View source for Finance:Patient Protection and Affordable Care Act

{{short description|Obamacare, ACA - U.S. federal statute}}
{{pp-semi-indef|small=yes}}
{{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 eliminated 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/03590/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 />Public Law 115-97 proposed as the Tax Cuts and Jobs Act of 2017
| SCOTUS cases = ''National Federation of Independent Business v. Sebelius''<br />''Burwell v. Hobby Lobby''<br />''King v. Burwell''
| name = Patient Protection and Affordable Care Act
| fullname = The Patient Protection and Affordable Care Act
| acronym = PPACA, ACA
| nickname = Obamacare, Affordable Care Act, Health Insurance Reform, Healthcare Reform
| acts amended = 
| title amended = 
| sections created = 
| sections amended = 
| unsignedpresident = 
| vetoedpresident = 
}}
The '''Patient Protection and Affordable Care Act''', also known as the '''Affordable Care Act''' ('''ACA''') or colloquially as '''Obamacare''', is a United States 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 passage of Medicare and Medicaid in 1965.<ref name="Oberlander2010" /><ref name="Blumenthal2015" /><ref name="CohenEtAl" /><ref name="ReutersSCOTUS" />

PPACA'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|title=Health Insurance Coverage and the Affordable Care Act, 2010–2016|accessdate=December 7, 2016|date=March 2, 2016}}</ref> The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After the law 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|accessdate=November 19, 2016}}</ref>

The increased coverage was due, roughly equally, to an [[Finance:Patient Protection and Affordable Care Act#Medicaid expansion 2|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]] reports said that overall these provisions reduced the budget deficit, that repealing PPACA 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 |accessdate=July 23, 2017 |doi=10.17310/ntj.2011.3.06|hdl=1721.1/72971}}</ref> Insurers were made to accept all applicants without charging based on pre-existing 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 fine/tax) and that insurers cover a list of "essential health benefits". 

Before and after enactment PPACA 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 PPACA's Medicaid expansion, although it upheld the law as a whole.<ref name="NatLawReview2012" /> The federal health 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 |accessdate=July 23, 2017 |date=December 1, 2016}}</ref> and the law gained majority support by 2017.<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 |accessdate=November 18, 2017 |work=The Hill |language=en}}</ref>

==Specific 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.]]

PPACA 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 |date=June 1, 2010 |volume=29 |issue=6 |pages=1112–1116 |doi=10.1377/hlthaff.2010.0447 |pmid=20530339 |language=en |issn=0278-2715 }}</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 |issn=0028-4793|url=https://semanticscholar.org/paper/2b0dcda73ff2a1903393ac3ac038a6033eba8aea }}</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=9780190231569 |url=https://books.google.com/books?id=H9DGBwAAQBAJ |language=en}}</ref><ref>{{cite news |last1=Stolberg |first1=Sheryl Gay |last2=Pear |first2=Robert |title=Obama Signs Health Care Overhaul Into Law |url=https://www.nytimes.com/2010/03/24/health/policy/24health.html |work=The New York Times |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=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|language=en|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 pre-existing conditions. 
* States were required to ensure the availability of insurance for individual children who did not have coverage via their families.
* A partial community rating allows premiums to vary only by age and location, regardless of preexisting conditions. Premiums for older applicants can be no more than three times those for the youngest.<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]]}}</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=Usa|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|language=en-us|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" />
* Insurers are forbidden from dropping policyholders when they become ill.<ref name="Top 18" />
* 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 the 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 |publisher=HealthCare.Gov, managed by 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 |title=Common Sense |last=Cohn |first=Jonathan |date=April 9, 2010 |work=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? |last=Cohn |first=Jonathan |date=April 2, 2012 |work=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? |last=Cohn |first=Jonathan |date=December 26, 2011 |work=The New Republic}}</ref> 

Among the groups who were not subject to the individual mandate are:
* Illegal immigrants, estimated at around 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 and are exempt from the penalty.<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|accessdate=December 21, 2017|publisher=Fox News}}</ref> reduced to 0 the fine/tax for violating the individual mandate, starting in 2019.<ref name="auto">{{Cite web|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}}</ref>

===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]] applied towards premiums for policies purchased via a PPACA exchange, provided they are not eligible for Medicare, Medicaid, the Children's Health Insurance Program, or other forms of public assistance health coverage, and provided they 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. Lawfully 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 name="KaiserFamily" />) Married individuals must file taxes jointly in order to receive subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.

The subsidies for an PPACA 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?|last=Fehr|first=Rachel|last2=Mar 05|first2=Gary Claxton Published|date=March 5, 2019|website=The Henry J. Kaiser Family Foundation|language=en-US|access-date=October 2, 2019|last3=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|last=Nov 20|first=Published|last2=2018|date=November 20, 2018|website=The Henry J. Kaiser Family Foundation|language=en-us|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 towards 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 [[Finance:Adjusted gross income|Modified 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|last=Research|first=UC Berkeley Center for Labor|last2=Education|date=July 1, 2014|website=Center for Labor Research and Education|language=en-US|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 4<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|last=Nov 20|first=Published|last2=2018|date=November 20, 2018|website=The Henry J. Kaiser Family Foundation|language=en-us|access-date=August 10, 2019}}</ref>
|-
! 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
(Second Lowest Cost Silver Plan)
! Out-of-pocket Max
|-
| 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>
|}

===Exchanges===

PPACA 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}}</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 gives them 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" />

===Cost-sharing reduction subsidies===


As written PPACA mandated that insurers reduce copayments and deductibles for PPACA 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"]. Center on Budget and Policy Priorities. September 14, 2017.</ref> 

The latter were 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.

===Risk management===

PPACA 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 |accessdate=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 PPACA insurance market from 2014–2016. For those years the Department of Health and Human Services (DHHS) 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 |work=Forbes |url=https://www.forbes.com/.../yes-marco-rubio-led-the-effort-to-end-obamacares-health-insuran... |date=December 15, 2015 |accessdate=February 10, 2017}}</ref> 

Many insurers initially offered exchange plans. However, 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 |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">{{citation |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 |publisher=LA Times |date=February 10, 2017 |accessdate=February 10, 2017 |author=Michael Hiltzik}}</ref><ref name="latimes_GOP_ACA_corridor" />

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 |accessdate=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|language=en|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 people 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|last=Semanskee|first=Ashley|last2=Claxton|first2=Gary|date=August 17, 2016|website=The Henry J. Kaiser Family Foundation|language=en-US|access-date=November 28, 2019|last3=2016}}</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===

PPACA 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, D.C. |publisher=U.S. Department of Health & Human Services |url=https://www.hhs.gov/news/press/2013pres/03/20130329a.html |accessdate=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.}}<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 | url=https://www.hhs.gov/news/press/2013pres/03/20130329a.html | title=Archive-It - News Releases}}</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 PPACA was coercive, and that states could choose to continue at pre-PPACA 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 journal |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 |publisher=Government Accountability Office |date=February 8, 2008 |accessdate=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 PPACA'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====

PPACA includes 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 web |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}}</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. 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 web |url=http://www.taxpolicycenter.org/briefing-book/what-are-major-federal-excise-taxes-and-how-much-money-do-they-raise |title=Briefing Book|publisher=Tax Policy Center}}</ref>

===SCHIP===

The State Children's Health Insurance Program (CHIP) enrollment process was simplified.<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://www.whitehouse.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf |title=Young Adults and the Affordable Care Act |url-status=dead |archiveurl=https://web.archive.org/web/20161111074656/https://www.whitehouse.gov/sites/default/files/rss_viewer/fact_sheet_young_adults_may10.pdf |archivedate=November 11, 2016 }}</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 |url=http://www.medscape.com/viewarticle/748502 |title=Access |website=Medscape |accessdate=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 |accessdate=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 |accessdate=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>https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html</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/ |title=Accountable Care Organizations, Explained |last= |first= |date=September 14, 2015 |website= |publisher=Kaiser Health News |language=en-US |accessdate=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 web |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 |website=Washington Post |accessdate=August 7, 2016}}</ref> By 2020, the "doughnut hole" would be completely filled.<ref>{{cite web |url=http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf |title=Closing the Coverage Gap – Medicare Prescription Drugs Are Becoming More Affordable |date=January 2015 |publisher=CMS |url-status=dead |archiveurl=https://web.archive.org/web/20130523191556/http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf |archivedate=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 PPACA, covers at least as many residents and does not increase the federal deficit.<ref name="StateWaiverConditions" /> These states can escape some of PPACA'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 PPACA, 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|url=https://www.nytimes.com/2010/03/30/health/30care.html|title=Options Expand for Affordable Long-Term Care|last=Span|first=Paula|date=March 29, 2010|newspaper={{wipe|The New York Times}}|accessdate=March 29, 2010}}</ref><ref name="multiple2" /><ref>Carney, Timothy (February 28, 2011) [http://washingtonexaminer.com/blogs/beltway-confidential/2011/02/so-yeah-health-care-bill-was-really-awful-piece-legislation-sent- So, yeah, the health-care bill was really an awful piece of legislation that sent the revolving door spinning faster]{{dead link|date=November 2017 |bot=InternetArchiveBot |fix-attempted=yes}}, ''Washington Examiner''</ref> The program was abolished as impractical without ever having taken effect.<ref>{{cite web|url=http://www.lifehealthpro.com/2013/01/02/watchdogs-class-still-dead|title=Watchdogs: CLASS still dead|date=January 2, 2013|publisher=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|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|website=FierceHealthcare|language=en|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|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.]]

PPACA 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 accounts]], which increased insurance options, but did not materially expand coverage. Health care was a major factor in multiple elections, but until 2009, neither party had the votes to overcome the other's opposition.

===Individual mandate===

The concept of an individual mandate goes back to at least 1989, when the conservative [[Organization:The Heritage Foundation|The Heritage Foundation]] 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}}</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><cite class="citation news">Cooper, Michael (February 14, 2012). [https://www.nytimes.com/2012/02/15/health/policy/health-care-mandate-was-first-backed-by-conservatives.html "Conservatives Sowed Idea of Health Care Mandate, Only to Spurn It Later"]. ''{{wipe|The New York Times}}''<span class="reference-accessdate">. Retrieved <span class="nowrap">July 2,</span> 2012</span>.</cite></ref> that ultimately failed.<ref><cite class="citation news">Cohn, Bob; Clift, Eleanor (September 18, 1994). [http://www.newsweek.com/lost-chance-188330 "The Lost Chance"]. ''Newsweek''<span class="reference-accessdate">. Retrieved <span class="nowrap">July 2,</span> 2012</span>.</cite></ref> Clinton negotiated a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997.<ref>{{cite news|url=http://www.newsmax.com/insidecover/hillary_health_care/2007/10/05/38601.html|title=Hillary Claims Credit for Child Program|last=Fouhy|first=Beth|date=October 5, 2007|archiveurl=https://web.archive.org/web/20080123174618/http://www.newsmax.com/insidecover/hillary_health_care/2007/10/05/38601.html|archivedate=January 23, 2008|agency=Associated Press for NewsMax}}</ref> 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 web |url=https://www.npr.org/2012/03/31/149767150/in-1993-republicans-proposed-a-mandate-first |title=In 1993, Republicans Proposed A Mandate First |publisher=NPR |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 |url=http://www.coloradostatesman.com/content/991732-ag-suthers-couldn%3Ft-be-more-wrong-his-decision-file-lawsuit |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 |url-status=dead |archive-date=April 18, 2010 |title=AG Suthers couldn't be more wrong in his decision to file lawsuit |newspaper=Colorado Statesman |accessdate=July 29, 2012}}</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?_r=2&adxnnl=1&adxnnlx=1333652503-360xnkv/rpzNURZGZh5Vdw |work=The New York Times |title=G.O.P. and Health Mandate |date=February 26, 2012}}</ref> At the time of these proposals, Republicans did not raise constitutional issues; 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 |url=https://www.bloomberg.com/news/2012-03-26/romneycare-s-98-success-rate-defies-gripes-on-obama-law.html |publisher=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 |accessdate=September 23, 2013}}</ref>

===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 |accessdate=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 journal |last=Rustgi |first=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 |url=http://www.commonwealthfund.org/publications/fund-reports/2008/oct/the-2008-presidential-candidates-health-reform-proposals--choices-for-america |language=en}}</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 |accessdate=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=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 |accessdate=April 1, 2012 |url-status=dead |archiveurl=https://web.archive.org/web/20130111185729/http://www.finance.senate.gov/hearings/index.cfm?PageNum_rs=1&maxrows=100 |archivedate=January 11, 2013}}</ref>

Congressional Democrats and health policy experts 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 |work=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 |work=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 |work=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 |first=Joe |last=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 |accessdate=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 |work=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=The Huffington Post |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 |accessdate=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 |work=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. 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 |work=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) |work=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 |work=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|accessdate=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 |accessdate=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 Edward 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 |accessdate=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 |accessdate=April 9, 2012}}</ref> His victory was significant because of its effects on the legislative process. The first was psychological: the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of 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}}</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)}}]]

Brown's election meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing it 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 |accessdate=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 PPACA 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}}</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 |work=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 |work=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" /> The next day, Republicans introduced legislation to repeal the bill.<ref name="PelosiSawyer" /> Obama signed PPACA into law on March 23, 2010.<ref>{{Cite news |title=Obama Signs Health Care Overhaul Bill, With a Flourish |first=Sheryl |last=Stolberg |first2=Robert |last2=Pear |url=https://www.nytimes.com/2010/03/24/health/policy/24health.html |newspaper=The New York Times |date=March 23, 2010 |accessdate=March 24, 2010}}</ref>

===Post-enactment===

Since passage, Republicans have voted to repeal all or parts of the Affordable Care Act more than sixty times; none have been successful.<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>{{Cite web|url=https://www.forbes.com/sites/kellyphillipserb/2019/12/20/congress-passes-bill-chock-full-of-extenders-healthcare-tax-repeal--retirement-plan-tweaks/|title=Congress Passes Bill Chock-Full Of Extenders, Healthcare Tax Repeal & Retirement Plan Tweaks|last=Erb|first=Kelly Phillips|date=December 20, 2019|website=Forbes|language=en|access-date=December 23, 2019}}</ref>

==Impact==

[[File:Health Insurance Coverage in the U.S. 2016 - v1.png|thumb|right|upright=2.05|U.S. health insurance coverage by source in 2016. CBO estimated PPACA/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=2.05|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 |accessdate=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/ |accessdate=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 PPACA'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=CBO |accessdate=November 23, 2016}}</ref> CBO estimated that PPACA would reduce the net number of uninsured by 22 million in 2016, using a slightly different computation for the above figures totaling PPACA 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 PPACA 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 |accessdate=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 |accessdate=December 5, 2016}}</ref> As of December 2016 32 states (including Washington DC) had adopted the Medicaid extension.<ref name="KFF_States">{{Cite web |url=http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/ |title=Current Status of State Medicaid Expansion Decisions |accessdate=December 5, 2016}}</ref>

A 2017 study found that the ACA reduced socioeconomic disparities in health care access.<ref>{{Cite journal|last=Griffith|first=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|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/ |accessdate=March 31, 2020 |publisher=USA Today |date=March 23, 2020 |archiveurl=https://web.archive.org/web/20200331233236/https://www.usatoday.com/story/opinion/2020/03/23/obamacare-10th-anniversary-amid-coronavirus-column/2888511001/ |archivedate=March 31, 2020}}</ref><ref name=NYT20200323GoodnoughAbelsonetAl>{{cite news |author1=Abby Goodnough, Reed Abelson, Margot Sanger-Katz and Sarah Kliff |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|accessdate=March 31, 2020 |date=March 23, 2020 |archiveurl=https://web.archive.org/web/20200330105840/https://www.nytimes.com/2020/03/23/health/obamacare-aca-coverage-cost-history.html |archivedate=March 30, 2020|publisher=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|frameless|right|450px|Excise taxes percentage 2015]]

Excise taxes from the [[Finance:Affordable Care Act|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 reduced to 0 at the end of 2018.<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 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>

PPACA reduced income inequality measured after taxes, due to the income tax surcharges and subsidies.<ref>{{Cite web|url=https://www.whitehouse.gov/sites/default/files/page/files/20160923_record_inequality_cea.pdf|title=The Economic Record of the Obama Administration: Progress Reducing Inequality|website=Whitehouse.gov|url-status=dead|archiveurl=https://web.archive.org/web/20161126124328/https://www.whitehouse.gov/sites/default/files/page/files/20160923_record_inequality_cea.pdf|archivedate=November 26, 2016|accessdate=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|language=en|access-date=November 29, 2019}}</ref>

===Medicaid expansion===

[[File:ACA Medicaid expansion by state.svg|thumb|upright=1.35|Medicaid expansion by state, as of July 1, 2020<ref name="KaiserMedicaid" />
{{legend|#232|Adopted the Medicaid expansion}}
{{legend|#898|Medicaid expansion under discussion}}
{{legend|#C8C8C8|Not adopting Medicaid expansion}}]]
[[File:Uninsured Rate Comparing Medicaid Expansion States vs. Non Expansion.png|thumb|upright=1.35|States that expanded Medicaid under PPACA had a lower uninsured rate in 2018 at various income levels.<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>]]

As of December 2019, 37 states (including Washington DC) had adopted the Medicaid extension.<ref name="KFF_States" /> 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 PPACA, 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.<ref name=":10" /> 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 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 Adultsin 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 able-bodied adults with children and with an income below 32% of the poverty line were eligible for Medicaid, those with incomes from 32% to 100% of the poverty level ($6,250 to $19,530 for a family of three) were ineligible for both Medicaid and federal subsidies to buy insurance. Absent children, able-bodied adults were not eligible for Medicaid 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 |work=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 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 news |title=Wonkbook: The terrible deal for states rejecting Medicaid |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/06/04/wonkbook-the-terrible-deal-for-states-rejecting-medicaid |date=June 4, 2013 |newspaper=The Washington Post |author1=Evan 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>{{Cite web |url=https://www.newscientist.com/article/2100311-obamacare-has-already-improved-health-of-low-income-americans |title=Obamacare has already improved health of low-income Americans |last=Rutkin |first=Aviva |date= |website= |language=en-US |accessdate=August 15, 2016}}</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>{{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 {{!}} News {{!}} Harvard T.H. Chan School of Public Health|website=www.hsph.harvard.edu|accessdate=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=The New York Times |issn=0362-4331 |accessdate=September 4, 2016}}</ref>

The Census Bureau reported in September 2019 that states that expanded Medicaid under PPACA 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" />

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|last=Miller|first=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}}</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>Matt Broaddus, Aviva Aron-Dine, "[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, November 6, 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 />

===Insurance costs===

[[File:US healthcare cost panel v1.png|thumb|upright=2.05|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%) PPACA's major provisions took effect.<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=Mali |first=Meghashyam |date=August 11, 2016 |accessdate=August 15, 2016}}</ref> However, some or all these costs were offset by tax credits. For example, the Kaiser 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 |url=http://kff.org/health-reform/issue-brief/2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/ |title=2017 Premium Changes and Insurer Participation in the Affordable Care Act's Health Insurance Marketplaces |website=Kaiser Family Foundation |accessdate=November 23, 2016|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|accessdate=November 23, 2016}}</ref> From 2008 to 2010 (before passage of PPACA) 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}}</ref><ref>{{cite news |title=Health Cost Growth Slows Further Even as Economy Rebounds |publisher=Bloomberg L.P. |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 = | 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 PPACA 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 web |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 |last=Johnson |first=Carolyn Y. |date=September 14, 2016 |website=Washington Post |accessdate=September 14, 2016}}</ref>

For the non-group market, of which two-thirds are covered by PPACA 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 PPACA 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 |accessdate=September 14, 2016}}</ref>

===Health outcomes===

According to a 2014 study, PPACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.<ref>{{Cite web |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 |website=Washington Post |accessdate=November 10, 2016}}</ref> Himmelstein and Woolhandler wrote in January 2017 that a rollback of PPACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.<ref>{{Cite web |url=https://www.washingtonpost.com/posteverything/wp/2017/01/23/repealing-the-affordable-care-act-will-kill-more-than-43000-people-annually/ |title=Repealing the Affordable Care Act will kill more than 43,000 people annually |website=Washington Post|access-date=January 23, 2017}}</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/|title=The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid|date=March 21, 2019}}</ref> A study by the [[Organization:National Bureau of Economic Research|National Bureau of Economic Research]] 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>Bureau of Economic Research, August 2019, [https://www.nber.org/papers/w26081 "Medicaid and Mortality: New Evidence from Linked Survey and Administrative Data"]</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>

Two 2018 ''JAMA'' studies found the Hospital Readmissions Reduction Program was associated with increased post-discharge mortality for patients hospitalized for heart failure and pneumonia.<ref>{{Cite journal|last=Fonarow|first=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|language=en|volume=3|issue=1|pages=44–53|doi=10.1001/jamacardio.2017.4265|pmid=29128869|pmc=5833526|issn=2380-6583}}</ref><ref>{{Cite journal|last=Yeh|first=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|language=en|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|language=en-US|access-date=June 6, 2019}}</ref> A 2019 ''JAMA'' study found that PPACA decreased emergency department and hospital use by uninsured individuals.<ref>{{Cite journal|last=Pines|first=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|language=en|volume=2|issue=4|pages=e192662|doi=10.1001/jamanetworkopen.2019.2662|pmid=31002327|pmc=6481443}}</ref> A 2019 paper by Treasury Department economists using a [[Randomized controlled trial|randomized controlled trial]] (the IRS sent letters to some taxpayers noting that had paid a fine for not signing up for health insurance but not to other taxpayers) found that over the span of 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=The New York Times|access-date=December 20, 2019|language=en-US|issn=0362-4331}}</ref><ref>{{Cite journal|last=Goldin|first=Jacob|last2=Lurie|first2=Ithai Z|last3=McCubbin|first3=Janet|date=2019|title=Health Insurance and Mortality: Experimental Evidence from Taxpayer Outreach|url=http://www.nber.org/papers/w26533|journal=|volume=|pages=|via=}}</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|last=Blanc|first=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|url=https://jamanetwork.com/journals/jamasurgery/fullarticle/2767686|journal=JAMA Surgery|language=en|doi=10.1001/jamasurg.2020.1495}}</ref>

===Distributional impact===

[[File:1b-ACA Distribution in 2014.png|thumb|right|upright=2.05|The distributional impact of the Affordable Care Act (ACA or Obamacare) during 2014. PPACA 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 PPACA 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=www.cbo.gov}}</ref>

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


The CBO reported in multiple studies that PPACA 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" /> 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=http://money.cnn.com/2012/03/13/news/economy/health-reform-costs |title=Health reform coverage cost falls slightly |publisher=CNN |date=March 13, 2012 |accessdate=June 29, 2012}}</ref>

The CBO in June 2015 forecast that repeal of PPACA 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 PPACA 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 |accessdate=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|language=en|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 |accessdate=April 1, 2012 |url-status=dead |archiveurl=https://archive.today/20120717095633/http://washingtonexaminer.com/opinion/op-eds/2010/06/sen-tom-coburn-obamacare-pr-campaign-anchored-spin-not-reality/32134 |archivedate=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 |accessdate=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 PPACA.<ref>{{cite web |url=http://www.cbo.gov/ftpdocs/113xx/doc11376/RyanLtrhr4872.pdf |title=Responses to Questions About CBO's Preliminary Estimate of the Direct Spending and Revenue Effects of H.R. 4872, the Reconciliation Act of 2010 |publisher=Congressional Budget Office |date=March 19, 2010 |accessdate=April 1, 2012}}</ref><ref>{{cite 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 |work=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|accessdate=March 28, 2010|date=December 4, 2009}}</ref><ref>{{cite news|url=http://voices.washingtonpost.com/ezra-klein/2009/12/can_congress_cut_medicare_cost.html|title=Can Congress cut Medicare costs?|work=The Washington Post|accessdate=March 28, 2010}}</ref> The doc fix became obsolete in 2015 when the savings provision was eliminated, permanently removing that spending restraint.<ref>Ezra Klein (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?]" ''The Washington Post'' 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=Uwe Reinhardt |newspaper=The New York Times |date=March 24, 2010 |url=https://economix.blogs.nytimes.com/2010/03/24/wrapping-your-head-around-the-health-bill |accessdate=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=The New York Times |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===

{{Details|topic=health insurance mandates|Health insurance mandate}}

The employer mandate applies to employers of more than fifty where health insurance is provided only to the full-time workers.<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=Forbes |accessdate=November 11, 2014}}</ref> A 2016 study found only limited evidence that PPACA 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}}<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 |archiveurl=https://web.archive.org/web/20140715044934/http://wonkwire.rollcall.com/2013/09/04/stop-blaming-obamacare-part-time-workers/ |archivedate=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 news |author=Timothy Jost |title=Implementing Health Reform: A One-Year Employer Mandate Delay |url=http://healthaffairs.org/blog/2013/07/02/implementing-health-reform-a-one-year-employer-mandate-delay |publisher=Health Affairs |date=July 2, 2013}}</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 |url=http://nymag.com/daily/intelligencer/2013/07/obamacare-haters-struggle-to-get-nonessential.html |work=New York |date=July 3, 2013}}<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 |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>[https://blogs.wsj.com/corporate-intelligence/2013/07/12/union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ "Union Letter: Obamacare Will 'Destroy The Very Health and Wellbeing' of Workers"], ''The Wall Street Journal'', July 12, 2013.</ref>

===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 |last=O'Donnell |first=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=USA Today |accessdate=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 |accessdate=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 |accessdate=May 6, 2015}}</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" />

==Attempted repeals==

The House, led by Republicans, repeatedly voted to repeal PPACA. The Senate, led by Democrats, did not follow suit.

===Economic consequences===

[[File:Obamacare Panel 2.png|thumb|upright=2.05|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 PPACA 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 PPACA's expanded eligibility for Medicaid and subsidies and tax credits that rise with income as disincentives to work, so repealing PPACA 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 PPACA 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|accessdate=August 11, 2016}}</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|title=Is the Affordable Care Act a Hidden Jobs Killer?|website=Center for Economic and Policy Research|publisher=CEPR|accessdate=August 26, 2015}}</ref>

CBO estimated that PPACA 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 PPACA'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 (pre-existing conditions) or opposed (individual mandate). 

In a 2010 [[Opinion poll|poll]], 62% of respondents said they thought PPACA 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|url=https://www.wsj.com/articles/SB10001424052748704784904575111993559174212|title=Why Obama Can't Move the Health-Care Numbers|last1=Rasmussen|first1=Scott|date=March 9, 2010|work=The Wall Street Journal|last2=Schoen|first2=Doug}}</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 pre-existing conditions, 61% favored allowing children to stay on their parents' insurance until age 26, 72% supported requiring companies with more than 50 employees to provide insurance for their employees, and 39% supported the individual mandate to own insurance or pay a penalty. By party affiliation, 19% of Republicans, 27% of Independents, and 59% of Democrats favored the mandate.<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 |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 |work=The Washington Post |author=Ezra Klein |date=June 26, 2012 |accessdate=June 28, 2012}}</ref><ref>{{cite news |author=Greg Sargent |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 Washington Post |date=June 25, 2012 |accessdate=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 Magazine}}</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#.T_m-ZJGmW_J "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 class="citation web">[http://www.realclearpolitics.com/epolls/other/obama_and_democrats_health_care_plan-1130.html#polls "Obama and Democrats' Health Care Plan"]. RealClearPolitics. October 13, 2013<span class="reference-accessdate">. Retrieved <span class="nowrap">March 26,</span> 2014</span>.</cite></ref><ref><cite class="citation news">Swanson, Emily (July 30, 2009). [http://www.huffingtonpost.com/2009/07/30/healthplan_n_725503.html "Health Care Plan: Favor/Oppose"]. ''Pollster.com''.</cite></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=USA Today|accessdate=March 24, 2010}}</ref>

A 2014 poll reported that 26% of Americans support PPACA.<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|accessdate=March 30, 2014|publisher=Associated Press}}</ref> A later 2014 poll reported that 48.9% of respondents had an unfavorable view of PPACA vs. 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|accessdate=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 |url=https://online.wsj.com/news/articles/SB10001424052702303678404579533362696579096 |title=The ObamaCare 8% |newspaper=The Wall Street Journal |date=April 30, 2014 |accessdate=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]", ''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 |publisher=CBS News |accessdate=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 PPACA 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 |publisher=NYT |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 A.C.A. 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|last=Dropp|first=Kyle|date=February 7, 2017|newspaper=The New York Times|access-date=February 8, 2017|last2=Nyhan|first2=Brendan|issn=0362-4331}}</ref> A 2017 study found that personal experience with public health insurance programs led to greater support for the Affordable Care Act, most prominently among Republicans and low-information voters.<ref>{{Cite journal |last=Lerman |first=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 |issn=0022-3816}}</ref>

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

The term "Obamacare" was originally coined by opponents as a pejorative. The term 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" /> 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" /> 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 by opponents.<ref name="NYT20120803" /> Obama 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{{'-}} |publisher=CBS News |date=August 15, 2011 |accessdate=April 28, 2012}}</ref>

===Common misconceptions===

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

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


On August 7, 2009, Sarah Palin pioneered 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 3-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 |first=Jack |last=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 |accessdate=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 |work=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! |work=The New Republic |date=August 13, 2009}}</ref> The provision was not included in PPACA.<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 |first=Christi |last=Parsons |first2=Andrew |last2=Zajac |newspaper=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}}</ref> The allegation was named PolitiFact's "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 |accessdate=November 19, 2010}}</ref> one of FactCheck.org's "whoppers"<ref>{{Cite news |title=False Euthanasia Claims |first=Jess |last=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=Lori Robertson |url=http://www.factcheck.org/2009/12/whoppers-of-2009 |publisher=FactCheck.org |accessdate=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|accessdate=October 8, 2010}}</ref> AARP described such rumors as "rife with gross—and even cruel—distortions".<ref name="snopes1" />

====Members of Congress====

PPACA 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====

PPACA 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 |accessdate=August 19, 2013}}</ref>

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

[[File:County By County Projected Insurer Participation in Health Insurance Exchanges.png|right|400px| ]]

Opponents claimed that combining immediate coverage with no provision for pre-existing conditions would lead people to wait to get insured until they got sick. They individual mandate was designed to push people to get insured without waiting. This 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=Bloomberg}}</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; and 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 PPACA debate Obama said, "If you like your health care plan, you'll be able to keep your health care plan."<ref>{{cite web|url=http://www.whitehouse.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay|title=A Town Hall, and a Health Care Model, in Green Bay|publisher=The White House Blog|url-status=dead|archive-url=https://web.archive.org/web/20131109162556/http://www.whitehouse.gov/blog/A-Town-Hall-and-a-Health-Care-Model-in-Green-Bay/|archive-date=November 9, 2013|accessdate=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|accessdate=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=|publisher=CNN|accessdate=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|accessdate=November 9, 2013}}</ref> 

Poltifact 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|accessdate=April 5, 2018|publisher=Politifact}}</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|accessdate=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|work=[[Finance:The Economist|The Economist]]|accessdate=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|accessdate=November 14, 2013|publisher=McClatchyDC}}</ref> Politifact later scored Obama's claims as the "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|language=en|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="wapo" /><ref name="WSJ" /> 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=The New York Times |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 |work=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 |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=CNBC |accessdate=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 |accessdate=January 25, 2017 |work=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 PPACA "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 PPACA 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 PPACA'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 |accessdate=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 |accessdate=November 28, 2013}}</ref>{{failed verification|reason=Probably want one of the subsidiary pages to this page|date=May 2016}} The Supreme Court ruled 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. PPACA 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 |accessdate=July 2, 2012}}</ref>

====Contraception mandate====


In March 2012, the Roman Catholic Church, while supportive of PPACA'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 |accessdate=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?_r=0 |newspaper=The New York Times |date=May 21, 2012}}</ref>

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' 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 |last1=News |first1=A. B. C. |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 |website=ABC News |accessdate=July 8, 2020 |language=en}}</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 |accessdate=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|url=https://www.commonwealthfund.org/publications/explainer/2017/apr/essential-facts-about-health-reform-alternatives-eliminating-cost|title=Eliminating Cost-Sharing Reductions in ACA|website=www.commonwealthfund.org|language=en|access-date=December 1, 2019}}</ref> Later, President Trump ended the payments. This led to further litigation.<ref name=":3">{{Cite journal|url=https://www.healthaffairs.org/do/10.1377/hblog20190217.755658/full/|title=More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments {{!}} Health Affairs|website=www.healthaffairs.org|language=en|doi=10.1377/hblog20190217.755658|access-date=December 1, 2019}}</ref>

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


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

Without the cost-sharing subsidies, the government estimated that premiums would increase by 20 percent to 30 percent for silver plans.<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 |website= |publisher=Politico |accessdate=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 percent the next year, as opposed to an increase of only 8.8 percent 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 |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> The judge 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 nineteen 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 PPACA was no longer constitutional.<ref>[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 PPACA in court, but seventeen 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, stating 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|url=https://thehill.com/policy/healthcare/421511-federal-judge-in-texas-strikes-down-obamacare|title=Federal judge in Texas strikes down ObamaCare|last=Sullivan|first=Peter|date=December 14, 2018|website=TheHill|language=en|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|website=The Wall Street Journal|access-date=}}</ref> Judge 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 | accessdate = December 14, 2018 | work = 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|work=CNN|accessdate=July 8, 2019}}</ref><ref name="wapost 20181214">{{cite web | 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 | accessdate = December 14, 2018 | work = {{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 | accessdate = December 31, 2018 | work = 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 PPACA was unconstitutional, while the Democratic states were joined by the Democrat-controlled U.S. House of Representatives. In addition to the questions on PPACA, an additional question on [[Social:Standing (law)|standing]] was addressed, as the Republican plaintiffs challenged whether the Democratic states had standing to defend PPACA.<ref>{{cite web | url = https://www.nytimes.com/2019/07/09/health/obamacare-appeals-court.html | title = Obamacare in Jeopardy as Appeals Court Hears Case Backed by Trump | first = Abby | last =Goodnough | date = July 9, 2019 | accessdate = July 9, 2019 | work = {{wipe|The New York Times}}}}</ref><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 | accessdate = July 9, 2019 | work = {{wipe|The New York Times}}}}</ref>

In December 2019, the Fifth Circuit agreed the individual mandate was unconstitutional. It did not, however, 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, but 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 | accessdate = March 2, 2020 | work = {{wipe|The New York Times}} }}</ref> with the ruling likely falling after the 2020 elections.<ref name="ollstein">{{Citation | last = Ollstein | first = 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-o0bamacare-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 pre-existing conditions, and that the Republicans had still not offered any replacement plan—important issues for the 2020 elections.<ref name="ollstein"/>

====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 |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 |work=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 |work=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 |work=The Washington Post |date=August 1, 2013 |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/08/01/inside-the-obamacare-resistance}}</ref>

===Repeal efforts===


PPACA was the subject of many unsuccessful repeal efforts by Republicans in the 111th, 112th, and 113th Congresses: Representatives [[Biography:Steve King|Steve King]] (R-IA) and [[Biography:Michele Bachmann|Michele Bachmann]] (R-MN) introduced bills in the House to repeal PPACA the day after it was signed, as did Senator Jim DeMint (R-SC) in the Senate.<ref>{{cite web |last=O'Brien |first=Michael |url=http://thehill.com/blogs/blog-briefing-room/news/88323-house-and-senate-republicans-quick-to-release-repeal-bills |title=GOP quick to release 'repeal' bills |work=The Hill |date=March 22, 2010 |accessdate=April 1, 2012}}</ref> In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill titled "Repealing the Job-Killing Health Care Law Act" (H.R. 2), which the House passed 245–189.<ref>{{cite web |url=http://thomas.loc.gov/cgi-bin/bdquery/z?d112:HR00002: |title=Bill Summary & Status – 112th Congress (2011–2012) – H.R. 2 |publisher=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 |accessdate=April 1, 2012}}</ref> President Obama said he would veto the bill had 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 |work=Reuters |date=February 3, 2015 |author=Deirdre Walsh |accessdate=February 4, 2015}}</ref>

====2013 federal government shutdown====

Strong partisan disagreement in Congress prevented adjustments to the Act's provisions.<ref name="NYT52613" /> However, at least one change, a proposed repeal of a tax on medical devices, has 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?pagewanted=all&_r=0 |newspaper=The New York Times |date=March 19, 2013}}</ref> Some Congressional Republicans argued against improvements to the law on the grounds they would weaken the arguments for repeal.<ref name="MandateRepeal" /><ref name="ChaitNotCollapsing" />

Republicans attempted to defund its 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 |work=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 the President unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay PPACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership stated the Senate would pass only a bill without any restrictions on PPACA. The government shutdown lasted from October 1–17.<ref>{{cite news |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 |work={{wipe|The Washington Post}} |date=October 1, 2013 |author1=Lori Montgomery |author2=Paul Kane}}<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{{'-}}|work={{wipe|The Washington Post}}|date=September 19, 2013 |author=Blake, Aaron |accessdate=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 |work=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?_r=0 |title=Senate Takes Major Step Toward Repealing Health Care Law |last=Kaplan |first=Thomas |date=January 12, 2017 |work=The New York Times |last2=Pear |first2=Robert|access-date=January 12, 2017 |via=}}</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 |last= |first= |date=January 11, 2017 |work=Fox News Politics|access-date=January 12, 2017 |via=}}</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 |last=Lee |first=MJ |date=January 12, 2017 |work=CNN |last2=Barrett |first2=Ted |last3=LoBianco |first3=Tom|access-date=January 12, 2017 |via=}}</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 |work=NBC News|access-date=January 12, 2017 |via=}}</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 |accessdate=March 7, 2017 |work=Washington Post}}</ref> On March 24 the effort 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|accessdate=March 24, 2017 |newspaper={{wipe|New York Times}} |date=March 24, 2017}}</ref>

On May 4 the House voted to pass the American Health Care Act 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 |accessdate=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 a lack of transparency.<ref>{{cite news |work=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 |first1=Thomas |last1=Kaplan |first2=Robert |last2=Pear |date=June 15, 2017 |url-status=live |archiveurl=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 |archivedate=June 18, 2017 }}</ref><ref>{{cite news |work=Washington Post |title=The remarkable steps Republicans are taking to obscure what's in their health-care bill |first=Philip |last=Bump |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 |archiveurl=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/ |archivedate=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 |archiveurl=https://web.archive.org/web/20170619162148/http://www.nbcnews.com/politics/congress/senate-s-health-care-bill-remains-shrouded-secrecy-n772456 |archivedate=June 19, 2017 }}</ref> On June 22 Republicans released the first discussion draft, which would rename 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 tiebreaking 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 |website=CNN |url-status=live |archiveurl=https://web.archive.org/web/20170725204952/http://www.cnn.com/2017/07/25/politics/senate-health-care-vote/index.html |archivedate=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 PPACA, failed by 49–51, with Collins, Murkowski, and McCain joining all the 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 | access-date = August 3, 2017}}</ref>

===Actions to hinder implementation===

[[File:2-TCJA Number Uninsured v1.png|thumb|right|upright=2.05|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,%20https://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|via=NYTimes.com}}</ref>]]

Under both PPACA (current law) and the AHCA, CBO reported that the health exchange marketplaces would remain stable.<ref name="CBO_Score1" /> However, Republican politicians took a variety of steps to undermine it, creating uncertainty that adversely impacted enrollment and insurer participation while increasing premiums.<ref>{{Cite web|url=https://www.nytimes.com/2017/07/27/opinion/health-care-obamacare.html|title=Opinion &#124; Killing Obamacare Softly|first=Thomas B.|last=Edsall|date=July 27, 2017|via=NYTimes.com}}</ref> Concern of 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 "Sarah Kliff-Trump's stance on insurance 'bailouts' is completely incoherent"] Vox.</ref> The insurers would need to make up the $7 billion they had previously received in 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 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>[https://www.cbo.gov/publication/53009 "The Effects of Terminating Payments for Cost-Sharing Reductions"]. Center on Budget and Policy Priorities. August 15, 2017.</ref> Several insurance companies who sued the United States for failure to pay cost-sharing reduction (CSR) payments won several cases in 2018 & 2019. The Judiciary decided the insurance companies are entitled to unpaid CSR payments.<ref>{{cite news |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/hblog20180906.295628/full/ |accessdate=March 31, 2020 |publisher=Health Affairs |date=September 6, 2018 |archiveurl=https://web.archive.org/web/20190817032812/https://www.healthaffairs.org/do/10.1377/hblog20180906.295628/full/|archivedate=August 17, 2019}}</ref><ref>{{cite news |last1=Keith |first1=Katie |title=More Insurers Win Lawsuits Seeking Cost-Sharing Reduction Payments |url=https://www.healthaffairs.org/do/10.1377/hblog20190217.755658/full/ |accessdate=March 31, 2020 |publisher=Health Affairs |date=February 17, 2019 |archiveurl=https://web.archive.org/web/20200208052713/https://www.healthaffairs.org/do/10.1377/hblog20190217.755658/full/ |archivedate=February 8, 2020}}</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 Rubio.<ref>{{Cite web|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|date=December 9, 2015|via=NYTimes.com}}</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 web|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|website=www.commonwealthfund.org|publisher=Commonwealth Fund|language=en|access-date=December 1, 2019|author=Timothy S. Jost|archive-url=https://web.archive.org/web/20200216164912/https://www.commonwealthfund.org/blog/2019/supreme-court-hear-case-affordable-care-acts-risk-corridors|archive-date=February 16, 2020}}</ref><ref>{{cite news |last1=Galewitz |first1=Phil |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 |accessdate=March 31, 2020 |publisher=National Public Radio |date=December 9, 2010 |archiveurl=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 |archivedate=March 31, 2020}}</ref><ref>{{cite news |author1=Ian 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 |accessdate=March 31, 2020 |publisher=Vox |date=December 10, 2019 |archiveurl=https://web.archive.org/web/20191230061526/https://www.vox.com/2019/12/10/21004821/obamacare-supreme-court-risk-corridors-maine-community |archivedate=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}}</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> CBO said the reductions would reduce PPACA enrollment.<ref name="VoxCBO1" />
* Trump reduced the enrollment period for 2018 by half, to 45 days.<ref>{{Cite web|url=https://www.nytimes.com/2017/11/04/opinion/obamacare-vs-the-saboteurs.html|title=Opinion &#124; Obamacare vs. the Saboteurs|first=The Editorial|last=Board|date=November 4, 2017|via=NYTimes.com}}</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/|title=10 ways the GOP sabotaged Obamacare|date=May 17, 2017|website=healthinsurance.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 pre-existing 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 |accessdate=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 |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 |last=Liptak |first=Adam |date=September 30, 2012 |publisher=Pittsburgh Post-Gazette |work=The New York Times |accessdate=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&nbsp;Decision |last= |first= |date= |website= |publisher=Kaiser Family Foundation |language=en-US |accessdate=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=Forbes |accessdate=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 |url=https://www.nytimes.com/2013/02/03/opinion/sunday/a-cruel-blow-to-american-families.html |title=A Cruel Blow to American Families |date=February 2, 2013 |work=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 |work=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 a disaster due to management and technical failings. HealthCare.gov, the website that offers insurance through the exchanges operated by the federal government, crashed on opening and suffered endless problems.<ref>{{cite news |url=https://www.usatoday.com/story/news/politics/2013/12/01/federalexchangmeetsgoal/3795523/ |title=White House claims success on HealthCare.gov repairs |last=Kennedy |first=Kelly |date=December 1, 2013 |newspaper=USA Today |accessdate=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 |accessdate=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 |last=Holland |first=Steve |date=November 6, 2013 |newspaper=The Christian Science Monitor |last2=Rampton |first2=Roberta |agency=Reuters |accessdate=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 web |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 |accessdate=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 |last= |first= |date=March 11, 2016 |website=cms.gov |accessdate=}}</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 |website= |publisher=Politico |accessdate=August 21, 2016}}</ref> and later until 2022.

An estimated 9 to 10 million people had gained Medicaid coverage in 2016, mostly low-income adults.<ref name=":10" /> The five major national insurers expected to lose money on PPACA 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=Wall Street Journal |issn=0099-9660 |accessdate=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=Wall Street Journal |issn=0099-9660 |accessdate=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=NYT |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 |work= |language=en-US |via=}}</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 |publisher=Congressional Budget Office |date=March 13, 2017}}</ref> In May the House voted to repeal PPACA using the American Health Care Act.<ref>{{cite news |title=House Passes Bill to Repeal Obamacare: Live Updates |url=https://www.wsj.com/livecoverage/house-gop-obamacare-repeal-bill-vote |accessdate=May 5, 2017 |work=WSJ}}</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/ |accessdate=May 5, 2017 |work=WSJ |date=May 5, 2017}}</ref> The individual mandate was repealed starting in 2019 via the Tax Cuts and Jobs Act.<ref name="hatchsays" /> The CBO estimated that the repeal would cause 13 million fewer people to have health insurance in 2027.<ref>{{cite journal|url=http://time.com/money/5043622/gop-tax-reform-bill-individual-mandate/|title=The Senate's Tax Bill Eliminates the Individual Mandate for Health Insurance. Here's What You Need to Know|journal=Money|date=December 2, 2017|first=Elizabeth|last=O'Brien}}</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?_r=0 |title=2 Senators Strike Deal on Health Subsidies That Trump Cut Off |authors=Thomas Kaplan and Robert Pear |date= |work=|access-date=}}</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 |url=https://www.advisory.com/daily-briefing/resources/primers/medicaidmap |title=Where the states stand on Medicaid expansion |website=Advisory.com |date=February 6, 2019}}</ref>

==See also==

* Comparison of the health care 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="NYT20120325">{{cite news |title=Fighting to Control the Meaning of 'Obamacare{{'-}}|url=https://www.nytimes.com/interactive/2012/03/25/us/politics/fighting-to-control-the-meaning-of-obamacare.html |newspaper=The New York Times|date=March 25, 2012|author=Amanda Cox |author2=Alicia Desantis |author3=Jeremy White |accessdate=June 29, 2012}}</ref>

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

<ref name="NYT52413">{{cite news |title=States' Policies on Health Care Exclude Some of the Poorest |url=https://www.nytimes.com/2013/05/25/us/states-policies-on-health-care-exclude-poorest.html |newspaper=The New York Times |date=May 24, 2013 |author=Robert Pear |accessdate=May 25, 2013 |quote=In most cases, [Sandy Praeger, Insurance Commissioner of Kansas], said adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) "will have no assistance".}}</ref>

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<ref name="WaPoWaiverFlexibility">{{cite news |url=https://www.washingtonpost.com/wp-dyn/content/article/2011/02/28/AR2011022806535.html |title=Obama offers states more flexibility in health-care law |last=Goldstein |first=Amy |date=March 1, 2011 |work=The Washington Post |last2=Balz |first2=Dan}}</ref>

<ref name="WashPost-04092010">{{cite news |title=Anger over health-care reform spurs rise in threats against Congress members |first=Sari |last=Horwitz |first2=Ben |last2=Pershing |date=April 9, 2010 |url=https://www.washingtonpost.com/wp-dyn/content/article/2010/04/08/AR2010040805476.html?nav=hcmodule |work={{wipe|The Washington Post}} |accessdate=April 9, 2010}}</ref>

<ref name="WSJ">{{cite news |url=https://blogs.wsj.com/corporate-intelligence/2013/07/12/union-letter-obamacare-will-destroy-the-very-health-and-wellbeing-of-workers/ |title=Union Letter: Obamacare Will 'Destroy The Very Health and Wellbeing' of Workers |newspaper=The Wall Street Journal |date=July 12, 2013 |accessdate=October 7, 2013}}</ref>

<ref name="WSJ-mar25">{{cite news |url=https://www.wsj.com/articles/SB10001424052748703312504575141533342803608 |title=What Health Overhaul Means for Small Businesses |last=McNamara |first=Kristen |date=March 25, 2010 |newspaper=The Wall Street Journal}}</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=9781421402185}}
* {{cite book |author=CCH |title=Law, Explanation and Analysis of the Patient Protection and Affordable Care Act: Including Reconciliation Act Impact |url={{google books |plainurl=y |id=tCTt0sq2vaEC}}|year=2010|publisher=CCH Incorporated|isbn=9780808022879}} 1183pp
* {{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}}|year=2011|publisher=CRC Press|isbn= 9781439879481}}
* {{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 U.P.|isbn=9780199781423}}
* {{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=9780520270190}}
* {{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=978-0812996951}}
* {{Cite news |url=https://www.reuters.com/article/us-usa-healthcare-cbo-idUSTRE71H77N20110218 |title=Repealing healthcare law would cost $210 bln: CBO |date=February 18, 2011 |newspaper=Reuters |last=Heavey |first=Susan |accessdate=August 14, 2016}}
* {{cite web |url=http://cbo.gov/publication/43471 |title=Letter to the Honorable John Boehner providing an estimate for H.R. 6079, the Repeal of Obamacare Act |publisher=Congressional Budget Office |date=July 24, 2012 |accessdate=July 27, 2012}}
* {{cite web |url=http://www.cbo.gov/doc.cfm?index=10781&type=1 |title=An Analysis of Health Insurance Premiums Under the Patient Protection and Affordable Health Care Act |publisher=Cbo.gov |date=November 30, 2009 |accessdate=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 |publisher=Congressional Budget Office |date=May 26, 2011 |accessdate=April 1, 2012}}
* {{cite web |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=Commonwealth Fund |author=Glied, Sherry |accessdate=February 20, 2016}}
* {{cite journal | title=Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act | publisher=Health Affairs |author=Jost, Timothy | date=February 24, 2014 | url=https://www.healthaffairs.org/do/10.1377/hblog20140224.037390/full/ | access-date=August 11, 2019| doi=10.1377/hblog20140224.037390 | doi-broken-date=2020-01-16 }}
* {{cite journal |url=https://www.economist.com/news/business/21613359-american-employers-are-rethinking-their-role-workers-health-care-paternalism-20 |title=Paternalism 2.0 |date=August 23, 2014 |journal=The Economist |accessdate=January 19, 2015}}
* {{cite web |url=http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |title=Multi-State Plans Under the Affordable Care Act |author1=Trish Riley |author2=Jane Hyatt Thorpe |publisher=George Washington University Medical Center, Department of Health Policy |url-status=dead |archiveurl=https://web.archive.org/web/20130626114302/http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_A80A0AAA-5056-9D20-3D25B59C65680B79.pdf |archivedate=June 26, 2013 }}
* {{cite web |title=Beyond the pledges: Where the states stand on Medicaid |url=http://www.advisory.com/Daily-Briefing/Resources/Primers/MedicaidMap |publisher=The Advisory Board Company |date=July 26, 2013 |accessdate=August 27, 2013}}
* {{cite news |title=Florida rejects Medicaid expansion, leaves 1 million uninsured |url=https://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/05/florida-rejects-medicaid-expansion-leaves-1-3-million-uninsured/ |newspaper=The Washington Post |date=May 5, 2013 |author=Sarah Kliff |accessdate=May 24, 2013 |number=WP5513}}
* {{cite web | author=Timm, Jane C. | title=Fact check: Trump claims GOP is protecting people with pre-existing conditions. Evidence says otherwise. | publisher=NBC News | date=October 23, 2018 | url=https://www.nbcnews.com/politics/elections/fact-check-trump-claims-gop-protecting-people-pre-existing-conditions-n923056 | access-date=March 8, 2019}}
* {{cite web | title=Following The Affordable Care Act: Updates with Archive On Changes and Proposed Changes | publisher=Health Affairs | 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|access-date=Apr 29, 2011|archive-url=https://web.archive.org/web/20110429193146/http://www.healthinsuranceinfo.net/guides_map.htm#altList|archive-date=April 29, 2011}}

===Preliminary CBO documents===

* [http://www.cbo.gov/doc.cfm?index=10868 Patient Protection And Affordable Care Act, Incorporating The Manager's Amendment], December 19, 2009
** Effects Of The Patient Protection And Affordable Care Act On The Federal Budget And The Balance In The Hospital Insurance Trust Fund (December 23, 2009)
** Estimated Effect Of The Patient Protection And Affordable Care Act (Incorporating The Manager's Amendment) On The Hospital Insurance Trust Fund (December 23, 2009)
* [http://cbo.gov/doc.cfm?index=10731 Base Analysis—H.R. 3590, Patient Protection and Affordable Care Act], November 18, 2009.<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==

{{Sister project links
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===PPACA text===

* Codification in U.S. Code is generally at 42 U.S.C. 18001 ''et sqq.'' To read it, start at [https://www.gpo.gov/fdsys/browse/collectionUScode.action?collectionCode=USCODE GPO FDsys] by selecting, in the Year menu, the most recent year that lists Title 42. In Title 42, seek section 18001 and subsequent sections.
* [http://docs.house.gov/energycommerce/ppacacon.pdf Public Law 111–148 after consolidating the amendments made by PPACA Title X and by HCERA.]
* [http://dpc.senate.gov/dpcissue-sen_health_care_bill.cfm Full text, summary, background, provisions and more], via Democratic Policy Committee (Senate.gov)
* [http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf Public Law 111–148] U.S. Government Printing Office



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