnn.com/2013/11/07/politics/obama-obamacare-apology |title=Obama apologizes for insurance cancellations due to Obamacare |date=November 7, 2013 |publisher=CNN|access-date=July 29, 2014}}</ref><ref>{{cite news |url=http://www.bizjournals.com/denver/news/2013/11/08/health-insurers-canceling-plans-say.html |title=Health insurers say they're canceling plans because of federal law |last=Sealover |first=Ed |date=November 8, 2013 |work=Denver Business Journal |access-date=November 9, 2013}}</ref>

Obama's previous unambiguous assurance that consumers could keep their own plans became a focal point for critics, who challenged his truthfulness.<ref>{{cite magazine |last=Weigel |first=David |date=November 8, 2013 |title=The White House's Website Still Says If You Like Your Plan You Can Keep It |url=http://www.slate.com/blogs/weigel/2013/11/08/the_white_house_s_web_site_still_says_if_you_like_your_plan_you_can_keep.html|magazine=Slate |access-date=November 9, 2013}}</ref><ref>{{cite news |url=https://www.economist.com/news/united-states/21588951-congress-hears-tales-baffling-ineptitude-debacle |title=Obamacare: The debacle |date=November 2, 2013 |newspaper=[[Finance:The Economist|The Economist]] |access-date=November 8, 2013}}</ref> Various bills were introduced in Congress to allow people to keep their plans.<ref>{{cite news |url=http://www.mcclatchydc.com/2013/11/08/207999/congress-weighing-laws-to-let.html |title=Congress weighing laws to let people keep health insurance |last=Schoof |first=Renee |date=November 8, 2013 |access-date=November 14, 2013 |publisher=McClatchyDC}}</ref>

PolitiFact initially cited various estimates that only about 2% of the total insured population (4{{nbsp}}million out of 262 million) received such notices,<ref>{{cite news |url=http://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |title=Lie of the Year: "If you like your health care plan, you can keep it |date=December 12, 2014 |access-date=April 5, 2018 |publisher={{wipe|Bloomberg News}}}}</ref> but readers later voted Obama's claims as the 2013 "Lie of the Year".<ref>{{Cite web |url=https://www.politifact.com/truth-o-meter/article/2013/dec/12/lie-year-if-you-like-your-health-care-plan-keep-it/ |title=Lie of the Year: 'If you like your health care plan, you can keep it' |last=Drobnic Holan |first=Angie |date=December 12, 2013 |website=PolitiFact|access-date=December 1, 2019}}</ref>

==Criticism and opposition==
Opposition and efforts to repeal the legislation have drawn support from sources that include labor unions,<ref name="WSJ" /><ref name="wapo" /> conservative advocacy groups,<ref name="NYT-20131018" /><ref name="NYT-20140126" /> Republicans, small business organizations and the [[Social:Tea Party movement|Tea Party movement]].<ref>{{cite news |last=Peters |first=Jeremy |title=Conservatives' Aggressive Ad Campaign Seeks to Cast Doubt on Health Law |url=https://www.nytimes.com/2013/07/07/us/politics/conservatives-aggressive-ad-campaign-seeks-to-cast-doubt-on-health-law.html |work={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |date=January 20, 2011}}</ref> These groups claimed the law would disrupt existing health plans, increase costs from new insurance standards, and increase the deficit.<ref>{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/article/113994/obamacare-implementation-conservatives-brace-it-working |title=Conservatives Brace for the Possibility Obamacare Won't Totally Suck |magazine=The New Republic |date=July 23, 2013}}</ref> Some opposed the idea of universal healthcare, viewing insurance as similar to other unsubsidized goods.<ref>{{cite web |author=Michael Cannon |url=http://www.cato.org/blog/anti-universal-coverage-club-manifesto |title=The Anti-Universal Coverage Club Manifesto |publisher=Cato Institute |date=July 6, 2007}}</ref><ref>{{cite news |first=Jonathan |last=Chait |url=http://nymag.com/daily/intelligencer/2012/06/health-care-as-privilege-what-gop-wont-admit.html |title=Health Care As a Privilege: What the GOP Won't Admit |work=New York Intelligencer |date=June 25, 2012}}</ref> President Donald Trump repeatedly promised to "repeal and replace" it.<ref>{{Cite web |url=https://www.cnbc.com/2016/11/09/trumps-first-100-day-agenda-may-be-stymied-by-his-own-party.html |title=Here's what's coming from the Trump administration |last=Schoen |first=John W. |date=November 9, 2016 |website={{wipe|CNBC}} |access-date=November 16, 2016}}</ref><ref>{{cite news |last1=Haberman |first1=Maggie |last2=Pear |first2=Robert |title=Trump Tells Congress to Repeal and Replace Health Care Law 'Very Quickly' |url=https://www.nytimes.com/2017/01/10/us/repeal-affordable-care-act-donald-trump.html |access-date=January 25, 2017 |issn=0362-4331 |oclc=1645522 |work={{wipe|The New York Times}} |date=January 10, 2017}}</ref>

{{As of|2013}} unions that expressed concerns included the AFL–CIO,<ref name="AFLCIO" /> which called ACA "highly disruptive" to union health care plans, claiming it would drive up costs of union-sponsored plans; the International Brotherhood of Teamsters, United Food and Commercial Workers International Union, and UNITE-HERE, whose leaders sent a letter to Reid and Pelosi arguing, "PPACA will shatter not only our hard-earned health benefits, but destroy the foundation of the 40-hour work week that is the backbone of the American middle class."<ref name="WSJ" /> 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."<ref name="wapo" />

In October 2016, Mark Dayton, the governor of Minnesota and a member of the Minnesota Democratic–Farmer–Labor Party, said ACA had "many good features" but it was "no longer affordable for increasing numbers of people"; he called on the state legislature to provide emergency relief to policyholders.<ref>{{cite news |url=http://www.politico.com/story/2016/10/minnesota-mark-dayton-obamacare-not-affordable-229690 |title=Democratic governor: Obamacare 'no longer affordable' for many |publisher=Politico |date=October 12, 2016 |first=Rachana |last=Pradhan}}</ref> Dayton later said he regretted his remarks after they were seized on by Republicans seeking to repeal the law.<ref>{{cite news |url=http://www.politico.com/story/2016/10/mark-dayton-obamacare-comments-affordable-230156 |title=Democratic governor expresses regret over Obamacare comments, requests emergency relief for rate hikes |publisher=Politico |date=October 21, 2016 |first=Paul |last=Demko}}</ref>

===Legal challenges===

====''National Federation of Independent Business v. Sebelius''====

Opponents challenged ACA's constitutionality in multiple lawsuits on multiple grounds.<ref>{{cite web |last=Cauchi |first=Richard |title=State Legislation and Actions Challenging Certain Health Reforms |url=http://www.ncsl.org/research/health/state-laws-and-actions-challenging-ppaca.aspx |publisher=National Conference of State Legislatures |date=November 15, 2013 |access-date=November 28, 2013}}</ref><ref>{{cite web |title=Health Care Lawsuit Case Challenges |url=http://www.healthcarelawsuits.org/cases.php |publisher=Independent Women's Forum |date=November 26, 2013 |access-date=November 28, 2013}}</ref>{{failed verification|reason=Probably want one of the subsidiary pages to this page |date=May 2016}} The Supreme Court ruled, 5–4, that the individual mandate was constitutional when viewed as a tax, although not under the Commerce Clause.

The Court further determined that states could not be forced to expand Medicaid. ACA withheld all Medicaid funding from states declining to participate in the expansion. The Court ruled that this was unconstitutionally coercive and that individual states had the right to opt out without losing preexisting Medicaid funding.<ref name="NatLawReview2012">{{cite web |title=Analysis: U.S. Supreme Court Upholds the Affordable Care Act: Roberts Rules? |url=http://www.natlawreview.com/article/analysis-us-supreme-court-upholds-affordable-care-act-roberts-rules |publisher=von Briesen & Roper, S.C. |work=The National Law Review |date=June 29, 2012 |access-date=July 2, 2012}}</ref>

====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,<ref>{{cite web |url=http://www.usccb.org/issues-and-action/religious-liberty/march-14-statement-on-religious-freedom-and-hhs-mandate.cfm |title=March 14, 2012 Statement on Religious Freedom and HHS Mandate |date=March 14, 2012 |publisher=United States Conference of Catholic Bishops |access-date=April 28, 2012}}</ref><ref>{{cite news |last=Goodstein |first=Laurie |title=Catholics File Suits on Contraceptive Coverage |url=https://www.nytimes.com/2012/05/22/us/catholic-groups-file-suits-on-contraceptive-coverage.html |issn=0362-4331 |oclc=1645522 |newspaper={{wipe|The New York Times}}|date=May 21, 2012}}</ref> including ''Burwell v. Hobby Lobby Stores, Inc.'', which looked at private corporations and their duties under the ACA.

In ''Little Sisters of the Poor Saints Peter and Paul Home v. Pennsylvania'', the Supreme Court ruled 7–2 on July 8, 2020, that employers with religious or moral objections to contraceptives can exclude such coverage from an employee's insurance plan. Writing for the majority, Justice Clarence Thomas said, "No language in the statute itself even hints that Congress intended that contraception should or must be covered. It was Congress, not the [administration], that declined to expressly require contraceptive coverage in the ACA itself." Justices Roberts, Alito, Gorsuch, and Kavanaugh joined Thomas's opinion. Justice Elena Kagan filed a concurring opinion in the judgment, in which Stephen Breyer joined. Justices Ginsburg and Sotomayor dissented, saying the court's ruling "leaves women workers to fend for themselves."<ref>{{cite web |title=Supreme Court allows Trump to exempt employers from Obamacare birth control mandate |url=https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |archive-date=July 25, 2020 |archive-url=https://web.archive.org/web/20200725005137/https://abcnews.go.com/Politics/supreme-court-trump-exempt-employers-obamacare-birth-control/story?id=71254754&cid=clicksource_4380645_2_heads_hero_live_headlines_hed |work=ABC News |publisher=Walt Disney |access-date=June 18, 2022 |last1=Dwyer |first1=Devin}}</ref>

In a later lawsuit brought by private health insurance buyers and businesses, Judge Reed O'Connor of the Federal District Court for the Northern District of Texas ruled in March 2023 that the ACA's provision of contraceptives, HIV testing, and screenings for cancer, diabetes, and mental health violated the plaintiffs' freedom of religious exercise, and placed an injunction on that portion of the ACA. The Biden administration planned to seek a hold on O'Connor's decision.<ref>{{cite web | url=https://apnews.com/article/obamacare-insurance-preventative-care-texas-aa57fa6fd782e2170bc80210fd00065b | title=Judge's ruling undercuts US health law's preventive care | website=Associated Press | date=March 30, 2023 }}</ref>

====''King v Burwell''====

On June 25, 2015, the U.S. Supreme Court ruled, 6–3, that federal subsidies for health insurance premiums could be used in the 34 states that did not set up their own insurance exchanges.<ref>{{cite news |url=https://abcnews.go.com/Politics/supreme-court-upholds-obama-health-care-subsidies/story?id=31931412 |title=Supreme Court Upholds Obamacare Subsidies, President Says ACA 'Is Here to Stay' |last1=Taylor |first1=Audrey |last2=Seanz |first2=Arlette |last3=Levine |first3=Mike |publisher=ABC News |date=June 25, 2015 |access-date=June 25, 2015}}</ref>

====''House v. Price''====

House Republicans sued the Obama administration in 2014, alleging that cost-sharing reduction subsidy payments to insurers were unlawful because Congress had not appropriated funds to pay for them. The argument classified the CSR subsidy as discretionary spending subject to annual appropriation. In May 2016, a federal judge ruled for the plaintiffs, but the Obama administration appealed.<ref>{{cite web |author=explainer |url=https://www.commonwealthfund.org/publications/explainer/2017/apr/essential-facts-about-health-reform-alternatives-eliminating-cost |title=Eliminating Cost-Sharing Reductions in ACA |date=April 28, 2017 |doi=10.26099/19sf-a521 |access-date=December 1, 2019 |publisher=Commonwealth Fund}}</ref> Later, President Trump ended the payments. This led to further litigation.<ref name=":3">{{Cite journal |last1=Keith |first1=Katie |url=https://www.healthaffairs.org/do/10.1377/forefront.20190217.755658/full/ |title=More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments |date=February 27, 2019 |journal=Health Affairs Forefront |doi=10.1377/forefront.20190217.755658}}</ref>

====''United States House of Representatives v. Azar''====

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

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

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

====''California v. Texas''====

Texas and 19 other states filed a civil suit in the United States District Court for the Northern District of Texas in February 2018, arguing that with the passage of the Tax Cuts and Jobs Act of 2017, which eliminated the tax for not having health insurance, the individual mandate no longer had a constitutional basis and thus the entire ACA was no longer constitutional.<ref>{{cite web |title=Complaint for Declaratory and Injunctive Relief |id=Case 4:18-cv-00167-O |date=2018-02-26 |url=https://www.courtlistener.com/recap/gov.uscourts.txnd.299449/gov.uscourts.txnd.299449.1.0.pdf}}</ref> The Department of Justice said it would no longer defend the ACA in court, but 17 states led by California stepped in to do so.<ref name="cnn 20181214" />

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

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

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

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

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

====Risk corridors====
The Supreme Court ruled that promised risk corridor payments must be made even in the absence of specific appropriation of money by Congress.<ref name=":1" />

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

===Repeal efforts===

ACA was the subject of many unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives [[Biography:Steve King|Steve King]] and [[Biography:Michele Bachmann|Michele Bachmann]] introduced bills in the House to repeal the ACA the day after it was signed, as did Senator Jim DeMint in the Senate.<ref>{{cite web |last=O'Brien |first=Michael |url=http://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |title=GOP quick to release 'repeal' bills |work=The Hill |date=March 22, 2010 |access-date=April 1, 2012 |archive-date=January 29, 2022 |issn=1521-1568 |oclc=31153202 |archive-url=https://web.archive.org/web/20220129173857/https://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |url-status=dead }}</ref> In 2011, after Republicans gained control of the House, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189.<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002: |archive-url=https://web.archive.org/web/20140922023012/http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002: |url-status=dead |archive-date=September 22, 2014 |title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=THOMAS |date=January 19, 2011 }}</ref> All Republicans and three Democrats voted for repeal.<ref>{{cite web |url=http://clerk.house.gov/evs/2011/roll014.xml |title=Final Vote Results for passage of Repealing the Job-Killing Health Care Law Act (H.R. 2) |publisher=THOMAS |date=January 19, 2011}}</ref> In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down.<ref>{{cite web |url=https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=112&session=1&vote=00009 |title=Motion to Waive All Applicable Budgetary Discipline Re: McConnell Amdt. No. 13 |publisher=U.S. Senate |date=February 2, 2011 |access-date=April 1, 2012}}</ref> President Obama said he would veto the bill had it passed.<ref>{{cite web |url=http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994 |title=House Passes Health Care Repeal 245–189 |publisher={{wipe|C-SPAN}} |date=January 19, 2011 |access-date=January 21, 2011 |archive-url=https://web.archive.org/web/20110708110210/http://c-span.com/Events/House-Passes-Health-Care-Repeal-245-189/10737418994/ |archive-date=July 8, 2011 |url-status=dead}}</ref>
[[File:2017 House budget.pdf|thumb|2017 House Budget]]

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

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

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

====2017 repeal effort====

During a midnight congressional session starting January 11, the Senate of the 115th Congress of the United States voted to approve a "budget blueprint" that would allow Republicans to repeal parts of the law "without threat of a Democratic [[Social:Filibuster|filibuster]]".<ref>{{Cite news |url=https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html |title=Senate Takes Major Step Toward Repealing Health Care Law |last1=Kaplan |first1=Thomas |date=January 12, 2017 |work={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |last2=Pear |first2=Robert |access-date=January 12, 2017}}</ref><ref>{{Cite news |url=http://www.foxnews.com/politics/2017/01/11/gop-senate-to-move-forward-on-obamacare-repeal.html |title=GOP Senate to Move Forward on ObamaCare Repeal |date=January 11, 2017 |publisher=Fox News Politics |access-date=January 12, 2017}}</ref> The plan, which passed 51–48, was named by Senate Republicans the "Obamacare 'repeal resolution.{{' "}}<ref>{{Cite news |url=http://www.cnn.com/2017/01/11/politics/senate-obamacare-repeal/ |title=Senate Opens Obamacare Repeal Drive with Overnight Marathon |last1=Lee |first1=MJ |date=January 12, 2017 |publisher=CNN|last2=Barrett |first2=Ted |last3=LoBianco |first3=Tom |access-date=January 12, 2017}}</ref> Democrats opposing the resolution staged a protest during the vote.<ref>{{Cite news |url=http://www.nbcnews.com/politics/congress/senate-vote-obamacare-repeal-measure-late-night-session-n705816 |title=Senate Approves First Step Toward Repealing Obamacare in Late-Night Session |last=Caldwell |first=Leigh Ann |date=January 12, 2017 |publisher=NBC News |access-date=January 12, 2017}}</ref>

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

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

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

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

===Actions to hinder implementation===
[[File:2-TCJA Number Uninsured v1.png|thumb|right|upright=2|Tax Cuts and Jobs Act—number of additional persons uninsured<ref>{{Cite web |url=https://www.nytimes.com/interactive/2017/12/29/opinion/2017-the-year-in-charts.html |title=Opinion &#124; 2017: The Year in Charts |first=Steven |last=Rattner |date=December 29, 2017 |issn=1553-8095 |oclc=1645522 |work={{wipe|The New York Times}}}}</ref>]]

Under both the ACA (current law) and the AHCA, the CBO reported that the health exchange marketplaces would remain stable.<ref name="CBO_Score1" /> But Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums.<ref>{{Cite news |url=https://www.nytimes.com/2017/07/27/opinion/health-care-obamacare.html |title=Opinion &#124; Killing Obamacare Softly |first=Thomas B. |last=Edsall |newspaper={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |date=July 27, 2017}}</ref> Concern about the exchanges became another argument for reforms. Past and ongoing Republican attempts to weaken the law have included:
* Lawsuits such as ''King v. Burwell'' and ''House v. Price''. 
* President Trump ended the payment of cost-sharing reduction subsidies to insurers on October 12, 2017. CBO estimated in September 2017 that discontinuing the payments would add an average of 15–20 percentage points to health insurance costs on the exchanges in 2018 while increasing the budget deficit nearly $200 billion over a decade.<ref name="VoxCBO1">{{Cite web |url=https://www.vox.com/policy-and-politics/2017/9/14/16308502/cbo-trump-obamacare-premiums |title=CBO: Trump is making Obamacare premiums more expensive |first=Sarah |last=Kliff |date=September 14, 2017 |website=Vox}}</ref> In response, insurers sued the government for reimbursement. Various cases are under appeal as of 2019.<ref name=":3" /> Several insurers and actuarial groups estimated this resulted in a 20 percentage point or more increase in premiums for the 2018 plan year. In other words, premium increases expected to be 10% or less in 2018 became 28–40% instead.<ref>Scott, Dylan (October 18, 2017). [https://www.vox.com/policy-and-politics/2017/10/18/16458316/obamacare-premiums-trump "Obamacare premiums were stabilizing. Then Trump happened"]. Vox.</ref><ref>Kliff, Sarah. (October 18, 2017). [https://www.vox.com/health-care/2017/10/18/16499806/trump-insurance-bailouts-completely-incoherent "Trump's stance on insurance 'bailouts' is completely incoherent"]. ''Vox''. Archived at [https://web.archive.org/web/20171108211628/https://www.vox.com/health-care/2017/10/18/16499806/trump-insurance-bailouts-completely-incoherent Wayback Machine] on November 8, 2017.</ref> The insurers would need to make up the $7 billion they had previously received in cost-sharing reductions (CSRs) by raising premiums. Since most premiums are subsidized, the federal government would cover most of the increases. CBO also estimated that initially up to one million fewer people would have health insurance coverage, although rising subsidies might eventually offset this. The 85% of enrollees who received subsidies would be unaffected. CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level.<ref>Congressional Budget Office. (August 15, 2017). [https://www.cbo.gov/publication/53009 "The Effects of Terminating Payments for Cost-Sharing Reductions"]. Archived at [https://web.archive.org/web/20171016113108/https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53009-costsharingreductions.pdf Wayback Machine] on October 16, 2017.</ref> Several insurance companies who sued the United States for failure to pay CSRs won cases in 2018 and 2019. The judiciary decided the insurance companies are entitled to unpaid CSRs.<ref name=":3"/><ref>{{cite journal |last1=Keith |first1=Katie |title=Insurer Wins First CSR Payment Decision; Updates On BHP And Risk Corridors Litigation |url=https://www.healthaffairs.org/do/10.1377/forefront.20180906.295628/full/ |journal=Health Affairs |date=September 6, 2018 |doi=10.1377/forefront.20180906.295628}}</ref>
* The 2015 appropriations bill had a rider that ended the payment of risk corridor funds. This was repeated in later years. This resulted in the bankruptcy of many co-ops. This action was attributed to Senator Marco Rubio.<ref>{{Cite news |url=https://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html |title=Marco Rubio Quietly Undermines Affordable Care Act |first=Robert |last=Pear |newspaper={{wipe|The New York Times}} |issn=0362-4331 |oclc=1645522 |date=December 9, 2015}}</ref> The cutoff generated some 50 lawsuits. The Supreme Court granted certiorari in 2019 in the case ''Maine Community Health Options v. United States''.<ref>{{Cite journal |url=https://www.commonwealthfund.org/blog/2019/supreme-court-hear-case-affordable-care-acts-risk-corridors |title=Supreme Court to Hear Case on Affordable Care Act's Risk Corridors |publisher=Commonwealth Fund |journal=To the Point |access-date=December 1, 2019 |author=Jost, Timothy S. |date=October 25, 2019 |doi=10.26099/pwc0-k005 |archive-date=February 16, 2020 |archive-url=https://web.archive.org/web/20200216164912/https://www.commonwealthfund.org/blog/2019/supreme-court-hear-case-affordable-care-acts-risk-corridors}}</ref><ref>{{cite news |last1=Galewitz |first1=Phil |date=December 9, 2010 |title=ACA Insurers In The Supreme Court: Why Consumers Should Pay Attention |url=https://www.npr.org/sections/health-shots/2019/12/09/786315240/aca-insurers-in-the-supreme-court-why-consumers-should-pay-attention?t=1585694181108 |access-date=March 31, 2020 |publisher=National Public Radio |archive-url=https://web.archive.org/web/20200331224050/https://www.npr.org/sections/health-shots/2019/12/09/786315240/aca-insurers-in-the-supreme-court-why-consumers-should-pay-attention?t=1585694181108 |archive-date=March 31, 2020}}</ref><ref>{{cite news |location=Washington DC |first1=Ian |last1=Millhiser |title=Obamacare had an unusually good day at the Supreme Court |url=https://www.vox.com/2019/12/10/21004821/obamacare-supreme-court-risk-corridors-maine-community |access-date=March 31, 2020 |publisher=Vox |date=December 10, 2019 |archive-url=https://web.archive.org/web/20191230061526/https://www.vox.com/2019/12/10/21004821/obamacare-supreme-court-risk-corridors-maine-community |archive-date=December 30, 2019}}</ref>
* Trump weakened the individual mandate with his first executive order, which limited enforcement of the tax. For example, tax returns without indications of health insurance ("silent returns") will still be processed, overriding Obama's instructions to reject them.<ref>{{Cite web |url=https://www.politico.com/story/2017/05/03/trump-obamacare-mandate-enforcement-237937 |title=Trump still enforcing Obamacare mandate |first1=Brianna |last1=Ehley |first2=Aaron |last2=Lorenzo |website=Politico|date=May 3, 2017 }}</ref>
* Trump reduced funding for advertising for exchange enrollment by up to 90%, with other reductions to support resources used to answer questions and help people sign-up for coverage.<ref>{{Cite web |url=https://www.vox.com/2017/8/31/16236280/trump-obamacare-outreach-ads |title=Trump is slashing Obamacare's advertising budget by 90% |first=Sarah |last=Kliff |date=August 31, 2017 |website=Vox}}</ref> The CBO said the reductions would reduce ACA enrollment.<ref name="VoxCBO1" />
* Trump reduced the enrollment period for 2018 by half, to 45 days.<ref>{{Cite news |date=November 4, 2017 |url=https://www.nytimes.com/2017/11/04/opinion/obamacare-vs-the-saboteurs.html |title=Opinion &#124; Obamacare vs. the Saboteurs |issn=0362-4331 |oclc=1645522 |author=The Editorial Board |newspaper={{wipe|The New York Times}}}}</ref>
* Trump made public statements that the exchanges were unstable or in a [[Finance:Death spiral (insurance)|death spiral]].<ref>{{Cite web |url=https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |first1=Louise |last1=Norris |access-date= |archive-date=November 18, 2017 |archive-url=https://web.archive.org/web/20171118012524/https://www.healthinsurance.org/blog/2017/05/17/10-ways-the-gop-sabotaged-obamacare/ |title=10 ways the GOP sabotaged Obamacare |date=May 17, 2017 |website=healthinsurance.org}}</ref>

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

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

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

==Implementation==


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

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

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

An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults.{{citation needed|date=September 2022}} The five major national insurers expected to lose money on ACA policies in 2016,<ref>{{Cite news |url=https://www.wsj.com/articles/aetna-to-drop-some-affordable-care-act-markets-1471311737 |title=Aetna to Drop Some Affordable Care Act Markets |last=Mathews |first=Anna Wilde |date=August 16, 2016 |newspaper={{wipe|The Wall Street Journal}}|publisher=News Corp |oclc=781541372 |issn=0099-9660 |access-date=August 16, 2016}}</ref> in part because the enrollees were lower income, older and sicker than expected.<ref>{{Cite news |url=https://www.wsj.com/articles/the-unstable-economics-in-obamas-health-law-1471452938 |title=The Unstable Economics in Obama's Health Law |last=Ip |first=Greg |date=August 17, 2016 |newspaper={{wipe|The Wall Street Journal}} |issn=0099-9660 |access-date=August 23, 2016}}</ref>

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

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

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

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

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

==See also==
* [[Biology:Broccoli mandate|Broccoli mandate]]
* Comparison of the healthcare systems in Canada and the United States
* Individual shared responsibility provision
* Massachusetts health care reform (sometimes called "Romneycare")
* Medicaid
* Medicare Access and CHIP Reauthorization Act of 2015 (Reform to the American Health Care system signed into law by President Obama)
* Single-payer health care
* [[Philosophy:Universal health care|Universal health care]]
* Universal health coverage by country
* U.S. health care compared with eight other countries (tabular form)

==References==

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<ref name="AFLCIO">{{cite web |url=http://www.aflcio.org/About/Exec-Council/Conventions/2013/Resolutions-and-Amendments/Resolution-54-AFL-CIO-Convention-Resolution-on-the-Affordable-Care-Act |title=Resolution 54: AFL-CIO Convention Resolution on the Affordable Care Act |publisher=AFL-CIO |date=September 11, 2013 |access-date=October 7, 2013}}</ref>

<ref name="aphabasics">{{cite web |url=http://www.apha.org/advocacy/Health+Reform/ACAbasics/insurance.htm |title=Insurance Exchanges |publisher=American Public Health Association (APHA) |url-status=dead |archive-url=https://web.archive.org/web/20130801135757/http://www.apha.org/advocacy/Health+Reform/ACAbasics/insurance.htm |archive-date=August 1, 2013 }}</ref>

<ref name="Beutler">{{cite news |url=http://www.salon.com/2013/09/19/john_boehner_just_made_ted_cruz_life_a_living_hell |title=New test could expose GOP's pack of charlatans |work=Salon |date=September 19, 2013 |author=Beutler, Brian |access-date=September 24, 2013}}</ref>

<ref name="ACAEconomyCohn">{{cite news |first=Jonathan |last=Cohn |title=Obamacare, Good for the Economy |url=https://newrepublic.com/blog/plank/104035/obamacare-romney-economy-benefit-job-regulation-noam |magazine=The New Republic |date=June 13, 2012}}</ref>

<ref name="AHPAMandate">{{cite web |url=http://www.apha.org/advocacy/Health+Reform/ACAbasics/MC_provision.htm |title=Minimum Coverage Provision ("individual mandate") |publisher=American Public Health Association (APHA) |url-status=dead |archive-url=https://web.archive.org/web/20140701171554/http://www.apha.org/advocacy/Health+Reform/ACAbasics/MC_provision.htm |archive-date=July 1, 2014 }}</ref>

<ref name="AP-20140731">{{cite news |url=http://apnews.excite.com/article/20140731/us-health-overhaul-de4c72c273.html |title=Probe exposes flaws behind HealthCare.gov rollout |last=Alonso-Zaldivar |first=Ricardo |date=July 31, 2014 |publisher=AP News |access-date=July 31, 2014 |archive-url=https://web.archive.org/web/20140808041622/http://apnews.excite.com/article/20140731/us-health-overhaul-de4c72c273.html |archive-date=August 8, 2014 |url-status=dead }}</ref>

<ref name="BUREAU OF LABOR AND STATISTICS">{{cite web |title=Employment Situation Summary |url=http://www.bls.gov/news.release/empsit.nr0.htm |publisher=Bureau of Labor Statistics |access-date=November 11, 2014}}</ref>

<ref name="BillPassageOptions">{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/blog/the-treatment/what-do-if-coakley-loses-contd |title=How to Pass the Bill--Whatever Happens Tuesday |magazine=The New Republic |date=January 17, 2010}}</ref>

<ref name="CBO-Pelosi2">{{Cite news |title=What does the health-care bill do in its first year? |first=Ezra |last=Klein |url=http://voices.washingtonpost.com/ezra-klein/2010/03/what_does_the_health-care_refo.html |newspaper={{wipe|The Washington Post}} |issn=0190-8286 |oclc=2269358 |date=March 22, 2010}}</ref>

<ref name="CBO-Reid-Dec2009">{{cite web |url=http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-Reid_Letter_Managers_Correction_Noted.pdf |title=Correction Regarding the Longer-Term Effects of the Manager's Amendment to the Patient Protection and Affordable Care Act |website=United States. Congressional Budget Office |date=December 19, 2009 |first=Douglas W. |last=Elmendorf |archive-url=https://web.archive.org/web/20091227204128/http://www.cbo.gov/ftpdocs/108xx/doc10868/12-19-Reid_Letter_Managers_Correction_Noted.pdf |archive-date=December 27, 2009 |access-date=March 22, 2010}}</ref>

<ref name="CBO43472">{{cite web |url=http://www.cbo.gov/publication/43472 |title=CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision |website=United States. Congressional Budget Office |date=July 24, 2012 |archive-url=https://web.archive.org/web/20121230065342/http://www.cbo.gov/publication/43472 |archive-date=December 30, 2012 |format=Blog |access-date=August 6, 2012}}</ref>

<ref name="CBO50252">{{cite web |url=https://www.cbo.gov/publication/50252 |title=Budgetary and Economic Effects of Repealing the Affordable Care Act |website=United States. Congressional Budget Office |date=June 19, 2015 |archive-url=https://web.archive.org/web/20150622234000/https://www.cbo.gov/publication/50252 |archive-date=June 22, 2015 |format=Report |access-date=June 19, 2015}}</ref>

<ref name="CBOjobs">{{cite news |first=Jonathan |last=Chait |title=Sorry, The CBO Did Not Say Health Reform Kills 800,000 Jobs |url=https://newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs |magazine=The New Republic|issn=2169-2416 |location=Penn Quarter, Washington DC |archive-url=https://web.archive.org/web/20130921055644/https://newrepublic.com/blog/jonathan-chait/83310/sorry-the-cbo-did-not-say-health-reform-kills-800000-jobs |archive-date=September 21, 2013 |date=February 11, 2011}}</ref>

<ref name="cbouninsured">{{cite web |url=http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf |first=Douglas W. |last=Elmendorf |title=Cost Estimate for Pending Health Care Legislation |date=March 20, 2010 |website=United States. [[Organization:Congressional Budget Office|Congressional Budget Office]] |archive-url=https://web.archive.org/web/20120404151231/http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf |archive-date=April 4, 2012 |access-date=March 28, 2010}}</ref>

<ref name="CBOMethodology">{{cite news |title=The GOP's Trick Play |first=Jonathan |last=Cohn |magazine=The New Republic |date=January 21, 2011 |url=http://www.tnr.com/blog/jonathan-cohn/81941/trick-play}}</ref>

<ref name="CBOTrackRecord">{{cite news |title=Is the CBO Biased Against Health Care Reform? |first=Noam |last=Scheiber |magazine=The New Republic |date=September 17, 2009 |url=http://www.tnr.com/blog/the-stash/the-cbo-biased-against-health-care-reform}}</ref>

<ref name="CBO-Pelosi">{{cite web |url=http://www.cbo.gov/ftpdocs/113xx/doc11355/hr4872.pdf |title=H.R. 4872, Reconciliation Act of 2010 |website=United States. Congressional Budget Office |date=March 18, 2010 |archive-url=https://web.archive.org/web/20100401203854/http://www.cbo.gov/ftpdocs/113xx/doc11355/hr4872.pdf |first=Douglas W. |last=Elmendorf |archive-date=April 1, 2010 |access-date=March 22, 2010}}</ref>

<ref name="CBO22077">{{cite web |url=http://www.cbo.gov/publication/22077 |title=CBO's Analysis of the Major Health Care Legislation Enacted in March 2010 |website=United States. Congressional Budget Office |date=March 30, 2011 |archive-url=https://web.archive.org/web/20121010231658/http://www.cbo.gov/publication/22077 |archive-date=October 10, 2012 |access-date=April 6, 2012}}</ref>

<ref name="CBO43104">{{cite web |url=http://www.cbo.gov/publication/43104 |title=Another Comment on CBO's Estimates for the Insurance Coverage Provisions of the Affordable Care Act |website=United States. Congressional Budget Office |date=March 16, 2012 |format=Blog |archive-url=https://web.archive.org/web/20121214031615/http://www.cbo.gov/publication/43104 |archive-date=December 14, 2012 |access-date=April 6, 2012}}</ref>

<ref name="CBPPEmpMand.">{{cite web |url=http://www.cbpp.org/cms/index.cfm?fa=view&id=2921 |title=Finance Committee Makes Flawed Employer Requirement in Health Reform Bill Still More Problematic |author1=Robert Greenstein |author2=Judith Solomon |publisher=Center on Budget and Policy Priorities |date=July 3, 2013}}</ref>

<ref name="ChaitNotWreck">{{cite web |first=Jonathan |last=Chait |title=Obama Employer Mandate Delay Train Wreck! Or Not |url=http://nymag.com/daily/intelligencer/2013/07/obama-employer-mandate-delay-train-wreck-or-not.html |work=New York Intelligencer |date=July 3, 2013}}</ref>

<ref name="Chaikind2011">{{Cite report |last1=Chaikind |first1=Hinda |last2=Copeland |first2=Curtis W. |last3=Redhead |first3=C. Stephen |last4=Staman |first4=Jennifer |date=March 2, 2011 |title=PPACA: A Brief Overview of the Law, Implementation, and Legal Challenges |url=http://www.nationalaglawcenter.org/wp-content/uploads/assets/crs/R41664.pdf |archive-url=https://web.archive.org/web/20131113201718/http://www.nationalaglawcenter.org/wp-content/uploads/assets/crs/R41664.pdf |archive-date=2013-11-13 |publisher=[[Social:Congressional Research Service|Congressional Research Service]] |id=R41664 |access-date=December 22, 2013}}</ref>

<ref name="ChaitNotCollapsing">{{cite news |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-still-not-collapsing.html |title=Obamacare Still Not Collapsing |last=Chait |first=Jonathan |date=July 3, 2013 |work=New York Intelligencer}}</ref>

<ref name="ChaitLegislativeStrategy">{{cite news |first=Jonathan |last=Chait |url=https://newrepublic.com/blog/the-plank/the-republican-health-care-blunder |title=The Republican Health Care Blunder |magazine=The New Republic |date=December 19, 2009}}</ref>

<ref name="choose">{{cite web |url=https://www.healthcare.gov/how-do-i-choose-marketplace-insurance |title=How do I choose Marketplace insurance? |website=HealthCare.Gov |publisher=the Centers for Medicare and Medicaid Services}}</ref>

<ref name="cmsprev">{{cite web |url=https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Prevention.html |title=Health Insurance Market Reforms: Prevention |date=December 21, 2010 |publisher=Centers for Medicare and Medicaid Services |access-date=September 8, 2013}}</ref>

<ref name="cmsprog">{{cite web |url=http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html |title=Medical Loss Ratio |publisher=Centers for Medicaid and Medicare Services |access-date=October 2, 2013}}</ref>

<ref name="CMSMedicarePPACA">{{cite web |title=Affordable Care Act Update: Implementing Medicare Cost Savings |url=http://www.cms.gov/apps/docs/aca-update-implementing-medicare-costs-savings.pdf |publisher=Centers for Medicare and Medicaid Services |date=August 2, 2010 |access-date=October 7, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130418015959/http://www.cms.gov/apps/docs/aca-update-implementing-medicare-costs-savings.pdf |archive-date=April 18, 2013 }}</ref>

<ref name="CNN-Mar18">{{Cite news |url=http://www.cnn.com/2010/POLITICS/03/18/health.care.latest/index.html |publisher=CNN|title=Where does health care reform stand? |date=March 18, 2010 |access-date=May 12, 2010}}</ref>

<ref name="CNNMedicaid">{{cite news |url=https://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html |title=States forgo billions by opting out of Medicaid expansion |author=Luhby, Tami |publisher=Time Warner |website=CNNMoney |access-date=June 21, 2022 |archive-date=July 4, 2013 |archive-url=https://web.archive.org/web/20130704110006/https://money.cnn.com/2013/07/01/news/economy/medicaid-expansion-states/index.html |date=July 1, 2013}}</ref>

<ref name="CohnOE">{{cite news |url=https://newrepublic.com/article/114163/limited-enrollment-periods-obamacare-means-young-people-cant-wait |title=Burn Your Obamacare Card, Burn Yourself |last=Cohn |first=Jonathan |date=August 5, 2013 |website=The Plank |issn=2169-2416 |location=Washington DC |archive-url=https://web.archive.org/web/20130819200715/https://newrepublic.com/article/114163/limited-enrollment-periods-obamacare-means-young-people-cant-wait |archive-date=August 19, 2013 |publisher=The New Republic}}</ref>

<ref name="CohnExchanges">{{cite news |url=https://newrepublic.com/article/112259/obamacare-sticker-shock-not-very-shocking |title=Obamacare Sticker Shock: Not Very Shocking |last=Cohn |first=Jonathan |date=April 29, 2013 |magazine=The New Republic}}</ref>

<ref name="CommonSense">{{cite news |url=https://newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |archive-url=https://web.archive.org/web/20131203014925/https://newrepublic.com/article/health-care/why-americans-should-support-individual-mandate |archive-date=December 3, 2013 |title=Why Americans should support individual mandate |website=Common Sense |last=Cohn |first=Jonathan |location=Washington DC |date=April 9, 2010 |issn=2169-2416 |agency=Kaiser Health News |publisher=The New Republic}}</ref>

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

<ref name="CNN20120625Obamacare">{{cite news |url=http://www.cnn.com/2012/06/25/politics/obamacare-word-debate/ |title='Obamacare': The word that defined the health care debate |last=Wallace |first=Gregory |date=June 25, 2012 |publisher=CNN|access-date=September 4, 2012}}</ref>

<ref name="cnncontra">{{cite news |url=http://www.cnn.com/2011/HEALTH/07/19/birth.control.iom/index.html |title=Birth control should be fully covered under health plans, report says |last=Park |first=Madison |date=July 19, 2011 |publisher=CNN|access-date=August 27, 2012}}</ref>

<ref name="CohnDelay">{{cite news |url=https://newrepublic.com/article/113745/obamacare-employer-mandate-delayed-not-what-doctor-ordered |title=Some Bad News About Obamacare That Isn't Bogus |last=Cohn |first=Jonathan |date=July 2, 2013 |magazine=The New Republic}}</ref>

<ref name="cwfstate">{{cite web |url=http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jul/State-Health-Insurance-Exchange-Laws.aspx?omni |title=State Health Insurance Exchange Laws: The First Generation |date=July 25, 2012 |publisher=The CommonWealth Fund |access-date=July 26, 2013 |archive-url=https://web.archive.org/web/20130928003716/http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Jul/State-Health-Insurance-Exchange-Laws.aspx?omnicid=20 |archive-date=September 28, 2013 |url-status=dead}}</ref>

<ref name="deficit_david_walker_cbo_innacurate">{{cite news |url=https://www.npr.org/blogs/thetwo-way/2010/03/health_overhaul_another_promis.html |title=Health Overhaul Another Promise U.S. Can't Afford: Expert |last=James |first=Frank |date=March 19, 2010 |publisher=NPR |access-date=April 7, 2010}}</ref>

<ref name="EdLaborJul2009">{{Cite news |url=http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml |title=Affordable Health Care for America Act |first=Mike |last=Kruger |date=October 29, 2009 |publisher=United States House Committee on Education and Labor |access-date=March 24, 2010 |archive-url=https://web.archive.org/web/20100106013943/http://edlabor.house.gov/blog/2009/10/affordable-health-care.shtml |archive-date=January 6, 2010}}</ref>

<ref name="EO13535">Executive Order 13535 of March 24, 2010—''Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act'', Vol. 75, No. 59 {{USFedReg|75|15599}}, March 29, 2010.</ref>

<ref name="essential">{{cite web |url=https://www.healthcare.gov/glossary/essential-health-benefits/ |title=Essential Health Benefits |date=September 23, 2010 |website=HealthCare.gov |access-date=February 9, 2016}}</ref>

<ref name="Families USA">{{cite web |url=http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf |title=Enrollment Policy Provisions in the Patient Protection and Affordable Care Act |publisher=Families USA |access-date=April 1, 2012 |archive-date=March 31, 2012 |archive-url=https://web.archive.org/web/20120331052051/http://www.familiesusa.org/assets/pdfs/health-reform/Enrollment-Policy-Provisions.pdf |url-status=dead }}</ref>

<ref name="faqs">{{cite web |url=http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013.html |title=Women's Preventive Services Coverage and Non-Profit Religious Organizations |publisher=Centers for Medicare and Medicaid Services |access-date=September 8, 2013}}</ref>

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

<ref name="FinalRule">{{cite web |url=http://www.gpo.gov/fdsys/granule/FR-2012-02-15/2012-3547/content-detail.html |title=Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act – Final Rules |date=February 10, 2012 |publisher=Federal Register |format=77 FR 8725 |quote=Summary: ''These regulations finalize, without change, interim final regulations authorizing the exemption of group health plans and group health insurance coverage sponsored by certain religious employers from having to cover certain preventive health services under provisions of the Patient Protection and Affordable Care Act''. |author=Dept. Health and Human Services |access-date=February 15, 2012}}</ref>

<ref name="Feb2009JointSessionAddress">{{Cite news |url=https://obamawhitehouse.archives.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress |title=Remarks of President Barack Obama – Address to Joint Session of Congress |date=February 24, 2009 |access-date=March 24, 2010 |archive-url=https://web.archive.org/web/20170120215853/https://obamawhitehouse.archives.gov/the-press-office/remarks-president-barack-obama-address-joint-session-congress |via=National Archives |work=whitehouse.gov |archive-date=January 20, 2017 |url-status=live}}</ref>

<ref name="fewer">{{cite web |last=Pecquet |first=Julian |url=http://thehill.com/blogs/healthwatch/health-reform-implementation/215795-cbo-health-law-to-cost-less-cover-fewer-people-than-first-thought |title=CBO: Obama's health law to cost less, cover fewer people than first thought |work=The Hill |issn=1521-1568 |oclc=31153202 |date=March 13, 2012 |access-date=June 29, 2012}}</ref>

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

<ref name="forbes1">{{cite news |work={{wipe|Forbes}} |title=The Tortuous History of Conservatives and the Individual Mandate |first=Avik |last=Roy |date=February 7, 2012 |url=https://www.forbes.com/sites/aroy/2012/02/07/the-tortuous-conservative-history-of-the-individual-mandate}}</ref>

<ref name="governorromney">{{cite web |first=Molly |last=Ball |title=Was Mitt Romney a Good Governor? |url=https://www.theatlantic.com/politics/archive/2012/05/was-mitt-romney-a-good-governor/257942 |work=The Atlantic |date=May 31, 2012 |access-date=October 28, 2013}}</ref>
<ref name="GPO">{{cite web |url=http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleD-chap43-sec4980H.pdf |title=Title 26 – Internal Revenue Code |author=Government Printing Office}}</ref>

<ref name="GPOStateWaiver">{{cite web |url=http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/html/PLAW-111publ148.htm |title=Public Law 111 – 148, section 1332 |publisher=Government Printing Office |access-date=June 29, 2012}}</ref>

<ref name="GruberBio2">{{cite web |url=http://economics.mit.edu/faculty/gruberj |title=Jonathan Gruber (economist) |publisher=MIT Department of Economics |access-date=September 2, 2013}}{{cite web |url=http://economics.mit.edu/files/7840 |title=Jonathan Gruber: short biography |publisher=MIT Department of Economics |access-date=September 2, 2013 |url-status=dead |archive-url=https://web.archive.org/web/20130928032016/http://economics.mit.edu/files/7840 |archive-date=September 28, 2013 }}</ref>

<ref name="HackerReform">{{cite news |first=Jacob S. |last=Hacker |url=https://newrepublic.com/blog/the-treatment/why-i-still-believe-bill |title=Why I Still Believe in This Bill |magazine=The New Republic|date=December 20, 2009}}</ref>

<ref name="healthcare">{{cite web |url=http://www.healthcare.gov/law/about/order/byyear.html |title=Provisions of the Affordable Care Act, By Year |website=HealthCare.gov |access-date=January 9, 2012 |url-status=dead |archive-url=https://web.archive.org/web/20110909133159/http://www.healthcare.gov/law/about/order/byyear.html |archive-date=September 9, 2011 }}</ref>

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

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

<ref name="hhs">{{cite web |url=https://www.hhs.gov/healthcare/facts/timeline/timeline-text.html#print |title=Key Features of the Affordable Care Act By Year |date=June 7, 2013 |publisher=HHS |access-date=June 7, 2013}}</ref>

<ref name="Hhs.gov">{{cite press release |title=HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress |date=July 11, 2011 |publisher=HHS |url=https://www.hhs.gov/news/press/2011pres/07/20110711a.html |access-date=April 9, 2012 |url-status=dead |archive-url=https://web.archive.org/web/20120414044029/http://www.hhs.gov/news/press/2011pres/07/20110711a.html |archive-date=April 14, 2012 }}</ref>

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

<ref name="H.R.3590Enrolled">[http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr H.R. 3590 Enrolled], section 1001 (adding section 2714 to the Public Health Service Act): "A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26&nbsp;years of age."</ref>

<ref name="HowTheyDidIt">{{cite news |first=Jonathan |last=Cohn |url=https://newrepublic.com/article/75077/how-they-did-it |title=How They Did It |magazine=The New Republic |date=May 21, 2010}}</ref>

<ref name="http">{{cite news |url=https://newrepublic.com/article/113257/low-wage-employers-try-avoid-obamacare-mandate |title=Weaseling Out of Obamacare |last=Cohn |first=Jonathan |date=May 21, 2013 |magazine=The New Republic}}</ref>

<ref name="IRSBusinessSubsidy">{{cite web |url=https://www.irs.gov/affordable-care-act/employers/small-business-health-care-tax-credit-and-the-shop-marketplace |title=Small Business Health Care Tax Credit and the SHOP Marketplace |date=October 20, 2016 |publisher=Internal Revenue Service |access-date=January 11, 2017}}</ref>

<ref name="KaiserExchangesNotes">{{cite web |url=http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#notes |title=State Decisions For Creating Health Insurance Exchanges, as of May 28, 2013 – Notes |date=May 28, 2013 |publisher=Kaiser Family Foundation}}</ref>

<ref name="KaiserEHB">{{cite web |url=http://kff.org/health-reform/perspective/questions-about-essential-health-benefits |title=Questions About Essential Health Benefits |last1=Levitt |first1=Larry |last2=Claxton |first2=Gary |date=October 18, 2011 |publisher=Kaiser Family |last3=Pollitz |first3=Karen}}</ref>

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<ref name="KaiserMedicaid">{{cite web |title=Status of State Medicaid Expansion Decisions: Interactive Map |url=https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ |publisher=KFF |date=July 27, 2023}}</ref-->

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<ref name="kaiserhealthnews1993">{{cite web |url=http://www.kaiserhealthnews.org/Graphics/2010/022310-Bill-comparison.aspx |title=Chart: Comparing Health Reform Bills: Democrats and Republicans 2009, Republicans 1993 |publisher=Kaiser Health News |date=February 23, 2010 |access-date=July 29, 2012}}<br />{{cite web |url=http://www.kaiserhealthnews.org/Stories/2010/February/23/GOP-1993-health-reform-bill.aspx |title=Summary Of A 1993 Republican Health Reform Plan |publisher=Kaiser Health News |date=February 23, 2010 |access-date=July 29, 2012}}</ref>

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

}}

==Further reading==

* {{cite book |last=Barr |first=Donald A. |title=Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America |url={{google books |plainurl=y |id=yZLJrmNoEzkC}} |year=2011 |publisher=JHU Press |isbn=978-1-4214-0218-5}}
* {{cite journal |publisher=University of Chicago Press |last1=Bossaler |first1=Jenny S. |title=Access to affordable care through public libraries |journal=The Library Quarterly |date=April 2016 |volume=86 |issue=2 |pages=193–212 |issn=0024-2519| jstor=26561661 |oclc=01755858 |doi=10.1086/685400|s2cid=147627006 }}
* {{cite book |title=CCH's Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact |location=Chicago, IL |publisher=Wolters Kluwer Law & Business |url={{google books |plainurl=y |id=tCTt0sq2vaEC}} |year=2010 |isbn=978-0-8080-2287-9}} Two volumes: This book contains an editorially enhanced version of the Patient Protection and Affordable Care Act that integrates in place changes made to it by the Reconciliation Act of 2010. ... A website, www.mediregs.com/cchhealthreform, has been created to expand access to key legislative materials.
* {{cite journal |last1=Fang |first1=Hanming |last2=Krueger |first2=Dirk |date=2022 |title=The Affordable Care Act After a Decade: Its Impact on the Labor Market and the Macro Economy |doi=10.3386/w29240 |journal=Annual Review of Economics |issn=1941-1391 |lccn=2008214322 |publisher=National Bureau of Economic Research  | location = Cambridge MA |oclc=190859329 |volume=14 |issue=1|doi-access=free }}
* {{cite book |last=Feldman |first=Arthur M. |title=Understanding Health Care Reform: Bridging the Gap Between Myth and Reality |url={{google books |plainurl=y |id=dSszUQPKSZIC}} | archive-url = https://archive.org/details/understandinghea0000feld | archive-date = 2022-06-16  |orig-date=2011 |publisher=CRC Press |year =2012 |isbn=978-1-4398-7948-1}}
* {{cite book |last1=Jacobs |first1=Lawrence R. |first2=Theda |last2=Skocpol |title=Health Care Reform and American Politics |url={{google books |plainurl=y |id=VcsmJybD32wC}} |year=2010 |publisher=Oxford University Press |isbn=978-0-19-978142-3}}
* {{cite book |first=John E. |last=McDonough |title=Inside National Health Reform |url={{google books |plainurl=y |id=e1Z6D-K9Rx8C}} |publisher=University of California Press |date=August 2, 2011 |isbn=978-0-520-27019-0}}
* {{cite book |last=Brill |first=Steven |title=America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System |url={{google books |plainurl=y |id=hnAOBAAAQBAJ}} |publisher=Random House |date=January 5, 2015 |isbn=978-0-8129-9695-1}}
* {{cite web |url=http://cbo.gov/publication/43471 |title=Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act |website=United States. Congressional Budget Office |date=July 24, 2012 |archive-url=https://web.archive.org/web/20120727001632/http://cbo.gov/publication/43471 |format=Cost estimate |archive-date=July 27, 2012 |access-date=July 27, 2012}}
* {{cite web |first=Douglas W. |last=Elmendorf |url=http://www.cbo.gov/doc.cfm?index=10781&type=1 |title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act |website=United States. Congressional Budget Office |archive-url=https://web.archive.org/web/20091205173644/http://www.cbo.gov/ftpdocs/107xx/doc10781/11-30-Premiums.pdf |archive-date=December 5, 2009 |date=November 30, 2009 |access-date=June 29, 2012}}
* {{cite web |url=http://cbo.gov/publication/41472 |title=Analysis Of A Permanent Prohibition On Implementing The Major Health Care Legislation Enacted In March 2010 |website=United States. Congressional Budget Office |archive-url=https://web.archive.org/web/20120303101517/http://cbo.gov/publication/41472 |archive-date=March 3, 2012 |date=May 26, 2011 |access-date=April 1, 2012}}
* {{cite journal |url=http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2013/dec/1718_glied_how_states_stand_gain_lose_medicaid_expansion_ib_v2.pdf |title=How States Stand to Gain or Lose Federal Funds by Opting In or Out of the Medicaid Expansion |date=December 2013 |publisher=The Commonwealth Fund |author1=Glied, Sherry |author2=Ma, Stephanie |journal=Issue Brief |volume=32 |pages=1–12 |pmid=24344468 |access-date=February 20, 2016}}
* {{cite journal |title=Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act |journal=Health Affairs |author=Jost, Timothy |date=February 24, 2014 |publisher=Project HOPE |location=Washington, DC |issn=1544-5208 |oclc=07760874 |doi=10.1377/forefront.20140224.037390}}
* {{cite web |title=Multi-state plans under the Affordable Care Act |author1=Riley, Trish |author2=Thorpe, Jane Hyatt |date=2012 |location=The George Washington University |publisher=School of Public Health and Health Services |work=Department of Health Policy |url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130626114302/http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |archive-date=June 26, 2013 }}
* {{cite web |title=Following The Affordable Care Act |website=Health Affairs |oclc=07760874 |issn=1544-5208 |url=https://www.healthaffairs.org/topic/bms010 |access-date=August 10, 2019}}
* {{cite web |title=Pre-Affordable Care Act (2011 Archived) Health Insurance Consumer Guides for the Fifty States From Georgetown University Health Policy Institute (Can be used to explore the pre-ACA health insurance system) |url=http://www.healthinsuranceinfo.net/guides_map.htm#altList |archive-url=https://web.archive.org/web/20110429193146/http://www.healthinsuranceinfo.net/guides_map.htm#altList |archive-date=April 29, 2011 |access-date=Apr 29, 2011}}
* {{cite book |last=Mettler |first=Suzanne |year= 2011 |title=The Submerged State: How Invisible Government Policies Undermine American Democracy |publisher=University of Chicago Press |isbn=9780226521664 |oclc=928901062}}
* {{cite web |last1=Mettler |first1=Suzanne |others = Society Pages |date=April 17, 2012|title=The Submerged State  |website = Office Hours podcast   |  url = https://archive.org/details/podcast_office-hours_suzanne-mettler-on-the-submerg_1000365943260  |  quote = Identifier 1000365943260}}
* {{cite journal |last1=Jacobs |first1=Lawrence R. |last2=Mettler |first2=Suzanne |date=2020 |title=What Health Reform Tells Us about American Politics |journal=Journal of Health Politics, Policy and Law |volume=45 |issue=4 |pages=581–593 |issn=0361-6878 |lccn=76646971 |oclc=2115780 |pmid=32186336 |doi=10.1215/03616878-8255505|s2cid=212752729 }}

===Preliminary CBO documents===

* [http://www.cbo.gov/doc.cfm?index=10868 Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment]. United States. Congressional Budget Office December 19, 2009. (Cost estimate)
** Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
** Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
* [http://cbo.gov/doc.cfm?index=10731 Base Analysis—H.R. 3590, Patient Protection and Affordable Care Act], United States. Congressional Budget Office. November 18, 2009. (Cost estimate)<br /><small>(The additional and/or related CBO reporting that follows can be accessed from the above link)</small>
** Estimated Distribution Of Individual Mandate Penalties (November 20, 2009)
** Estimated Effects On Medicare Advantage Enrollment And Benefits Not Covered By Medicare (November 21, 2009)
** Estimated Effects On The Status Of The Hospital Insurance Trust Fund (November 21, 2009)
** Estimated Average Premiums Under Current Law (December 5, 2009)
** Additional Information About Employment-Based Coverage (December 7, 2009)
** Budgetary Treatment Of Proposals To Regulate Medical Loss Ratios (December 13, 2009)

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

* [https://www.cms.gov/ActuarialStudies/downloads/PPACA_2010-04-22.pdf Estimated Financial Effects of the "Patient Protection and Affordable Care Act", as Amended]. April 22, 2010.
* [https://www.cms.gov/ActuarialStudies/Downloads/PPACA_Medicare_2010-04-22.pdf Estimated Effects of the "Patient Protection and Affordable Care Act", as Amended, on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts]. April 22, 2010.

===CMS Estimates of the impact of H.R. 3590===

* [http://www.cms.gov/ActuarialStudies/Downloads/S_PPACA_2009-12-10.pdf Estimated Financial Effects of the "Patient Protection and Affordable Care Act of 2009", as Proposed by the Senate Majority Leader on November 18, 2009]. December 10, 2009.
* [http://www.cms.gov/ActuarialStudies/Downloads/S_PPACA_Medicare_2009-12-10.pdf Estimated Effects of the "Patient Protection and Affordable Care Act" on the Year of Exhaustion for the Part A Trust Fund, Part B Premiums, and Part A and Part B Coinsurance Amounts]. December 10, 2009.

===Senate Finance Committee meetings===

[https://archive.today/20120802043711/http://www.c-spanvideo.org/videoLibrary/search-results.php?organization=%22Finance%22&organization=%22Senate+Committee%22&date-from=01/06/2009&date-to=01/02/2011 Senate Finance Committee Hearings for the 111th Congress recorded by C-SPAN]; also available from [https://web.archive.org/web/20130111185729/http://www.finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 Finance.Senate.Gov (accessed April 1, 2012).]

==External links==

===ACA text===

* [https://www.govinfo.gov/content/pkg/COMPS-9307/uslm/COMPS-9307.xml Patient Protection and Affordable Care Act] as amended ([https://www.govinfo.gov/content/pkg/COMPS-9307/pdf/COMPS-9307.pdf PDF]/[https://www.govinfo.gov/app/details/COMPS-9307/ details]) in the GPO [https://www.govinfo.gov/help/comps Statute Compilations collection]
* [http://dpc.senate.gov/dpcissue-sen_health_care_bill.cfm Full text, summary, background, provisions and more], via Democratic Policy Committee (Senate.gov)



[[Category:Excises]]

{{Sourceattribution|Affordable Care Act}}